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Archive for the ‘cardiology & cardiac surgery’ Category

As readers know, I recently gave a CME presentation on The Syntax Trial   and discussed the new Revascularization guidelines that were released last month.  I’ve posted the slides for anyone who wants to use them.  (It would be nice if you mentioned where you got them – but feel free to use them.)

Now – new criticisms of these revised guidelines are already emerging.  But before tackling these new criticisms, we should review the old controversies surrounding the previous guidelines.

In a interesting article (by one of my favorite summarists) Reed Miller over at The Heart.org reviews the issues behind the old (2009) guidelines..  It’s a good article that talks about many of the issues behind the 2012 revisions. I’ve re-posted the article below.

PCI appropriateness criteria draw criticism

(originally posted February 8th, 2012 at the Heart.org)

Kansas City, MO – The interminable controversy about appropriate use and overuse of PCI is being stirred up again [1].

Dr Steven P Marso (St Luke’s Mid-America Heart Institute, Kansas City, MO) and five other cardiologists have published a paper online February 8, 2012 in the Journal of the American College of Cardiology: Cardiovascular Interventions criticizing both the 2009 coronary revascularization appropriate-use criteria (AUC) and how those criteria have been applied to the study of contemporary practice patterns.

As reported by heartwire, the AUC were created by a technical committee representing six professional societies. Last summer, Marso’s colleague in Kansas City, Dr Paul Chan (St Luke’s Mid-America Heart Institute), led a study of PCI cases in the National Cardiovascular Data Registry (NCDR) that showed that only 50.4% of nonacute cases in the registry during the yearlong study period would be classified as appropriate under the AUC and that 11.6% of nonacute cases were classified as inappropriate.

“We are duty bound to evaluate appropriate use of PCI and other medical procedures,” Marso told heartwire. “The problem is that we are no closer to being able to identify overuse based upon these appropriate-use criteria than before they were created. The reason is that there are too many assumptions and too much variability that go into that 11.6% inappropriate rate.”

For example, Marso et al argue that the AUC put too much emphasis on stress testing without precise definitions to guide the interpretation of those tests. “The vast majority of AUC scenarios require knowledge of preprocedural stress-test findings . . . [but] the NCDR does not require interpreting physicians to determine this risk. Therefore, this data-collection burden falls onto the data abstractors, who are required to assign a risk category based on vague guidelines,” they say. “Essentially, they are required to interpret the interpretation.”

Chan told heartwire that the appropriateness criteria were never intended to be perfect, but they are the best effort to sort out which procedures are supported by evidence and which are not. They will evolve over several iterations, including the recent update, which provides more detail on patients with unstable angina. However, Chan does not expect any major changes from the 2009 version to be made soon.

Chan also pointed out that the purpose of the AUCs is to explain the existing evidence base, not pass judgment on each procedure, so nobody should interpret “inappropriate” in the AUCs to mean “fraudulent.”

“Ultimately, my main concern is that we don’t lose sight of the forest for the trees. Our profession of cardiology has taken an amazing leadership role in defining quality and appropriateness of care—in a way that no subspecialty has done to date. In so doing, we have moved the quality yardstick forward,” Chan said. “[But] we need to be humble as physicians to recognize that sometimes we may actually be doing procedures that have little evidence to support their use . . . and that not only are we not providing benefit but perhaps subjecting patients to unnecessary procedure risks and costs.”

Who decides which side is “right” and which side is “wrong?”

Marso et al are especially concerned with the AUC’s treatment of patients with one- or two-vessel disease, no proximal left anterior descending artery involvement or prior coronary artery bypass graft, class I or II symptoms, low-risk noninvasive findings, and on no or minimal medications. The AUC state that PCI in this scenario, labeled scenario 12b, is “inappropriate.” This scenario accounted for nearly 40% of the inappropriate nonacute procedures categorized by Chan et al as inappropriate, making it the most common type of procedure in this category.

Prior to the release of the 2009 AUCs, Chan et al surveyed 85 cardiologists—including 44 interventionalists and 41 noninterventional cardiologists—on the appropriateness of 68 coronary revascularization indications also addressed by the AUCs. That group classified scenario 12b as “uncertain.” Instead of assuming that the cardiologists in the survey need to be educated about the appropriateness of this procedure, Marso et al suggest it’s the technical panel that could learn something from the cardiologists in the survey. “These are 80 clinical cardiologists who answered questions about what they thought was appropriate, driven by medical decision-making, and they concluded that the technical panel just plain got it wrong,” Marso told heartwire.

