Exercise lacking as medicine for secondary prevention

Exercise is Medicine….so why don’t some patients get the medicine they need?

Cardiac Rehabilitation remains under utilized, is this due to lack of referrals by physicians, lack of insurance so patients don’t attend, co pays and program expenses prohibitive for patients, or are patient barriers to significant to  attend? Probably all of the reasons listed.  I know when working in the industry it wasn’t unusual for patients to have co-pays of $50-$100 for one session of rehabilitation, at that price few will ever receive  the full secondary  prevention. There are limited hours and availability especially in rural areas.  Dr. Franklin and Dr. Wenger  are the movers and shakers within the cardiac rehabilitation industry, but this issues may be more of the health care reform issue of lowering costs for healthcare. Embracing telemedicine for secondary prevention and putting it not in the hands of the insurance companies, but those who have a vested interest the cardiac care departments, the cardiac rehabilitation units, and the hospitals themselves.  If the benefits of exercise came in a pill form rather than physical effort I bet it would be a megablockbuster drug.

Albany, NY - If exercise is a miracle drug, as it has been recently described, then it is a drug that is not prescribed enough for the prevention of cardiovascular disease. And if exercise is a “central and indispensable component” of a strategy in the primary prevention of coronary artery disease, then it is even more valuable in secondary prevention, according to a new viewpoint in the Journal of the American Medical Association [1].

In the article, published January 8, 2013, Dr William Boden (VA Medical Center Albany Medical College, NY), DrBarry Franklin (William Beaumont Hospital, Royal Oak, MI), and Dr Nanette Wenger (Emory University School of Medicine, Atlanta, GA) argue that despite the known benefits of physical activity and structured exercise for patients with stable ischemic heart disease, it is neglected and “woefully underutilized.”

“The mantra here is that exercise is medicine,” Boden told heartwire. “We focus so much of our attention on modifiable risk factors, such as treating cholesterol with statins, treating blood pressure to target, reducing hemoglobin A1c levels, and getting people to stop smoking, but we don’t view physical activity in quite the same context as a modifiable risk factor. So the viewpoint is really a call to arms, to get physicians to look at physical inactivity in the same context as they do with other treatments for other risk factors.”

In addition, Boden said that if physicians focused on getting patients to exercise 30 to 60 minutes a day, five days a week, it would go a long way toward reducing the prevalence of overweight and obesity in society, which are becoming epidemic.

In the viewpoint, Boden, Franklin, and Wenger note that increasing exercise or physical activity and cardiorespiratory fitness can mitigate cardiovascular disease progression, with exercise having known antiatherosclerotic, antithrombotic, anti-ischemic, antiarrhythmic, and positive psychological effects. Secondary-prevention programs that utilize physical activity with optimal medical therapy have been shown to reduce total mortality by 20%, cardiac mortality by 26%, and nonfatal MI by 26% [2]. Despite the proven benefits, many patients, including women, older patients, patients with limited education, and non-English-speaking patients, are frequently not referred for clinic-based cardiac rehabilitation.

“I think there are many factors involved,” Boden told heartwire. “In some instances, physicians are reluctant to recommend exercise or structured rehab programs. There are often uncertainties about whether such costs will be reimbursed by healthcare plans. Cardiologists often see patients for subspecialty referral care, and they view exercise to be more the realm of the internist or the primary-care physician. I think there are reasons why exercise might fall into the category of a ‘missed handoff.’ “

Reluctance among patients, conservative docs

In addition to some patients falling through these healthcare cracks, Boden said that some patients might be overly cautious or reluctant to participate in exercise programs, as they view an acute coronary syndrome or MI as a life-altering event. Some physicians might also be overly cautious or conservative and not recommend exercise as part of the recovery process. However, low to moderate exercise, such as walking, ideally started in a structured cardiac-rehabilitation program, can promote self-confidence and reassurance so that patients can transition to unstructured and unmonitored programs outside the clinic, he said.

“We also know that angina is exercise-induced and related to physical exertion, so there might be a fear of undertaking additional exercise because of concerns that it might provoke or exacerbate angina or worsen coronary disease, yet most of the data would support the opposite,” said Boden. “And one of the things we don’t preach enough in training our residents and fellows and younger physicians is the prophylactic role of short-acting nitrates before the activity. This can actually be a prophylactic measure to prevent or forestall angina during exercise.”

Boden said that most physicians regard short-acting nitrates as a treatment for angina and not as a preemptive strategy. “If physicians were aware of this, they might be inclined to better prepare patients for how to manage and live with their ischemic heart disease.”

After heart attack caring for your heart

The piece below is from a blog is written by Dr. Fogoros. He has presented the information very well. Every person discharged should have a care plan, they or their caregiver should have an understanding of what happens with a heart attack, what medications are necessary including how and why to take them, a plan to address the risk factors that contributed to the disease, and an action plan for recovery. He has summed it up very well. If you had a heart attack and were discharged from the hospital recently did you have a plan like the one listed below? From experience patients often have had such a whirlwind experience  with a rollercoaster emotional response, topped off with plenty of medications that upon discharge they are overwhelmed and confused. This is why the Cardiac Rehabilitation Programs are so important, they help you understand the what, where, why and how, and how to emotionally and physically recover.

