Chapters Transcript Video Update on Pritikin Intensive Cardiac Rehab Program Dr. Sattler reviews the evolution of cardiac rehab and an introduction to intensive cardiac rehab. Uh So to start, I just kind of wanna address maybe the elephant in the room, some people might think it's a little bit out of character for an interventional cardiologist to be giving a talk on cardiac rehab. Um But I really like to think that um some of my interventional colleagues would agree with me that an important part of our job is having the wherewithal to know when to intervene and when not to intervene and when to ask for help. And that can um continue for both the procedural and non procedural level. And I think uh we also can agree that we really want our patients to thrive as much as possible after interventions. And that involves a lot of secondary prevention. So I've always personally had a little bit of an interest in preventive cardiology. And when Dr Goldberg retired, and um I took up the role of director of cardiac rehab for centric care plex, it gave me a really unique opportunity to be able to delve into that a little bit more. Um So I've learned a lot about the nuances benefits and even some barriers about cardiac rehab over the past few months and I want to share that with you today. So um you can see that I titled this talk Cardiac Rehab, Beyond the stent. But really, it's supposed to be Beyond the Surgery, the valve replacement, heart failure, hospitalization and so on. Um There's so much that our patients go through um after they come out of one of these procedures or deal with one of these different cardiac events and while we have some awareness of it, it's very hard for us to be able to manage that just within a 30 minute visit. Um So it's, it's hard for us to manage that just in a 30 minute visit. And um we know that a lot of depression comes out of a diagnosis of M I. Um there's also a lot of anxiety that patients have just with being able to get back into the swing of things. And they ask us a lot of these questions, what should I do now to change my life? Um How can I better my diet? How can I get back into exercising and while we try and manage those questions as best we can in the time that we have allotted, it definitely takes more than that to extend life long. And I think that's where cardiac rehab comes into play. So I don't have any um financial disclosures or conflicts of interest. This is going to be our outline for the talk. Um So I want to talk a little bit about the evolution of cardiac rehab through the years. Uh We'll give a brief introduction to what traditional cardiac rehab is. And then for the majority of the time we're gonna talk about intensive cardiac rehab um mostly as a comparison to traditional cardiac rehab. Um Some of the C MS approval criteria for intensive cardiac rehab, the three main types. And we're really gonna focus on critic in cardiac rehab because that's something that's new to Centra. Now, um we'll talk about the clinical evidence and then some of the qualifying events to get into intensive cardiac rehab. I wanna let you know a little bit about what the patient experience is like after you refer them. Um then we'll talk a little bit about invent uh intensive cardiac rehab at Centra and then barriers and physician involvement. So, um pretty much the advent of cardiac rehab was in the 19 fifties. And that's when we really developed the concept of the importance of early mobilization after M I. And this was really a novel idea for us because prior to the advent of P CIA, lot of our treatment for acute M I was bedrest and medical therapy. Um We started to see obviously that outcomes despite that treatment were still uh pretty poor. And we lended that a lot to deconditioning and some stability after acute M I. Um But at that point, um since we didn't really have PC I at the forefront. Um We struggled with the timing and how that early mobilization came into play. So in the 19 seventies, once PC I became more prevalent, then that's really when we were able to um get a sense of this structured program of cardiac rehab that we know of as a um physician sponsored EKG monitored exercise program. And then in the early 19 eighties, um cardiac rehab extended to include things beyond post M I and Post A CS. Um it started to cover um different cardiac surgeries and um also heart failure. In the early 2000s, Cardiac Rehab started to become a more comprehensive model beyond exercise to include focus on diet and also lifestyle changes. And then it wasn't really until 2010, that intensive cardiac rehab started. So the World Health Organization, um this is the definition for cardiac rehab. So it's the sum of activity and interventions required to ensure not only the best possible physical conditions, but also the mental and social conditions that patients need um for any kind of chronic or post acute cardiovascular disease to both preserve and resume their proper place in society and lead an active life. And this is something through their own efforts. So it's really this comprehensive model that is founded on three key components, which is not just nutrition and exercise, but also lifestyle. So this obviously includes a multidisciplinary team approach. We know that obviously a physician, usually a cardiologist is going to head a cardiac rehab program. Nurses are involved to support patients in reducing a lot of different risk factors that are monitored along the way, including blood pressure, cholesterol and diabetes. Physiotherapists help to uh develop an exercise plan for patients, dieticians create a healthy eating plan. And then sometimes social workers and psychologists are also involved to help