Heart Disease!
UCLH Trust Members 2010
Dr Malcolm Walker
Consultant Cardiologist
UCLH & the Heart Hospital
Dr Malcolm Walker
 Consultant Cardiologist - general adult
interventional cardiologist with special interests
in rehabilitation and myocardial iron overload
 Director of Hatter Cardiovascular Institute UCH
 Immediate past president British Association of
Cardiovascular Rehabilitation (BACR)
 Scientific board member of the Thalassaemia
International Federation (TIF – a WHO
sponsored NGO - a patients & families lobby)
Question
 “What treatment has randomised trial evidence of
long term benefit by mortality reduction of >20%,
morbidity reduction of a similar magnitude,
causes weight loss, reduces blood pressure,
improves mood, improves functional capacity,
raises HDL cholesterol, improves glucose
metabolism and does not cost the earth?”
 Heberden 1772
 “one patient nearly cured himself of his
angina” by retreating to his country
estate “and sawing wood every day for
some months”
Case history:
June 2003
59 yr old male
Collapse – Rx DCC CPR
Urgent angiography
Urgent CABG
Case history:
June: Emergency CABG
October …..
7 Marathons in 7 days
Does fitness affect survival ?
• After Myocardial infarction
• In primary prevention
Cooper Clinic experience
Blair et al JAMA 1989
% Dead
30
25
1
2
3
4
5
20
15
10
5
0
Category of Fitness from 1 (low)
to 5 (very fit)
Does fitness affect survival ?
• After Myocardial infarction
• In primary prevention
Harvard alumni study
Exercise
No
Moderate
exercise
Strong
Very
strong
Overweight
BMI>27.5
21%
16%
13%
10%
Current smoker
17%
9.4%
6.8%
4.8%
Alcohol >7/wk
/wk
37%
42%
42%
44%
Red meat
>3/wk
40%
34%
29%
28%
Vegetables
< 6 /wk
30%
25%
23%
22%
Harvard alumni study
No
Moderate
exercise
Strong
Very
strong
Relative Risk of
CHD
Age adjusted
1.0
Referent
0.81
(0.62-1.04)
0.64
(0.48-0.85)
0.60
(0.440.81)
Relative Risk of
CHD
Multivariate adj
1.0
Referent
0.81
(0.62-1.06)
0.62
(0.46-0.84)
0.60
(0.440.83)
Relative Risk of
CHD
Multivariate adj
1.0
Referent
0.86
(0.66-1.13)
0.69
(0.51-0.94)
0.72
(0.521.00)
REDUCED
RISK
20%
40%
40%
p for trend
0.0002
0.0003
0.02
Harvard alumni - summary
• Self reported Borg-type scale useful
• Graded benefit according to amount of
exercise, when compared to those not
doing any
So not everybody has to wear lycra
pants & join a gymnasium
• Limitations of the study:
– Men, American, higher social class
Walking – benefit to high risk group
demonstrated
• Decreased death rate in diabetics
– 2896 adults with diabetes
– Those walking >2hr per week
• 39% lower all cause mortality
• 34% lower cardiovascular mortality
– Largest benefit in those walking 3-4hr per
week and for those reporting moderate
increase in heart rate & breathing rate
Arch Intern Med 2003; 163: 1440-1447
Exercise as therapy in CHD
BUT can we provide an intervention that
works?
Cardiac Rehabilitation
• The patients can do more
• Their cholesterol is lower
• They are taking their tablets regularly
• They are no slimmer
Is anything more being achieved for
them?
Cardiac Rehabilitation in CHD
 Taylor, R.S. et.al. Am J Med 2004
 Hospitalised for CHD
 48 RCTs, n= 8940
 20% reduction in all cause mortality 24% in
cardiovascular mortality
 Gains still evident when statins given to both arms
of trial
So exercise does matter
 Both for “victims” of CHD and as a method of
prevention
Cardiovascular Rehabilitation
 Why?
 Because there is good evidence that it helps
 Because we’ve been told to..
NSF CHD – Cardiac Rehabilitation
Chapter 7 (Standard 12)
“NHS Trusts should put in place agreed
protocols/systems of care so that, prior to leaving
hospital, people admitted to hospital suffering from
coronary heart disease have been invited to
participate in a multidisciplinary programme of
secondary prevention and cardiac rehabilitation.”

NSF Goal
“Every hospital should ensure
a) that more than 85% of people with a primary
diagnosis of AMI are offered cardiac
rehabilitation.

Cardiovascular Rehabilitation
 Why?
 Because there is good evidence that it helps
 Randomised control trial (RCT) data
 Because we’ve been told to..
 NSF
 Because there is an unmet need
% Eligible patients offered CR England & Wales
1997
2000
2005
AMI
14 – 23
17
25
CABG
33 – 56
44
65
PCI
6 – 10
6
10
Surveys by Dr Hugh Bethel – BACR/BHF
University College Hospital Foundation Trust
Cardiovascular Health & Rehabilitation
 2005 Co-operative bid with Camden PCT for BHF NOF
funding – Grant £120,000
 To develop a new self management method to deliver
CR in association with Prof Stan Newman
 Aims to reduce DNA rates
 Improve adoption & maintenance of behaviour
change
 Plan to roll out to whole sector & beyond if successful
UCH Cardiovascular Health &
Rehabilitation
 Patient recruitment
 Heart Hospital
 Cardiology patients identified from cath. lab database
 All receive standard letter or contacted by telephone
 Camden patients reviewed whilst in-patients – if time
N.B. all Heart hospital patients (90+) are eligible for
CR!
 Surgical patients referred by surgical audit team
 UCH
 Daily ward round AAU – most eligible patients will
transfer to Heart Hospital

Number of Patients referred to CR
2500
2000
1500
No. Patients
1000
500
0
2001
2002
2004
2005
Currently represents between 88-92 % of eligible patients
Number of patients referred for CR at
UCH CV Health
400
350
300
250
200
No. Patients
150
100
50
0
2001
2002
2004
2005
2006
UCH Cardiovascular Health & Rehabilitation
45
40
35
30
25
% DNA
20
15
10
5
0
pre 2005
2005
2006
UCH Cardiovascular Health &
Rehabilitation

Important service characteristics

Close liaison with sector – rehabilitation task group


Strategic alliance with central YMCA 2003




Exercise classes move out of hospital environment
Exercise professionals supported through BACR training
Flexibility – timing, course structure & content


Evidenced by Patient choice funding & Combined BHF NOF bid
Menu of choices for patients
Early adoption of national (BACR/ BHF/ York University)
minimum dataset
Introduction of self-management programme
UCH Cardiovascular Health &
Rehabilitation

New developments

Expanded remit
Heart failure – initially from hospital clinics, expanding to
offer to primary care – now in full swing
 “Primary” prevention in diabetics – initially from hospital
clinic with a view to expand to primary care – supports
existing initiative of Camden Active Health Team


Improve accessibility

Walk in assessment service – as per R1

Pilot with one local primary care provider in first instance
Conclusions on Cardiovascular
Rehabilitation

Task worth the effort



Individuals committed to the service


Trained to deliver high quality CR – use BACR/ ACPIR resources
Good quality data



CR evidence is compelling
Anecdotal experience will amplify!
National CR audit makes this easier
Simple local databases are a starting point – get your kids to design you one!
Good quality communication


Fax, telephone, e-mail !
CR administrator invaluable/ sine qua non ?
It’s mostly about teamwork!