 

After you’ve survived a heart attack (also called a myocardial infarction, or MI), you’ve got a lot to learn about and a lot to think about. While in the good old days you might have had a week or two of hospitalization to go through all the testing, risk assessment, education, and initiation of therapy necessary to optimize your long-term prognosis, today whatever is going to get done must happen in the first three (or four, if you’ve got a liberal health plan) days.

Doctors and hospitals have mobilized nicely to provide adequate acute care for the patient showing up with an acute MI. But too often, many have dropped the ball when it comes to giving appropriate care after those first critical hours. As a consequence, all too often patients don’t receive all the assessments, education, and treatment they need to assure an optimal outcome. For instance, recent studies show that less than half the patients who need statin drugs receive them. Other studies show that only a minority of heart attack survivors receivebeta blockers. And the proportion of patients who get an adequate assessment for the risk of sudden death, let alone those who receive the implantable defibrillator when it is indicated, is laughable.

The key to successfully navigating your way to a long, healthy life after a heart attack is you. You need to insist that the appropriate tests are done, the appropriate referrals are made, and the appropriate medications are begun. To this end, here is a convenient checklist of the things that should be done — ideally before you even leave the hospital — after your heart attack.

Doctors really do want to do the right thing. It’s just that, given all the pressure and constraints they’re operating under, from both insurance companies and the government, sometimes you need to remind them of who they’re really obligated to, and what your expectations are in that regard.

The Post-Heart Attack Checklist:

1) Lifestyle changes and other education:

  • I have been fully instructed on the warning signs and symptoms of heart attack, and the actions to take if I experience these signs or symptoms. (y/n) _____
  • If I am a smoker, I have been counseled to stop, and referred to one or more smoking cessation programs. (y/n) _____
  • I have been fully instructed on a heart-healthy diet. (y/n)_____
  • I have received detailed activity instructions for the next 4-6 weeks, and have been referred to a cardiac rehabilitation program. (y/n) _____
  • The importance of long-term exercise has been explained to me. (y/n) _____
  • My doctor has talked to me about when I can resume sexual activity. (y/n) _____
  • My doctor has talked to me about when I can resume driving. (y/n) _____

2) Assessing the risk of another heart attack in the near future:

  • The status of my coronary arteries has been assessed by either stress/thallium study (y/n) _____ or cardiac catheterization. (y/n) _____
  • The condition of my coronary arteries has been explained to me as follows: __________________________
  • The plan for following the status of my coronary arteries over time is: __________________________

3) The amount of damage done to my heart has been assessed by:

4) Important numbers I need to know:

  • My lipid profile has been measured, and the results are: Total cholesterol _______ LDL cholesterol _______ HDL cholesterol _______ Triglycerides _______
  • My blood pressure is _______
  • My ejection fraction is _______

5) Names and doses of medications prescribed for me:

  • Aspirin ___________________________
  • Beta blocker ___________________________
  • ACE inhibitor ___________________________
  • Statin ___________________________
  • Note: All of these medicines have been shown to help prevent further heart attacks and reduce the risk of death. If I have not received a prescription for one or more of these medications, the reason is ___________________________.

6) Preventing sudden death

  • If my ejection fraction is 30% or less, (or if I have had heart failure, and my ejection fraction is 35% or less) I have been referred to an electrophysiologist to discuss the possibility of an implantable defibrillator on: ______ (date)
  • Members of my family have been trained in CPR (y/n): ______

Sources:

Smith, SC Jr, Allen, J, Blair, SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006; 47:2130.

Richard N. Fogoros, M.D.
Heart Health Center Guide

Health Devices

Today’s technology allows heart patients to monitor their own health changes and be proactive in caring for themselves. I believe we are on a medical breakthrough using the internet and new technologies. In the past one would have to go to their doctor and report transient changes in blood pressure, heart arrhythmia - (palpitations) out of range blood sugars, etc.  The modern healthcare approach is to then order several very expensive tests in hopes of capturing the data and then making changes to the patients care plan once there is evidence of the changes. Today’s rapidly emerging technologies now allow patients to capture this information with home devices which cost much less than the tests ordered by our modern healthcare system.

Let’s look at heart rhythm monitors as an example. Atrial fibrillation is a very common heart rhythm problem, and for many patients they will go in and out of this rhythm. They may feel the heart racing, skipping beats, or feel shortness of breath and fatigue when the rhythm is abnormal. If A fib is dangerous immediate care can be initiated and then  managed with blood thinners to decreased risk of stroke. Therefore it is worth monitoring and catching it earlier vs. later.   There are now  monitors one can purchase for about $200 that would capture the rhythm put it to memory, then you can send to your physician electronically. Other heart arrhythmia that can be detected and managed this way  include heart blocks, abnormally slow heart rhythms, tachycardia -  fast heart rhythms.  The modern course is to order a holter monitor or an event monitor. The holter monitor is worn for 24 hours or more, then it takes up to two weeks for it to be interpreted  dictated and the reports received and acted on by the ordering physicians. Event monitors are placed below the skin and worn for 30 days or more. Consider given the progressive nature of heart problems, that these tests are not  usually run only one time on an individual over the course of their life.

