HJERTEREHABILITERING. State of the art. Ann-Dorthe Zwisler Speciallæge i kardiologi, PhD Medlem af ESC/EACPR

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1 HJERTEREHABILITERING State of the art Ann-Dorthe Zwisler Speciallæge i kardiologi, PhD Medlem af ESC/EACPR

2 Iskæmisk hjertesygdom (STEMI, Non-STEMI, UAP, AP) 64 år Tømrermester med 3 ansatte Gift, 2 børn, 1 barnebarn Ryger Fysisk aktiv på arbejde Førstegangs-brystsmerter EKG viser STeMI KAG - et karssygdom Primær PCI Ingen angina, normal LVEF Udskrives på 5. dagen Velinformeret Rygeophør under indlæggelsen Udskrives med 5 tabletter Model ==>> Lige efter bogen

3 Seneste retningslinjer Piepoli MF et al. EJCPR 2010:1-17

4 Definition Cardiac rehabilitation is a multifaceted and multidisciplinary intervention, which improves functional capacity, recovery and psychological well-being. Adapted by WHO Piepoli MF et al. EJCPR 2010:1-17

5 Evidens-baseret behandling Oldridge Cochrane Taylor Cochrane Diagnoser AMI CHD CHD CHD Forsøg CR ex-only /CCR - 20/14 30/18 17/29 Patienter ,794 Alder (mean) (48-71) 57 (46-84) Kvinder % 2,9% 9% 20% 20 Effektmål Overlevelse Overlevelse Risikofaktorer HRQL Overlevelse Risikofaktorer HRQL Overlevelse MI Re-hospitalisering HRQL

6 Evidensens svagheder Selekteret patientpopulation (mænd, AMI, <65 år) Spørgsmålstegn ved forsøgenes kvalitet Mange forsøg før 1995 Stor variation i varighed, opfølgning og intervention Manglende beskrivelser af interventionerne

7 Evidens-baseret behandling Effekt Iskæmisk hjertesygdom Alle forsøg Antal forsøg 47 Antal patienter Dødelighed (OR) 0,87 (0,75-0,99)* Kardiovaskulær mortalitet (OR) 0,74 (0,63-0,87)* Re-hospitalisering (short term) 0,69 (0,51-0,93)* Blood preasure dia. (WMD mmhg) -0,56 (-1,68-0,69) T- Cholesterol (WMD mmhg) -0,36 (-0,60--0,12)* HDL Cholesterol (WMD mmhg) 0,04 (-0,03-0,11) LDL Cholesterol (WMD mmhg) -0,19 (-0,47-0,08) Triglycerid (WMD mmhg) -0,20 (-0,35-0,07)* Rygning (OR) 0,73 (0,60-0,89)* HQRL Forbedring (7/10 trials) Cochrane review CHD 2001 Cochrane-review 2011

8 Genoptagelse af arbejde og sygefravær Registerbasret opfølgning 3 år Poisson (95% CI)* p-value Keep working CR UC Hazard ratio = % CI ( ) P = 0.47 CR reference group 1.00 (ref) Days recieving Sickness benefits 1.19 ( ) <0.01 Days of Unemployment 1.04 ( ) <0.01 * Zero-inflated Poisson model Unpublished data

9 Fase-inddelt rehabilitering Phase I Inpatient rehabilitation Phase II Early outpatient rehabilitation Phase III Long-term outpatient rehabilitation Piepoli MF et al. EJCPR 2010:1-17

10 ens 3 faser I INDLEDENDE FASE (primær kontakt ofte under indlæggelse) Tidlig mobilisering Undervisning og psykosocial støtte Risikofaktormodifikation påbegyndes Visitering til efterbehandling II TIDLIG AMBULANT EFTERBEHANDLING Optimering af symptomatisk behandling Vedligeholdelse af symptomatisk og profylaktisk behandling Fysisk træning (8-12 uger) Psykosocial støtte Livsstilsintervention (Rygning, kost, fysisk aktivitet) Patientundervisning III VEDLIGEHOLDELSESFASEN Vedligeholdelse af symptomatisk og profylaktisk behandling Vedligeholdelse af opnåede livsstilsændringer Kilde: på danske sygehuse. Netværk af forebyggende sygehuse, 2003