In response to this specific point, Chan told heartwire, “The decision of the AUC technical panel to make this scenario inappropriate was based on the lack of available clinical evidence to support PCI in patients who have only mild to moderate symptoms with intermediate stress tests without a trial of medical therapy. This is, indeed, consistent with the COURAGE trial, wherein medical therapy was found to be comparable to PCI for patients with even greater symptoms and more severe ischemia.

“Although the COURAGE quality-of-life substudy did find that patients who underwent PCI, compared with medical therapy, had modestly improved angina relief during the first year, this benefit was likely concentrated in those COURAGE patients who had far greater symptoms than [Canadian Cardiovascular Society (CCS)] class I or II—eg, CCS class II or IV,” Chan said. “Dr Marso’s assertion that this indication should be uncertain, however, is not supported by any evidence to date.”

Who decides who gets to decide?

Marso et al also object to the composition of the technical panel, which included only four interventionalists out of 16 total members. The panel was put together according to the so-called Rand method to prevent conflicts of interest. Marso objects to the technical panel’s insinuation that “interventional cardiologists are inherently biased due a financial bias or an intellectual bias, that their ideas are preconceived, and that they are unwilling to evaluate data in an objective manner.” He points out that the FDA, which certainly has a vested interest in rooting out both financial and intellectual bias from its advisory panels, does not limit whole categories of experts from serving on these panels. Instead, it evaluates the background and potential conflicts of interest of each individual.

Dr John Spertus, the director of outcomes research at Saint Luke’s Mid America Heart Institute and senior author of the AUC writing group, does not agree that the AUC technical committee needs more interventionalists. “The benefits of revascularization should be very transparent. Clinicians caring for patients should all be on the same page with the same perspectives of revascularization of patients. That isn’t information that is uniquely known to the interventional community,” he said. “While they have extensive expertise and knowledge around the technical aspects of doing the procedure, whether it should be done or not is something that all clinicians caring for patients with coronary disease should know, appreciate, and be able to communicate to their patients.”

The missing voice: The patient

In an accompanying editorial [2], Dr James Blankenship (Geisinger Medical Center, Danville, PA) argues that the AUC “will never fully define the best treatment decision for a particular patient . . . because occasionally, patients will have exceptional circumstances that dictate treatment different from that recommended by AUC and guidelines; and different patients experience a given level of symptoms differently.

“Determinations of appropriateness by the AUC based on angina class fail to take patients’ perceptions and preferences into account. This is a fundamental flaw, because patients’ perceptions and preferences are a critical component of decision making,” Blankenship argues. However, he acknowledges that “factoring in patient preferences raises a host of new problems. Patients’ preferences are routinely based on incorrect perceptions and nonobjective factors; [they] routinely overestimate the benefits of PCI, underestimate its risks, and underestimate the efficacy of medical therapy [and] tend to discount the sometimes-superior benefits of one treatment (eg, CABG for very complex triple-vessel disease), because those benefits accrue later, and instead prefer the more immediate but lesser benefits of another treatment (eg, PCI) because they accrue sooner (temporal discounting).”

More data on the way

Chan said that a prospective study of 7000 to 8000 patients measuring the change in quality of life from baseline to six months among patients who have undergone PCI will soon be complete. Results of this study, intended to validate the ratings of the AUC, will probably be available this summer, he said.

“We anticipate that we will find that patients with inappropriate AUC ratings will have little to no improvement in quality of life at six months, appropriate AUC ratings will have substantial improvements in quality of life, and uncertain AUC ratings will have modest improvements in quality of life,” Chan said. “Once we have these results, we will be able to say with confidence whether indications such as 12b should be kept as inappropriate or changed to uncertain.”

Spertus said that the AUC will be updated when there are methodological or technical deficiencies in the current approach or if important new evidence on PCI is published. One of the goals of the AUC is to identify gaps in the scientific knowledge that need further study.

Marso reports no personal conflicts of interest during the previous 24 months.
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Updates to this story have been posted here.

In an article re-post from the Heart.org, Lisa Nainggolan discusses a recent memo issued by Medicare & Medicaid services (CMS) on potential coverage for TAVI/ TAVR.    This memo lays out the necessary criteria and conditions that must be met for CMS coverage.

Don’t have medicaid or medicare?  Well, the privately insured should still sit up and take notice:  CMS decisions usually set the pace for everyone else – meaning, if Medicare won’t pay for it – then Blue Cross, Anthem and most of the big private insurances won’t either.

