Scott Webb (Host): Welcome to BayCare HealthChat. I'm Scott Webb. And today we're discussing the benefits to cardiac rehab with cardiologist Dr. Zara Babayan and Roxany Leon, she's the cardiac rehabilitation supervisor at BayCare.

It's nice to have you both here today. We're going to talk about cardiac rehab and what that is and how it helps patients. And Doctor, I'm going to start with you. Maybe the most obvious one. What is cardiac rehabilitation?

Dr. Zara V. Babayan: So cardiac rehabilitation is a personalized and individual exercise plan, which includes evaluation and instruction on physical activity, but also added benefits of discussions about nutrition, stress management, smoking cessation, and other health-related areas. So it's a very comprehensive plan individualized to a patient's condition.

Everybody comes in and gets a plan, structured plan, that's supervised by nurses and exercise physiologists, and everybody comes out stronger and feeling better. And there is good research that cardiac rehab reduces the risk of heart attacks in the future, reduces the symptoms associated with heart conditions, lessens the emotional burden of heart disease and gets the patients an outlet to see that there are other people with similar conditions and comprehensive recovery from the condition.

So it improves the stamina, strength, ability to return to work and activities and hobbies and improves overall wellbeing and confidence in the future. So the benefits are incredible.

Scott Webb: Yeah, so lots of benefits, a real team approach, not a one-size-fits-all for patients. It all sounds like good stuff. And Roxany, let’s talk about prevention here and maybe decreasing hospital readmission rates and physician office visits.

Roxany Leon: Of course. Like you mentioned, cardiac rehab decreases depression and anxiety levels, shows positive improvement in blood pressure management, in cholesterol management. And we're educating patients to reduce recurrent cardiac events.

So, we're also increasing their exercise tolerance, their confidence in being able to return to all prior activities regardless of what they did before. We do have people enrolling in all different levels of exercise, so we have people that have been exercising all of their lives and people who have never exercised.

So regardless of what their level of activity is, we're helping them get back to that or get to an even better state than what they were before. Therefore, cardiac rehab does increase their quality of life. It helps with their weight management and their ability to perform their daily tasks as well. We cover all that in cardiac rehab.

Scott Webb: Yeah, it sounds really comprehensive, a lot of education, so many physical benefits of course, but let's say mental and psychological benefits. It all sounds good to me.

And Doctor, I mentioned there that it feels very comprehensive, and maybe you can take us through that. It sounds like reducing risk factors or managing risk factors, those kinds of things. But from you, talk about the comprehensive nature of the program.

Dr. Zara V. Babayan: The cardiac rehab starts with an evaluation, an initial evaluation that looks at everything. The event leading to referral to cardiac rehab, the patient's baseline, effort tolerance and activity level and medications, comorbidities, mental state. All of that is taken into account to create this individualized program that's tailored particularly to that patient and his condition and his particular circumstances.

And that's not to replace the physicians that take care of the patient. That's really complementary to what the cardiologist and primary care doctor are doing for the patient. It creates this relationship that is very close because cardiac rehab is 36 sessions, typically two, three times a week for 12 weeks.

So, it’s a good program where the patient comes in and probably sees cardiac rehab team the most in that period of the time. So it creates this really close observation and relationship and opens up an opportunity for patient to discuss all kinds of issues and really manage cardiovascular factors, adopt a heart healthy diet, increase physical fitness activities, exercise safely, pace it right.

Usually after surgery some patients have pain and restrictions from the surgeons that we will guide how much is the right amount of exercise. We teach them to keep up and follow through on the treatment plan and keep them honest about it and, because it's a recurring program, so there is that accountability on both sides.

And then it also focuses on the emotional health and support and importance of staying engaged socially and physically and opening up about discussing that and creating this comprehensive plan of improvement. So cardiac rehab will help you make these heart healthy changes in the daily life, with the guidance and encouragement from the team, of course, to stay the course.

Scott Webb: Yeah, and it does sound like folks become quite close, spend a lot of time together, 36 visits over 12 weeks, so probably a lot of conversations, good and worthy and helpful ones.

And Roxany, let's talk about maybe the guideline recommendations. Recommendations for secondary prevention. Take us through that.

Roxany Leon: Okay. So the guidelines for cardiac rehab. Cardiac rehab is considered a Class 1a recommendation, which is really the strongest level of evidence, right? Clinical evidence that we have. That means that it's right up there with taking your aspirin, recommending taking your medication compliance. It is just as important to start an exercise program right when you leave the hospital. The benefits are definitely outweighing the risk.

With that being said, doctors typically have an automated script for cardiac rehab enrollment post-hospitalization. So typically, the guideline is a secondary prevention, like Dr. Babayan said, to prevent future events after disease. It's a preventative therapy, secondary prevention, which means you've already been diagnosed with coronary artery disease. We know it's something that you're going to be living with, but let's help you prevent future reoccurrence or future events from your coronary artery disease.

Scott Webb: Yeah. So it's not just helping folks with what they've already been through, but it's a team effort to prevent future episodes. And Doctor, do you have anything to add about the guidelines?