11 SEKTORER Det sammenhængende forløb FASE I Primær kontakt Sygehuseniveau FASE II Tidlig opfølgning FASE III Vedligeholdelse og forebyggelseaf tilbagefald Praksis niveau Komunalt niveau Overgangsfaserne Transition zones

12 Rehabilitering i lokal praksis UK model

13 Har vi effekt af rehabilitering i daglig praksis? This study was covered in the Belgian press and already led to questions about further reimbursement of such multidisciplinary programs.. (PostScript: Conrads V et al. Heart 2012: 674) West et al. Heart 2012:

14 Design og materiale Randomiseret pragmatisk forsøg (N=1,813) Multicenter (14 hospitalet) Integreret rehabilitering (CCR) vs. ususal care Fysisk træning, patientuddannelse, relaxation multidiciplinær intervention, (10+ sessioner) Primære effektmål: Død efter 2 år Sekundær effektmål: HRQL Livsstilsændringer Forbrug af sundhedsydelser Morbiditet West et al. Heart 2012:

15 Resultater West et al. Heart 2012:

18 Konklusion Conclusion: In this trial, comprehensive rehabilitation following MI had no important effect on mortality, cardiac or psychological morbidity, risk factors, healthrelated quality of life or activity. The value of cardiac rehabilitation as practiced in the UK is open to question.

19 Kritiske overvejelser ved CR eksperter Varighed af intervention (10 sessioner / 6 uger) Indhold (exercise, education and relaxation) Træningsdosis Manglende evaluering af intervention Manglende lægeinvolvering Patientselektion The RAMIT trial reminds us that CR, like any other treatment, can be delivered ineffectually. Clinical audit of all CR programmes is an essential safeguard to ensure that services are being delivered effectively. Editorial: Doherty et Lewin. 2012;

20 Rehabilitering State of the art Lever vi op til standarderne?

21 Delelementer Individuel visitering og tilrettelæggelse Fysisk træning Kostintervention Patientundervisning Psykosocial støtte Rygeintervention Farmakologisk behandling (profylaktisk, symptomatisk) Risikofaktor kontrol og opfølgning Piepoli MF et al. EJCPR 2010:1-17

22 Individuel vurdering og visitering Clinical history, co-morbidity and current symptoms Adherence to medical regimes ECG, echocardiography, blood testing Physical activity level and measurement of exercise capacity Smoking habits Dietary habits Self-assessed health Screening for psychological distress Interview vs. standardized measurement tools Piepoli MF et al. EJCPR 2010:1-17

23 Spisevaner og kostsammensætning Hjerteforeningen og Ålborg Universitetssygehus

24 Selvvurderet helbred og livskvalitet

25 Rådgivning om fysisk aktivitet A minutes/daily moderately intense aerobic activity life long Emphasize sedentary lifestyle as risk factor, and benefits of physical activity Recommend gradual increases in daily lifestyle activities over time, and how to incorporate it into daily routine Advise individualize physical activity according to patient s age, past habits, co-morbidities, preferences and goals Reassure regarding the safety of the recommended protocol Encourage involvement enjoyable activities Piepoli MF et al. EJCPR 2010:1-17

26 Fysisk træning Prescribed on an individualized approach according to capacity and risk-factors Supervised 12 weeks of aerobic exercise training at least 3 times pr. week Starting at 50% of maximal work load or V02 peak and increasing to 70% Resistance training is recommended 1 h/week Special recommendations for patients with CHF and low LVEF Piepoli MF et al. EJCPR 2010:1-17

