How to get patients into cardiac rehabilitation, who qualifies for it, and what benefits can be expected are the topics of this interview by Andrew Perry, MD, with Linda Peterson, MD.
A transcript of the podcast follows:
Andrew Perry, MD: Today I’ll be talking with Dr. Linda Peterson. She’s been at Washington University School of Medicine since she was a medical student. She is a full professor of medicine, and she is the Director of the Cardiac Rehab Program here at Wash. U. I think cardiac rehab is a very underutilized service and can provide a lot benefits for our patients. So I sat down and talked with her a bit about it. I hope you enjoy it.
Perry: I had sent you a couple of cases before. I just want to review those, because I think those will launch us into the talking points about cardiopulmonary rehab. These are all cases that I’ve encountered here on the wards or in clinic. For example, a 60-year-old male. He’s got a history of type 2 diabetes. He had a three-vessel CABG [coronary artery bypass graft] a few years ago, and he was recently admitted for an NSTEMI [non-ST segment elevation MI]. He had a cath at that time. All of his grafts were patent. His troponin peak went up to 8. He was treated with the standard aspirin, Plavix [clopidogrel], heparin, and then discharged to home. When I see him in the primary care medicine clinic about a week later for a post-hospital discharge, talking to him about things. He’s never been to cardiopulmonary rehab. Another time, this was in the CCU. I had seen a 33-year-old female with idiopathic dilated cardiomyopathy, and she was admitted for heart failure exacerbation. She had an EF [ejection fraction] of 30%. She already had an ICD [implantable cardioverter-defibrillator] and she had been admitted three times in the past 12 months over the last year. She’s very limited at home. She can perform her basic ADLs [activities of daily living] and gentle walks, but anything much more than that she gets really winded.
Then lastly, there was a 26-year-old female just a year out from her aortic valve replacement, and speaking with her, she had never undergone any cardiopulmonary rehab either. First off, of all these patients, who are the people that qualify and should be referred for cardiac rehab?
Linda Peterson, MD: The standard qualifications for cardiac rehab, in general, are a myocardial infarction within the last 12 months. It doesn’t have to be a STEMI, it can be an NSTEMI. With CABG, there’s no time limit. Current stable angina, basically any cardiac surgery, heart transplant, heart-lung transplant, heart valve repair or replacement, and certainly, like I said, CABG. Any PCI [percutaneous coronary intervention] or stenting — even if the person didn’t have a heart attack, they still qualify for cardiac rehab — and patients with heart failure. If they have non-ischemic heart failure, they’re only qualified for cardiac rehab as opposed to intensive cardiac rehab, which we can get into in a little bit.
Perry: Okay. Very good. One of the issues that I also came up with on the floor was that when I wanted to refer somebody to cardiac rehab after discharging from the hospital, I was told that they needed to have an accepting cardiologist to be able to go over her cardiac rehab. Do you need to be a cardiologist to refer somebody to cardiac rehab, or how does that work logistically?
Peterson: You don’t have to be a cardiac physician, a cardiologist to refer to cardiac rehab. Generally, we want to have a point person to be able to call back to if the patient has any issues or any problems, somebody needs to follow them up or admit them if they need to be admitted. You don’t have to be a cardiologist to refer to cardiac rehab.
Perry: Okay. The indications for cardiac rehab sound pretty broad, but also it seems like it’s very unutilized.
Perry: Why is that the case?
Peterson: There’s multiple reasons for people not going to cardiac rehab. One is not being referred. Or it’s the last thing in their discharge packet of 14 pages. “Oh, by the way, I think you should go to cardiac rehab.” Patients don’t read through their whole discharge packet and actually go there. There’s several inertia barriers to overcome. A lot of reasons that patients don’t go also are just logistical. They need to go back to work, so they don’t think they have time or if they have multiple comorbidities or travel issues. They don’t have a car to get to cardiac rehab. Those sorts of things can really impact whether a patient actually goes to cardiac rehab or not. But by and large, one of the strongest reasons that patients choose to go to cardiac rehab is if their doctor strongly recommends that they go. That has the biggest impact in studies whether patients actually participate in cardiac rehab is whether their doctor strongly recommends that they go.
