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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 27-32

Evidence-based review for cardiac rehabilitation program development status and necessity in India

1 Department of Nursing, AIIMS, Rishikesh, Uttarakhand, India
2 Department of CTVS, AIIMS, Rishikesh, Uttarakhand, India
3 Department of Cardiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission03-Mar-2021
Date of Acceptance31-May-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Maneesh Sharma
College of Nursing, AIIMS, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_14_21

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India has a high burden of cardiovascular disease, morbidity and mortality due to CVD has been causing a high economic burden and leading to an overall increase in health care cost. Research evidence from different parts of the world indicates that structured approach to secondary prevention such as cardiac rehabilitation (CR) have health-favoring impact. When CR is supplemented with pharmacological interventions and percutaneous coronary intervention (PCI) has shown a significant improvement in quality of life, reduces morbidity, and mortality rate, cardiac-related parameters, depression and minimizes readmission rates among cardiac patients. Primarily, CR is delivered in three phases: Phase – I begin in the hospital, Phase – II outpatient phase, and Phase – III maintenance phase. Various organizations around the world deliver structured home-based and center-based CR program to cardiac patients also provides training and certification courses in CR to healthcare professionals (HCPs). However, in India, no such organization exists; therefore, CR delivery is under prevalent; further, other factors such as lack of skilled task force, adequate infrastructure, education, and training also contribute for suboptimal use of CR in the country. Awareness among HCPs and patients is also considered one of the primary factors to minimize the uptake of CR program in India. Therefore, there is a great need to revisit the CR delivery protocol and develop an evidence-based uniform approach to increase the uptake of the CR program. Government health care agencies should also frame guidelines to facilitating better infrastructure and training to resulting in increased uptake of CR program among cardiac patients. This review article has compiled various international studies to justify the benefits of CR program development necessity and status in India.

Keywords: Cardiac rehabilitation, coronary artery bypass graft surgery, home-based and center-based cardiac rehabilitation, percutaneous coronary intervention, quality of life

How to cite this article:
Sharma M, Darbari A, Sharma R, Kumar B. Evidence-based review for cardiac rehabilitation program development status and necessity in India. Heart Mind 2021;5:27-32

How to cite this URL:
Sharma M, Darbari A, Sharma R, Kumar B. Evidence-based review for cardiac rehabilitation program development status and necessity in India. Heart Mind [serial online] 2021 [cited 2023 Jun 10];5:27-32. Available from: http://www.heartmindjournal.org/text.asp?2021/5/2/27/319649

Coronary artery disease (CAD) is the most common cause of death from cardiovascular disease (CVD) around the globe.[1] India has high burden of CVD, resulting in an economic burden to patients, with many of them being unable to afford even the basic preventive medications. Hence, there is a need for cost-effective measures for controlling CVD.[2] It has been estimated that non-communicable diseases (NCDs) account for around 61.8% of total deaths in India. The situation is very alarming due to increasing prevalence of CVD in the productive age groups, which has increased to around 24.8% among people between the ages of 25 and 69 years. The impact of NCDs on disability-adjusted life years, which estimate years of healthy life lost to premature death and suffering has increased from 30% of the total disease burden in 1990 to 55% in 2016.[3] CAD is a specific manifestation of CVD and ubiquitous across the country with some regional variations, i.e., 2%–7% for rural areas and 7%–13% for urban areas. CAD has also been reported as the number one cause of years of life lost due to premature death, with a percentage change of 41.5% between 2005 and 2016.[4] Research evidence from different parts of the world indicates that structured approaches to secondary prevention such as cardiac rehabilitation (CR) have health-favoring impacts on quality of life (QOL), morbidity, and mortality. While percutaneous coronary intervention (PCI) along with medication aids for acute management of myocardial infarction (MI), increasing evidence indicates that when these interventions are supplemented with CR, even better patient outcomes can be achieved in terms of risk factor modification, rejoining work, and improve QOL.[5],[6] CR is a multidisciplinary and systematic approach to exercise training and risk factors management through regular patient evaluation and monitoring and support of compliance and adherence.[7] CR program has three phases: In-hospital (Phase I); early outpatient (Phase II), and long-term outpatient (Phase III) CR. Clinical recommendations for Phase I rehabilitation for patients undergoing coronary artery bypass graft (CABG) surgery are few and are based on sparse evidence from trials with small sample sizes and nonrepresentative trial populations. Patients with CAD undergo surgical intervention; however, the postoperative period can be challenging, with physical and psychological problems, and symptoms such as anxiety and depression, immobility issues, respiratory complications, insufficient sleep, and fatigue were the common problems patients encounter.[8]

