Richard A. Josephson MS, MDFACC, FAHA, FACP, FAACVPR

Cardiac RehabilitationIndividualized Healing for Patients

with Cardiovascular Disease

Director of Cardiac Intensive Care Director of Cardiovascular and Pulmonary Rehabilitation

University Hospitals, ClevelandProfessor of Medicine CWRU

richard.josephson@uhhospitals.org

Treatment vs. Healing

TREATMENT • The act or manner or an instance of treating someone or something • The techniques or actions customarily applied in a specified situation

HEALING• To become healthy or well again• To make (someone or something) healthy or well again

Miriam Webster Dictionary

CVD Secondary Prevention with Medication

Reduction of BP with a variety of drugsLipid lowering with statinsAntithrombotic treatment with aspirin or clopidogrelBlockade of the RAAS with a variety of agentsBlockade of the SNS with beta blockers

…..are beneficial in a wide spectrum of patients

They each produce, in general, approximately a 15-20 % RRR in CV events over a period of 2-5 years.

Benefits of Cardiac Rehabilitation-ThenMeta-analysis of 32 randomized trials

8440 patients, mean age 55 yrs, >90% maleTrials between 1972-1999, varied regimensExercise-based rehab for patients with CADIssues with methodology, data reporting, changing therapy

Improved LDL, TG, BP, Reduced Tobacco Use

Decreased Mortality:Total mortality OR 0.73 (0.54 – 0.98)CV mortality OR 0.69 (0.51 – 0.94) RRR ~ 30%

Jollife J, et al. Cochrane Database Syst Rev2001

Benefits of Cardiac Rehabilitation-Now

Dramatic Reduction in Mortality

12.2%

5.3%

10.1%

14.8%

19.6%

16.3%

2.2%

5.2%

8.5%

24.6%

0%

10%

20%

30%

0 12 24 36 48 60Months from discharge

Cum

ulat

ive

mor

talit

y ra

te

CR users

Non-CR users

Absolute: 8.3%

Relative: 33.7%

1.1%

3.6%

6.4%

10.0%

14.0%

17.2%

13.1%

9.2%

5.6%

2.6%

0%

10%

20%

30%

0 12 24 36 48 60Months from discharge

Cum

ulat

ive

mor

talit

y ra

te

CR 25 plus sessions

CR 1-24 sessions

More CR is better !

Absolute: 3.2%

Relative: 19%

Cardiac Rehabilitation means a physician-supervised program that furnishes physician prescribed

ExerciseCardiac risk factor modification Psychosocial assessmentOutcomes assessment

Individualized Treatment Plan (ITP) means a written plan tailored to each individual patient that includes

DiagnosisType, Amount, Frequency, Duration of ServicesGoals set for the Individual

Federal Register Vol . 74 No. 226 2009

Exercise is MedicineIncreases

Exercise CapacityCardiac OutputTissue 02 ExtractionV02 MaximumEndothelial FunctionPlasminogenActivatorHDL CholesterolInsulin SensitivityBone MassCognitive Function

Decreases

MortalityRecovery HRResting BPFibrinogenC-Reactive ProteinLDL CholesterolTriglyceridesBody WeightDepressionDisability

UH Cardiac Rehab Program

• Individualized Risk Assessment• Individualized Exercise Prescription• Monitored Exercise (including telemetry)• Educational Program• Access to Smoking Cessation Program• Psychological evaluation and treatment as appropriate• Monitoring of individual patient and goals• Comprehensive discharge prescription• Communication and interaction with physicians

UH Cardiac Rehab Education• Nutrition – lipids, salt, prudent diet, weight loss, label

reading, dining in restaurants• Cardiac anatomy and physiology• Cardiac terms and diagnoses• Cardiac procedures• Cardiac drugs• Smoking cessation• Psychosocial, stress, sex• Work activity• Lifetime healthy lifestyle program