Perry: What does that mean “strongly recommend”? What does that look like in the hospital or in clinic?
Peterson: Right. Taking just a little bit of time to say, “I really want you to do cardiac rehab. These are all the benefits from it. This is a location of one nearby you,” and if you don’t know, as a cardiologist, what are all the cardiac rehab institutions, we here at Wash. U. have nurses. You can just call our heart care institute nurses at cardiac rehab and we will find a cardiac rehab close by where that person lives, because a lot of times we get patients from all over, from different states, even. But we will find a cardiac rehab place for the patient.
Perry: We’re here in Missouri, is it hard to find a cardiac rehab in some of these smaller towns like out towards Joplin or down in Springfield? Springfield is kind of a bigger town, but…
Peterson: Yeah, and especially patients living in very rural areas. That can be a problem, because it’s quite a drive for them to get in every other day or everyday to cardiac rehab. So it definitely is an issue nationwide, not just in Missouri, but especially for places that are very remote for patients to get to cardiac rehab.
Perry: Now what are the benefits from cardiac rehab?
Peterson: There’s multiple benefits for all comers 5 years after participation and up to 10 years after coronary artery bypass grafting. There’s a decrease in mortality.
Perry: I think this point of the mortality benefit after cardiac rehab deserves to be expounded on a little bit. The most impressive data that I found came from the Mayo Clinic and their study of Olmsted County population. So looking at patients who underwent coronary artery bypass grafting, or CABG, and following them up for 10 years. Looking at those who were referred to cardiac rehab versus those who weren’t referred and using a propensity score to match those, they found a relative risk reduction in all-cause mortality of 50% with an absolute reduction of 12.7%, giving you a number needed to treat of 8. That’s pretty good. There’s very few things in medicine that require a number needed to treat of less than 10.
Similarly, they did a study of patients after PCI and the mortality benefits from there, and that was about an average of a 6.3-year follow up and using a Kaplan-Meier curve, then found a hazard ratio of about 50%, again, reduction in all-cause mortality with those referred to cardiac rehab versus those who weren’t referred to cardiac rehab.
Now in 2016, there was a large meta-analysis published in the Journal of American College of Cardiology. This was looking at the effectiveness for cardiac rehab. In contrast to some of those earlier studies and earlier meta-analyses, they did not find an all-cause mortality benefit. However, they did find a reduction in cardiovascular mortality with cardiac rehab. In the discussion, the authors reflect upon this and state that some of the more recent studies that were included in their meta-analysis were more heterogeneous in their patients with coronary heart disease.
Additionally, within the last 10 years, 15 years, there have been a lot of advances in the management for coronary disease, most notably being statins. So while the Mayo studies that I have reported earlier, they included patients up until about 2006, 2007, this is right at the dawn of really the statin era. Overall, while I still think that there is a mortality benefit from cardiopulmonary rehab, I think that that benefit may be less than what was previously reported.
Peterson: Patients who do cardiac rehab do better than patients who don’t do cardiac rehab. There was even one study that looked at patients who just had a PCI but didn’t even have myocardial infarction, and those patients who went to cardiac rehab still did better than patients who didn’t. Obviously, it’s not a randomized study. Patients have to show up and go to cardiac rehab, but still the benefits of exercise are obviously multiple. There’s benefits for conditioning, then patients are able to do their activities of daily living better. Multiple markers of aerobic capacity are better, but there’s also mental benefits. I mean exercise is associated with good mental health, and a lot of patients who come to us have a lot of depression, demoralization, anger issues because they’re confronted with something that’s potentially a mortal problem for them. They have to learn how to deal with it. Doing cardiac rehab, seeing supportive staff multiple times a week, seeing other patients that are going through it so they know that they’re not alone. I think there’s multiple benefits, like I said, from both a physical standpoint and from a mental standpoint.