  Benefits of Cardiac Rehabilitation Top

Randomized controlled trials, systematic reviews, and meta-analysis conducted on CR have advocated the benefits of CR program; some of them are reduced mortality, hospital readmission, improved QOL, and improvement of cardiac-related parameters, i.e., total cholesterol.[9] CR delivered to patients with acute coronary syndrome after the PCI and coronary artery bypass grafting reduces cardiovascular mortality by 20%–30%.[10] A population-based surveillance study was conducted by Dunlay et al.[11] on 2991 first time diagnosed patients with MI has shown reduction in cardiovascular mortality risk (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.49–0.68; P < 0.001) and readmission (HR, 0.80; 95% CI, 0.65–0.99; P = 0.037) after patients were enrolled in CR program. Another retrospective study conducted by Martin et al.[12] on 5641 CAD patients had shown improvement of cardiorespiratory fitness results in a decrease in overall mortality. According to a recent meta-analysis conducted by Barth et al.[13] of 7 prospective studies highlighted that depressive symptoms increase the risk of mortality in CHD patients, and risk of depressed patients dying in the two years after the initial assessment is two times higher than of non depressed patients (OR,2.24;1.37-3.60). An observational cohort study conducted by Milani et al.[14] has revealed that improvement in depression exhibited statistically (mean ± standard deviation from 11.2 ± 3.5 to 7.4 ± 3.5) after the CR program. Another retrospective study conducted by Graham et al.[9] on cardiac patients following MI, PCI, and CABG has proven reductions in mortality in CR group (odds ratio [OR] =0.22, 95% CI 0.12–0.39) and decrease in hospital readmission (OR = 0.48, 95% CI 0.24–0.96) after CR program. On the contrary, Anderson and Taylor[15] conducted a Cochrane review and meta-analysis of 148 randomized controlled trials that included 98,093 patients of MI or PCI or heart failure showed that CR has no impact on mortality but did reduce hospital readmission and improve health-related QOL. Substantial data suggest that elevated triglyceride is associated with increased CAD risk and is an independent coronary risk factor. Lavie and Milani[16] conducted a study on 313 patients with CAD to compare the response of the patients before and after the CR has shown a significant improvement in cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol levels, low-density lipoprotein (LDL) cholesterol levels, LDL/HDL ratios, and body mass index (P ≤ 0.001).

