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Secondary Prevention & Cardiac Rehabilitation

Secondary Prevention & Cardiac Rehabilitation. Malcolm Walker Consultant Cardiologist UCLH & the Heart Hospital, London. Malcolm Walker NO CONFLICT OF INTEREST TO DECLARE. COURAGE Trial. When the PCI is over, what else could there possibly be left to do?.

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Secondary Prevention & Cardiac Rehabilitation

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  1. Secondary Prevention & Cardiac Rehabilitation Malcolm Walker Consultant Cardiologist UCLH & the Heart Hospital, London

  2. Malcolm Walker NO CONFLICT OF INTEREST TO DECLARE

  3. COURAGE Trial

  4. When the PCI is over, what else could there possibly be left to do?

  5. Patients with significant coronary stenoses are at increased risk of future cardiac events. However, in the absence of acute coronary syndrome or recent MI and residual ischemia, elective PCI has not been shown to improve prognosis. J Am Col Cardiology. 2008; 52: 889-893

  6. Reviews of Exercise Based Rehabilitation Cochrane Review: Joliffe et al. 2000 8440 patients after MI or Revascularisation Exercise only: 27% fall in all cause mortality; 31% fall in cardiac mortality Exercise + : 13% fall in all cause mortality; 26% fall in cardiac mortality

  7. Cardiac Rehabilitation - the Statin era • 2004 Metanalysis • 48 RCTs, n= 8940 • Patients hospitalised for CHD • Conclusion: 20% reduction in all cause mortality 24% in cardiovascular mortality Taylor, R.S. et.al. Am J Med 2004

  8. Hambrecht group – Event-free survival in exercise versus PCI groups at 24 months Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112

  9. hs CRP levels at Baseline & 24 Months p = 0.025 p = ns Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112

  10. How might exercise improve CAD outlook • Improved associated cardiovascular risk factors • Improved physical fitness • Weight • Diabetes • HDL levels • Adherence to improved diet • Reduced smoking • Improved compliance with medication • Markers of inflammation: e.g. hs CRP • Endothelial function

  11. Cardiac Rehabilitation (CR) - after PCI • 2008 • 213 patients post PCI • Non-randomised: 133 received CR, 80 no CR • Mean follow-up 4.5yr • Results: • Readmission for CAD event 45% CR vs 75% no CR • Revascularisation 7% CR vs 17% no CR • Total health care cost: 4862 Eu/pt vs 5498 Eu/pt • 15/12 MACE 24% CR vs 42% no CR P<0.005 Dendale P. et.al. ActaCardiol 2008

  12. Core components of CR

  13. NACR Annual Statistical Report: 200812 week Medication Record

  14. NACR Annual Statistical Report: 200812 month outcome (NSF Targets)

  15. NACR Annual Statistical Report:Reasons for referral to CR 2006-2007

  16. NACR Annual Statistical Report:2008Percentage Eligible Patients Who Receive CR in England

  17. Barriers to CR • Speed of throughput • Tertiary centre syndrome • Not my responsibility • The nurses will do it • It’s primary care’s job • Patient reluctance the “Andy Capp syndrome”

  18. Well Mr Capp, just have the PCI

  19. Overcoming the Barriers to CR • Local CR programmes have to be • Accessible • Flexible • Responsive • Visible • Provide CR to a level known to improve prognosis • Cardiologists have to take responsibility for the complete “package” of care… or assume the role of cardiac interventional radiologists

  20. Can we see a time when all PCI patients from CR? Dream on

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