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SECTION 2 Treatment ofcoronary artery disease
to the question of the clinical benet conferred by multiple arterial
bypass graing.
latest updates on dual antiplatelet therapies, also focusing on the
surgical population., In addition, the outcomes depend on the
management of several additional comorbidities, such as the aggres-
On- pump versus off- pump
sive management of hypertension and hyperlipidaemia, glycaemic
control, prophylaxis of surgical site infection, treatment of dysrhyth-
mias, and cardiac rehabilitation, which is recognized in a timely
e use of cardiopulmonary bypass is associated with the manipulation of the ascending aorta and initiates a systemic inammatory
response that is linked with numerous perioperative complications.
On the other hand, the technique of performing CABG without
cardiopulmonary bypass support (o- pump), which was initially
developed to decrease perioperative complications, has shown a
tendency for higher rates of repeat revascularization aer the opump procedure in institutions with insucient experience with
this technique.
By 2011, only the Randomized On/ O Bypass (ROOBY) trial
comparing on- pump versus o- pump CABG had been published,
manner and comprehensively covered in the EACTS and the AHA
guidelines on perioperative medications., Despite such recom-
mendations, the use of guideline- directed medical therapy remains
stubbornly low with fewer than 50% of patients in RCTs of PCI and
CABG receiving optimal therapy at 5years. Furthermore, the use
of therapy is substantially lower in CABG than PCI patients leading
to inferior clinical outcomes than would be achieved with more op-
timal therapy. is is a critical issue that has compromised CABG
in comparison to PCI in virtually every RCT that has contributed to
the evidence base upon which both European and American guide-
lines have been based.
inuencing the American guidelines to consider either approach
to be reasonable for the majority of patients undergoing CABG.
In the meantime, two large clinical trials, the German O- Pump
Coronary Artery Bypass Graing in Elderly Patients (GOPCABE)
and the CABG O or On Pump Revascularization (CORONARY)
trials have shown no dierence in early and mid- term clinical outcomes between on- and o- pump surgery when performed by experienced surgeons. Based on the accumulated data, the 2018 ESC/
EACTS Guidelines on myocardial revascularization recommend
o- pump CABG with classIIaB for high- risk surgical patients (le
ventricular dysfunction, renal impairment, severe anaemia, old
age, prior stroke, redo- CABG, and chronic lung disease) and with
classIB for patients with signicant atherosclerotic aortic disease to
reduce the incidence of stroke in high- volume centres in the hands
of highly trained teams.
Reasons fordifferences inthe
givenrecommendations
Possible causes for dierent recommendations between guidelines
certainly include dierent publication timings, but also dierent
methodological approaches, interpretations of the evidence, and
healthcare environments. e diverging methodology starts with
the composition of task force members. In general, cardiologists
have far outnumbered cardiac surgeons on all guideline writing
committees and task forces on both sides of the Atlantic. Weighing
outcomes’ importance and grading the overall quality of the evi-
dence involve complex and potentially subjective decision- making.
Methods for achieving consensus among task force members and the
rules for managing possible conict of interest relationships within
Otherissues
e 2018 ESC/ EACTS Guidelines suggest a time frame during
which revascularization procedures should be performed, probably reecting specic European issues of access to care. Patients
requiring myocardial revascularization are at higher risk of adverse
events during the waiting period. According to the European recommendations, stable patients with symptomatic complex CAD
or depressed le ventricular ejection fraction should be preferably
treated within 2 weeks, while others should wait for no longer than
6 weeks for treatment.
Another vital factor that is proven to markedly aect short- and
long- term CABG results is optimal medication management before, during, and aer surgical intervention. Numerous antiplatelet
and anticoagulation agents have been introduced for both bridging
and chronic use since the 2011 ACC/ AHA CABG Guidelines.
e management of CABG patients is a delicate issue due to the
need to balance both the bleeding and the thrombotic risks carefully. Importantly, the number of patients with prior PCI who subsequently undergo CABG is increasing yearly. Recognizing the
importance of the consensus regarding optimal antithrombotic
strategies in CABG, both groups of guidelines have released the
the industry might lead to dierences in the nal recommendations.
