Chapters Transcript Video Incorporating the Principles of Cardiac Rehabilitation Throughout the Continuum of Care Carmen M. Terzic, M.D. Ph.D. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on November 20, 2019. Her. Thank you so much. Thank you very much here. Have Yeah. Yes, yes. Thank you, Councilor. That's true. Right? And we see. Yes, definitely you some business, but it's not gonna be. Thanks guys. Hello. Hello. OK. All right. I think um I think this is too loud. Um OK, so welcome everybody. Uh This is uh great to have you here. Um I'm just gonna give a brief introduction. Um So it is uh a really a true pleasure uh to, to introduce you or to welcome an O I guess to officially talk about uh the ninth Clinical Research Prem Expo. Um We have been doing this as the number, the title says nine years now and I think we have been growing very nicely. Uh I really like the spirit of this event uh where we have representation of research, uh Q I activities, clinical activities, uh all display. Uh This is very uh also inclusive because we invite people from all the disciplines. Basically all rehab staff is here today. Um The number of posters this year is a little bit less than last year. But I think the quality of the posters is a little bit better. So it's OK, we cannot quality for quantity is always a good, good relationship. Um So thank you buddy for coming today and participating, uh having posters and so on. And with these, I like to uh give uh a strong thank you. Maybe a round of applause for uh um Michelle Siva and Kev mclaughlin for organizing this event. And uh if they did a good job, we have food afterwards. Uh we'll see. Yes, they're saying yes, but I don't know, maybe over confident. Um I also want to say thank you to um to a few folks who have reviewed the posters and the abstract presentation. So this is Megan Buyer, uh Robin uh sorry, Ryan Sonia Campbell, uh who uh produce all your uh abstracts and so on. So, uh that's also very important work and pretty Ragavan who is uh as you know, the new vice chair for research in the department who also helped coordinate uh all the events of today. And so I just didn't do much at all. I'm just taking the credit of coming here and introducing the event. Um But I'm very happy uh actually to, to introduce a very good friend of mine. Uh This is doctor. Um So it's a really uh honestly, it's a true pleasure um and a privilege and an honor to be introducing her here today and to have her here visiting for a couple of days. Uh Carmen has been going around and talking to different folks. Um And I have heard that she has been impressed with the things that she's been talking about and, and the things that we've been doing, which is also nice and rewarding. Um So let me uh tell you a little bit about Carmen uh doctor uh is the chair of the PM R department um at um and the associate medical director for cardiovascular Rehabilitation at Mayo Clinic. Uh She is uh a physician, she's a clinician scientist and she specializes in cardiovascular uh rehabilitation and neuromuscular rehabilitation. As a scientist. Um Carmen has done a very impressive amount of work uh supported by NIH and other agencies. Uh focus on uh developing regenerative medicine and stem cell based cardiac repair uh as well as optimizing uh the properties of the cardiac uh heart and the cardiac commitment, as well as studying the role of uh nuclear transport during stem cell differentiation into Carboy sites. I mean, the, the work on regenerative medicine the government has been doing has been uh an instrumental in pushing this field. She's gonna talk a lot about the heart today, but I think that a lot of the lessons learned are also being translated to the muscular system. Uh So it's very, very important for, for uh the things that we do in rehabilitation in the future we have. So, so, you know, Carmen uh did her medical school in Venezuela. So she has uh an accent like me, maybe a little less than me. Um And, and of course, we have a Latino connection uh there. Uh If you leave us alone, we start speaking Spanish and we don't stop. Um She did her phd and residency in PR uh in Mayo Clinic and she remained in Mayo Clinic since, since then. So, uh with that uh Carmen, thank you again for coming here, spending a couple of days with us and sharing uh the science and knowledge that you have acquired over the years. Thank you. Thank you very much. And I want to say that it's a privilege and an honor to be here with all of you. I have a, I had a wonderful day yesterday meeting with uh some of you leaders and therapists and student and resident. It was really very refreshing energizing. I was very excited to listen all the listening and learning of all the wonderful things that you are doing and I really have some plan to come back or to send some of my staff here to learn more as you are doing wonderful things. So, thank you. Thank you very much uh Pablo and all of you for giving me this opportunity. And as a Pablo said, I speak with accents. So, but because you are now at this point, used to a Latin accent, so I don't think that you will have any problem to understand me. I hope so. So. I don't have any disclosure. And this is a picture of the outpatient setting at the Mayo Clinic, Mayo Clinic. And I am going to mention this because it will be important for some of the data and some of the slides that I am going to show. But Mayo Clinic is a big center. We have 60,000 employees. It is the number one private employee employer in the state of Minnesota, the largest one and the town is only 100 5000 people. So you can imagine that basically Rochester is May or May Rochester is a, is a combination. So this is has a lot of negative connotation. But that being a big medical center in in the coal field, as we say in the middle of, of the United States or the middle of nowhere. But also give us the opportunity as we are the only medical center that provide medical service to the town, but also the town surrounded until Minneapolis. So we have a very robust epidemiological data collection or database with basically every single individual in town. We have we have information about their health care, social status, everything. So that give us the give us these opportunities. This is one of the positive aspects of the lonely medical center in the area. So some of the data that I am going to show is not just because I'm showing Mao data and that you feel that is pretentious is because we have so much information about our cardiac rehabilitation because