Monitored Rehab or unsupervised daily physical

activity?Dr. med. C. H. Kamani

Service de Cardiologie – Hôpitaux Universitaire de Genève

SSC / SSCC / SSP 15-17.6.2016

Lausanne

Plan

• Historical Background of the cardiac rehabilitation

• Monitored cardiac rehabilitation

• Alternatives to monitored cardiac rehabilitation (unsupervised dailyphysical activity)

• Conclusions

Historical Background• 1772: Case-report of a patient who improved from angina pectoris by

working in the woods half an hour per day (Heberden)

• 1912: description of the myocardial infarction by Herrick

• 1930: recommandations of 6 weeks of bed rest after acute coronaryevents

• Early 1950: introduction of very short daily walk of 3 to 5 min 4 weeksafter coronary events

Historical Background• 1953: Study showing that the bus drivers in London had a higher rate

of coronary events compared to ticket sellers (1)

• 1966: detrimental effects of prolonged immobilization by the trainingof candidates for space flights (2)

• 1968: Dallas Bed Rest and Exercice Study (3)

• 60’s: Studies of Sarnoff, Sonnenblick, Hellerstein, Naughton,Braunwald

Monitored cardiac rehabilitation (CR)• Sum of activity and interventions required to ensure the best possible physical, mental, and social

conditions so that patients with chronic or post-acute cardiovascular disease may, by their ownefforts, preserve or resume their proper place in the society and lead an active life (WHO 1993)

Evolution of CR

In the early ages Nowadays

Inclusion criteria Post-infarction patients without complications - Post-infarction patients with complications- Patients recovering from CABG, PTCA- Older patients with comorbidities- Patients with high risk for structured CR (residual myocardial ischemia, compensated heart failure, seriousarrythmia, implateted devices- Patients with cardiovascular risk factors- Patients after cardiac transplantation

Initiation Time remote from the acute event In the early days after the acute event

Components Physical exercice - Baseline patients assessment- Physical activity councelling and exercice training- Nutritional councelling- Risk factors management (lipids, hypertension, weight, diabetes, smoking)- Psychosocial management- Vocational councelling- Optimised medical therapy

Goals Safe return to physical activity - Achievement of a clinical stability, limitation of physiological and psychological effects of cardiac illnessImprovment of the overall functionnal status and maintenance of an independance with emphasising on quality of life- Reduction of the risk of future coronary events, of the progression of underlying atherosclerotic process and clinical deterioratio, of morbidity and mortality 4

4

Monitored cardiac rehabilitation (CR)• Physical activity is defined as any bodily movement produced by

contraction of skeletal muscles and resulting in energy expenditureabove the basal level and, as such, part of lifestyle intervention.

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Monitored cardiac rehabilitation (CR)The benefits achived with CR are the result of the combination of all its components

• Lifestyle:• Patient life quality benefits are also achieved through the improvement of symptoms (lessening of chest pain,

dyspnea and fatigue), stress reduction and the enhancement of the overall sense of psychosocial well-being(8)

• Improvement in exercise performance (increase of tolerated metabolic equivalents by 33% and of maximaloxygen consumption by 16%) with beneficial effects on the quality of life and cardiovascular events (8)

• Heart failure:• Meta-analysis of 9 randomized studies confirmed a 35% decreases in mortality for heart failure patients (9)• Randomized controlled trial of exercice training in heart failure (HF-ACTION) involving 2331 patients with an

ejection fraction of 35% or less showed that exercise training can achieve significant reduction (15%) in all-cause and cardiovascular mortality and heart failure hopsitalisation (10)

• Coronary artery desease:• Meta-analysis of 63 randomized trials (21295 patients) 17% reduction of recurrent myocardial infarction at

12 months and a 47% reduction of mortality at 2 years with cardiac rehabilitation (6)• Meta-analysis of 48 randomized trials (8940 patients with coronary disease) CR was associated with a

significant reduction in all-cause mortality (OR = 0.80; CI 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95%CI 0.61 to 0.96) (7).

Bradley G. Hammill et al. Circulation. 2010;121:63-70

Cumulative incidence of death by number of cardiac rehabilitation sessions attended. Cumulative incidence of MI by number of cardiac rehabilitation sessions attended.

Monitored cardiac rehabilitation (CR)• Ades et al. showed that cardiac rehabilitation was more cost-effective

following myocardial infarction, compared to lipid lowering drugs,thrombolytics and CABG. Only smoking cessation was more cost effectivethan cardiac rehabilitation (12).

• Levin et al. showed that cardiac rehabilitation participation following MI orbypass surgery (with a 5-year follow-up) decreased rehospitalizations from16 to 11 days, increased the rate of return to work from 38% to 53% andresulted in an overall cost savings of $12,000 per patient (13).

• Oldridge et al. showed that a 12-weeks participation in cardiac rehabilitationreduces medical costs by 739$ per patient after only 21 months follow-up(14).

