Open Access Short Communication

Cardiac Rehabilitation

SHORT COMMUNICATION
CARDIAC REHABILITATION AS A DEDICATED CLINICAL SERVICE:
RECENT ACHIEVEMENTS AND REMAINING CHALLENGES
Maryam Zahid, Usman Iqbal, Aleena Khan, Hafsa Khlil, Naheed Kausar*, Sehrish Mumtaz, Mawara Hassan, Afsheen Iqbal
Armed Forces Institute of Cardiology/National Institute of Heart Disease/National University of Medical Sciences (NUMS) Rawalpindi Pakistan, *Combined
Military Hospital Nowshera/National University of Medical Sciences (NUMS) Pakistan

ABSTRACT
Cardiac rehabilitation reduces the risk of cardiovascular disease (CVD), is a concept easy to understand but difficult to
implement in practice. Pillars of cardiovascular health maintenance include smoking cessation or avoidance, a prudent diet,
weight management, regular exercise, stress management, and regular blood sugar, cholesterol, and blood pressure checks.
Our primary objective in AFIC & NIHD is to provide a high- touch compassionate care to our patients. Our department
consists of a Cardiologist, Clinical Dietitian, Psychologist, Physiotherapist and a Research Officer who are working to educate
and counsel our cardiac patients regarding healthy lifestyle in wards and outdoor clinics.
Despite robust evidence of clinical and cost effectiveness, uptake of cardiac rehabilitation is not as good due to several factors,
including physicians’ reluctance to refer some patients, psychological wellbeing, geographical location, access to transport,
and a dislike of group-based rehabilitation sessions. In countries like Pakistan treatment options are expensive and limited
and most of the population does not have access to the tertiary care hospitals. It would therefore be more logical to
concentrate on prevention of diseases
Keywords: Cardiac rehabilitation, Clinical services.

How to Cite This Article: Zahid M, Iqbal U, Khan A, Khlil H, Kausar N, Mumtaz S, Hassan M, Iqbal A. Cardiac Rehabilitation as a Dedicated Clinical
Service: Recent Achievements and Remaining Challenges. Pak Armed Forces Med J 2022; 72 (Suppl-1): S82-85.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cardiac Rehabilitation hypertension, and abnormal lipid profile is increasing.

Cardiac rehabilitation (CR) is a complex interven- As a result, the prevalence of non-communicable disea-
tion offered to patients diagnosed with heart disease, ses, such as CVD, is increasing in developing countries
which includes components of health education, adv- where nearly one quarter (24.3%) of people above the
ice on cardiovascular risk reduction, dietary intake, age of 18 years have been reported as hypertensive.
physical activity and stress management.1,2 Similarly, 25% of people above the age of 40 years were
found to be suffering from coronary artery diseases
In the US, the participation rate in CR programs is
(CAD).5
only 20-30%. It has been estimated that increasing this
rate to 70% would save 25000 lives and prevent 18000 As one of the country's finest hospitals, Armed
hospitalizations per year.3 Worldwide, only 38.8% of Forces Institute of Cardiology and National Institute of
countries have CR programs: 68% of high-income cou- Heart Diseases (AFIC-NIHD) has a proud heritage of
ntries, 28.2% of median-income countries and 8.3% of serving the county for more than 35 years. This tertiary
low-income countries. The availability of CR is much care cardiac hospital with 404 beds is located in the
lower than that of other evidence-based interventions, heart of Rawalpindi. It has the honor to serve large
such as revascularization and pharmacological the- population of upper Punjab, The Federal Capital,
rapy. In high-income countries, the density of CR prog- Khyber Pakhtunkhwah, Azad Kashmir, northern areas
rams ranges from 1:100 000 to 300 000 population.4 and referred cases from the Military hospitals of all
over the country. The hospital is noted for its devotion
Globally, the leading cause of deaths is cardiovas-
to patients, dedication to its professional goals, motiva-
cular disease (CVD). A total of 19% deaths are a result
tion to the achievement of excellence and a very caring
of CVDs, with age standardized death rates of 255 and
and collaborative spirit. Evidence that cardiac rehabi-
295 per 100,000 for males and females, respectively.1
litation reduces mortality, morbidity, and unplanned
In developing countries with high population density,
hospital admissions in addition to improvements in
the prevalence of risk factors such as physical
exercise capacity, quality of life and psychological well
inactivity, poor diet, obesity, smoking, type-2 diabetes,
-being is increasing, and it is now recommended in
Correspondence: Ms Maryam Zahid, Clinical Dietitian, Armed Forces international guidelines.1,2 This review focuses on what
Institute of Cardiology/NIHD, Rawalpindi Pakistan cardiac rehabilitation is and the evidence of its benefit

