Presented By: Sarah Borders, Keri Howard, Justin Klenke, Conner Zuber Center vs Home Based Cardiac Rehabilitation: Post Myocardial Infarction Presented By: Sarah Borders, Keri Howard, Justin Klenke, Conner Zuber

Introduction Cardiac Rehabilitation Improve Physical Health Decreased Morbidity and Mortality 20% reduction in all cause mortality 27% in cardiac mortality at 2-5 years (Dalal, 2010)

Introduction Cardiac Rehabilitation 3 year survival rate of participants vs non-pariticipants Improves prognosis post-MI in cost effective manner Participation increases long term compliance Positively affects the basic pathophysiology of CAD and underlying causes (Williams, 2006) Completed CR: 3 year survival rate 95% compared to 64% on non complete Cost effective: reduce recurrent hospitalization and health care expenses Its important therapuetic modality warrants more widespread application Basic pathophys: positive affects on CAD, underlying disease process- impacts events of morbidity and mortality

Introduction Cardiac Rehabilitation Significant increases in: VO2 6 Minute Walk Test Anaerobic Threshold Positive gains seen in patients with congestive heart failure, etc. (van Tol, 2006)

Introduction Primary Goals of Cardiac Rehabilitation Components Develop individualized therapuetic plan Aim of regaining/maintaining optimal status Components Home vs Center Based (Piotrowixz,2008) Other Goals: Control of pharmacotherapy Maintaining optimal mental and physical condition Reduction of risk factors Promotion of health lifestyle Cardiac Rehabilitation Components Clinical Evaluations Optimization of Pharmacotherapy Physical Training Psychosocial Rehabilitation Evaluation and Reduction of Risk Factors Lifestyle Modification Patient Education http://www.sabethahospital.com/pictures/content/31817.jpg

Role of Physical Therapist Minimally involved 1960s: Physical Therapist considered “Exercise Specialist” 1980s: exercise physiology increases in population Now: small amount of PT’s specialize in Cardiopulmonary fields Require special training to become program director Definition of PT training (William,2008) Minimally involved directing CR programs and writing prescriptions RN or exercise physiologist majority of program directors 1960s: become more responsible with exercise prescription The PTs who do specialze more involved in acute care setting PT training: “they would particularly qualified to manage complex patietns with cardiac and pulmonary diseases who present with orthopedic or nuerologic co-morbidities

Center-Based Cardiac Rehabilitation Supervised group program undertaken in hospital or community setting (Dalal, 2010) Pro’s Con’s Pros: Constant monitoring with trained staff Group based exercises Provides equipment which may not be at patients home Cons: Pt. must travel to facility Possibly decreased compliance Expense http://www.harthosp.org/Portals/1/Images/21/cardiac_rehab_home.png

Home-Based Cardiac Rehabilitation Structured program with clear objectives Completed in patient’s home Must include PT/Physician monitoring (Dalal, 2010) Pro’s Con’s Pro’s: No travel Completed at patient’s desired time Increase compliance? Can be monitored via phone Less expense Con’s: No on site monitoring Lack of exercise equipment possible Pt. must be self- motivated Decrease compliance? http://www.cantonmercy.org/uploads/Image/cardiac_mainimage.jpg

Center-Based Research Combined leg ergometry and circuit training 6 week program Intensity and duration increased at week 3 Participants completed a home exercise program (Leitch,1997) 30 minute session (first week) and 60 minutes by third week. Intensity increased to 70% of max HR by week 3 Participants also completed a home exercise program 5 minutes (week 1) and 30 minutes (week 6) 2x/week

Center-Based Research 40 total sessions during a 5 week period stretching and flexibility exercises endurance training (Marchionni, 2003) Hospital based setting Comprehensive cardiac rehab programmes (Jolly, 2003) Study #2 24 sessions of endurance training on a cycle ergometer: complete 3x a week 16 sessions of stretching and flexability: complete 1 hour sessions 2x a week STUDY #3 Comprehensive cardiac rehab program consisted of risk factor counseling, relaxation and supervised exercise sessions for 6-12 weeks 1 to 2x a week.