Perry: Now someone might argue that cardiac rehab isn’t necessarily what is needed, but maybe just exercise by the person at home. Are there certain situations where maybe home exercise is equivalent to cardiac rehab or should we always do cardiac rehab?
Peterson: That’s a great question because there’s a lot of patients who are fit and active and doctors might think, “Well, they don’t really need to do this.” But I would argue we have patients on the monitor, and we see a lot of arrhythmias. We’re checking their blood pressure. A lot of patients have hypertensive responses to exercise that wouldn’t be picked up if they are just going to the gym. Or hypotensive issues. Patients feel a little dizzy. Okay, you’re out walking the mall, but how do you know what’s the problem with that? Is it a rhythm problem? Is it a blood pressure problem? Is it a blood sugar problem? We have nurses and physicians there to address those issues right away. I mean it’s rare, but we do have emergencies or urgent medical issues that do come up in patients at cardiac rehab. Can you always predict them? No. So I think it’s a good thing for people, at least initially, to start doing cardiac rehab so that we can monitor people and look out for some of these potentially life-threatening problems.
I’ve had patients who are young. You would look at them and say, they’re healthy, they’re not markedly overweight and they occasionally work out. They’ve told me, “I think I’m fairly fit. But now that I’ve come here and I’m doing it three times a week, and with intensive cardiac rehab,” we give them a lot of dietary information as well. They say, “Gosh, I wasn’t really fit. I thought I was active. I’m not really active compared to what we’re doing here.” I think when in doubt I would refer to cardiac rehab for all those reasons.
Perry: Gotcha. How long do the benefits last after undergoing cardiac rehab? Because cardiac rehab is a short-term sort of thing.
Peterson: Correct. Kind of as I mentioned before, even up to 5 years after participation, you can see mortality benefits for all-comers. For CABG, certainly there’s a mortality benefit even up to 10 years after doing cardiac rehab. It’s definitely a sustained benefit — and like you said, we’re only doing this for 36 sessions — but good habits are as hard to break as bad ones. Part of what we’re trying to do also is to get patients into good habits. So coming three times a week for 36 times, for 12 weeks, you’re engendering a habit. You’re setting up a habit that’s easier to keep up than if you’re just out by yourself trying to decide to do this.
Perry: That was going to be my follow-up question. Do some of the benefits stem from setting new habits and a new lifestyle for these patients or… ? I could imagine that after 36 weeks of rehab one guy goes back to sitting on a couch eating potato chips while somebody else continues on exercising everyday and trying to eat healthfully.
Peterson: Right. Like I said, the studies showing the benefits are not randomized studies, so you can’t deny cardiac rehab to people who would qualify for it, right? You do a randomized study, so are you picking healthier patients or more motivated patients to begin with? There’s other confounders in those studies. But we’re doing currently a study on intensive cardiac rehab versus cardiac rehab. In intensive cardiac rehab [ICR], you basically give patients double the number of hours, not double the number of sessions. They’re coming 36 times, but they get 72 hours worth of either exercise or diet intervention. They get to meet with a dietitian. They go to cooking classes. They learn about heart healthy eating, mindful eating, how to read a label, what to look for for sodium content, how to look for sugar content.
Especially with ICR, we’re really giving patients the tools with which to live a heart-healthy life. It’s not just telling patients, “I want you to be on a low-sodium, low-fat diet.” Most people have no idea. What does that mean? A 2,000-mg sodium diet, no one is going to add up the milligrams of sodium that they’ve eaten that day, everyday, for the rest of their lives. But if you give them tools with which to read a label and say, “Oh, that’s not low salt. This is. This product is the one I should take instead.” I think that’s really setting patients up for a much healthier lifestyle, and I’m not surprised that it translates into mortality benefit.
Perry: Now you were just kind of getting into some of those differences between cardiac rehab and intensive cardiac rehab. I mean could you further elucidate what those differences are?
