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.”

8 thoughts on “Exercise lacking as medicine for secondary prevention

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