Cardiac Rehabilitation 2011 Update for Primary Care Providers心臟康復2011更新初級保健提供者

Cardiac

Rehabilitation

20111Update

for

Primary

CareProvidersDouglass

A

Morrison,

MD,

PhDCardiac

Rehabilitation,

Medical

DirectorYakima

Regional

and

Yakima

Valley

MemorialHospitalsRehabilitation2To

restore

to

good

health

or

useful

life,through

therapy

and

education.Changing

our

own

behavior,for

better

healthChanging

BehaviorResistances3Therapy:

connotation

of

‘mental

illness’

Rehabilitation:

connotation

of

‘substanceabuse’

Personal

Responsibility

is

much

more

difficthan

blaming

No

one

can

rehabilitate

another;

most

of

thework

is

done

by

the

patient,

for

himself..Active

versus

Passive4Second

Person

versus

First

PersonIt

is

easier

to

tell

others

how

they

should

chathan

tochange

ourselves:

empathyCardiac

Rehabilitation

2011Bill

of

Fare5What

is

cardiac

rehabilitation?What

is

the

difference

between

primary

and

secondary

prevention?

Is

there

good

clinical

evidence

which

supports

the

efficacy

of

cardiarehabilitation?SurvivalMyocardial

infarct

(MI)

reductionStroke

(CVA)

preventionAvoidance

of

subsequent

bypass

surgery

(CABG)Reduced

repeat

stenting

(PCI)Reducedfrequency

of

hospitalizationCardiac

Rehabilitation

2011Bill

of

Fare

(2)6Does

the

evidence,

which

supports

the

use

of

cardiac

rehabilitationapply:In

the

‘reperfusion-era’

of

post

MI

care?To

the

elderly

(Medicare

population)?Women?Care-givers,

themselves?5.

In

your

personal,

and

professional

experience,

is

behavior

change:Easy,

i.e.

a

‘slam-dunk’?Impossible,

and

therefore,

not

even

worth

discussingPossible,

but

requiring

sustained

effortDefinition

of

Cardiac

Rehabilitati7

A

multi-component

intervention,

which

isdesigned

to:

Optimize

a

cardiac

patient"s

physical,psychological

and

social

function,

and

Stabilize,

slow,

or

even

reverse

theunderlying

atherosclerosis;

thereby

Reducing

the

morbidity

and

mortality

ofcoronary

artery

disease

(CAD).Physical

Activity

and

the

Prevention

of

CoronaHeart

Disease8

Meta-analysis

of

43

studies

from

world

literature

ofphysical

activity

andCAD

up

to

1987Objective

assessments

of

individual

activity,andof

CH

Attempt

to

infer

causal

relationship

based

on

criteriaAB

Hill

and

RothmanSequence:

activity

precedes

incidence

of

CHDConsistency

across

studiesStrength

of

associationGraded

across

multiple

levels

of

activityPlausibilityCoherenceSupported

by

biological

studiesPowell

et

al;

Ann

Rev

Public

Health1987;8:253Diet,

Exercise,

and

Smoking

Modificationafter

acute

coronary

syndrome

(ACS)9

18,809

patients

from

OASIS

5

prospectiverandomized

trial,

conducted

in

41

countries.

Most

patient

were

compliant

withaspirin

(96statins

(79%);

ACE-I/beta

blockers

(72%).

29%

did

not

follow

diet

or

exercise;

1/3

ofsmokers

persisted;

42%

did

either

diet

orexercise;

30%

did

both

diet

and

exercise.

MI

risk

reduced

significantly

by

diet,

exercand

smoking

cessation.Circulation

2010;121:750-758Cardiac

Rehabilitation:Contemporary

Era

and

Elderly

Population

601,099

Medicare

beneficiaries,

who

werehospitalized

for

coronary

conditions

and/orrevascularization

(PCI

or

CABG).

1-

5

year

mortalities

examined

using

multiplstatistical

methods

Only

12%

used

cardiac

rehabilitation

servicethey

averaged

24

sessions.

Mortality

rates

were

21-34%

lower

amongusersof

cardiac

rehabilitationDose-response

noted:

more

is

better.10Performance

Measures

for

PrimaryPrevention11Risk

factor

screeningDietary

counselingPhysical

activity

counselingSmoking

assessmentSmoking

cessation

interventionWeight/adiposity

assessmentWeight

managementBlood

pressure

measurementBlood

pressure

controlLipid

measurementLipid

controlGlobal

risk

assessmentAspirin

useCirculation

2009;120:1296-1336.Core

Components

of

Cardiac

Rehabilitation/Secondary

Prevention12EvaluationPatient

assessmentNutritionalWeight

managementBlood

pressureLipidsDiabetesSmokingPsychosocialPhysical

ActivityExercise

trainingInterventionCardiac

Rehabilitation

2011:

Summary

(1)

Neither

coronary

bypass

graft

surgery(CABG),

nor

percutaneous

coronaryintervention

(PCI),

with

or

without

stentshave

been

shown,

in

stable

patients,

toprevent

heart

attacks.13Cardiac

Rehabilitation

2011:

Summary

(2)14

Lipid

lowering

(primarily

with

statin

drugs

such

asLipitor,

Crestor,

or

Zocor);Aspirin;Beta-blockers;

andACE-inhibition;

have

all

been

shown

to

reduce

the

risk

of

futuremyocardial

infarction

(MI),

among

post

MI

patientsand

patients

with

stable

coronary

disease.

Compliance

can

be

enhanced

with

the

educationalcomponent

of

cardiac

rehabilitation.Cardiac

Rehabilitation

2011:

Summary

(3)15

Diet,

exercise,

and

smoking

cessation

have

beenshown

to

reduce

the

risk

of

subsequent

heart

attack.

Cardiac

rehabilitation,

in

a

large,

Medicare

studyhas

been

sown

to

be

associated

with

reducedlikelihood

of

heart

attack.

Getting

p