Pak Armed Forces Med J 2022; 72 (Suppl-1): S82

 Cardiac Rehabilitation

and effects on cardiovascular mortality, morbidity and Historically, cardiac rehabilitation in the UK,
quality of life. US, and most European countries has been delivered
Patient Groups who Benefit from Cardiac to groups of patients in healthcare or community cent-
Rehabilitation res.8 Recent guidance from the UK Department of
Health9 refers to a seven stage pathway of care that be-
• Patients with acute coronary syndrome - including
gins with diagnosis of a cardiac event and is followed
ST elevation myocardial infarction, non-ST eleva-
by assessment of eligibility, referral, clinical assess-
tion myocardial infarction, and unstable angina -
ment, and core delivery of cardiac rehabilitation before
and all patients undergone reperfusion (such as cor-
progressing to long term management.
onary artery bypass surgery, primary percutaneous
coronary intervention, and percutaneous coronary
intervention).
• Patients with newly diagnosed chronic heart failure
and chronic heart failure with a step change in
clinical presentation.
• Patients with heart transplant and ventricular assist Program and Services
device. Core components of cardiac rehabilitation inclu-
• Patients who have undergone surgery for implan- ded health behavior change and education, lifestyle
tation of intra-cardiac defibrillator or cardiac resyn- risk factor management. The ongoing programs of
chronization therapy for reasons other than acute preventive cardiology include:
coronary syndrome and heart failure.
• Patients with heart valve replacements for reasons 1. Cardiac Rehabilitation.
other than acute coronary syndrome and heart 2. Stress Management.
failure. 3. Healthy Diet Management.
Fundamental to this is developing optimally 4. Smoking Cessation.
structured and functional department of Preventive
5. Cardiac Risk Assessment.
Cardiology with well-trained human resource, proper
infrastructure and necessary resources in every insti- Delivery of the core components requires exper-
tute and major hospitals, private hospitals and district tise from a range of different professionals. The team
hospitals especially those hospitals offering invasive may include:
cardiac services. Close liaison has to be encouraged
between medical units, diabetic units, cardiac surgical
units and these departments. It should provide facili-
ties to assess risk factors like blood pressure, weight
and waist measurement and check cholesterol and blo-
od glucose. It should develop special literature about
heart problems in local language, Urdu and English for
educating general public visiting the clinics for any ail-
ment. It should provide detailed information on speci-
fic risk factors –their importance and ways to control
them for patients diagnosed to have specific risk fac-
tors. Such departments should establish free drug
banks for treatment of hypertension, diabetes and cho-
lesterol. Expert help should be available for quitting
smoking and treating obesity in these special centers. Preventive Cardiology Clinic
They should hold regular seminars for general public Our expert cardiologists provide you the tools
awareness. They should develop special software for you need to live a heart healthy life. Our team's inte-
GP clinics for record keeping and more importantly for grated approach to patient care includes an evaluation
follow up. This may be centrally connected for a data of your heart disease risk factors.
base and regular follow up.6,7 At clinic, a patient can expect:

