Editorials
Late Phase II Cardiac Rehabilitation, Which Is Adding Life to Years and Years to Life, Is Still Underused in Japan
2016 Volume 80 Issue 8 Pages 1697-1699
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2016 Volume 80 Issue 8 Pages 1697-1699
Cardiac rehabilitation (CR) has been demonstrated to improve not only the physical effects (Table), but also psychological distress and quality of life, and to reduce major morbidity and mortality in patients with cardiovascular disease (CVD).1 A nationwide survey conducted in 2001–2003 in Japan revealed that both exercise-based CR and exercise testing are generally safe, and that formal CR, in which an individual exercise prescription is determined by exercise testing, is particularly safe.2 As the length of stay in acute-phase specialized hospitals for phase I CR and early phase II CR become shorter, late phase II CR programs are provided as ambulatory programs after discharge. As patients with CVD typically visit the clinic biweekly during the first 1–2 months after discharge for follow-up during this period, they should participate in comprehensive CR programs in which outpatient nurses play a central role in educating patients on smoking cessation, diet, and lifestyle interventions. In addition to education, patients should continue exercise training mainly consisting of endurance training, and undergo exercise stress tests at months 1 and 3 and at the end of the program to assess the efficacy of the CR program, predict prognosis, and reissue exercise prescriptions.1
| Category | Effects | Rank |
|---|---|---|
| Exercise capacity | Increase peak uptake | A |
| Increase anaerobic threshold | A | |
| Symptoms | Decrease the incidence of anginal attacks by increasing myocardial ischemic threshold | A |
| Reduce symptoms of heart failure associated with the same intensity physical activities | A | |
| Respiration | Decrease ventilatory volume at given submaximal workloads | A |
| Heart | Decrease heart rate at given submaximal workloads | A |
| Decrease cardiac work (double product) at given submaximal workloads | A | |
| Prevent left ventricular remodeling | A | |
| Prevent the deterioration of left ventricular systolic function | A | |
| Improve left ventricular diastolic function | B | |
| Improve myocardial metabolism | B | |
| Coronary arteries | Prevent the progression of coronary atherosclerotic lesions | A |
| Improve myocardial perfusion | B | |
| Improve endothelium-dependent and -independent vasodilation responses | B | |
| Peripheral oxygen utilization | Increase the maximum arteriovenous oxygen difference | B |
| Peripheral circulation | Decrease total peripheral vascular resistance at rest and during exercise | B |
| Improve peripheral arterial endothelial function | B | |
| Inflammatory reactions | Decrease CRP and proinflammatory cytokines | B |
| Skeletal muscle | Increase mitochondrial density | B |
| Increase the activity of oxidative enzymes in skeletal muscle | B | |
| Increase capillary density in skeletal muscle | B | |
| Promote the conversion from type II to type I muscle fiber | B | |
| Coronary risk factors | Decrease systolic blood pressure | A |
| Increase HDL cholesterol and decrease triglycerides leveles | A | |
| Decrease smoking rate | A | |
| Autonomic nervous system | Reduce the sympathetic nervous activity | A |
| Increase parasympathetic nervous activity | B | |
| Improve the baroreflex sensitivity | B | |
| Blood | Reduce platelet aggregation | B |
| Reduce blood coagulation | B | |
| Prognosis | Reduce the incidence of coronary events | A |
| Reduce hospitalization rate due to exacerbation of heart failure | A (CAD) | |
| Improve prognosis (reduce all-cause mortality and cardiac death) | A (CAD) |
A, supported by substantial evidence; B, supporting reports are high in quality but limited in number; CAD, coronary artery disease; CRP, C-reactive protein; HDL, high-density lipoprotein. (Adapted with permission from the JCS Joint Working Group.1)
Article p 1750
The regional clinical alliance path (RCAP), also called “regional liaison critical pathway” or “community cooperation critical pathway”, is a patient care program in which acute-phase specialized hospitals and chronic-phase medical institutions (family physicians and/or rehabilitation facilities) work cooperatively to manage post-acute phase patients in the community. National surveys of RCAP after stroke or femoral neck fracture have been performed.