CMS draft of proposed coverage – the Heart.org 

Lisa Nainggolan

Baltimore, MD – The US Centers for Medicare & Medicaid Services (CMS) has issued a memo detailing its proposed coverage for transcatheter aortic-valve replacement (TAVR) [1]. The move follows a request for national coverage determination (NCD) from the ACC and Society for Thoracic Surgeons (STS), made last September.

The memo—which is a draft and will be open for public comment until March 3—outlines the conditions under which the CMS will cover TAVR, also known as transcatheter aortic-valve implantation (TAVI), and follows hard on the heels of an expert consensus document on the new technology, published earlier this week.

An estimated 45 000 patients have received TAVI worldwide, with most procedures so far being performed in Europe. US approval of the Edwards Sapien valve at the end of last year means that the country must now gear up to introduce this technology nationwide, and the expert guidance has been designed to act as a roadmap for the rollout of TAVI in the US.

Five conditions must be met for Medicare coverage of TAVR

TAVR will be covered for the treatment of severe symptomatic aortic-valve stenosis only, says the CMS, and the following five conditions must be met:

  • The procedure is performed for an approved indication with a valve and implantation system that has received FDA approval for this indication.
  • Two cardiac surgeons have evaluated the patient’s suitability for open valve-replacement surgery. (traditional cardiac surgery)
  • The procedure is performed in a facility that meets certain requirements with regard to surgical and interventional cardiology expertise. In addition, institutions with prior TAVR experience must participate in ongoing trials or postapproval studies, and all centers performing TAVR must commit to the “heart-team” concept and enroll in a prospective national TAVR study.
  • TAVR must be carried out by sufficiently qualified and experienced physicians.
  • The treating team must participate in a national registry that enrolls TAVR patients and tracks the following outcomes: major stroke; all-cause mortality; minor stroke/transient ischemic attack; major vascular events; and acute renal injury.

For unlabeled uses of TAVI, the CMS proposes coverage only in the context of a clinical trial, for which it lists 13 conditions.

The CMS also indicates that it will not cover TAVR for any other indications not specified in its memo, nor will it cover the procedure in patients who also have concomitant conditions, including: mixed aortic-valve disease; isolated aortic regurgitation; untreated clinically significant coronary artery disease requiring revascularization; hypertrophic cardiomyopathy; echocardiographic evidence of intracardiac mass; significant aortic disease; and severe obstructive calcification or tortuosity of the iliofemoral vessel or small vessel size.

It’s a mixed win for American cardiologists and cardiac surgeons – and certainly opens the door to the expanded use of this criteria.  The good news is that CMS is taking the initiative to stem off a flood of inappropriate procedures.  The release of this memo, along with the recent publication of new guidelines re-affirming the role of CABG, and relegating PCI to specific circumstances  is almost certainly a response to the numerous scandals and allegations affecting cardiology in 2011 (and ongoing.)

Which hospitals should have TAVR/ TAVI programs?

This article outlines the basic requirements for a safe and successful TAVR program – including the minimum skill requirements for surgeons and interventionalists.

But I suspect – it won’t be long before more and more hospitals open their own programs.  This article highlights the financial gains for hospitals with TAVR programs.

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On the heels of the SYNTAX study which evaluated the effectiveness of using stents to treat multiple blockages, a new journal article outlined the appropriateness of both PCI (stenting and angioplasty) and CABG (bypass surgery) has been published.

For the Full Guidelines – click here..

Here’s an early glimpse of the article’s main points – most of which reinforce guidelines we’ve known since the early 1980’s (but which were questioned during the height of the stent-enthusiasm.)

[As usual, my comments are in italics and brackets.]

Article Re-post:

Title:  ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update Date

Posted:  January 30, 2012

Authors:  Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, on behalf of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, American Society of Echocardiography, Heart Rhythm Society. Citation:  J Am Coll Cardiol 2012;Jan 30:[Epub ahead of print].

Comments (6)Related Resources Cardiosource Video News Update on Appropriate PCI

Cardiosource Video News PCI AUC, Hydration and Afib Ablation

Perspective: The following are 10 points to remember about this focused update on appropriate use criteria for coronary revascularization:

1. The writing group and technical panel felt that some quantification of coronary artery disease (CAD) burden, either by description or SYNTAX score, could be helpful to clinicians. Coronary artery bypass grafting (CABG) was rated as appropriate in all of the new clinical scenarios developed, whereas percutaneous coronary intervention (PCI) was rated as appropriate only in patients with two-vessel CAD with involvement of the proximal left anterior descending artery (LAD) and in patients with three-vessel disease with a low CAD burden. [This means that people with a lot of blackages or disease should not receive multiple stents – but should have bypass surgery instead.  The ‘syntax score’ is a rating system used by cardiologists to assign a number to the amount of blockage.  The higher the number, the more blockage.].

