B Pierre

Which patients should be adressed to
cardiac rehabilitation centers ?
PATIENTS WITH VALVULAR HEART DESEASE
Bernard PIERRE
Déclaration de Relations Professionnelles
Disclosure Statement of Financial Interest
J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts
financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une
rémunération ou des redevances ou des octrois de recherche d'une société commerciale :
I currently have, or have had over the last two years, an affiliation or financial interests or
interests of any order with a company or I receive compensation or fees or research grants
with a commercial company :
Affiliation/Financial Relationship
•
•
Grant/Research Support
Consulting Fees/Honoraria
Company
•
•
•
•
•
•
•
•
•
•
Bayer
BMS
Bouchara – Recordati
Daïchii
MSD
Novartis
Pfizer
Pierre Fabre
Sanofi
Servier
A PARADOX !
• The cardiac rehabilitation : a program
mostly indicated by cardiac surgeons
• Nevertheless, their validation and
recommendation level remains inferior to
other indications
• WHY ?
Maladie Coronaire
(hors chirurgie)
Classe
Niveau
SCA
« stabilisé »
- Évaluation à l’effort
-Prévention II
-Education thérapeutique
-Ambulatoire si possible
I
A
Après ATL
programmée
-Évaluation à l’effort
-Pas de sur-risque
-Prévention II
-Education thérapeutique
-Ambulatoire si possible
I
B
Angor stable
-Évaluation à l’effort
-Optimisation du traitement
-Prévention II
-Education thérapeutique
-Ambulatoire si possible
I
B
Management of ACS by cardiac rehabilitation
Regional disparities
de Peretti C.InVS. BEH 2014
Insuffisance Cardiaque
Dysfonction
systolique VG
-Prise en charge globale
-Programmes + longs Education thérapeutique
-Ajustement traitement
Fonction
systolique
préservée
-Amélioration qualité de vie
-Réduction hospitalisations
Resynchronisati
on cardiaque
-Potentialisation effets de
resynchronisation
-Evaluation de la
resynchronisation
Assistances
ventriculaires
-Reconditionnement
physique
-Education : appareillage et
AVK
Transplantation
Cardiaque
-Pré-transplantation
-Spécificités chirurgie,
physiologie, immunologie
-Aides psycho-sociales
Classe
Niveau
I
A
II b
C
I
B
IIa
C
I
B
Artériopathie des membres
inférieurs
IPS < 0.9
Claudication ou
Ischémie
chronique
Revascularisation
-Améliore rhéologie,
fonction endothéliale et
extraction O2
-Améliore rendement
-Marche
-Exercices analytiques
-Education thérapeutique
-Sevrage tabagique
-Appareillage
Classe
Niveau
I
A
I
A
I
B
Autres indications
Classe
Niveau
DAI
- Évaluation à l’effort
-Education thérapeutique
-Aides psychologiques
IIa
B
Cardiopathies
congénitales
-Amélioration des capacités
fonctionnelles post-opératoire
-Souvent IC, tr rythme, HTAP
IIa
C
Haut risque
CV
-Évaluation à l’effort
-Optimisation du traitement
-Prévention II
-Education thérapeutique
-Ambulatoire+++
I
A
Chirurgie cardiaque
Classe
Niveau
Pontages aortocoronaires
- Prise en charge précoce
en Centre privilégiée
-Surveillance et SS
- Type entraînement: IT
I
B
Chirurgie
valvulaire
- Prise en charge précoce
I
B
Chirurgie aorte
thoracique
- Prise en charge après
dissection efficace bien
tolérée
- Surveillance PA
II a
C
Pré-opératoire
-Education
- Ventilation, préparation à
chirurgie coronaire
IIb
C
en Centre privilégiée
-Surveillance et SS
-Type d’entraînement :
combiné
Cardiac surgeons have a
better understanding of…
•
•
•
•
Short hospitalization, but…
Danger in home care (pericardial tamponade…)
p-value < 0.05 for mortality is not α and Ω
Better quality of life, lesser need of
(re)hospitalization, morbidity reduction, rather than
life expectancy
• Cardiac rehabilitation center : ideal facility
« Life is movement »
Aristotle (4th century before Christ)
Gohlke-Barwolf study
1200 patients
120
100
80
1 mois
6 mois
60
40
20
0
Rehabilitation program ?
How ?
RVM sur RVM sur RVA sur RVA sur
IM
RM
IA
RA
1 mois
55
40
76
70
6 mois
72
65
105
105
Exercise tolerance after valve replacement. Journal of Heart valve Dis. 1992;1:189-95
Per-cutaneous transluminal
mitral stenosis plasty
10 days after
•15 patients
•VO2 peak :
952 + 271 to 1029 + 342 ml/mn
(p = NS)
Takaki et al. Heart Vessels. 1995;10(6):323-7
Exercise tolerance after mitral valve repair
216 + 80 days after MVR; n = 16
Exercise duration
700
680
660
640
620
600
580
560
Exercise duration
peak VO2
*
Before Surgery
7 months after
678
605
22
21,5
21
20,5
20
19,5
19
Before Surgery
Le Tourneau et al. Circulation. 2000;36:2263-69
7 months after
Hemodynamics abnormalities
• Persist from 6 to 12 months after surgery
Carstens V et al. Exercise capacity before and after cardiac valve
surgery. Cardiology. 1983;70:41-49
• LVEF deterioration at exercises persists after
3months for many patients
Jairath N et al. The effect of moderate exercise training on oxygen
uptake post-aortic/mitralvalve surgery. Jcardiopulm Rehabil.
