Cardiac Rehabilitation Dr R.Kacenelenbogen Cardiac Rehabilitation Department CHU St Pierre ,Brussels PATIENTS WITH CLASS IA INDICATIONS OF CR: LESS THAN HALF HAVE THEIR CR DONE Age Dependency < 62 yrs: 46% CR > 62 yrs: 21% CR Cause n°1= Cardiologist ! NOT CONVINCED BY CR … WHY ? Mr B: 65 yr-old man you see him after a coronary event (NSTEMI) no heart failure no renal insufficiency A. B. C. D. E. F. Obese High cholesterol HTN Type2 Diabetes Smoking PAL= 1.1 All the Traditional Risk Factors + Inactivity Question : You are the wizard of Oz , but you can kill only one wicked witch.. You want to optimize Mr B’s survival at 3 years Wich risk factor do you choose to correct with a snap of a finger? Mr B: CHOOSE ONE A. B. C. D. E. F. Obese Cholesterol HTN T2D Smoking PAL= 1.1 BMI 25 LDL 70 12/8 HbA1c 6 QUIT PAL 2 (CR) You voted for CR THANK YOU Exercise-Based CR: 50% reduction in Re-Infarction E: SMOKING cessation real life: difficult… 20% at 6 months +CR 10% without Comp CR OR for MI= 2.9 36% of global pop.atribut.risk Effectiveness: not before 2 y HR 1.62 1.02 EXERCISE & something OR 0.52 for Ex & Diet OR 0.78 for Ex only RR 1.0 for Ex & No Smoker RR 1.6 for Quit Smoking and no Rehab RR 3.2 for no Ex & Continue Smoking Worcester Cohort Clin. Epidemiology 2013:5 229-236 Mr B: 3 y-mortality = 33% risk factors: T2D; HR= 1.26 HTN : HR= 0.9 Smoking , BMI, Lipids, Physical Fitness/ Activity Level not studied CRUSADE long-term MORTALITY model: 43.000 NSTEMI patients Cox PH model Mean score= 32; Mean 3 y- mortality= 40% MrB: score 8, risk 15% at 3 years ?? Predictors: Age, sex(M) Heart Failure, hypotension Low Weight Creatinine, High Troponin Target Organ Damages Diabetes (1.24) Smoking C/P (1.21) not included ?? Treatable CV Risk Factor: Only DIABETES is predictive (HR 1.24) , but < TOD But DIGAMI2 : no benefit of INSULIN HTN & Weight & hyperlipemia are REVERSED ! Target organ damages ++ prior stroke, PAD, MI, renal i.e. multiple vascular beds Am Heart J 2011;162:875-883 Fitness predicts long-term survival after a cardiovascular event: a prospective cohort study Martine J Barons, BMJ Open 2015-007772 Always report the Fitness ! improve PAL INTENSITY OF EXERCISE High Risk : High Intensity benefit of Exercise : primary prevention Effect on OUTCOME 30 diab chol htn obes smok TOT EXERCISE 23 15 8 0 Risk Factors 60% explained by improved RF (filling the treatment gap) TOT RF Circulation 2007;116:2110-2118 CV Events prevention (10 year follow-up) 40% explained by improved RF OTHER MECHANISM(S) BEHIND THE SCENES General On the heart Collaterals Ischemic Preconditionning (IPC) Cardiac Remodeling Ortho-Parasympathic Bal Anti-Arhytmic Insulin-Resistance Endothelial Function Platelet Aggregation Anti-Inflammatory Other? GENERAL: MYOKINES (Interleukins, Tissue Necrosis Factor) Anti-Inflammatory Insulin Sensitivity Memory ‘gold standard’ collaterals collaterals A= HIT B= MCE C= CONTROL IPC Ischemic preconditioning Animals having repeated episodes of temporary FWOP: occlusion have smaller MI when occlusion is first coronary window of protection permanent Electrical stability and reduced ventricular fibrillation ischémie FWOP: First Windows Of Protection Duration: 10 - 60 minutes ATP adenosine K-ATP channel G-recepteur Stabilité de membrane Arrythmie Décès cellule IPC Ca++ cell protection IPC Action Potential Duration, Ca++ influx VFib microRNA 250 genes coding for miRNAs Epigenetic regulation of messengerRNA transcription Influenced by Environment (Exercise) microRNA In MICE In MEN J Physiol 589.16 (2011) pp 3983–3994 3983 The Journal of Physiology Dynamic regulation of circulating microRNA during acute exhaustive exercise and sustained aerobic exercise training Aaron L. Baggish1, Andrew Hale2, Rory B.Weiner1, GregoryD. Lewis1, David Systrom1, Thomas J.Wang1 and Stephen Y. Chan2 1Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA microRNA MicroRNA-34a Regulates Cardiac Ageing and Function Boon et al Nature. 2013;495:107–110. PNUTS* in your heart to live longer… *Protein Phosphate NUclear Targeting Subunit microRNA ANTAGOMIRS Modified fragments of ssRNA Coupled to cholesterol Silencing of microRNA Targets: Atheroma, neointimal proliferation Apoptosis Arrythmogenesis Cardiac Hypertrophy and Fibrosis Infammation Neovascularization CONCLUSION YOU ONLY NEEDED TO KNOW WHY And HOW IT WORKS The suppository paradox (unpublished, Ray Kace , 1957)