Heart Failure patient and

Cardiac Rehabilitation

Sonia CORONE s.corone@chbligny.fr

Monaco nov 2016

Jean LE, 64 year-old builder retired 88kg, 1.66m, BMI 32

Medical History Hypertension since 1991 Diabetic since1998 Nocturnal sleep apnea . Device since 2002 Renal failure 47ml/min/kg Dilated cardio myopathy since 2008, LV EF 40% Alcohol consumption Coronary angiography sub-normal Permanent atrial fibrillation

Monaco nov 2016

Jean LE, 64 year-old builder retired

Global cardiac decompensation : short of breath and lower limb

edema, no chest pain LV EF decline from 40% to 28%

o Coronary angiography Left coronary artery : no lesion Mid RCA : 70% obstruction > angioplasty and drug-

eluting stent

8 days later o weight loss : 8 kg with diuretics o asymptomatic at rest o discharged home with a prescription

Monaco nov 2016

Jean LE, 64 year-old builder retired

Prescription = 15 medications and 25 pills per day

Aspirin , Clopidogrel, Apixaban, Furosemide 120mg, Diffu K Bisoprolol 3.75 mg, Ramipril 1.25 mg, Atorvastatine 10mg Repaglinide, Sitagliptine, Metformine Levothyrox, alopurinol, Hydroxyzine (atarax), Esoméprazole

And then, what ….?

Monaco nov 2016

Re hospitalized 20 days later for congestive heart failure

Monaco nov 2016

Re hospitalized 20 days later for congestive heart failure

So what….?

Monaco nov 2016

Monaco nov 2016

328 : 189-92

Cardiac rehabilitation : meta-analyse

Mortality - 35%

Piepoli, BMJ 2004; 328 : 189-92

Monaco nov 2016

801 patients, EF 28%; Training 30 Wk, follow up 23 months

J0 J 725

Rehabilitation? Why?

1. Optimization of medication prescription (Bisoprolol 3,75mg, Ramipril 1,25mg, furosemide 120mg)

Therapeutic education. To improve adherence. Salt/diuretic…. Chronic Disease

2. Exercice Training individualy tailored, daily, with encouragements. To Improve maximum exercise capacity. To decrease waist size.

And motivate to maintain…

Monaco nov 2016

1- Medication adherence

and dose optimization .

Observance médicamenteuse et optimisation des doses

Monaco nov 2016

Medication adherence at one year after hospitalization for acute coronary event

Rehab No Rehab

Monaco nov 2016

Therapeutic education integrated in medical care

Physician trained in education Health care

provider Nurse

patient

ACTOR Understand adherence

adapts instructions

SPECTATOR listen

obey or not obey try to follow instructions

Monaco nov 2016

Monaco nov 2016

Furosemide and Salt

If you plane to have a good meal with friends at restaurant, what do you do with your Lasilix (furosemide)? I don’t take the pill to avoid to go piss I take it, like every day I take double dose the day after

Monaco nov 2016

2- Physical training

Monaco nov 2016

Monaco nov 2016

Poumon Muscles Coeur

Incapacity of the heart to ensure suffisant cardiac output for organism needs

"Incapacité du cœur à assurer un débit sanguin suffisant pour les besoins de l'organisme"

Circ

ulat

ion

Circ

ulat

ion

Monaco nov 2016

Poumon Muscles •Amyotrophy •Decrease of skeletal muscle performances •Decrease of mitochondria

Coeur

Tachycardia

•Peripheral vasoconstriction • decrease of vasodilatation capacity by endothelial dysfunction

Circ

ulat

ion

Circ

ulat

ion

Monaco nov 2016

• congestion • hyperventilation • bronchial hyper activity •Mismatch of Ventilation-perfusion

Poumon Muscles •Amyotrophy •Decrease of skeletal muscle performances •Decrease of mitochondria

Coeur

Tachycardia

•Peripheral vasoconstriction • decrease of vasodilatation capacity by endothelial dysfunction

Circ

ulat

ion

Circ

ulat

ion

these limiting changes become autonomous…..

