Cardiac Rehabilitation: Future of Heart Health in Saudi Arabia, a Perceptual View

Objective: Having a heart healthy life is one of the most rewarding gifts that you can own yourself in the modern lifestyle practices. Cardiac rehabilitation (CR) is the next step to recover and reverse the limitations experienced by patients who have undergone all the adverse pathophysiological and psychological consequences of cardiac events. Design: This is a review article. The need for cardiac rehabilitation: CR describes all the methods and measures used to prevent recurrent cardiac attaches and to return people with heart diseases to an active and a satisfying lifestyle. CR services should be offered by all health professionals who are in direct contact with the patient, like cardiac specialist, general practitioner, and other health care providers. The success rate of the CR program improves dramatically when it comes in parallel with limiting modifiable risk factors of cardiovascular diseases. The CR programs not only manage episodes of cardiac events, but also it is a comprehensive tool for preventing future heart problems and improving the patients’ life standard. Goals of Cardiac rehabilitation (CR): CR program has been evolved with a wide range of indications that aims to regain autonomy and maximize the physical, psychological and social activities. This makes people with cardiac diseases more confident and inspires behaviors that may minimize risk of further cardiac events. The vision to improve CR in Saudi Arabia: This article will focus on the methods and parameters that will lead to an improvement in the CR services in the Kingdom of Saudi Arabia.

prehensive in nature, but it must be also individualized in its functions and activities [1].
The utility of scientific evidence-based practice concepts recognizes importance of CR. There are research studies that reveal the help of CR in decreasing rate of mortality, morbidity, and recurrence of the cardiac events along with lifestyle modification practices, activity improvement and psychosocial wellness. This review analyzes evidence of cardiac rehabilitation benefits and utilization of this service [1] [2].
The Need for Cardiac Rehabilitation CR describes all the methods and measures used to prevent recurrent cardiac attaches and to return people with heart diseases to an active and a satisfying lifestyle CR services should be offered by all health professionals who are in direct contact with the patient, like cardiac specialist, general practitioner, and other health care providers [2] [3] [4].
Increasing number of deaths from cardiovascular diseases made a pressing need to search for a life-saving approach, which could prevent incidence of cardiac diseases and reduce rate of mortality related to heart problems. Recent evidence shows that, people who follow the proper CR services may decrease up to 30 percent of fatal cardiac events in patients, who are also less likely to die compared to those cardiac patients following standard management regimens. Clients who are managed with CR have a benefit of lowering the chance of contracting a second cardiac event [5].
Inception and Progression of Cardiac Rehabilitation By 1980s, CR developed from a simple exercise program to a multidisciplinary approach, which speeds up the recovery and improves the quality of life of cardiac patients. This approach involves the utilization of a medical and a lifestyle modification model. A systematic review by the American Heart Association (AHA) [3] [4] stated that the CR program should not be based solely on an exercise training, but also should cover multiple individual strategies aimed at reducing modifiable risk factors for coronary heart disease [3] [4].
Development of standardized guidelines sponsored jointly by the Agency for Health Care Policy and Research and the National Institute of Health, helps to broaden the opportunity of CR programs. They recommended to add the assessment of patient's current status and risk factor modification by various strategies to improve the overall health. Various guidelines for the clinical practice of cardiac rehabilitation has been formed by agencies of health care, and currently the program functions as an important tool in primary and secondary prevention of cardiac events [5].

