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

2. Malcolm Walker NO CONFLICT OF INTEREST TO DECLARE

5. COURAGE Trial

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

7. J Am Col Cardiology. 2008; 52: 889-893 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.

8. 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 1989 1098434745542260YesYesYes 24% (8 to 37%) 20% (4 to 34%) 32% (14 to 47%) 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

9. 2004 Metanalysis 2004 Metanalysis 48 RCTs, n= 8940 48 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

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

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

13. 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

14. 2008 2008 213 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<0.005 15/12 MACE 24% CR vs 42% no CR P<0.005 Cardiac Rehabilitation (CR) - after PCI Dendale P. et.al. Acta Cardiol 2008

16. Core components of CR

17. NACR Annual Statistical Report: 2008 12 week Medication Record

18. NACR Annual Statistical Report: 2008 12 month outcome (NSF Targets)

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

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

22. 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”

24. Well Mr Capp, just have the PCI

25. 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

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