Circulation May 1, 2018 Issue

Dr Carolyn
Lam:               
Welcome to Circulation on the Run, your weekly podcast summary
and backstage pass to the journal and its editors. I'm Dr.
Carolyn Lam, associate editor from the National Heart Center of
Singapore and Duke National University of Singapore. Our featured
discussion today is a wake-up call because despite substantial
efforts to promote cardiac rehabilitation in guidelines and
performance measures only a small percentage of patients are
receiving this and there is a remarkable regional variation. Lots
of lessons to be learned here coming right up after these
summaries.


                                               
More children with congenital heart disease are surviving into
adulthood, and congenital heart disease is associated with risk
factors for dementia. But what is the actual risk of dementia in
congenital heart disease adults? Well, in this first paper from
first and corresponding author Dr. Bagge from Aarhus University
Hospital in Denmark, the authors used medical registries and a
medical record review of all Danish hospitals to identify more
than 10,600 adults with congenital heart disease diagnosed
between 1963 and 2012 and followed up until the hospital
diagnosis of dementia or death, emigration, or the end of the
study in the end of December 2012.


                                               
For each individual with congenital heart disease the authors
identified 10 members of the Danish general population matched on
sex and birth year. They found that the risk of all-cause
dementia was increased by about 60% in congenital heart disease
adults compared with the matched general population. The risk was
higher for early onset dementia, that is dementia at less than 65
years of age, in which the risk was more than double. The risk
was also elevated for all levels of congenital heart disease
complexity, including those with cyanotic potential. The relative
risk remained increased for those without extra cardiac defect or
acquired cardiovascular diseases.


                                               
These results really underscore the importance of understanding
the risk of adverse long-term neurologic outcomes in the growing
and aging population with congenital heart diseases.


                                               
The next paper suggests that patient outcomes after lower limb
revascularization have improved in England over recent times.
This paper from first and corresponding author Dr. Heikkila from
London School of Hygiene and Tropical Medicine used individual
patient records from hospital episode statistics to identify
almost 104,000 patients who underwent endovascular or surgical
lower limb revascularization for infrainguinal peripheral artery
disease in England between 2006 and 2015. During this 10-year
period the estimated one-year risks of major amputation and death
reduced after both endovascular and surgical lower limb
revascularization in England. These trends were observed for all
categories of peripheral artery disease severity, with the
largest reductions seen among patients with the most severe
underlying disease.


                                               
These encouraging trends coincided with a period of
centralization and specialization of vascular services in
England, although the current findings cannot be interpreted as
resulting directly from this reconfiguration of services.


                                               
The next paper presents experimental data showing that targeting
the Janus kinase and signal transducer and activator of
transcription or JAK-STAT pathway may represent a
disease-modifying strategy in inflammatory vasculopathy. First
author Dr. Zhang, corresponding author Dr. Weyand from Stanford
University School of Medicine examined whether persistent vessel
wall inflammation in giant-cell arthritis is maintained by
lesional T cells and whether such T cells are sensitive to the
cytokine signaling inhibitor tofacitinib, which is a JAK
inhibitor that targets JAK3 and JAK1.


                                               
To do this, vascular inflammation was induced in human arteries
and grafted into immunodeficient mice that were reconstituted
with T cells and monocytes from patients with giant-cell
arthritis. Mice carrying inflamed human arteries were then
treated with tofacitinib or vehicle. They found that tofacitinib
suppressed T cell invasion into the artery, inhibited
proliferation and cytokine production of vasculitogenic T cells
and curbed survival of artery resident T cells. Tofacitinib
treatment prevented neoangiogenesis and intimal hyperplasia in
these inflamed arteries. Thus, inhibition of JAK-STAT signaling
with tofacitinib effectively targeted multiple disease-relevant
processes in inflammatory vasculopathy and thus represents a
potential disease-modifying agent.