alleviate any stress, identify other psychological conditions that might be affecting these patients, um particularly for those that suffer with tobacco use and even just support getting back into the workplace, the setting looks different from center to center. Most are going to be in a hospital setting like our cardiac rehab programs here at Centra, but some are going to have more of a community based center and then some even allow for some remote home based options. Of course, this is not something that um we emphasize to start with. We would really like patients to be more interactive and involved in the group setting um with our staff there to support them. Um So a lot of cardiac rehab programs actually offer this as an option after phase two of cardiac rehab is complete, which we'll see. So these are the phases. Um phase one is actually an inpatient program. So this is a little bit of an introduction to cardiac rehab, right from the gecko in the hospital. And this simple start to cardiac rehab before leaving the hospital can really improve a patient's outlook on their recovery um as well as facilitate a smoother return to their regular activities of daily living. Um And like we talked about, many patients have anxiety about this. Um and it starts in their hospital stay, especially if it's a prolonged hospital stay. Um So, phase one provides them an opportunity to start testing their physical abilities just with simple motion exercises that can be in bed or just getting up and starting to walk again. Phase two is what we really think about for cardiac rehab. This is the traditional outpatient sessions. Um It starts with an intake assessment. Um So this intake assessment is going to allow for identification of different risk factors upfront like cholesterol measurements, blood pressure, body composition. If they're suffering with depression, anxiety or tobacco use, they also do a functional capacity test to get an idea of where their function is at at the start of cardiac rehab. And this really helps identify what their goal should be going forward for exercise. And then phase three is long term maintenance. Um We know that the benefits of cardiac rehab are really optimized if there's long term adherence to this. Unfortunately, this phase three is really something that sometimes patients have to pay out of pocket if they want to continue with. Um But now that some of the more um intensive cardiac rehab programs allow for a home based virtual approach. Um It's becoming a little bit more financially sustainable for patients. The timing of each phase, um can start as early as the day after the qualifying event for the inpatient program because this is just an introduction phase two really depends on what the qualifying event is. Um So post PC I, you can start as early as a week. There's not as much recovery time after a cardiac surgery. It can take 4 to 6 weeks because we're waiting for the chest wall to heal. And then if there's a lengthy hospital hospitalization, it can be 6 to 8 weeks after hospital discharge. Um So this is the part that really depends on physician approval and referral to start and then phase three happens immediately after phase two. So regular cardiac rehab sounds pretty good. Um What happens with intensive cardiac rehab? And why is it so much better? So you can see that um both are pretty similar and that there's physician supervision. Um There's an individualized treatment plan, monitored exercise. They both occur in the outpatient settings, but it's really the way in which they structure their exercise and education. That is um the big difference between the two. So in traditional cardiac rehab here, you can see that C MS only allows for 36 reimbursed sessions with a 36 week time limit. So max, they might have two sessions per day and that means that there's gonna be limited lifestyle education in order to get reimbursement for this, you either have to put their education on top of their exercise, meaning that they're gonna have some kind of virtual talk or powerpoint slide or something going on while they're exercising, which may not reinforce their ability to retain that. Or you have to forego an exercise session for an education session in intensive cardiac rehab, you get 72 sessions and this is particularly for the predictive intensive cardiac rehab. There is up to an 18 week time limit to complete that. So you can get up to six sessions per day, which is intensive. Um But this allows for more comprehensive lifestyle education because you can still do those 36 exercise sessions. But now you get an additional amount of sessions just dedicated to education. And uh because of this, um we think that it achieves better patient engagement and um they do better overall and it's still financially sustainable both for patients and for a hospital system. So this is just another way of showing that um 36 sessions for traditional cardiac rehab in order to get reimbursement, we kind of have to try and balance the two and sacrifice one versus the other in terms of exercise or education. But um with an intensive cardiac rehab program like Pritikin, which we're gonna talk a little bit more about soon. Um You have 72 sessions that you can use um at well that are all reimbursed and that exercise component can include videos in person workshops, um hands-on demos, like cooking classes, one on one consults and um different resources for patients to take home. In order for um any intensive cardiac rehab program to get C MS approval, there has to be certain stringent criteria that are met. Um So one or more of the following has to be shown and that is lowered risk factors for coronary artery disease. So either