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Chuck Kitchen, MA, FAACVPR [email protected]
Chuck Kitchen, MA, [email protected]
http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=270
NCD 20:10Effective date: February 18, 2014
CAG # 00437N HF patients are not eligible for ICR
Evidence of benefit based on CR model, not ICR
4
Same regulation for HF: 42 CFR 410.49 1-2 hour sessions/day
> 91 minutes=2 sessions < 90 minutes=1 session
Up to 36 sessions per course Up to 36 weeks to complete CR course Required components
Physician-prescribed exercise (CR team)
Cardiac risk factor reduction interventions
5
CMS criteria were derived from HF-ACTION Trial for patient eligibility.
Research design often differs from “real world” procedure for valid reasons.
6
Beneficiaries with stable, chronic heart failure meeting ALL of following:1. Left ventricular ejection fraction <
35%2. NYHA class II-IV symptoms despite
being on optimal heart failure therapy for at least 6 weeks
3. Stable=have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures
7
Beneficiaries with stable, chronic heart failure meeting all of following:1. Left ventricular ejection
fraction < 35%
Measurement by any method is OK EF >35% not eligible
▪ EF not always an exact measurement
8
Beneficiaries with stable, chronic heart failure meeting all of following:2. NYHA class II-IV symptoms
despite being on optimal heart failure therapy for at least 6 weeks
Goal for HF patients is not symptom-free, but that patients are able to monitor and control their symptoms
Similar to stable angina
9
Beneficiaries with stable, chronic heart failure meeting all of following:3. Stable=have not had recent (<
6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures
Hospitalization is not required No per year or per lifetime limit,
as with all CR dx
11
30-day all-cause re-admission penalties for HF dx Role for CR to provide transitional
treatment to improve care coordination▪ Start education earlier post-DC?
12
What about patient with AMI who has EF < 35%?
What about patient who would benefit from > 36 sessions? Similarities to stable angina
diagnosis Goal is to prepare patient for
self-management
13
5.1 MILLION people have CHF825,000 new cases per year279,000 total mention mortality-
201057,000 underlying cause 20101,084,000 hospital discharges-2005Estimated cost 2005-34.8 BILLION
YES!!!HF-ACTION TRIAL
There was a small reduction in the combined end-point of all cause death or all-cause hospitalization. This was the primary endpoint for the trial and is what is driving some of the media headlines.
There was a modest reduction in the important protocol-specified disease-specific combined end-point of CV death or HF hospitalization. Yes, this ~14% reduction is modest, but please note that this improvement occurred in patients already receiving (on-top-of) excellent evidence-based background therapy…. ~92% were on ACE inhibitors or angiotensin receptor blockers; 95% on beta-blockade; and 40% were enrolled with ICD device already implanted.
19
Exercise did not increase the risk for events. There was a modest improvement in quality of
life scores among the patients in the exercise group.
Finally, “Based on the safety of exercise training and the modest reduction in clinical events, the HF-ACTION study results support a prescribed exercise training program for patients with reduced LV function and HF symptoms in addition to evidence-based therapy.”
Steven Keteyian, PhD CEPA website
20
“Cardiac Rehabilitation Exercise and Self-Care for Chronic Heart Failure”. Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, et al. JACC Heart Fail 2013;1:540-547. Evidence to support Exercise prescription Self-care counseling
21
Constant Work Rate (CWR) The workload is fixed and remains the same
throughout the exercise session Example: Treadmill 3.0mph 2% grade for 20
min Interval Training
The workload varies throughout the exercise session.
Example: Treadmill 2.5mph 2% grade for 5 min increase to 3.0mph 3.5% grade for 5 min, etc
22
AIT-Aerobic Interval TrainingMCT-Moderate Continuous TrainingMICE-Moderate Intensity Aerobic
Continuous ExerciseHIIE-High Intensity Aerobic Interval
Exercise
Exercise Intensity Domains Assumes the use of CWR method
Light to ModerateModerate to HighHigh to SevereSevere to Extreme
24
All work rates with steady state VO2 below the 1st VT.