For example, the ESC/ EACTS methodology manual for joint guidelines suggests the use of the voting system, in which at least 75% of
task force members should agree on the nal recommendation. On
the other hand, the ACC/ AHA methodology manual species that,
when consensus is not achievable, formal voting of at least 51% of
task force members is required to endorse any of the recommendations. Importantly, developers of both guidelines strongly agree that
the task force member(s) with the relevant conict of interest may
participate in the discussion but must be excluded from the nal
voting.
Continuous improvements in the outcomes of CABG and PCI
technology have made the 2011 AHA/ ACC CABG Guidelines outdated. is is particularly relevant when considering the procedural
aspects of both CABG and PCI. Since the 2011 AHA/ ACC CABG
Guidelines were published, PCI has undergone signicant improvement with the introduction of newer- generation drug- eluting stents,
intracoronary pressure measurements, intracoronary imaging, and
better adherence to secondary prevention medications. Similarly,
despite an increasingly higher risk prole among patients, advances
in surgical techniques— as well as in the whole spectrum of patient
care— are associated with a continuous reduction in postoperative complications, even in contemporary practice. Future research
12 Differences and similarities betweenAmerican and European myocardial revascularizationguidelines 119
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studies are warranted to enhance the selection of patients with
multivessel disease who will benet from both modern CABG and
PCI, and who are treated with optimal secondary prevention medications. Unfortunately, there is a lack of ongoing studies in the eld.
Conclusion
In summary, the CABG guidelines on both sides of the Atlantic are
globally concordant in multiple ways. Importantly, both recommend
a ‘Heart Team’ approach for managing patients with complex stable
CAD. ere are specic variances in these two guidelines due to the
dierent timings of publication and methodological aspects. With
the increasing number of clinical studies, guideline updates at regular
intervals are becoming obligations for guideline developers to ensure
the selection of the most appropriate treatment using the best contemporary evidence. e ESC and the EACTS will issue a new version of
the myocardial revascularization guidelines in 2021– 2022. Similarly,
the ACC/ AHA have planned to update the American guidelines in
the year to come. Joint forces from scientic societies are warranted to
ensure broad implementation of clinical guidelines and optimize their
adherence to improve patient safety and the quality of care.
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13
Comprehensive secondary cardiovascular
prevention and cardiac rehabilitation
aercoronary artery bypass grasurgery
Suegene K. Lee, Jay Khambhati, Pratik Sandesara, Danny Eapen, Gina Lundberg,
Basil Margolis, Neil Gordon, Barry Franklin, and Laurence Sperling
Introduction
Atherosclerotic cardiovascular disease (ASCVD) remains
the leading cause of mortality worldwide. Although the agestandardized years of potential life lost per 1000 have decreased in
recent years, more than 50years aer the rst coronary artery bypass gra (CABG) surgery in 1964, the incidence and prevalence
of ASCVD remain high. Following coronary revascularization,
risk factor and lifestyle modications are critical for improving
long- term outcomes. Comprehensive, exercise- based cardiac rehabilitation (CR) is an integral component of secondary prevention of ASCVD (Fig. 13.1).
Overview ofcardiacrehabilitation
CR is dened as ‘the provision of comprehensive long- term services involving medical evaluation, prescriptive exercise, cardiac risk
factor modication and education, counselling, and behavioural
interventions’. It is traditionally delivered in three or four phases
and includes ve core components (Table 13.1).