                                               
The next paper provides important insights into how coronary
artery calcification burden and cardiorespiratory fitness, which
are actually two independent predictors of cardiovascular disease
but may interact with each other to impact cardiovascular risk.
First author Dr. Radford, corresponding author Dr. Levine from
the Institute of Exercise and Environmental Medicine Texas Health
Presbyterian Hospital and UT Southwestern Medical Center studied
8,425 men without clinical cardiovascular disease who underwent
preventive medical examinations that included an objective
measurement of coronary artery calcification and
cardiorespiratory fitness between 1998 and 2007.


                                               
They found that cardiovascular disease events increased with
increasing coronary artery calcification and decreased with
increasing cardiorespiratory fitness. Adjusting for coronary
artery calcification levels for each additional MET of fitness
there was an 11% lower risk of cardiovascular disease events.
When both coronary artery calcification and cardiorespiratory
fitness were considered together there was a strong association
between continuous cardiorespiratory fitness and cardiovascular
disease incident rates in all coronary artery calcium groups.
Thus, the take-home message is for any baseline age and level of
coronary artery calcification greater fitness is associated in a
continuous fashion with lower risks of cardiovascular disease
events.


                                               
And that wraps up our summaries. Now for our feature discussion.


                                               
We all know how cardiac rehabilitation is. It's strongly
advocated in guidelines, it's very well highlighted in
performance measures. But how well are we actually doing? Well,
today's feature paper really gives us some very valuable
information and really kind of holds a mirror in our face,
doesn't it? I'm so pleased to have with us the first and
corresponding author of the paper Dr. Alexis Beatty from VA Puget
Sound Health Care System and University of Washington as well as
Jarett Berry, our associate editor from UT Southwestern. Alexis,
could you tell us what did you see when you looked at cardiac
rehabilitation among the Medicare and VA populations?


Dr Alexis
Beatty:              
Overall participation in cardiac rehab after an MI or a PCI or a
bypass surgery is pretty low, only about 16% of people in
Medicare and about 10% of people on the VA actually participate
in cardiac rehab. But the interesting thing is that we saw pretty
wide variations from state to state in participation. So some
states had pretty high participation, upwards of 40% of patients,
and some states had only 1, 2, 3% of people participating.


Dr Carolyn
Lam:               
Were there any patterns to this, any factors that you teased
apart?


Dr Alexis
Beatty:              
We did observe that some regions of the country appeared to be
doing better than others. So for instance, the West North Central
region of the United States, Nebraska, South Dakota area has high
participation in both populations and other regions like the
Pacific, California, Oregon, Washington, Hawaii, Alaska, have
lower participation in both populations.


Dr Carolyn
Lam:               
And any postulations on why this may be the case?


Dr Alexis
Beatty:              
Yeah, I have some theories. We did try to look at whether it was
due to patient characteristics, hospital characteristics,
socioeconomic status, and it doesn't really seem to be any of
those things that are driving the differences, which leads me to
believe that it's actual practice variations. So I think that
literally the systems are set up better in some areas of the
country than others to get patients into cardiac rehab.


Dr Carolyn
Lam:               
And as you beautifully wrote in your paper, that means that there
may be an opportunity here to identify best practices here, isn't
it? Jarett, you've been thinking about this a lot. What do you
think?


Dr Jarett
Berry:                
Yeah, I was curious, Alexis, it is interesting that the hospital
variation that you saw, the on-site cardiac rehab was fairly
consistent across cardiac rehab participation rates in Medicare
but there was quite a bit of variability in the access to an
on-site cardiac rehab site in the VA patients. I thought that was
an interesting observation because it does suggest perhaps that
what's driving regional variability looks to be fairly complex as
you point out in your paper. But I just wanted to have you
speculate a little bit or think a little bit about strategies for
how we might think about improving cardiac rehab participation
given the fact that there doesn't seem to be one particular
answer to this problem. And so as you think about this
longstanding challenge, how would you think about the future,
about how we could actually really move the needle in increasing
cardiac rehab participation?


