risk stratification ontario cardiac rehabilitation pilot project
TRANSCRIPT
![Page 1: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/1.jpg)
Risk StratificationRisk Stratification
Ontario Cardiac Rehabilitation Pilot Project
![Page 2: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/2.jpg)
Recommendation: CACR Recommendation: CACR
“ …programs consistently use some form of risk stratification for all their patients entering cardiac rehabilitation…”
![Page 3: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/3.jpg)
Why risk stratify?Why risk stratify?
Ensure safety of the patientIdentify patient’s prognosis and
progression variables – direct intervention
Assess long term outcomesAssist in allocation of resources
![Page 4: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/4.jpg)
Risk Stratification GuidelinesRisk Stratification Guidelines
AACVPRACCACPAHACACRDuke treadmill score
![Page 5: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/5.jpg)
AACVPR GuidelinesAACVPR Guidelines
Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, AACVPR, Human Kinetics, 1999
Low Moderate High Functional Capacity
>7 METs < 5 METs
LVEF >50% 40-49% <40%
History Uncomplicated
MI, CABG, PTCA, no CHF
CA survivor, cardiogenic shock post MI or CABG, CHF, post procedure ischemia
Signs or symptoms
Assymptomatic Signs, symptoms
5-6.9 METs Signs, symptoms <5 METs
Dysrhythmia Nil
Complex ventricular arrhythmias, rest or exercise
Hemodynamics Normal with exercise
Abnormal with exercise
Depression Nil Clinically significant depression
![Page 6: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/6.jpg)
CACR GuidelinesCACR Guidelines
Prognosis score (short-term absolute risk)– GXT: functional capacity– Ischemia, CCS class or max ST depression– LVEF– Dysrhythmias
Heart hazard score (long-term absolute risk)– Smoking– Lipids– BP– Diabetes– Psychological distress
![Page 7: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/7.jpg)
Absolute vs. relative riskAbsolute vs. relative risk
Absolute: probability of suffering an acute CVD related event within a finite time period – Short-term (<5-10yrs)– Long-term (>10 yrs)
Relative: ratio between two levels of absolute riskIndividual’s absolute risk
Absolute risk of low-risk reference population
![Page 8: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/8.jpg)
Short-term Absolute RiskShort-term Absolute Risk
< 5 yr risk of future cardiac eventLinked to prognostic variablesAssist in:
– optimizing safety of exercise – allocating resources
![Page 9: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/9.jpg)
Short Term Absolute RiskShort Term Absolute Risk
Functional Capacity (METs)
Score Pt’s Score
> 12 0
> 10 1
> 9 2
> 8 3
> 7 5
> 6 7
< 6 10
![Page 10: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/10.jpg)
Short Term Absolute RiskShort Term Absolute Risk
LVEF (%) Score Pt’s Score
> 55 0
45 - 54 3
36 - 44 7
< 35 15
![Page 11: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/11.jpg)
Short Term Absolute RiskShort Term Absolute RiskIschemic Burden: use one of following
Score Pt’s Score
History CCS Class I 0
CCS class II 3
CCS class III 5
CCS class IV 7
ST dep. @ MaxHR None 0
1 mm 3
1- 2 mm 7
> 2 mm 10
Myocardial Perfusion None 0
Mild-mod, 1 vessel 3
Mod, multivessel 7
Severe, single-multi 15
![Page 12: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/12.jpg)
Short Term Absolute RiskShort Term Absolute Risk
