Kentucky Cardiopulmonary Rehabilitation Association



76200-342900KCRA NewsletterMay / June 2019In this issuePulmonary Rehab Program ToolkitNutrition: One Size Does Not Fit AllCardiac Rehab in 2019: Benefits in the LVAD and Cardiac Transplant PatientKCRA Executive Committee – Member SpotlightPulmonary Rehab Program ToolkitLast month, AACVPR unveiled a new education resource designed for the pulmonary rehabilitation professional in search of the tools needed to build a strong program. The AARC-approved Essentials of Pulmonary Rehabilitation Program Management consists of a series of four webinars, built on evidence-based guidelines and emerging evidence for alternative PR models. Learn the essentials of pulmonary rehab program management to support the strong growth of your PR program. FeesAACVPR members: $325Non-members: $375CEUsAACVPR CE credit: 4.0AARC CE credit: 4.0Module 1: Review of Program Management Basics presented by Trina Limberg, BS, RRT, FAARC, MAACVPRModule 2: Program Formatting & Physician Involvement presented by Gerilynn Connors, BS, RRT, FAARC, MAACVPRModule 3: Billing, Coding and Documentation presented by Janie Knipper, RN, MA, MAACVPRModule 4: Tracking Program Metrics Beyond Outcomes presented by Chris Garvey, FNP, MSN, MPA, MAACVPR Nutrition: One Size Does Not Fit AllBy?Carol Guarino, MS, RD, CDE, Clinical Dietitian, Helen Hayes HospitalDuring a meeting with a patient, I once again heard, “I don’t know what I am allowed to eat.” ??This is a sad statement. We are adults. We are allowed to eat as we choose. However, I do understand the confusion with the overwhelming advice from the cardiologist, the endocrinologist, the gastroenterologist, and, of course, family, friends and advertisements. Each piece of advice is just that: a piece. We have neglected to treat the individual as a whole. I believe a more accurate statement would be, “I am confused as to what is best for me.”Of course, medical diagnoses should play a part in food choices, but we also need to be mindful of lifestyle, culture and willingness to receive education. Our patients have been through a life-altering experience. Some are afraid to eat while others are stress eating. ?DASH, Mediterranean, plant-based and Choose My Plate are all nutritionally sound meal plans, but will these fit into an individual’s life? Are they sustainable? Can we mix and match? Encouraging small frequent meals to an individual with a food addiction and constant thoughts of eating might not be the best solution. You just may lose the interest of the cattle farmer when you mention plant-based. My advice? Listen, advise and repeat as needed. Work with your patient to make small sustainable changes. Let them try it on for size, and if it doesn’t fit, try on another. Collaborate with your patient to find what will work with their life and their body.Here is a starting point for an individual plan: Begin with the basics: the food label. Narrow down what is important for that individual. Is it sodium? Carbohydrates? Calories?Encourage home cooked meals. Review favorite recipes. Assess if modifications are needed and how they can be made (and accepted). If one is culinary challenged, offer simple recipes or meal kits now widely available in supermarkets.Review portion sizes. No food is off limits, but try to set limits with portions.Focus on what should be eaten as opposed to what should not.Encourage your patient to enjoy their life’s journey.Cardiac Rehab in 2019: Benefits in the LVAD and Cardiac Transplant PatientBy Michael Salama, MD, FIT (Fellow in Training), and Alison L. Bailey, MD, FAACVPR, FACCWith an estimated 6.5 million currently living in the United States people with heart failure (HF) and more than 650,000 new cases diagnosed annually, HF is one of the most common and complicated cardiovascular disorders seen in the medical community1. Nearly half of these cases represent HF with reduced ejection fraction (HFrEF; EF<40 percent).It is well established that HF is a progressive disorder, and a staging system has been introduced to clarify therapies as well as prognosis2. The first two stages (A and B) are not clinical HF but are an attempt to provide early identification of patients who are at risk for developing HF and thus can have preventative strategies employed. Stage A represents the presence of risk factors for HF but no structural changes of the heart. Stage B patients are asymptomatic but have structural changes of the left ventricle (LV) and/or impaired LV function. Stage C denotes patients with current or past symptoms of HF associated with underlying structural heart disease.Stage D designates patients with refractory HF. Up to 10 