Dr Alexis
Beatty:              
There's a lot of different ways that I think that we can work to
start moving the needle. And as you point out, not every VA
location has a cardiac rehab center on-site and sites that do
have cardiac rehab on-site do tend to do better at getting their
patients into cardiac rehab. And I think it may just be that
there are people there who are interested in cardiac rehab and
are promoting it to patients. And then there probably are some
access issues as well. But I think it's not just kind of an "if
you build it they will come" sort of proposition. Having cardiac
rehab centers is important but then having systems in place to
get people into cardiac rehab and get people going to cardiac
rehab are just as important.


                                               
And so I've talked to a lot of the VAs that have centers, don't
have centers, do a good job of getting people in, don't do a good
job of getting people in. And even in these places that don't
have cardiac rehab on-site, if they have a system in place that
helps get patients into cardiac rehab they're still able to
achieve pretty high rates. And so a lot of that is just doing
kind of setting it up as an automatic order and having a nurse or
exercise physiologist or somebody be a navigator for the patients
through the process.


                                               
And then the other thing I really want to stress is the
importance of providers recommending it to patients. I think
that's the strength with which the providers sell cardiac rehab
can really make a big difference.


Dr Jarett
Berry:                
It's interesting, I just took over cardiac rehab as a medical
director here at Southwestern about a year and a half ago and
I've been struggling with this. And one of the interesting things
that I just would love to get your thoughts on that I noted,
which doesn't seem to get a lot of attention in the literature to
me, is the role of co-payments. I don't know if most physicians
who aren't involved in this space appreciate that for most
insurance and for Medicare, it may not be the case for VA, I
can't speak to that, but the co-payment amount for each time you
come, for each visit is between $30 and $50 per visit. That seems
to me in some ways ... I know you didn't address it at all in
your paper, but just keeping this conversational ... What do you
think the role of some of these other less discussed factors are
such as just co-payment amounts that might actually be having a
bigger effect on participation? Because I know if I had to pay a
1,000 bucks to go to cardiac rehab I might think twice about it.


Dr Alexis
Beatty:              
Yeah, and I think the co-payment issue is a very real issue too
and there's a lot of policy level things that makes cardiac rehab
difficult. So one is this co-pay issue, there also then other
changes to the way it's administered like where the location of
the cardiac rehab can be and how hospitals get reimbursed for
that. It has to be prescribed by a physician, it can't be
prescribed by a nurse practitioner or a PA, it has to be
supervised by a physician. There's a lot of restrictions on
cardiac rehab that can just, practically speaking, make it
difficult to deliver both from the patient and the provider and
health system level.


                                               
And what I tell my patients when I am trying to get them to go to
cardiac rehab, and we do have co-payers in the VA too that are
kind of on a sliding scale depending on patients’ means. And so I
tell them that it's an investment. You are making this upfront
investment of your time and money and effort to get yourself
healthy and learn how to be healthy in the long term. So we know
that people who attend cardiac rehab are less likely to be
hospitalized and are less likely to die from their heart disease,
and so it's an important investment to make and that's sometimes
the hard message to sell and I wish it were easier to sell.


Dr Jarett
Berry:                
I totally agree with you. My own patients and also the patients
that I helped manage through cardiac rehab have received such
benefit in many different areas from the participation. But yeah,
it is an investment.


                                               
I wanted to ask another question, if I may Carolyn, about the
future. And you alluded to this in your paper, I know your work
with Mary Whooley, you guys have done great work thinking about
rolling out home-based cardiac rehab. And I think personally that
the future of cardiac rehab for most patients, that we're really
going to move the needle—I mean some of the policy issues are
really important—but can you comment on just telling us what
home-based cardiac rehab is and to what extent you think that is
a potential solution to deal with these persistently low
participation rates?


Dr Carolyn
Lam:               
Actually Jarett, if I may just butt in before Alexis answers, I
was about to ask that because I was just placing myself in the
patient's point of view. And I mean even me, I hate going to gyms
now and much rather work with a home app instructing me what to
do and I can just do it here, you know what I mean? So I think
that's a great question. Alexis?


Dr Alexis
Beatty:              
I agree, the future is home cardiac rehab and using all the tools
that we have at our disposal to make it easy to deliver home
cardiac rehab. The evidence isn't quite as strong for home
cardiac rehab but the existing evidence does suggest that it's
equally effective to center-based cardiac rehab, it's just not
reimbursed in the United States. So functionally it only exists
in sort of integrated health systems like the VA.


