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Cardiopulmonary Rehabilitation
Jacob Comstock, Kelsey Hagerdon,
Adam Cook, Brandon Bergquist
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Objectives
• Examine benefits of Cardiopulmonary Rehab
• Comparison of Hospital, Outpatient, and home
health care for cardiopulmonary Rehab
• Referral strategies for cardiopulmonary
rehabilitation
• Clinical guidelines for exercise when working
with a cardiopulmonary patient
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What is
Cardiopulmonary
Rehabilitation?
• Medically supervised multifaceted program
aimed to reverse limitations in patients who
have suffered a cardiac event or required
surgery or medical care.
• Program consists of:
• Exercise training/Physical activity
• Education on heart healthy living, tobacco
cessation, prescription management
• Stress management/psychosocial effects
• Integration into functional status in family and
society
• Limit risk of re-infarction or sudden death
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Indication for
Cardiopulmonary
Rehab
• Recent MI
• Percutaneous coronary intervention
• CABG
• Chronic stable angina
• Congestive heart failure
• Cardiac transplantation
• Valvular heart disease
*Medicare provides reimbursement for all
except congestive heart failure.
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Phases of
Cardiopulmonary
Rehabilitation
I. In hospital patient period
• Pt. and family education
• Identify CV risk factors
• Lifestyle modification plan
• Discharge planning and activity program
II. Post discharge period
• Reinforce cardiac risk factor modification
• Continued education
• Gradual activity and low level exercise regime 4-6 weeks post MI.
III. Cardiac Rehabilitation and Prevention
• Structured exercise training
• 6 week duration
• Exercise class including warm up, and cool down.
IV. Maintenance
• Support groups/family involvement
• Telephone follow up
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Statistics of
cardiopulmonary
rehabilitation
• Of the 935,000 Americans having a coronary event, more
than 30% will have a second, potentially fatal one.
• Fewer than 20% of those eligible for a CR program,
participate in one.
• Utilization rate for Medicare patients is only 12%.
• 14-35% of eligible heart attack survivors participate in
cardiopulmonary rehab
• 31% of CABG patients participate in cardiopulmonary
rehab
• Participation can reduce likelihood of hospital readmissions
by 25%
• 25% reduction in all-cause mortality rates
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STUDY:
Outpatient vs home-based pulmonary
rehabilitation in COPD: a randomized control
trial
• Comparison of outpatient
pulmonary rehab to home-based
pulmonary rehab (Also included a
control)
• 117 patients with COPD (after
exclusions: 42 home-based, 46
outpatient, 29 control
• Comparisons were made using
6MWT and BODE scale
• Outpatient and home-based rehab
had similar results
• Both were superior to the control
BODE index variation before and after rehabilitation program
Intra-group results of distance walked on six-minute walk test
before and after rehabilitation program
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STUDY:
Home-based versus centre-
based cardiac rehabilitation
• The purpose of this study was to look at the efficacy of
cardiac-centered home health programs versus the efficacy
of a cardiac rehabilitation center.
• Methods:
• The authors included randomized controlled trials,
systematic reviews, and meta-analyses
• Populations included adults who have, or had, an MI,
angina, revascularization, heart failure, or invites to take
part in cardiac rehabilitation
• Outcome measures used included mortality, morbidity,
exercise capacity, modifiable coronary risk factors, health
service utilization, or adherence to intervention.
• Conclusions:
• Both settings appear to be equally effective towards
improving clinical and health-related quality of life
outcomes in acute MI and revascularization patients.
• This review found no difference in healthcare
costs between the 2 settings.
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Effect of Rehabilitation Referral Strategies on
Utilization Rates: A Prospective, Controlled
Study
• 4 referral systems:– automatic referral using electronic patient records or
standard discharge orders as a systematic prompt before
hospital discharge
– liaison referral(referral is facilitated through a personal
discussion with a health care professional)
– a combination of both
– “usual” referral at the discretion of health care providers
• Compares 4 referral strategies for
referring patients with acute
coronary syndrome to Cardiac
Rehabilitaion(CR)
• 1809 participants completed a
mailed survey that assessed CR
utilization.
