Comprehensive Cardiac Rehabilitation Program in. Sarawak General Hospital Heart Centre. Coordinated By

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1 Comprehensive Cardiac Rehabilitation Program in Sarawak General Hospital Heart Centre Coordinated By Dr. Yew Kuan Leong, Dr. Leong Be Kim Cardiac Rehabilitation Program Directors Coronary Artery Disease Coronary artery disease is a very common disease affecting Malaysian nowadays. Coronary artery disease is caused by a pathological process called atherosclerosis. Atherosclerosis causes plaque build-up in the coronary arteries over time. The risk factors associated with atherosclerosis and coronary artery disease are hypertension, diabetes mellitus, smoking, male gender, high cholesterol, kidney failure, obesity, sedentary lifestyle, strong family history of coronary artery disease and immune-suppressant therapy. Men generally are at greater risk but the risk for female increases after menopause. A family history of heart disease is associated with a higher risk of coronary artery disease, especially if a close relative developed heart disease at an early age. Your risk is highest if your father or a brother was diagnosed with heart disease before age 55 or your mother or a sister developed it before age 65. The narrowing of the coronary artery may limit the blood supply to the heart muscle. If the narrowing happens gradually, the patient will experience increasing chest symptoms such as chest heaviness during exercise and reduced daily functional activity. This is called stable coronary artery disease. The affected patient will stop the physical activity, rest and usually the chest symptoms will disappear. If the narrowing of the coronary artery worsens immediately to the degree of almost total blockage of the blood flow, this is an emergency situation. The most feared scenario is acute myocardial infarction or commonly called heart attack. The affected heart attack patient often will be in great distress and must be advised to seek urgent medical attention. The doctor will assess the patient by performing clinical evaluation, electrocardiography and blood test related to the heart attack. If confirmed to be heart attack, there are two ways to treat it either with powerful blood thinner or opening up the blockages with metallic stent, a process called angioplasty.

2 As a consequence of the heart attack, there would be permanent damage to the heart muscle. The efficiency of the heart as a vigorous pump is indefinitely reduced. The more damage to the heart, the less efficient it will become. Heart attack patient will be given medications consisting of anti-platelet drug (blood thinner), cholesterol lowering drug, hypertensive drug and heart beat lowering drug. Coronary Artery Bypass Graft (CABG) is a treatment option for selected candidates with coronary artery diseases. CABG surgery involves median sternotomy, in which the sterum is literally cut in two and spread apart, allowing access to the heart. Special catheters are inserted into the heart and large vessel ascending aorta so that cardiopulmonary bypass (CBG) can be performed while the heart is stopped. The number of bypass grafts the patient receives depends on the number of diseased arteries that need to be bypassed as well as suitability of these arteries for being bypassed. After the procedure, patients typically require few days of intensive care management and then up to weeks for further care. Full recovery requires approximately 4 weeks and in some cases significantly longer. Percutaneous Coronary Intervention Coronary Artery Bypass Graft Surgery Multifaceted Cardiac Rehabilitation Program Cardiac Rehabilitation Program (CRP) in Sarawak General Hospital is a comprehensive coordinated, multifaceted program aim to improve functional status of cardiac patient in additional to slowing down the progression of the underlying atherosclerosis process. Suitable candidates for Cardiac Rehabilitation Program include the following: i. Post myocardial infarction ii. Stable angina iii. Post Coronary Artery Bypass Graft Surgery

