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Mayo Clinic: Heart patients fare better in 3-year program

ROCHESTER, Minn. - People recovering from acute heart problems such as heart attack and heart surgery are more likely to develop habits to control heart attack risk factors when they meet regularly with cardiac "disease managers," according to researchers at Mayo Clinic in Rochester. These managers are nonphysician cardiac rehabilitation specialists who lead long-term follow-up programs that last three years. With these risk factors under control, heart patients are likely to live longer and have fewer heart problems, the Mayo researchers conclude.

The Mayo Clinic researchers studied the effects of a long-term cardiac disease manager model on 503 patients involved in cardiac rehabilitation. Their findings appear in The Journal of Cardiopulmonary Rehabilitation and Prevention, (;jsessionid=LF6LdjP3QQ81SY2PjTbLQ9Tn1rGbBr5yszv1vyq6chS8wfhl1pgy!634347399!181195628!8091!-1). The disease manager's role was to monitor the patient's status, and to coach the patients in adopting heart attack prevention behaviors. At each meeting, the following factors were assessed and management strategies were discussed: blood lipid levels, blood pressure and body weight, tobacco use, cardiac medication compliance, exercise regimen and physical activity, nutrition and cardiopulmonary symptoms. After initial rehabilitation training about risk factor management, each patient met with a trained disease manager every three to six months for three years.

Their report demonstrates:

  • It is feasible to provide long-term disease management to heart patients in an outpatient setting. Mayo's model calls for trained cardiac rehabilitation specialists to function as disease managers who maintain a relationship with the patients and meet face-to-face every three to six months. This follows an initial intensive training period about lifestyle changes and medications. In contrast, aftercare programs often are only a few months long and lack coordination and direct involvement of health care providers who are specifically trained in cardiac rehabilitation, or who rigorously review clinical and lifestyle data.
  • The approach offers clear clinical benefits. At three years, the participants attained and maintained most of the behaviors for preventing subsequent heart attacks. These behaviors are known as secondary heart-attack prevention measures. They include exercising regularly and taking specific heart-protecting medications. Most lowered their cholesterol levels and blood pressure to within recommended levels. Of the 503 participants, compliance with aspirin usage was 91 percent; statin usage, 91 percent; beta-blocker usage, 78 percent; and angiotensin-converting enzyme inhibitor usage, 76 percent.
  • Patients in the disease manager model of care versus traditional care had a lower death rate. While larger studies will need to validate this finding, over the three years of the study, 29 participants died, (25 men and four women), an annual death rate of 1.9 percent. This compares to the Centers for Disease Control and Prevention's expected annual death rate of 1.6 percent for Americans of comparable ages in the general population without heart problems. By comparison, the annual death rate over three years for an additional group of 102 patients who were enrolled in cardiac rehabilitation but who did not receive long-term disease management, was 6.5 percent.
  • Being overweight remains a prevalent and persistent risk factor for heart attack. As measured by body mass index, being overweight was the one heart disease risk factor that did not respond well to this disease manager approach. Other studies also have shown body weight to be the most change-resistant variable in efforts to promote heart health.

Significance of the Mayo Research

The findings are important because heart disease is the number one cause of death and disability in the U.S - and though many people survive due to advances in medical care, many patients and physicians don't realize the importance of cardiac rehabilitation in extending survival benefits. Mayo researchers developed the disease manager model of cardiac rehabilitation to extend the lifesaving benefits modern medicine offers, and spare patients the trauma and the expense of repeat surgeries and hospitalizations, says lead researcher Ray Squires, Ph.D.

"Earlier studies indicate that under traditional approaches, most patients don't comply with treatment recommendations, including taking medications and modifying their lifestyle. We need to change that," Dr. Squires says. For example, he says that during 2004 in Minnesota, 38 percent of coronary heart disease patients received optimal care for controlling heart attack prevention. The goals of heart attack prevention for patients with coronary heart disease in the Minnesota survey included:

  • Achieving a low-density lipoprotein (LDL) cholesterol of less than 100 milligrams per deciliter
  • Lowering blood pressure to less than 140 systolic and 90 diastolic
  • Taking a daily aspirin to help prevent blood clots
  • Quitting smoking
"This suggests the remaining 62 percent of Minnesota coronary heart disease patients in 2004 remained at higher risk of further heart problems," Dr. Squires says. "Our feeling is that medical science can offer more people better methods for living a heart-healthy - and longer - life. We designed our cardiac rehabilitation program to do that. Using the disease manager model, we have demonstrated that three years of intervention in routine clinical practice was generally effective in achieving secondary prevention goals."

Mayo's Leadership Role

Mayo Clinic is a leader nationally in emphasizing the savings in lives and costs that cardiac rehabilitation offers heart patients. "Many studies demonstrate that cardiac rehabilitation is extremely beneficial to patients, and the data also show that cardiac rehab is vastly underutilized," says Randal Thomas, M.D., director of the Cardiovascular Health Clinic at Mayo Clinic.

To improve the referral of patients to cardiac rehabilitation programs and to stimulate high-quality care in cardiac rehabilitation centers, Dr. Thomas recently helped draft new national performance measures. Adding a disease manager into this approach extends the benefits of cardiac rehabilitation, in his view. "The kind of cardiac rehabilitation program we'd like to see serves not only as a coach for the patient, but also as a key communicator in patient care, and a coordinator with other health care providers. When all those roles are filled, it's likely that patients get the follow-up care they need," Dr. Thomas says.

About the Study

Mayo's study is based on a review of the clinical progress made by 503 heart patients at Mayo treated under a long-term management model led by cardiac rehabilitation experts. Patients entered the rehabilitation program in 1999 and 2000. Of the patients, 54 percent were 65 years or older. All had suffered some form of acute cardiac event, such as a heart attack, or had undergone heart surgery.


Contact: Traci Klein
Mayo Clinic

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