  Cardiac Rehabilitation around the Globe Top

The WHO global action plan for prevention and control of noncommunicable diseases (2013–2020) recommends that all patients with cardiac ailments should have an access to CR as a policy. Despite its clear and tangible benefits, CR uptake is suboptimal worldwide and is only available in approximately one-quarter of the middle-income countries and one-tenth of the low-income countries (LICs). Only 38.8% of the countries globally have CR programs, 68% of the high-income countries, 23% of lower-middle-income countries (LMICs), and 8.3% of LICs have CR.[17] There are various international organizations delivering hospital and home-based cardiac rehabilitation (HBCR) services across the globe; some of them are American Association of Cardiovascular and Pulmonary Rehabilitation, International Council for Cardiovascular Prevention and Rehabilitation (ICCPR), Canadian Association of Cardiovascular and Pulmonary Rehabilitation, Cardiac Health Foundation of Canada, and Australian Cardiovascular Health and Rehabilitation Association.[18] A United State-based Million Hearts, a national initiative co-led by the Centers for Disease Control and Prevention, brought together the healthcare professionals (HCPs) and systems, federal and private sector organizations, communities, and individuals to prevent 1 million cardiovascular events by increasing the participation of patients to CR program from 20% to 70% by 2022 through individual and collective action.[19] A review conducted by Woodruff et al.[20] in Australia stated that, despite the overwhelming evidence of the effectiveness of CR program, it is currently underutilized in Australia. However, the reasons for underutilization of CR in Australia are not mentioned in the study, but considering the underutilization, the National Heart Foundation of Australia put forwarded nine key action areas to improve equity and access, uptake, and quality of services of CR for patients with CVD. Specific recommendations included the importance of identifying measures that reflect the results of care in three domains, i.e., behavioral, clinical, and health. In 2020, a position paper was released from the European Association of Preventive Cardiology to revise cardiac rehabilitation components and its objectives to update the practical recommendations on the core components and goals of cardiac rehabilitation intervention in different cardiovascular conditions, to assist the cardiac rehabilitation staff in the design and development of the program, and to support healthcare providers, insurers, policy makers and patients in the recognition of the positive nature of cardiac rehabilitation.[21] Various studies published in this context are tabulated in [Table 1] for description.
Table 1: Empirical evidence on cardiac rehabilitation

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  Cardiac Rehabilitation in India Top

Since the burden of CVD in India has increased significantly in the past 15 years, both primary and secondary prevention play a vital role in minimizing the incidences of CAD and preventing further complications. The uptake of CR program has been very low in the country. There are many strategies carried out by AHA, like the million heart project, to facilitate and improve adherence and participation in CR program. However, there are no reported strategies used in the Indian context to improve the participation of the patients in the CR program.[29] Despite this strong need, there are very few CR centres present in India. Currently, there is no official registry like western countries that offer such CR program; therefore, it is hard to accurately quantify the number of structured CR programs in the country. The best estimate would be that there are currently less than 50 such programs running across the country which are considered to be less in numbers and these programs offer exercise-based CR, with electrocardiography monitoring in an outpatient setting. There is no dedicated department and skilled workforce present to run such CR program. CR program in these centres is run by physical therapists, along with physicians, dietitians, and nurses. For the effective implementation of CBCR, a dedicated CR department is a critical requirement as it needs a skilled multidisciplinary team to run such programs where every team member's role is crucial. A large space is also a prerequisite to deliver their services at one point in the form of teaching and demonstrating various types of exercises, smoking cessation and stress management counseling, and sedentary lifestyle instructions in each follow-up. However, very limited healthcare facilities (HCFs) across the country that provide specialized care for CAD patients do offer Phase I CR and very few of them provide Phase I CR by unstructured approach.[18] These are delivered by physical therapists and combine respiratory therapy along with patient mobilization. Recently, a global audit on CR was conducted by Babu et al.[2] in collaboration with the ICCPR to identify the CR delivery institutions in India, 33 CR centres were identified. According to study estimate, each year, one CR spot would require for every 360 patients which was among the lowest density of any country in CR. Furthermore, there is a need for 3,304,474 more CR spots each year to treat cardiac patients in the country, which is the greatest unmet needs of any LMIC. However, few nonhealthcare centres in India provide yoga-based CR program for CAD patients, including meditation, low-fat diet instructions, and moderate amount of exercise therapy.[18] As per report published in the Times of India on September 29, 2020, on CR in India – a way to go stated that, despite increasing in trend of CAD and PCI hospitals even specialized in cardiology did not show interest in CR and numbers are negligible. CR is under prevalent in India; the reasons are many, and one of them is lack of facilities, infrastructure, and awareness among cardiologist and patients.[30] Rehabilitation council of India is one of the statutory bodies since 1993, which monitor services given to person with disability and to maintain central rehabilitation register to all qualified professionals and personnel working in field of rehabilitation, but RCI has not included cardiac rehabilitation in their core objectives and being an only government organization working for rehabilitation in the country should endorsed CR in their sphere that can add new prospect to CR in India and more cardiac patients can be benefited.

