Small Vessel Heart Disease

Have you seen this great picture?  Former NCCRA President Mike Dunlap uses to educate his patients about small vessel disease.  Here is what he shares with them:

Small vessel disease is a condition in which the walls of the small arteries in the heart are damaged. The condition causes signs and symptoms of heart disease, such as chest pain (angina).

Small vessel disease is sometimes called coronary microvascular disease or small vessel heart disease. It’s often diagnosed after a doctor finds little or no narrowing in the main arteries of your heart, despite your having symptoms that suggest heart disease.

Small vessel disease is more common in women and in people who have diabetes or high blood pressure. The condition is treatable but can be difficult to detect.  The large vessels in your heart can become narrowed or blocked through a condition in which fatty deposits build up in the arteries (atherosclerosis).

In small vessel disease, damage to the small vessels affects their ability to expand (endothelial dysfunction). As a result, your heart doesn’t get enough oxygen-rich blood.  “Mayo Clinic Website”

This photo of the thousands of blood vessels in the heart really drives home the point that the potential for CAD doesn’t lie just in the major coronary arteries.  We have this photo as our background on our classroom TV/computer screen.  Whenever we have an education class, our patients see this photo.  I hope it motivates them to take more responsibility in preventing the progression of their CAD.  I’m quick to tell patients that if they already have disease in the major arteries of the heart, what are the chances you don’t also have small vessel disease.  And we remind them that regular cardiorespiratory exercise is one of the best ways to treat this.

Thanks Mike!  What educational tools or teaching points do you use with your patients.  Please share with us!

NCCRA Survey

We would like your feedback as we make future plans for our annual meeting. Please complete this survey and forward the link to others that work within CVP rehab in our state. We appreciate your participation!

Congratulations to one of the NCCRA Greats! Sue Seymour

We recently received the following message to one of the NCCRA Greats!

After over 52 years in nursing and 42 years in Cardiac Rehab, I am hanging up my cap or in this case my work running shoes.  I will officially retire on 11/12/20.  It has been quite a ride!  Thank you to all my NCCRA friends and the support you have given me through these many years.  It has been a pleasure to have been a part of the development of NCCRA.  Our networking helped us all to survive the early years of DHS certification and Rule writing.  There was such a sharing of information and support and it continues today.  I have to admit I miss visiting programs across the State on the review team and seeing the wonderful work that is being done.  My Life Time Achievement Award is a cherished possession.  Thank you for the honor and thanks for the memories.  May God bless you and hope to see you at the State convention in the future.

Love to all,
Sue Seymour

Congratulations Sue on your retirement!  Thank you for all your contributions to our field and our organization!  We wish you the best!🎉

Million Hearts Cardiac Rehab

Have you been signing in for the regular webinar through Million Hearts?  It’s a great resource to hear about what your colleagues are doing to increase enrollment and better meet our patients needs.

Most recently they provided some great resources including recordings of past webinars.  Check it out!

Slides – Million Hearts Cardiac Rehabilitation 101 webinar_10202020Slides – Million Hearts Cardiac Rehabilitation 101 webinar_10202020

Working Draft – New Cardiac Rehabilitation Models in the US_10202020

Million Hearts Cardiac Rehabilitation Webinar Series – Recordings and Resources



Review of “Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries”

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries

Peter K. Lindenauer, MD, MSc1,2,3Mihaela S. Stefan, MD, PhD1,2Penelope S. Pekow, PhD1,4; et alKathleen M. Mazor, EdD5Aruna Priya, MA, MSc1,4Kerry A. Spitzer, PhD, MPA1Tara C. Lagu, MD, MPH1,2Quinn R. Pack, MD, MSc1,2,6Victor M. Pinto-Plata, MD2,7Richard ZuWallack, MD8

Author Affiliations

JAMA. 2020;323(18):1813-1823. doi:10.1001/jama.2020.4437



Key Points

Question  Is initiation of pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease (COPD) associated with better survival?

Findings  In this retrospective observational study that included 197 376 Medicare beneficiaries discharged after hospitalization for COPD, initiation of pulmonary rehabilitation within 3 months of discharge, compared with later or no initiation of pulmonary rehabilitation, was significantly associated with lower risk of mortality at 1 year (hazard ratio, 0.63).

Meaning  These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.


Importance  Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge.

Objective  To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival.

Design, Setting, and Patients  This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015.

Exposures  Initiation of pulmonary rehabilitation within 90 days of hospital discharge.

Main Outcomes and Measures  The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality.

Results  Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], –6.7% [95% CI, –7.9% to –5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, –4.6% [95% CI, –5.9% to –3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, –11.1% [95% CI, –13.2% to –8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01).

Conclusions and Relevance  Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Editor’s Note: Pulmonary Rehabilitation has tended to publish results related to improved functional capacity, improved quality of life and reduced hospitalizations. This article points out a significant mortality benefit. All of these outcomes are extremely important and the mortality benefit is very important to the physician community.

The referral rate for PR continues to be around 10% of eligible patients, most of whom have severe or highly severe lung function. We need to examine ways to recruit patients at a stage of the disease where there is a greater rehab potential. We also need to encourage physicians to include simple spirometry as a part of the physical exam especially in older patients and patients who have a significant history of smoking.

Review of the article “Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults”

by Mary Ann Compton

An article in The Journal of Cardiovascular and Pulmonary Rehabilitation caught my eye recently both because of the subject matter and because I recognized several of the investigators and their ties to UNC.  The lead investigator, Montika Bush, PhD, surveyed program directors in our state last year and will soon be submitting information from that survey for publication.