basically everybody to go into the hospital with a cardiac event is from the area and we keep following them forever. So we have a very robust data. So why we were going to talk about that? And I would like to convince you on the end of the conversation that all the principles that we can apply in our c rehabilitation program also can be applied to every single disease and every single primary and secondary prevention. And this is just an example of what we call the ecology of cardiovascular prevention. All the impact in other diseases and all the connection, coronary artery disease, affecting stroke, stroke may produce coronary artery disease. I mean, those are vascular diseases. So they have the same risk factor atrial fibrillation involving those peripheral artery disease, heart failure, diabetes playing an important role in all of them. So what you see is a huge combination on many other diseases that we put it together into the vascular concept. So prevention is key. I always say that when we treat somebody with diabetes or a stroke or a heart attack is a failure of medicine, we should be preventing. So starting with the patient. So the patient has to learn how to live under the umbrella or good cardiovascular health. So what do we need to do? Exercise, good diet, good nutrition. II, I don't call it diet but good nutrition and uh be active and stop smoking or non smoking. So those are the aspect that the patient should do that. We should tell the patient to do so. It's their responsibility if we do that. So we hopefully will have an ideal level of three key factors that play an important role in multiple vascular disease, which is good, fasting blood glucose, LDL, and blood pressure under control. But if some of these are out of control for other factor, genetic, for example. So the role of the physician in controlling that play important role. So together a combination between patient and physician but also community. I mean, I'm going to bring that. As I said, I have a wonderful time yesterday and I had the opportunity to spend almost two hours with the residents. And many of you I think are here and we have a wonderful discussion about community prevention and they gave me some ideas about some new slide that should be presented today. So I brought this which is it has a slide showing the importance of where the so many studies have shown that the life expectancy difference in the same city is around uh 15 to 20 years. So you may live in Baltimore and depend if you live in the west or in the east of Baltimore. I heard that the east of Baltimore is not as good as the other areas. So they the life expectancy can actually vary by 15, 20 years. So, so we need to be sure and to understand also not only genetic factor, personal factor, but also a racial, ethnic socio-economic factor and environmental factor that play an important role. And there is something that the Center for Disease Control called Dead by zip code. I don't know if you have heard about that, but they have to develop what they call the distressed community index. And those are the aspects of this index that you can see their unemployment education level. So take a consideration the community or this factor and they can develop a score that go from zero, no distress to 100 severe distress and community with an index. More than 75 they are considered on a danger. And those are the community that the life expectancy decrease by 15, 20 years. So it is important to incorporate this injury evaluation and the discussion with the patient and how we can help. So and in specifically for cardiovascular disease, there is an an isa paper that was just a problem in this year showing that a patient that coming from this community that have an index factor, more than 75 they are increased risk for adverse event and death after coronary artery bypass. So the mortality is higher. So how cardiovascular rehabilitation principle can help us to control vascular diseases? I mean only cardiovascular disease but other vascular condition. So what is the best? Uh And I will bring this question. I had this question to the students. So now I bring it to, to the rest of you. What is the best, best medicine that we have for every single disease? Exercise? Yes. So, and I, I wanted to bring and I forgot, but what we did in the cardiac rehab is we have a bottle like a medicine bottle and we give it to the patient at the end of the appointment and they say, what is that, what the medication is? That it is empty, read it and it said exercise prescription, but we give it in a, in a bottle. Exactly. Look. Exactly. So, so they start laughing like you know, we did and they, and they got it. So that's uh this is the best medicine. And what happened with when patients are involved in cardiac rehab. And we will see that is that for patients with cardiovascular disease, the most well established model for healthy lifestyle intervention in the current health care, a mother system is cardiovascular rehab. We see this patient in a repetitive way. We tell them the importance of exercise, lifestyle change. So after 36 sessions, this is the session that we have in the rehab program. They got it in 36 times, telling the same thing you got it. So this is as today the most successful intervention. So we should learn from this and extrapolate to other conditions. So what is cardia we have? And it's a multidisciplinary approach. So that is very important it's not only one group of individuals, of medical specialty, it's a more disciplinary in our group. We have many other centers have the same thing. We have physical therapist PM R physicians, cardiologist, endocrinologists, psychologist, experts on sleep. So pulmonologist and also uh psychology expert on tobacco cessation. So it's a really more disciplinary and nurses and exercise physiology play an important role and we are focusing on therapeutic education. So this is very important because people in general believe or think that uh cardiac rehabilitation is only exercise, exercise like 60% of of the program. And uh and I will say that uh some studies show that the effect, the positive effect that we get from cardia rehab is due probably 60% or 70 due to the exercise. But the other is due to the extensive education. So we take opportunity to teach, teach, teach and then risk factor management or risk factor for vascular condition and others optimization, functional status and mental health. And we will see some data talking about how important it is and also regular patient evaluation, monitoring, support patient and be sure that they are in compliance and adherence to the recommendation. So that's what makes it this model. The more disciplinary and attacking the problem in different levels is what it makes it successful. And the next group of slide talking about, so we can spend hours and hours talking about the data, the support is going to be. But some of the positive effects that we see in multiple organs. So, cardio rehabilitation, we see improvement in symptoms of exertion, Disney fatigue cloud. That is pretty clear, the patient improve that autonomic tone, cardiovascular fitness. 