Surviving a heart attack is difficult enough, but for many patients, this is just the beginning of an often overlooked journey. Dr. Alain Bouchard discusses cardiac rehabilitation and secondary prevention with Dr. Chip Lavie, Professor of Medicine and Medical Director of Cardiac Rehabilitation and Prevention and Director of the Exercise Laboratories at the John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine in New Orleans.
Learn more about cardiac rehab here.
About the Host
Dr. Alain Bouchard is a clinical cardiologist at Cardiology Specialists of Birmingham, AL. He is a native of Quebec, Canada and trained in Internal Medicine at McGill University in Montreal. He continued as a Research Fellow at the Montreal Heart Institute. He did a clinical cardiology fellowship at the University of California in San Francisco. He joined the faculty at the University of Alabama Birmingham from 1986 to 1990. He worked at CardiologyPC and Baptist Medical Center at Princeton from 1990-2019. He is now part of the Cardiology Specialists of Birmingham at St. Vincent’s Health System, Ascension.
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This is the My heart dotnet podcast. This show is produced by Dr. Philip Johnson in conjunction with Lydell engine.com. Please welcome your host, Dr. La Bouchard of cardiology specialist in Birmingham, Alabama, at St. Vincent's medical center part of ascension.Dr. Alain Bouchard:
Well, welcome to our podcast on cardiac rehabilitation and secondary prevention. And actually, if you go to a presentation or cardiac rehab here in the US, very likely you're you should hear Dr. Chip levy doing a presentation somewhere and that's because he's written a lot of the literature on the subject over the last several years. Dr. Levy is professor of medicine and medical director of the cardiac rehabilitation and preventive cardiology program at the John Ochsner Heart and Vascular Institute at the Austin political school at the University of Queensland School of Medicine. And, Dr. Levy are chip, thank you for taking part of your Sunday afternoon and dance, cardiac rehab pleasure to be here to talk about cardiac rehab. Thank you. So today we're going to try to In summary, we will try to present something about what is cardiac rehab and secondary prevention? Who is more likely to benefit from that? What kind of exercise program are we talking about? And in the cardiac rehab? What are the components are there because a lot of people think it's just about exercise. And I can do that at home? What are the clinical benefits of cardiac rehab? And then we'll finish by talking about what are the barriers? And maybe how can we solve them? So let's start chip, what is cardiac rehab? And what is secondary prevention? Well,Dr. Chip Lavie:
it's a comprehensive program. And as you mentioned, most people think about when they think about even even some clinicians and cardiologists might even think that it's exercise. And it's it is that that is probably the most important thing, but it is a comprehensive program. That also involves education, comprehensive risk factor modification, counseling, and particularly psychological counseling for the for the large amount of psychological distress that our cardiac patients have, as well as the exercise. And when they think about the exercise, they think it's all, you know, basically patients walking on the treadmill, or writing an exercise, bicycle riding an elliptical machine, but it's also resistance exercise to because because muscle strength, and bone strength is also very important part of cardiac rehab. And the purpose of cardiac rehab is to return our patients to an optimal physiological and psychological function, and getting them back to where they were before their cardiac event, or maybe to a higher level than they were before their cardiac event because many of the patients had low exercise capacity and had psychological risk factors like depression, anxiety, and psychological distress that can be lessened with cardiac rehab. Many of them had these before their cardiac event. And so it's a comprehensive program to accomplish all of this to improve the quality of life of our patients, but also to reduce their risk of a subsequent major cardiovascular outcome, including cardiovascular mortality, as death from heart disease, as well as all cause mortality. Now we'd like to do, we'd like to reduce the symptoms of engineering, shortness of breath, we'd like to improve, you know, again, the quality of life, we'd like to reduce their risk of having heart attacks. Some of this is harder to show than others, but certainly showing the benefits on functional capacity, improving the risk factors, reducing psychological distress, and reducing cardiovascular mortality and all cause mortality has been now well shown in the medical literature with cardiac rehab. So it's a pretty important program that's very underutilized in our practices.Dr. Alain Bouchard:
So who's likely to benefit from cardiac rehab? Well,Dr. Chip Lavie:
well, honestly, there's many patients who would benefit and many patients who even have cardiac risk factors would would benefit from from cardiac rehab. Right now the insurance companies typically PE and Medicare, etcetera, pays for cardiac rehab in patients after a major cardiac event that could be a heart attack, bypass surgery or a stent or A balloon to treat that block coronary artery. That's probably the majority of patients in cardiac rehab, but many other patients also all candidates like patients with heart failure who is stable with reduced systolic function that means reduced contractility of the heart they have a weakened heart squeeze patients who even have stable angina you know, sometimes could qualify patients who have had a device put in like, like an ICD implantable defibrillator patients who have had a an LVAD for heart failure, people who have had an aortic or mitral valve replacement, all potentially candidates as well as patients who have blockages in their leg arteries. peripheral arterial disease is also a more recent indication right now really in the country. By far the majority of patients, and probably the evidence is strongest for the patients who have a following a major cardiac event, like heart attack, a bypass surgery or a stent to treat the blocked coronary artery. That's the majority of patients enrolled in cardiac rehabilitation today.Dr. Alain Bouchard:
