Extended Cardiac Rehab Plus Tailored Counseling May Help Some Patients: OPTICARE

Marlene Busko

September 06, 2016

ROME, ITALY — In a randomized study of close to 1000 patients with ACS who were referred for cardiac rehabilitation to a single center, those who received an additional 9 months of rehab on top of the standard 3 months did not have a better coronary risk-factor score based on systolic blood pressure, total cholesterol, and smoking (the primary outcome), at 18 months[1].

However, patients who completed the extended program with face-to face counseling (but not the extended program with counseling delivered by phone) had less anxiety, an improved quality of life, and took 700 more steps a day than those in the 3-month program, Dr Ron T van Domberg (Erasmus Medical Center and Capri Cardiac Rehabilitation, Rotterdam, the Netherlands) reported in a press briefing prior to his presentation at the European Society of Cardiology (ESC) 2016 Congress.

Does this mean that, based on this Optimal Cardiac Rehabilitation (OPTICARE) trial, an educational program that is just extended, without the additional face-to-face component, does not benefit ACS patients? "I don't think so," said assigned discussant at the session, Dr Ana Abreu (Hospital Santa Marta, CHLC, Lisbon, Portugal), noting that study limitations included that it enrolled a very low-risk population.

"A multicenter trial is needed," she stressed, "with a better characterized and more heterogeneous ACS population sample, reflecting real-world patients and including quality of life as a primary outcome." In the meantime, clinicians should offer ACS patients more tailored cardiac-rehabilitation programs.

Comoderator at the press session, Dr Joep Perk (Linnaeus University, Kalmar, Sweden), said that starting this fall, cardiologists who perform PCI in Sweden will receive training about the importance of referring a patient for rehab. They can tell a patient: "Congratulations! You made it! But the rest is up to you." Surviving a heart attack is similar to soccer where if "you get a yellow card, you play the ball; but if you get your second yellow card, you're off the field."

To heartwire from Medscape, he added that that along with tweaking the design of a cardiac-rehab program it is important to get a patient into a program to start with. "The take-home message is to get patients into a program, and whatever you do, it will be better."

Van Domberg agreed, telling heartwire , "The most important point to change a lifestyle habit is just after the infarction . . . and then it is important that patients sustain lifestyle changes." OPTICARE suggests that patients need sustained, in-person coaching, perhaps combined with telephone or e-health lifestyle counseling, he said, "otherwise the patient falls back into his old habits."

Cardiac-rehab programs "have barely changed since the 1980s," according to van Domberg.

Extended vs Standard Rehab to Promote Heart-Healthy Lifestyle

OPTICARE aimed to compare the effects of two extended cardiac-rehab programs designed to stimulate permanent adoption of a heart-healthy lifestyle compared with a standard 3-month program.

From 2011 to 2014, the trial enrolled 914 patients with ACS who were referred to their center in Rotterdam, the Netherlands, for cardiac rehab.

Patients with heart failure, LVEF <40%, chronic obstructive pulmonary disease, renal failure, or psychological or cognitive impairments that could limit cardiac rehab were excluded.

On average, patients began cardiac rehab 6 weeks after their ACS event. They were randomized to receive standard cardiac rehab alone (90 minutes of lifestyle-counseling group sessions twice a week for 12 weeks); standard rehab followed by three face-to-face fitness-and-lifestyle counseling sessions during 9 months; or standard rehab plus 5 to 6 lifestyle counseling sessions given by phone during 9 months.

About 83% of patients in each of the three groups stuck to the 3-month program, but only 61% of patients in the face-to-face counseling group completed the follow-up 9-month program and only 57% of patients in the telephone-counseling group completed that follow-up program.

"Before their heart attack, almost 50% of the patients were smoking," van Domberg told the press. But when they began cardiac rehab 6 weeks later, only 10% smoked. By 18 months, only 10% of patients in the extended-rehab groups smoked, but 20% of patients in the 3-month standard-rehab group smoked.

At the 18-month study end, among patients who completed their rehab programs (motivated patients), those in the extended-rehab groups had significantly lower total cholesterol levels than those in the standard-rehab group, and systolic blood pressure remained below 140 mm Hg in all three groups.

Among motivated patients, compared with patients in the standard program, those in the telephone-counseling extended program were less likely to smoke and had lower cholesterol and more improved quality of life; patients in the face-to-face-counseling program had these benefits plus improved physical activity (steps/day) and less anxiety.

Patients walked about 6000 steps a day when they began rehab, and at 18 months, those who had completed the 3-month program walked 6679 steps/day, whereas those who had completed the extended face-to-face program walked 7282 steps/day. This is still below the recommended 10,000 steps a day, Perk noted, adding that based on his iPhone app, he and other attendees at this stretched-out conference center were easily walking 20,000 steps/day.

"Important Issue," Rehab Should Be Individualized

This is the first trial to address the important issue of extended vs standard cardiac rehab, Abreu said. However, these were selected, low-risk ACS patients who were young (mean age 57) and mostly male (81%) without a previous MI (>90%) who had reached optimal levels for many risk factors prior to starting rehab—so it is not surprising that the cardiovascular risk scores (based on smoking, cholesterol, and blood pressure) at 18 months were similar in the three groups.

"Cardiac-rehabilitation programs should be simple, agreeable, and adapted to patients' choices and needs," she summarized.

In the same vein, Perk said: "I see cardiac rehab as a supermarket where for each patient you pick just that basket that that very patient needs." Clinicians need to know their patient and know what they should tackle first, since some people mistakenly try to make multiple changes (for example to diet, exercise, and smoking) all at once and then fail, get depressed, and give up.

Moreover, probably not all patients need prolonged rehab programs, according to Abreu. "This longer duration should be restricted to some particular groups, probably to higher-risk patients or to those who do not accomplish the target risk values after standard cardiac rehabilitation," she said.

Van Domberg and Abreu have no relevant financial relationships.

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