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Cardiac rehab provides opportunity to improve outcomes after CV events
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SAN ANTONIO — Cardiac rehabilitation may be moving from a uniform program to one that is more personalized to a person’s needs, according to findings presented at the American Society for Preventive Cardiology Congress on CVD Prevention.
Even with this promise of more personalized care, cardiologists have not been recommending cardiac rehabilitation as often as they should, according to the presentation.
“Cardiac rehabilitation has been the ugly stepchild of cardiology, especially in the era of [transcatheter aortic valve replacement] and a lot of sophisticated interventions that bring in a lot of money to the hospital,” Pam R. Taub, MD, FACC, director of the Step Family Cardiac Wellness and Rehabilitation Center and associate professor of medicine at University California, San Diego, said during the presentation. “Cardiac rehabilitation has been neglected.”
Changes in cardiac rehab
In the era of value-based care, opinions of cardiac rehabilitation may be changing through collaboration within the CV service line to prevent readmission and improve outcomes, according to the presentation.
“More and more hospitals are realizing that it’s a service line and that we all have to work together and sometimes one very profitable part of the service line may need to subsidize another part of the service line just because working together yields improved outcomes,” Taub said.
Another trend is increasing reimbursement because of an emphasis on value-based care. Reimbursement for cardiac rehabilitation is nearly five times higher than it was 15 years ago, according to the presentation. Despite this, the cardiac rehabilitation program has not changed much in the past 30 years, even with the introduction of new technology such as wearables.
“It’s time for us to be more innovative and take cardiac rehabilitation to a new level,” Taub said.
For some health care professionals, cardiac rehabilitation just involves exercise, but it goes beyond that, according to the presentation. It can also include components such as smoking cessation, weight management and nutrition. Lifestyle interventions have been shown to decrease parameters such as BP.
Most centers have traditional cardiac rehabilitation programs, which is mainly focused on exercise with some education in 36 sessions over 12 weeks. University of California, San Diego, has an intensive cardiac rehabilitation program that consists of nutrition education, physician-supervised exercise, stress management and group support and is completed in 72 sessions over 18 weeks.
Not only does CV health improve during cardiac rehabilitation, but also a patient’s mental health, according to the presentation. The rate of depression is typically higher after a patient has a CV event, which is associated with worse outcomes. The cardiac rehabilitation program at University of California, San Diego, calculate depression scores at the beginning and at the end.
“It’s incredible that in addition to improving exercise capacity, we also improve their depression scores,” Taub said. “This is because of that community that cardiac rehabilitation provides. In an era where we’re trying to move a lot of things to more remote-based cardiac rehab, I can’t emphasize the importance of that high-touch environment that cardiac rehabilitation provides.”
Indications covered by insurance
The indications for cardiac rehabilitation that are currently covered include MI, CABG, chronic stable angina, cardiac transplantation, heart valve repair or replacement, systolic HF and peripheral artery disease. HF with preserved ejection fraction is not covered because data are limited on the benefits of cardiac rehabilitation in this patient population.
All studies that have assessed the effect of cardiac rehabilitation found that there is a clear benefit for readmission and a reduction in mortality, according to the presentation. Cardiac rehabilitation was given a class IA recommendation in the American Heart Association/American College of Cardiology guidelines.
One of the biggest reasons why patients are not utilizing cardiac rehabilitation is because physicians are not recommending it, according to the presentation. There are other patient-related issues for the lack of utilization including high copays and transportation.
“When we make that recommendation, they’re much more likely to follow it,” Taub said.
Wearable technology such as watches and other devices may be part of the new paradigm for cardiac rehabilitation, but sometimes they may not lead to a meaningful change and improved outcomes, according to the presentation.
“It’s important for us to do rigorous clinical trials with a lot of this technology,” Taub said. “Cardiac rehab is an incredible setting to study these technologies.”
Incorporating visceral fat and other measurements at the beginning of an exercise regimen will allow cardiologists to personalize the program a patient receives, according to the presentation. For example, if a patient has high visceral fat, their exercise regimen should focus on high-intensity interval training.
“We’re trying to get cardiac rehab to the era of personalized medicine instead of just putting everyone on a couple different machines and then having them switch,” Taub said. “It’s very useful for patients when you show them what their body composition is.” – by Darlene Dobkowski
Reference:
Taub PR. Rebranding and rehabilitating cardiac rehabilitation in 2019. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 19-21, 2019; San Antonio.
Disclosure: Taub reports she is a consultant or on the speakers bureau for Amarin, Amgen Pfizer, Boehringer Ingelheim, Janssen, Novo Nordisk and Sanofi/Regeneron and has received research funding from the AHA, Department of Homeland Security and the NIH.