Our patient is a 46-year-old Vietnamese woman with an extensive history of cardiovascular disease (CVD) dating back to April 2016. Her past medical history is significant for poorly controlled diabetes, hypertension, and coronary artery disease with multiple coronary interventions. In April 2016, she received percutaneous coronary intervention (PCI) to her right coronary artery (RCA), and the decision was made to treat the diffuse left anterior descending artery (LAD) disease medically. She was initiated in cardiac rehabilitation (CR) and was adherent to this. A few months later, she developed chest pain again and underwent stenting of her distal LAD and proximal circumflex artery. Several months later, she developed recurrent symptoms and received PCI to her proximal RCA. The patient then underwent stenting of her proximal RCA due to recurrent symptoms. Several months later, she received stenting to the distal circumflex and first obtuse marginal due to recurrent chest pain. During her eighth cardiac catheterization within just over 1 year, a new significant obstructive lesion was noted in the distal LAD. Given significantly elevated systemic blood pressure and rapid recurrence of disease despite angiography, the patient underwent medical optimization of her regiment.
On echocardiography, she had no significant valvular disease, no regional wall motion abnormalities, mild increased concentric left ventricular wall thickness, and a normal ejection fraction of 63%.
She was enrolled in CR after her first coronary angiogram and PCI in April 2016. Despite this, her blood pressure remained elevated in the 150-180 mmHg systolic, with poorly controlled blood glucose and a hemoglobin A1c of 8.3%.
Despite an individualized treatment plan and aggressive CR, the patient continued to struggle with significantly uncontrolled diabetes and significantly elevated blood pressures. Additionally, her aggressive early-onset atherosclerosis was extremely concerning. Initially, there were some issues with medication intolerance secondary to severe nausea; however, with the help of CR, she was able to be initiated on an optimal medical regimen. This included aspirin, atorvastatin, clopidogrel, isosorbide mononitrate, losartan, metformin, metoprolol, insulin, and ranolazine. She was seen by medical genetics, who considered the possibility of other connective tissue disorders that may present with aggressive early-onset atherosclerosis; however, genetic testing was negative.
The correct answer is: D. Patients after acute coronary syndrome (ACS) should be referred to CR.
ACS is a Class 1A indication for CR and is included in the American Heart Association and American College of Cardiology guidelines1 as a validated secondary prevention method for CVD. There have been multiple studies that have shown improved outcomes when patients undergo CR. Answer A is incorrect because there are limited data in patients post-transcatheter aortic valve replacement. Conceivably, this may be a population that would benefit from CR, but this has yet to be proven. Answer B is incorrect because although CR is underused in general, it is more underused among women than men. Answer C is incorrect because although the nature of the CR facility is important, patient factors play a key role in the success of CR. Patient involvement and motivation are key factors contributing to the success of CR. Answer E is incorrect because heart failure with preserved ejection fraction is not a Class I indication for CR. Again, patients with heart failure with preserved ejection fraction may experience benefit from CR, but this has yet to be studied in large clinical trials and is currently not an approved indication for CR.
Thus, our case is that of a young Vietnamese female with aggressive, early-onset CVD who was enrolled in CR but, despite this, continued to have uncontrolled hypertension, uncontrolled diabetes, and recurrent coronary lesions requiring PCI. Our patient met criteria for enrollment in CR and was appropriately enrolled after her first cardiovascular event. Despite data suggesting lack of adherence and underutilization in minority females, our patient was adherent with CR yet derived little benefit from it. Her diabetes and hypertension remained poorly controlled despite efforts to implement healthy lifestyle into her routine.
This case illustrates the limitations of CR and the importance of patient engagement and motivation in successfully reaching improvement endpoints. Aggressive risk factor modification is possible in many patients with CR, but there is a subset of patients that may derive little benefit. Cultural barriers when treating patients of different ethnicities must also be considered. For example, the Vietnamese diet is different from that recommended by CR, and there remains room for CR to tailor differing cultural needs. Additionally, in some patients, longer duration or more frequent implementation of CR may be necessary due to varying patient factors including differences in patient engagement and patient health literacy.
References
- Smith SJ Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124:2458-73.