Transcription:
Cardiac Rehabilitation: Low Cost, Low Tech, Great Medicine!

Melanie Cole (Host): Have you or a loved one experienced a cardiac event? If so, your physician may prescribe cardiac rehab. According to the American Heart Association, cardiac rehabilitation programs can extend overall survival and improve quality of life for those with coronary disease. My guest today is Dr. Murray Low. He's the director of cardiac rehabilitation at Burke rehab hospital, a rehab partner of St Luke's Cornwall Hospital. Welcome to the show Dr. Low. For those that do not know, what is cardiac rehab and why do they call it low cost, low tech, great medicine?

Murray Low, EdD, MAACVPR, FACSM, FAACVPR (Guest): First of all thank you for inviting me and I think if you, if we examine what happens to patients in cardiac rehab, in many ways the benefits are more effective and more powerful than almost anything else a physician or the health care system can provide patients who've suffered with cardiac disease, We call it a low tech, low cost, because it is; and especially we call it great medicine and the benefits of this are specifically, one: cardiac rehab lowers mortality. Number two: it reduces re-hospitalizations for all causes in addition to cardiovascular causes. The effects of three months of cardiac rehab are long term.

So, when we look at research we see that the benefits accrue at five years or ten years even at fourteen years for those who have participated. We know for sure now that it reduces our health care costs and something that one can really feel internally is quality of life and it dramatically changes that, and the reason is I think is because cardiac rehab focuses on lifestyle changes. What it does is it tries to give the patient the responsibility to take care of their lifestyle and the vehicle that cardiac rehab uses is primarily first, exercise to get people to move and education, so they learn about nutrition, stress management, the medications they're taking and the importance of those medications. But the foundation continues to be exercise, in fact, just to share with the audience a very interesting study that was done about fifteen years ago. Took a little over 400 patients. it randomized them. One group went to what we call poor treatment in other words the doctor said look I want you to exercise, I want you to take your statin medications, stay on a low-fat diet. Another group listened to the doctor's advice and received statin medications and went on an American Heart Association low fat diet. But the last group also received thirty minutes of exercise most days of the week about 150 minutes a week.

What was interesting was they looked at what the event rate was over a five-year period to see how many of these people suffered a heart attack again or did not survive and here's the data. Those who simply took no advice and continued with their lifestyle had a th30% event rate. Those who took their statin medications and low-fat diet had a 20% event rate. But those who added exercise to their program had a “6.6%” event rate. That's an enormous reduction over five years, when people are doing the proper nutrition, taking their medication and adding that at least thirty minutes of activity most days of the week and that led us to a whole bunch of other studies much more recent. If I may just share with your audience a very recent study because it was a very large study. It was published in the American Journal of Cardiology. It was published in 2009, and it looked at 601,000 Medicare patients and statistically it divided them into what we call seventy thousand match groups, seventy thousand went to cardiac rehab, seventy thousand did not go to cardiac rehab. But they were matched for the severity of their disease, the medication whether they had stents, whether they had bypass surgery and the results of this study were really, really got my attention and the scientific community. At the end of one year and I should add that cardiac rehab generally lasts for three months, thirty six exercise sessions, three times a week but at the end of one year the group, the seventy thousand that went to cardiac rehab had a 58% relative reduction in their mortality versus seventy thousand Medicare members who did not attend cardiac rehab and then it really gets interesting> Because these people were followed for a five year period. At the end of five years, those who attended those first three months of cardiac rehab had a 34% reduction in mortality versus those that did not attend.

So, we're seeing that somehow something changes, that if we get people to participate in a better lifestyle and alter that with the foundation of being physical activity, we see a benefit even after the three months of cardiac rehab and note that with medication that's not the case. If you don't stay within your medication, your blood pressure just does not continue to stay low. So just to add that one other important piece of information. In this that subgroup of seventy thousand people who went to cardiac rehab, many of them or some of them were more than 85 years of age and they compared that group to the group that was over 85 years of age that did not attend cardiac rehab. And after five years, the group that attended cardiac rehab again over age 85 had just about a 20% reduction in mortality. Now to get that type of reduction in mortality something really powerful is going on in cardiac rehab even in the elderly and I think the important message there is that it is never too late. That whether you are 40, 50, 60, 70, or 90, participating in cardiac rehab has very significant benefits and that was one of the studies I wanted to highlight.

There are multiple other studies such as studies show that we reduce rehospitalization costs - not cost themselves but just getting people into the hospital and out by over 25%. We have similar reductions in health care utilization costs of 25-30% reductions and even in people with what was considered severe coronary disease such as heart failure; we again see these dramatic reductions in cost, in mortality and benefits. In fact, we kind of sometimes used they okay you have got the heart failure and you know what this person doesn't have many years left. We now have data showing that if people participate in a cardiac rehab program; we can follow them for a ten-year period with again, significant reductions in mortality, significant increases in the strength of their heart which is something we measure called ejection fraction and huge increases in quality of life. And just a final thought, sometimes when people attend cardiac rehab, they say well I'll just go a couple of weeks and that's about it. You may recall I said that typical cardiac rehab is 36 weeks and there's a reason for that three times a week.

We've actually followed, which was published recently in the Journal of Circulation a group of over 30,000 people who attended cardiac rehab and we measured or quantified how many sessions they attended. So, for example we compared people who only came once, people who came 36 times, people who came 24 times. If we compared those who came once versus those who came 36 times, there was a 47% percent reduction in mortality and a 31% percent reduction in either a new or another heart attack. So, that once again more is better, 36 is optimal but the responsibility is ultimately to get people to change their lifestyle, change their physical activity habits, modify what they eat and manage stress.

