1. Cardiac Rehabilitation 2011 Update for Primary Care Providers Douglass A Morrison, MD, PhD Cardiac Rehabilitation, Medical Director Yakima Regional and Yakima Valley Memorial Hospitals

2. Rehabilitation To restore to good health or useful life, through therapy and education. Changing our own behavior, for better health

3. Changing Behavior Resistances Therapy: connotation of ‘mental illness’ Rehabilitation: connotation of ‘substance abuse’ Personal Responsibility is much more difficult than blaming No one can rehabilitate another; most of the work is done by the patient, for himself..

4. Active versus Passive Second Person versus First Person It is easier to tell others how they should change, than to change ourselves: empathy

5. Cardiac Rehabilitation 2011 Bill of Fare 1.What is cardiac rehabilitation? 2.What is the difference between primary and secondary prevention? 3.Is there good clinical evidence which supports the efficacy of cardiac rehabilitation? –Survival –Myocardial infarct (MI) reduction –Stroke (CVA) prevention –Avoidance of subsequent bypass surgery (CABG) –Reduced repeat stenting (PCI) –Reduced frequency of hospitalization

6. Cardiac Rehabilitation 2011 Bill of Fare (2) 4. Does the evidence, which supports the use of cardiac rehabilitation apply: –In the ‘reperfusion-era’ of post MI care? –To the elderly (Medicare population)? –Women? –Care-givers, themselves? 5. In your personal, and professional experience, is behavior change: –Easy, i.e. a ‘slam-dunk’? –Impossible, and therefore, not even worth discussing –Possible, but requiring sustained effort

7. Definition of Cardiac Rehabilitation A multi-component intervention, which is designed to: Optimize a cardiac patient's physical, psychological and social function, and Stabilize, slow, or even reverse the underlying atherosclerosis; thereby Reducing the morbidity and mortality of coronary artery disease (CAD).

8. Physical Activity and the Prevention of Coronary Heart Disease Meta-analysis of 43 studies from world literature of physical activity and CAD up to 1987 Objective assessments of individual activity, and of CHD Attempt to infer causal relationship based on criteria of AB Hill and Rothman –Sequence: activity precedes incidence of CHD –Consistency across studies –Strength of association –Graded across multiple levels of activity –Plausibility –Coherence –Supported by biological studies Powell et al; Ann Rev Public Health1987;8:253

9. Diet, Exercise, and Smoking Modification after acute coronary syndrome (ACS) 18,809 patients from OASIS 5 prospective randomized trial, conducted in 41 countries. Most patient were compliant with aspirin (96%); statins (79%); ACE-I/beta blockers (72%). 29% did not follow diet or exercise; 1/3 of smokers persisted; 42% did either diet or exercise; 30% did both diet and exercise. MI risk reduced significantly by diet, exercise and smoking cessation. Circulation 2010;121:750-758

10. Cardiac Rehabilitation: Contemporary Era and Elderly Population 601,099 Medicare beneficiaries, who were hospitalized for coronary conditions and/or revascularization (PCI or CABG). 1- 5 year mortalities examined using multiple statistical methods Only 12% used cardiac rehabilitation services; they averaged 24 sessions. Mortality rates were 21-34% lower among users of cardiac rehabilitation Dose-response noted: more is better.

11. Performance Measures for Primary Prevention 1.Risk factor screening 2.Dietary counseling 3.Physical activity counseling 4.Smoking assessment 5.Smoking cessation intervention 6.Weight/adiposity assessment 7.Weight management 8.Blood pressure measurement 9.Blood pressure control 10.Lipid measurement 11.Lipid control 12.Global risk assessment 13.Aspirin use Circulation 2009;120:1296-1336.

12. Core Components of Cardiac Rehabilitation/ Secondary Prevention Evaluation –Patient assessment –Nutritional –Weight management –Blood pressure –Lipids –Diabetes –Smoking –Psychosocial –Physical Activity –Exercise training Intervention

13. Cardiac Rehabilitation 2011: Summary (1) Neither coronary bypass graft surgery (CABG), nor percutaneous coronary intervention (PCI), with or without stents, have been shown, in stable patients, to prevent heart attacks.

14. Cardiac Rehabilitation 2011: Summary (2) Lipid lowering (primarily with statin drugs such as Lipitor, Crestor, or Zocor); Aspirin; Beta-blockers; and ACE-inhibition; have all been shown to reduce the risk of future myocardial infarction (MI), among post MI patients, and patients with stable coronary disease. Compliance can be enhanced with the educational component of cardiac rehabilitation.

15. Cardiac Rehabilitation 2011: Summary (3) Diet, exercise, and smoking cessation have been shown to reduce the risk of subsequent heart attack. Cardiac rehabilitation, in a large, Medicare study, has been sown to be associated with reduced likelihood of heart attack. Getting people to take personal responsibility for their own health involves behavior modification. It is not easy, but we can all do it, one step at-a-time.

16. ‘When we study biology, we are life, contemplating its nature.’ George Wald, PhD In the catheterization lab, or echo lab, or exercise lab, or pulmonary function lab, We are contemplating life’s nature And we are applying the fruits of our contemplations to the care of our fellow human. We follow the same biological principles.

17. Care-Giver, Heal Thyself