Dr. Zara V. Babayan: When we talk about the guidelines, Class 1 indication, I want you to think of it as a must do. Class 3 indication is must not do. And Class 2 has A and B where it's a little shaded and it's individualized to the patient. So Class 1 means that it's completely proven to be beneficial and it should be done in most the cases.

So with that said, a recent study found that one in three patients who are eligible for cardiac rehabilitations don't receive a referral from their doctor. And only one in four patients who were referred actually completed the program. So there is a significant gap in accessing the cardiac rehab for the patients despite this being a Class 1 indication. Wanted to put that in a perspective that we should be doing it because there is so many proven benefits to it.

And, the gap needs to be filled. And some of it is not knowing about it, that's where Roxany talks about automatically after an event that would qualify you for cardiac rehab, you would get the referral, and then it will be reinforced by your cardiologist, the importance of doing it and a referral again.

The patients would have an opportunity to participate and we can talk a little bit about the difficulties in enrollment. That's a separate discussion. But what we want to focus on is how important it is to actually take advantage of the program that is proven to improve the outcomes.

Scott Webb: Yeah, and as you say, the Class 1 recommendation means it's kind of a must for most. And Roxany, maybe you could talk a little bit about some of the barriers to the program and enrollment. We've addressed them here a little bit, but folks either maybe not knowing about the program, being distracted by their other health things and not really grasping exactly what it is, whatever it might be. What are some of the barriers that prevent folks from enrolling?

Roxany Leon: One of the barriers is number one, lack of awareness, like Dr. Babayan has covered. There is lack of awareness that we even exist. I would say another pretty evident is lack of transportation. There's a lot of people that are unable to drive to get to us, a lot of people that don't have transportation or anybody to bring them here or live at a distance. Distance and accessibility to cardiac rehab programs is also an issue.

Another major issue that we cannot ignore is the cost even though there's many people that are insured, and most of the clientele that we see is insured, there's out of pocket cost. Some of them may have co-payments, depending on what their insurance plans are. So that's definitely an added barrier of concern which should be discussed, and we normally discuss in the initial evaluation because the hospital, of course, has programs for those people that are underfunded and people that can't afford, they may qualify for.

There's some language and cultural barriers. Lack of awareness for people that are missed through the cracks or not properly being informed. Some people are not comfortable coming here and exercising or talking to others in this environment.

I would say, more accessibility than anything too. The programs are limited. The brick and mortar programs are limited. So that's another barrier. Work conflict is a common one that we see. We have many patients that are savvy enough and know to apply for FMLA. Others don't have that option. So that's another barrier.

Scott Webb: Yeah, so it sounds to me, Roxany, like getting folks enrolled. So educating them, getting them enrolled is at least half the battle, if you will, right? And then we've discussed here what goes on, the team approach, individualized exercise prescriptions and all the good work that everybody there is doing to help folks.

Doctor, just want to give you a chance here at the end, final thoughts, takeaways. When we're trying to educate and encourage folks if they're Class 1, if they really must have cardiac rehab, how do we get them into the program?

Dr. Zara V. Babayan: So the way we structure cardiac rehab is in phases, right? So the phase one cardiac rehab is that first decision to refer to cardiac rehabilitation. And it usually happens after a heart attack or a heart surgery, valve replacement bypass graft surgery, stent placement, coronary disease, heart failure, hospitalization, heart transplantation, things like that. So, that's usually involves hospital procedure or some kind of an event.

So phase one is really just educating the patient about, what's your treatment besides the procedure that you had, the medication that you're going to take. Also, that's the first discussion about the cardiac rehabilitation and its benefits and what it involves.

After they go home, they get the referral from their cardiologist for a phase two, which is coming in for that 36-session program. We recommend it in person because the benefits are beyond just purely exercising, but also psychosocial support. Seeing other people with the same condition and getting that team approach and eyes on you and monitoring of heart rate and blood pressure and discussions about medications and all that.

And then phase three is when you continue to exercise on your own. Taking all the lessons and the fitness that you achieved in doing the cardiac rehab out of those 36 sessions and just making it into a lifestyle, right?

So it all comes in stages. We do encourage patients after that first discussion to talk to their cardiologist about the cardiac rehab. As I said, about two-thirds of patients do get referred, but then only a quarter of them complete it. So, it's not even so much lack of referral as other barriers that Roxany was talking about.

So we're trying to improve access. And the reason we encourage it is because there's proven benefit in mortality and morbidity.

People that complete cardiac rehab live longer, live better, and that's what we want for all our patients.

Scott Webb: Yeah, that's perfect. Live longer, live better, love it all. I appreciate your time, your expertise. Thank you both for being here.

Dr. Zara V. Babayan: Thank you so much.

Roxany Leon: Thank you.

Scott Webb: And for more information, go to BayCare.org. And that wraps up this episode of BayCare HealthChat. Always remember to subscribe, rate and review this podcast and all of the other BayCare podcasts, so we can share the wealth of information from our experts together. I'm Scott Webb. Stay well.