1. Benefits of Cardiac Rehabilitation: Impact on Mortality, Hospitalizations and Risk Factors
Reggie Higashi, MSS
Exercise Physiologist

2. Core Program Components
Baseline clinical evaluation & patient assessment
Risk factor management and goal setting
Psychosocial management
Physical activity counseling
Exercise training
The core components identified by the AHA/AACVPR Scientific Statement are not intended "...to promote a rote approach or homogeneity among programs, but rather to foster a foundation of services upon which each program can establish its own specific strengths and identity and effectively attain outcome goals for its target population."
Balady, G. et al. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation, 2000; 102:

3. Approved Diagnoses (Medicare)
Myocardial infarction
Within 1 year
Stable angina
Coronary artery bypass grafting
Medicare provides reimbursement for the following diagnoses with the specific diagnosis code present. MI
Stable Angina
Coronary artery bypass surgery
Ref: Section 35:25 of the "Medicare Procedure Manual" Cardiac Rehabilitation Programs

4. Approved Diagnoses (Non-Medicare)
Myocardial infarction
Stable angina
CABG
PTCA/Stent placement
Heart failure
PAD
Recent ICD implant
Arrhythmias
Valve replacement/repair
Heart transplant
Commercial insurance may cover these diagnoses. Pre-approval is often required.

5. Cardiac Rehab Programs
Monitored outpatient program
3 days/week for up to 12 weeks
Covered by Medicare (MI, angina, CABG)
Modified monitored outpatient program
3 days/week for up to 4 months
Not covered by insurance
Extended outpatient program (after monitored or modified program)
Maintenance program (after extended program)
2 days/week

6. Monitored Outpatient Program
One hour cardiac monitored exercise sessions
3 days/week, MWF for up to 12 weeks
Various class times in morning and afternoon
Guided warm-up, three 10-minute aerobic stations, guided cool-down
Blood pressure monitored pre, during and post-exercise
Monthly and final reports sent to referring M.D.
Medicare/Insurance covered diagnoses (MI, CABG, Stable Angina)

7. Modified Monitored Outpatient Program
Telemetry monitored for first 2 weeks, then patient is placed on personal heart rate monitor for the remainder of program
3 days/week, MWF for up to 4 months enrollment limit
Various class times in morning and afternoon
Guided warm-up, three 10-minute aerobic stations, guided cool-down
Blood pressure monitored pre, during and post-exercise
Monthly and final reports sent to referring M.D.
Costs: $325 for initial month (includes costs of personal heart rate monitor) then $40 per month for the remaining 3 months.
(Self-Pay; Not covered by insurance)

8. Extended Outpatient Program
One hour non cardiac-monitored exercise sessions
3 days/week, MWF for up to 4 months enrollment limit
Various class times in morning and afternoon
Guided warm-up, three 10-minute aerobic stations, guided cool-down
Blood pressure monitored pre, during and post-exercise
Cardiac monitoring 1x/month
Monthly reports with telemetry cardiac monitoring sent to referring M.D.
Self Pay: $40/month (Not covered by insurance)
Must complete monitored or modified monitored program to enroll in this program.

9. Maintenance Program One hour non cardiac-monitored exercise sessions
2 days/week, Tu & Th, 8:00 a.m. - 9:00 a.m.
Guided warm-up, four 10-minute aerobic stations, guided cool-down
Blood pressure monitored 1x/month as as needed
Heart Rate checks pre, during and post-exercise by patient
Copy of monthly exercise logs given to patient.
Self Pay: $30/month (not covered by insurance)
Must complete extended out-patient program to enroll in this program.

10. Comprehensive Program
Effect of Exercise-Based Cardiac Rehab on Cardiac Events in Patients with CAD (MI, angina, CABG, PCI)
Exercise Only
Comprehensive Program
Non-fatal MI
- 4%
- 12%
Cardiac Mortality
- 31% *
- 26% *
Jolliffe et al. Meta-Analysis, 2001.
51 randomized, controlled trials (n = 4,000)
2 –6 months of supervised rehab, then unsupervised
Mean follow-up of 2 – 4 years

11. Utilization of Cardiac Rehab by Patients After MI
Ades et al , 1992 reviewed utilization of cardiac rehab by patients within 1 hour of rehab center
Age Dependence of Utilization
< 62 yrs: 46% utilization
> 62 yrs: 21% utilization
Most powerful predictor of utilization was recommendation of primary care physician to participate

12. Potential Explanation for Reduced Mortality Without Impact on Non-fatal MI
Ischemic preconditioning
Animals having repeated episodes of temporary coronary occlusion have smaller MI when occlusion is permanent
Electrical stability and reduced ventricular fibrillation

