Cardiac rehab reduces CV events after MI

WASHINGTON — Exercise-based cardiac rehabilitation benefits patients who have had an MI in preventing adverse events, according to evidence presented at the American College of Cardiology Scientific Session.

The ACC/American Heart Association guidelines recommend exercise-based cardiac rehab as secondary prevention. Rehabilitation includes nutrition counseling, patient assessment, weight management, lipid management, BP management, diabetes management, tobacco cessation and psychosocial management. The presentation mainly focused on physical activity counseling and exercise training.

“Exercise training and an increase in habitual physical activity is associated with improvements in [CV] risk factors such as a reduction in LDL, a reduction in triglycerides, [C-reactive protein], [BP] and body mass,” Thijs Eijsvogels, PhD, postdoctoral fellow at Radboud Institute for Health Sciences’ Department of Physiology and the Research Institute for Sports and Exercise Sciences at Liverpool John Moores University in England, said in his presentation. “At the same time, cardiac rehab and exercise training specifically improves HDL, insulin sensitivity, endothelial function and vagal tone.”

Levels of cardiac rehab

There are two levels of training that patients can be prescribed. Moderate-intensity training, which is most common, comprises of three 45 to 60 minute sessions per week, where patients reach 60% to 80% of maximum heart rate. Patients prescribed high-intensity interval training have three 35 to 40 minute sessions per week. With interval training, the patient alternates 4 minutes at 85% to 95% of maximum heart rate, then 4 minutes at 50% to 70% of maximum heart rate.

“If you look at outcomes such as quality of life, endothelial function, heart rate recovery, resting heart rate and blood markers, there was no difference observed between the moderate- and high-intensity exercise training,” Eijsvogels said.

Eijsvogels referenced a study published in Circulation in 2012, where researchers analyzed data from 4,846 patients enrolled in moderate- or high-intensity programs. Although the event rate was higher in the patients in the high-intensity program, there were only three events total among the entire cohort.

In another study that Eijsvogels referenced, results from a study published in JACC in 2016 showed that participants in exercise programs had a 4% reduction in all-cause mortality. “In other outcomes such as [CV] mortality rate, there was a significant reduction of 26%,” Eijsvogels said. “For unplanned hospitalizations, there was a benefit for the cardio-rehabilitation group compared to the control group, so I think there is very strong evidence that cardio rehab is very effective and reduces the risk for adverse outcomes in those patients.”

Minimal participation

Although there is sufficient evidence that cardiac rehab helps patients, referral and participation rates are low. In a study in JAMA Internal Medicine in 2015, only 60% of eligible patients are referred to these programs, and half of eligible patients enter the program, Eijsvogels said.

The AHA/ACC guidelines also recommend an improvement in habitual physical activity, specifically 30 to 60 minutes of moderate-intensity activity per day. “Those patients that exercise the least have the highest risk for adverse outcome, whereas if you increase your physical activity pattern, you will get a risk reduction,” Eijsvogels said. A reduction in patients’ sitting time contributes to a reduced risk for mortality while improving CV health.

A study published in the European Heart Journal in 2015 noted the benefits of reduced sitting time. “If you reallocate 2 hours of sitting per day by standing or just simply stepping, there is an increase of triglycerides, and there is no difference between the standing and stepping intervention,” Eijsvogels said. There was also modification in other risk factors such as BMI, waist circumference and fasting glucose that either changed with standing, stepping or both.

He also pointed out that when patients who were active less than 2 hours a day replaced 1 hour of that time with exercise or activities such as household chores, garden work and walking, they saw a reduction in all-cause mortality.

Devices such as Fitbit can help patients to increase their activity time. “Maybe the simplest way [to use] Fitbit is just to reach the 10,000 steps per day or just maybe if it provides information about the total amount of exercise time per day, you can set a half hour a day to start with, and maybe later you can increase it to 45 minutes or an hour of moderate-intensity physical activity per day,” Eijsvogels said.

Robin Wedell, RN, FPCNA, program director at Heart Fit for Life, Palo Alto, California, and a member of the discussion panel, said it is important to counsel patients who were very active prior to their MI, as they often see cardiac rehab as an unnecessary step. “I usually suggest that they should give themselves the opportunity to get a full foundation of how to get back on track after an event,” Wedell said. “It’s not just exercise, but really learning your self-monitoring skills, knowing how to push your heart to its potential, not overdoing, not underdoing, but also getting the whole comprehensive approach of education, stress reduction, nutritional counseling, which I think sometimes is lost in the shuffle when they are doing it on their own. I think they owe it to themselves to get just a 3-month opportunity to get the whole package.” – by Darlene Dobkowski

Reference:

Eijsvogels T. I Can Do WHAT After My Heart Attack? Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.

Disclosure: Eijsvogels and Wedell report no relevant financial disclosures.