Randal J. Thomas

Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond A Presidential Advisory From the American Heart Association

Each year, an estimated 785 000 Americans will suffer a new myocardial infarction (MI; heart attack), and nearly 470 000 will have a recurrent attack.1 Within 5 years of an initial MI, 15% of men and 22% of women 45 to 64 years of age and 22% of men and women >65 years of age will suffer a recurrent MI or fatal coronary heart disease (CHD).1 Given this high recurrence rate, preventing secondary cardiac events is an essential part of the care for patients with cardiovascular disease (CVD). Cardiac rehabilitation/secondary prevention programs (CR/SPPs) are medically supervised programs that help patients with CVD to recover more quickly after a cardiac event and to stay healthy. CR/SPPs are more than just diet and exercise programs; these programs offer a multifaceted and multidisciplinary approach to optimize the overall physical, mental, and social functioning of people with CVD. CR/SPPs include specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle for patients with CVD.2 Comprehensive CR/SPPs consist of baseline patient assessment, nutritional counseling, aggressive risk factor management (ie, lipids, hypertension, weight, diabetes mellitus, and smoking), psychosocial and vocational counseling, and physical activity counseling and exercise training. Patients participating in CR/SPPs are also prescribed cardioprotective drugs that have evidence-based efficacy for secondary prevention. The goal of cardiac rehabilitation and secondary prevention is to stabilize, slow, or even reverse the progression of CVD, which in turn reduces the risk of a future cardiac event. The interventions provided by CR/SPPs are especially important because of the limited time available during the shortened hospital stays and brief outpatient physician visits now common in contemporary medical practice. There is ample evidence on the proven benefits of CR/SPPs on CHD risk factors …

Impact of Cardiac Rehabilitation on Mortality and Cardiovascular Events After Percutaneous Coronary Intervention in the Community

Background— Although numerous studies have reported that cardiac rehabilitation (CR) is associated with reduced mortality after myocardial infarction, less is known about its association with mortality after percutaneous coronary intervention. Methods and Results— We performed a retrospective analysis of data from a prospectively collected registry of 2395 consecutive patients who underwent percutaneous coronary intervention in Olmsted County, Minnesota, from 1994 to 2008. The association of CR with all-cause mortality, cardiac mortality, myocardial infarction, or revascularization was assessed with 3 statistical techniques: propensity score–matched analysis (n=1438), propensity score stratification (n=2351), and regression adjustment with propensity score in a 3-month landmark analysis (n=2009). During a median follow-up of 6.3 years, 503 deaths (199 cardiac), 394 myocardial infarctions, and 755 revascularization procedures occurred in the study subjects. Participation in CR, noted in 40% (964 of 2395) of the cohort, was associated with a significant decrease in all-cause mortality by all 3 statistical techniques (hazard ratio, 0.53 to 0.55; P<0.001). A trend toward decreased cardiac mortality was also observed in CR participants; however, no effect was observed for subsequent myocardial infarction or revascularization. The association between CR participation and reduced mortality rates was similar for men and women, for older and younger patients, and for patients undergoing elective or nonelective percutaneous coronary intervention. Conclusions— We found that CR participation after percutaneous coronary intervention was associated with a significant reduction in mortality rates. These findings add support to published clinical practice guidelines, performance measures, and insurance coverage policies that recommend CR for patients after percutaneous coronary intervention.

AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services

Endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Paul K. Whelton, MB, MD, MSc, FAHA, Chair, Writing Committee, Robert M. Carey, MD, FAHA, Vice Chair, Writing Committee, Wilbert S. Aronow, MD, FACC, FAHA, Writing Committee Member, Donald E. Casey, Jr., MD, MPH, MBA, FAHA, Writing Committee Member, Karen J. Collins, MBA, Writing Committee Member, Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA, Writing Committee Member, Sondra M. DePalma, MHS, PA-C, CLS, AACC, Writing Committee Member, Samuel Gidding, MD, FACC, FAHA, Writing Committee Member, Kenneth A. Jamerson, MD, Writing Committee Member, Daniel W. Jones, MD, FAHA, Writing Committee Member, Eric J. MacLaughlin, PharmD, Writing Committee Member, Paul Muntner, PhD, FAHA, Writing Committee Member, Bruce Ovbiagele, MD, MSc, MAS, MBA, FAHA, Writing Committee Member, Sidney C. Smith, Jr., MD, MACC, FAHA, Writing Committee Member, Crystal C. Spencer, JD, Writing Committee Member, Randall S. Stafford, MD, PhD, Writing Committee Member, Sandra J. Taler, MD, FAHA, Writing Committee Member, Randal J. Thomas, MD, MS, FACC, FAHA, Writing Committee Member, Kim A. Williams, Sr., MD, MACC, FAHA, Writing Committee Member, Jeff D. Williamson, MD, MHS, Writing Committee Member, Jackson T. Wright, Jr., MD, PhD, FAHA, Writing Committee Member