10 sorry, 10 to 40% increase in aerobic capacity in patients that participated and increasing the metabolic equivalent 35%. And why this is important when we just mentioned that the exercise is the best medicine. We know that the people that are involved in physical activities, even if it's not going to the gym two or three hours killing themselves. But the leisure time, physical activities increase the mortality, myotic infection, mortality for cardiovascular condition by approximately 35 50%. And this is data from 78. So you know that from a long time ago and uh if we keep going in time, so there is uh this study, the aerobic center study, very comprehensive. They did uh almost uh 13,000 participant, men and women. This was uh um published, I think in 80 in the eighties, 89. And this study showed that regardless of the gender, there is a, a very direct and strong correlation between cardio pulmonary fitness level and uh debt. So as you can see there in uh the individual with low cardio pulmonary fitness level, men or women, when you compare with high the rate of debt, uh it's a significant decrease, very huge impact. Uh What are the effects of physiological effect of the cardiac rehab in general, improve endothelial function. So, patients that participate in cardio rehab, have improvement of endothelial function, antithrombotic effect, peripheral adaptation, skeletal muscle, decrease arterial stiffness and endo depends dilation and say endothelial function. So, those are a very specific functional and physiological effect in the cardiovascular system. Improve our autonomic function and uh lipid and inflammation. So individuals that participate have improvement on all this lipid profile as you can see there and the greater improvements are are observed in patients that they have or abnormal level. But even people with normal level, there is further improvement. We have also changed in c reactive protein. So, c reactive protein protein is a marker of inflammation in the body. And we know now that coronary artery disease is an inflammatory disease as well. So there is a strong correlation of the level of CCR protein and uh uh death or advance or of um coronary artery disease. So, we have been used as a market for prevention, secondary prevention and and help us to define medication or not the intensity of the medication. So we know that people that participate in card, as you can see over there, there is a significant decrease in uh c reactive protein, cardiovascular risk factors. So we are talking, we talk about the specific physiological change and the cardiovascular system and lipid and inflammatory. But what happened in other control of other diseases that play an important role in cardiovascular disease, diabetes, insulin resistant, improve blood pressure, improve in patients that participate in the program, metabolic syndrome, reduction of percent of fat and uh promote weight loss and uh weight maintenance. And this is a data from 377 patient one year participation. This is more or less the average of patient that we have in our program a year. And we see that the weight loss intentional with diet and exercise uh was the uh significant associated with decrease of uh major cardiovascular events in patients that participate in the program. Now, this is important too. So we also not only the classic of the traditional cardiovascular risk uh diseases or factor, we take care of that. And as we mentioned before, diabetes hypertension, but we also are working in, in a new emerging factor that now we know more and and know that they play an important role in in vascular diseases and death and mortality in patients with this condition. One of them is psychosocial stress. So they trigger cardiovascular event. It's a huge risk factor, high prevalence specifically in in white Americans and it's a barrier for medical intervention. So then this is a data from um it was published in 2014 showing the depression is associated with an increased risk of death either or caused but also heart failure, myo infection or stroke and also rehospitalization. So, the patient, the most depressed is the patients with the high risk of mortality. And we know that there is data by us and others showing that the cardia rehabilitation program has a significant effect in psychological stress parameters, including depression, anxiety, anxiety and hostility, regardless of the age. So there are significant improvement in these parameters. So knowing that depression is playing an important role in mortality after um my acardiac event. And uh knowing that the cardia rehabilitation decrease this uh this depression. So that is really another area that we need to focus. And um what I I want to mention uh to, we discussed about that yesterday as well that it's interesting that um this is a side comment that the depression, we assess depression by P HQ nine in all of our patient. And it's interesting that the Hispanic American who first or second generation, they specifically from Mexico, they have a low uh uh good P HQ nine. So they don't have so much anxiety, depression uh compared to why the Americans. So that's, that's uh probably play an important role what we call the Hispanic paradox. So, the Hispanic paradox in cardiovascular diseases mean that patient from Hispanic origin when they have a myocardial infarction, the mortality associated with this is less than a white American that they have the in and uh and the data has been, you know, validated and correlated for, for other uh funders. So the, the, the analysis has shown that probably the reason is because this uh Hispanic population they have less depression. So this is uh will play an important role in this outcome and also the social support family support that they have comparing with the white American. So that is uh interesting data side, comment, sleep apnea screening. So this is important too. And we do this