HOLTER MONITOR SCANNING $312.00
HOLTER MONITOR RECORDING $345.00

Handheld home devices purchased for about $200 can be used by the patient with  little education,and a plan of care is devised  between the patient and the physician..  This could potentially allow you to  manage their issues more in a much more convenient and timely manner. The device is owned by you and thus can be used over many years. Below is the typical physician algorithm for managing arrhythmia’s.

 

Figure.

 

With today’s hand held monitors available at a cost of approximately two hundred dollars, patients can capture the irregular rhythm when it occurs, save the data, report it to physicians and have their care evaluated much quicker – provided they can get an appointment with their healthcare practitioner. Wouldn’t it be even better to be able to transmit the information to the physicians email, and then be triaged based on the data?

The problem is $$$$$$$, and the medical system in the US is slow to adopt change. If it cuts in to the profit of healthcare it isn’t likely to be adopted.  This a role where I believe mid level practitioners like PA’s, CNA’s can play a role in triaging care, as the current work demand doesn’t allow most physician the time to undertake electronic care of patients. It may take patients to make the change, those who are under insured, uninsured, or have significant financial obstacles which impede access to traditional care.

On a side note I really enjoyed Eric Topol’s book The Creative Destruction of Medicine. It makes one think about how medicine can change practice models.

With personal technology, doctors can see a full, continuously updated picture of each patient and treat each individually. Powerful new tools can sequence one’s genome to predict the effects of any drugs, and improved imaging and printing technology are beginning to enable us to print organs on demand. Topol offers a glimpse of the medicine of the future—one he is deeply involved in shaping.

Below are a couple of examples of how patients can control and manage their health data:

http://www.misfitwearables.com/health_device_at_a_glance

health_device_at_a_glance.jpg

http://online.wsj.com/article/SB10001424052702303404704577311421888663472.html

TOPOLcollage

http://www.favoriteplus.com/easy-ecg-handheld-monitor-fp180.php

 

Recovery from Open Heart Surgery: Common Complications

Issues affecting recovery from open heart surgery

How many of you heard from you cardiac surgeon that you would feel great in a couple of months after open heart surgery? Did  you bounce back fast, or are you finding it a long slow process of feeling like you have recovered? I consistently have told patients it takes a year to heal up completely from open heart surgery. One month for the vessels to heal, two months for the muscles, three months for the bone to mend, three months for blood counts to return to normal and a year for inflammation to settle down, and strength to return. I bet most didn’t hear those comments before going into surgery. This is information gleaned from 20 years of working with post operative open heart patients.

Common complications of open heart surgery

The first few months present the most challenges. What types of challenges? Well in cardiac rehabilitation the challenges we faced most included:

  • Heart rhythm problems – usually atrial fibrillation and tachycardia,  followed by heart blocks requiring pacemakers, rarely  ventricular fibrillation and ventricular tachycardia
  • Plueral Effusions -A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. This creates shortness of breath, anxiety, a feeling of drowning
  • Anemia – blood counts that don’t return back to normal, produces fatigue, shortness of breath, activity intolerance
  • Infections of the surgical site or where the harvested graph occurred
  • Pump head - in some patients, the use of the cardiopulmonary bypass pump can cause foggy thinking and confusion after surgery
  • Nerve damage – it isn’t uncommon for patient to have their ulnar nerve irritated and experience numbness of the fourth and fifth fingers of their hand. The technical term is brachial plexopathy. My belief it this is due to the prolonged position they are in during the operation places stress on the neck which pinches the nerve.
  • Diaphragm nerve damage  due to phrenic nerve injury. This causes the diaphragm to only have limited ability to  work causing permanent shortness of breath problems.
  • Vocal cord nerve damage. Cardiac surgery represents a risk to normal voice function as the nerves serving the larynx (voice box) are near the heart.

How to manage complications in recovery of open heart surgery

If you or your loved one is having a hard time recuperating, know that these type of complications do occur, and are not that unusual. Keep notes of the issues you are finding as you recover. Don’t be afraid to report even minor problems to your healthcare provider, as they may be able to be addressed and the sooner they are addressed the better.

If you are finding you just aren’t bouncing back, either due to fatigue, shortness of breath, lightheartedness, anxiety – make sure you talk to your physician about this. Be persistent, come in with a list of what you are concerned about. Often this is where cardiac rehabilitation is very helpful, as the clinicians are very familiar with these complications and can assist in communicating their finding with the physician and educating the patient on the implications to them. This helps to get referrals to the appropriate providers, whether it is pulmonologist, physical therapy, emergency room, surgeons. And we all know how easy it is to navigate through our US healthcare is…..yeah right!