Benefits ofand indications forcardiacrehabilitation
A systematic review and meta- analysis of randomized controlled
trials of CR in patients with myocardial infarction (MI), angina,
or coronary revascularization, including 63 studies in 14,486 participants, demonstrated reductions in cardiovascular mortality and
hospital readmissions by 26% and 14%, respectively, as well as improvements in many quality of life measures. Specically, patients
who have undergone CABG have demonstrated 35– 46% risk reductions in all- cause and cardiovascular mortality aer CR participation., Other benets include decreased angina, increased exercise
capacity, and overall improvement in risk factor proles and quality
of life.
Accordingly, the American Heart Association (AHA) statement
on secondary prevention aer CABG recommends CR for all patients aer CABG with early initiation postoperatively (classIrecommendation, level of evidence A). Similarly, the European Society
of Cardiology and the European Association for Cardio- oracic
Surgery Guidelines recommend that CR be initiated for all
revascularized patients during the index admission, with exercise
training serving as an integral component of the intervention.
Principles of exercisetraining
Cardiovascular response toexercise
In response to exercise training, organ systems respond to meet the
associated increasing metabolic demands and energy expenditure.
Modulations in heart rate (HR), stroke volume (SV), cardiac output
(CO), and blood pressure (BP) serve to increase the delivery of oxygenated blood to metabolically active tissues. Initially, HR increases
in a linear manner before gradually plateauing at a steady state. is
is mediated by a withdrawal of parasympathetic stimulation or vagal
tone followed by heightened sympathetic activity. Although maximum HR may be approximated by the equation 220– age (in years)
for healthy men and women, this widely used formula may underestimate and overestimate the maximum or peak HR in older adults
and cardiac patients, respectively. With an increase in le ventricular
ejection fraction, SV increases in a hyperbolic fashion with exercise
intensity, generally plateauing at 50% of the maximum oxygen consumption (VO max). Due to relative increases in HR and SV, CO
(SV × HR) may be 20– 25 L/ min at maximum exercise in healthy,
young adults. Systolic BP increases linearly with exercise intensity,
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Lifestyle modification and pharmacotherapies
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SECTION 2 Treatment ofcoronary artery disease
Patient
assessment
of
Blood pressure
Lipid
management
Nutrition
counseling
Weight
management
management
Second
event
First event
Clinical disease
Angina, MI, CHF, PAD,
stroke, sudden death
Subclinical disease
(if appropriate)
hypertension, dyslipidemia,
Poor dietary habits Physical inactivity Cigarette smoking
Left ventricular dysfunction, carotid
stenosis, coronary calcification,
myocardial ischemia, more vulnerable
plaque, potential for thrombosis
Traditional
Age, family history,
diabetes, obesity
Risk factors
Secondary
prevention
Primary
prevention
Nontraditional
Psychosocial stressors,
air pollution,
inflammation, other (?)
Physical
activity
counseling
Psychosocial
management
Tobacco
cessation
Primordial
prevention
Exercise
training
Core components
cardiac rehabilitation
Diabetes
management
Unhealthy
lifestyle
practices
Fig.13.1 Cardiac rehabilitation and the ASCVD prevention pyramid. Pyramid (left) shows how unhealthy lifestyle practices lead to development
of risk factors, progression of ASCVD, and, ultimately, to adverse outcomes or clinical endpoints. There are three types of prevention:primordial
(prevention of risk factors); primary (treatment of risk factors); and secondary (prevention of recurrent cardiovascular events), which can be modulated
by environmental and psychosocial stressors, lifestyle changes, and cardioprotective medications, if appropriate. The first- line strategy to prevent initial
or recurrent cardiac events is to favourably modify unhealthy lifestyle habits or practices, including poor dietary habits, physical inactivity, and cigarette
smoking. Circular chart (right) shows core components of CR/ secondary prevention programmes, outlined in Table 13.1. AF, atrial fibrillation; ASCVD,
atherosclerotic cardiovascular disease; CABG, coronary artery bypass graft; CHF, congestive heart failure; MI, myocardial infarction; NSTEMI, non- STsegment elevation myocardial infarction; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention.