with all our patients. They have a Berlin question, a screening questionary to see the patient may be in a risk of sleep apnea and if they are in a risk. So we do uh overy in this patient. And the sleep apnea has been shown to be an independent risk factor for ischemic heart disease, other vascular disease, a stroke and also increase or cause of mortality. So we can see that a patient with uh sleep apnea, they have an increase the number of dead or caused and then death due to myo cardiac infection, PTC A stroke and even non fatal. Um this, I mean repetition of this condition or rehospitalization for this condition. And it's interesting that this individual with CPA P if you can see the curve though when you introduce the the treatment for sleep apnea, so the data almost gets close to control. So it's really you can reverse that. So that is an important component on on the cardiac rehabilitation program. And this is another, this is a meta analysis showing that all combining the sleep apnea was associated with an increased risk of developing cardiovascular disease. In this meta analysis So, smoking, smoking, they, they, I don't remember who published that, but the impact of uh if I buy a magic one, we eliminate tobacco from the planet. The impact in, in uh health care is huge is they, they think that it will be the same impact putting together the introduction of vaccine and the introduction of antibiotics, the impact on, on uh on life. So wish we can do that. So tobacco is there. So tobacco is uh number one cause of uh many diseases including cardiovascular. And you can see here the burden and the global burden of smoking and physical activity too. If you see there, this is very interesting uh the data is about smoking. But if you see the last in, in red or pink, you can see the the the um amount of death due to tobacco. Is it a little bit lower than the amount of inactivity? So we we again, we were discussing about that yesterday that uh sitting is the new smoking. So if you spend all day sitting, the it doesn't matter after sitting eight hours, seeing your patient, you go to the gym and kill yourself two hours that two hours really will not produce so much significant effect in your health because you were an eight hour sitting during the day and this eight hour sitting have a the uh similar um negative uh um effect in your body like if you were smoking. So, so now we're calling them seeding is the new. So I have to be careful, just keep moving. Iii I see, I saw Pablo office that he has stand up office so that we, we did with uh in our, in our department too, we change over the desk and can be stand up desk. So at least you are not sitting. So the tobacco is an important thing. And uh in we of course, assess uh tobacco status, the patient and do intervention. And uh it has been shown that uh really can be successful in this uh in this program because again, 36 stations talking about tobacco, stop, stop, stop and helping giving this ecological support is really making it more successful. And uh having showed that the strongest predictor of a smoking cessation six months after intervention, PC I was participation in cardia rehabilitation. So that was published in 2015. So again, it's uh giving, giving us um the tool or the fundament to say that what we do in cardia rehabilitation really can be extrapolated to primary or the primary secondary prevention programs for the disease. That's important too. Uh No in influenza vaccination, pneumococcal, pneumococcal vaccination too. So all of our patients, we assess this status and be sure that they are up to all the immunization. There have been a strong correlation of uh uh mortality in patient that have vascular disease and and develop influenza. Now, this is uh we talk about risk factor, physiological uh uh aspect of the category we have. What about mortality, rehospitalization and, and patients that are involved or participating in cardia rehab? Very strong data. And this is where the data I'm going to show is coming more from Mayo Clinic for the reason that I explained before. So this is the data about cardia rehabilitation after PC I. So we analyze those patients following for 10 years and as you can see, 50% so the death rate of 50% lower in patients that participate. So what other intervention do you think that can have this huge impact? What other intervention medicine has this huge impact in mortality? We were talking yesterday that maybe, ok, forget antibiotics. I mean, we're talking about the other and forget the surgeon, eliminating surgeon because they will say one of the surgery surgeon told me, well, if somebody have appendicitis and we intervene, it's 100% safe. Almost 100 it's fine. I mean, forget surgery or other intervention for chronic conditions. So none that I that I know. So this is huge. It is 45% and uh it can be persisted. So it's not only during the first year or few months after you participate in the program. So this persist in 10 years. What about in my infection? So again, we have, we follow almost 3000 patients for 10 years and it show a decrease of rehospitalization for all costs. 25% for cardiovascular disease, 20%. And for non cardiovascular disease, 28 actually, it helped for non cardiovascular disease more than for cardiovascular disease, rehospitalization. So huge impact. What about mortality after myocardial infection? And again, so there is a, as you can see in the curve, there is a significant difference in mortality in patients that participate in cardiac rehab compared with patients that they don't, they didn't. And uh this is not only my infection PC I, but also when we do re vascularization bypass surgery, there is a 46% decrease in uh all cause mortality, all cause not only cardiovascular disease. So this is huge and again, 10 years follow up this patient. So it's important also that uh it's not only to go to cardiac rehab. So there is a dose curve response or like a medication. So if you participate and complete the 36 session in the program, so the impact is much that if you only do one or or 11 session. So nevertheless, one is better than, than known. But the idea is to try not only to refer this patient to the cardia, but to be sure that they complete the program. And I'm going to ask to the group and the the resident that were with me yesterday, please do not answer, you know the answer. But what do you think that is the number one barrier for participation, rehabilitation, knowing everything that we know, I mean, there is no doubt that every patient with cardiovascular condition should be uh eligible for this program. So what is the number one reason? Say it again. He's one of them but he's the number one. No, he's not. The number one is one of them, but it is not the number one. So we say transportation, social support, they are very important. They are like two or third patient willingness is another. But it's another number one who save referring refer is us. We don't tell the patient to go to rehab is the number one factor by cardiology, cardiovascular surgery. This is a, a shame. Uh So, but this is the number one and uh you know how much uh how many patient eligible for rehab participate in United States in the whole United States? 