1995;15:424-430
Per-cutaneous transluminal
mitral stenosis plasty
• 26 patients
Evolution VO2
*
26,6*
19,9
21,1
18,9
Avant chir
90j post chir
Contrôle
réadaptés
w atts
29
27
25
23
21
19
17
15
Puissance d'effort
150
140
130
120
110
100
90
80
70
125*
94,6
108
96,1
Avant chir
Douard H. Eur Heart J. 1997;18(3):464-9
90j post chir
Contrôle
Réadaptés
• Improvement by 19% of VO2 peak
after mitral valve replacement and 8 weeks
rehabilitation program
(while no positive evolution was noticed regarding
the blank sample)
Habel-Verge C et al. Cmaj. 1987;136:142-147
• Same results for aortic valve replacement
Borg G et al. Int J Sports Med. 1982;3:153-158
• Whatever the age of the patient
Ades PA et al. Am Heart J. 1990;120:585-589
Grands Prés
Ph Meurin
Broussais
MC Iliou
B Pierre
IRIS
S Corone
Bligny
Château Lemoine M Fischbach
Kugler
Beauvallon
Ghannem
Ollencourt
L'Heritier
Callian
Ross
Abreshviller
Henry
Recor
Feige
Rhone Durance
Paemelaere
Cambo
Borgat
Carquefou
Cardiopulmonary Exercise Tests Evolution
Early exercise training after mitral valv repair. CHEST 2005
% increase p
Peak VO2
+ 22 %
10-4
AT
+ 16 %
10-4
O2 pulse
+ 18 %
10-4
Ex duration
+ 34 %
10-4
Chron reserve
+ 18 %
10-4
PHYSICAL ACTIVITY
AND MORTALITY
6 213 males referred to EFX ; 6 years
Myers J et al. N Engl J Med. 2002;346:793-801
The most powerful life expectancy
predictive factor
• Excluding the age factor,
VO2 pic: Stronger predictive value than classic risk
factors (all death causes)
Winning 1 MET = life expectancy increase of 12%
Myers JN et al.N Engl. J. Med. 2002
• Physical condition = modifiable factor
Gaining 1 min of effort = mortality reduction of
7.9%
Blair SN et al. JAMA. 1995
GOALS
1 - Detect and treat complications and other pathologies
2 - Functional and risk evaluation
3 - Conform the therapy
4 - Optimize the secondary prevention : B.A.S.I.C.
5 - Make work resumption possible ; elderly ’s autonomy
6 - Attention, information, anti-overdramatization; teach self-evaluation
7 - Cost reduction
8 - Convey the « analysis » to correspondants
* QoL and PRONOSTIC improvement*
- ambulatory if possible: 2 to 5/week- ~ 20 days
- hospitalization (recent surgeries, complications or associated desorders ,
seniors, unfavourable socio-psychologic conditions, high risk, severe HF)
MEANS
Global, Positive, pluridisciplinary treatment
Medical (compulsory cardiologic presence)
Paramedical
. Occupational therapy
. Physical therapy
. Endurance training
. Balneotherapy, hydrotherapy
. Relaxation, support psycho-therapy, stress-management assistance
. Anti-tobacco struggle
. Dietetics
. Professional reinsertion
INITIAL & FINAL
EVALUATION
• Risk and capacities stratification
– Clinical examination- ECG - biology- Chest X-ray - echocardiography- Holter
– Patient and desease story
– Pronostic factors (LVEF - ischemia - arrhythmia)
– Associated comorbidities (pneumo - ortho - neuro)
– Treatment to adapt
– Initial motivation
– Psychological impact
– Work station
– EFX(i) - 6 min walk test
– To specify the rehabilitation program
SPECIFICITIES
• Elderly (TAVI)
• Frequent comorbidities
• Frequent complications :
*arhythmias (AF +++, 50 %) with high risk of thomboembolic events
*high degrees of A-V blocks
*postoperative pericardial effusion (50 – 85 %),
late tamponade : 60 % during cardiac rehabilitation
*infectious
*heart failure
*psychological disorders
• Therapeutic education : septic endocarditis, VKA
• 3 – 4 weeks
Return to work ?
• One of the main goals of cardiac rehabilitation
• Several studies show that RTW predictive factors
after valve surgery are closely linked to functional
exercise capacity, pre-operative pofessional status
and psycho-sociological factors
Gohlke-Barwolf C et al. J Heart Valve Dis. 1992;1:189-95
Sire S et al. Eur Heart J. 1987;8:1215-20
Hedback B et al. Eur Heart J. 1993; 14:831-35
PHYSICAL ACTIVITY:
A FANTASTIC THERAPY?
• « An agent with lipid-lowering,
antihypertensive,positive inotropic,negative
chronotropic, vasodilatating, diuretic,
anorexigenic, weight reducing,
hypoglycemic, tranquilizing, hypnotic and
antidepressive. »
• Williams C. Roberts, editor-in-chief
Am J Cardiol. 1984;53:251
THANK YOU
For your kind attention