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From Cardiac Rehabilitation to Cardiovascular Prevention (.Pdf) saner_pap_BOOK.qxp 14/4/05 10:53 am Page 14 Prevention of Cardiovascular Risk From Cardiac Rehabilitation to Cardiovascular Prevention a report by Dr Hugo Saner Director, Cardiovascular Prevention and Rehabilitation, Swiss Cardiovascular Centre, Bern University Hospital Coronary heart disease (CHD) is the leading cause of Target Population death in most countries. It is also a major cause of physical disability, particularly in the rapidly growing After the initial concentration on post-infarction population of elderly people. The prevention of patients and patients recovering from coronary artery subsequent coronary events and the maintenance of bypass graft (CABG), percutaneous transluminal physical functioning in such patients are major coronary angioplasty (PTCA) or other forms of challenges in preventative care. myocardial revascularisation and changes in demography led to the expansion of cardiac Dr Hugo Saner is Professor of Cardiac rehabilitation (CR) programmes were first rehabilitative care to older patients, many of whom had Medicine at the University of Bern developed in the 1960s. Benefits of ambulation severe and complicated coronary illness and serious and Director of Cardiovascular Prevention and Rehabilitation at the during prolonged hospitalisation for coronary events associated pathologies. Many patients once considered Swiss Cardiovascular Centre, Bern have been recognised. After hospital discharge, the to be too high-risk for structured rehabilitation University Hospital, Switzerland. He process of physical reconditioning was continued at programmes (e.g., patients with residual myocardial is a Fellow of the European Society of Cardiology (ESC) and served as home. Programmes for supervised highly structured ischaemia, compensated heart failure, serious President of the European Working exercise regimes have been developed due to arrhythmias and implantable cardiac defibrillators Group on Cardiac Rehabilitation and Exercise Physiology from concern over the safety of unsupervised exercise. (ICDs)) currently derive benefit from more gradual, 2001–2003. He is Co-Editor-in- The focus of the programmes was almost exclusively protracted and often supervised exercise training. CR Chief of the European Journal of on exercise. During the past 20 years it has been is also appropriate for patients with chronic heart failure Cardiovascular Prevention and Rehabilitation and is also National increasingly recognised that most patients in CR and those who have undergone cardiac transplantation. Co-ordinator of the ESC and the programmes suffer from the consequences of Swiss Society of Cardiology for cardiovascular disease (CVD) atherosclerosis, and that this condition is a lifelong Programme Components prevention in Switzerland. process in patients likely to be affected by cardiovascular (CV) risk factors and are not There is convincing evidence that the combination genetically protected against it. At the same time, the of regular exercise with interventions for lifestyle physical condition of patients after cardiac surgery changes and modification of risk factors favourably and coronary interventions improved considerably. It alter the clinical course of CVDs. Exercise is therefore still an important goal of CR to prevent interventions are therefore combined with disability resulting from CHD, particularly in older education, counselling, behavioural strategies and people and those with occupations involving physical other psychosocial interventions and vocational exertion. The primary goal of current CR counselling strategies. These are designed to assist the programmes is to prevent subsequent CV events, patient in achieving coronary risk reduction and hospitalisation and death from cardiac conditions. other CV health-related goals, so that these programmes function as comprehensive secondary Secondary Prevention Through CR prevention services. Secondary prevention through CR is an essential The Integration of Acute Care, component of the contemporary management of In-patient and Out-patient patients with various presentations of CHD and Programmes with heart failure and it should be integrated into the long-term care of all patients with Different patterns of rehabilitative care are currently cardiovascular disease (CVD). Comprehensive CR delivered by specialised hospital-based teams – has well-documented effects on symptoms, exercise residential CR for more complicated, disabled tolerance, blood lipid levels and global risk profiles, patients and out-patient CR for more independent, cigarette smoking, psychosocial wellbeing, low risk and clinically stable patients requiring less progression of atherosclerosis and subsequent supervision. There may be variations of individual or coronary events resulting in reduced hospitalisation group programmes and centre-based or home-based 14 and decreased morbidity and