23%. And everybody knows this data, the cardiologist and the cardiac surgeon know this data and only 23% of patients participated. And the reason is because of referral and then come transportation. Social economic people have to go back to work, women have less participation because of family issues. And uh African American also because of some of the socio socioeconomical issues. So and uh and uh Hispanic of Asian, some of them because of language barriers. So yeah, so there's uh many other transportation is uh number one is one of the top two but the number one is referral. So no excuse now, I want to talk about. This is an old data but it's still very relevant. This was like one of the key studies that really changed the mentality in the area of cardiovascular disease, the courage where they show there is a decrease when you, when you do optimal medical therapy to treat cardiovascular condition patients specifically with a stable angina comparing with intervention at PC I, do you see the curve there is no change. So we were doing PC I to every single patient that has an obstruction of coronary artery disease, even if they didn't have. Uh we show that this doesn't hm is a percutaneous, the percutaneous intervention when you put a ste Yeah. Thank you. So when you put a stent to open the coronary artery, um this is what that we were selling our patients. So we have a patient with a little bit of chest pain when they, when they exercise, but it is stable when they exercise a level, not so much EK changes, but it's an angina with non coronary disease. Boom, we put the stent. So showing that uh if we do vary, I mean focus therapy, optimization, the medical therapy, very intense, everything that we talked before. So the outcome are the same and the cost of course, much less. So that was a very key and it has been a key, a key trial that have changed the way that we work with uh cardiovascular disease. So what about this is important people that participate in the cate rehab program. We saw, you saw the outcome, probably many of them is because they continue doing what we taught them to do. And there is a data from our group showing also that there is a significant medication adherence in patients. Even we follow for three years in a static Aspirin ac inhibitor and a beta blocker. It is not perfect. We would like to be 100% but it's not, not so bad. And uh with patient that complete the, the entire program and uh we patiently complete the program after, you know, again, three years, the risk factor control and goals are there accepting uh the BM I and we, we had a nice discussion yesterday about that. Still the BMBM I people don't lose as much weight as we expect. But what we have noticed is that maybe the weight is the same, but we have seen some change in the body composition. So the decrease of percent of fat, maybe they're developing a little bit more muscles. So that's the reason why the weight doesn't change. So, but that is the only one that, that we didn't see um significant change as we expected. But the other, they even some of them, the majority of them, they increase a little bit, they are better after three years compared to one year. So it really make uh people to be compliant and adherence to their recommendation that we're giving financial issues. This is important. And he has, he has shown from a financial point of view that is a highly cost-effective manner because reduced hospitalization, healthcare expenditure and prolonged life and quality of life. And this is some of the data, how much you can save it cost. But also you saw the percent decrease of rehospitalization, 46% and the mortality, no doubt is saved. This is a good question and I think that the resident or somebody comment, I forgot who commented yesterday about no death. Here in the job and rehabilitation program, we have one death in 45 years. It was a triple transplant patient that was participating there unfortunately, but it's very safe. So basically you expect one fatality every 80 years, every 83 years for a program that has an average 250 patients a year. So very safe because some people feel a little bit uncomfortable having a patient with heart failure or posttransplant or after M I uh my card infection getting into the program one week because the referral now everything has been shortened. So they can start phase two program one week, 1 to 2 week after and even surgical to we take patient after they are dismissed from the surgical team one or two weeks. So some modified exercise again. If they have sternotomies extremity, you need to be careful lift, weight restriction or lifting, but they can start the program. Remember the program have a component of education plus assessment of all the risk factors. So you can start with that and introduce the exercise uh later. So, applying to other medical conditions. So we talk about cardiovascular disease. What about the medical condition? And look at this article is from 1976 and was published in the Archive of Physical Medicine Rehabilitation. Already talking about some thinking about the cardiac um approach or the medical approach for cardiac condition applied with a patient with uh amputee. Why we uh what, what is the number one cause of amputation, vascular? So we have been traumatic, but the majority is specifically for lower extremity. So, patient with diabetes, vascular um vasculopathy induced by diabetes. So they have uh they already have an amputation mean that they, they don't have a vascular disease in only one artery. So you have, you have to assume that it's generalized. So that is in 76 already talking about that. But this is one that was published in November of this uh this year. And I think our colleagues uh doctor from JJ FK Johnson Rehabilitation and, and a very nice uh study where they, they introduced, they took