Congestive Heart Failure Patients finally Get Cardiac Rehabilitation

Congestive Heart Failure Patients finally Get Cardiac Rehabilitation

This is great news. I worked for many years petitioning our Congress and Senate to urge CMS to cover Cardiac Rehabilitation services for Congestive Heart Failure patients. There is a large subset of patients who can be much better served and monitored through cardiac rehabilitation to prevent readmissions. Congratulations to the AACVPR for helping attain this coverage from CMS, that is a very big deal.

 

 

 

WASHINGTON — Medicare has proposed covering cardiac rehabilitation services for patients with chronic heart failure 4 years after saying there was little evidence to support doing so.

The proposed coverage decision would expand access to rehab for a wider range of heart patients. Medicare currently covers rehab only for patients who have had an acute MI in the preceding year, coronary artery bypass surgery, heart or heart-lung transplant, or other major events.

The Centers for Medicare and Medicaid Services (CMS) came to the determination after reviewing literature on the rehab service from 2006 to August 2013. It announced the decision online late last week.

“Since chronic heart failure often results from coronary artery disease and hypertension, evidence on behavioral interventions in the treatment of these conditions provide additional supportive evidence,” the agency wrote. “With the accumulated evidence that supports the benefits of the individual components of cardiac rehabilitation programs, the evidence is sufficient to determine that participation in these multi-component programs improves health outcomes for Medicare beneficiaries with chronic heart failure.”

The agency is seeking public comments on the proposed decision and will post a final determination later.

Under the proposal, the agency would pay for rehab services — exercise, behavioral risk factor reduction, health education, and personal counseling — for patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms with at least 6 weeks of heart failure therapy.

The American Heart Association praised the CMS announcement.

“We are gratified that the agency recognized the evidence that pointed to the need for this expansion, and look forward to the day when this coverage will enable millions of heart failure patients to reap the benefits of cardiac rehabilitation,” AHA President Mariell Jessup, MD, said in a statement.

The AHA, along with the American College of Cardiology, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Heart Failure Society of America had asked CMS to consider adding CHF for coverage of cardiac rehab.

The CMS decision follows a study of nearly 2,300 patients that showed that aerobic exercise is safe for heart failure patients and effectively improves clinical outcomes. The patient population CMS is including is effectively the same as that in the trial, Ileana Pina, MD, professor at Albert Einstein College of Medicine in the Bronx, N.Y., told MedPage Today in a phone interview.

“Even though we knew all the good things exercise can do, a lot of physicians were not recommending it because the patients would have to pay out of pocket to go to a cardiac rehab program,” Pina, vice chair of the clinical cardiology council at the AHA, said.

She said many patients without this rehab option end up going to skilled nursing facilities because of their condition.

Roughly 17% of those age 65 and older have heart failure, according to CMS.

Good Information for the heart patient

The two articles below are from American College of Sports Medicine and are position stands. Both of these articles are helpful for the heart patient to understand in the care and prevention of heart conditions. A couple of things to point out to the rehabilitating heart patient would be, the expected drop in blood pressure from exercise is 5-7 mmHg, but can remain lower for quite some time afterwards. This is why you must be alert for dizziness, lightheadedness, fainting, especially after getting up from lying or seated positions.

The article mentions controlled hypertension.Understand you blood pressure as there are levels of hypertension mild moderate and severe. Exercise is not recommended when blood pressure is elevated in the severe ranges.  Most should focus their effort in keeping the intensity mild to moderate. This is harder than you think keeping exercise light to moderate, be patient.

The second article, yes there are risks involved with exercise and they can be life threatening. What can you do to lower the risk? The intensity of exercise is important to understand. Learn about MET levels and exercise intensity here after you finish reading the article.

