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?

J Am Col Cardiology. 2008; 52: 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.

Reviews of Exercise Based Rehabilitation Reviews No. of RCTs No. of Patients Meta- analysi s Relative Reduction in Total Mortality Exercise or Exercise plus CR Oldridge 1988 O’Connor 1989 Bobbio YesYesYes 24% (8 to 37%) 20% (4 to 34%) 32% (14 to 47%) Cochrane Review: Joliffe et al 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

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

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

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

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

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

Core components of CR

NACR Annual Statistical Report: week Medication Record

NACR Annual Statistical Report: month outcome (NSF Targets)

NACR Annual Statistical Report: Reasons for referral to CR

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

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”

Well Mr Capp, just have the PCI

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

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