Cardiac Rehabilitation 2011 Update for Primary Care Providers心脏康复2011更新初级保健提供者

To restore to good health or useful life, through therapy and education. Changing our own behavior, for better health Therapy: connotation of mental illness Rehabilitation: connotation of substance abuse Personal Responsibility is much more difficult than blaming No one can rehabilitate another; most of the work is done by the patient, for himself.1.What is cardiac rehabilitation?2.What is the difference between primary and secondary prevention?3.Is there good clinical evidence which supports the efficacy of cardiac rehabilitation?SurvivalMyocardial infarct (MI) reductionStroke (CVA) preventionAvoidance of subsequent bypass surgery (CABG)Reduced repeat stenting (PCI)Reduced frequency of hospitalization4. Does the evidence, which supports the use of cardiac rehabilitation apply: In the reperfusion-era of post MI care? To the elderly (Medicare population)? Women? Care-givers, themselves?5. In your personal, and professional experience, is behavior change: Easy, i.e. a slam-dunk? Impossible, and therefore, not even worth discussing Possible, but requiring sustained effort A multi-component intervention, which is designed to: Optimize a cardiac patients physical, psychological and social function, and Stabilize, slow, or even reverse the underlying atherosclerosis; thereby Reducing the morbidity and mortality of coronary artery disease (CAD). Meta-analysis of 43 studies from world literature of physical activity and CAD up to 1987 Objective assessments of individual activity, and of CHD Attempt to infer causal relationship based on criteria of AB Hill and Rothman Sequence: activity precedes incidence of CHD Consistency across studies Strength of association Graded across multiple levels of activity Plausibility Coherence Supported by biological studies Powell et al; Ann Rev Public Health1987;8:253 18,809 patients from OASIS 5 prospective randomized trial, conducted in 41 countries. Most patient were compliant with aspirin (96%); statins (79%); ACE-I/beta blockers (72%). 29% did not follow diet or exercise; 1/3 of smokers persisted; 42% did either diet or exercise; 30% did both diet and exercise. MI risk reduced significantly by diet, exercise and smoking cessation. Circulation 2010;121:750-758 601,099 Medicare beneficiaries, who were hospitalized for coronary conditions and/or revascularization (PCI or CABG). 1- 5 year mortalities examined using multiple statistical methods Only 12% used cardiac rehabilitation services; they averaged 24 sessions. Mortality rates were 21-34% lower among users of cardiac rehabilitation Dose-response noted: more is better.1.Risk factor screening2.Dietary counseling3.Physical activity counseling4.Smoking assessment5.Smoking cessation intervention6.Weight/adiposity assessment7.Weight management8.Blood pressure measurement9.Blood pressure control10.Lipid measurement11.Lipid control12.Global risk assessment13.Aspirin useCirculation 2009;120:1296-1336. Evaluation Patient assessment Nutritional Weight management Blood pressure Lipids Diabetes Smoking Psychosocial Physical Activity Exercise training Intervention Neither coronary bypass graft surgery (CABG), nor percutaneous coronary intervention (PCI), with or without stents, have been shown, in stable patients, to prevent heart attacks. Lipid lowering (primarily with statin drugs such as Lipitor, Crestor, or Zocor); Aspirin; Beta-blockers; and ACE-inhibition; have all been shown to reduce the risk of future myocardial infarction (MI), among post MI patients, and patients with stable coronary disease. Compliance can be enhanced with the educational component of cardiac rehabilitation. Diet, exercise, and smoking cessation have been shown to reduce the risk of subsequent heart attack. Cardiac rehabilitation, in a large, Medicare study, has been sown to be associated with reduced likelihood of heart attack. Getting people to take personal responsibility for their own health involves behavior modification. It is not easy, but we can all do it, one step at-a-time. In the catheterization lab, or echo lab, or exercise lab, or pulmonary function lab, We are contemplating lifes nature And we are applying the fruits of our contemplations to the care of our fellow human. We follow the same biological principles.