Exercise and Hypertension

Hypertension (HTN), one of the most common medical disorders, is associated with an increased incidence of all-cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the prevention, treatment, and control of HTN, with exercise being an integral component. Exercise programs that primarily involve endurance activity prevent the development of HTN and lower blood pressure (BP) in adults with normal BP and those with HTN. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise with BP decreasing approximately 5-7 mm Hg after an isolated exercise session (acute) or following exercise training (chronic). Moreover, BP is reduced for up to 22 h after an endurance exercise bout (e.g., postexercise hypotension), with the greatest decreases among those with the highest baseline BP.

The proposed mechanisms for the BP lowering effects of exercise include neurohumoral, vascular, and structural adaptations. Decreases in catecholamines and total peripheral resistance, improved insulin sensitivity, and alterations in vasodilators and vasoconstrictors are some of the postulated explanations for the antihypertensive effects of exercise. Emerging data suggest genetic links to the BP reductions associated with acute and chronic endurance exercise. Nonetheless, definitive conclusions regarding the mechanisms for the BP reductions following endurance exercise cannot be made at this time.

Individuals with controlled HTN and no CVD or renal complications may participate in an exercise program or competitive athletics, but should be evaluated, treated, and monitored closely. Preliminary peak or symptom-limited exercise testing may be warranted, especially for men over 45 and women over 55 yr planning a vigorous exercise program (i.e., ≥ 60% V̇O2R, oxygen uptake reserve). In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate intensity exercise training (40-<60% V̇O2R) such as walking. When pharmacologic therapy is indicated in physically active people it should, ideally: a) lower BP at rest and during exertion; b) decrease total peripheral resistance; and, c) not adversely affect exercise capacity. For these reasons, angiotensin converting enzyme (ACE) inhibitors (or angiotensin II receptor blockers in case of ACE inhibitor intolerance) and calcium channel blockers are currently the drugs of choice for recreational exercisers and athletes who have HTN.

Exercise remains a cornerstone therapy for the primary prevention, treatment, and control of HTN. The optimal training frequency, intensity, time, and type (FITT) need to be better defined to optimize the BP lowering capacities of exercise, particularly in children, women, older adults, and certain ethnic groups. Based upon the current evidence, the following exercise prescription is recommended for those with high BP:

Frequency: on most, preferably all, days of the week

Intensity: moderate-intensity (40-<60% of V̇O2R)

Time: ≥ 30 min of continuous or accumulated physical activity per day

Type: primarily endurance physical activity supplemented by resistance exercise

 

Exercise risk for cardiovascular event

Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons. This scientific statement discusses the potential cardiovascular complications of exercise, their pathological substrate, and their incidence and suggests strategies to reduce these complications. Exercise-associated acute cardiac events generally occur in individuals with structural cardiac disease. Hereditary or congenital cardiovascular abnormalities are predominantly responsible for cardiac events among young individuals, whereas atherosclerotic disease is primarily responsible for these events in adults. The absolute rate of exercise-related sudden cardiac death varies with the prevalence of disease in the study population. The incidence of both acute myocardial infarction and sudden death is greatest in the habitually least physically active individuals. No strategies have been adequately studied to evaluate their ability to reduce exercise-related acute cardiovascular events. Maintaining physical fitness through regular physical activity may help to reduce events because a disproportionate number of events occur in least physically active subjects performing unaccustomed physical activity. Other strategies, such as screening patients before participation in exercise, excluding high-risk patients from certain activities, promptly evaluating possible prodromal symptoms, training fitness personnel for emergencies, and encouraging patients to avoid high-risk activities, appear prudent but have not been systematically evaluated.

Regular physical activity is widely advocated by the medical community in part because substantial epidemiological, clinical, and basic science evidence suggests that physical activity and exercise training delay the development of atherosclerosis and reduce the incidence of coronary heart disease (CHD) events (1-4). Nevertheless, vigorous physical activity can also acutely and transiently increase the risk of acute myocardial infarction (AMI) and sudden cardiac death (SCD) in susceptible individuals (5-7). This scientific statement presents the cardiovascular complications of vigorous exercise, their pathophysiological substrate, and their incidence in specific patient groups and evaluates strategies directed at reducing these complications. The goal is to provide healthcare professionals with the information they need to advise patients more accurately about the benefits and risks of physical activity.

