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Risk Stratification

Risk Stratification. Ontario Cardiac Rehabilitation Pilot Project. Recommendation: CACR. “ …programs consistently use some form of risk stratification for all their patients entering cardiac rehabilitation…”. Why risk stratify?. Ensure safety of the patient

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Risk Stratification

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  1. Risk Stratification Ontario Cardiac Rehabilitation Pilot Project

  2. Recommendation: CACR “ …programs consistently use some form of risk stratification for all their patients entering cardiac rehabilitation…”

  3. Why risk stratify? • Ensure safety of the patient • Identify patient’s prognosis and progression variables – direct intervention • Assess long term outcomes • Assist in allocation of resources

  4. Risk Stratification Guidelines • AACVPR • ACC • ACP • AHA • CACR • Duke treadmill score

  5. AACVPR Guidelines Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, AACVPR, Human Kinetics, 1999

  6. CACR Guidelines • Prognosis score (short-term absolute risk) • GXT: functional capacity • Ischemia, CCS class or max ST depression • LVEF • Dysrhythmias • Heart hazard score (long-term absolute risk) • Smoking • Lipids • BP • Diabetes • Psychological distress

  7. Absolute vs. relative risk • Absolute: probability of suffering an acute CVD related event within a finite time period • Short-term (<5-10yrs) • Long-term (>10 yrs) • Relative: ratio between two levels of absolute risk Individual’s absolute risk Absolute risk of low-risk reference population

  8. Short-term Absolute Risk • < 5 yr risk of future cardiac event • Linked to prognostic variables • Assist in: • optimizing safety of exercise • allocating resources

  9. Short Term Absolute Risk

  10. Short Term Absolute Risk

  11. Short Term Absolute Risk

  12. Short Term Absolute Risk

  13. Short Term Absolute Risk Sum of: • Functional capacity score • LVEF score • Ischemic burden score • Dysrhythmia score

  14. Long Term Absolute Risk • Risk of disease progression • Increasing number of points reflects increasing ‘exposure’ of heart hazard • 10 year absolute risk of CVD development/progression • Only traditional risk factors

  15. Disease Progression Risk

  16. Disease Progression Risk

  17. Disease Progression Risk

  18. Disease Progression Risk

  19. Long Term Absolute Risk Sum of: • Age score • Lipid (TC, LDL, HDL) score • BP score • Diabetes score • Psychosocial distress score • Smoking score Women = sum of scores x 1.5 Men = sum of scores x 1.4

  20. CACR Guidelines: Overall Risk Canadian Guidelines for Cardiac Rehabilitation & CVD Prevention, CACR, 1999

  21. Use of Risk Stratification Scores Low S/T & L/T risk Minimal or no intervention Low S/T, high L/T risk Home or unsupervised programs & heart hazard modification High S/T & L/T risk Supervised exercise & structured heart hazard modification

  22. High or very high short term risk: Supervised exercise Consider ECG monitoring Higher degree of supervision May need to hold exercise until further investigation Satellite sites: refer to coordinating centre High or very high long term risk: Structured approach to heart hazard modification Educational tool for patients Clinical Application

  23. Medical History IWMI May 2000 Cath: LM, LAD, Cx normal; RCA 100% distally; LVEF 76% PTCA/stent RCA, 100% to 0 GXT: 8.3 METs, no angina, no ST changes, no arrhythmias Heart Hazards 63 yrs., male BP: 130/78 BMI: 28.2 Girth: 98 cm Physical activity: 75 min/week TC 4.8, LDL 2.7, HDL 1.12, Tg 2.25, FBG 4.8 D/c smoking x 25 yrs Case Study #1

  24. Case Study #1: S/T Risk

  25. Case Study #1: L/T Risk

  26. Case Study # 1 • Low-Mod S/T risk • High L/T risk • Total = 12.8, low-mod overall risk • Cardiac rehab program: • Home exercise program: 200-400 min/wk, resistance training • Nutrition counselling: weight control, dyslipidemia • Pharmacotherapeutic intervention: Baycol

  27. Case Study #1: Outcomes

  28. Medical History IWMI 1992, PTCA RCA PTCA RCA x 2 1993 Recurrent angina 2000, cath: LAD 70%, Cx 100%, RCA 95/90%, LVEF 34% PTCA/stent RCA mid and distal GXT: 6.1 METs, ST depression to 3 mm, assymptomatic, frequent PVCs & couplets Heart Hazards 71 yr old male D/C smoking x 35 yrs BP 168/68 No regular exercise BMI 27.5, girth 103 cm TC 4.3, LDL 1.7, HDL 1.3, Tg 2.77, FBG 5.6 Case Study #2

  29. Case Study #2: S/T Risk

  30. Case Study #2: L/T Risk

  31. Case Study #2: • Very high S/T risk • High L/T risk • Total = 49.2, very high overall risk • Cardiac rehab program: • Referred back to cardiologist, exercise initially on hold, now returned to supervised exercise, ExRx below ischemia, telemetry monitoring, booked for CABG July 2001. • BP monitored, multiple therapy

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