Peterson: Yeah. In cardiac rehab, patients can get exercise. They get up to 36 sessions of exercise for phase II. Phase III cardiac rehab is unmonitored. Patients are still allowed to come back to our rehab center and stay unmonitored if they want. A lot of them use it as a gym after they’ve done the phase II cardiac rehab. But for intensive cardiac rehab, basically patients get twice as many hours of rehab. Like I said, it’s not just comprised of exercise, but it’s also comprised of hours-worth of instructions on heart-healthy living, heart-healthy diet, healthy mindset, how to read labels. Like I said, going to cooking classes. A lot of this is one-on-one or they watch informational videos that have been approved by Medicare for intensive cardiac rehab.
They’re getting hours and hours of instruction of information that we would like to tell all of our patients. But realistically in a 15-minute office visit in which time you have to also examine the patient, go over their medications, hear about any current complaints. You’re not going to have 36 hours to then tell the person all about how did heart disease happen in them in the first place, what’s going on inside their artery, in their heart, how can they prevent this for the future. We also go over smoking cessation for those people who smoke. It’s really repetitive and reinforcing this heart-healthy lifestyle, and we’ve had a really overwhelmingly positive response to it.
Perry: Awesome. Are there also diabetes educators for those?
Peterson: Right, our dietitian is also a diabetes educator, certified. She’s been doing it for years. Dottie Durband and she’s wonderful at it. The ICR is based on the Pritikin diet, which is basically low saturated fat, low sugar, low processed sugar, and high nutritional value. We want patients to be eating foods that are low calorie-dense foods, so heavy on the fruits and vegetables and less on the processed foods and less meat, in general. They go first to the dietitian because patients may also have some other particular dietary needs, whether it’s to avoid kidney stones or for diabetes or renal disease or things like that. She goes over all of their issues individually and we set up a plan for that person that’s based on the Pritikin diet.
Perry: Very cool. Now that’s a lot of support. Is that just through the Wash. U. cardiac rehab facilities or is that kind of a standard that’s even nationwide?
Peterson: That’s a standard nationwide. There’s only, I think two, maybe three programs. For sure two programs that are qualified programs to get Medicare reimbursement for intensive cardiac rehab. One is Ornish and one is based on the Pritikin diet. They’re very similar, low saturated fat. There are some differences. But basically the cardiac rehabs have to contract with those companies so they’re getting standardized materials. Everybody is teaching the same thing in order to be reimbursed by Medicare. There are more centers around the country. It’s not just Wash. U. We were the first in the country to be able to offer the Pritikin program as an outpatient facility.
Perry: Kudos. There we go. So to kind of recap: Cardiac rehab, primarily exercise-based. Intensive cardiac rehab, a lot of extra support like nutritionists, dietitians educating to help tailor towards their specific needs with their other comorbidities.
Perry: Now who are the kinds of people you refer to cardiac rehab and who goes to intensive cardiac rehab? Or maybe a better question, who qualifies to go for those?
Peterson: Right, that’s a great question. I said Medicare supports ICR. Not all insurances support ICR reimbursement. If somebody doesn’t have the insurance for it, they can still pay for it. But it’s obviously more expensive, so patients might not elect to do that if they’re not of Medicare age, Medicare eligible. That’s one issue. Even if a person has had an MI and would otherwise qualify for ICR, if their copay is too high or they’re paying out of pocket, they might not want to do it, which is, I think, a real shame that patients that are that young and obviously have a life-threatening problem can’t get all of the information through the ICR program.
Perry: Yeah. It would seem that then they could develop the healthy habits that they need and have a longer sustained benefit over their life as opposed to just hitting them later at the gate when they’re 65.
Peterson: Correct. Absolutely correct. Most insurances will only pay for cardiac rehab, just the exercise, including Medicare age, if there’s no coronary artery disease involved. If patients have, for example, non-ischemic cardiomyopathy. For those patients, only cardiac rehab is reimbursed, including Medicare patients.
Perry: Okay. For example, a young 33-year-old female with her non-ischemic cardiomyopathy, she wouldn’t qualify for intensive cardiac rehab.
Peterson: Correct. She does not qualify for intensive cardiac rehab.
Perry: So to get intensive cardiac rehab, basically you need a diagnosis of coronary artery disease.
