Cardiovascular Rehabilitation

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Cardiovascular Rehabilitation

• The Art and Science of Managing Individuals with
  Cardiovascular Disease
• Presented by
• Esther Burchinal, MS, ACSM CES RCEP (SM)

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Significant Statistics

• Cardiovascular disease
• Claims more lives than all forms of cancer
  combined, males and females.
• Heart Disease is the No. 1 cause of death in the
  World and in the US.
• Causes over 375,000 American deaths/year.

American Heart Association, Dallas Texas
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Significant Statistics

• Nearly 735,000 Americans sustain a myocardial
  infarction each year
• 120,000 are fatal
• 5 of myocardial infarctions occur before age 40
• 45 of myocardial infarctions occur before age 65

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Significant Statistics

• The of Americans hospitalized, undergoing
  operations and procedures, for cardiovascular
  disease increased 28 between
• 2000-2010.
• CVD is the first diagnosis in
• 6,000,000 hospitalizations
• 5,225,000 outpatient procedures
• 65,843,000 physician office visits

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Mission of Cardiac Rehabilitation

• To restore and maintain an individuals optimal
  physiological, psychological, social and
  vocational status

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Overview of Cardiovascular Rehabilitation

• Medically supervised secondary prevention program
  for patients with diagnosed cardiovascular
  disease
• Physician referral required
• Generally meets three times per week for up to 12
  weeks
• Risk stratification process based on probability
  of future event and disease progression

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Phases of Cardiac Rehab

• Phase I during hospitalization
• Phase II early outpatient
• - Supervised program with telemetry
  monitoring, exercise, education, and support.
• -Usually 2-4 weeks post event lasting
  3-6months.
• Phase III lifetime maintenance.

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Continuum of Care Model

• Initial Assessment ? Problem List ?
• Goal Setting ? Plan of Care ?
• Plan Implementation ? Outcomes Evaluation

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Core Program Components

• Baseline patient assessment
• Risk factor management
• Nutritional counseling
• Psychosocial management
• Physical activity counseling
• Exercise training
• Balady, G. et al. Core components of cardiac
  rehabilitation/secondary prevention programs A
  statement for healthcare professionals from the
  American Heart Association and the American
  Association of Cardiovascular and Pulmonary
  Rehabilitation. Circulation, 2000 1021069-1073.

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Common Program Components

• Initial and on-going evaluation
• Monitored sessions
• EKG
• HR, RPE, Talk test
• BP
• Signs/symptoms
• Lifestyle education sessions
• Support group

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Common Program Components

• Initial and ongoing evaluation typically
  includes
• Medical history
• Risk factor identification and assessment
• Psychosocial and quality of life indicators
• Functional assessment
• Exercise prescription

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Common Program Components

• Patients are monitored for
• Exercise related physiologic parameters
• Wound healing/sternotomy integrity
• Emotional status
• Muscular-skeletal status
• Risk factor management (i.e. hypo/hypertension,
  diabetes management, medication management)

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Common Program Components

• Lifestyle education sessions
• Individual and/or group interactions targeting
• Risk factor education, intervention, and
  modification including
• Exercise Activity, Heart Disease, Medications,
  Nutrition, Stress Physiology Stress Management
• Support group

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Approved Diagnoses

• Medicare Guidelines
• Angina
• Myocardial Infarction
• Coronary Artery Bypass Graft
• Heart Transplant
• Valve Surgery
• Stent
• Coronary Artery Disease (CAD)
• Heart Failure (EF lt 35)

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Approved Diagnoses

• Non-Medicare Beneficiaries
• Myocardial infarction
• Stable angina
• CABG
• PTCA/stent placement
• Heart transplant
• call for verification

• Heart failure
• Cardiomyopathy
• Recent ICD implant
• Arrhythmias
• Valve replacement/repair

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Multidisciplinary Team Approach May Include

• Medical Director
• Referring Physician
• Registered Nurse
• Exercise Physiologist
• Registered Dietitian
• Physical Therapist

• Licensed Social Worker
• Pharmacist
• Occupational Therapist
• Health Educator
• Other consulting practitioners

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Certifications and Accreditations

• American Heart Association
• Basic Life Support (BLS)
• Advanced Cardiac Life Support (ACLS)
• American Association of Cardiovascular and
  Pulmonary Rehabilitation
• Program Certification
• Certified Cardiac Rehabilitation Professional
  (CCRP)

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Certifications and Accreditations

• American College of Sports Medicine
• Certified Exercise Specialist (CES) bachelors
  prepared
• Registered Clinical Exercise Physiologist (RCEP)
  masters prepared
• American Nurses Credentialing Center
• Others RD, LICSW
• For hospitals JCAHO, now called TJC

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Benefits of Participation

• Improved functional abilities
• Improved Quality of Life
• Reduction of lifestyle related risks
• Increased knowledge of disease process and
  prevention strategies
• American Heart Association Consensus Panel
  Statement. Preventing heart attack and death in
  patients with coronary disease. Circulation.
  1995922-4.

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Benefits of Participation

• Improved compliance with medical regimen
• Improved metabolic profile
• Malbut-Shennan, K. and Young, A. The physiology
  of physical performance and training in old age.
  Coronary Artery Dis. 19991037-42.
• Gottlieb, S.S., Fisher, M.L., and Freudenberger,
  R. et al Effects of exercise training on peak
  performance and quality of life in congestive
  heart failure patients. Journal of Cardiac
  Failure, 19995188-194.
• Lavie, C.J., Milani, R.V., and Littman, A.B.
  Benefits of cardiac rehabilitation and exercise
  training in secondary coronary prevention in the
  elderly. J Am Coll Cardiol. 199322678-683.
• Agency for Health Care Policy and Research, U.S.
  Department of Health and Human Services. Cardiac
  Rehabilitation Clinical Practice Guidelines.
  Publication No. 96-0672, October 1995.

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Benefits of Participation

• Reduced risk of fatal MI (lt25).
• Decreased severity of angina need for
  anti-angina meds.
• Decreased hospitalizations.
• Decreased cost of physician office visits
  hospitalizations (lt35).
• Decreased ER visits.
• Ades, PA, et al (2000) Medical Clinics of North
  America
• Sudlow, C, et al (1999) Clinical Evidence
• Lavie, CJ, et al (1999) Cardiology Clinics

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Utilization Trends

• Nearly 2 million Americans are eligible for
  secondary prevention
• On average, only 10 to 30 of eligible patients
  receive cardiac rehabilitation
• (Ranges vary between 11 and 38 depending on the
  area of the country.)

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Dose Response Relationship for CR Sessions and
Risk of Death / MI 36 vs 24
36 vs 12 36 vs 1 Death - 14
- 22 - 47 MI - 12
- 23 - 31 Relationship
Between Cardiac Rehabilitation and Long-Term
Risks of Death and Myocardial Infarction Among
Elderly Medicare Beneficiaries. Hammill, BG. et
al. Circulation. 201012163
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What can we do?

• Continue to educate ourselves and the public
  about risk factors, heart disease, and Cardiac
  Rehab
• Learn CPR and AED use
• Lead by example
• Join professional organizations MACVPR, ACSM,
  CEPA, MACEP..

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Questions ?