uh stroke survivors and they introduced a modified cardio program to them. And they show there is a reduction in all cause mortality and they improve the cardiovascular performance and functional cardiovascular and functional performance. And uh and this is some of the data from this uh publication and I will really recommend it to read it. This is a very, very well done and written and there is an uh progression of a Met on those uh individuals that participate, those are stroke individual that participate in this cardia rehab program. And again, it's uh those response too. So the the most that you, they do the improvement in Met on this patient also, there was an increase survival. I mean, it was not so long, I mean, they did a study for 400 days, but in 400 days, you can see there is a significant difference in survival on the patient that participate in the in this cardiac rehabilitation program, modified cardiac program or using cardiac rehabilitation principle to stroke. Let's put it that way. And also not only in death or cardiovascular thing, but another thing that we are very passionate about that. So quality of life. So the patient, as you can see, they have an improvement in mortality and in daily activities and overall quality of life and a cognitive tool. So positive impact in this uh uh study. So now their their plan is to try to see if we can do a multi center study and we have a conversation with uh yesterday. So we were talking about the possibility maybe to connect with Sara. She tried to explore that and be probably job Hopkin as well as Mayo clinic to be part of this study. I think it is very exciting, very exciting stroke is a vascular disease. So it makes sense, completely sense. What about spinal cord injury or cardiovascular disease? So there is a lot of change. This is an area that has not been studied so much. And we have been very successful in keeping our patient spinal cord injury patient alive for a long time before they didn't survive 50 years. Now, they have almost a normal life expectancy. So they are developing cardia vascular diseases. So, but there is not so much study about that. This is a different population because we still don't know if some of his cardiovascular diseases that they develop is because all the risk factors that we know that they have or is due to the physiological change that the cardiovascular system has specific in a high lesion patient like a quadriplegic. So we know there is a significant change in the physiology and control specific autonomic control of the cardiovascular system. So we don't know, but we know that during the chronic stage, cardiometabolic and cardiovascular disease risk factor become more prevalent in this patient. And some of it is estimated that 30 to 50% of individuals with chronic spinal cord injury, they have already cardiovascular disease and a risk factor. Physical activity. We know how important a role play they have also low high density lipoprotein because this is associated to physical activity. They develop type two diabetes again, because of the physical inactivity hypertension, the visceral adiposity, we know that the fat on the tummy is more dangerous for the heart than the fat in, in your legs or in your body. So that is another thing that we are learning. All the fat tissue are the same. And our patient with spinal cord injury, they develop more visceral abdominal adiposity and they have a lot of elevated inflammatory Prothero genetic, they have high CRP protein as well. So many risk factors. And this is interesting that I know if you are familiar with the spin cord injury rehabilitation care, high performance indicator or high project. So it is a program that was developed to implement and evaluate consensus, the high quality of care indicator for some domains specifically related to rehabilitation in patients with spinal cord injuries. One of the just published is to develop a cardio metabolic health indicator to advance the quality of spinal cord injury rehabilitation. So you have the opportunity to, to read the article I will recommend it, give us a lot of tools that we can use to to to assess this patient during the acute inpatient rehabilitation as as we follow in our own life and then give us opportunity also for for research to try to understand what is the right um intervention that we can do with this population of the patient. So, so they continue, there's a continue cardiovascular care. We talk about personal lifestyle, public health, community intervention, primary prevention aspect. Then sometime our patients have the disease and they end in cardio rehabilitation. This is the current model and then they continue with secondary prevention. But as we saw this uh cardiac rehabilitation paradigms and program and goals and what we are doing on those programs, those principles can apply to primary secondary permission of any other disease and continue of care in our rehabilitation program. Why? Because lifestyle modification are key smoke cessation, diet, exercise, activity, weight control and we do in this program, those are the the lipid management, blood pressure control, exercise, tolerance, psychological well-being, stress management, or maximizing medical treatment, comorbidities and return to work and increase our quality of life or improve the quality of life. So all of these principles as you can see can be applied to any, any of the aspects of the rehabilitation medicine that we do. So with this. I want to thank you again for giving me the opportunity to be here. I really have enjoyed a lot. So thank you and any questions and I hope you understood, understood the accent. So yeah, any questions that you have? Um it's a big room but you can. Yeah. Mhm. Mhm. Yeah. It's a, it's a good question and as you see, we we are not able to completely eliminate the mortality. So still there is some mortality and probably because the patient that fails a patient that they don't have a right and there is no way to control it could be, we don't know, but we haven't studied that. That's true. It's very difficult. So nutrition is very difficult to, to control. You tell the patient you ask the patient when they come to the council, we follow this patient after they are dismissive for by phone call or face to face 369, 12 months. And we, we ask about that. So we, we trust what they said when they say that they are following the diet. But uh yeah, we don't know now with the BM I, we are not following this is the parameters that the outcomes that are