you're improving their blood pressure, their cholesterol, their B M I, um maybe better tobacco cessation, slow disease progression or reduced need for coronary artery bypass surgery. In addition to that, um there has to be a statistically significant reduction in five or more of the six different factors. L D L triglycerides, B M I, systolic blood pressure, diastolic blood pressure or need for any of their medications for cholesterol, blood pressure or diabetes. Um So with this being a very stringent type of requirement, um it's not surprising that C MS has only approved three intensive cardiac rehab programs. Thus far Benson Henry, Ornish and Preti, however, the only two commercially available cardiac rehab programs are Ornish and Preti Benson Henry is um a more single centered based intensive cardiac rehab program that was started between Benson Henry Institute for Mind and Body Medicine and M G H Cardiovascular Disease Prevention Center. Um So this is still available for their patients, but not available nationwide. And so we'll see that all of these different intensive cardiac rehab programs focus in some degree on education, nutrition and healthy mindset, but they do so in slightly different ways. Um So right at the top, you can see that the first difference between all three of them is how they look at diet. Uh Pritikin um tries to boast this good diet, um that allows for a reduction in cardiovascular risk factors. Um But by being a little bit more manageable long term, it's low fat, it's low cholesterol, it's more of a Mediterranean style diet. So while it's more plant based, it does allow for fish and some lean meats, garnish is a lot more of a strict diet. It's ultra low fat. So less than 10% of your daily caloric intake can include fat. Um It is primarily plant based and while calories are unrestricted, if you're not trying to lose weight, you still have to be within those confines. And so some people say that maybe that's hard to continue long term. And then Benson Henry is just a personalized heart healthy diet depending on each particular patient. They all have regular exercise. They all have different interactive educational sessions that look at things like heart disease prevention and management. Um Cardiac medication symptom recognition, nutrition and principles for safe exercise. And then they also all focus on some component of lifestyle modification, including stress management techniques and specific targeted risk factor reduction. Um The reason why Ben and Henry is a little bit different is you can have optional consultations with a psychiatrist or behavioral health specialist. And they also do guided meditation and weekly relaxation sessions every Friday, which does sound pretty nice. So the evidence for intensive cardiac rehab is pretty abundant. There are over 100 peer reviewed studies that have consistently shown the value of an intensive cardiac rehab program. Um One of the things that has particularly been shown is how chronic inflammation is reduced. And we know that this is one of the factors that contributes to M I in particular. So within three weeks of a perkin lifestyle, high intensity C R P decreased by 45% in women. About 40% in men and 41% among Children. And after just two weeks of predict living different inflammatory cytokines were reduced including tumor Nero factor alpha and interleukin six. Um So here, um we're gonna delve more into the results of the Pritikin program in particular. Um So out of 1100 hypertensive patients, cysto and diastolic blood pressure fell on average by 9% within three weeks of starting the program. And many patients were actually able to completely eliminate their antihypertensive medications. 93 patients um in the studies had lowered their cholesterol by 20% using statins before entering the program. And then after two weeks of the program, they were able to lower their cholesterol by an additional 20%. Out of 4500 adults L D L decreased on average by 23% in three weeks and triglycerides decreased a little bit more than that by 33%. We already talked about how chronic inflammation um decreased by about 40% after 2 to 3 weeks into the program. And then lastly, for overweight adults, they lost about 7 to £11 within 2 to 3 weeks of starting the program. The benefits of the first perkin outpatient intensive cardiac rehab were published in this journal of cardio pulmonary rehab and prevention. And their purpose was really to show the benefits of a Preti intensive cardiac rehab comp compare compared to traditional cardiac rehab. Um So this was a retrospective analysis of almost 2000 patients that were referred for Preti or traditional cardiac rehab from 2013 to 2019. Um Their assessments included different anthropometry like weight B M I dietary patterns based off sur surveys, like rate your plates, um functional capacity assessments with six minute walk tests and particularly hand grip strength and then health related quality of life surveys. The results across the board um showed that intensive cardiac rehab excelled. Um So not only did it result in improvement in all of these different factors but particularly when looking at body weight and B M I, it decreased significantly in intensive cardiac rehab, but not in cardiac rehab. And the same was true for grip strength and grip strength is really a better reflection of whole body strength and health status and and most predictive of mortality for all of the different functional assessments that they looked at and this was only significantly increased for intensive cardiac rehab, but not traditional. So looking here, um these are changes in body weight for intensive cardiac rehab compared to traditional. Um So while