Most studies of exercise-related cardiovascular events have examined events associated with sports participation in young subjects and with vigorous exercise in adults. Vigorous exercise is usually defined as an absolute exercise work rate of at least 6 metabolic equivalents (METs), which is historically assumed to equal an oxygen uptake (V˙O2) of 21 mL·kg-1·min-1. Six METs approximates the energy requirements of activities such as jogging. Six METs is an arbitrary threshold and does not account for the fact that the myocardial oxygen demands of any physical activity are more closely related to the V˙O2requirements relative to maximal exercise capacity than to the absolute work rate per se. Consequently, exercise work rates < 6 METs may still place considerable stress on the cardiovascular systems of unfit and older individuals.

Sodium: What gives Caregivers and Cardiac Rehab Staff Nightmares

Working cardiac rehabilitation, one wants to take time off around Saint Patrick’s day and Easter. Often patients come in with weight up 10 lbs in one to three days, short of breath, swollen, and having elevated blood pressure. When asked, they report celebrating Saint Patrick’s day with sauerkraut and sausage, corned beef and cabbage, with lots of bread on the side, then celebrated Easter early with a ham dinner with gravy.

Caregivers take note, well-intentioned friends and family may have prepared meal or stocked freezers full of sodium laden foods thinking they are helping out during a  medical crisis. Be alert to sodium and it’s effect on heart health.  Programs such as  Meals on wheels also has a tendency to have very salty meals. 

If you find weight up, swollen feet/ankles/belly/face, shortness of breath and elevated blood pressure consider the  dietary sources of sodium. 

Sodium causes fluid retention, weight goes up,  and is often treated with increased diuretics (Lasix, Aldactone, Demedex, Bumex, Zaroxolyn etc.). The body can become resistant to diuretics however, so adding more and more diuretics can be dangerous. These throw off the electrolytes and disrupt the sodium potassium balance of the body, which can set in motion additional heart problems including arrhythmia’s – irregular heart beats that could be deadly. Other side effects of diuretics include:

  • increased blood glucose levels
  • increased calcium
  • increased cholesterol
  • potassium loss
  • increased uric acid, which might trigger a gout attack in certain people

Bought raw or in a can, corned beef brisket is very salty. One 3 ounce serving of cured corned beef has 964 mg of sodium, 40 percent of your daily value of sodium. In addition to sodium, corned beef is generally made from the fattier brisket areas, so the fat and cholesterol levels tend to be on the high side when compared to some of the more commonly available beef cuts. 1 cup of Cooked Sauerkraut has about 900 mg of sodium. Ham isn’t better - 4 oz. of ham can have between 1000 and 3000 milligrams of sodium. 

Sodium, Salt, Na, MSG, natural flavors, natural spices, Sodium Nitrate,

  • Monosodium glutamite,
  • Sea salt,
  • Disodium phosphate,
  • Baking soda,
  • Sodium citrate, sodium bicarbonate, sodium algonate, are all names of sodium.

 If your diet is going be high in sodium, eat more potassium-rich foods. Potassium helps to lessen the dangerous effects of sodium. Foods high in potassium include bananas, potatoes, squash, spinach, raisins, cantaloupe, beans and lentils.

Rinsing foods such as sauerkraut, or canned beans or veggies in a colander can remove up to 40%. Read labels and aim for foods with 300 milligrams or less of sodium per serving.

 To learn more about salt and heart health click here

To learn more about how to lower sodium in diet click here.

To learn more about sodium and it’s effects on the body

What are my chances of getting Heart Disease?

What Are My Chances of Getting Heart Disease Infographic

The Multiplier Effect

  • 1 risk factor doubles your risk
  • 2 risk factors quadruple your risk
  • 3 or more risk factors can increase your risk more than tenfold
By doing just 4 things – eating right, being physically active, not smoking, and keeping a healthy weight – you can lower your risk of heart disease by as much as 82 percent