Pak Armed Forces Med J 2022; 72 (Suppl-1): S83

 Cardiac Rehabilitation

• Plans tailored for you, with specific lifestyle nurse led prevention clinics to be linked with primary
recommendations and medication management as care and cardiac rehabilitation services.12
needed. Novel ways of providing cardiac rehabilitation
• Counseling and education to promote a healthy are emerging using the internet and mobile phones. A
lifestyle. recent systematic review has evaluated alternative
In rehabilitation department approximately 944 models of delivery13 that can be provided via secon-
patients are provided with psychological counseling, dary prevention clinics. Offering patients a choice of
1274 are provided with physiotherapy services and center based, home, or online programmes on an equit-
2556 are provided with dietary counseling and diet able basis is likely to improve uptake across all groups
plan from April - September 2021. Patients are not only of cardiac patients. Self-management and collaboration
counseled verbally but also given written plans and with care givers can also improve uptake and outco-
pamphlets. Cardiac rehabilitation program enrollment mes.
performa is maintained since Feb 2021 under the sup- The burden of non-communicable diseases is
ervision of research department and has data regar- rapidly increasing in the developing countries. With
ding the lipid profile, blood glucose level, smoking increase in the incidence of non-communicable disea-
status, co morbidities, exercise routine, psychological ses on one hand and inability to control the menace of
health of 705 patients. infectious diseases on the other hand, leaves the deve-
Competing Goals and Conflicting Values in the loping countries extremely vulnerable. In countries like
COVID-19 Problem Pakistan treatment options are expensive and limited
and most of the population does not have access to
At the time of writing, the world is facing
the tertiary care hospitals. It would therefore be more
a rapidly progressing COVID-19 fourth wave. It was
logical to concentrate on prevention of diseases.
difficult to gather discharged patients in an auditorium
for cardiac rehabilitation program lecture. Previously Conflict of Interest: None.
150 patients were educated regarding healthy lifestyle Author’s Contribution
adoption through these lecture. Health care professio- MZ: Principal contribution, UI: Proof reading, AK, SM, MH:
nals including cardiologist, dietitian, physiotherapist Manuscript writing, NK: Proof reading, AI: Intellectual
and psychologist either visit each patient discharged contribution.
from hospital in wards or these patients are referred to REFERENCES
outdoor clinic. 1. Taylor R, Dibben G, Faulkner J, Dalal H. More evidence of
cardiac rehabilitation: need to consider patient quality of life.
Overcoming Barriers to Cardiac Rehabilitation Can J Cardiol 2021; 37(10): 1681-1682.
Despite robust evidence of clinical and cost effec- 2. Cook R, Davidson P, Martin R. Cardiac rehabilitation for heart
failure can improve quality of life and fitness. Br Med J 2019; 367:
tiveness, uptake of cardiac rehabilitation varies world-
l5456.
wide and by patient group, with participation rates 3. Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K,
ranging from 20-50%.10 Poor uptake has been attribu- Newlin K, et al. Increasing cardiac rehabilitation participation
ted to several factors, including physicians’ reluctance from 20% to 70%: a road map from the million hearts cardiac
rehabilitation collaborative. Mayo Clin Proc 2017; 92(2): 234-
to refer some patients, lack of resources, capacity, and
242.
funding. Adherence to cardiac rehabilitation program- 4. Turk-Adawi K, Sarrafzadegan N, Grace SL. Global availability
me is affected by factors such as psychological well- of cardiac rehabilitation. Nat Rev Cardiol 2014; 11(10): 586-
being, geographical location, access to transport, and a 596.
5. GBD 2019 Diseases and Injuries Collaborators. Global burden of
dislike of group-based rehabilitation sessions.11 Alth-
369 diseases and injuries in 204 countries and territories, 1990-
ough announcements were done prior to the preven- 2019: a systematic analysis for the Global Burden of Disease
tive cardiology lecture, posters regarding time and inf- Study 2019. Lancet 2020; 396(10258): 1204-1222.
ormation of the lecture were displayed on each floor, 6. Grace SL, Parsons TL, Duhamel TA, Somanader DS, Suskin N.
The quality of cardiac rehabilitation in Canada: a report of the
the patients were reluctant to join the lecture regular-
canadian cardiac rehab registry. Can J Cardiol 2014; 30(11): 1452-
ly. The most effective way to increase uptake and opti- 1455.
mize adherence and secondary prevention is for clini- 7. Doherty P, Salman A, Furze G, Dalal HM, Harrison A. Does
cians to endorse cardiac rehabilitation by inviting pati- cardiac rehabilitation meet minimum standards: an observa-
tional study using UK national audit? Open Heart 2017; 4(1):
ents still in hospital after a recent diagnosis of coronary
e000519.
heart disease or heart failure to participate and for

Pak Armed Forces Med J 2022; 72 (Suppl-1): S84

 Cardiac Rehabilitation

8. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, 11. Menezes AR, Lavie CJ, Milani RV, Forman DE, King M, Williams
Martin N, et al. Exercise-based cardiac rehabilitation for coronary MA. Cardiac rehabilitation in the United States. Prog Cardiovasc
heart disease: cochrane systematic review and meta-analysis. J Dis 2014; 56(5): 522-529.
Am Coll Cardiol 2016; 67(1): 1-12. 12. National Clinical Guideline Centre (UK). MI-secondary preven-
9. Mampuya WM. Cardiac rehabilitation past, present and future: tion: secondary prevention in primary and secondary care for pa-
an overview. Cardiovasc Diagn Ther 2012; 2(1): 38-49. tients following a myocardial infarction: partial update of NICE
10. British Heart Foundation. The National Audit of Cardiac Reha- CG48 [Internet]. London: Royal College of Physicians (UK); 2013.
bilitation: Annual Statistical Report 2014 [Internet] Available at; 13. Clark RA, Conway A, Poulsen V, Keech W, Tirimacco R, Tide-
https://www.bhf.org.uk/informationsupport/publications/stat man P. Alternative models of cardiac rehabilitation: a systematic
istics/cardiac-rehabilitation-statistics-2014 review. Eur J Prev Cardiol 2015; 22(1): 35-74.

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