![Exercise-based
Rehab
• 2016 meta-analysis of 63 trials
• 14,486 patients
• A lower risk of cardiovascular death (relative risk [RR]
0.74, 95% CI 0.64-0.86)
• A lower risk of hospital admission (RR 0.82, 95% CI
0.70-0.96).
• There was no significant effect on rates of all-cause
death, MI, or revascularization.
Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac
rehabilitation. J Am Coll Cardiol 2016; 67.](https://image.slidesharecdn.com/cardiacrehabilitationpastandpresent-160304044458/85/Cardiac-rehabilitation-past-and-present-12-320.jpg)
![Program Completion
• The patients who completed cardiac
rehabilitation, compared to the combination
of non-completers and non-enrollers, had a
lower risk of death (adjusted hazard ratio [HR]
0.59, 95% CI 0.49-0.84) and all-cause
hospitalization .
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac
rehabilitation and long-term risks of death and myocardial infarction among elderly
Medicare beneficiaries. Circulation 2010; 121:63.](https://image.slidesharecdn.com/cardiacrehabilitationpastandpresent-160304044458/85/Cardiac-rehabilitation-past-and-present-23-320.jpg)
Cardiac rehabilitation past and present
- 1. Cardiac Rehabilitation Past & Present Pishgahi A.MD, Assistant Professor of PMR, Tabriz Medical Science University
- 2. Definition
- 3. History
- 4. History
- 5. History • Mobility restriction was imposed on patients with acute coronary events • In the 1930s, patients with acute coronary events were advised to observe 6 weeks of bed rest • Chair therapy was introduced in the 1940s • In the early 1950s, a very short daily walk of 3 to 5 minutes was allowed 4 weeks after the coronary events
- 6. History Morris JN, Heady JA. Mortality in relation to the physical activity of work: a preliminary note on experience in middle age. Br J Ind Med 1953;10:245-54.
- 7. Billion Dollar Heart Attack
- 10. Phases
- 11. Indications Kwan G, Balady GJ. Cardiac rehabilitation 2012: advancing the field through emerging science. Circulation 2012; 125:e369.
- 12. Exercise-based Rehab • 2016 meta-analysis of 63 trials • 14,486 patients • A lower risk of cardiovascular death (relative risk [RR] 0.74, 95% CI 0.64-0.86) • A lower risk of hospital admission (RR 0.82, 95% CI 0.70-0.96). • There was no significant effect on rates of all-cause death, MI, or revascularization. Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation. J Am Coll Cardiol 2016; 67.
- 13. Stable Angina • men age ≤70 with class I to III angina and angiographic evidence of coronary disease • training program (20 minutes of bicycle ergometry per day) or PCI with stenting • At one year, survival free of cardiac events (cardiac death, cardiac arrest, MI, stroke, revascularization, or hospitalization for worsening angina) was significantly higher with exercise training (88 versus 70 percent). Hambrecht R, Walther C, Möbius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004; 109:1371
- 14. Post-PCI • study of over 600,000 older Medicare patients with coronary artery disease • who had undergone PCI • significantly lower one- to five-year mortality rates (approximately 30 percent) in users of cardiac rehabilitation compared with non- users. Suaya JA, Stason WB, Ades PA, et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol 2009; 54:25.
- 15. Post-CABG • community-based analysis of 846 individuals • who underwent CABG between 1996 and 2007 • those who participated in a cardiac rehabilitation program (compared to those who had not) had a lower incidence of all- cause mortality (adjusted) at 10 years (23.0 versus 35.7 percent; adjusted hazard ratio 0.54, 95% CI 0.40-0.74) Pack QR, Goel K, Lahr BD, et al. Participation in cardiac rehabilitation and survival after coronary artery bypass graft surgery: a community-based study. Circulation 2013; 128:590.
- 16. Heart Transplantation • Although data are limited, cardiac rehabilitation may provide benefit both early and later after transplant. Long-term improvement is limited, which may be due to the effects of aging, cardiac denervation, transplant therapy, and prior heart failure. • Post-transplantation rehabilitation should begin in the immediate post-operative period if possible and should continue and progress as the patient’s condition allows. Ileana L Piña, Rehabilitation after cardiac transplantation, UpToDate, May 21, 2014.
- 17. Mechanism • Lipid profile improvement • Blood pressure reduction • Treat and prevent DM2 • Smoking cessation • Normalize body weight Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post- myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J 2011; 162:571.
- 18. Mechanism • Reduction in inflammation • Decrease C-reactive protein concentration • Ischemic preconditioning • Improved endothelial function • Fibrinolytic balance Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol 2004; 43:1056.
- 19. Post-MI mechanism • Improve left LV function • Attenuate remodeling • Exercise in Left Ventricular Dysfunction (ELVD) trial • efficacy of exercise was evaluated in patients with a first Q wave MI and a left ventricular ejection fraction below 40 percent • A six-month exercise training program increased both exercise capacity and the left ventricular ejection fraction (from 34 to 38 percent) Giannuzzi P, Temporelli PL, Corrà U, et al. Attenuation of unfavorable remodeling by exercise training in postinfarction patients with left ventricular dysfunction: results of the Exercise in Left Ventricular Dysfunction (ELVD) trial. Circulation 1997; 96:1790.
- 20. Post-MI mechanism • a 2011 systematic review • beneficial effect of exercise training on left ventricular remodeling • The greatest benefit occurred when training started earlier following MI (from one week) and lasted longer than three months Haykowsky M, Scott J, Esch B, et al. A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling. Trials 2011; 12:92.
- 21. Psychosocial interventions • ENRICHD trial • psychosocial interventions in 2481 patients after MI • patients receiving psychosocial intervention had less depression and better levels of perceived social support, but there was no reduction in mortality Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003; 289:3106.
- 22. Program Completion • prospective cohort study of 5886 patients following coronary angiography • subsequently referred for cardiac rehabilitation between 1996 and 2009 • 2432 did not start, 554 started but did not complete, and 2900 completed a program • The median length of follow-up was 5.4 years and • the median time to enrollment (among those who participated) was 84 days
- 23. Program Completion • The patients who completed cardiac rehabilitation, compared to the combination of non-completers and non-enrollers, had a lower risk of death (adjusted hazard ratio [HR] 0.59, 95% CI 0.49-0.84) and all-cause hospitalization . Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63.
- 24. Program Completion • patients who attended 36 sessions had a 22 percent lower risk of death than those who completed 12 sessions (HR, 0.78; 95% CI, 0.71 to 0.87). Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63.
- 25. Long-term Impact • In ELMI, 322 patients • usual care or ongoing intervention • At four years, the Framingham risk score, total and low density lipoprotein-cholesterols were significantly lower compared to baseline in the intervention group • The blood pressure fell significantly in the intervention group and rose in the usual care group. Lear SA, Spinelli JJ, Linden W, et al. The Extensive Lifestyle Management Intervention (ELMI) after cardiac rehabilitation: a 4-year randomized controlled trial. Am Heart J 2006; 152:333.
- 26. Safety • The 2007 American Heart Association scientific statement on exercise and acute cardiovascular events estimated that The risk of any major cardiovascular complication (cardiac arrest, death, or MI) is one event in 60,000 to 80,000 hours of supervised exercise 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.
- 27. Utilization Rate Despite the benefits of cardiac rehabilitation described below, only 10 to 20 percent of eligible patients following myocardial infarction participate in formal structured cardiac rehabilitation in the United States and the United Kingdom
- 28. Barriers