So the if we're talking about an exercise program, a lot of people are scared by that some of them have never really exercised, or they may say, maybe I'm too sick to exercise, particularly with the patients with heart failure. What kind of exercise program can you explain to us a little bit an example of what would be done with a patient.Dr. Chip Lavie:
So typically, typically, during the exercise portion of the of the of the program, patients are often evaluated, and many times they evaluated with a stress test. And I'll, I'll institution and we actually even do a cardiopulmonary stress test, which is the gold standard stress that very few places will do that more people will have a stress test just walking on the treadmill. And, and then they'll use the heart rate responses, you know, to be able to give an exercise prescription, and you can certainly do cardiac rehab without a stress test. But by starting the patient's off at low levels of exercise, meaning the only increase their heart rate by about 20 beats per minute off over their resting levels. But in cardiac rehab, the patients have monitored. So you have trained personnel in the center, like like a nurse, an exercise physiologist, maybe even sometimes a dietitian, you know, but they are very much trained in dealing with the with heart patients, they know they understand heart disease, and IV have a lot of experience taking care of patients who have the similar problems to any given patient in cardiac rehab. And so they start the exercise slowly. And you it's usually on a treadmill or a bicycle or an elliptical machine and gradually build up the the exercise capacity. Over the 12 weeks. Typically, cardiac rehab right now after a major cardiac event is three times a week for 12 weeks of 36 education exercise sessions. And you gradually build up the amount of exercise one is doing during the program. Now, we want all of our patients to be exercising for over 150 minutes per week. And we typically want patients to be wrecked exercise of over 30 minutes per day, at least five days a week and, and really it's okay to be doing six to seven days a week. Even cardiac rehab is only three days a week. So patients do need to be exercising outside of the cardiac rehab program. But this is a start for many of the patients who have not been regular exercises, they can now get used to exercise and they can build their confidence of exercise. And they can gain confidence when they know that they're being monitored. And people are giving them constant feedback about their exercise. And that's something that you don't get on your own outside of cardiac rehab. And so certainly some some of our patients are already exercising, even without going to cardiac rehab, even those patients often still get benefit from the cardiac rehab program because they get the education, they get the risk factor modification. They get the counseling and the psychological benefits. They're also able to push their exercise a little bit harder than they might be comfortable doing on their own outside of the monitoring system. So there are a lot of benefits of cardiac rehab and again, the patients in randomized studies who have been randomized to cardiac rehab compared to those randomized to no cardiac rehab or having not only symptom improvements, but they're having reductions in cardiovascular and all cause mortality. That's a pretty strong finding.Dr. Alain Bouchard:
Yeah, I was gonna ask you about the data. I mean, what is the data that we have? It's not, you're not going to, obviously, this is someone who's had a heart attack, a lot of times, you preventing a recurrence, or you prevent the you improving their quality of life as well as reducing mortality,Dr. Chip Lavie:
there's certainly evidence that we're improving their functional capacity, we're improving their exercise, their ability to do more exercise, and that actually leads to improvements in their in their quality of life. One of the biggest things that cardiac rehabilitation does is is and it correlates with the improvement in the exercise capacity is reduces psychological distress. And the one that gets the most attention is depression. But we've published data showing that it also reduces anxiety and hostility, which is another way to say unexpressed anger, and just total quality of life scores improve with cardiac rehabilitation. But the randomized studies show that it also improves and significantly reduces and it varies between as little as 10% to as much as 30%, depending on exactly what studies and what what studies you include. In meta analysis, meta analysis means you put many studies into one analysis, and it keeps in and continues to be updated. And people continue to do additional analyses of the published data. But somewhere between 2010 and 30%, reductions in cardiovascular mortality as cardiac death. all cause mortality, all cause mortality is usually a little bit harder to show reductions in. And a couple of men analysis don't show that it's statistically significant, but many of them do, almost all of them are showing very significant reductions in the range of usually 15 to 30%. Reductions in cardiovascular mortality, which is a very, very strong finding. Now we have published, and we've published also large series where we reviewed other studies, that the biggest thing that correlates