mortality. activity programmes. BUSINESS BRIEFING: EUROPEAN CARDIOLOGY 2005 saner_pap_BOOK.qxp 14/4/05 10:54 am Page 15 From Cardiac Rehabilitation to Cardiovascular Prevention While the objectives are identical to those of the The Science Behind the out-patient CR programmes, residential rehab- Practice ilitation programmes are specifically structured to provide more intensive and/or complex Potential benefits of CR and secondary prevention interventions and have the advantage of starting have been shown by numerous scientific papers. early after the acute event, including more Four meta-analyses of exercise-based CR pro- complicated high risk or clinically unstable patients grammes show a reduction in overall and CV and more severe incapacitated and/or elderly mortality by 25% to 30% during one to three years of patients (particularly those with co-morbidity), follow-up. Five prospective randomised studies thus facilitating the transition from hospital phase indicate that the slowing of progression of the to a more stable clinical condition, which may atherosclerotic process can be achieved by either allow the maintenance of an independent life at lifestyle intervention alone or by lifestyle home. One major disadvantage of in-hospital interventions combined with preventative medical programmes is the relatively short duration of therapy. Two prospective randomised studies intervention with regard to risk factor management indicate that rates of subsequent coronary events and and lifestyle changes. Residential CR programmes rehospitalisations have decreased – therefore CR is a should therefore be followed-up by a long-term cost effective treatment. Within the measures applied out-patient risk reduction and secondary in CR exercise training is the cornerstone of prevention programme, with appropriate clinical treatment: CV fitness has become one of the most and functional monitoring. powerful predictors for mortality in CV patients. Formal Requirements for Guidelines In-patient and Out-patient CR Programmes In 2003 the European Working Group on Cardiac Rehabilitation and Exercise Physiology of the CR/secondary prevention programmes should be European Society of Cardiology (ESC) published a delivered under the guidance of a cardiologist position paper in the European Heart Journal on experienced in the exercise testing and exercise “Secondary prevention through cardiac rehabil- training of patients with various forms of CVD itation”. Just a few weeks previously, from the time suitable for such programmes, with a specific of press, an expert panel of the American Heart knowledge in all important aspects of rehabilitative Association (AHA) released a scientific statement and secondary preventative care. from the Council on Clinical Cardiology on Cardiac Rehabilitation and Secondary Prevention of The staff should include a cardiologist, Coronary Heart Disease. Secondary prevention physiotherapists or sport teachers, nutrition through comprehensive CR should become an counsellors or dieticians, psychologists or essential component of the contemporary psychiatrists and preferably also a social worker or management of patients with CHD and with heart vocational counsellor. failure. It should be integrated into the long-term care of all patients with CVD. There are no formal requirements on an international level for equipment, logistics and The Gap Between certification; however, there are national guidelines Scientific Evidence and and recommendations in most European countries. Clinical Practice Although life-threatening CV complications are rare during formal CR programmes, a well Despite the well-established benefits of exercise designed and regularly controlled emergency and nutritional counselling, physicians are generally concept is crucial for each programme. Staff not well trained enough to provide this type of members should be regularly trained in instruction and do not have the time to provide cardiopulmonary resuscitation (CPR) and basic life effective nutritional advice, guidance about weight support, an alarm system has to be established and management and prescriptions for exercise. The also regularly tested, and very early defibrillation provision of all these services at cardiac- and rapid access to advanced life support have to be rehabilitation centres, with the use of well- assured. With regards to equipment, there is established algorithms to set goals for risk reduction consensus in most European countries that easy and in co-ordination with the primary care access to 12-lead echocardiogram (ECG), physician, is efficient and effective. ■ ergometry with either bicycle or treadmill ergometer, two-dimensional (2-D)-doppler This article is continued, with references, in the Reference echocardiography, chest X-ray and telemetry or Section on the website supporting this business briefing Holter-ECG is needed. (www.touchbriefings.com). 15 BUSINESS BRIEFING: EUROPEAN CARDIOLOGY 2005.
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