Cardiac Rehabilitation for Heart Failure Patients

Pam R. Taub MD, FACCDirector of Step Family Cardiac Wellness and Rehabilitation Center

Associate Professor of MedicineUC San Diego Health

Overview of Talk• The current state of cardiac rehabilitation

• Review of patients eligible for cardiac rehabilitation• Outcome data supporting the use of cardiac rehabilitation• Intensive versus traditional cardiac rehabilitation

• Future directions in cardiac rehabilitation• Our program at UCSD

Fruits and vegetables

Creatine

Low inflammation diet

Whole grain

10,000 steps

Low fat diet

Atkins diet

Vegan diet

Organic food

Juice fasting

Branched Chain Amino acids

Aerobic exerciseDon’t skip breakfast

Watch your diet Breathing Exercise

Exercise

Coenzyme Q

Chinese medicinesMindfulness

Intermittent fasting

Low CholesterolOlive oil

Vitamins

Nicotinamide riboside

Moderate coffee

MeditationAnti-oxidant

Fasting mimicking diet

Chocolate

Low carb diet

Low dose aspirin

Drink warm water

Drink waterDrink milk

SleepNo sugar

Never go hungry diet

Electrolytes

Moderate alcohol

Metformin

Probiotic

Resveratrol

Strength training

Stress reduction

Regular health check up

Nicotinamide

Fiber

Take a napVitamin D

Red wine

FishNo Smoking

Short chain fatty acids

Green tea

Ayurvedic medicines

Low sodiumMediterranean diet

Caloric restriction

Melatonin

Happiness

Protein

5:2 DietYoga

Calcium

Omega-3

Detox

Stretching

Nuts

EffectofLifestyleInterventions

Overview of Cardiac Rehabilitation Programs

Currently Covered Indications for Cardiac Rehabilitation

§ Heart attack§ Coronary artery bypass grafting (CABG)§ Chronic stable angina§ Cardiac transplantation§ Heart valve repair or replacement§ Stable, chronic heart failure (EF<35%)§ Peripheral Arterial Disease

Outcomes Associated with Cardiac Rehabilitation§ Meta-analysis of 34 randomized controlled trials

showed that exercise-based CR programs are associated with:• A lower risk of reinfarction (OR 0.53; 95% CI: 0.38 to 0.76)• Decreased cardiac mortality (OR 0.64; 95% CI: 0.46 to 0.88)• Decreased all-cause mortality (OR 0.74; 95% CI: 0.58 to 0.95)

• CR reduces 90 day hospital readmission rate after acute MI or PCI

§ Class IA recommendation by AHA/ACC Guidelines

Am J Med 2004;116:682–92.

Barriers to Utilization of Cardiac Rehabilitation

§ Fewer than 20% of all eligible patients participate in a CR § Of those who are referred to CR, only 34% actually enroll

§ Factors contributing to poor utilization1) Lack of a centralized method for referral

2) Inadequate communication among treatment teams, patients, and CR facilities

3) Unfamiliarity with CR among potential referring physicians

4) Limited access, and perceived inconvenience for the patient (e.g. copays)

Mazzini MJ et al n. Am J Cardiol. 2008;101(8):1084-7.

Automatic Referrals to CR via Electronic Medical Record

Intensive Cardiac Rehab: Ornish Versus PritikinOrnish Pritikin

Total Number of Sessions covered 72 (max per day is 6 sessions) over 18 weeks

72 sessions (divided into 18 sessions that are 4 hours each)

72 sessions(can customize how many sessions per day)

Diet 100% plant based Allows for lean meat and fish

Format All with live instructors:1 hour of exercise1 hour of nutrition counseling1 hour of yoga and1 hour of group therapyPatients are in groups of 10-12 and stay with the same cohort throughout the program

Some parts are Video Instruction.Sessions duration can be customized over 18 weeks

Outcome Data The Lifestyle Heart Trial showed significant regression of coronary atherosclerosis measured by angiography in the experimental group randomly assigned to intensive lifestylechanges.(5 year results reported by Ornish JAMA 1998)

Data from Pritikin residential treatment centers showed improvement in lipids, A1c, blood pressure and weight. (Barnard Am J Cardiol 1992)

Improvement after only 9 weeks of ICR at UCLA Case Study of a Patient from UCLA- Enrolled in ICR

New Paradigm For Cardiac Rehabilitation

§ “Living Lab” for research and secondary prevention§ Ideal population to deploy new technologies to prevent

readmission § Good outcome trials needed

§ Using devices/wearables to expand the length and scope of cardiac rehabilitation

Mayo Clinic Study (Apps + Cardiac Rehab )• 44 patients

• 25 in the app +cardiac rehab arm• 19 in cardiac rehabilitation without the app arm

• The app tracked and monitored patient weight, BP, blood sugar and physical activity and provided educational content

• The app group had 40% less readmissions and lower blood pressure and weight

Date of download: 4/28/2016 Copyright © The American College of Cardiology. All rights reserved.

From: THE AUGMENTATION OF USUAL CARDIAC REHABILITATION WITH AN ONLINE AND SMARTPHONE-BASED PROGRAM IMPROVES CARDIOVASCULAR RISK FACTORS AND REDUCES REHOSPITALIZATIONS

J Am Coll Cardiol. 2014;63(12_S). doi:10.1016/S0735-1097(14) 61296-1

New Approaches to Cardiac Rehab

Landscape Site Plan

27

Patient Outcomes with Intensive Cardiac Rehabilitaiton

Baseline PostHemoglobin A1c:Goal: < 5 – 7

5.1 4.9

CRP: Goal: < 0.5

0.3 0.3

Total Cholesterol: 144 126LDL:Goal: < 70

55 47

HDL:Goal: > 40

70 61

Triglycerides: Goal: < 150

96 88

Cholesterol/HDL Ratio: 2.06 2.07Visceral Fat:Goal: < 10

10 9

Body Fat: 39.3 37.3Waist Circumference:Goal: <40 Men <35 Women

39 33

METS:Goal: 2 MET increase from baseline

4.5 6.5

Weight: 155.6 142.8Muscle Mass %: 57.6 59.5

Conclusions§ New era in cardiac rehabilitation ushered in by change in

focus and reimbursement of our health care system§ Appropriate use of cardiac rehabilitation can lead to

improved outcomes§ Many digital health devices/apps but need good outcome

data

Heart Disease is Preventable