Blood lactate does not elevate above resting levels
Metabolism is aerobic Generally well tolerated with modest
fatigueAble to maintain for greater than 30-
40 minutes25
Work rates between 1st VT and CPTypically can be sustained for about
30 min
26
All work rates above CPNo steady state is achievedBlood lactate continually risesDuration less than 20 minutesCan only be used for interval
training, not continuous
27
Work rate is so high that fatigue comes before peak VO2 can be reached
Less than 3 minutes durationAs a result of short duration blood
lactate levels not as high as with High to Severe intensity
28
29
31
0
10
20
30
40
50
60
70
80
90
100
Warm-up
60-70%
8-10 minutes
Cool-down
60-70%
3-5 minutes
Intervals-Green Arrows
85-95%
4 minutes
Active Recovery-Blue
60-70%
3 minutes
32
0
5
10
15
20
25
30
35
40
Baseline End Baseline End
CADCHF
AIT MCT
*
*
Meta analysis, over 5800 patients High intensity, vigorous intensity,
moderate intensity, low intensity groups Peak VO2 increased 23% in High intensity
vs control Vigorous and moderate intensity also
showed significant improvement Low intensity did not show improvement
▪ Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522
Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522
Higher intensity groups increased VO2 the most
Higher peak VO2 equals lower mortality
NO DEATHS with over 123,000 patient hours of exercise training!!
Higher intensity exercise is safe and effective
Women showed similar increases in peak VO2 as men
However, women had larger decrease in hospitalization and larger reduction in all cause mortality.
▪ Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on Outcomes in Women with Heart Failure: Analysis of HF-ACTION by Sex” JACC Heart Fail Published online February 26, 2014.
F.I.T.T. PRINCIPLEFrequency IntensityTimeType
FREQUENCY3 Days per week initiallyBuild up to 4-5 days per week
INTENSITYRPE ScaleDyspneaHeart Rate
67 very, very light89 very light1011 light1213 somewhat
hard
1415 hard1617 very hard1819 very, very hard20
INTENSITYINTENSITYRPE SCALERPE SCALE
INTENSITYDYSPNEA SCALE (Modified Borg)
0 None 5 Severe0.5 Very, Very slight 61 Very slight 7 Very
Severe2 Slight 83 Moderate 9 Very, Very
Severe4 Somewhat severe 10
Maximum
INTENSITYHEART RATE
40% to 85% of HR reserve methodStart slowly and progress slowlyProgress to 60 to 85% of HR reserveBeware of failure of HR to rise
appropriately!With increased HR’s use interval
training
TIME Initially 10 to 20 minutes20 to 40 minutes/session May have to use shorter bouts (2-6
mins) more frequently with 2 to 4 minute rest periods
TYPEAerobic Interval Training
Exercise Prescription is an Art!!Every patient is different
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Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, et al. “Cardiac Rehabilitation Exercise and Self-Care for Chronic Heart Failure” JACC Heart Fail 2013;1(6): 540-547
Go AS, Mozaffarian D, Roger VL, et al. “Heart Disease and Stroke Statistics 2014 Update: A Report From the American; Heart Association” Circulation 2014 129: e28-e292
Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522
Mezzani, A, Hamm, LF, Jones AM, et al. Aerobic Exercise Intensity Assessment and Prescription in Cardiac Rehabilitation: A Joint Position Statement of the European Association for Cardiovascular Prevention and Rehabilitation, The American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation. JCRP 2012; 32(6): 327-350
O’Connor CM, Whellan DJ, Lee KL, et al. “Efficacy and Safety of Exercise Training in Patients with Chronic Heart Failure: HF-ACTION Randomized Controlled Trial” JAMA 2009; 301(14): 1439-1450
Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on Outcomes in Women with Heart Failure: Analysis of HF-ACTION by Sex” JACC Heart Fail Published online February 26, 2014.
