The Best Medicine for Your CAD Patients James A. Stone BPHE, BA, - - PowerPoint PPT Presentation

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The Best Medicine for Your CAD Patients James A. Stone BPHE, BA, - - PowerPoint PPT Presentation

May 04, 2023 225 likes •573 views

Cardiac Rehabilitation The Best Medicine for Your CAD Patients James A. Stone BPHE, BA, MSc, MD, PhD, FRCPC, FAACVPR, FACC Clinical Professor of Medicine, University of Calgary Total Cardiology, Calgary Cardiac Rehabilitation The Best

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Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

James A. Stone

BPHE, BA, MSc, MD, PhD, FRCPC, FAACVPR, FACC

Clinical Professor of Medicine, University of Calgary Total Cardiology, Calgary

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Acknowledgements and Disclosures

  • Acknowledgements
  • Jacques Genest and Rob Welch
  • National CPG Committee Memberships
  • All of you!
  • Disclosures
  • No Current Industry/Government Funding
  • National CPG Committee Memberships
  • Canadian Diabetes Association 2013
  • Canadian Cardiac Rehabilitation Cardiac Rehabilitation (Chair)
  • Canadian Hypertension Education Program
  • C-CHANGE (Canadian Cardiovascular HArmonization of National Guidelines Endeavour) (Chair)
  • CCS Dyslipidemia 2102
  • CCS Smoking Cessation 2011
  • CCS Committee on Chronic Stable Angina
  • CCS Committee on Refractory Angina
  • Physical Activity for Adults 2011
  • Physical Activity for Persons with Spinal Cord Dysfunction (Chair) 2011

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Cardiac rehabilitation:

  • 1. Improves CAD outcomes
  • 2. No effect on CAD
  • utcomes
  • 3. Is primarily an

exercise program

  • 4. Is not cost-effective
  • 5. Is over-utilized in

Canada

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Something Old,…

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Something Old

"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”

Hippocrates 460-377 BC

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Something Old

Superior doctors prevent the disease Mediocre doctors treat the disease before evident Inferior doctors treat the full blown disease

Huang Dee: Nai-Chang (2600 BC. 1st Chinese Medical text)

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Something Old

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

JAMA 1988;260:945-950

10 Studies; N=4347

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Something Old

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

  • Circulation. 2002;106:666-671

< 5 METs 5-8 METs > 8 METs

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Something Old

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Am J Med. 2004;116:682– 692

48 Trials 8940 patients

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Something New

  • Cochrane Review 2011
  • 47 studies: 10,794 patients
  • Total Mortality:

.87 CI .75-.99

  • Cardiac Mortality:

.74 CI .63-.87

  • One year Readmission:

.69 CI .51-.93

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Heran et al., Cochrane Database Syst Rev 2011; Jul 6.

63 Studies; N=21295

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Something New

34 RCTs; N = 6,111

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N=601,099

Suaya JA, Stason WB, Ades PA, et al. J Am Coll Cardiol. 2009; 54:25-33,

Something New

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

N=5886

Clinical Variables

  • 1. Age
  • 2. Sex
  • 3. Ejection fraction
  • 4. Chronic obstructive pulmonary disease
  • 5. Cerebrovascular disease
  • 6. Elevated creatinine
  • 7. Congestive heart failure
  • 8. Dialysis
  • 9. Hypertension
  • 10. Hyperlipidemia
  • 11. Diabetes mellitus
  • 12. Presence of malignancy
  • 13. Current smoking status
  • 14. Former smoking status
  • 15. Prior myocardial infarction
  • 16. Prior percutaneous coronary intervention
  • 17. Prior coronary artery bypass grafting [CABG]
  • 18. Peripheral vascular disease
  • 19. Liver or gastrointestinal disease
  • 20. Severity of CAD (Duke jeopardy score)
  • 21. Treatment strategy (percutaneous coronary intervention or CABG within 1 year of referral)
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Martin BJ et al. Circulation 2012

Something New

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Eur J Cardiovasc Prev Rehab 2009;16:102-113

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Int J Cardiol 2011;27:355-356

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

In Press: Mayo Clin Proceed 2013

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Something New

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Cardiac rehabilitation:

  • 1. Is proven to be

cost-effective

  • 2. Is cost-ineffective
  • 3. Is cost-saving
  • 4. Is just a touchy feely

kumbaya program

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Something Old and New

  • Cost-Effectiveness
  • Potentially cost-saving1
  • Highly cost-effective2-4
  • < 20,000 per QALY

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

1. Brown et al 2003 2. Oldridge et al 2008, 2005, 1998 3. Wong et al., 2012 4. CWIC 2013

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Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Something Borrowed

CMAJ Oct 2011

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  • Acronym for Secondary Prevention

Stone JA et al. 2009

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Something Borrowed

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Cardiac rehabilitation:

  • 1. Has a high

attendance rate.

  • 2. Has a high

completion rate

  • 3. Is attended more

by women

  • 4. Programs mostly

serve males

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Something Blue

  • Referrals

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Under Review JACC

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Something Blue

  • Referrals

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Under Review JACC

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  • Waiting Times
  • D/C - 65.6 ± 88.4 days
  • Referral - 40.1 ± 73.9 days

Something Blue

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Something Blue (or not)

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

Can J Cardiol: 2011

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Summary

  • Systematic process-oriented care
  • Treatment target driven
  • Minimizes vascular oxidative stress
  • Maximizing cardiometabolic fitness
  • Reduces recurrent adverse CAD events
  • Yes it does!
  • Principle elements of chronic disease care
  • Patient empowerment

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients

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Summary

  • Something Old
  • Something New
  • Something Borrowed
  • Something Blue

Cardiac Rehabilitation

The Best Medicine for Your CAD Patients