2. ST-segment elevation myocardial infarction (STEMI) ≤12 hours from onset of symptoms and revascularization of the culprit artery is rated as appropriate with a score of 9 (on a 1-9 scale). [in the middle of a heart attack, stenting is an appropriate treatment to open the blockage that is causing the heart attack.]

3. Revascularization in patients with one- or two-vessel CAD without involvement of the proximal LAD and no noninvasive testing performed is considered inappropriate.  [This says that You can’t just stent disease that isn’t causing a problem unless the disease is located in critical areas, or just take asymptomatic people to the cath lab.]

4. PCI is considered inappropriate for left main stenosis and additional CAD with intermediate to high CAD burden. [This artery is too important to risk treating with stents.  If this vessel were to have a stent thrombosis – the patient almost always dies.]

5. Revascularization is considered uncertain in unstable angina/NSTEMI and low-risk features (e.g., Thrombolysis in Myocardial Infarction [TIMI] score ≤2) for short-term risk of death or nonfatal MI, but appropriate for those with intermediate-risk features (e.g., TIMI score 3-4) and for those with high-risk features.

6. Appropriateness for PCI is uncertain for three-vessel CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, presence of chronic total occlusion, or high SYNTAX score), but CABG is appropriate.  [this means that this is still ‘under discussion.’]

7. PCI for isolated left main stenosis is now graded as uncertain. [see number 4.]

8. For patients with acute MI (STEMI or NSTEMI) and evidence of cardiogenic shock, revascularization of one or more coronary arteries is appropriate.

9. It should be noted that uncertain indications require individual physician judgment and understanding of the patient to better determine the usefulness of revascularization for a particular clinical scenario.  [not all treatments fit all patients].

10. The Appropriate Use Criteria writing group and technical panel favor the collaborative interaction of cardiac surgeons and interventional cardiologists heart team approach regarding revascularization decisions in complex patients or coronary anatomy, as recommended in the PCI guidelines. [We should work together to treat the patient, which kind of works against PCI without surgical backup.]

Author(s): Debabrata Mukherjee, M.D., F.A.C.C.

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Sat down today with Dr. Kevin Brady to talk about TAVI, or as he corrects me with a smile, TAVR (R is for Replacement).  Dr. Brady is a cardiothoracic surgeon, and one of the few currently performing TAVI/ TAVR here in Arizona.  As we’ve discussed before, I have mixed feelings on this procedure but have elected to provide the information here for my interested readers.

Dr. Brady shares many of my apprehensions, that the public will come to view this currently quasi-experimental treatment for very high risk, and inoperable patients with Aortic Stenosis as a ‘easy fix’.   We discuss this at length, and he reviews the current recommendations guiding the implementation of TAVR programs, and the TAVR registry with me.

As part of this discussion, I have invited Dr. Brady to write a short post here, explaining the procedure, patient selection criteria and other facts about TAVI/ TAVR.  With over 41 Core-valve implantations (since March 2011, as part of the Core Valve Pivotal trial) and seven Sapien valve implantations this month, he certainly qualifies as an expert on the topic.

Dr. Brady will be able to give readers a more in-depth perspective on this procedure.  As all of you know, I have taken a fairly cautious stance on this issue.  (I haven’t talked him into letting me observe yet, but I am working on it.)

Dr. Kevin M. Brady, MD

Southwest Heart & Lung

www.swheartlung.com

10930 North Tatum Boulevard, Suite 103

Phoenix, Arizona 85020

Tele: 602-263-7600

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New allegations of gross medicare fraud from overstenting and unnecessary interventional procedures has been filed against surgeons in Pennsylvania, including the prestigious UPMC medical center.  This story, (based on cases dating back to 2001 and onwards), comes just as the dust in settling from an outbreak of unnecessary stent cases in neighboring Maryland.

What is overstenting?

Article by Michael R’iordan from the Heart.com re-posted below:

Cardiologists accused of defrauding Medicare by performing unnecessary cardiac procedures

Erie, PA – A new whistle-blower lawsuit filed in US District Court in Erie, PA claims that five cardiologists from two medical practices defrauded Medicare by performing unnecessary cardiac and vascular surgeries and interventional procedures between 2001 and 2005.