Dysrhythmias Score Pt’s Score
None 0
Atrial 2
Isolated PVC, <10/hr 3
Isolated PVC, >10/hr 6
Nonsustained VT 8
Recurrent VT 15
Hx VF MI < 6hr 6
MI > 6hr 15
No MI with ischemia 15
No MI no ischemia 12
![Page 13: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/13.jpg)
Short Term Absolute RiskShort Term Absolute Risk
Sum of:Functional capacity scoreLVEF scoreIschemic burden scoreDysrhythmia score
![Page 14: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/14.jpg)
Long Term Absolute RiskLong Term Absolute Risk
Risk of disease progressionIncreasing number of points reflects
increasing ‘exposure’ of heart hazard10 year absolute risk of CVD
development/progressionOnly traditional risk factors
![Page 15: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/15.jpg)
Disease Progression RiskDisease Progression RiskHeart Hazard Women Men Pt’s score
Age, yrs
< 34 - 9 - 1
35 – 39 - 4 0
40 – 44 0 1
45 – 49 3 2
50 – 54 6 3
55 – 59 7 4
60 – 64 8 5
65 – 69 9 6
70 – 74 10 7
> 75 15 10
![Page 16: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/16.jpg)
Disease Progression RiskDisease Progression RiskHeart Hazard: Cholesterol Women Men Pt’s scoreTotal: <4.14 mmol/L -3 -2
4.15-5.17 0 0
5.18-6.21 1 1
6.22-7.24 2 2
>7.25 3 3
LDL: <2.59 mmol/L -2 -1
2.60-3.36 0 0
3.37-4.14 1 1
4.15-4.92 3 2
>4.93 5 3
HDL: <0.9 mmol/L 5 2
0.91-1.16 2 1
1.17-1.29 1 0
1.30-1.55 0 -1
>1.56 -3 -2
![Page 17: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/17.jpg)
Disease Progression RiskDisease Progression RiskHeart Hazard: BP (mmHg) Women Men Pt’s score
Systolic
<120 -3 0
120-129 0 0
130-139 1 1
140-159 2 2
>160 3 3
Diastolic
<80 0 0
80-84 0 0
85-89 1 1
90-99 2 2
>100 3 3
![Page 18: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/18.jpg)
Disease Progression RiskDisease Progression Risk
Heart Hazard Women Men Pt’s score
Diabetes
Yes 6 4
No 0 0
Psychological distress
Yes 4 4
No 0 0
Smoking
Yes 4 4
No 0 0
![Page 19: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/19.jpg)
Long Term Absolute RiskLong Term Absolute Risk
Sum of: Age score Lipid (TC, LDL, HDL) score BP score Diabetes score Psychosocial distress score Smoking score
Women = sum of scores x 1.5Men = sum of scores x 1.4
![Page 20: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/20.jpg)
CACR Guidelines: Overall RiskCACR Guidelines: Overall Risk
Low - Moderate
High Very High
Risk of Disease Progression < 7 7-14 >14
Risk of Acute Cardiac Event <7 7-14 >14
Total <14 14-28 >28
Canadian Guidelines for Cardiac Rehabilitation & CVD Prevention, CACR, 1999
![Page 21: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/21.jpg)
Use of Risk Stratification ScoresUse of Risk Stratification Scores
Low S/T & L/T risk Minimal or no intervention
Low S/T, high L/T riskHome or unsupervised
programs & heart hazard modification
High S/T & L/T risk Supervised exercise & structured heart hazard
modification
![Page 22: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/22.jpg)
Clinical ApplicationClinical Application
High or very high short term risk:
Supervised exercise Consider ECG
monitoring Higher degree of
supervision May need to hold
exercise until further investigation
Satellite sites: refer to coordinating centre
High or very high long term risk:
Structured approach to heart hazard modification
Educational tool for patients
![Page 23: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/23.jpg)
Case Study #1Case Study #1