Combining Body Mass Index With Measures of Central Obesity in the Assessment of Mortality in Subjects With Coronary Disease : Role of “Normal Weight Central Obesity”

OBJECTIVES This study sought to assess the mortality risk of patients with coronary artery disease (CAD) based ona combination of body mass index (BMI) with measures of central obesity. BACKGROUND In CAD patients, mortality has been reported to vary inversely with BMI (“obesity paradox”). In contrast,central obesity is directly associated with mortality. Because of this bidirectionality, we hypothesized that CAD patients with normal BMI but central obesity would have worse survival compared to individuals with other combinations of BMI and central adiposity. METHODS We included 15,547 participants with CAD who were part of 5 studies from 3 continents. Multivariate stratifiedCox-proportional hazard models adjusted for potential confounders were used to assess mortality risk according to different patterns of adiposity that combined BMI with measures of central obesity. RESULTS Mean age was 66 years, 60% were men. There were 5,507 deaths over a median follow-up of 2.4 years (IQR: 0.5 to 7.4 years). Individuals with normal weight central obesity had the worst long-term survival: a person with BMI of 22 kg/m2 and waist circumference (WC) of 101 cm had higher mortality than a person with similar BMI but WC of 85 cm (HR: 1.10[95% CI: 1.05 to 1.17]), than a person with BMI of 26 kg/m2 and WC of 85 cm (HR: 1.20 [95% CI: 1.09 to 1.31]), than a person with BMI of 30 kg/m2 and WC of 85 cm (HR: 1.61 [95% CI: 1.39 to 1.86]) and than a person with BMI of 30kg/m2 and WC of 101 cm (HR: 1.27 [95% CI: 1.18 to 1.39), p < 0.0001 for all). CONCLUSIONS In patients with CAD, normal weight with central obesity is associated with the highest risk of mortality [corrected].

Long-term Medication Adherence after Myocardial Infarction: experience of a community

BACKGROUND Adherence to evidence-based medications after myocardial infarction is associated with improved outcomes. However, long-term data on factors affecting medication adherence after myocardial infarction are lacking. METHODS Olmsted County residents hospitalized with myocardial infarction from 1997-2006 were identified. Adherence to HMG-CoA reductase inhibitors (statins), beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers, were examined. Cox proportional hazard regression was used to determine the factors associated with medication adherence over time. RESULTS Among 292 subjects with incident myocardial infarction (63% men, mean age 65 years), patients were followed for an average of 52+/-31 months. Adherence to guideline-recommended medications decreased over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, beta-blockers, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, respectively. Enrollment in a cardiac rehabilitation program was associated with an improved likelihood of continuing medications, with adjusted hazard ratio (95% confidence interval) for discontinuation of statins and beta-blockers among cardiac rehabilitation participants of 0.66 (0.45-0.92) and 0.70 (0.49-0.98), respectively. Smoking at the time of myocardial infarction was associated with a decreased likelihood of continuing medications, although results did not reach statistical significance. There were no observed associations between demographic characteristics, clinical characteristics of the myocardial infarction, and medication adherence. CONCLUSIONS After myocardial infarction, a large proportion of patients discontinue use of medications over time. Enrollment in cardiac rehabilitation after myocardial infarction is associated with improved medication adherence.