The suit, filed under the False Claims Act (FCA) and first reported January 22, 2012 in the Erie Times-News [1], states that as a result of the fraud, Medicare overpaid for these procedures, which wasted substantial public money, and patients were placed at significant and unnecessary risk of harm.

According to a copy of the lawsuit obtained by heartwire, the physicians named are Drs Richard Petrella, Robert Ferraro, Charles Furr, Timothy Trageser, and Donald Zone. The two medical practices named in the lawsuit are Medicor Associates Inc—and its affiliate Flagship Cardiac, Vascular, and Thoracic Surgery (CVTS)—and the University of Pittsburgh Medical Center (UPMC) Hamot (formerly known as Hamot Medical Center). The Medicor practice is the full-service cardiology center affiliated with UPMC Hamot.

The lawsuit states that from June 2001 and earlier, the defendants “knowingly, systematically, routinely, and repeatedly submitted false claims to and received reimbursements from Medicare and other federal healthcare programs for medically unnecessary cardiac catheterizations and cardiac and vascular surgical procedures, including but not limited to . . . PCI.”

As result of the false claims, the physicians received money to “which they were not entitled.”

Paid directorships and kickbacks

Dr Tullio Emanuele, who worked at Medicor and Hamot Medical Center from 2001 to 2005, filed the suit and claims that Medicor engaged in illegal “kickbacks” with Hamot Medical Center and referred cardiac patients to the hospital. In the lawsuit, it is alleged that Hamot signed contracts with Medicor and Flagship CVTS, valued at $75 000 per physician and as high as $525 000 per year, and the doctors would refer patients in need of medical procedures to Hamot Medical Center.

“Specifically, Hamot identified physicians who referred a high volume of patients and/or had potential to refer a high volume of patients for special treatment and offered remuneration to them in the guise of sham contracts for medical directorships or other similar personal service arrangements,” according to the lawsuit.

The claim states the physicians and the participating hospitals violated the federal Anti-Kickback Statute and the federal Stark Act, which says that a hospital is not allowed to submit a claim for reimbursement from Medicare if the procedure has been referred by a physician with improper financial ties to the hospital.

The suit also claims that Emanuele began to grow suspicious in 2004 when he noticed higher rates of intervention among certain physicians within the group. Between 2004 and 2005, 4408 catheterizations were performed, and Petrella, Trageser, and Ferraro had a “rate of surgical intervention following catheterization of double the junior members of the group.”

Emanuele, according to the lawsuit, believes that many of the procedures were performed unnecessarily. For example, Trageser is accused of performing a cardiac catheterization in a patient with chest pain, despite the symptomology being inconsistent with angina. Ferraro is accused of implanting a stent in an artery with moderate stenosis, even though Emanuele previously recommended medical therapy. Zone performed a cardiac catheterization and overstated the severity of stenosis, sending the patient on to CABG surgery, where he/she later died.

UPMC Hamot and the named physicians received copies of the lawsuit last week, according to the Erie Times-News, and have 20 days to respond. If they are found guilty, UPMC Hamot and the Medicor physicians would be required to reimburse Medicare at triple the cost of the original procedure. Emanuele, as the whistle-blower in the case, would be entitled to 30% of the reimbursed money.

More on similar stories here at Cartagena Surgery:

The Ethics of the Syntax Trial

Stent Scandal series:

Cardiology takes another hit

Mark Midei – or the man who started it all..

This is just a sample of the articles available here at Cartagena Surgery.. For more on this topic, look under the cardiology tab..

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As many of my long time readers know, that during the last month or so, I have been reviewing studies, and data on the Syntax trial as part of a presentation at my hospital.  This has been more time-consuming and angst-wrenching than I would have ever expected; the more data I reviewed, the more conflicted I became about the ethical questions involved in a study of this kind.

Granted, I have a sensitive nature, and as a nurse, patient advocacy is one of my primary goals.  But thankfully, I found that I am not alone in questioning the legitimacy of subjecting patients to a ‘non-inferiority’ trial.

