A cardiac event could be life-altering in more than one way. Playing a crucial role in the recovery of individuals following a cardiac event, is cardiac rehabilitation, which is a structured and medically supervised programme to help patients build cardiac endurance in a systematic way. Yet, cardiac rehab remains an underutilised service and there needs to be greater awareness about it, say doctors.

Muralidar Babi, cardiac rehab physician at Cardiac Rehab, Hyderabad, says heart attacks are the leading cause of death worldwide but they are 100% preventable. "Awareness of the potential benefits of cardiac rehab has been lacking, including among physicians and cardiologists. This is one of the biggest challenges. Cardiac rehabilitation as primary prevention offers a high potential to prevent heart attacks, and to rehabilitate patients who have suffered heart attacks and who have undergone procedures as secondary prevention. But it remains an underutilised service," he says.

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Making a patient who has undergone a heart procedure stand up or walk until discharge is what is conventionally done in many places, but physician-supervised cardiac rehab is much more than this. It is a customised, tailored, graded exercise programme done under medical supervision, notes Dr. Babi. "The duration ranges from three to six months depending on individuals and the extent of damage to their hearts. They will spend 90 minutes at the outpatient department three times a week. The aim is to build cardiac endurance in heart attack survivors or in people at risk. The heart is strengthened systematically. As the rehabilitation progresses, we give them a choice to engage in sports of their choice or in running. The rehab helps in preventing frequent admissions/hospitalisation and heart attacks."

Not many centres offer a proper cardiopulmonary rehabilitation programme, notes Lakshmi Nair, consultant rehabilitation physician and in-charge of cardiac rehabilitation services, Apollo Hospitals, Chennai. "Cardiac rehabilitation is strongly recommended evidence-based care that is as important as the medications prescribed by doctors. The unmet need for cardiac rehab is high in India," she says.

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According to the World Health Organization, access to rehabilitation services should be increased by 2030. But more than 50% of patients who need rehabilitation do not get access to it. There are a lot of gaps, including lack of awareness, access, funding and trained professionals such as nurses for cardiac rehabilitation, observes Dr Lakshmi. "At Apollo, all patients who undergo cardiac surgery are automatically referred for cardiac rehab. It helps to empower the patient to manage their own health better, improves their quality of life and prevents readmissions in future. It is important that cardiac rehab picks up," she adds.

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Who is eligible for cardiac rehab? Those who have suffered an acute myocardial infarction, those who have undergone percutaneous coronary intervention, coronary artery bypass grafting, heart valve repair/replacement, heart/heart-lung transplant. While these are the primary cardiac rehab qualifying events, the secondary events include chronic stable angina, heart failure, as well as diagnosis, procedure-based and implantation of ventricular assistive device and biventricular pacemaker, Dr. Lakshmi says.

Dr. Babi says that those who have undergone an angioplasty can start cardiac rehabilitation within two days, while those who have undergone bypass surgery with major sternotomy can start after 20 to 25 days as the bones need tine to heal. In the case of minimally invasive procedures, they can start in 10 to 15 days.

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At Christian Medical College (CMC), Vellore, cardiac rehabilitation services are offered by the department of cardiology and the department of physical medicine and rehabilitation (PMR). Judy Ann John, professor and head of department of PMR, CMC Vellore, said the programme is individually designed depending on the diagnosis and stability of the heart. "It is recommended for persons after a cardiac event such as a myocardial infarction or procedures such as angioplasty. Once the patient is medically stable, he/she is assessed and the programme is run by a nurse and physiotherapist," she says.

Post a cardiac event, the cardiovascular functional status such as the ejection fraction may not be good as the pumping action is reduced, Dr. Judy points out. "Rehabilitation is important for the weak muscles after a cardiac event. In cardiac rehab, we gradually train the heart to become more efficient by strengthening the heart muscle. This is done through a protocol that comprises systematic exercises, to build up the capacity of the body to take the stress of physical exertion. We gradually increase the exercises and closely monitor the capacity of the heart to function better. Psychologically, this makes a big difference in patients. It definitely improves their quality of life. Once they are out of the structured programme, they can take up running or jogging or other aerobic exercises to keep healthy," she adds.

CMC has now started cardiac rehabilitation in a branch of physical medicine and rehabilitation at its Chittoor campus as well.

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What is the success rate of cardiac rehab programmes? Dr. Lakshmi says that as per the Centers for Disease Control and Prevention, U.S., individuals who attend 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack than those who attend only one session.

Dr. Babi says the aim is to prevent early heart attacks and recurrent heart attacks. "It is the need of the hour for the rising trend of early heart attacks and premature deaths. We actively screen the public, conduct workshops and encourage people to build cardiac endurance, which is key to preventing heart attacks," he says. The centre conducts cardiac rehab runs every World Heart Day to raise awareness, with this year's event happening on September 21.

"Besides this, we have Cardiac Rehab Runners, a maintenance club of around 180 heart patients who have completed the cardiac rehab. We meet up every Sunday and call it the Sunday Morning Run. We meet up at various parks and events and run together and network with each other to build confidence in each patient. Each patient participates in around 30 to 40 runs per year," he adds.

Dr. Babi points out that very few centres offer cardiac rehabilitation programmes. "The volume of patients is high but less than 1% know about cardiac rehab in India, whereas it is mandatory in countries such as the U.S. and U.K. The government should bring in cardiac rehab as a policy so that more people can be reached and rehabilitated," he emphasises.

Building the heart's endurance through cardiac rehabilitation