secondary prevention & cardiac rehabilitation malcolm walker consultant cardiologist uclh &...
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Secondary Prevention & Cardiac Rehabilitation
Malcolm Walker
Consultant Cardiologist
UCLH & the Heart Hospital, London
Malcolm Walker
NO CONFLICT OF INTEREST TO DECLARE
COURAGE Trial
When the PCI is over, what else could there possibly be left to do?
J Am Col Cardiology. 2008; 52: 889-893
Patients with significant coronary stenoses are at increased risk of future cardiac events. However, in the absence of acute coronary syndrome or recent MI and residual ischemia, elective PCI has not been shown to improve prognosis.
Reviews of Exercise Based Rehabilitation
Reviews No. of RCTs
No. of Patients
Meta-analysis
Relative Reduction in Total Mortality
Exerciseor Exercise plus CR
Oldridge 1988O’Connor 1989Bobbio 1989
10
9
8
4347
4554
2260
Yes
Yes
Yes
24% (8 to 37%)
20% (4 to 34%)
32% (14 to 47%)
Cochrane Review: Joliffe et al. 2000
8440 patients after MI or Revascularisation
Exercise only: 27% fall in all cause mortality; 31% fall in cardiac mortality
Exercise + : 13% fall in all cause mortality; 26% fall in cardiac mortality
• 2004 Metanalysis• 48 RCTs, n= 8940• Patients hospitalised for CHD• Conclusion: 20% reduction in all cause
mortality 24% in cardiovascular mortality
Cardiac Rehabilitation - the Statin era
Taylor, R.S. et.al. Am J Med 2004
Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112
Hambrecht group – Event-free survival in exercise versus PCI groups at 24 months
hs CRP levels at Baseline & 24 Months
0
0.5
1
1.5
2
2.5
3
3.5
Exercise Group PCI Group
Baseline
24 months
p = 0.025
p = ns
Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112
How might exercise improve CAD outlook
• Improved associated cardiovascular risk factors
– Improved physical fitness– Weight– Diabetes– HDL levels– Adherence to improved diet– Reduced smoking– Improved compliance with medication– Markers of inflammation: e.g. hs CRP– Endothelial function
• 2008• 213 patients post PCI• Non-randomised: 133 received CR, 80
no CR• Mean follow-up 4.5yr• Results:
• Readmission for CAD event 45% CR vs 75% no CR
• Revascularisation 7% CR vs 17% no CR• Total health care cost: 4862 Eu/pt vs 5498
Eu/pt• 15/12 MACE 24% CR vs 42% no CR P<0.005
Cardiac Rehabilitation (CR) - after PCI
Dendale P. et.al. Acta Cardiol 2008
Core components of CR
95%94%
71%73%78%77%
94% 94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aspirin ACEi Beta-block Statin
Before CR
After CR
NACR Annual Statistical Report: 200812 week Medication Record
73% 74%
36%
56%
13%8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
BMI < 30 Exercise Smoker
Before CR
After CR
NACR Annual Statistical Report: 200812 month outcome (NSF Targets)
NACR Annual Statistical Report:Reasons for referral to CR 2006-2007
56%
7%
14%
18%4% 1%
MI
ACS
CABG
PCI
Angina
CCF
NACR Annual Statistical Report:2008Percentage Eligible Patients Who Receive CR in
England
42%
73%
31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
MI CABG PCI
MI
CABG
PCI
Barriers to CR
• Speed of throughput– Tertiary centre syndrome
• Not my responsibility– The nurses will do it– It’s primary care’s job
• Patient reluctance the “Andy Capp syndrome”
Well Mr Capp, just have the PCI
Overcoming the Barriers to CR
• Local CR programmes have to be– Accessible– Flexible– Responsive– Visible– Provide CR to a level known to improve
prognosis• Cardiologists have to take responsibility for
the complete “package” of care… or assume the role of cardiac interventional radiologists
Can we see a time when all PCI patients from CR?
Dream on