officially are people follow for research purposes. But we are focusing more on body fat composition. And I did embrace this data, but we have seen significant body fat not so much in body weight as I mentioned, but body fat composition and decreasing that with people that do the exercise and then continue. So we are getting a little bit of a BM. I, although a healthy weight is the best, but it's more about what we have. We have many individuals and I didn't bring this data. Maybe next time we can share about that. We have published data associated with people. We have a good group of individuals with normal BM I and they have high fat composition. So we call obese with normal weight, normal weight of obesity. And we put them in the category of obesity and the risk factor. The risk to get cardiovascular disease in 10 years are as high than people with high BM I and less the people with high BM I and lower body fat composition. So we are getting more into that area as well. We have it, we have a nutrition. So every single patient get an appointment with a nutrition. We have a lot of education and classes about how to read the label, how to understand them to go and shop and buy the right food and also how to identify the food that is healthy and is not so expensive. Because if you go to a supermarket and you try to eat vegetables and fruit, it is very expensive. So how you can eat healthy, not so expensive and how you can understand because it's not only the fat or sugar or salt. So how you can read the level, the level of the food. We have a nutritional and a nutritionist. And also in our program, they get classes, cooking classes. There is a chef that go once a week and on Wednesday. And they, we have a kitchen in the rehabilitation program. I should have put some pictures about our gym and area, but they, they had classes by a chef and they learn how to cook healthy food tasty because the concept is that everything that is healthy doesn't taste good. So there is a nice food that they are healthy and tasteful. So we, we, we do we do that in that aspect and, and the area where they exercise all is full of posters showing the equivalent, for example, a can of Coca Cola, how much is on, on sugar. So there's a picture of the can of Coca Cola and also a glass with uh how much sugar has this coca-cola is like a half of the glass Coca Cola. The same thing with fry, we talk about that fry. How much fat that we have a um a tube where we show how much fat uh contain a package of fries from mcdonald, for example. So people when they see this vision, they get impacted, there is a book also called Perfect Picture Your Perfect Diet. And we use that book a lot. It's just picture of food and what is the equivalent and a picture of salt or sugar or fat. And it's really even myself, I don't eat pizza anymore. I got so like what I mean, a triangle of pizzas like this of fat and no way. So any other questions? Yes, I'm sorry. Really? But we can still mhm Patience Nations for and in. Thank you. That's true. My regular shit. Yeah. So we, we had this question was I think when some of the resident asked that question too. So what we are doing and not so much in our in, in, in the prevention clinic. The what? Oh And the question is how we can incorporate some of the principles that we talk in our daily activity. When I see a patient in, in, in, in the consul service, no, specifically a cardiac patient. That's the question. So how we can do that? So what we have done in some areas in the preventive clinic is uh we have an exercise physiology and we have a nutritionist on floor. So when we detect an individual that will benefit for, for to have a co about activity exercise and also nutrition. So we they are sitting there for them to visit and to give the education and share material and video and access resources. So it's free. So we absorb the time. So what we are doing is some of the exercise physiology that work in the category we have, we there is a schedule so we board them and bring them to the floor. So let's say you are in charge of Monday, you are coming on Tuesday. So they are on the floor waiting and we use them. So we get out of the room and said, stay in the room. One of my colleagues is going to talk with you about exercise and nutrition and they step in and talk with that. So it's an extra cost. But at the end, we from a financial point of view and we did our analysis and it helped but the patient like it too. So that's some of the things we ask smoking to the patient and if there are, we offer to an appointment with our smoke cessation clinic. So we do that as well on the and we, it doesn't take so much that, I mean, five minutes that you give a glance of uh, of the glucose level. I mean, the blood pressure, we take the blood pressure of our patient when they get there and we ask about that. So it, it had to be an extra two or three minutes that you have to put in your mind to assess the risk factor. But specifically smoking, nutrition and activities, we assess it and we have that tool on the floor. This the cat regeneration. Yeah. Yeah, I will be happy to do that. So we, I am part of the team that is working with using region meth cardiac regeneration, regenerate the heart after myo cardiac infection, using stem cell therapy, we call that. So we started in 20 in 2000. It was the first paper published showing that in animal models, it may help. So since then we and others have done, there is a lot of research work in that area as you know, it is the number one cause of death. So there is a lot of resources invested on that. So it is interesting. So we were talking about how the field has progressed. So initially, you were injecting these stem cell in animals embryonic stem cells in mice that we induce a myocardial infarction by alle in the coronary artery. And then we do open heart and inject around the infer area. The stem cell and those animals respond so nicely improvement in the cardiac function by measuring with the ejection fraction. And also when we did the histology, you could see that the area of infers really regenerate. So it was much better. And there was neovascularization interesting when we were injecting more than 3 million or cells, those animals develop. So it means that there was a dose less than 3 million that we we needed to use. Otherwise, this embryonic stem cells were injected and they just differentiate whatever they want and without any control. So the heart, the environment of the heart could not control those those cells to make them