Peterson: In general. For your third example, your 26-year-old woman who had the AVR, I’ll have to double check. If there’s ever a question, just call us and we’ll sort through that person’s individual insurance and what they’re covered for. Certainly anybody who qualifies for ICR, we’ll put them in that because we think we’re getting so many benefits out of it. Patients get so much more information, and so we preferentially try to get patients into the ICR program if we can.
Perry: How do you approach referrals to cardiac rehab with your patients, either in a clinic or when you’re on service?
Peterson: When I’m on service, I make it a point to tell people when they’re getting ready for discharge that I really want them to do cardiac rehab after they’ve been discharged from the hospital. I sit down and tell them some of the benefits. I mean you don’t have to sit down for a long time, but I say, “I really want you to do this.” And then I find out do they live close to here, to the Washington University campus or do they live close to our cardiac rehab site, which is at Olive and Mason. If they do, then I strongly encourage them to go there because it’s close by. I know what they’re going to be getting. If they don’t live close by, then I’d say, “Please go. We’ll find you a place that’s closer or one that you want to go to. But I really want you to go to cardiac rehab afterwards because I think there’s just so many proven benefits to it.”
Perry: What about the timing for cardiac rehab? For example, a lot of approved conditions to go for it. Does it matter… now a few of these, I guess at least as far as having an MI, it has to be within 12 months. But say for the other ones, like if you had a CABG, there’s no time restriction on having that. If you have heart failure, there’s no time limitation. Is there an improved benefit if you refer them earlier after their CABG or if you refer them earlier after the diagnosis of their heart failure, etc.?
Peterson: There’s actually a study done that was published in Circulation showing the benefit of early referral is that more patients actually enroll. Because the farther they get out from their event, the less likely they are to think, “Okay, I need to come to cardiac rehab. I’m at home. I’ve developed this pattern of being at home and not going to rehab.” I really strongly recommend that people start as soon as they physically can to do it. In that study, there was no downside in terms of major cardiac events or things like that in patients who started on the early side.
Perry: Thank you. Those are the questions that I had come prepared with. Are there other pearls of wisdom that you have about cardiac rehab that we haven’t covered?
Peterson: I would just say in my experience just having been there for years now is that I’ve just been surprised at how much of a mental benefit people get from doing cardiac rehab. They are very appreciative. They see the benefits for themselves and they can see the difference from when they started cardiac rehab ’til when they end cardiac rehab. They’re just very appreciative and a lot of them stay on and do phase III because they’ve developed friendships kind of like at the gym. It’s more of almost a social club, too, because they have this social support with people that they’ve met while doing cardiac rehab.
It’s just a really lovely thing to see patients who are supporting each other, feeling better, seeing that they’re doing better. They can see it for themselves. The other thing, like I said, is that even in patients who are young and you would consider, “Oh, he’s pretty healthy otherwise.” They can still see the benefits for themselves as well. They may be surprised by it and go, “Oh, gosh. I thought I was doing pretty well on my own, but now I’m doing even better.” They can see it for themselves.
Perry: Great. Well, it’s been a very informative time talking with you. I really appreciate your time.
Peterson: Thank you very much.
Perry: To recap, patients that you should refer for cardiac rehab include patients who have had an MI, patients with coronary artery bypass grafting, with stenting, people with current stable angina, or with heart failure. There is a reduction in all-cause mortality for all-comers, up to 5 years, and up to 10 years for those after coronary artery bypass grafting. Intensive cardiac rehab is primarily for your patients with a diagnosis of coronary artery disease, and that provides them with a lot of extra support in terms of nutrition and lifestyle counseling. Lastly, one of the main barriers to patients going to cardiac rehab is a lack of endorsement from their provider. So make it a point to at least talk to your patients about it. It doesn’t have to be long, just a minute or 2, and that’ll greatly increase the chances of those patients following through with cardiac rehab and reaping the benefits of it.
Thank you for listening to this episode of AP Cardiology. This series is co-sponsored by MedPage Today and by the Division of Medical Education at Washington University in St. Louis, School of Medicine.