3 iv. Post Percutaneous Coronary Intervention v. Compensated Heart Failure Our Cardiac Rehabilitation Program consists of 4 phases, phase I to phase IV. Phase I is early inpatient phase, followed by phase II intensive outpatient program. There are 8 sessions in phase II Cardiac Rehabilitation Program, 2 sessions per week. Patients will be advised to come back for phase III review for management of cardiovascular risk factors three months after completion of phase II. If cardiovascular risk factors are not well controlled, patients will be given long term follow up. Circuit exercise program is an important component, it is crucial to make sure this program is safe and effective. To achieve this, proper risk stratification needs to be conducted before enrolment in the program. Target heart rate will be prescribed to cardiac rehabilitation patients. Education program will cover management of modifiable risk factors. Cardiac Rehabilitation program will also serve as platform for cardiac patients to interact and share their own experience. This peer support may help to improve motivation and adherence to treatment. Life style intervention is often a neglected treatment for cardiac patients if no formal education or exercise program is provided. Comprehensive Cardiac Rehabilitation Program in Sarawak General Hospital will ultimately improve the quality of life of cardiac patients. Love our hearts to stay healthy and fit. Cardiac Rehabilitation Program Book Rehabilitation Physician Review Exercise Stress Testing Multidisciplinary Team Discussion for Exercise Prescription

4 Dietician Intervention During phase I of cardiac rehabilitation, doctors will refer their patients who have diabetes to the dietitian. The dietitian will assess the patients anthropometry, biochemical, clinical and dietary. Dietary advice will be given on how to control the blood sugar before procedures are done. If patients are referred for poor oral intake, nutrition support will be given. During phase II of cardiac rehabilitation, when patients have discharged, they will be told to come back in group. The dietitian will give a talk on how to lose weight, how to control blood cholesterol and how to control blood pressure via dietary modification. Patients will be taught on how to read their food label and how to modify their cooking. During phase III of cardiac rehabilitation, if patients still fail to compliance to control their diet, the doctors will refer the patients back to dietitian. The dietitian will reassess the patients eating habit individually. Dietary advice will be reinforced to this group of patients. Education Program (Presentation by Dietician) About Stress Management One hour sessions on stress management are conducted monthly during the Cardiac Rehabilitation Program Phase II. Stress appears to be a buzz word that many seem to be using to denote several unpleasant thoughts/ feelings. What actually constitutes stress? Is stress a normal part of life or is it something that just shouldn t be present at all in one s life? And, if it s a normal part of life, when does it become troublesome or pathological? When & how does stress actually affect the physical body? Ideas with regard to the above questions are delved into rather comprehensively during the hour-long sessions that are held. The word stress is dissected and situations that are stressful are discussed. The mind-body connection and the effects of the mind on the body are discussed. Various examples of mind body connections are provided to illustrate this point. Also, the difference between having a lot to do and yet not feeling stressed is discussed. What it is about situations that puts one in a stressful state is deliberated upon.

5 Once the idea of stress and its genesis is understood, then thoughts about its management are elucidated. The various traditional methods of stress management which are already inherent and well embedded in our culture are drawn upon and discussed. Those present are made aware of the wisdom of our ancient cultures and their abilities to tackle stress even before it surfaces. The wealth and value of our ancient principles and philosophies are brought into awareness. With regard to this, Mindfulness is briefly discussed. Education Program on Stress Management (Presentation by Doctor) Innovation of Occupational Therapy Occupational therapist (OT) is a profession concerned with promoting health and well-being through occupation. Occupational therapist achieves this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation. Occupational Therapist started to involve in Cardiac rehabilitation program (CRP) in early 2011 by visiting from Occupational therapist from Hospital Umum Sarawak. The therapist-in-charge has focused on phase 1 with education talk about ADL and BADL guideline after surgery to lessen rise in cardiac distress. Beginning in 2014 Occupational therapists expand their role in CRP for phase I, phase II and phase III. For phase I, OT was add their service who provide chest binder to all Cardiothoracic cases. That binder was used to maintain a normal pattern of breathing after surgery. It will help to make a faster of wound healing and also to prevent other complication of sternum and ribcage when patient does the active movement especially while cough. Beside that the things that need to be emphasized is to monitor low level self-care activity (in bed) after surgery. Phase II, OT more focus on work hardening and word reconditioning program and some slot of talk every ends of month. That talk discuss about Ergonomic in ADL and BADL, Energy conservation and Work simplification and also practical session of relaxation therapy technique.