Goals of Cardiac Rehabilitation (CR)
This program has been evolved with a wide range of indications that aims to regain autonomy and maximize the physical, psychological and social activities.
This makes people with cardiac diseases more confident and inspires behaviors that may minimize risk of further cardiac events [6] [7]. The CR program prevents the recurrent hospital admissions by offering a lot of goals that help reducing duration of hospital stay including: speed recovery time after an acute cardiac event motivates patients to follow a healthy lifestyle, maintains the achieved behavior change and self-management. All these goals should be in parallel with the prescribed medications and professional advice [8].
Indications CR should be provided to the following patient groups irrespective to age, sex, ethnic and clinical condition.
According to the British association for cardiovascular prevention and rehabilitation (BACPR), the major groups of patients must benefit from the program are: [8]  Acute coronary syndrome, Class I, level of Evidence: B  Coronary revascularization, Class I, level of Evidence: B  Heart failure, Class I, level of Evidence: B Other clinical indications of the program include: [8] patients with stable angina, peripheral arterial disease, post-cerebrovascular event, post-implantation of cardiac defibrillators and resynchronization devices, post-heart valve repair/replacement, post-heart transplantation and ventricular assist devices, Adult Congenital Heart Disease (ACHD) and Recent stable myocardial infarction.
The CR program can be started upon hospital admission and after discharge with regular continues visits.
Phases of Cardiac Rehabilitation Cardiac rehabilitation program consists of three phases. Phase I is intended to be both preventive and diagnostic and typically an inpatient service., It encompasses early mobilization, patient and family education, the treatment, safe discharge, risk factors modifications, and follow-up planning. Phase II is mainly directed to ambulatory outpatient program. Phase III is a lifetime maintenance phase, where the goal is to continue the risk factors, lifestyle change and exercise training. There is another way of CR delivery including home-based programs and e-health programs; such as those using Internet and mobile phones applications [5] [6] [7] [8] [9].

Core Components
Cardiac rehabilitation program's end benefit is based on the combination of all its components. The principle elements of CR includes: 1) patient selection and good assessment; 2) physical activity counseling; 3) nutritional counseling; World Journal of Cardiovascular Diseases 4) risk factors control; 5) patient education; 6) psychosocial management, and 7) vocational advice, with physical exercise being a central component [6]- [11].

Patient Assessment with Medical Control
Assessment is an important tool to make the client aware of concepts on cardiac rehabilitation and to optimize the benefits. Assessment starts with completing medical history sheets by asking well-framed questions about cardiovascular risk factors, other co-morbidities (psychological stress), and the extent of compliance to medical treatment. A clinical examination and diagnostic test results should be also obtained as a part of the assessment [10] [11].
Physical activity counseling: Physical activity has many associated benefits like; weight loss, lowering blood pressure, and improvement of lipid profiles. A minimum of two hours/week of moderate intensity aerobic activity in a good weather, in multiple bouts (each lasts ≥ 10 minutes), on 5 days a week is recommended. The prescription of these activities should be concordant with the patient's age, habits, co-morbidities, preferences and goals [12] [13] [14].

Exercise:
One of the most important components of the CR program is the exercise.
The development of exercise protocol is a key element for patients who are undergoing CR. The assessment of exercise capacity by symptom-limited stress testing, either on a treadmill or on bicycle ergometer should be considered. Exercise protocol must be developed on personalized basis according to the outcomes of the physical capacity tests. In this respect, the intensity of exercise could be moderate or high intensity interval aerobic training [15] [16].

Dietary Modifications/Nutritional Counseling:
The modification of dietary habits is one of the best approaches that can be adopted for fighting cardiovascular diseases and promoting wellbeing of patients.
A healthy diet is based on the assessment of the daily caloric intake, consumption of dietary fat, especially the amount of saturated fat, the amount of sodium, and quantities of other nutrients.
Education on healthy diet and encouragement for coping with the modified dietary patterns has got a key role in management and prevention of cardiac events. Studies revealed that the occurrence of cardiovascular events is less among people whom diet is low in saturated fat and cholesterol and rich in fiber and fish contents. High content of saturated fat not only increases serum cholesterol levels, but also increases the activity of clotting factor VII, which correlates with the risk of cardiovascular events [17] [18] [19]. The concept of reducing obesity and proper weight management has a great importance in health promotion. The motivation to maintain an appropriate balance of physical activity and caloric intake is a fulfilled characteristic in CR program. Therefore, a healthy body mass index (BMI; 20 -25 kg/m 2 ) for an adult is recommended. Also, measurement of waist circumference is another indicator (reference is ≥80 cm for women and ≥94 cm for men), to initiate lifestyle modifications and consider management strategies for metabolic syndrome [20] [21].  Low cholesterol level Assessment of the lipid profiles and modifying diet, physical activity, and medication as appropriate may help to achieve the target reference level of low-density lipoprotein cholesterol (LDL-c), which is <1.8 mmol/l (<70 mg/dL) [22] [23] [24].  Blood pressure management The main advice here is to measure the blood pressure at rest on a regular basis. According to the guidelines if resting systolic blood pressure is 140 mmHg or diastolic blood pressure is 90 mmHg, lifestyle changes are recommended. Then continue monitoring of blood pressure if it rises more than the guidelines limits despite lifestyle changes, initiate drug therapy [21] [22] [23].
Vocational advice: It is better to arrange patient's relative meeting before discharge, in order to discuss and encourage return to prior activities, and to help them to overcome barriers to return to work; such as re-training, capacity-building and reasonable adjustments [25] [26].