  Barriers to Cardiac Rehabilitation in India Top

Despite having robust evidences of clinical and cost-effectiveness of CR program, endorsement of cardiac rehabilitation varies by patients and health professionals, with participation rates ranging from 20% to 50%.[31] Many potential barriers to participation in CR have been proposed in ample research evidences, including poor referral rates, low socioeconomic status of patients, poor adherence to CR program, lack of endorsement by cardiologists, multiple morbidities, poor exercise habits, depression among patients, lack of transport facilities, lack dedicated infrastructure for CR, poor social support, lack of leave from work to attend center-based CR (CBCR) sessions, and lack of regulatory body in the county.[2],[10],[29],[31],[32] Poor uptake has been attributed to several factors, including physicians' reluctance to refer some patients and those from or lower socioeconomic classes, and lack of resources, dedicated infrastructure, capacity enhancement, and funding.[2],[7] Numerous factors affect the adherence to CR program such as psychological and physical well-being of patients, geographical location, access to transport, and socioeconomic status of patients.[7] The most effective way to increase uptake and optimize adherence of CR for cardiologist and team is to endorse CR by encouraging and motivating patients and counsel them to participate in home based cardiac rehabilitation (HBCR) program by briefing the benefits of it.[33] A Randomized controlled trial conducted to assess the effect of nurse led CR program have shown promising result by improving overall health and performance of CAD patients, could be a novel strategy to overcome the barrier of effective implementation of CR program in the country.[34] Further, to overcome the lack of transport barrier, the use of telemedicine or internet and mobile phone can help in effective delivery of CR program at home setting, where self-management and collaboration with healthcare providers at remote level may improve uptake and outcome.[35] A multilevel and multifactorial approaches using a combination of changes in policy, healthcare programs, process implementation, physician education and task shifting, practice paradigm shift, population-wide interventions, primary prevention, better patient management, and patient empowerment can lead to a substantial reduction in mortality and burden of CVD in India.[7],[10],[18] Furthermore, one potential approach to overcome transportation, geographical location, and economical barrier is HBCR which can be carried out in a variety of settings, including the home or other nonclinical settings such as community centers, health clubs, and parks. The use of HBCR, either alone or in combination with CBCR, represents a possible alternative that may improve the delivery of CR to eligible patients. HBCR has been incorporated into the healthcare systems of several countries, including Australia, Canada, and the United Kingdom, and could be a game changer in LMICs.[31] However, the European guidelines on CVD prevention state that home-based rehabilitation with and without telemonitoring holds promise for increasing participation and supporting behavioral change.[36] Although research evidences related to HBCR in India is very scarce and we did not find an even single research evidence on HBCR. There could be multiple reasons for not having HBCR in the country such as dedicated infrastructure, skilled taskforce, and financial constraints to run such programs.

  Conclusion Top

CR is increasingly recognized as an integral component of patient care with cardiovascular diseases as growing evidences on CR has proved that CR services are lifesaving and underutilized. There is a great need to revisit the CR delivery protocol and spread awareness among HCPs and major stakeholders, including cardiac patients to increase the uptake of CR. The primary focus of this review was to provide an insight about available evidences and barriers to CR program. In country like India, where there is exponential rise in CAD patients, PCI procedures, and the younger population trend getting affected by the disease, both HBCR and CBCR can play a pivotal role in reducing mortality and improving QOL, depression, and other cardiac-related parameters. Therefore, central and local health agencies of the country should work to facilitate the infrastructure to increase the uptake of CR program and that will help to reduce readmission rate in hospital and decrease mortality among cardiac patients.

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