6 There are two task requirement in work training namely lifting activity and carrying activity. In CRP II, patient were divide into three categories likes, high risk, moderate risk and low risk. Usually, for high risk patient, there will start to carrying or lifting (0.5kg -1kg), moderate risk (1.5kg-2kg) and low risk (2kg-2.5kg). During training session, blood pressure, heart rate, RPE of patients and other symptoms such as chest pain need to monitor strictly. Hence, for phase III, Occupational therapist more focus to empower the self monitoring and maintain of balanced life style of patient. Reassessment will be made to monitor whether patient able to reinforce and promote the application of skills and knowledge learned in phase II. Otherwise, OT also identify any changes in personal lifestyle and give recommendation whenever necessary. Assessment on Activities of Daily Living Training for Lifting & Carrying Objects Relaxation Technique

7 Role of Pharmacist in CRP Post-operative patients, whether percutaneous coronary intervention (PCI) stenting or coronary artery bypass grafting (CABG), will take home a long list of medications at discharge. Although these medications are necessary to maintain the patient's outcome after discharge, they can cause many unwanted side effects to the patient especially when taken incorrectly. Patients who are not counselled on the side effects and the proper way to take their medications will experience these unwanted side effects which in the end compromise on their compliance. Most patients will even choose to ignore their therapy altogether. Following this, the pharmacist role in the Cardiac Rehabilitation Program is to give a thorough knowledge via individual counselling and group presentations to all patients post PCI or post CABG. Individual counselling, which is usually given at discharge, provide a one-on-one environment between the patient and the pharmacist. On the other hand, group counselling which is usually given in a form of a presentation, allows the pharmacist to reach out to a greater number of patients. In addition to that, patients are able to share their experiences regarding their therapy. Counselling group and individual done routinely enables patients to have full awareness and knowledge on the function, correct administration (before or after meal), common side effects, and benefits of each and every medication. This counselling focuses on patients concordance to therapy rather than compliance. This means that the interaction between the pharmacist and the patient is an utmost importance to understand each patient s lifestyle in order to tailor their medication administration times. During these counselling (group and individual), patients are first counselled on the pathophysiology of their disease and the procedures that they have undergone. A complete understanding of the pathophysiology of their disease is necessary prior to the counselling of their medications. From here, patients will be counselled on the different classes of mediations and briefed on the mechanism of action of each drug. Patients will also be educated on the short term and long term benefits of the drugs. It is also essential for the patients to understand if the drugs should be taken before or after meal. This will either reduce the side effects or increase the bioavailability of their drugs. Since individual counselling is done at discharge from ward, group counselling is done every month at the second phase of the cardiac rehabilitation program. At the end of the 1 hour session, patients are free to consult the pharmacist regarding their medication therapy. A copy of the slide presentation is also provided at the end of their program. Pharmacists' counselling focus on concordance to medications

8 Physiotherapists Approach in CRP For cardio-thoracic patients who are undergoing surgeries; the physiotherapists assess and prepare the patients by giving them the Pump-Talk (pre-operative physiotherapy). Postoperatively, the physiotherapists will treat the patients in Intensive Care Unit to prevent pulmonary, circulatory and musculoskeleltal complications (Phase I) CRP, then a home bassed program is given and taught to the patients before they are being discharged home. Similarly, Phase 1 CRP is taught to Cardiology patients in the ward. After 6 weeks, the cardio-thoracic and cardiology patients are called to attend Phase II CRP as outpatients. The physiotherapists will assess each patient by conducting a 6 minutes walk test. Together with multidisciplinary team; an individual exercise regime is prescribed for each patient. Then the physiotherapist will conduct 5 sessions of circuit exercise training for patients. Two lectures Exercise in Cardiac Patients and Sexual Activities in Cardiac Patients are given by physiotherapists to the outpatients during eight sessions of CRP Phase II. 6 Minute Walk Test Circuit Exercise Training Education Program (Presentation by Physiotherapist) Quit Smoking Program in Cardiac Rehabilitation