Reproduced from Sandesara, P.B., etal. (2015). Cardiac rehabilitation and risk reduction:time to “rebrand and reinvigorate.” J Am Coll Cardiol. 65(4):389– 95 with permission from Elsevier.
Table13.1 Overview ofmultidisciplinary, exercise- based cardiac rehabilitation
Indications
Phases Phase 1 (inpatient phase)
Core components Initial patient assessment
ACS, acute coronary syndrome; CABG, coronary artery bypass grafting; CR, cardiac rehabilitation; CV, cardiovascular; ECG, electrocardiogram; PCI, percutaneous coronary
intervention.
• ACS in the last 12months
• CABG, PCI
• Chronic stable angina
• Systolic heart failure
• Heart valve surgical repair or replacement
• Heart or heart/ lung transplantation
Phase 2 (early outpatient)
Phases 3 and 4 (outpatient)
Nutritional counselling
Risk factor management
Psychosocial counselling
Physical activity counselling,
exercise training
• Patient education, counselling, physical therapy following cardiac event
• Essentially non- existent in modern era of CR, given decreased length of hospitalization following
cardiac event
• Individualized exercise regimen, cardiac risk factor reduction in a medically supervised, ECG-
monitored setting carried out in 36 sessions over 8– 12 weeks
• Independent continuation of an outpatient programme that focuses on long- term lifestyle
modification for CV risk reduction
• Review of medical, surgical diagnoses, cardiac symptoms, CV risk profile
• Physical exam
• Resting 12- lead ECG
• Assessment of daily caloric intake, saturated fat, trans fat, cholesterol, sodium content, and nutrients
• Specific dietary modifications for optimized nutrition, individualized to comorbidities and cultural
preferences
• Lifestyle modification and medical management for blood pressure, lipids, diabetes control
• Counsel on tobacco cessation
• Identification of depression, anxiety, social stress factors, and substance abuse
• Referral for individual or group therapy
• Assessment of baseline activity level
• Exercise prescription
13 Comprehensive secondary cardiovascular prevention and cardiac rehabilitation aftercoronary artery bypass graftsurgery 123
Potential cardioprotective effects of regular physical activity
atherosclerotic
↑
HR variability
↓
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while diastolic BP typically decreases slightly or remains unchanged,
resulting in an increase in pulse pressure.,
An individual’s cardiorespiratory tness is typically synonymous with their VO max, which is the highest rate of oxygen
transport and utilization at maximum physical exertion. During
exercise, VO increases linearly until it plateaus with increasing
workloads at volitional fatigue, corresponding to the ‘true’ VO
max. However, many inactive healthy adults and cardiac patients
are unable to demonstrate the levelling o of oxygen consumption with increasing workloads. Most reach a level of fatigue or
symptom- limited peak performance far below their physiological
maximum, precluding attainment of a ‘true’ VO max. us, the
highest attained level of oxygen consumption, or VO peak, may
dier considerably from the physiological VO max. Derived by
a rearrangement of the Fick equation, VO is HR × SV × (SaO–
SvO) and represents somatic oxygen consumption (where
VO=O consumption in mL/ min; HR in beats per minute;
SaO– SvO=arteriovenous oxygen dierence or skeletal muscle
oxygen uptake in mL O/ dL blood). e energy requirement for
basal homeostasis is referred to as 1 metabolic equivalent (MET)
which approximates 3.5 mL/ kg/ min for a 70kg male. Objective
measures of cardiorespiratory tness, expressed as mL/ kg/ min or
maximal METs, are powerful, independent predictors of mortality
in patients with and without ASCVD.,
Cardioprotective benefits ofcardiorespiratory
fitness and physicalactivity
Regular physical activity and increased cardiorespiratory tness
provide potential cardioprotective benets via multiple mechan-