you can see that more weight was lost in all three groups, um it was particularly true for intensive cardiac rehab. And this was statistically significant, especially for those patients that were in the obese category for um rate your plate. Um It's a comparison of rate your plate at baseline to follow up. Um And absolute scores increased for intensive cardiac rehab more significantly than compared to traditional cardiac rehab. Um So the white up on top is where um patients said that they made many healthy choices. Gray is where they said they had some healthy choices and uh black is where they said they could definitely improve their diet a lot more. So you can see that after intensive cardiac rehab, up to 73% of patients felt that they had more healthy choices in their diet. Um So the key um study points, uh obviously, the strength that was a large study over a long period of time, but it was retrospective and some of the patients did not finish all 72 sessions um across the board intensive cardiac rehab with a pre again, lifestyle showed improvement in not just anthropometry but also dietary patterns. Um particularly grip strength was improved from her get intensive cardiac rehab. And then um finally, it showed that there was a session dosed response. So looking at that a little bit more, the more sessions of cardiac rehab that a patient attends, obviously, the greater their ability to take control over their disease process and reduce their risk of not only mortality but also M I according to this study in circulation. So it's not just strongly recommended that patients start cardiac rehab, but that they also complete all 72 sessions. So you can see here um at the top, the dotted line is patients that only did up to 11 sessions and each line down are more and more sessions up to those patients that completed more than 36 sessions. And that allowed for a statistically significant reduction in cumulative incidence of mortality and M I. Um so a lot of time and effort goes into intensive cardiac rehab. It's also very um time, it can be very time demanding for patients. Um So how many patients actually complete the program? What does program performance look like? It's not perfect, but it is actually better than traditional cardiac rehab as well. So I'm looking at different metrics from recent operations for predict cardiac rehab. The average Preti intensive cardiac rehab, Medicare patient completed about 48 sessions compared to just 24 traditional cardiac rehab sessions. Um So that accounted for a completion rate of almost 50% for predict cardiac rehab as compared to only 27% for traditional cardiac rehab. So I think this also um supports the idea that intensive cardiac rehab generates more patient engagement and therefore maybe appreciation for what they're getting out of the program. And so therefore, they want to continue with the program more long term. From 2010, the pre and cardiac rehab program has grown a lot. Um It's now licensed coast to coast and it's nearing about 34,000 new patient starts recently. They exceeded over a million sessions across all their licensed facilities. And this includes two of our own new sites at centric care hospital and center Martha Jefferson in Charlottesville. Um So cardiac rehab is very good intensive cardia rehab is even better. How do we get our patients into this who qualifies? Um So from the beginning, any patient within the preceding 12 months who had an acute M I was a, a qualifier for cardiac rehab. Um and these are actually the same for traditional and intensive cardiac rehab. So, nothing has changed um in this regard. Um Any patient that has had a Coronary bypass surgery, there's no time limit for these. Um any patient with stable angina despite being on medical therapy, any patient who's undergone a heart valve replacement or repair again, no time limit. Um Any patient who's undergone PC I in general, any heart or um heart level transplantt patient and then um those patients with chronic heart failure as Well, um the only one thing is that right now, C MS defines chronic heart failure as only those patients with reduced ejection fraction. That's less than or equal to 35% who are N Y G A class 2 to 4 despite being on optical medical therapy for up to six weeks. The other thing that's different for cardiac rehab as compared to other rehab programs like vascular or pulmonary rehab is that it's not a once in a lifetime referral. So patients can be reef referred as long as it's clinically justified once you get your patients into cardiac rehab, um this is kind of what a program might look like. Um So here at Terra Care Plex, what we're doing is we're doing it over 12 weeks. Um We want to get patients in on Mondays, Wednesdays and Fridays. Each session is going to include some type of exercise session and some type of educational component. Um So we start the week off a little bit light with maybe education with videos, um midweek with workshops and then at the end of the week with more hands on cooking schools, each patient receives a guidebook um to help them along the way. So this goes through pretty against three pillars of exercise, nutrition and lifestyle. Um gives them some information on the different types of cooking recipes that they're going to be exploring and some of the exercise that they're going to be engaging in. Um it gives them more information about one on one consult resources and places to keep notes for themselves. The video library for pre and cardiac rehab is also rather extensive. Um So these are some of the many topics that are covered. And again, they are divided into the three main pillars of exercise, nutrition and healthy mindset. So some of these