9 Quit smoking is one the most cost effective healthcare intervention. Smokers who quit will experience many benefits especially a reduction in the risk of cardiovascular and respiratory diseases. Although majority of smokers quit unassisted (on their own), some of them need additional support from health care professionals. You may consider various evidence-based behavioral and pharmocological approach depending on the availability of resources. Sarawak General Hospital has established Quit Smoking Clinic since 2011 at SGH Heart Centre and year 2014 at Sarawak General Hospital main building. Patient Education and Health Promotion Unit has been recommended to coordinate and facilitate the development and implementation of quit smoking program at the hospital setting by Ministry of Health. However the team members for Quit Smoking Clinic should be trained staffs and consist of Health Education Officer, Respiratory Specialist Doctor, Pharmacist, Medical Assistant Officer and other healthcare providers. The roles of Health Education Officer in Quit Smoking Program are to promote behavioural intervention for patients as following: To set a quit date, ideally the quit date should be within 2 weeks. Reduce the number of cigarettes gradually before the set date. To tell family, friends and co-workers about quitting and request understanding and support. Also, to help patient obtain extra-treatment social support from self- help group. Other smokers in the household, patients should encourage household members to quit with them or not smoke in their presence to minimize risk of treatment failure and exposure to second hand smoking Advice patient to remove tobacco products from his or her environment. Prior to quitting, avoid smoking in places where a lot of patient s time is spent (e.g. work, home, car). Provide a supportive healthcare environment while encouraging the patient in his or her attempt. Anticipate challenges to plan quit attempt, particularly during critical first few weeks. These include nicotine withdrawal symptoms. Discuss challenges/triggers and how patient will succefully overcome them. Provide patients with problem solving skills training. Total abstinence is essential. Not even a single puff after the quit date. For past quit experience, identify what helped and what hurt in previous quit attempt. Since alcohol can cause relapse, the individual should consider limiting/abstaining from alcohol while quitting. To provide supplementary quit smoking materials. Therefore, 3A, 5A, and 5R are the brief intervention approach and strategies for smokers which focus on smokers motivation to quit. The way in which you talk to patients about their health can substantially influence teir motivation for behavior change.

10 Cardiac Rehabilitation Nurse as Program Coordinator During Phase I, Cardiac Rehabilitation Nurses will introduce concept of risk factor reduction, self assessment and self care in heart health. Based on the level of readiness to learn, patients in Phase I are given education regarding their heart proble, activity, exercise, nutrition, medication, risk factors, life style changes, emergency planning and availbale community resources. Appoinment will be arranged for Phase II CRP. In Phase II, Cardiaic Rehabilitation Nurses will be in charge of registration and vital signs checking before reviewed by rehabilitation doctors. Phase II exercise sessions are monitored by Cradiac Rehabilitation Nurses. They will record patient s progress during every follow up. If patients had any ischemic symptoms, patients will be sent to emergency department for further assessment. After completion of one month program during Phase II, patient will continue with home based exercise and physical activity will be recorded in a booklet. Appointments are arranged by Cardiac Rehabilitation Nurse at 3 month after Phase II, this is known as Phase III review. Rehabilitation Doctor will review all risk factors profile during Phase III review and provide consultation accordingly. Creating A Folder for New Patient Vital Signs Checking

11 As Conclusion From the moment the patient is nursed in the intensive care unit to the normal ward, the first phase of cardiac rehabilitation is gently introduced by a dedicated team of health professional. After successful discharge from the ward, the next phase of cardiac rehabilitation at the outpatient rehabilitation department is as equally important. The affected patient will be assessed and stratified based on their overall risk profile. The exercise program will be tailored according to the severity of the heart attack and pumping capability of the heart. The outpatient rehabilitation program helps to gradually condition the heart to progressive higher functional workload based on the individual needs and capability. We aim to restore their functional capability to as close as possible before the heart attack episode. Once they have completed the hospital based cardiac rehabilitation program, they will be continuously followed up at the cardiology or cardiothoracic outpatient clinic and the journey never ends. Graduation Ceremony Cardiologist Review at Cardiac Clinic Cardiac Rehabilitation Group Photograph