Home-Based Research Walking program (considered control group) (Leitch, 1997) Received similar exercise prescription as the center-based participants (Marchionni, 2003) STUDY #1 Just completed the walking program with no other exercise in order to be a control group (compared to the center based program listed early: combination of leg ergometry and circuit training for 6 weeks, 30 mins for first weeek to 60 mins for third week. Also increased intensity to 70% of mac HR by week 3, also completed a home walking prgram for 30 mins 2x/week in week six and 5 mins 2x/week in week one) STUDY #2 4 to 8 supervised instruction sessions in the cardiac rehab unit Received similar exercise prescription as the center based parcipants: center based participants prescription included 40 sessions: 24 (3x a week) of endurance training on a cycle ergometer, and 16 sessions (2x/week) 1 hour sessions of stretching and flexibility exercises A PT made home visits every other week to adjust if necessary the exercise prescription, to enhance the adherence with intervention, and to record number of completed sessions and distance cycled.

Home-Based Research Given a manual, telephone contact, and home visits Heart manual program for first 6 weeks post MI Home visits at 1-2 weeks, 6 and 12 weeks Telephone contact at 3 weeks (Jolly, 2003) STUDY #3 The heart manual: this is a facilitated home-based programme for the first 6 weeks following MI, which included education, a home based exercise prgramme, and a tape-based relaxation and stress management programme Telephone contact at 3 weeks during which the rhav nurse discusses the contents of the manual with the patient and partner and sets individual objectives with the patient with respect to smoking cessation, diet and exercise

Results Peak oxygen and endurance increased in the exercise groups. (Leitch, 1997) Home and center based showed similar improvements in: Exercise capacity Systolic blood pressure and serum cholesterol Reduced hospital admits and increased QOL (home heart manual only) (Jolly, 2003) STUDY #1 (Leitch et al)- where home walking program was used as a control group Results showed minimal additional benefits on cardiac autonomic function compared with a standard home walking program An additional supervised exercise training does not appear to result in clinically significant changes in cardiac autonomic function compared with a home walking program. STUDY #2 Home based programme using the heart manual reported significantly reduced hospital admissions and report a significantly improved QOL compared to center based.

Results Improvements in both settings continued: Home based Total work capacity (TWC) Exercise tolerance Heart related quality of life (HRQL) Home based Cost saving and better permanent changes in lifestyle Higher drop out rates (Marchionni, 2003) Post MI cardiac rehab enhances exercise tolerance in all patients of all ages Costs for center based was $21,298, while it was $13,246 for home Cardiac rehab. Home CR was associated with cost savings more than hospital Home cardiac rehab with implicit self management of the exercise program, induces a permanent change in lifestyle more effectively than hospital cardiac rehab.

Results Exercise capacity Short term showed no difference Long term showed better results with home based (Dalal, 2010) Pooled analysis across all studies showed no significant differences in short term exercise capacity between home and center based CR Pooled analysis of three studies reported longer term data (14-24 months) that exercise capacity was better with home based CR.

Exercise Capacity Comparisio (Dalal, 2010)

Patient Preference (Dalal, 2010) Patient’s preference has been hypothesized to have an impact on uptake and adherence to home based vs center based CR. This meta anlysis states that patients were split on setting preference. This meta analysis found no difference between the 2 groups, regarding postive physical performance benefits. We agree that there is no true optimal setting to complete cardiac rehab. There are mutliple factors patients must consider when deciding which setting is best for him/her. (Dalal, 2010)

Further Benefits for Cardiac Rehab Patients were coronary artery bypass graft. Shows beneifts of CR outside of MI Can’t conclude that center based is better for any heart complication based on this graph. Just proves that CR is beneficial in increasing exercise capacity when patients complete. (Arthur,2002)

Conclusion Any exercise is better than nothing Positive physical benefits similar in both settings Programs must be patient specific Questions? Cardiac Rehabilitation

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