exercise training and cardiac rehabilitation › dtmhf_support › taub_2.pdfpatient outcomes with...

Exercise Training and Cardiac

Rehabilitation

Pam R. Taub MD, FACC

Founder and Director of Step Family Cardiac Wellness

and Rehabilitation Center

Associate Professor of Medicine

UC San Diego Health

Disclosures

No conflict of interest related to topics discussed in this talk

Overview of Talk

• Review of current state of cardiac rehabilitation

• New paradigms in Cardiac Rehabilitation

• Overview of our program at UCSD

• Review of Outcomes at UCSD Cardiac Rehabilitation Program

Overview of Cardiac Rehabilitation Programs

72 sessions over 9 weeks

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

Depression & Psychosocial Stress Post MI

• Major depression occurs in 20% patients post MI; depressive symptoms in 33%

• Associated with poor compliance

• Increased adverse outcomes and higher cardiac mortality

• Increased risk of suicide

• Several nonrandomized studies have shown a benefit with stress reduction and enhanced social support post-MI

• Cardiac rehabilitation (which includes stress management and group therapy) is an important tool in treating depression after MI

.

Lecture: Coronary Artery Disease: Acute Coronary Syndromes & Post MI Depression

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 re-infarction (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.

Lifestyle Heart Trial

% Diameter Stenosis: Quantitative Coronary Arteriography

Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001.

Case study of a patient from enrolled in Intensive Cardiac Rehabilitation Program

New Approaches to Cardiac Rehab

17

Assessment of Visceral Fat

Patient Outcomes with Intensive Cardiac RehabilitationBaseline Post

Hemoglobin A1c:

Goal: < 5 – 75.1 4.9

CRP:

Goal: < 0.5 0.3 0.3

Total Cholesterol: 144 126

LDL:

Goal: < 70 55 47

HDL:

Goal: > 40 70 73

Triglycerides:

Goal: < 15096 88

Cholesterol/HDL Ratio: 2.06 2.07

Visceral Fat:

Goal: < 1010 8

Body Fat: 39.3 37.3

Waist Circumference:

Goal: <40 Men

<35 Women

39 32

METS:

Goal: 2 MET increase from

baseline

4.5 9

Weight: 155.6 142.8

Muscle Mass %: 57.6 59.5

OBJECTIVES

• To evaluate the effectiveness of intensive cardiac rehabilitation

(ICR) for improving clinical outcomes and biomarkers

• To compare the effectiveness of TCR and ICR programs for

improving clinical outcomes and biomarkers

• To evaluate the effectiveness of traditional cardiac rehabilitation

(TCR) for improving clinical outcomes and biomarkers

METHODS

• Retrospective review of numerous biomarkers data pre- and post- participation in CR

programs in the hospital databases

• Retrospective review of longitudinal clinical outcome data (including major adverse

cardiac events, MACE) in the long-term follow-up in the hospital databases

• Inclusion criteria for the analysis: patients who participated in the CR program and

have data available to review

• Comparative analysis of clinical outcomes and biomarkers between the groups of

patients participating in the TCR and ICR programs

• Paired t-test was used for testing equality of means of continuous parameters within

the ICR and TCR groups. Repeated Measure Analysis of Variance (RM-ANOVA) was

used for testing differences between the groups. Demographic and clinical parameters

were tested with analysis of variance (ANOVA) for continuous variables and chi-

square analysis for dichotomous variables.

RESULTS

• 101 patients were enrolled in the intensive cardiac rehabilitation (ICR)

program

• Treatment adherence: 66.3% of sessions attended in the TCR

program and 95.8% of sessions in the ICR program

• 216 patients were enrolled in the traditional cardiac rehabilitation

(TCR) program

• Mean long-term follow-up: 6.7 months in the TCR program and 7.8

months in the ICR program (p = 0.023)

• Enrollment in the study: in total 317 patients

RESULTS

DEMOGRAPHIC CHARACTERISTICS

Variable ICR TCR p value

Age (years) 66.0 65.6 ns

Gender: male (%) 68 73 ns

Gender: female (%) 32 27 ns

Race: white (%) 76 72 ns

Post-menopausal females (%) 100 90 ns

ns - difference between the groups is not significant

Weight

Difference within the groups Difference between the groups

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*

*difference is statistically significant

initial

discharge

initial

dischargeW

eig

ht

ch

an

ge

[

kg

]

-3

-2

-1

0

ICR TCR

*


discharge - initial discharge - initial

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p < 0.001

p < 0.001

Body mass index (BMI)


BM

I [

kg m

-2 ]

27.0

27.2

27.4

27.6

27.8

28.0

28.2

28.4

ICR TCR

*


initial

discharge

initial

dischargeB

MI

ch

an

ge

[

kg

m-2

]

-1.2

-1.0

-0.8

-0.6

-0.4

-0.2

0.0

0.2

ICR TCR

*



Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p < 0.001

p < 0.001

Body fat


Body fat

[ %

]

29.0

29.5

30.0

30.5

31.0

31.5

32.0

ICR TCR

*


initial

discharge

initial

discharge

*

Bo

dy f

at

ch

ang

e

[ %

]

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

0.5

ICR TCR

*



Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p < 0.001 p = 0.002

p = 0.046

Visceral fat


Vis

cera

l fa

t [

% ]

10.0

10.5

11.0

11.5

12.0

12.5

13.0

ICR TCR

*


initial

discharge

initial

discharge

*

Vis

cera

l fa

t change [ %

]