“In our opinion, the Syntax study disregarded the safety of the patients, by including death and major complications of a primary end-point of a non-inferiority study.”
— Mantovani et. al (2010).
Mantovani et al. (2010) Non-inferiority randomized trials, an issue between science and ethics: the case of the Syntax study.  Scandinavian Cardiovascular Journal, 2010; 44: 321-324.  Mantovani et al. full text pdf.   They question the benefit of subjecting patients to unproven therapies using a trial design that really fails to prove much at all about the effectiveness of the proposed treatment, (in this case, PCI).  They have an excellent discussion (and definitions for the uninitiated) on trial designs and what they really mean, in real terms.
As they point out – studies with this kind of trial design – really don’t prove anything at all.  It was a methodology designed by pharmaceutical companies in order to get new drugs on the market (whether or not these newer, more expensive versions of existing drugs were an improvement over older, safer, cheaper versions or not.)
But in this case – the real results were the unintended ones! Despite a skewed set of accounting (weighing heavily in cardiology’s favor) the results were determinedly negative, showing worse patient outcomes with stents, more deaths, more serious adverse events with stents.
As I delved even further into the data,  I began to question the concept of patient ‘informed consent’ all together.  Can a patient really comprehend the risks involved and what these outcomes really mean in practical terms for something like this?  Would anyone in the study actually break it down in a honest and straight-forward (no BS) fashion to potential study participants?
And how do patients (lay public) understand all of this anyway?  Their perceptions might radically differ from what we (researchers) think we’ve presented.  And, in fact – there are some HUGE differences, as multiple studies attest.  What patients hear and understand is DRAMATICALLY different from what we might expect.
Somehow, I don’t expect that researchers said to patients (for example):
“Mr. X, you are 50 years old, with HTN, diabetes and severe CAD affecting all three major arteries.  Since your labs, and general health is otherwise unremarkable, according to experience and the STS risk calculator, your risk for death with bypass surgery is Y (pretty darn safe). However, we would like to put you in a study where you may receive anywhere from 3 to 20 stents with extensive exposure to nephrotoxic (kidney-harming) dye,  and radiation.  These stents may close either acutely (stent thrombosis) or over time, causing a potentially fatal heart attack.  Stent occlusion happens much more frequently then bypass graft occlusion.  Oh, and by the way – we aren’t doing this study to see if stents are better than bypass surgery (we already know it isn’t) – we are doing it to see how much worse it is – within acceptable margins, of course [whatever than may be].”
No, somehow – I don’t think it went down like that.
More on the Syntax Trial comparing PCI and CABG:
Syntax, part II: New guidelines for revascularization
More on PCI appropriateness  (we have an entire series on PCI here at Cartagena Surgery)

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A new article on MedPage underscores the importance of cardiac rehabilitation.  The article reviews a meta-analysis on the benefits of cardiac rehabilitation by Sandercock et. al (2011).  This analysis of data from 38 different studies surrounding cardiac rehabilitation and exercise after cardiac events reinforces the principles of aerobic exercise for rehabilitation after MI (heart attack), stent placement/ angioplasty or cardiac surgery.

As we discuss daily with our patients – several studies show that patients that complete the 12 week out-patient exercise program live longer than people who don’t.   These patients also enjoy a better quality of life, and a faster return to baseline health than patients who do not participate in formal exercise program after a cardiac event.

As Piotrowicz (of Poland) states, Cardiac rehabilitation can be effective in all stable patients.

 

References:

The effects of cardiac tertiary prevention program after coronary artery bypass graft surgery on health and quality of life.  [Iranian study, full free text].  Mosayebi A, Javanmard SH, Mirmohamadsadeghi M, Rajabi R, Mostafavi S, Mansourian M. Int J Prev Med. 2011 Oct;2(4):269-74

Exercise rehab can reduce the mortality of cardiac patients with poor heart rate recovery = article from the Heart.org

Rev Port Cardiol. 2011 May;30(5):479-507.  Age does not determine the physical, functional and psychosocial response to a cardiac rehabilitation program.  [Article in English, Portuguese]  Rocha A, Araújo V, Parada F, Maciel MJ, Azevedo A.
Why aren’t all cardiac patients referred to cardiac rehab?
Rev Port Cardiol. 2011 May;30(5):509-14.  Barriers to participation in cardiac rehabilitation programs.  [Article in English, Portuguese]  Mendes M.

Cardiac Rehabilitation Programs and Health-Related Quality of Life. State of the Art. Cano de la Cuerda R, Alguacil Diego IM, Alonso Martín JJ, Molero Sánchez A, Miangolarra Page JC.  Rev Esp Cardiol. 2012 Jan;65(1):72-79. Epub 2011 Oct 19. English, Spanish.  Discusses the use of cardiac rehab in areas of endemic poverty and limited resources.

Now don’t forget about your incentive spirometer.

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