It's also interesting that we've also had studies that have taken some of these populations who attended those first 36 sessions looking at them 10-14 years later and we continue to see reduced hospitalizations and lower mortality and that means that if people attend these programs; they really do change and the benefits are really long term. And that's an important message I'm delivering over and over. And just one other point, we have not unfortunately - we see that while two thirds of our patients are men only one third are women. We've tried to understand what that reason is in the past we thought well maybe a cardiologist just didn't think it was important for women to go. We now look at it somewhat differently and that women seem to have responsibilities other than themselves but if they get a cardiac rehab, the evidence shows their benefits are not only equal to the benefit that men get but even greater. In fact, a recent study showed that there was over a 60% reduction in mortality for women over 4 or 5-year period versus a 49% percent reduction in men. So, women get that benefit they simply have to attend and show up as we say.

Melanie: Well you know women, we tend to be the caregivers of society as you say and we have to put our own mask on before we put on the mask of our loved one so cardiac rehab is that much more important for a woman to help her prevent further events. So, tell us a little bit about your partnership with St. Luke's Cornwall Hospital and how did that come about and what can patients expect from this great partnership in rehab services?

Dr. Low: Well I think Burke has had generations literally of experience in the field rehabilitation medicine. I think that it's probably one of the best institutions to provide that type of service and in sharing that service with Cornwall and other hospitals, we can bring the best of what we know and share it with the great clinicians that you have in Cornwall and provide an even better program. So, I think it's a win-win for both hospitals. A win in that Burke can share, can partner and Cornwall can improve the program that it delivers to its patients.

Melanie: And what type of lifestyle changes would cardiac patients learn? You mentioned all of the studies that prove these benefits and prove that it's low cost, low tech, great medicine but what lifestyle changes as far as reducing some of those further events, besides exercise are they learning something about nutrition and high-fat diets, are they learning about exercises that they can do at home? Things that they can do to make their lives more active to help go along as an adjunct therapy with their cardiac rehab?

Dr. Low: Yeah, yeah, I think that the foundation of what we do as I said was one toward dietary habits, two physical inactivity and smoking and I should add a fourth one which is in some patients managing stress. I think if we start with the physical activity part and get people to take responsibility to become more active; in a very inactive society that we live in, in fact we do way too much sitting. We in effect are saying look, I quote here “the greatest opportunity we have to reduce premature death and improve health, lies in our own personal behavior.” So when a patient comes to us in cardiac rehab, and says okay, I’m done with cardiac rehab now, should I buy a treadmill or should I get a bicycle or a rowing machine? My response to that patient is buy any equipment you want; it's what you're going to use and that is that is the key. It's kind of use it all lose it and we help people changing that lifestyle and for example beginning to moderate and modify the intake of food, increasing caloric utilization, learning perhaps some meditation skills and when you put that combined and the patient can continue with that sometimes even in what we call a phase three supervised program where they no longer need the ECG monitoring and the intense supervision they get. We create an environment for them where they continue with the changes they learned and follow them for the rest of their life.

Melanie: Dr. Low what type of providers are involved? Tell us about the multi-disciplinary team of healthcare providers that are involved in cardiac rehab.

Dr. Low: Well obviously we have the cardiac rehab program which is usually run by nurses and clinical exercise physiologists and physical therapists, allied health workers would include nutritionists or psychosocial professionals such as a clinical social worker who may work with stress modification. We also have a smoking cessation program and I should add one other thing that I think patients need to know; that today most insurance carriers do cover for cardiac rehabilitation. For example Medicare provides total coverage for cardiac rehab for three months 36 sessions for people who've had a heart attack, people have angina which is some chest pain from heart disease, people have had bypass surgery, people have had valve repair or valve replacements, heart transplants and also people with heart failure and the commercial insurance carriers also and the reason they cover is because the scientific evidence is overwhelming for the benefit for the patient and for the health care system.

Melanie: What great information. So, wrap it up for us Dr. Low and how somebody gets involved in a cardiac rehab program, what you really want them to know about the importance of managing their stress and good nutrition and exercise and lifestyle behaviors so that hopefully that they don't have to come back and do it all over again.

Dr. Low: Yeah, you know, patients have a mistaken belief that when they have bypass surgery or a stent or their doctor prescribes a statin medication everything is solved, and I want I'll give you some data on this here. First of all, we know that getting a stent or getting bypass surgery does not reduce mortality. It's simply it's simply stops the symptoms that people have with their coronary artery. When people take a statin medication which lowers cholesterol, lowers the L.D.L. cholesterol. People think that's it I'm taking the medication, I have the best doctor in the world, I’m all set, I don't need to take any more responsibility for myself. And what I tell them is if you look at the data of people who take statins, we get a reduction of 20 or 30% that most of mortality. Now if you take that same population already taking statins and now they participate in cardiac rehab, which really requires lifestyle management changes we get a further reduction in mortality of on average 40-50% on top of taking the medication. So, I think one of the challenges that we have with patients is to recognize it's not enough to have the best doctors, it's not enough to have a great procedure, it's not enough to take medication. They have to take responsibility for their lifestyles and the foundation of that certainly is increasing physical activity, modifying their dietary habits, certainly smoking cessation and if needed a learning how to meditate and relax.

Melanie: Thank you so much Dr. Low. You're so well spoken. Such a great guest. Thank you so much for all the great information. This is Doc Talk presented by St. Luke's Cornwall Hospital for more information please visit www.stlukescornwallhospital.org that’s www.stlukescornwallhospital.org This is Melanie Cole. Thanks so much for tuning in.