In this issue of the Journal, Arakawa et al3 report the first national survey 2009 of RCAP after acute myocardial infarction (AMI) in the responding cardiology training hospitals authorized by the Japanese Circulation Society (response rate 62.9%): the implementation rate of emergency percutaneous coronary intervention (PCI) was high (91%), but that of outpatient late phase II CR (OPCR) was very low (18%). The implementation rate of RCAP after AMI was significantly lower (10%) than after stroke (57%). CR was adopted as part of RCAP in only 19% of currently operating RCAP programs. Although patient education programs and exercise prescription based on cardiopulmonary exercise testing (CPX) were implemented at a higher rate in RCAP hospitals than non-RCAP hospitals, the implementation rate of OPCR was low in both.3
The authors discuss several reasons for the poor RCAP implementation after AMI in comparison with stroke.3 In Japan, the PCI implementation rate is very high and the OPCR implementation rate is very low, regardless of hospital size, which suggests there may be low awareness of the importance of OPCR and RCAP in post-discharge management and secondary prevention after AMI. Moreover, non-RCAP hospitals are relatively small and staff shortages may reduce the likelihood of RCAP implementation. RCAP is not considered to be necessary when patients are discharged directly home after AMI.
Although the benefits of CR have been established, participation rates for eligible patients with CVD are poor (in the USA 14–35% after AMI and 31% after coronary artery bypass graft surgery; 29% after AMI in the UK; 23% after AMI in France).4 In the Japanese survey, the implementation rate of recovery-phase CR was 11.8% overall and only 19.8% even in Japanese Circulation Society training hospitals. The estimated participation rate in outpatient recovery-phase CR was 4–8% in Japan.5 Thus, patient participation in recovery-phase CR is the lowest in Japan (Figure).6
Comparison of patient participation rates in cardiac rehabilitation according to clinical background and country. (Adapted with permission from Goto Y.6)
Populations are aging and patients have a larger number of comorbidities. As a super-aged society has come, the number of persons with multimorbidity and multiple disabilities (MMD) and their need for rehabilitation has increased more rapidly than we had expected.7 Medical science basically aims to “adding years to life” by increasing life expectancy. Rehabilitation generally aims to “adding life to years” by helping patients with impairment achieve, and use, their full physical, mental and social potential. However, recent growing evidence suggests that rehabilitation for patients with visceral impairment such as cardiac, renal and pulmonary impairment can not only improve exercise performance and quality of life, but also increases survival.8 Therefore, modern comprehensive rehabilitation for patients with visceral impairment does not aim simply to “adding life to years” but “adding life to years and years to life”, which is a new rehabilitation concept and an ideal medicine.8
In the USA, an estimated 785,000 Americans will have a new coronary attack each year, and 470,000 will have a recurrent attack.9 Of those who have a first MI, the percentage with recurrent MI or fatal CHD within 5 years is 22% of men and women of more than 65 years of age.9 The importance of late phase II CR programs has been recognized more than ever because it reduces recurrent attack, major morbidity and mortality in patients with CVD and its management targets have been standardized by guidelines.1 Cardiologists and physiatrists should take part in late phase II CR and have an important role in increasing the rate of late phase II CR.
The Japanese Association of Cardiac Rehabilitation (JACR) was established in 1995. In order to improve the quality of CR services and to educate the professionals playing a pivotal role in a primary CVD prevention programs in Japan, JACR established a certification program for the Registered Instructor of Cardiac Rehabilitation (RICR) in 2000. The JACR also established a non-profit organization, Japan Heart Club (JHC), in 2004 in order to publish educational materials for health promotion and prevention of CVD. JHC also provides opportunities to participate in CR programs in the community through the activities of the “MedEX Club”, a multidisciplinary facility that provides RICR-supervised exercise sessions, and education for patients, and training classes for citizens and health professionals.10
In the future it will be important to more widely establish RCAP, not only as a system of patient referral, but also to increase OPCR participation, reduce coronary risk factors, improve quality of life, prevent heart failure, and improve long-term prognosis. Thus CR is an ideal modern medicine and urgent efforts should be made to increase the implementation rate of CR. The number of members of JACR and RICR in 2016 has rapidly increased to 12,731 and 3,806, respectively, compared with approximately 6,000 and 1,500 in 2009. The JACR and RICR may each have an important role in increasing the implementation rate of high-quality CR.