topics um are also covered in workshop. It's really, it really just depends on how each patient wants to do it. Um And some of these topics might not apply to each particular patient. Um for example, some patients might not need to do any classes or videos on sleep disorders or tobacco cessation. So it really just allows for more of a patient centered approach. So some of the topics you can see here, they talk a lot about a nutrition action plan label, reading, um body composition, getting into some of the biomechanics of movements. Um and then for healthy mindset, uh they look at healthy minds, bodies, hearts, um diseases of our time focusing on diabetes. So um there's a lot of a lot of different content for our patients to explore. This workshop content is divided not only into lesson plans and power points, but also patient handouts to reinforce some of these key principles. And then um here are some more um topics that are covered as well. The cooking school workshop is a particular favorite for a lot of patients. So these are actually hands on sessions that allow um for a dietician to be involved and do these demonstrations in front of patients. And the goal here is for attendees to learn not only to prepare meals that are affordable for them and, and quick and simple to make but also healthy and still taste good. And we really focus on trying to use ingredients from local stores. So patients know where to be able to get these ingredients. Um So we tell them exactly where we found them in the community. So examples of some of the class topics that are going to be covered in cooking schools are adding flavor, sodium, free, um different types of fast and easy salads and breakfasts, um simple sauces, appetizers, delicious desserts. Um Looking at what plant based proteins look like. Um weekend breakfasts, fast evening meals. One thing um that we're really doing at centric care plex as well is to try and um have more physician involvement and physician outreach by allowing the physicians to be able to sample some of the meals that uh predict in cardiac rehab is going to be doing with patients. Um So that way we can, we can see what the patients are going to be eating. Um So the pre in meal plan is what uh we're we focus on in each of these different cooking classes. So, again, Mediterranean style plant based a modest amount of fish and seafood is allowed uh minimal intake of red meat and animal products, fat and sugar. And um this diet as we know has very much so been proven to reduce risk factors for coronary artery disease. Um Group workshops are again divided into each of the three different pillars of Pritikin. Um So here you can see um an example of some of the different types of foods that patients are gonna be looking at for their label reading class. So this includes not just healthy foods, we do label reading for patients for non healthy foods as well. Um Just so they can start getting a sense of looking at these things. Um We know a lot of packages, both that they're heart healthy and we show them that they're really not. And um exercise classes, not only are um cardio exercise classes, they really focus a lot on resistance training and core strength. And that's why critic and cardiac rehab has been shown to increase that hand grip strength so well. Um and then again, once predict cardiac rehab is done in the outpatient center, it still has the option for patients to continue predict at home with virtual diet and exercise plans. So that brings us now to intensive cardiac rehab at Centra, um which is hopefully evolving this year with the inception of pre and intensive cardiac rehab. Um at some of our own home bases, we actually already have a lot of traditional cardiac rehab programs in the hospital system that many of you have probably referred to. And we have one intensive cardiac rehab program, which is the Ornish program. So it's that ultra low fat plant-based diet that we were talking about earlier. And that's uh centered at Centra Princess Ann. Um that was actually the first site in the state of Virginia to have an Ornish intensive cardiac rehab program. Um But over the past year, there was a system executive team, evaluation of Sana's cardiac rehab programs and the objectives focused on trying to enhance our programs, grow volumes, improve quality for patients and demonstrate value. And one of the things that came out of this was that we should pilot the pre and intensive cardiac rehab program because of all the benefits that were demonstrated and also the prospect of better cost effectiveness. Now, due to that C MS reimbursement that allows for all education sessions to be reimbursed. So as of January of this year, um both Centra Carle and Hampton and Centra Martha Jefferson in Charlottesville have been piloting the predict intensive cardiac rehab program for our health system. So that pilot time is going to be six months and at six months, we'll do an analysis that includes a side by side comparison of Pritikin to our own traditional cardiac rehab data that we have over the past few years. So again, those variables that we're going to be looking into are some that we already discussed. Um B M I Weight blood pressure reduction, functional capacity assessments and tobacco cessation. There's also going to of course, be a financial analysis on cost effectiveness. Um But it's anticipated that because of C MS reimbursement that now it'll be both cost effective for patients and the health care system. It's already allowed for a significant expansion of resources in our cardiac rehab program. So, not just um do we have a few nurses and exercise physiotherapists? But um we're able to have additional nurses and now