Cardiac Rehabilitation for Patients With Resistant Hypertension
Physical activity is known to improve blood pressure (BP), especially in patients with cardiovascular disease (CVD). However, a new study examined the effects of cardiac rehabilitation on exercise capacity and outcomes in patients with resistant hypertension.1
The study was led by Luke Joseph Laffin, MD, who is a physician in the Preventive Cardiology & Rehabilitation Section in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart & Vascular Institute at the Cleveland Clinic Foundation in Cleveland, Ohio. Dr Laffin also presented his study’s findings at the American Heart Association’s Hypertension 2019 Scientific Sessions.
Consultant360 caught up with Dr Laffin after his session.
CONSULTANT360: Phase 2 cardiac rehabilitation is typically 36 sessions that are supervised by medical personnel and includes an educational program. Does participation in phase 2 cardiac rehabilitation affect exercise capacity and outcomes in patients with resistant hypertension?
Luke Laffin: We looked at patients that completed phase 2 cardiac rehabilitation over a 5-year period and assessed how many had apparent treatment-resistant hypertension, the characteristics of these patients, and how that affected short-term outcomes (exercise capacity changes) and long-term outcomes (hospitalizations and mortality.)
We found that cardiac rehabilitation increases the exercise capacity of patients with resistant hypertension. We did not look at how patients with resistant hypertension who completed cardiac rehabilitation compared with patients with resistant hypertension who did not complete cardiac rehabilitation. We did study, and find, that patients with resistant hypertension had worse outcomes after completing cardiac rehabilitation than other participants in cardiac rehabilitation (without resistant hypertension.)
C360: Among the findings of your study was that cardiac rehabilitation participants with resistant hypertension were more likely to be hospitalized within 2 years of completion of cardiac rehabilitation than their counterparts without resistant hypertension. What methods might cardiologists and other health care providers employ to reduce this hospitalization rate? Is more cardiac rehabilitation indicated?
LL: We don’t have enough data to tell us if more prolonged cardiac rehabilitation would be useful. I think the findings reflect an older, sicker patient population with more risk factors for emergency department visits and hospitalizations. To reduce their adverse outcomes, I believe we need to be more proactive about aggressive BP control, identifying patients who should be referred to a hypertension specialist (which we now have and are doing at the main campus of the Cleveland Clinic), and emphasizing evidence-based therapy for resistant hypertension treatment.
C360: What tips or best practices would you give to other health care providers looking to improve their patients’ exercise capacity?
LL: For those patients already enrolled in cardiac rehabilitation, I would emphasize keeping lines of communication open between nurses, exercise physiologists, and the medical directors of cardiac rehabilitation, and encourage continued participation even after completing phase 2 cardiac rehabilitation (moving on to so-called phase 3 cardiac rehabilitation).
The bigger issue nationwide is that not enough individuals enroll in cardiac rehabilitation (even when it is highly recommended to do so) and are not improving their cardiovascular outcomes or exercise capacity. We, as a health care system, need to do a better job at putting systems in place to identify and engage these individuals.
C360: What is the key take-home message from your study?
LL: Phase 2 cardiac rehabilitation is more than just exercise. It is a medically supervised exercise training and secondary prevention program. As physicians we need to be aware of the increased risk of poor outcomes that comes along with a diagnosis of resistant hypertension and implement systems to identify and treat these patients appropriately.
- Laffin LJ, Khan A, Lang K, Van Iterson EH. Abstract P3053: Cardiorespiratory fitness and cardiovascular outcomes in patients with resistant hypertension participating in cardiac rehabilitation [published online September 4, 2019]. Hypertension. https://doi.org/10.1161/hyp.74.suppl_P3053.