Cardiac Rehabilitation Referral & ITP ProcessPhysician Order for CR CR Team Drafts Initial ITPInpatient or Outpatient

ITP Review and Signatureby Physician

CR Team Drafts 30 Day ITPITP Review and Signature

by Physician

CR Prescriptions/ITPs

Dr. Signature

Dr. Signature

Available via paper, fax, email, AEMR

Cardiac Rehabilitation-Heart FailureMedicare Approval 2014Large Evidence Base Proving Benefit

Exercise Capacity

Quality of Life

LV structural and functional remodeling

Cardiac Rehabilitation-Heart Failure

Systolic HF LVEF < 35%

Optimal medical therapy (unspecified)

Stable on tx for 6 weeks

No planned proceedures (e.g. BivICD, surgery)

Cardiac Rehabilitation-Heart Failure

UH Individualized ApproachMedical Hx, ExamBaseline Multidimensional QuestionnairesCPX TestingExercise Prescription including:

Strength TrainingHigh Intensity Interval Training

Cardiac Rehabilitation-Heart Failure

What about everyone else?• Phase 2-if another qualifying dx

• Phase 3

• Approx $65/month

• Higher staff/pt ratio

Diagnosis Functional Capacity

QOL Morbidity Mortality

AMI +++ +++ ++ +++

CABG Surgery

+++ +++ ++ ++

Chronic Stable Angina

+++ +++ + +

PCI +++ ++ + ?

CHF +++ ++ + +

Cardiac Transplant

+++ ++ ? ?

Heart Valve Surgery

+++ ++ ? ?

Williams MA, et al. Am Heart J 2006;152:835-41

Benefits of Cardiac Rehabilitation

Evidence for Cardiac RehabilitationCurrent ACC/AHA Guidelines

• Post CABG• STEMI• NSTEMI• Stable Angina• PCI• Heart Failure

• Class I, Level B• Class I, Level C• Class I, Level B• Class I, Level B• Class I, Level B• Class IIa, Level B

ACC/AHA Clinical Practice Guidelines

Case CR PRChagrin CR PRConneaut CR PRElyria CR PRGeauga CR PRMentor CR PRParma CR PR

UH Cardiovascular & Pulmonary Rehabilitation

ReferencesKing M, Bittner V, Josephson R, Lui K, Thomas RJ, Williams MA., Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondardy Prevention Programs: 2012 Update: A Statement for Health Care Professsonals from The American Association for Cardiovascular and Pulmonary Rehabilitation and The American Heart Association. Circulation. 2012 Nov 20; 126 (21): 2535-43. PubMed PMID: 23091064.

Josephson, R, and J. Weingart, “Cardiac Rehabilitation” Update to Chapter 67 “Rehabilitation of the Patient with Coronary Heart Disease”. Fuster, V., O’Rourke, R. A., Walsh, R. A., Poole-Wilson, P,, Editors, King, S. B., Roberts, R., Nash. I. S., Prystowsky, E. N., Associate Editors: Hurst’s The Heart, 12th Edition: July 2010. htttp://www.accessmedicine.com/updatesContent.aspx?aid=1001647.

Cochrane Database Syst Rev. 2014 Apr 27;4:CD003331. doi: 10.1002/14651858.CD003331.pub4.Exercise-based rehabilitation for heart failure.Taylor RS1, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, Lough F, Rees K, Singh S.

Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease, Philip A. Ades, M.D., N Engl J Med 2001; 345:892-902September 20, 2001DOI: 10.1056/NEJMra001529

Carl J. Lavie, Richard V. Milani. (2011) Cardiac Rehabilitation and Exercise Training in Secondary Coronary Heart Disease Prevention. Progress in Cardiovascular Diseases 53:6, 397-403

JAMA. 2009 Apr 8;301(14):1439-50. doi: 10.1001/jama.2009.454.Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial.O'Connor CM1, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie RS, Zannad F, Piña IL; HF-ACTION Investigators.

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