II. Background

  1. Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 14-31% participation)
  2. Cardiac Rehabilitation has great efficacy as a secondary prevention tool

III. Indications

  1. Medicare reimbursed indications (3 sesssions per week for 3 months)
    1. Following acute Myocardial Infarction (STEMI or non-STEMI) in the last 12 months
    2. Status-post Coronary Artery Bypass Graft (CABG)
    3. Status-post Percutaneous Coronary Intervention (PCI)
    4. Stable Angina Pectoris
    5. Status-post Vascular Surgery
    6. Status-post Heart Transplantation
    7. Status-post Heart Valve Repair or Replacement
    8. Recent CVA (women only)
  2. Other indications
    1. Stable Congestive Heart Failure with reduced left-ventricular ejection fraction
    2. Peripheral Arterial Disease
    3. Status-post Ventricular Assist Device placement
    4. Pacemaker or Implantable Cardioverter-Defibrillator

IV. Protocol: Cardiac Rehabilitation Phases

  1. General
    1. Standard programs
      1. Exercise training program for a total of a 36 session program over 12 weeks
      2. Medicare covers up to two, 1 hour sessions per day
    2. Intensive programs (limited availability)
      1. Intensive programs may include up to 72 sessions over up to 18 weeks
      2. Medicare approved programs
        1. Dean Ornish Program for Reversing Heart Disease
        2. Pritikin Intensive Cardiac Rehab Program
        3. Benson-Henry Institute Cardiac Wellness Program
  2. Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
    1. Supervised, structured early Physical Activity
    2. Patient Education
    3. Risk stratification (low level, graded, Exercise tolerance testing)
  3. Phase II Cardiac Rehabilitation (Early Outpatient)
    1. Supervised Physical Activity program
      1. Reassess symptom-limited Exercise tolerance
      2. Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
    2. Monitoring of Blood Pressure, pulse, cardiac rhythm
      1. Maintain Blood Pressure <140/90 mmHg
    3. Nutrition counseling
      1. May involve education on cooking and grocery shopping
      2. Diabetes Mellitus Type II control with Hemoglobin A1C <8%
      3. LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
      4. Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
    4. Cardiac Risk Factor modification
      1. Tobacco Cessation
    5. Reassess cardiac symptoms at rest and with activity
    6. Psychosocial support to screen for and manage Major Depression
  4. Phase III Cardiac Rehabilitation (Late Outpatient)
    1. Maintain and reinforce phase I and II management
    2. Reinforce medication use, Patient Education

V. Protocol: Activity restrictions following acute Myocardial Infarction

  1. Gradually increase activity over 6-8 weeks following MI
  2. Return to work by 8 weeks after MI
  3. Activity program may start by 3-4 weeks after MI
  4. Sexual activity restarted at 4-6 weeks after MI
    1. See Sexual Intercourse after Myocardial Infarction

VI. Protocol: Other Measures

  1. Influenza Vaccine each year

VII. Efficacy

  1. Reduced Angina, Dyspnea, and Fatigue
  2. Reduced Major Depression after acute coronary event
  3. Exercise performance improved
  4. Activities of Daily Living (ADL) performance improved
  5. Quality of life improved
  6. Decreased re-hospitalization rate
  7. Decreased work absence
  8. Reduced age-adjusted cardiovascular mortality by 50%
  9. References
    1. Bondestam (1995) Am J Cardiol 75:767-71 [PubMed]
    2. Milani (2007) Am J Med 120(9): 799-806 [PubMed]

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