be attributed to decreased platelet aggregation and enhanced brinolysis activity. Moreover, increased cardiorespiratory tness optimizes cardiac autonomic function, decreasing sympathetic activity
and increasing vagal tone. Improved myocardial perfusion and ischaemic preconditioning of the myocardium confer anti- ischaemic
and antiarrhythmic benets, reducing infarct size and/ or the potential for malignant ventricular arrhythmias.,
Cardiorespiratory tness is a powerful independent predictor of
mortality in patients with ASCVD. In fact, each 1 MET increase in
exercise capacity is associated with an 8– 35% decrease in mortality
(median, 16%) in coronary patients— which compares favourably
with the survival benet conferred by low- dose aspirin, statins, beta
blockers, and angiotensin- converting enzyme inhibitors aer acute
MI. In addition to optimizing medication dosing and addressing
prescription nonadherence,– lifestyle modication (poor dietary
habits, physical inactivity, and cigarette smoking/ second- hand
smoke) and CR should be recommended to all revascularized patients for secondary prevention. e ultimate goal of this multidisciplinary approach is to reduce patients’ cardiovascular risks,
stabilize or even reverse their ASCVD, decrease or eliminate their
symptoms, and enhance functional capacity to prevent recurrent
cardiovascular events and the need for repeated revascularization
procedures, while simultaneously providing referring physicians
with serial surveillance data to potentially enhance their medical
management.
In addition to cardiorespiratory tness, regular moderate- tovigorous physical activity provides numerous other health benets,
including decreased anxiety and depression, improved cognitive
function, enhanced physical function, and reduced stress.
isms (Fig. 13.2), including decreasing total cholesterol, low- density
lipoprotein cholesterol, triglycerides, BP, body weight, and fat stores,
while increasing high- density lipoprotein cholesterol and insulin
sensitivity. Reductions in plasma C- reactive protein, a biomarker
for inammation, also suggest anti- atherosclerotic benets. Antiischaemic adaptations result via enhanced release of nitric oxide and
improved endothelial function, whereas antithrombotic eects may
Exerciseprescription
Pre- exercisescreening
Within the rst 2 weeks aer hospital discharge, most clinically
stable patients can safely initiate CR. All patients eligible for CR
Anti-
Improved lipids
Lower BPs
Reduced adiposity
↑ Insulin sensitivity
Inflammation
Fig.13.2 Multiple mechanisms by which moderate- to- vigorous exercise training may reduce the risk of cardiovascular events. ↑, increased; ↓,
decreased; BP, blood pressure; CACs, cultured/ circulating angiogenic cells; EPCs, endothelial progenitor cells; O2, oxygen.
Reproduced from Franklin, B.A., etal. (2015). Reduced walking speed and distance as harbingers of the approaching Grim Reaper. Am J Cardiol. 116(2):313– 317 with permission
from Elsevier.
↓ Depression
↓ Stress
↑ Social support
Anti-
Thrombotic
↓ Platelet
adhesiveness
↑ Fibrinolysis
↓ Fibrinogen ↓ Endothelial
↓ Blood viscosity
Anti-
Ischemic
↓ Myocardial
O
demand
2
↑ Coronary flow
dysfunction
↑ EPCs and CACs
Nitric oxide
Anti-
ArrhythmicPsychologic
↑ Vagal tone
↓ Adrenergic
activity
↑
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SECTION 2 Treatment ofcoronary artery disease
should be initially evaluated to ensure that they do not have residual
signs/ symptoms of myocardial ischaemia, heart failure, or arrhythmias that might be precipitated or exacerbated by increasing levels
of physical exertion. Providers should also assess patients’ exercise
tolerance and establish baseline exercise training levels (workloads),
as well as a target HR range. Medication adjustments should be
carefully monitored to yield reproducible haemodynamic responses
during outpatient CR sessions. e AHA recommends classifying
patients into one of four categories according to their risk for exercise training (Table 13.2). Typical patients referred for outpatient
CR are detailed in class B or C.