-2.0

-1.5

-1.0

-0.5

0.0

0.5

ICR TCR


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p = 0.001

p < 0.001

Waist circumference


Wa

ist

[ c

m ]

95

96

97

98

99

100

101

ICR TCR

*


initial

discharge

initial

discharge

*

Wa

ist

ch

an

ge

[

cm

]

-3

-2

-1

0

ICR TCR

*



Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p < 0.001

p = 0.002

p = 0.002

RESULTS - SUMMARY

• TCR program resulted in improvements of body fat, visceral fat,

and waist circumference

• ICR program resulted in improvements of weight, BMI, body fat,

visceral fat, and waist circumference

• Compared with TCR, the ICR program resulted in more significant

improvements of weight, BMI, body fat, and waist circumference

METABOLIC BIOMARKERS

Metabolic equivalents (METS)


ME

TS

[

mLO

2 k

g-1

min

-1 ]

3

4

5

6

7

ICR TCR

*


initial

discharge

initial

discharge

*

ME

TS

ch

an

ge

[

mLO

2 k

g-1

min

-1 ]

0.0

0.5

1.0

1.5

2.0

2.5

ICR TCR


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



p < 0.001

p < 0.001

Systolic blood pressure (SBP)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



SB

P

[ m

m H

g ]

114

116

118

120

122

124

ICR TCR

*


initial

discharge

initial

dischargeS

BP

ch

an

ge

[

mm

Hg ]

-6

-5

-4

-3

-2

-1

0

ICR TCR


p = 0.001

Diastolic blood pressure (DBP)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



DB

P c

hange [ m

m H

g ]

-8

-6

-4

-2

0

ICR TCR

*



SB

P [

mm

Hg ]

60

62

64

66

68

70

72

ICR TCR

*


initial

discharge

initial

discharge

p < 0.001

p < 0.001

Heart rate (HR)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

dischargeW

eig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



HR

[

bpm

]

66

68

70

72

74

76

ICR TCR

*

difference is statistically significant

initial

discharge

initial

dischargeH

R c

ha

ng

e

[ b

pm

]

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

ICR TCR

*

difference is statistically significant


p = 0.007

p = 0.05

RESULTS - SUMMARY

• TCR program resulted in improvement of METS

• ICR program resulted in improvements of METS, SBP, and DBP


improvements of DBP and HR

HEMODYNAMIC PARAMETERS

Low-density lipoprotein cholesterol (LDL-C)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*


discharge - initial discharge - initialL

DL

-C c

han

ge

[

mg

dL

-1 ]

-10

-8

-6

-4

-2

0

ICR TCR


LD

L-C

[

mg d

L-1

]

60

65

70

75

80

ICR TCR

*


initial

discharge

initial

discharge

p = 0.006

Non-high-density lipoprotein cholesterol (Non-HDL-C)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*


discharge - initial discharge - initialN

on

-HD

L-C

ch

an

ge

[

mg d

L-1

]

-14

-12

-10

-8

-6

-4

-2

0

ICR TCR


No

n-H

DL

-C

[ m

g d

L-1

]

80

85

90

95

100

105

110

ICR TCR

*


initial

discharge

initial

discharge

p = 0.001

Triglycerides (TG)


Weig

ht [

kg ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

We

ight

[ k

g ]

80

81

82

83

84

85

ICR TCR

*


initial

discharge

initial

discharge

Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



Weig

ht change [ kg ]

-3

-2

-1

0

ICR TCR

*



TG

[

mg

dL

-1 ]

110

115

120

125

130

135

ICR TCR

initial

discharge

initial

dischargeT

G c

han

ge

[

mg d

L-1

]

-10

-8

-6

-4

-2

0

ICR TCR


RESULTS

CLINICAL OUTCOMES IN LONG-TERM FOLLOW-UP

MACE ICR TCR p value

Death n (%) 1 (1) 6 (2.8) ns

Cardiovascular death n (%) 1 (1) 3 (1.4) ns

Non-fatal myocardial infarction n (%) 1 (1) 3 (1.4) ns

Hospitalization for unstable angina n (%) 3 (3) 3 (1.4) ns

PCI n (%) 2 (2) 2 (0.9) ns

CABG n (%) 0 (0) 1 (0.5) ns

Hospitalization for heart failure n (%) 2 (2) 9 (4.2) ns

PAD intervention n (%) 0 (0) 2 (0.9) ns

Both CR programs resulted in a decrease of incidence of angina. After ICR the incidence

of angina was 5%, and after TCR 6% (ns between the groups).

SUMMARY

• A trend towards lower incidence of adverse clinical outcomes in the long-term

follow-up in the ICR group vs. TCR group with low readmission rates for heart

failure was observed

• We are conducting further studies with a larger patient population and a longer

follow-up for the assessment of the effectiveness of the ICR program


improvements of metabolic biomarkers (weight, BMI, body fat, and waist

circumference), hemodynamic parameters (DBP and HR), and lipid biomarkers

(TC, LDL-C, and Non-HDL-C)

• Our results emphasize the importance of a comprehensive lifestyle approach

going beyond exercise for improving biomarkers and clinical outcomes

Conclusions

▪ Lifestyle approaches such as cardiac rehabilitation can decrease CV risk.

▪ These strategies are synergistic with device and pharmacotherapy.

▪ New era in preventive cardiology ushered in by shift to value based care.

exercise training and cardiac rehabilitation › dtmhf_support › taub_2.pdfpatient outcomes with...

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