B P4 C33 Comprehensive Cardiac Rehabilitation

Question 1

The United States currently has seven patient groups for which CR is recommended in clinical prac- tice guidelines and covered by the Centers for Medicare and Medic- aid Services (CMS),as well as commercial insurance providers. Those indications include:

Answer 1

MI
Percutaneous coronary intervention (PCI)
Coronary artery bypass graft surgery (CABG)
Stable angina
Heart valve repair/replacement
Heart transplantation
Heart failure with reduced ejection fraction (HFrEF).

In addition, supervised exercise training is covered by CMS for patients with symptomatic peripheral arterial disease of the lower extremities (claudication).

Question 2

The CR care team is comprised of a multidisciplinary team of health care professionals including a physician medical director who over- sees the safety and effectiveness of the CR program elements, and a team composed of nurses, exercise physiologists, physical therapists, dietitians, psychologists, social workers, and other professionals. The CR team members have appropriate training, skills, and certification to:

Answer 2

• Administer lifestyle therapies
• Assess and manage the underlying cardiovascular risk of a patient
• Coordinate the cardiovascular care for a patient’s specific cardiovascular condition
• Identify and refer patients for appropriate care of their comorbid conditions
• Prevent and manage medical complications and emergencies that may occur during the course of a patient’s CR program

Question 3

Patients undergo clinical assessments as they begin an outpatient CR program and at key checkpoints during the program. These assessments include:

Answer 3

(1) safety evaluation for high-risk cardiovascular conditions (e.g., unstable symptoms)
(2) screening evaluation for comorbid conditions that may require additional evaluation and/or treatment (such as depression, diabetes)
(3) evaluation of clinical factors (such as functional capacity) that will be used by the CR staff and patients to formulate the individualized treatment plan (ITP
(4) measure patient progress and outcomes.

Question 4

For center-based CR programs, patients ideally attend ____ in-person CR sessions over a period of ____ weeks or more, usually attending three sessions per week. With the help of the CR staff, the patient develops a patient-centered ITP that is followed in the CR center and also at home

Answer 4

36 session over 12 weeks or more

Question 5

The ITP includes patient actions that help the patient implement guideline-directed medical therapy and also appropriate lifestyle therapies, including:

Answer 5

(1) Physical activity and exercise training
(2) Nutritional therapy
(3) Smoking/tobacco cessation (if indicated)
(4) Psychological health management

Question 6

Current Indications for Cardiac Rehabilitation in the United States

Answer 6

Myocardial infarction
Coronary artery bypass graft surgery
Percutaneous coronary intervention
Stable angina
Heart valve repair/replacement
Heart transplantation
Heart failure with reduced ejection fraction
*Peripheral artery disease with claudication (Currently indicated for supervised exercise training.)

Question 7

Physical and psychological recovery after a CVD are enhanced for patients who participate in outpatient CR. Functional capacity improves _____% in CR participants compared to non-CR participants. Likewise, CR participation helps to significantly improve health-related quality of life and other measures of psychological health.

Answer 7

15-25%

Question 8

Exercise training helps improve symptoms of ______, a common diagnosis in patients recovering from a CVD event.

Answer 8

Depression

Question 9

Exercise training itself produces a number of beneficial physiologic adaptations including:

Answer 9

(1) Increase in peak cardiopulmonary oxygen uptake and myocardial oxygen supply
(2) Decrease in myocardial oxygen demand
(3) Improvement in endothelial function

Question 10

Patients with HFrEF who undergo exercise training in CR also experience clinically meaningful improvements symptoms, functional capacity, hospital readmission rates, and health-related quality of life. They experience improvements in:

Answer 10

(1) cardiopulmonary efficiency and function
(2) skeletal muscle oxygen transport and utilization
(3) various neurovascular mechanisms
(a) increase in heart rate variability
(b) baroreceptor sensitivity
(c) reduction neurohumoral factors

Question 11

Patients recovering from a CVD event who participate in CR are more likely to have their risk factors controlled than those who do not participate. This improved control is probably related to several factors related to CR participation, including:

Answer 11

Systematic use of protocols and other strategies to optimize the prescription of and adherence to guideline-directed lifestyle and medical therapies.

Question 12

Participation in CR has been associated with _____% reduction in hospital readmission (both CVD and non-CVD readmissions) for patients recovering from a CVD event.

Answer 12

25-30%

Question 13

Longer-term randomized and observational studies have shown _____% reductions in all-cause and cardiovascular mortality in CR participants.

Answer 13

20-45%

Question 14

Gaps in CR participation have been documented throughout the United States in all patient sub-groups, but the gap is even more notable in groups at highest risk for poor CVD outcomes (including ____)

Answer 14

Women
Individuals older than 65 years of age
Individuals from racial/ethnic minority groups

Question 15

Limitations to current cardiac rehabilitation models:

Answer 15

Low patient referral, enrollment and participation rates
Lack of sufficient cardiac rehabilitation program capacity
Long term maintenance of cardiac rehabilitation

Question 16

Gaps in CR participation have been documented throughout the United States in all patient sub-groups, but the gap is even more notable in groups at highest risk for poor CVD outcomes (including: _____)

Answer 16

Women
Individuals older than 65 years of age
Individuals from racial/ethnic minority groups

Question 17

Evidence-based strategies to improve cardiac rehabilitation (CR) participation from current levels (20%) to more optimal levels (70%)

Answer 17

Cardiac Rehabilitation REFERRAL
- EMR based referral
- CR staff liaison
- CR referral as performance measure

Cardiac Rehabilitation ENROLLMENT
- CR staff liaison
- Early appointment at CR
- CR enrollment as performance measures
- Work to minimize co-pays

Cardiac Rehabilitation ADHERENCE
- Set 36 CR sessions goal
- Home-based CR option
- Flexible CR hours
- Work to minimize co-pays

Question 18

To increase the capacity of CR services, it will be necessary to _____ that will effectively expand the scope and capacity of CR.

Answer 18

Increase the capacity of existing CR centers, build new CR centers

and/or

Develop additional CR delivery models (community-based programs and home-based telehealth programs)

Question 19

However, until additional longer-term research is available (showing similar or greater reductions in mortality and morbidity rates with home-based CR as with center-based CR), _____ programs will remain the first line of CR therapy, with home-based CR being used as an adjunct to center- based CR and/or as a secondary option for patients who are not able to participate in center-based CR

Answer 19

Center-based programs

Question 20

Limitations of current cardiac rehabilitation models

Answer 20

Low patient referral, enrollment, and participation rates
Lack of sufficient cardiac rehabilitation program capacity
Long-term maintenance of cardiac rehabilitation

Question 21

To increase the capacity of CR services, it will be necessary to _____ that will effectively expand the scope and capacity of CR.

Answer 21

(1) Increase the capacity of existing CR centers
(2) Build new CR centers
(3) Develop additional CR delivery models (community-based programs and home-based telehealth programs)