Impact of CR on CVD
CR data in recent studies showed more than 20% reduction in all causes of death and about 25% in cardiovascular disease-related death. Both, regular exercise and physical fitness are associated with a reduced risk of coronary events and sudden death due to cardiac issues [8] [27].
Exercise and cardiovascular diseases: Physical activity is a key lifestyle behavior with numerous beneficial effects on exercise competence, and acts as a tool for prevention of coronary artery disease. In recent public health recommendations, all people should be physically active for 30 min. of moderate strength exercise on most days of the week. These recommendations are agreed by the American College of Sports Medicine [28] [29].
For the past 30 years, exercise was started to be used for cardiac patients' rehabilitation gradually and has also been recommended for cardiac patients upon discharge [29].
In normal physiology, the heart rate (HR) response during exercise is linear; it increases with exercise because of the balance between the vagal and the sympathetic tone, whereby increasing the sympathetic stimulation and reducing the vagal tone, the patient achieves a higher HR during exercise. In recovery, the HR decreases because of the vagal tone, which causes a rapid decrease of the HR. World Journal of Cardiovascular Diseases The phenomenon of abnormal heart rate recovery is defined as a delayed decrease in heart rate of ≤12 beats per minute at 1 min, and ≤22 beats per minute at 2 min. The presence of either chronotropic incompetence or abnormal heart rate recovery during exercise is partly due to abnormalities of the sympathetic and the parasympathetic tone and known predictors of higher cardiovascular morbidity and mortality. With CR training protocols, the achievement of increased vagal tone and decreased sympathetic tone is documented, resulting in a lower resting HR and improvement in chronotropic incompetence [29] [30] [31].
During the time of exercise, in normal responders, the systolic blood pressure (SBP) is progressively increasing with the strength and amplitude of exercise of about 10 ± 2 mmHg/metabolic equivalent (MET); this can reach a possible plateau at peak exercise. Whilst in cardiac patients, the response of SBP during exercise could be normal, or it may increase or decrease abnormally. During stress test, when the SBP reaches more than 250 mmHg with exercise, the term exertional hypertension is coined. Exertional hypertension may harm the patient and indicate termination of the test. On the other hand, failure of SBP to rise during exertion is referred to exertional hypotension. This drop may be below the resting or the initial blood pressure. If the SBP decreased by ≥10 mmHg during an exercise stress test, the test should be stopped. This may be endorsed to heart failure, a large area of ischemia induced by exercise or papillary muscle dysfunction with mitral regurgitation, and in this case, there is increased risk of future cardiac events. During the CR program, there is a significant reduction in both SBP and DBP. This reduction in blood pressure has a great value in patients with mild-to-moderate hypertension with average values of 6-8mmHg for SBP and 3 -5 mmHg for DBP [31] [32].
The oxygen uptake increases by 8 to 10 folds during sustained exercise, which will help the heart to maintain normal cardiac output and muscles contraction.
In this regard, the CR program helps the patient to increase the oxygen uptake up to 20% to 30%.
In cardiac patients, the cardiac output may be reduced either due to chronotropic incompetence or due to causes of left ventricular failure. These include myocardial infarction or ischemia, resulting in a decrease in both heart rate and stroke volume. This reduction in cardiac output will be improved by rehabilitation [32] [33].
The improvement of the modifiable risk factors by the personalized rehabilitation plan, side by side with the pharmaco-therapy, is associated with a rapid improvement in physical function. However, the recovery period may extend from six weeks to six months or longer to manage the medical condition and build up healthier habits.
In addition, CR program helps the physician and the patient to improve lipid profile, control blood pressure, and may also help to treat and prevent diabetes mellitus Type -II. Also, the inflammatory markers (C-reactive protein, for ex-World Journal of Cardiovascular Diseases ample) are reduced during the rehabilitation, which also leads to weight loss, and possibly ischemic preconditioning. Exercise is also associated with improved endothelial function with a more favorable fibrinolytic balance. It also decreases emotional distress and depression allowing the patient to have a higher quality of life.
Such benefits of CR noticeably occur only if the patient attends and completes an appropriate program. A susceptibility matched analysis stated that the survival was higher in completers, so, The Adherence of patients to exercise maximizes the benefits of CR [32] [33].