Exercise intensity withand withouta
preliminary exercisetest
e general recommendations for exercise include a 5– 10- minute
warm- up, 30– 60 minutes of continuous or accumulated moderateto- vigorous intensity physical activity, and a 5– 10- minute cooldown, ideally 5 days a week. e prescribed exercise intensity
should approximate 40– 80% of VO max or HR reserve, at a rating
of perceived exertion (RPE) that corresponds to 11 (fairly light) to
16 (hard) on the Borg 6- to- 20 category scale. As the HR response to
exercise in patients with ASCVD may be attenuated by medications
(e.g. beta blockers), autonomic dysfunction, or both, RPE ratings
may be particularly helpful in modulating the exercise intensity.
Similarly, the ‘talk test’ provides an alternative method to gauge exercise intensity, with patients advised to exercise at the highest intensity that enables them to carry on a conversation comfortably.
METs provide another measure of exercise intensity, as well as the
associated energy expenditure. Moderate- intensity exercise, such as
brisk walking, approximates 3– 6 METs, whereas vigorous exercise,
such as jogging, is greater than 6 METs. However, the variability
of METs based on age, sex, cardiorespiratory tness, and body habitus is a limitation of this measure. Aer an acute cardiac event or
revascularization intervention, the ability to tolerate approximately
5 METs without adverse signs/ symptoms is an indicator of safe return to usual daily activities, such as resuming work or engaging in
sexual activity.
One study compared the CR outcomes in 229 post- MI and CABG
patients who had undergone preliminary peak or symptom- limited
exercise testing with 271 matched patients who did not. All patients underwent a 12- week CR programme, including electrocardiographic telemetry monitoring for the rst 3– 6 weeks. e group
with no preliminary exercise test started at a training intensity of
2– 3 METs and progressed using HR and RPE. Both groups showed
similar physiological improvements, and there were no exerciserelated cardiovascular events in either group. In the absence of a
baseline exercise test, the threshold for training in CR can be approximated by the patient’s standing resting HR plus 20– 30 beats/
min,, using RPE (‘fairly light’ to ‘s omewhat hard’) as an adjunctive
intensity modulator. Our empirical experience and the previously
referenced studies have demonstrated the safety and ecacy of early
outpatient medically supervised CR in selected cardiac patients, including those who have undergone CABG, without a preliminary
peak or symptom- limited exercise test.
Resistancetraining
Current CR programmes primarily focus on aerobic activity, as
cardiorespiratory tness is a strong predictor of all- cause and cardiovascular mortality in patients with ASCVD. However, resistance training provides an eective method for improving muscular
strength and endurance, preventing and managing a variety of
chronic medical conditions, favourably modifying selected coronary risk factors, and enhancing functional independence and
quality of life. It has also been shown to attenuate the rate- pressure
product when liing any given load, potentially decreasing cardiac
demands during daily activities such as carrying groceries or liing
moderate- to- heavy objects.
Generally, 4 weeks of regular participation in a supervised cardiovascular endurance exercise training should precede participation
in resistance training. Patients should begin with one set of 10– 15
repetitions and progress to one to three sets of 8– 15 repetitions, on
2– 3 non- consecutive days per week. e training regimen should
involve major muscle groups of the upper and lower extremities,
such as chest press, biceps curl, or quadriceps extension. However,
patients should be counselled to avoid the Valsalva manoeuvre, or
forced expiration against a closed glottis, which causes increased
intrathoracic pressure, decreased preload, and potentially reduced
cardiac output and related sequelae (e.g. lightheadedness). Signs or
symptoms of myocardial ischaemia may also result from dramatic
acute increases in systolic BP and associated cardiac demands.