                                               
The VA, for instance, has started delivering home-based cardiac
rehab programs. I think it's now at over 30 centers in the US.
And this has basically started in the last five years. And the
programs are pretty similar to a center-based cardiac rehab
program in that patients come in and they get an in-depth
assessment from cardiac rehab professionals. But then the
difference is that they go and exercise on their own at home and
they check in with the cardiac rehab professionals usually on a
weekly basis over the telephone. And so it ends up being more of
like a coaching relationship between the cardiac rehab
professionals and the patients who are exercising on their own at
home. And a lot of patients really like it because, as you
pointed out, it's much more convenient for them, they don't like
going to a gym, they'd rather be walking around in their
neighborhood or going to their local community pool to swim. So
it just sort of addressed a lot of these patient issues and they
don't have to pay a co-payment. So it can take some of these
other barriers that are there.


Dr Jarett
Berry:                
Like a Peloton bike for cardiac rehab, right?


Dr Alexis
Beatty:              
Yeah. I mean you could even do that. For instance, in HF-ACTION
they actually gave people exercise equipment for a HF-ACTION
study for the home segment of the HF-ACTION study. So there
certainly are models whereby we could just be giving exercise
equipment. And in the VA I can mail people these little exercise
paddlers that they can put on their floor or their table and you
can use them with your legs or your arms. So certainly being able
to send some of this exercise equipment to your patients may help
them get them into doing things. But I think home cardiac rehab
is the future.


                                               
And then also I do work on using technology to help deliver home
cardiac rehab and I view technology for this space not as the
solution but as a tool to help you deliver home cardiac rehab.
And now that technology is so ubiquitous, I think that we need to
now learn how to use the technology to help us better deliver
cardiac rehab in a way that meets the patients' needs.


Dr Carolyn
Lam:               
Wow. Jarett, I've actually got a question for you. You were just
saying that you run the rehab unit there, so what messages did
you take home from this paper?


Dr Jarett
Berry:                
What I took home from this was exactly what we've been
discussing, this issue of low uptake of cardiac rehab even in the
scenario where you have a model where you're delivering this
through Medicare or the VA we still see very low participation,
albeit there is some variability. And so my interpretation after
doing cardiac rehab here at Southwestern for the last year and
half is exactly what Alexis is saying, is that we need to be
really thinking more creatively about how we can deliver cardiac
rehab where the patients are and not requiring them to
participate in centers of cardiac rehab that are maybe 30, 40
miles from their home and in the middle of the workday, all of
which just really makes such a model inefficient.


                                               
So I just think what this paper does really solidify is that we
really need to be thinking broadly and creatively about how to
bring cardiac rehab to more patients because the way we're doing
this now I think unfortunately is just ineffective.


Dr Carolyn
Lam:               
Anything to add, Alexis? This is great.


Dr Alexis
Beatty:              
So one other point that I would like to mention. I think about 10
years ago there was another paper that used a very similar
method, and we based a lot of our methods off of that paper by
Suaya about 10 years ago. And they found that the rate of
participation in cardiac rehab was somewhere very close to ours,
I think it was 18% and we observed 16%. And since that paper was
published cardiac rehab got included in guidelines, included as a
performance measure, and there has been a big push and a lot of
attention to try to get people into cardiac rehab and we have
moved the needle zero since that time. So I think clearly
something new is needed to move the needle for cardiac rehab just
as Jarett was pointing out. So we got to do something because
what we're doing isn't working.


Dr Carolyn
Lam:               
That's a great call and thank you for showing that to us so
clearly in your paper.


Dr Jarett
Berry:                
Yeah, thanks Alexis and thanks for being so responsive in the
revision process, it was a real pleasure to work with you all on
this really important paper.


Dr Alexis
Beatty:              
Thank you so much for publishing this paper. I feel I've been
working on this for like five years.


Dr Carolyn
Lam:               
Well you heard it here, listeners. Thank you for joining us
today. Don't forget to tune in again next week.