13. Exercise Training in Patients with Angina
Improved myocardial oxygen supply at a given level demand
Increase in rate pressure product at onset of angina (reduction in exercise heart rate)
Decrease in nuclear scan perfusion defects (as early as 8 weeks)
Less ST segment depression
Proposed mechanisms
Improved endothelial function (angio studies)
Increased coronary collaterals
Regression and reduction in progression of CAD (1 yr studies)

14. Exercise Training After Coronary Revascularization (CABG/PCI)
No large studies
ETICA Trial (Exercise Training Intervention after Coronary Angioplasty Trial, 2001
118 patients underwent 6 months of exercise training or control. Follow-up of months
Improved exercise capacity (26% increase in v02)
Fewer cardiac events (12 vs 32%)
Fewer hospital admissions (19 vs. 46%)
No impact on restenosis

15. Exercise Training for Patients With CHF
> 20 studies document improvements in
Exercise capacity
20% improvement in v02 after 4 weeks
18 – 34% increase in time on treadmill after 12 wks
Quality of life
Hospitalization and mortality
Belardinelli et al (Circ, 1999): Small trial that demonstrated improved exercise capacity, decreased hospitalization and improved 1 yr survival
HF-ACTION – NIH Study
Compares “usual care” with addition of formal exercise training
Endpoints of mortality and hospitalization

16. Exercise Training for Patients with PAD and Claudication
Improvements in distance to onset of pain (increased by 179% [225 m]) and distance to maximal tolerated pain (increased by 122% [397 m])
Improvements with exercise exceed those with meds (I.e., Trental, Pletal)
Most significant improvements when:
Walking as training
Walking to maximal pain
Training period for 6 months
Meta-Analysis of 21 exercise programs Gardner and Poehlman, JAMA, 1995

17. Proposed Mechanisms for Improved Outcomes with Exercise Therapy
Favorable impact on risk factors
Lipids
Blood pressure
Body weight
Insulin sensitivity
Enhanced parasympathetic tone
Improved endothelial function
Lower catecholamine levels with exercise may reduce platelet aggregation

18. Impact on Risk Factors: Cholesterol Reduction
LDL decrease of 5% (8 – 12% decrease with combined exercise and diet therapy)
HDL increase of 4.6%
Triglyceride decrease of 3.7%
Meta-Analysis (2001) of 52 trials,
n = 4700, > 12 weeks of training

19. Impact on Risk Factors: Diabetes Mellitus
Decrease in hemoglobin A1C by 0.5 to 1.0
Mechanisms proposed: Increased insulin sensitivity and decreased hepatic glucose production
Data from 9 trials, 337 patients with diabetes mellitus, type 2
Role of physical activity and weight loss * in preventing type 2 diabetes mellitus in patients at risk
Diabetes Prevention Program (NEJM, 2002)
58% reduction in onset of diabetes over 2.8 years (vs 31% reduction with metformin 850 mg BID)
* Average weight loss of 4.4 kg
Increase activity by 8 met hr/week = 6 mile walk per week

20. Impact on Risk Factors: Blood Pressure Reduction
Overall
Normotensive
Hypertensive
Systolic
- 3.4
2.6
- 7.4
Diastolic
- 2.4
- 1.8
- 5.8
44 Trials, n = 2,674

21. Impact on Risk Factors: Smoking
Useful as adjunct to behavioral programs
Results of 12 week exercise program in 281 women
19% abstain after program (vs 10%)
12% abstain at 1 year (vs 5%)

22. Impact on Risk Factors: Weight Reduction
Exercise
2 – 3 kg
Diet
5 – 5 ½ kg
Diet and Exercise
8 ½ kg

23. Favorable Effects of Exercise Training
Endothelial Function
Fibrinolytic System
Platelet Function

24. Exercise Therapy and Platelet Function
An increase in platelet aggregation can occur after exercise in sedentary individuals (possibly related to increased catecholamines)
After 12 week exercise training program, platelet aggregation decreased by 52% in a study of middle age, hypertensive male subjects

25. Exercise Therapy and Fibrinolytic System
Plasma Fibrinogen
- 13%
Tissue Plasminogen Activator
+ 39%
Plasminogen activator inhibitor - 1
- 58%

26. Summary: Benefits of Exercise-Based Cardiac Programs
30% decrease in mortality in patients with CAD (Decrease in mortality also reported in CHF)
Decrease in hospitalizations after coronary revascularization and with CHF
Improved exercise tolerance in patients with claudication and PAD
Favorable impact on risk factors

27. Exercise Recommendation (AHA/CDC/ACSM)
30 minutes or more of moderate intensity of physical activity on most (preferably all) days of the week
Moderate intensity
Absolute intensity = 4 – 6 mets *
Relative intensity = 40 – 60% of v02 max
4 mets may be “vigorous” for an 80 yr old and
“light” for a 20 yr old

28. Thank you all for attending today’s lecture.
Any Questions???