CR in Guidelines and its Application in the Middle East: [34] [35] [36] [37]
CR program is implemented in a wide variety of models. These are based on well-framed and standardized guidelines. Different levels of valid programs had been used by many cardiology societies.
The American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) afford more detailed guidelines. It was entitled "Putting More Patients on the Road to Recovery", the working group reported that better health outcomes from cardiac rehabilitation were associated with reduced hospitalizations and hence can control the financial load.

The British Association for Cardiovascular Prevention and Rehabilitation
(BACPR) group updated their guidelines which based on the six standard strategies summarized in a simple pathway to deliver high quality medical and educational plans for all cardiac patients as follows: [8] [37] [38] The six standards for cardiovascular prevention and rehabilitation are: 1) The delivery of six core components by a qualified and competent multidisciplinary team, led by a clinical coordinator.
2) Prompt identification, referral and recruitment of eligible patient populations.
3) Early initial assessment of individual patient needs which informs the agreed personalized goals that are reviewed regularly.

4) Early provision of a structured cardiovascular prevention and rehabilitation
program (CPRP), with a defined pathway of care.

5) Upon program completion, a final assessment of individual patient needs
and demonstration of sustainable health outcomes.
6) Registration and submission of data in a specific program.
The Canadian Association of Cardiac Rehabilitation (CACR) has also developed detailed guidelines, their study resulted in a 31% reduction in hospital readmissions and a 26% drop in cardiovascular mortality for a 7% return on investment.
In Asia, English-language cardiac rehabilitation guidelines have only been published in Japan [39] [40]. World Journal of Cardiovascular Diseases All the mentioned guidelines and statements recommend the use of a medical protocol parallel to an exercise protocol when applicable, and also they reported limitations for referral to CR unit including, the elderly, women, minority populations, lack of knowledge about CR and patients with lower socioeconomic status, and unfortunately, the mentioned group are less likely to take that first critical step to enroll after referral. This is of great concern because women and minorities are far more likely to die within five years after a first heart attack as compared to their white male patient counterparts. In

The Vision to Improve CR in Saudi Arabia
Both awareness of CR programs and patient referrals are considered the main corners of these programs. There is a noticeable effort used to increase the patient's participation in CR programs, along with subsequent program enrollment and completion. Patients must be referred to participate in CR. This step takes place before or soon after hospital discharge following a cardiac event. Many factors are associated with limited referral and enrollment such as:  Female sex, old age, comorbidities including depression and musculoskeletal diseases. The arrangement of regular home visits with well trained personnel will add in helping those people to engage the CR program with the feasibility of choosing appropriate scheduled times and date.  Lack of awareness of CR program should be eliminated by the assigned treatment council and discussing the importance of CR program with patients clearly before discharge through different types of communications.  Lack of referral to participate from the patient's physician. This point is the limiting step in the program and should be avoided by changing each Hospital policy to include the CR referral form within the discharge papers of the patient and scheduling the appointment.  The cooperation between cardiology, cardiothoracic and physiotherapy departments should be achieved to handle the cardiac patients in the CR program.  The highly qualified physicians should be available in different regions to help in providing the appropriate CR services by creating small training groups in each Hospital and mastering the service.  Establishing a link between the college of Medicine, college of Applied Medical Sciences and college of Nursing to provide the manpower of the CR unit.  The cooperation between governmental and the private centers that provide CR program. The financial, academic and equipment support will give a great help in such cooperation.  Increase the number of CR units.
 Distance to CR facility from patient's home.
 Work or home responsibilities towards patients doing CR.
 Male gender-dominated programs and little female staff.
 The Lack of specific Arab countries guidelines.
 Language problems and cultural believes.
All the above factors are considered obstacles in the future of the CR program in the Kingdom. Healthcare policy is a critically important part of the solution to fill the gap in delivery of cardiac rehabilitation.