The article reviewed here is the “Effect of Initiating Cardiac Rehabilitation after Myocardial Infarction on Subsequent Hospitalization in Older Adults.”

As we all know, there is a gradual shift in our country from fee-for-service care towards value-based care.  If value-based care comes to fruition, providers and hospitals will be financially compensated for keeping patients well and out of the hospital. In addition, hospitals and providers would pay a penalty for exceeding “standard” costs to care for a patient.  We all know that Cardiac Rehabilitation helps to not only decrease mortality, but also helps to keep our patients well.  But knowing something is not always enough.  If scientific studies show that participation in Cardiac Rehab will improve the health of our patients while also saving the hospital money (i.e. keeping patients out of the hospital), then the value of Cardiac Rehab increases and the support we will get in our larger organizations should be immense.

This study looked back at 32,851 Medicare beneficiaries in 2008 and compared those patients who initiated CR within 60 days post-discharge with those patients who did not.  The study was limited to those patients age 65-88 years of age who were hospitalized with an AMI, had a revascularization, and had not previously experienced an MI.  It is one of the few studies to look at readmissions after cardiac rehabilitation in an older population.

While the article is dense with statistical analysis, the conclusions are fairly succinct.  The authors were primarily looking to see if there was a difference between the two groups (CR initiators vs CR noninitiators) in admission for AMI in the year following discharge.  There was not a substantial difference for AMI admission between the two groups, but there was a difference for all-cause hospital admissions.  The CR initiators had a lower risk of hospital admission for a major cardiac event (MACE) and for all-causes compared to the CR noninitiators.  Of note, the older beneficiaries (>75 years) had a greater reduction in all-cause hospitalization risk than MACE risk.

The authors made several references in the paper regarding the need for more information on the effects of cardiac rehab, or exercise therapy, on nonmortality outcomes.   This study noted, that “the risk of each study outcome for CR initiators with 1 to 2 medications at day 60 is similar to the risk of that same outcome in CR noninitiators with 3 to 4 medications at day 60” and that since older patients are not always able to tolerate medication therapy, the exercise therapy could be even more important.  This finding, if repeated in other studies, could greatly enhance the value of cardiac rehabilitation.

Similar to other studies, the mortality rate was lower for initiators than noninitiators, and the participation rate for cardiac rehab was 21%.  This low percentage of participation has got to improve, and should be a focus of our programs.  I suspect, also, it will be a focus as we learn from changes we have all had to implement in our programs due to the COVID pandemic.

Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults

Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; More

Bush, Montika; Kucharska-Newton, Anna; Simpson, Ross J. Jr; Fang, Gang; Stürmer, Til; Brookhart, M. Alan Less

Journal of Cardiopulmonary Rehabilitation and Prevention. 40(2):87-93, March 2020.

Legislative Updates: We need your help!

Cardiac and pulmonary rehab professionals – it is time to act!

In March, representatives from NCCRA joined AACVPR in their efforts in Washington, DC to gain support for the Sustaining Outpatient Services Act.  This Act has the potential to directly affect the ability of cardiopulmonary rehab departments from growing and in some cases, remaining open.

This bill will exempt certain hospital outpatient services from a drastic reimbursement reduction that are based solely on the location of the hospital outpatient service which is explained in depth in the Legislative Priority (

Now we need your help to get this included into legislation that will be considered by the legislation in July. 

Please support and assist in getting this legislation moved forward by taking part in the follow-up letter writing campaign. Template follow-up email letters requesting sponsorship (signature) of these bills will be posted on the DOTH advocacy web page. The virtual lobbying tool used this spring has been put on hold during this interim, so template letters and how to contact your US Congressional members are on the Advocacy web page and can also be found below.

How to find your U.S. House Representative: For the contact information of your House Representative, click here.

How to find your U.S. Senators: For the contact information of your two Senators, click here.

Letter to co-sponsor the Senate bill:

Letter to co-sponsor the House bill:

The world of Cardiopulmonary Rehab in the days of COVID19

The NCCRA Board will be hosting a few online conversations that will allow our membership to hear about the current status of a few programs across the state and then engage in a round table discussion. We hope this will be helpful to our membership as they navigate this new landscape of the COVID19 pandemic.  The dates that are currently planned include:

Wed, May 27 at 1pm and Friday, May 29 at 2pm.

If you are interested in attending please rsvp to and let us know what date you are interested in participating in.

We look forward to a great discussion!

COVID19 resources

These are  great resources that can help support our programs and patients during this time:

Cardiosmart videos

Heart failure:



Coping with your emotions

Cardiac come back

Dealing you’re your emotions after a heart attack:

Depression and CAD

Cardiac curriculum

Patient Education Resources


Send us others that you feel need to be added to this list!


NCCRA Board Updates

We hope you are all remaining healthy and well.  It seems that many programs are either closed or working at decreased capacity right now.  Since our state symposium was cancelled, we wanted to share the changes in our NCCRA Board as of today.  Usually when you agree to a position as a Regional Vice President our bylaws require you to serve in that capacity for three years.  During that time you host yearly fall meetings for your region. We are so very happy to announce Jeff Soukup will be taking on this roll for the coastal region!  Congratulations Jeff and welcome to our NCCRA Board.  Susanne Bice and Beth Ann Scott will remain as the Piedmont and Mountain Vice Presidents.

We also want to congratulate Kelly Forrest as she moves from the Coastal VP position into the Incoming President role, Jennifer Simmons is now in the role of President and Candace Langston is the Immediate Past President.

We look forward to a productive year for the NCCRA and we hope that our membership stays safe, healthy and well.