Accordingly, resistance training is contraindicated in patients with
unstable coronary disease, hypertrophic cardiomyopathy, and severe aortic stenosis. Specically, post- CABG patients should avoid
engaging in conventional upper extremity resistance training within
5 weeks of their sternotomy, and remain cautious during upper body
exertion with a weight liing limit of 4.5– 7kg (10– 15 pounds) for
Table13.2 AHA risk classification forexercise training
Class A Healthy individuals without evidence of increased cardiovascular risk
Class B Individuals with known, stable heart disease with low risk of complications with vigorous exercise
ClassC Individuals with moderate to high risk for cardiac complications with exercise:
Class D Individuals with unstable disease with activity restriction:
Source data from Fletcher, G.F., etal. (2013). Exercise standards for testing and training:a scientific statement from the American Heart
Association. Circulation. 128(8):873– 934.
• NewYork Heart Association classIII or IV symptoms
• Ischaemia on exercise testing history or cardiac arrest
• Uncontrolled angina
• Decompensated heart failure
• Severe, symptomatic valvular disease
• Uncontrolled arrhythmias
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up to 12 weeks aer surgery, in the absence of sternal instability.
Upper extremity weight liing should be scrupulously avoided in
the presence of sternal instability and not resumed until at least 8
weeks aer the healing sternum is stable.
Aerobic intervaltraining
High- intensity aerobic interval training may be an eective alternative to continuous moderate- intensity training for improving exercise tolerance in coronary patients with and without heart failure
who are being optimally medically managed. e format involves
intense exercise (90– 95% peak HR) for 3– 4- minute bouts alternated
with lower- intensity (60– 70% peak HR) recovery periods of 3 minutes. Compared to continuous, moderate- intensity exercise, interval
training three times a week for 12 weeks has been shown to lead to
greater improvements in peak VO, le ventricular remodelling, and
Some centres have adopted female- only CR classes in addition
to traditional mixed- sex programming to improve enrolment in
women. Both formats are associated with improved quality of life
and increased physical activity levels. However, women attending
female- only classes reported improved dietary habits and less depressive symptoms as compared with women attending mixed- sex
classes.
Patients with systolic heart failure on optimal medical management may demonstrate modest additional reductions in all- cause
mortality, hospitalization, and improved quality of life with CR.
Following a prolonged warm- up period, heart failure patients should
initially exercise at an intensity of 40– 60% of the peak oxygen uptake, or at an RPE of 10– 13 on the Borg 6- to- 20 scale, corresponding
to ‘fairly light’ to ‘somewhat hard,’ as the HR response is oen impaired in patients with heart failure.
brachial artery ow- mediated dilation (endothelial function) in patients with stable postinfarction heart failure. However, long- term
studies assessing safety, compliance, and morbidity and mortality in
coronary patients following interval training are required before this
Current challenges and thefuture ofcardiac
rehabilitation
approach can be more widely adopted.
Safety ofcardiacrehabilitation
Exercise training is safe in most patients with ASCVD and associated with a low risk of acute cardiovascular events, especially under
medical supervision. e risk of adverse, exercise- related cardiovascular events, such as cardiac arrest, MI, or death, is estimated to be 1
event in every 100,000 patient- hours of supervised exercise. More
recently, a study involving three Norwegian CR centres reported an
overall rate of cardiovascular complications of 1 per 58,607 hours
of exercise. Accordingly, the AHA classication of risk of exercise
training in the screening stage can be helpful in optimizing the safety
of CR. Patients categorized as classC risk are advised to participate
in a medically supervised programme for at least 8– 12 weeks aer
the index event, to allow ample time to establish the safety of a prescribed moderate- to- vigorous intensity exercise regimen.
Despite strong evidence showing the benets and safety of CR, less
than 30% of eligible patients in the United States participate in medically supervised, structured CR programmes. e lack of a centralized
method for referral; suboptimal communication among treatment
teams, patients, and CR facilities; potential referring physicians’ lack
of knowledge about CR; limited access; competing responsibilities;
and perceived inconvenience for the patient are common reasons
eligible patients are not being referred. Patient- specic barriers to
CR participation include reduced functional capacity, obesity and/
or activity- limiting comorbid conditions, poor patient motivation,
geographic inaccessibility, high insurance co- pays, and competing
domestic or vocational responsibilities.