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability. Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …

Prognostic importance of weight loss in patients with coronary heart disease regardless of initial body mass index

Background Recently, mild elevations in body mass index (BMI) have been related to better outcomes in patients with coronary heart disease. Our aim was to determine whether patients with coronary heart disease who are participating in cardiac rehabilitation would have improved outcomes if they lost weight and whether this would depend on initial BMI. Methods This is a prospective cohort study of 377 consecutive patients enrolled at a cardiac rehabilitation program, aged 30–85 years with a mean follow-up of 6.4 ± 1.8 years. We measured total mortality, acute cardiovascular events (fatal and nonfatal myocardial infarction, fatal and nonfatal stroke, emergent revascularization in the setting of unstable angina, and hospitalization for congestive heart failure) and a composite outcome (mortality + acute cardiovascular events). Statistical testing used Cox Proportional Hazards Regression. Results On average, the weight loss group (n = 220) lost 3.6 ± 4.1 kg, and the nonweight loss group (n = 157) gained 1.5 ± 1.4 kg (P< 0.0001). The rate of the composite outcome was 24% (53/220) in those who did lose weight versus 37% (58/157) in those who did not lose weight. Weight loss was significantly associated with lower rate of the composite outcome after adjustment for age, sex, smoking, dyslipidemia, diabetes, hypertension, myocardial infarction, and obese status [hazard ratio (HR) = 0.62; P = 0.018]. Subgroup analysis showed that patients who lost weight had favorable outcomes both in patients with BMI ≤25 (HR = 0.32; P = 0.035) and those with BMI ≥ 25 kg/m2 (HR = 0.64; P = 0.032). Conclusions Weight loss in cardiac rehabilitation is a marker for favorable long-term outcomes, regardless of initial BMI.

Cardiovascular risk after bariatric surgery for obesity.

Obese patients have an increased prevalence of cardiovascular (CV) risk factors, which improve with bariatric surgery, but whether bariatric surgery reduces long-term CV events remains ill defined. A systematic review of published research was conducted, and CV risk models were applied in a validation cohort previously published. A standardized MEDLINE search using terms associated with obesity, bariatric surgery, and CV risk factors identified 6 test studies. The validation cohort consisted of a population-based, historical cohort of 197 patients who underwent Roux-en-Y gastric bypass and 163 control patients, identified through the Rochester Epidemiology Project. Framingham and Prospective Cardiovascular Munster Heart Study (PROCAM) risk scores were applied to calculate 10-year CV risk. In the validation cohort, absolute 10-year Framingham risk score for CV events was lower at follow-up in the bariatric surgery group (7.0% to 3.5%, p <0.001) compared with controls (7.1% to 6.5%, p = 0.13), with an intergroup absolute difference in risk reduction of 3% (p <0.001). PROCAM risk in the bariatric surgery group decreased from 4.1% to 2.0% (p <0.001), whereas the control group exhibited only a modest decrease (4.4% to 3.8%, p = 0.08). Using mean data from the validation study, the trend and directionality in risk was similar in the Roux-en-Y group. The test studies confirmed the directionality of CV risk, with estimated relative risk reductions for bariatric surgery patients ranging from 18% to 79% using the Framingham risk score compared with 8% to 62% using the PROCAM risk score. In conclusion, bariatric surgery predicts long-term decreases in CV risk in obese patients.

Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction

BACKGROUND Participation in cardiac rehabilitation has been shown to decrease mortality after acute myocardial infarction, but its impact on readmissions requires examination. METHODS We conducted a population-based surveillance study of residents discharged from the hospital after their first-ever myocardial infarction in Olmsted County, Minnesota, from January 1, 1987, to September 30, 2010. Patients were followed up through December 31, 2010. Participation in cardiac rehabilitation after myocardial infarction was determined using billing data. We used a landmark analysis approach (cardiac rehabilitation participant vs not determined by attendance in at least 1 session of cardiac rehabilitation at 90 days post-myocardial infarction discharge) to compare readmission and mortality risk between cardiac rehabilitation participants and nonparticipants accounting for propensity to participate using inverse probability treatment weighting. RESULTS Of 2991 patients with incident myocardial infarction, 1569 (52.5%) participated in cardiac rehabilitation after hospital discharge. The cardiac rehabilitation participation rate did not change during the study period, but increased in the elderly and decreased in men and younger patients. After adjustment, cardiac rehabilitation participants had lower all-cause readmission (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.65-0.87; P < .001), cardiovascular readmission (HR, 0.80; 95% CI, 0.65-0.99; P = .037), noncardiovascular readmission (HR, 0.72; 95% CI, 0.61-0.85; P < .001), and mortality (HR, 0.58; 95% CI, 0.49-0.68; P < .001) risk. CONCLUSIONS Cardiac rehabilitation participation is associated with a markedly reduced risk of readmission and death after incident myocardial infarction. Improving cardiac rehabilitation participation rates may have a large impact on post-myocardial infarction healthcare resource use and outcomes.