Monitored cardiac rehabilitation (CR)• In a study from French registry of over 25,000 patients participating

in 65 cardiac rehabilitation centers in 2003, there was one cardiacevent for every 8484 exercise tests performed, one cardiac event forevery 50,000 patient hours of exercise training, and 1.3 cardiacarrests for every million patient hours of exercise (15).

• The 2007 American Heart Association scientific statement on exerciseand acute cardiovascular events estimated that the risk of any majorcardiovascular complication (cardiac arrest, death or myocardialinfarction) is one event in 60,000 to 80,000 patient-hours ofsupervised exercise (16).

• Patients most at risk are those with residual ischemia, complexventricular arrhythmia and severe left ventricular

Monitored cardiac rehabilitation (CR)• Fewer than one-third of patients eligible for CR currently participate in formal

rehabilitation programmes in most European countries (17,18)

Unsupervised daily physical activity

Unsupervised home based cardiac rehabilitation

Balady GJ et al, Circulation 2011;124:2951-60.

Meyer P, Kayser B, Kossovsky MP, Sigaud P, Carballo D, Keller PF, et al. Stairs instead of elevators at workplace: cardioprotective effects of a pragmatic intervention. European journal of cardiovascular prevention and rehabilitation :official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology. 2010; 17(5): 569-75

Kamani et al; Eur J Clin Invest. 2015 Jun 17. doi: 10.1111/eci.12480.

• Article Kamani escaliers

Kamani et al; Eur J Clin Invest. 2015 Jun 17. doi: 10.1111/eci.12480.

• Triggering of acute myocardial infarction by heavy physical exertion,particularly in people who are habitually sedentary (Mittlemann et al, NEJM1993;329:1677–1683)

• During 12 years of follow-up, 122 sudden deaths were confirmed amongthe 21,481 male physicians who were initially free of self-reportedcardiovascular disease and who provided information on their habituallevel of exercise at base line.

• The relative risk of sudden death during and up to 30 minutes aftervigorous exertion was 16.9 (95 percent confidence interval, 10.5 to 27.0;P<0.001). However, the absolute risk of sudden death during any particularepisode of vigorous exertion was extremely low (1 sudden death per 1.51million episodes of exertion).

• Habitual vigorous exercise attenuated the relative risk of sudden death thatwas associated with an episode of vigorous exertion (P value for trend=0.006). The baseline level of exercise was not associated with the overallrisk of subsequent sudden death. (Albert et al, N Engl J Med 2000; 343:1355-1361)

Meta-analyses provide strong evidence that exercise-based cardiac rehabilitation reduces mortality in CAD patients,

but the absence of a sufficiently powered, randomized clinical trial prohibits absolute certainty that exercise

training alone reduces cardiac mortality in CAD patients. Recent clinical trials suggest that exercise training

markedly reduces cardiovascular events after angioplasty and is superior to angioplasty in managing selected patients

with angina pectoris.

Jolly K, Lip GY, Taylor RS, et al. The Birmingham Rehabilitation Uptake Maximisation study BRUM): a

randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart 2009;95:36-42.

Interventions (exercise,relaxation, education and lifestyle counselling)

Centre-based programmes Home-based programmes- The four centre-based programmes varied in length, includingnine sessions at weekly intervals, 12 sessions over 8 weeks and24 individualized sessions over 12 weeks.

- Programmes commenced between 4 weeks and 8 weeksfollowing the cardiac event.

- Patients exercised to 65–75% of their predicted maximal heartrate and the exercise element of the sessions lasted from 25minutes to 40 minutes plus warm-up and cool-down elements.

- The home-based programme consisted of a manual, threehome visits (at 10 days, 6 weeks and 12 weeks) and telephonecontact at 3 weeks.- Patients who had had an MI were discharged home with theHeart Manual (2nd edition)14 or an adapted version of theHeart Manual for revascularization patients which commencedon their discharge.- Additional visits were made as deemed necessary by therehabilitation nurse.- All the nurses who provided the home-based cardiacrehabilitation programme attended a two-day training courserun by the originators of the Heart Manual.- The manual encourages patients to build up their exercisegradually to achieve a minimum of 15 minutes of moderatelyintense activity daily.

Jolly K, Lip GY, Taylor RS, et al. The Birmingham Rehabilitation Uptake Maximisation study BRUM): a

randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart 2009;95:36-42.

• Significantly more of the participants in the home arm reported undertaking at least three episodes ofat least 15-minutes’ duration of physical activity in the previous 7 days at 6 weeks (95.2% v 85.1%,p=0.01), but the difference was no longer present at 12 weeks (90.1% v 93.4%, p=0.3)

• Participants in the home arm reported a significantly higher exercise score than those in the centre-based arm at 9 weeks median (IQR) 5 (3–7) v 3 (3–6) in the centre-based arm (p=0.01).

• Participants allocated to be offered the centre-based arm attended 66% of scheduled rehabilitationsessions; 73 (28%) did not attend any of the supervised sessions. In the home-based arm participantsreceived an average of 4.8 (SD 1.5) home contacts. While 241 (96.1%) of the home-participants receivedfive contacts (by visit or telephone) with a cardiac rehabilitation nurse, only 147 (56.1%) of the centre-based participants attended this number of classes (p,0.001).