• Combined automatic and liaison
referral was found to result in the
largest degree of CR referral and
enrollment, followed by automatic
only, and liaison only.
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Outpatient interventions
for patients with cardiac
diseases
http://journals.sagepub.com/doi/pdf/10.1177/2047487316657669
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Clinical practice guidelines for pulmonary rehab from American
College of Chest Physicians (ACCP) and the American Association of
Cardiovascular and Pulmonary Rehabilitation. (AACVPR)
• Exercise training of the muscles of ambulation is a mandatory component of pulmonary rehabilitation for patients with COPD. (1A recommendation)
• Both low- and high-intensity exercise training produce clinical benefits for patients with COPD. (1A recommendation)
• Unsupported endurance training of the upper extremities is beneficial in patients with COPD. (1A recommendation)
• Six to 12 weeks of pulmonary rehabilitation produces benefits in several outcomes. (1A recommendation)
• Addition of a strength training component increases muscle strength and mass. (1A recommendation)
• High-intensity exercise of the lower extremities produces greater physiologic benefits than low-intensity training in patients with COPD. (1B recommendation)
• Education should include information on collaborative self-management, prevention, and treatment of exacerbations. (1B recommendation)
Grading
Grade 1: strong
recommendations with
certainty that the benefits do
or do not outweigh risk.
grade 2: indicates weaker
recommendations with less
certainty .
A: High-quality RCT
B: RCT's with limitations or
inconsistent results
C: Non RCT studies
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Local cardiopulmonary
rehabilitation facilities
• Norton Health Care
• Baptist Health Louisville
• Kentucky One Health
• Jewish Hospital
• Frazier Rehab Institute
• Robley Rex VA Medical Center
• Sts. Mary & Elizabeth Hospital
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Conclusion
• Cardiopulmonary Rehab is heavily underutilized but provides
many physiological benefits.
• Outpatient and Home based pulmonary rehabilitation are viable
options for patients.
• Home based and center-based cardiac rehab programs are
equally effective towards improving clinical and health-
related quality of life outcomes in acute MI
and revascularization patients
– No difference in healthcare cost was found between the 2 settings
• Combined automatic and physician referral results in largest
enrollment to cardiopulmonary rehabilitation.
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References
1. American Heart Association. Cardiac Rehab Fact Sheet 2013 Final. 2013.
https://www.heart.org/idc/groups/heart-
public/@wcm/@adv/documents/downloadable/ucm_449722.pdf
2. Anderson L, Sharp G, Taylor R, et al. Home-based versus centre-based cardiac rehabilitation. The Cochrane
Database Of Systematic Reviews [serial online]. June 30, 2017;6:CD007130. Available from: MEDLINE,
Ipswich, MA. Accessed November 13, 2017.
3. Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization
rates: A prospective, controlled study. Archives of Internal Medicine. 2011;171(3):235-241.
4. Lowe R. Cardiac Rehabilitation. Physiopedia. http://www.physio-pedia.com/Cardiac_Rehabilitation.
Accessed November 7, 2017.
5. Mendes de Oliveira JC, Studart Leitão Filho FS, Malosa Sampaio LM, et al. Outpatient vs. home-based
pulmonary rehabilitation in COPD: a randomized controlled trial. Multidisciplinary Respiratory Medicine.
2010;5(6):401-408. doi:10.1186/2049-6958-5-6-401.
6. Price KJ, Gordon BA, Bird SR, Benson AC. A review of guidelines for cardiac rehabilitation exercise
programmes: Is there an international consensus? European Journal of Preventive Cardiology.
2016;23(16):1715-1733.
7. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-
Based Clinical Practice Guidelines. Chest. 2007;131(5, Supplement):4S-42S.