27 Rygeafvænning All smokers should permanently stop smoking Importance of structured approaches should be emphasized Should be advised by cardiologists and general practitioner (OR 1.69 (( )) Behavioral advice and counseling is corner-stone (3 4 visits) Pharmacoterapy 2-3 month Nikotine (OR 1.73 ( )) Vareniclin (OR 3.22 ( )) BupropionSR (OR 1.97 ( )) ==>> 1 year cessation rate % Piepoli MF et al. EJCPR 2010:1-17

28 Rygeafvænning gør vi det godt nok? Kotseva k et all. Lancet 2009;373:929-40

29 Vejledning i kostomlægning Daily caloric intake, content of nutrients (fat, vegetables, fruit and fish) should assessed systematically Caloric intake should be balanced by energy expenditure to avoid weight gain Mediterranean diet with low level of saturated fat, high level of fibre, fruit, vegetables and fish (omega-3 fatty acids) Piepoli MF et al. EJCPR 2010:1-17

30 Kostintervention gør det nogen forskel? 100 Percent CR UC 80 * * P< * 40 * * 20 0 Less fat More vegetables More fruit More fish Zwisler et al. Am Heart J, 2008

31 Effekt af livsstilsintervention Chow et al. Circulation. 2010;121:

32 Chow et al. Circulation. 2010;121:

33 Chow et al. Circulation. 2010;121:

34 Patientuddannelse Patient education is an important part of rehabilitation and should approach the themes: Information on the disease, treatment and medication, compliance, lifestyle changes, re-laps, coping with chronic disease, sexual dysfunction, social isolation, return to work, driving licence, insurance, travel etc. 13 RCTs involving 68,556 patients Conclusion: There was some evidence to suggest that education may improve HRQL and reduce overall healthcare costs. Whilst our findings are generally supportive of current guidelines that CR should include not only exercise, lifestyle changes and psychological interventions, further research into education is needed. Cochrane review: Brown et al. Patient education in the management of coronary heart disease Piepoli MF et al. EJCPR 2010:1-17

35 Psykosocial støtte Assessment of psychosocial parameters is recommended alongside intervention approaching anxiety and depression 24 RCTs involving 9,296 patients Conclusion: We found evidence that psychological interventions may produce small to moderate reductions in depression and anxiety, and may also reduce cardiac mortality. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions. Cochrane review: Whalley et al. Psychological interventions for coronary heart disease Piepoli MF et al. EJCPR 2010:1-17

36 Risikofaktor kontrol, medicin og klinisk opfølgning Target No T2DM T2DM Symptoms CCS 0, NYHA I-II BT 130/80 <130/80 (125/75) Lipids LDL <1,8 mmol/l <1,8 mmol/l Fasting glucose Fasting glucose< 6 mmol/l HbA1C < 6,5% Medication ASA B-blokker Statin (ACE-hæmmer) ASA Statin B-blokker ACE-hæmmer Piepoli MF et al. EJCPR 2010:1-17

37 Odds ratio Physical aktiv Fastlæggelse af mål for behandling Life style 0,0 1,0 2,0 BP sys mmhg Risk factor control - 25,0 0,0 25,0 Eating less fat Eating More vegetables BP dia mmhg Totale Cholesterol mmol/l - 0,5 0,0 0,5 Eating lmore fruit HDL Cholesterol mmol/l Eating more fish LDL Cholesterol mmol/l Not smoking Triglycerid mmol/l CR UC Period I Period III CR UC [Cardiac rehabilitation a health technology assessment]. National Board of Health, Denmark, 2006

38 Fastlæggelse af mål for behandling Period I Period III Composite outcome of death, re-infarction and rehospitalisation [Cardiac rehabilitation a health technology assessment]. National Board of Health, Denmark, 2006

39 Delelementer Individuel visitering og tilrettelæggelse Fysisk træning Kostintervention Patientundervisning Psykosocial støtte Rygeintervention Farmakologisk behandling (profylaktisk, symptomatisk) Risikofaktor kontrol og opfølgning Piepoli MF et al. EJCPR 2010:1-17