to differentiate into car. So this progress to test it in uh in humans. So taking a stem cell, we cannot use embryonic for issues that you know, including ethical issues. So we were injecting a stem cell coming from uh the bone marrow. So, hematopoietic stem cell or adult stem cell. So what we saw was very interesting that that some patients respond. Well, there was there was some increase increase in the ejection fraction but some of them know. So when you put together the result of the trial, the changes are known or three or 4% of the ejection fraction. Well, guess if the patient participating in cardia rehab, you have an increase of ejection fraction by 10%. So I was telling the, the scientist in the group, we are doing this procedure just still rehabilitation, cardia, rehabilitation much better. So what we did is taking those cell, the cell that he did, the patient that they did in no response with. By the way, those are patients with a chronic um um they have a myotic infection and now they have a um cardiovascular disease, chronic cardiovascular disease uh induced by that. So there was no acute Mycal infection. So we took the those patients that they didn't respond, we took the stem cell and we brought it in vitro and realized that those cells in vitro, they didn't differentiate into Cary and they have a genetic background and, and an expression of a factor background that was different to the cells of the patient that did respond. The patient that did respond. We took this cell and the cell were able to differentiate into cardiomyo. So we have individuals that we apply in the same treatment, different response because some of your cells, the stem cell of this individual didn't work. The the stem cell of this individual work, which is not surprising because we know that we are all different that, that we respond different to medication. So it was not surprising that we respond different to this intervention as well. So what we need as a next next step, it was taking those cells. Now, instead of injecting a stem cell coming from the bone marrow to all patients. We are taking these cells and we are pretreating this cell in vitro with something that we call cardiogenic cocktail. And the cardiogenic tell is a mix of transcription transcription factors that we know by studying angiogenesis that those factors are released by the endoderm. Go to the mesoderm and activate the cardiogen in 3.54 or five days post fertilization. So we took those transcription factors put it in, in a Petri dish with the cells and then we allow the cell to start the process of differentiation to cardiomyo. And when those cells were already expressing some of the early genes of cardiac cell, we took this cell and those were the cell that we injected now in the heart of individual my in and then we saw significant improvement of ejection fraction in all of them. So, so that's uh that's, that was very surprising, very rewarding. So knowing that we need to tell probably the cell OK, you are going to be hard, just don't, don't go there and just die, you're going to be hard. So teaching them and then what we um uh I forgot what I want to say. But um oh yeah, yeah, yeah. But there was something when yeah, this is important. But uh um I forgot what I want to say. Well, but we injected these cells. So they the patient respond, improve the ejection fraction and also improve the six minute walking on this patient. So it was very safe. So, oh, I remember what I want to say that the other thing that we realized that was the first study safety was very safe. 300 then we did another one. Now, more uh randomized uh double blind blind. And we realized that the patient that respond to this treatment were patients that have uh moderate heart failure. So patients that have uh little heart failure. So ejection fractures is not normal but not so bad. They didn't respond to this therapy. There was no more improvement. Patients that have severe heart failure with the ejection fraction are less than 20. The patient didn't respond either. It was the 30 40% the ejection fraction, 30 40% that they respond well, moderate heart failure, which also have been seen in colleges that have injecting PR P or injecting B mac uh on joints, diseases like knee joint arthritis. So they also see that it's too advanced. If the arthritis too advanced, they don't see any response to plats. So, so similar that and um you say that oh yeah. So the other thing that we we saw is that uh these cardiogenic cells. So we call this. So there there were two new concepts that we developed, which is the uh cardiogenic cocktail. And then the other thing is was the cardio cell. So instead of hematopoietic cell, so we are injecting cells that are not full cardiac cells, there are no stem cell. So they are cardiogenic uh cells or cardio stem cell. So we, we then said this is just a uh artificial cell that we are creating in vitro that really exists in the nature. So what we did is that analyzing in animals and we found that they, they have some level of these cells circulating in the blood, but also human. That was very interesting. And uh what we did in our rehabilitation program is analyzing um we were able to, the clinic were calling us. There is a patient with M I. So we were immediately and take blood and analyze the number of these circulating cells. And then when the patient participate in the CIA rehab, we follow these 36 months, one year. And what we see there is an incremental circulation stem cell and this increment is associated with improvement in the ejection fraction. So there was a few number of individuals but we see significant association. So we are planning to do more study about that. But it was very interesting. What did that mean? It was just a correlation study. We don't know if it is a reaction to the body to heal or was induced by the exercise. So we don't know we need to understand more. But it was very interesting data. We have cardio poetic cells circulating. We were talking yesterday about and the group when I studied medicine, we were told that the heart does not regenerate, the liver does not regenerate the brain. And now we know that they have the potential and all of these organs have a stem cell stem cell. Now, we need to understand how we can potentiate those cells. So really giving the tool to individuals to heal by themselves. Inner healing. Ok. Thank you. Thank you everybody on 1937 posters and food outside the Thank you, you. Created by
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