Medical History IWMI May 2000 Cath: LM, LAD, Cx
normal; RCA 100% distally; LVEF 76%
PTCA/stent RCA, 100% to 0
GXT: 8.3 METs, no angina, no ST changes, no arrhythmias
Heart Hazards 63 yrs., male BP: 130/78 BMI: 28.2 Girth: 98 cm Physical activity: 75
min/week TC 4.8, LDL 2.7, HDL
1.12, Tg 2.25, FBG 4.8 D/c smoking x 25 yrs
![Page 24: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/24.jpg)
Case Study #1: S/T RiskCase Study #1: S/T Risk
Variable Pt’s Results Range Pt’s Score
FC (METs) 8.3 >8 3
LVEF 76% >55 0
Ischemic Burden
No ST depression
No ST depression
0
Dysrhythmias None None 0
Total 3 = low-mod
![Page 25: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/25.jpg)
Case Study #1: L/T RiskCase Study #1: L/T Risk
Heart Hazard Pt’s value Range Pt’s score (M)
Age 63 60 - 64 5
T-Chol 4.8 4.15 – 5.17 0
LDL-C 2.7 2.60 – 3.36 0
HDL-C 1.12 0.91 – 1.16 1
SBP 130 130 –139 1
DBP 78 <80 0
Diabetes No No 0
Psychological distress
HADS n/a, none
No o
Smoking D/C 25 yrs No 0
Total 7 X 1.4=9.8 = high
![Page 26: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/26.jpg)
Case Study # 1Case Study # 1
Low-Mod S/T risk High L/T risk Total = 12.8, low-mod overall risk Cardiac rehab program:
– Home exercise program: 200-400 min/wk, resistance training
– Nutrition counselling: weight control, dyslipidemia
– Pharmacotherapeutic intervention: Baycol
![Page 27: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/27.jpg)
Case Study #1: OutcomesCase Study #1: Outcomes
Clinical variable Intake score Exit score
Smoking No No
BP 130/78 120/72
Physical activity 75 min/wk 305 min/wk
BMI 28.2 27.6
Waist, girth 98 92
T-chol 4.8 3.5
LDL-C 2.7 1.8
HDL-C 1.12 1.17
Triglycerides 2.25 1.26
Glucose 4.8 4.1
FC (METs) 8.3 8.8
CACR Risk score 12.1-low-mod 5.6 – low-moderate
![Page 28: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/28.jpg)
Case Study #2Case Study #2
Medical History IWMI 1992, PTCA RCA PTCA RCA x 2 1993 Recurrent angina 2000,
cath: LAD 70%, Cx 100%, RCA 95/90%, LVEF 34%
PTCA/stent RCA mid and distal
GXT: 6.1 METs, ST depression to 3 mm, assymptomatic, frequent PVCs & couplets
Heart Hazards 71 yr old male D/C smoking x 35 yrs BP 168/68 No regular exercise BMI 27.5, girth 103 cm TC 4.3, LDL 1.7, HDL 1.3,
Tg 2.77, FBG 5.6
![Page 29: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/29.jpg)
Case Study #2: S/T RiskCase Study #2: S/T Risk
Variable Pt’s Results Range Pt’s Score
FC (METs) 6.1 >6 7
LVEF 34% <35 15
Ischemic Burden
3 mm ST depression
>2mm 10
Dysrhythmias Freq PVC PVC>10/hr 6
Total 38 = very high
![Page 30: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/30.jpg)
Case Study #2: L/T RiskCase Study #2: L/T Risk
Heart Hazard Pt’s value Range Pt’s score (M)
Age 71 70 – 74 7
T-Chol 4.3 4.15 – 5.17 0
LDL-C 1.7 <2.59 -1
HDL-C 1.3 1.30 – 1.55 -1
SBP 168 >160 3
DBP 68 <80 0
Diabetes No No 0
Psychological distress
HADS n/a, none
No o
Smoking D/C 35 yrs No 0
Total 8 X 1.4=11.2 = high
![Page 31: Risk Stratification Ontario Cardiac Rehabilitation Pilot Project](https://reader036.vdocuments.mx/reader036/viewer/2022062516/56649e045503460f94aefb5a/html5/thumbnails/31.jpg)
Case Study #2:Case Study #2:
Very high S/T risk High L/T risk Total = 49.2, very high overall risk Cardiac rehab program:
– Referred back to cardiologist, exercise initially on hold, now returned to supervised exercise, ExRx below ischemia, telemetry monitoring, booked for CABG July 2001.
– BP monitored, multiple therapy