Evidence for Cardiovascular Prevention & Rehabilitation

• Modern day definition of cardiovascular prevention and rehabilitation:

  • the coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease
• Guideline & Policy Documents

  • BACPR
  • ACPICR
• Types of patients who attend cardiovascular prevention & rehabilitation programmes

  • acute coronary syndrome
  • NSTEMI
  • STEMI
  • unstable
  • angina
  • awaiting or post revascularisation (PCI or CABG)
  • stable heart failure
  • post ICD or CRT insertion
  • stable angina
  • post valve surgery
  • post heart transplantation
  • post LVAD
  • CVA/TIA
  • PVD
  • high multi-factorial risk
• Goals of cardiovascular prevention & rehabilitation:

  • dependent on the patient
  • enable the patient to regain full physical, psychological and social status
  • promote secondary prevention to optimise long term prognosis
• Core components of cardiovascular prevention & rehabilitation

  • patient assessment
  • management and control of cardiovascular medical risk factors
  • physical activity counselling, prescription of exercise training
  • dietary advice
  • tobacco counselling
  • patient education
  • psychosocial management
  • vocational support
• Members of the cardiovascular rehabilitation team

  • multi-professional:
  • overall coordinator
  • interdisciplinary working
  • multitasking/skill extension
  • rehabilitation services should be available from people trained in:
  • cardiology (cardiologist/physician, cardiac specialist nurse, pharmacist)
  • physiotherapist, clinical exercise physiologist exercise/physical activity specialist
  • dietitian
  • occupational therapist
  • smoking cessation councillor
  • psychologist/councillor
• The role of the team:

  • prevention & rehabilitation is a long term process therefore all team members have a role to play in:
  • facilitating adjustment to the event
  • identifying areas requiring action/change
  • motivating behaviour change if necessary
  • helping patients adjust to changes in lifestyle over a period of time
  • reducing negativity, encouraging positive attitudes
  • empowering patients and families to adapt to altered health status
• BACPR pathway for cardiovascular prevention & rehabilitation:

  1. identify and refer patient
  2. manage referral and recruit patient
  3. assess patient
  4. develop patient care plan
  5. deliver comprehensive cardiac rehabilitation programme
  6. conduct final cardiac rehabilitation assessment
  7. discharge and transition to long term management
  8. patient discharge
• Class of Evidence:

  
• Level of Evidence:

  • Class 1 evidence is based on different levels of evidence

  
• Level of evidence:

  • participation in a medically supervised, structured, comprehensive, multidisciplinary EBCR and prevention programme for patients after ASCVD events and/or revascularisation, and for patients with heart failure (mainly HFrEF), is recommended to improve patient outcomes
  • this recommendation is based off of class 1 and level A evidence

  
• Evidence for Cardiac Prevention Rehabilitation Programmes:

  • over 30 years worth of evidence
• Early rehab through to the modern era

  • the first meta-analysis by Oldridge et al 1988 and O'Connor et al 1989 (10 to 12 RCTs, > 4300 participants) demonstrated that exercise based cardiac rehab leads to 20 to 25% reduction in all cause and CVD mortality compared to standard care
  • this led to the first Cochrane review by Jolliffe et al (2001), followed by Taylor et al (2004) and Heran et al (2011)
  • all of these reviews demonstrated that exercise based cardiac rehab led to 13 to 27% reduction in all cause and 26 to 36% CVD mortality compared to standard care
  • limitation: randomised controlled trials included fewer women, fewer elderly and fewer high risk groups
• Early rehab through to the modern era continued

  • in another Cochrane review by Anderson et al (2016) including 63 studies, n = 14 486 participants, pts completing an exercise based CPER programme led to an absolute risk reduction in CVD mortality from 10.4% to 7.6% and hospitalisation from 30.7% to 26.1% when compared to usual care
• In summary - minimal requirements for successful cardiovascular prevention/rehab

  • intervention:
  • supervised multicomponent
  • start:
  • within 3 months after discharge
  • setting:
  • any (inpatient/outpatient/community based/home based/ mixed/tele-rehabilitation)
  • exercise component:
  • frequency: more than/equal to 2 times/week
  • duration: more than 3 months
  • more than/equal to 36 sessions
  • intensity: 40 to (60%) 70% HRR max
  • more than 1000 units (no, of exercise weeks x average no. of session/week x average duration of session in minutes)
  • other components:
  • at least once a week: information, motivational techniques, education, psychological support and interventions, social and vocational support
  • management of 6 or more risk factors: smoking cessation, physical exercise training, counselling for exercise/activity, diet, blood pressure, cholesterol, glucose levels, checking medication, stress management
• The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial identified four key risk factors strongly linked to long-term survival in patients with stable coronary artery disease (CAD). These risk factors were:

  1. Smoking – Continued tobacco use significantly increased mortality risk.
  2. Diabetes – Patients with diabetes had worse long-term survival compared to non-diabetics.
  3. Heart Failure (Left Ventricular Dysfunction) – Reduced ejection fraction (a sign of weakened heart pumping ability) was a strong predictor of poor outcomes.
  4. Extent of Coronary Artery Disease – More severe blockages and multi-vessel disease were associated with higher mortality risk.