Alternative delivery models may be implemented to overcome
a major patient barrier to CR— inaccessibility to CR facilities.
Telemedicine and Internet- based programmes are promising alternatives, especially for low- to intermediate- risk patients who are un-
Specialpopulations
able to attend in- person programmes. Mobile apps have also been
developed for many lifestyle interventions to track weight, calories,
physical activity, and vital signs. Previously published studies have
CABG patients are oen older men and women with varied
comorbidities and associated physical limitations. Elderly patients
are at greater risk of deconditioning and disability aer a major cardiovascular event or coronary revascularization procedure. Due to
their reduced functional capacity and higher rates of depression
and social isolation, such patients may benet the most from CR
programmes, but are less likely to be referred to CR than younger
patients. Women are also less oen referred to CR, especially minority women, despite studies that have demonstrated that women
benet as much from CR participation as men. Furthermore, older
post- MI patients generally participate less in exercise- based CR programmes at 6months, as compared with their younger counterparts.
In addition to low referral rates, low adherence appears to be a component of underutilization in the elderly. Referred women are also
less likely to participate in CR at 1month aer an acute MI than men,
even aer adjusting for demographic and clinical characteristics.
Transportation problems and/ or caregiver responsibilities represent
common barriers to attending conventional centre- based CR.
reported improved health outcomes using mobile phone technology
for delivery of CR.
An emerging area of investigation related to CR is preoperative
rehabilitation (prehab). Oentimes patients scheduled for elective
CABG are instructed to avoid moderate- to- vigorous physical exertion which may lead to deconditioning, increased short- term morbidity and mortality, and prolonged recovery time following surgery.
e concept of prehab involves medically supervised, low- intensity
exercise training for patients awaiting surgery. Asystematic review
reported that preoperative physical therapy in patients undergoing
elective cardiac surgery signicantly shortened the postoperative
hospital stay by 3.2days, and reduced the risk of postoperative pulmonary complications. Moreover, Smith etal. reported that low
preoperative VO peak (<5 METs) was associated with higher operative and 30- day mortality aer CABG (P <0.05). e PREHAB
study is currently ongoing to clarify the impact on 3- and 12- month
postoperative clinical outcomes in patients who receive prehab before CABG and valvular surgeries.
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SECTION 2 Treatment ofcoronary artery disease
Conclusion
Between 1980 and 2000, mortality rates from coronary heart disease fell by more than 40%. Using a previously validated statistical
model, researchers reported that approximately half the decline in
cardiovascular deaths was attributed to reductions in conventional
risk factors, and approximately half was due to contemporary medical therapies, including cardioprotective medications (e.g. aspirin,
statins, beta blockers, and angiotensin- converting enzyme inhibitors), exercise- based CR, and initial treatments for acute MI. In contrast, emergent and elective coronary revascularization accounted
for only 7% of the overall decline in coronary mortality, highlighting
the critical importance of cardiovascular risk reduction and aggressive medical management following CABG.
CR provides comprehensive, multidisciplinary services integral to secondary prevention in CABG patients that reduces mortality, morbidity, and rehospitalization. In addition, CR facilitates
improvement in quality of life and favourably impacts return to
work and activities of daily living. Importantly, CR promotes sustainable, long- term behavioural modications that stabilize, if not
improve, cardiovascular health, especially when combined with the
independent and added benets of cardioprotective medications.
Unfortunately, underutilization, from low referral and participation
rates in patient subsets that may benet the most, remains a major
challenge. Education of providers and healthcare systems regarding
innovative strategies for CR delivery, such as internet or home- based
programmes, are potential approaches to improving access to costeective and quality patient- centred care.
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