with the benefits for reducing mortality and cardiovascular mortality is the improvement in exercise capacity that the patients get with cardiac rehab. So we really do need to do a good job at making sure our patients improve their exercise capacity, that can be measured on a, you know, in clinically, we can have people do a six minute walk test to see how far they walk in six minutes. Or we can put them on the treadmill and see how far they go, what's their incline and his speed. At the end of the of the treadmill test, we actually do it by putting a mask on and measure oxygen consumption, that's cardiopulmonary stress testing, and we measure gas exchange, that's considered the gold standard to measure exercise capacity. Most of the country doesn't do that. It's it's a, we do it in the academic setting. But you know, so the improvement in exercise capacity really correlates with the reductions in psychological distress, and the improvements in cardiovascular mortality.Dr. Alain Bouchard:
It's very important that you mentioned also that there was something beyond exercise, obviously, do you find that you know, with the education that you provide, you have better adherence to medication, better control of cholesterol, better control of blood pressure, and so forth. AndDr. Chip Lavie:
certainly, all of that typically happens in cardiac rehab, I have to admit, you know, most most patients who start off in cardiac rehab have already stopped smoking, you know, so so we get a little bit better smoking cessation, but most of the patients that attend cardiac rehab, or a select group that they decided to attend, they've usually stopped smoking on their own, but we can get improvements in the in the cholesterol, not so much in a bad cholesterol, we can do way better with the statins with that, but we can get improvements in the HDL, the good cholesterol, with the cardiac rehab and exercise training, we really reduce the triglycerides, that's probably the biggest fat that improves, sugar gets lower. Inflammation gets low at C reactive protein, which is, which is a very important predictor. We don't always measure that clinically, but it's a very important predictor of prognosis, we improve blood pressure, and so many components, we certainly improve Wait, wait only falls a little bit with cardiac rehab, but the waist circumference falls a little bit more than percent body fat falls a little bit more. I've actually published a lot on the obesity paradox, you know, in cardiac diseases. So I think that the improvement in weight is not the most important thing that we were doing, I think the improvement in the other parameters, particularly the psychological distress, the quality of life, and improvement in exercise capacity, is what really corresponds to improvement in prognosis,Dr. Alain Bouchard:
SERP if it's so good, why can't we get more of our patients to participate in cardiac rehab? What are the barriers to get the patients in rehab, andDr. Chip Lavie:
there are many barriers, you know, one over the years has been lack of referral to the program. And that's that's been largely negated now by many places have automatic referrals, it's considered a quality metric. So many times, the clinician checks the box on the electronic medical record that referral. But the strength of the referral is also very important. So if a patient just gets a call, you know, a week or two later, and no one's ever mentioned it, no clinician ever told them, it's really important that you attend cardiac rehab, they're less likely to attend. And then there are other barriers to certainly there's age barriers, there's racial barriers, there's the socio economic barriers, this distance from the cardiac rehab center, that's a barrier. And the fact is, I mean, you see some quotes saying that only 30% of people attend cardiac rehab, I actually think it's way way lower than that, I think it might be five to 10% in the country, because even if you look at the old Medicare papers, where people Medicare's covered cardiac rehab for decades, in the Medicare pay pay papers, only 13 to 15%, attend even one cardiac rehab session, and very few of those actually complete the program. So there are many, many barriers. And so we do need to do a better, better job. And one of the ways is to have the clinician, be a vigorous advocate. And it doesn't have to be the cardiologists can be the primary care could be the pharmacists, it could be the nurse, you know, taking care of the patients, we all have to do a better job of advocating cardiac rehab to our patients and doing it over and over again, and then we have a much better chance of getting attendance. Now, in the long term, we also need to have remote cardiac rehab, we need to have we have to use more digital and telemedicine. So we have to we have to bring cardiac rehab into the patient's homes, instead of just having them come to the, to the center the way it mostly is now, we really learned this during COVID. During COVID, every, all the cardiac rehab programs was shut down. And so because you noted because of the fear of the spread of the virus, and actually only only in recent months has the it has that has the program's opened up to full capacity. But from even when it opened up and in, in in the later 20, early 2021, they still had reduced capacity because of the social distancing, they always have to patients had to wear a mask, which is it's not as easy. It's not as easy to exercise wearing a mask, you know. And so now now at least the restrictions of all remove some of the patients still feel more comfortable wearing the mask, but we don't mandate it now. And so, so we found out early in COVID, that we really need remote cardiac rehab, and we needed it before COVID, we need it because right now there's still many patients who would attend, if they could do it remotely if they could do to sessions, you know, not at the strict times that we require them to come in, you know, for the for the program. But and I do think that happened, the Senate pace, cardiac rehab is very, very good. And that that works for so many patients that do actually attend and, and the patients who do attend, they love it. And they big advocates, they will we'll talk about it today to the other patients that did they really should do cardiac rehab, but we do need to be better at getting cardiac rehab, to the patients who don't attend.Dr. Alain Bouchard:
I know a good friend of mine that at the mouth, as you know, at the Montreal Heart Institute, they've been doing home cardiac rehab for years. And I know you've written a lot about this, I guess its problem of getting reimbursement for it. Right.Dr. Chip Lavie:
I mean, that's that's certainly has been an issue that's, that's, that's that we made some momentum during COVID. It's still not where it needs to be. I think that people are, you know, all around, you know, continuing to work on this. I think we're making some strides, but as of today, it's it's, we can get cardiac rehab reimbursed at the center, and we can always do so remotely. And obviously in the future. If medicine is all prepaid and it's all, you know, help, you know, you know, that's not going to be as much of an issue, but really, the fact is that for many of us, it's still, you know, a fee for service. You know, you know, we've been thinking for years that it's going to be all you know, health playing like a Kaiser model, and that's how most of the country is going to be, you know, run in health care, but that's not the case. For us in New Orleans. I don't think that's the case. for you.Dr. Alain Bouchard:
Yeah, I agree. Well, that's, that's what I was gonna ask you chip. What's the research? What are we doing? And what what do we what should we expect in the future?Dr. Chip Lavie:
And yeah, so I think we certainly have continuing to get more and more research on remote cardiac rehab. And typically, what's been there so far is that it's doing His will to improve quality of life, psychological function and, and exercise capacity. There's not data right now on clinical events. But generally, as I mentioned earlier, that clinical events really correlate very strongly with the improvements in psychological risk factors and exercise capacity. So I do suspect that remote cardiac rehab is going to be just as good for reducing cardiovascular mortality and all cause mortality, further research is going to have to prove that. And when it does, I think that it'll be certainly an added advantage. But I do think many people accept that the improvement in psychological risk factors quality of life and exercise capacity is a pretty good surrogate endpoint, and it's going to correlate with, with prognosis, we also need to do a better job at getting improvements in exercise capacity, we've actually published data that even in cardiac rehab, if you actually monitor the peak vo two with the gas exchange 23% with the standard rehab are not improving that peak vo to now, if you estimated on the treadmill, if you estimated by speed and incline, you have a much better percentage of patients who get improvement. But if you actually measure the peak vo to it's a little bit less. And so we do need to do a better job of getting the patients who are not improving with the standard cardiac rehab to get improvements in peak oxygen consumption. And we do think we can do that with with more high intensity interval training, getting people to exercise for at least small amounts of time at higher heart rates. And that's a very good way to improve your exercise capacity. If you think about it, the athletes, if they're training to run a race, they don't just go out and run slow every day they have they have somebody that runs for short periods of time where they run very fast, even faster than their race pace. And that's how they get faster and they get more fit. And the same thing would apply to patients with cardiac disease is that doing some higher intensity training, even if it's even, and when you hear about high intensity, when you hear high intensity, high intensity, you think boy, that's really sprinting, that's, that's really doing hard, hard exercise? Well, for a patient, that could be just getting their heart rate a little bit high. And just instead of walking at 1.8 miles an hour, they could be walking for short period of time at two miles an hour, it depends on where they're starting from. So high intensity is relative to the patient. And again, you know, somebody could still see somebody doing high intensity training, and think that they're still exercising at a very low level, because some people are starting at a very low level. And you know that so you can if you went to people that they had to go out and run, you know, there'd be many patients that have a hard time walking fast, you know, and so we try and improve everyone's relative exercise capacity.Dr. Alain Bouchard:
I think that's a very good principle. And, you know, there's something we can apply to each of us. You know, actually, it's sometimes you feel like, you're stagnant, you know, in your physical training, it's probably because of, you know, you're just doing the same thing at the same level all the time, doing this short interval training, where you pushDr. Chip Lavie:
for two or three minutes, two or three minutes to go a little bit fast. And you do that three, four or five times during your exercise, you can improve your performance for sure.Dr. Alain Bouchard:
Well, thank you very much chip. I mean, everything you want to know about cardiac rehab chip Lavie from the John Ochsner, Heart and Vascular Institute in New Orleans. Thank you very much.Dr. Chip Lavie:
It's a pleasure being with you today. I enjoyed it.Announcer:
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