40 Øget fokus på standarder, audit og kvalitetssikring The RAMIT trial reminds us that CR, like any other treatment, can be delivered ineffectually. Clinical audit of all CR programmes is an essential safeguard to ensure that services are being delivered effectively. Editorial: Doherty et Lewin. 2012;

41 Quality of care continuum Research Consensus Guidelines Accreditation /adherence Quality of care continuum in cardiac rehabilitation Education Clinical practice Zwisler et al. EJCPR, 2011 Adapted from the EuroHeart Survey Programme

42 Audit anbefales Regular audit is essential and aims to demonstrate that programmes are achieving the desired clinical outcomes and to enable local evaluation and national comparison. Every cardiac rehabilitation service should audit locally and also register with their respective national audit programme. Piepoli et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. EJCPR, 2012

43 National databases around Europe By 2008 No (40%) Yes (35%) Plan to establish (25%) ESTABLISHED Austria Lithuania Netherlands Italy Poland Portugal Russia Sweden Switzerland United Kingdom PLANS Belgium Cypres France Germany Norway Ireland Serbia Zwisler et al. European Cardiac rehabilitation Inventory Survey (ECIRS). EJCPR,2011.

44 Dansk hjerterehabiliteringsdatabase (DHRD) Danmark 5.6 mill. indbyggere 52 hospitaler 98 kommuner Dansk hjerterehabiliteringsdatabase (DHRD) Drift fra 2013 All hospitaler er forpligtigede til at registrer På sigt skal kommunerne også være med Skal dække >90% af alle IHD udskrivelser Del af den kommende akkrediteringsmodel

45 Measuring levels LEVEL Patient Programme Referral to CR Pre-CR-data Content Post-CR-data AACVPR/ACC/AHA 2007 Performance Measures. JCRP, 2007 EuroCardioRehab. EJCRP, 2004

46 Programme content Criteria for participation Components of intervention (duration, numbers, content) Staff (structure, disciplines available, level of competence) Facilities Safety Cost (budget, patient fees, main care providers) EuroCardioRehab. EJCRP, 2004

47 Referral data Logistical referral information (dates, clinic, etc.) Basic demographic (age, gender, educational level etc.) Initiating event and date of event Co-morbidity Reason for non-inclusion Reason for non-acceptance EuroCardioRehab. EJCRP, 2004

48 Pre-cardiac rehabilitation data Working status Biometric data and biochemistry Risk factor status Mental health status Medication EuroCardioRehab. EJCRP, 2004

49 Post-cardiac rehabilitation data Working status Biometric data and biochemistry Risk factor status Mental health status Medication Intervention received Adverse events Compliance Onward referral EuroCardioRehab. EJCRP, 2004

50 Nationale ambitioner og bench-marking Accreditering Nationale standarder IHD patienter vurderet til rehablitering 90% Deltagelse blandt alle IHD patienter 35% Deltagelse blandt egnede patienter 70% Compliance i forbindelse med træning (80%+ of sessions planned) 70% 10%+ forbedring i fysisk arbejdskapacitet 80% Ex-rygere efter rehabilitering blandt rygere 60% LDL < 1,8 mmol/l or 50% reduktion 60% Blood preasure < 140/90 70% Screening for Diabetes mellitus 90% Screening for Depression 80% Medicin: Antitrombotica, statiner, beta-bolckers, ACE 95%, 80%, 80%

51 Hvad kan vi forvente at få ud af rehabilitering Evidens for: Forbedring i fysisk funktionsniveau Forbedring i HQRL Reduktion i sygedage Lavere sengedagsforbrug (Lavere mortalitet) Model ==>> Living better lives

52 Hvad kan vi forvente at få ud af rehabilitering Evidens for: Forbedring i fysisk funktionsniveau Forbedring i HQRL Reduktion i sygedage Lavere sengedagsforbrug (Lavere mortalitet) Model ==>> Living better lives