HEART FAILURE - swoogo.s3.amazonaws.com · heart failure(HF) to receive cardiac rehabilitation services is: February 18, 2014 . Who is Eligible STABLE CHRONIC HEART FAILURE PATIENTS
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HEART FAILURE
AN OMINOUS DISEASE
Conflicts of Interest
• I Have No Conflicts
of Interest to Disclose
Objective
• At the conclusion of this presentation, the participants will be able to identify benefits and details of Cardiac Rehabilitation Program for heart failure patients
BREAKING NEWS
The Centers for Medicare and Medicaid Services (CMS) has confirmed effective date for patients with heart failure(HF) to receive cardiac rehabilitation services is: February 18, 2014
Who is Eligible
STABLE CHRONIC HEART FAILURE PATIENTS
• Pts. who have not had recent (<6 weeks) or
planned (< 6 months) major cardiovascular
hospitalizations or procedures.
• Left ventricular ejection fraction <35%
• New York Heart Association (NYHA) class II
to IV symptoms (despite being on HF therapy
for at least 6 wks)
(HF is preferred over CHF because some pts. present without signs or symptoms of volume overload)
Why CMS Supported CR for HF
• 2009- CMS found little evidence in existing literature that supported CR for HF pts.
• 2009- (O’Connor) HF-ACTION Study (HF:A Controlled Trial Investigating Outcomes of Exercise Training)
a. Largest single trial (n=2331)- most well
designed and provided best evidence of
benefit
HF-ACTION STUDY- April 2003 to
February 2007
• Randomly assigned
a. Exercise training (60-70% HRR)
b. Usual Care (no formal exercise
prescription-exercise was simply
encouraged)
HF-ACTION STUDY (published in 2009)
• Age range 51-68 (Median age of 59)
• 72% men
• LVEF < 35% (Mean 25%)
• Follow-up ( goal of a minimum of 1 yr. and
maximum of 4 yrs. - median 30.1 months)
HF-ACTION STUDY
• Exercise Training Group
a. Structured, group based, and supervised
exercise
b. 3 sessions/week for a total of 36 sessions
in 3 months
c. Followed by home based 5x/week for 40
min. exercise on a treadmill or stationary
bicycle
HF-ACTION STUDY
All Patients Received Educational Materials
a. Medications
b. Fluid Management
c. Symptom Exacerbation
d. Sodium Intake
e. Activity Level of 30 min (as tolerated)
HF-ACTION STUDY RESULTS
• 11% reduction in the adjusted risk for the combined endpoint of all-cause mortality or hospitalization
• Quality of life and mental depression also improved
COURSE of ACTION
• One of the most propitious course of action
in helping HF patients deal with their
complications is…….
Cardiac
Rehabilitation 36 sessions- for most insurances
3 x/week- highly encouraged
30-60 min of aerobic exercise and weight training if tolerable
Monitor HR, O2, BP and RPE
Progress according to patients’ tolerance
COMPONENTS OF CARDIAC REHAB
Education • Nutrition and Heart Disease • Dining In/Dining Out • Making Sense of Food Labels • Achieving a Healthy Weight • Heart Talk: How it Works and More • Stress and Heart Disease • Relaxation • Managing Risk Factors • Cardiac Meds- Part 1 and 2 • Heart Stories • The Science of Exercise • Tools for Empowering Your Healing Process
Aerobic Benefits of CR for HF Patients
• Lower response to submaximal exercise • Improves diastolic function • Improved endothelial function • Increased skeletal muscle oxidative capacity • Enhanced vagal tone and lower sympathetic tone • Has anti-inflammatory and anti-oxidative effects • Lower all-cause mortality or hospitalization • Improved quality of life • Reduced peripheral vasoconstriction • Decreases circulating catecholamine levels • Affects left ventricular remodeling
COMPONENTS OF CARDIAC REHAB Aerobic Exercise
Low-intensity, longer duration workout are preferred over
high-intensity activities
Start with shorter sessions and gradually build up
Take frequent breaks
Include warm-up and cool-down
Watch for fatigue and SOB
Benefits of Strength Training in CR for HF Patients
• Dynamic resistive training has anti-inflammatory effects
• Improves insulin resistance
• Counteract loss of skeletal mass and strength
• Increases muscle strength and endurance
• Improves QOL
Best Practice in Weight Training
• Training in a dynamic way • Avoid valsalva maneuvers • Keep training at low to moderate intensity- high repetition and low resistance • Sustained maximal isometric exercise is contraindicated because of excessive rise in BP and lowering of SV
Program Statistics for CHF Patients
From January, 2017 thru July, 2017 Total patients enrolled= 268 Total CHF patients= 78 (38%) Average EF= 36% Average EF for non CHF= 54%
Average MET level starting for CHF patients= 4.85 Finishing program= 6.59
Average MET level starting for non CHF patients= 4.9 Finishing program= 7.18
GOALS FOR CR
Control symptoms
Improve QOL
Prevent hospitalization
Prevent mortality
Provide patient education
OUR CHALLENGE
As exercise specialists, we need to break down possible existing barriers and fears related to exercising patients with HF and use our knowledge in delivering effective health interventions so that both efficiency and safety are guaranteed.
POSTER PATIENT
1972- CABG (36 yrs old)
Current Age=81
1979- CABG (43 yrs. old)
1990- MI (54 yrs old)
1994- CABG (58 yrs old)
2007- Pacemaker (71 yrs. old)
2013- ICD (77 yrs. old)
2016- Angioplasty (80 yrs. old)
Current- CHF and EF= 30-35%
1990-Cardiac Rehab- at New Heart
2016 Cardiac Rehab- Presbyterian Healthplex
2017- Current Member in Cardiac Maintenace Program – Presbyterian Healthplex
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