percent of all heart failure patients are considered to have advanced heart failure, Stage D, which is a term that has overlapping definitions. According to the 2007 Heart Failure Society of America position statement, Stage D HF is “a stage where conventional treatments (guideline-directed drugs, devices, conventional surgery) are insufficient to control the patient’s symptoms, and advanced therapies (cardiac transplantation, mechanical circulatory support) or palliative therapies (inotropic infusions, ultrafiltration or peritoneal dialysis to control volume, or end-of-life comfort care) are needed”3. Despite the advancements in therapy for HF patients, the disorder is still associated with high morbidity and mortality. In a recent report from a large HF referral center, roughly one in four patients with Stage C HF progressed to Stage D HF or died within three years4. The outcomes in community centers are likely worse, since patients who are not deemed a candidate for advanced therapies may never be referred.Cardiac Rehabilitation (CR) has been shown to improve survival, functional capacity and quality of life in cardiovascular disease patients in a dose-dependent manner5-7. It has been indicated for stable HFrEF patients for many years. Now, new data is emerging of the role of CR in patients with both left ventricular assist devices (LVAD) and those who have received a cardiac transplant. A review of LVAD therapy and CR can be found here. It has been established that CR improves maximal oxygen consumption, peak heart rate, ventilatory capacity, autonomic function and quality of life in cardiac transplant patients who attend the program9. Long-term data regarding hard outcomes like morbidity and mortality for CR in cardiac transplant recipients, however, is sparse. A recent study showed that individuals who attended CR after cardiac transplant experienced a 29 percent lower one-year readmission risk than those who did not attend as well as the improvements in functional capacity and quality of life.Cardiac rehab has been shown to improve symptoms and functional capacity in patients with continuous-flow LVADs10. A randomized study demonstrated that CR compared to usual care, provided a significant improvement in functional capacity (increased total treadmill time and increased leg strength) as well as a significant difference in health status (higher scores on the Kansas City Cardiomyopathy Questionnaire). Recently, it was shown that CR attendance after implantation of an LVAD was associated with a 23 percent lower risk of one-year hospitalization as well as a 47 percent lower risk of mortality at one year11. The likelihood of attending CR varies among indications. Rates of initiation of CR in HF patients is <10 percent and ranges from 10-20 percent in patients post-acute myocardial infarction and percutaneous coronary intervention, up to 35 percent in post coronary artery bypass grafting12-15. Only about 30 percent of patients who receive an LVAD participate in CR while initiation rates of 55 percent have been reported post cardiac transplant9,11. While this number marks the highest initiation rate among the various CR indications, it is still surprisingly low when the cost of CR is considered relative to the global cost of care for a cardiac transplant recipient. Some of the reported barriers to CR participation in cardiac transplant and LVAD patients are similar to those of other groups and include work responsibilities, distance to the nearest CR center, availability of transportation, caregiver responsibilities and social anxiety9. Additionally, time to CR initiation remains a challenge in the United States and may be a larger barrier in these groups. It has been demonstrated that median wait time from referral to initiation of CR is 42 days for overall referrals and for every day of delay after discharge, a 1 percent reduction in participation rates for CR are seen16. Longer wait time to start CR has also been significantly associated with less improvement in cardiopulmonary fitness, body fat percentage, resting heart rate, and poorer attendance to CR classes and completion rate17. Reported median times from hospital discharge to the first CR appointment are 54 days in transplant patients and 83 days for LVAD patients9,11.Heart or heart-lung transplant is currently an indicated diagnosis for CR. VAD implantation is not currently a covered indication for CR, however, most VAD recipients are eligible for CR under the HFrEF indication, which covers patients with stable, chronic HF and a LVEF of <35 percent.What does this mean for the CR professional?Patients with HFrEF are increasing in our population and receive proven benefit from CR. Once these patients have progressed to advanced therapies like LVAD or transplant, CR can be useful to improve outcomes, functional capacity and quality of life as well as readmission and mortality. Cardiac rehab centers should develop protocols for patients receiving an LVAD or cardiac transplant that encourage early utilization of this proven non-pharmacologic therapy.References:1.Benjamin, EJ et al. Heart Disease and Stroke Statistics—2017 Update. A Report from the American Heart Association. Circulation 2017; 135: e146-e603.2.Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused Update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 119: e391-479.3.Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced Heart Failure: A Position Statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20: 1505-1535.4.Kalogeropoulous AP, Samman-Tahhan A, Hedley JS, et al. Progression to Stage D Heart Failure Among Outpatients With Stage C Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol HF 2017; 5: 528-537.5.Dugmore LD, Tipson RJ, Phillips MH, et al. Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Heart 1999; 81: 359-66.6.Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016; 67:1–12.7.Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between Cardiac Rehabilitation and Long Term Risks of Death and Myocardial Infarction among Elderly Medicare Beneficiaries. Circulation 2010; 121: 63-70.postella, L, Russo, N, Setzu T, et al. A Practical Review for Cardiac Rehabilitation Professionals of Continuous-Flow Left Ventricular Assist Devices: HISTORICAL AND CURRENT PERSPECTIVES. J Cardiopulm Rehabil Prev 2015; 35: 301-11.9.Bachmann JM, Shah AS, Duncan MS, et al. Cardiac rehabilitation and readmissions after heart transplantation. J Heart Lung Transplant. 2018;37: 467-476.10.Kerrigan DJ, Williams CT, Ehrman JK, et al. Cardiac rehabilitation improves functional capacity and patient-reported health status in patients with continuous-flow left ventricular assist devices: The Rehab-VAD randomized controlled trial. J Am Coll Cardiol HF 2014; 2: 653-659.11.Bachmann JM, Duncan MS, Shah AS, et al. Association of Cardiac Rehabilitation with Decreased Hospitalizations and Mortality after Ventricular Assist Device Implantation. J Am Coll Cardiol HF 2018; 6:130–9.12.Golwala H, Pandey A, Ju C, et al. Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: findings from Get with the Guidelines- Heart Failure Registry. J Am Coll Cardiol 2015; 66:917–26.13.Doll JA, Hellkamp A, Ho PM, et al. Participation in cardiac rehabilitation programs among older patients after acute myocardial infarction. JAMA Intern Med 2015; 175: 1700-2.14.Schopfer DW, Takemoto S, Allsup K, et al. Notice of Retraction and Replacement. Schopfer DW, et al. Cardiac Rehabilitation Use Among Veterans With Ischemic Heart Disease. JAMA Intern Med 2014;174(10):1687-1689. JAMA Intern Med 2016;176(11):1726–1727.15.Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007; 116:1653–62.16.Russell KL, Holloway TM, Brum M, Caruso V, Chessex C, Grace SL. Cardiac rehabilitation wait times: effect on enrollment. J Cardiopulm Rehabil Prev 2011;31(6):373-7.17.Marzolini S, Blanchard C, Alter DA, Grace SL, Oh PI. Delays in Referral and Enrolment Are Associated With Mitigated Benefits of Cardiac Rehabilitation After Coronary Artery Bypass Surgery. Circ Cardiovasc Qual Outcomes 2015;8(6):608-20.KCRA Executive Committee: Member SpotlightTreasurer – Katelyn KingKatelyn King is the current Treasurer for the Kentucky Cardiopulmonary Rehab Association. She received her master’s degree in Exercise Physiology from Marshall University in 2013 and has worked in Cardiopulmonary Rehab for 7 years. Katelyn is the Transitions of Care Coordinator at UK Healthcare. She works in the inpatient and outpatient setting, and is responsible for making sure all eligible inpatients receive a cardiac rehab referral to the closest facility to their hometown. Katelyn also has the privilege to visit patients with Carmine, an English Labrador Retriever who has been working as a therapy dog for 3.5 years. Katelyn recently passed the AACVPR, Certified Cardiac Rehab Professional (CCRP) exam in May and highly recommends it for anyone in the cardiac rehab field. On her off time, she enjoys anything outdoors, gardening, farming, and spending time with family. Katelyn lives in Nicholasville with her husband Jonathan, two sons, Mac and Preston, and 3 furry sons, Meeko, Ranger, and Willie.Questions about this edition of KCRA Newsletter can be directed toKatelyn King, EP, CCRPKCRA TreasurerKatelyn.king@uky.edu ................
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