PARIS – A cardiac rehabilitation program can help cerebrovascular-disease patients as much as it helps patients with cardiac disease, based on results from 89 patients treated in a Canadian pilot program.
"Patients suffering a non-disabling stroke or TIA [transient ischemic attack] gain the same, if not better, outcomes from being part of a multifactorial, risk-reduction program traditionally offered to patients with coronary artery disease," said Dr. Nicholas B. Giacomantonio at the annual congress of the European Society of Cardiology. "We believe programs such as Hearts in Motion should be the standard of care for all patients with established vascular disease."
Dr. Nicholas B. Giacomantonio
Based on the positive results from the pilot study, run at three sites in Nova Scotia, referral of patients following stroke or TIA to cardiac rehabilitation programs modeled on Community Cardiovascular Hearts in Motion are now operating at two additional Nova Scotia sites as well at several locations in New Brunswick. The total of about a dozen sites are testing the efficacy of a standard, 12-week cardiac rehabilitation program of diet, exercise, and education against usual care in a prospective study (BMC Neurol. 2010;10:122), said Dr. Giacomantonio, a cardiologist and director of cardiac rehabilitation at Dalhousie University in Halifax, N.S.
The three Nova Scotia sites that ran programs for the pilot phase of Hearts in Motion – a small regional hospital, a sports complex, and a drug store – began enrolling patients in 2006 to the 3-month intervention, and by 2010 the program had 12-month follow-up data on a total of 705 patients. In addition to the 89 patients enrolled following a nondisabling stroke or TIA, the programs enrolled 397 patients with coronary artery disease, 12 with peripheral artery disease, and 207 people for primary prevention. As of last August, a total of about 1,400 people had enrolled at the first three Hearts in Motion sites, but follow-up on the other roughly 700 patients had not yet reached at least 1 year.
The program directly targets family physicians as a source for referrals, Dr. Giacomantonio said. Other referral sources are specialist physicians and hospitals. Following stroke or TIA, patients entered the program after an average of 4 weeks. Among enrolled patients, 94% completed the 3-month program (defined as attending at least 80% of the 36 hours of classes), 87% completed 6-month follow-up, and 77% returned for a 12-month follow-up assessment. He attributed the excellent retention rate to "family physicians who refer patients who are likely motivated to attend the program."
The "traditional" cardiac rehabilitation program used by Hearts in Motion includes 2 hours per week of supervised exercise and 1 hour each week of education, along with referrals to ancillary programs when needed, such as smoking cessation. The participants averaged 62 years old, and 10% of the cerebrovascular patients were current smokers. During the 3-month intervention, participating patients generally did not undergo any changes in their medical management.
"We believe programs such as Hearts in Motion should be the standard of care for all patients with established vascular disease."
The most dramatic changes in risk profile occurred in functional capacity, measured as metabolic equivalents (METs). The 60 post-stroke or TIA patients without diabetes averaged a 27% improvement in METs at the end of the 3-month intervention, while the 29 post–cerebrovascular disease patients with diabetes averaged a 29% boost in METs after the 3-month program, increases comparable to the 18% and 21% METs rises in the coronary artery disease patients with or without diabetes, respectively.
Retention of the functional improvement fared somewhat less well in the post-stroke and TIA patients without diabetes at 12-month follow-up, when these patients averaged a 0.9 METs increase over baseline. Cerebrovascular disease patients with diabetes had an average 1.6-MET increase at their 12-month follow-up compared with baseline, similar to the 1.6-MET and 1.4-MET improvements over baseline seen in the two coronary disease subgroups at 12-months. A 1.6-MET improvement sustained over 12 months corresponds to a roughly 12% reduced risk for cardiovascular disease death, Dr. Giacomantonio noted.
By other measures, the post-stroke and TIA patients tracked close to their coronary disease counterparts. Systolic blood pressure fell by an average of 4% in the coronary group and 3% in the cerebrovascular disease patients, diastolic pressure dropped by averages of 3% and 2% in the two subgroups, respectively, and LDL-cholesterol levels dropped by an average of 1% and 4%. All patients lost an average of 1 inch in waist circumference regardless of their subgroup. Depression and anxiety scores also dropped by similar amounts in the coronary- and cerebrovascular-disease subgroups.