• At 6 months 15.2% of patients allocated to the home programme were attending some form of group-based exercise (either a phase IV cardiac rehabilitation programme or classes at a leisure centre)compared to 32.5% of patients allocated to the centre-based programme.

• When all costs including those to patients of travel to the centres was included (societal cost perpatient), the hospital arm cost £896 (95% CI 745 to 1047) per patient compared to £807 (95% CI 684 to930) in the home arm, making the hospital arm more costly, but with overlapping confidence intervals.

Jolly K, Lip GY, Taylor RS, et al. The Birmingham Rehabilitation Uptake

Maximisation study BRUM): a randomised controlled trial comparing

home-based with centre-based cardiac rehabilitation. Heart 2009;95:36-

42.

First randomized controlled trials to investigate the effect of a combinedmode of unsupervised exercise training (walking and musclestrengthening using body weight) on physical activity and physiologicalmeasures after supervised cardiac rehabilitation.

Kazuhiro et al, Journal of the japanese physical therapy association9: 1-8, 2006

Interventions

Before beginning the programme, each subjectreceived instruction regarding the exercise regime,which consisted of at least one hour of walkingevery day, including rest periods as necessary

Subjects were contacted by telephone on aweekly basis in order to assess progress andreiterate the recommended walking guidelines.

Subjects were instructed to complete exercisediaries in order to improve accuracy of self-reported exercise duration.

Roberts et al; Eur J Vasc Endovasc Surg 2008; 36, 319-324

Roberts et al; Eur J Vasc Endovasc Surg 2008; 36, 319-324

Conclusions

• Cardiac rehabilitation has been proven to be safe and effective inimproving cardiovascular patients` life quality and reducing morbidityand mortality.

• Despite the evidence of its benefits, cardiac rehabilitation remainsunderused.

• More patients would benefit from this cost-effective tool byimproving referral and participation to cardiac rehabilitation programsand individualizing services taking into account the patients' profile.

• Unsupervised cardiac rehabilitation could be a valuable alternative forselected patients

Conclusions

• In the absence of a local cardiac rehabilitation program by stablepatients, physicians should advise the patient on how to start anexercise program.

• Instructing patients to exercise daily may increase the possibility thatthey will exercise at least 3 times weekly, a frequency commonly usedin exercise training studies of cardiac patients.

• unsupervised patients should exercise at a target HR of 60% to 75% oftheir predetermined maximal HR. This value is intentionally lowerthan that used in supervised cardiac rehabilitation programs (70% to85%) to reduce the chance of ischemia in an unsupervised setting.

Thanks for your attention

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• 2: Cardus D. Effects of 10 days recumbency on the response to the bicycle ergometer test. Aerosp Med 1966;37:993-9.

• 3: Saltin B, Blomqvist G, Mitchell JH, et al. Response to exercise after bed rest and after training. Circulation 1968;38:VII1-78.

• 4: Secondary Prevention Through Cardiac Rehabilitation. Position Paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. P. Giannuzzia*, H. Sanerb, H. Bjo¨rnstadc, P. Fiorettid, M. Mendese, A. Cohen-Solalf, L. Dugmoreg, R. Hambrechth, I. Hellemansi, H. McGeej, J. Perkk, L. Vanheesl, G. Veressm. European Heart Journal (2003) 24, 1273–1278

• 5: Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training. Key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. EACPR Committee for Science Guidelines: Ugo Corra` (Chairperson), Massimo F. Piepoli, Franc¸ois Carre´ ; Peter Heuschmann; Uwe Hoffmann; Monique Verschuren; Julian Halcox. Document Reviewers: Pantaleo Giannuzzi, Hugo Saner, David Wood. European Heart Journal doi:10.1093/eurheartj/ehq23

• 6: Clark AM, Hartling L, Vandermeer B, et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005;143:659-72.

• 7: Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004;116:682-92.

• 8: Maines TY, Lavie CJ, Milani RV, et al. Effects of cardiac rehabilitation and exercise programs on exercise capacity, coronary risk factors, behavior, and quality of life in patients with coronary artery disease. South Med J 1997;90:43-9.

• 9: Piepoli MF, Davos C, Francis DP, et al. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ 2004;328:189.

• 10: 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;301:1439-50.

• 11: Hammill BG, Curtis LH, Schulman KA, et al. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010;121:63-70.

• 12: Ades PA, Pashkow FJ, Nestor JR. et al. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997;17:222-31.

• 13: Levin LA, Perk J, Hedbäck B. Cardiac rehabilitation—a cost analysis. J Intern Med 1991;230:427-34.

• 14: Oldridge N, Furlong W, Feeny D, et al. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol 1993;72:154-61.

• 15: Pavy B, Iliou MC, Meurin P, et al. Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation. Arch Intern Med 2006;166:2329-34.

• 16: Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007;115:2358-68.

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• 18: Vanhees L, McGee HM, Dugmore LD et al. on behalf of the Carinex Working Group. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex Survey. J Cardiopul Rehabil in press.