Cardiac RehabilitationUpdate for Primary Care Providers心脏康复更新初级保健提供者

1、Cardiac Rehabilitation 2011Update for Primary Care ProvidersDouglass A Morrison, MD, PhDCardiac Rehabilitation, Medical DirectorYakima Regional and Yakima Valley Memorial HospitalsRehabilitationTo restore to good health or useful life, through therapy and education. Changing our own behavior, for be

2、tter healthChanging BehaviorResistancesTherapy: connotation of mental illnessRehabilitation: connotation of substance abusePersonal Responsibility is much more difficult than blamingNo one can rehabilitate another; most of the work is done by the patient, for himself.Active versus PassiveSecond Pers

3、on versus First PersonIt is easier to tell others how they should change,than to change ourselves: empathyCardiac Rehabilitation 2011Bill of FareWhat is cardiac rehabilitation?What is the difference between primary and secondary prevention?Is there good clinical evidence which supports the efficacy

4、of cardiac rehabilitation?SurvivalMyocardial infarct (MI) reductionStroke (CVA) preventionAvoidance of subsequent bypass surgery (CABG)Reduced repeat stenting (PCI)Reduced frequency of hospitalizationCardiac Rehabilitation 2011Bill of Fare (2)4. Does the evidence, which supports the use of cardiac r

5、ehabilitation 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 discussingPossible, but requiring sustai

6、ned effortDefinition of Cardiac RehabilitationA multi-component intervention, which is designed to:Optimize a cardiac patients physical, psychological and social function, andStabilize, slow, or even reverse the underlying atherosclerosis; therebyReducing the morbidity and mortality of coronary arte

7、ry disease (CAD).Physical Activity and the Prevention of Coronary Heart DiseaseMeta-analysis of 43 studies from world literature of physical activity and CAD up to 1987Objective assessments of individual activity, and of CHD Attempt to infer causal relationship based on criteria of AB Hill and Rothm

8、anSequence: activity precedes incidence of CHDConsistency across studiesStrength of association Graded across multiple levels of activityPlausibilityCoherenceSupported by biological studiesPowell et al; Ann Rev Public Health1987;8:253Diet, Exercise, and Smoking Modification after acute coronary synd

9、rome (ACS)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 an

10、d exercise.MI risk reduced significantly by diet, exercise and smoking cessation.Circulation 2010;121:750-758Cardiac Rehabilitation:Contemporary Era and Elderly Population601,099 Medicare beneficiaries, who were hospitalized for coronary conditions and/or revascularization (PCI or CABG).1- 5 year mo

11、rtalities examined using multiple statistical methodsOnly 12% used cardiac rehabilitation services; they averaged 24 sessions.Mortality rates were 21-34% lower among users of cardiac rehabilitationDose-response noted: more is better.Performance Measures for Primary PreventionRisk factor screeningDie

12、tary counselingPhysical activity counselingSmoking assessmentSmoking cessation interventionWeight/adiposity assessmentWeight managementBlood pressure measurementBlood pressure controlLipid measurementLipid controlGlobal risk assessmentAspirin useCirculation 2009;120:1296-1336.Core Components of Card

13、iac Rehabilitation/ Secondary PreventionEvaluationPatient assessmentNutritionalWeight managementBlood pressureLipidsDiabetesSmoking PsychosocialPhysical ActivityExercise trainingInterventionCardiac Rehabilitation 2011: Summary (1)Neither coronary bypass graft surgery (CABG), nor percutaneous coronar

14、y intervention (PCI), with or without stents, have been shown, in stable patients, to prevent heart attacks.Cardiac Rehabilitation 2011: Summary (2)Lipid lowering (primarily with statin drugs such as Lipitor, Crestor, or Zocor); Aspirin; Beta-blockers; and ACE-inhibition; have all been shown to redu

15、ce 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.Cardiac Rehabilitation 2011: Summary (3)Diet, exercise, and smoking cessation have been shown to red

16、uce 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.When we study biology, we are life, contemplating its nature. George Wald, PhD In the c