Cardiac Rehabilitation Overview PDF

Cardiac Rehabilitatio n OVERVIEW Objectives: Define Cardiac Rehabilitation (CR) Discuss clinical practice guidelines for CR programming Examine the continuum of CVD care and importance of integration of CR into standard CVD care Benefits of Cardiac Rehabilitation Discuss Cardiac Rehabilitati...

Cardiac Rehabilitatio n OVERVIEW Objectives: Define Cardiac Rehabilitation (CR) Discuss clinical practice guidelines for CR programming Examine the continuum of CVD care and importance of integration of CR into standard CVD care Benefits of Cardiac Rehabilitation Discuss Cardiac Rehabilitation structure Discuss the indications for CR Discuss the main components of Cardiac Rehabilitation program Discuss CR barriers and program adaptations What is Cardiac Rehabilitation(CR)? Medically supervised, structured, exercise-based program that has evolved to be an accepted therapy in the healthcare community. Includes exercise, education and counseling designed to reduce cardiovascular (CV) risk Goal of CR Secondary prevention program - reduce the risk of another cardiac event or to keep an already present heart condition from getting worse and to improve quality of life (not just prolong life). Primary prevention program –for a patient who has not had a previous cardiac event, to prevent the occurrence of a cardiac event if the individual is at risk due to his or her risk factor profile. Clinical Practice Guidelines (CR): Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention (The Canadian Association of Cardiovascular Prevention and Rehabilitation, CACPR) ACSM’s Guidelines (American College of Sports Medicine) Clinical Practice Guidelines (CR): Why important? Provide guidance in our practice Link scientific evidence with clinical practice recommendations Knowledge translation into clinical actions  CV Disease Care Continuum Has evolved over the years Bed rest is no longer recommended if you have serious heart problems CV Disease Care Continuum 1960’s – outcomes for patients with CVD were poor 1-month mortality (post-MI) ~30% 5-year mortality (post-MI) ~60% 2000’s – significant improvements in outcomes 1-year mortality (post-MI) ~5% (further reduction for those who attend CR) 5-year mortality (post-MI) ~10% CV Disease Care Continuum These positive patient outcomes have mandated the need to provide chronic cardiovascular disease care → CARDIAC REHABILITATION Seamlessly transitioning patients from acute care setting to chronic disease care environments (inpatient to outpatient) CR facilitates re-integration of patients back into primary care practices and community CR Benefits ↓ cardiac mortality 26% reduction in mortality for patients completing CR vs. standard care ↓ CVD morbidity through ↓ hospitalizations ↓ in need of invasive myocardial revascularizations procedures (PCI, CABG) cost effective by ↓ costs to health care system Cardiac Rehabilitation: Structure In-patient program (previously termed Phase 1) Out-patient program (previously termed Phase 2) In-patient Program Begins soon after a cardiac event (ie., post-MI, post-PCI, post-CABG) and finishes when the patient is ready to go home from the hospital Discharge Instructions: Education for the patient and family Diet – any dietary restrictions (ie., sodium, fluid restrictions) Physical activity and exercise progression details (ie., weightlifting restrictions) Medication In-patient Program (continuation) Risk factor management (blood pressure, cholesterol) When to seek medical care (when to call 911) symptoms Follow-up after hospital discharge Family physician Cardiologist/ Surgeon Other specialists? Referral to outpatient CR (automated) Out-patient Program Depending on cardiac event, can begin approximately 2 weeks after hospital discharge (CABG ~6-8 weeks) Program delivery can vary duration and frequency (program specific) Example: CR sessions 1 day per week for 12 weeks (2 days/week for 8-12 weeks) emphasizes monitored exercise and continued education on risk factor management Who benefits from cardiac rehabilitation? (indications for CR) Medically stable post MI Stable angina CABG PCI Stable CHF (cardiomyopathy) Heart transplantation Valvular heart disease/ surgery PVD At risk for CAD (dx with DM, dyslipidemia, HTN, obesity) Who are the cardiac rehabilitation staff? multidisciplinary team approach for risk factor/ lifestyle modification ◦Program Physician/ Nurse ◦Exercise Specialist/ Kinesiologist/ Physiotherapist ◦Dietitian ◦Social worker/ Psychologist/ Psychiatrist ◦Pharmacist ◦Cardiovascular Technologist ◦Family Physician, Cardiologist The most important member of the team is the patient  Empower patient to take control of their health and enable self- management of health behaviours: Learn about their heart condition Learn what they can do to help their heart (risk factor management) Follow the treatment plan – exercise prescription, a heart healthy diet, smoke-free lifestyle, etc. Report symptoms or problems promptly Getting started in a cardiac rehabilitation program Automated CR referrals as part of hospital discharge planning Patient can also be referred by Family Physician, Cardiologist Main Components of Cardiac Rehabilitation Four Main Components of Cardiac Rehabilitation Evaluation component Exercise-training component Lifestyle education component Psychosocial support component Evaluation component – Patient Assessment History and physical examination (HR, BP, body composition, co-morbidities/ medical limitations) Risk stratification (health status) Exercise stress testing (functional capacity) Risk factor assessment (blood work- cholesterol profile, blood sugars) Psychosocial assessment (assessment of depression, anxiety, social support, substance abuse) Evaluation component – Patient Assessment (continuation) Nutritional assessment Other pertinent information (physical limitations ie., musculoskeletal or balance difficulties, mobility aids) Based upon the patients' assessment, a plan is developed around their individual physical abilities and goal(s) while ensuring a safe and effective program delivery.  