nu- uh nutritionists that can be involved as well to um provide those nutritional classes. And finally, I just really wanted to emphasize that despite all of its benefits for patients, cardiac rehab is still very underutilized. So this chart here, I think is very descriptive of that fact. Um It gives a comparison of the major class one, a interventions that should be implemented, post A CS or post PC I and it compares them in terms of their relative risk, percentage of side effects and discharge use. So you can see here that despite having a pretty good relative risk and zero side effects, its discharge use is only as high as 34% and can be as low as 19%. And this is really a global issue. There's many reasons for it that are obviously outplay. So at the health system level, it includes a lack of available programs and access to different intensive cardiac rehab programs. At the patient level, there's a myriad of factors including need for transportation, distance that they have to travel cost and coverage. So in particular for insurance coverage, Medicare only covers 80% of an intensive cardiac rehab program. If they have a supplement, then that will cover the remainder um with only a small copay. But there are still some insurance companies including some Blue Cross Blue Shield that don't cover intensive cardiac rehab at all. Yet. Um patients might also feel that they have competing responsibilities like with work um different time constraints and a lot of patients just don't have awareness of how good a a cardiac rehab program is for them. Um but all of these factors can be mitigated. So we still say refer patients, um we can figure out coverage, we can figure out timing, we can get them in and get some sessions. And actually some patients that have had a lot of issues with coverage do find that they get such benefit out of the program that some have paid out of pocket even for it. Um work schedules can definitely be worked around again. It's a dose response. Um So even just getting some sessions in is more beneficial than getting none. And at the provider level, there's still a lot of low referral rates. And I think this is because a lot of providers obviously focus on reimbursed cardiac interventions rather than long term lifestyle treatments that are very beneficial for patients that maybe aren't as reimbursed. Um But now that we see that C MS has increased reimbursement for intensive cardiac rehab, hopefully that barrier can be overcome. So, on the physician side factors that really affect this are the medical specialty that the patients are seeing. So obviously, if they're seeing a cardiologist, they're more likely to be referred to cardiac rehab even compared to a cardiothoracic surgeon. Um the physician attitude toward cardiac rehab also matters. Um But really research has found that it's the strength of a physician recommendation that has the greatest influence on patient enrollment and cardiac rehab. So that's where we can do our part by really emphasizing to patients the benefits of cardiac rehab and promoting that they not only enroll but complete their sessions. So I just wanted to show you what um our referral looks like in epic. Um So this is the outpatient referral to cardiac rehab. It's very easy and it's very straightforward. You just type in referral to cardiac rehab. Um All of these dark blue highlighted boxes are already preselected for you. You don't have to change any of them you have to do is just choose the site that's going to be most convenient for patients. Um So these are all of our Centra sites. Most of these are still traditional cardiac rehab programs except for Centra Care, Sentra, Martha Jefferson, and Centra Princess Anne, which is the Ornish intensive cardiac rehab program. This is the rest of that order set. Um So while each patient does have that intake assessment that we talked about to identify, there are specific risk factors that might need more careful attention. You can also highlight some of those risk factors as well when you're putting in the referral, diabetes, heart failure, smoking cessation or specify a particular one like weight management, blood pressure, et cetera. So in summary, intensive cardiac rehab is a more comprehensive structured cardiac rehab program that is approved and fully reimbursed by C MS for having demonstrated excellent outcomes in hundreds of peer reviewed studies. The three main types are Perin, which we are starting now at Centra Ornish, which we have had already at Princess Anne and Benson Henry, which is not commercially available. And all of them focus on nutrition, exercise and a healthy mindset with their own spin on it. Intensive cardiac rehab is not just limited to post M I patients. It's also for post cardiac surgical patients, those with chronic stable angina and those with chronic heart failure and physician recommendation is really paramount. So refer early, encourage your patients to participate and complete their cardiac rehab programs, please. And then finally, um I just wanted to give a special thanks to um Donna Gannon and our team at Centra Care Plex. Um obviously Donna, she's a great leader for us um in cardiac rehab and we're really lucky to have her. Um but she also provided a lot of information for me to be able to share with you today. So thank you, Donna. Um Together, her and the team are really doing a great job at um spearheading this initiative to start predicting cardiac rehab for us at Centra. Um So we're very thankful for all of their efforts. Published March 30, 2023 Created by Related Presenters Megan Sattler, M.D. Sentara Cardiology Specialists View Full Profile
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