Monaco nov 2016

• congestion • hyperventilation • bronchial hyper activity •Mismatch of Ventilation-perfusion

Pysical exercise is active on peripheral factors

Poumon Muscles

•Amyotrophy •Decrease of muscles performances •Decrease of mitochondria

• congestion • hyperventilation • bronchial hyper activity •Mismatch of Ventilation-perfusion

Tachycardia

•Peripheral vasoconstriction • Decrease of vasodilatation capacity by endothélial dysfonction

Monaco nov 2016

mai 2008

Increase of mitochondrial

activity

Heart failure patient muscle

Improvement of oxygen utilization in muscles with physical training

Hambrecht, JACC;1995

After training Monaco nov 2016

Restoration of vasodilatation endothelium dependant

Hornig, Circulation;1996

4 weeks Handgrip

Diamètre artère radiale

après hyperhémie

19 patients FE 20% Effet local

Monaco nov 2016

Improvement of oxygen utilization in peripheral : a-vO2 difference

Sullivan,Circulation;1988

Différence AV en O2 membres inf

After training

Monaco nov 2016

Reduction of the excessive ventilatory response to exercise

Coats. Circulation;1992

p< 0,05

After training

Ventilation /mn

Avant

11pts, FE 19%

Monaco nov 2016

Individually tailored exercise training

Baseline assessment of patient fitness Evaluation de la capacité d’effort

Monaco nov 2016

Jean LE, 64 year-old builder retired 88kg, 1,66m, BMI 32

PeakVO2 13 ml mn kg

Maximum load 90W

Monaco nov 2016

standard ?

25-34 >64ans 35-44

Monaco nov 2016

Ventilatory threshold : VT1

What is his endurance capacity?

he is comfortable with his breathing under this level of effort

Monaco nov 2016

Jean LE, 64 year-old builder retired

Peak VO2 13 ml mn kg

Maximum load 90W

90

Monaco nov 2016

VE ventilation

VT 1= 60W

Monaco nov 2016

Monaco nov 2016

Monaco nov 2016

Physical exercice is a validated therapy

Monaco nov 2016

SV1 75W

SV1 60W

Max load +45W, +6 pts of VO2 Ventilatory treshold + 15W

18 gym sessions / cycle /muscu 5 outside walk

Tai Chi, Blowpipe sessions

Pic VO2 19 ml mn kg

Pic VO2 13 ml mn kg

Monaco nov 2016

Lack of relationship between Peak VO2 and resting ejection fraction

Monaco nov 2016

Modalities of training?

Monaco nov 2016

Endurance training

« continuous»

échauffement récupération échauffement

interval récupération

Monaco nov 2016

Greater improvement with interval training compare

to continuous U Wisloff. Circu 2007;115

Norway, 27 patients, 76 y, EF 29%

Continu

Interval speedwalk; 3’/4’; 50%/90%

VO2 max + 46%

VO2 max +14%

Monaco nov 2016

Respiratory muscle training Blowpipe. Sarbacane

Simple activity and fun Work on concentration ++

Monaco nov 2016

And maintain… the dose…

Monaco nov 2016

Exercise dose maintained ….

0

20

40

60

80

100

120

140

160

180

200

1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 25-36Study Months

Med

ian

(25t

h, 7

5th)

Exe

rcis

e Ti

me

(min

/wk)

In center

At home

Moyenne : 50 min

2331 pts, 59 ans FE VG 25%

min /sem

O'Connor. HF Action JAMA. 2009;301

Monaco nov 2016

Monaco nov 2016

6 METS-hr per Week =

2h of brisk walking, speed 5.5 km/h,

each week

Monaco nov 2016

1 METS-hr per Week =

30’ of walk

Hope…

Mobile applications Tracking devices

Telephonic coaching

Recall session Telemedecine with connected bicycle at home : READ , A Belin in

normandy. : positive results Family members and social support

Monaco nov 2016

Loi de santé. janvier 2016

How to motivate ? How to promote ?

Comment motiver ?

Monaco nov 2016

Be convinced and engaged Être soi-même convaincu et engagé

Monaco nov 2016

POMS = Profil of mood state questionary

Jean LE

Monaco nov 2016

The right activity and right dose for ?

Monaco nov 2016