Exercise-training component Aerobic training Strength (Resistance) Training Flexibility Training CR helps to guide patient in providing safe and effective exercise prescription. Goal of improving cardiovascular fitness, strength and flexibility Lifestyle education component Focus on health behaviour interventions and risk factor modification Education classes may include: ◦ Nutritional counselling ◦ Lipid management ◦ Hypertension management ◦ Smoking cessation ◦ Weight management ◦ Diabetes/ Blood sugar management ◦ Medications (adherence to appropriate pharmacotherapy) ◦ Psychosocial management (Stress management) ◦ Physical activity counselling ◦ Symptom management (angina, heart attack) Lifestyle education component (continuation) Provide guidance and help patients learn/understand CV risk factors and ways to manage to reduce risk of future CV complications. CR team helps patients to recognize and change unhealthy habits with new, healthier habits. Psychosocial support component After a heart event, it is very common for patients to experience depression or anxiety, lose touch with their social support system, become dependent on unhealthy substances or have to stop working for several weeks. Assessment as part of evaluation Education and support (stress management) Referral – psychosocial support Goals of CR Maximize physical, psychological and social functioning to enable people with cardiac disease to lead fulfilling lives with confidence. Introduce and encourage behaviours that may minimize the risk of further cardiac events and conditions. Goals of CR (continued) Facilitate and shorten the period of recovery after an acute cardiac event. Promote strategies for achieving mutually agreed goals of ongoing prevention. Develop and maintain skills for long- term behaviour change and self- management. Knowledge is power: Benefits of CR Gives patients the confidence through knowledge Reduces the risk or reduces the reoccurrence of heart disease Increases the HDL cholesterol and lowers the LDL Moderates blood pressure Makes it easier to reach and maintain a healthy weight Helps to control diabetes Enhances self-image Improves quality of life Improves quality of sleep Relieves stress, anxiety, depression Cardiac rehabilitation can make a difference No one is too old or too young Women benefit as much from a cardiac rehabilitation program as men Barriers to Cardiac Rehab Well-established CR benefits but underutilized ~20% eligible patients participate Why are rates low? Barriers to Cardiac Rehab Needs/ health care Physician does not recommend Lack of knowledge Unaware of program & benefits Logistical Cost Transportation/ distance/ location Family/ support Work/ Time Work/ time/ travel Comorbidities Psychological risk factors (ie., depression, anxiety) Fear of exercising/ new event Lack of energy Overcoming Barriers How can Cardiac Rehab program be more accessible, adaptable, affordable? Societal change → shifting models of CR Overcoming Barriers Adaptations of program models to improve accessibility especially for underserved populations: Home-based exercise, program supervised Home-based exercise with web-based, program supervision Hybrid programs, both home and program-based exercise Overcoming Barrier - program delivery Overcoming Barrier - program delivery Goal of study: To explore the feasibility and user- experiences, associated with the first-year implementation of a preventative Learning Health System (LHS). Summary: Patients were evaluated following referral from primary and/or specialty care providers from the Halton and Greater Toronto Area between December 2020 and December 2021. The integration of a LHS into medical care was facilitated using a digital e-learning platform, and consisted of exercise, lifestyle, and disease-management counselling. Program cost covered using a physician fee-for–service payment model (OHIP). Overcoming Barrier - program delivery Results: 378 of 437 patients (86.5%) enrolled in the 6-month program Average age 61.2 +/-12.2 156 (41.3%) were females 140 (37%) with establish CAD Outcomes: Weekly MET-minutes increased by 191.1 (improvement in exercise) Participants reported significant improvements in perceived health status and health knowledge Overcoming Barrier - program delivery Conclusion: The implementation of an integrative preventative learning health system was feasible, with high patient engagement and favorable user-experiences. Further research is required to compare health outcomes against usual care.  References American College of Sports Medicine. (2018). ACSM’s guidelines for exercise testing and prescription (10th ed.). Lippincott Williams & Wilkins. Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention: Translating knowledge into action (3rd ed. ). (2009). Canadian Association of Cardiac Rehabilitation. Chindhy, S., Taub, P. R., Lavie, C. J., & Shen, J. (2020). Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers. Expert review of cardiovascular therapy, 18(11), 777–789. https://doi.org/10.1080/14779072.2020.1816464 Rosenfeld, A., Ball, J., Rattanasithy, S., Tsilas, C., Miller, R., Berardi, J., Pupulin, A., Carvalho, C., Segal, S., Kruger, S., Bajaj, R., & Alter, D. (2023). The implementation of a value-based learning health system for preventative care in Ontario, Canada. American journal of cardiovascular disease, 13(2), 87–100.