Observational Study of Recurrent Heart Attacks and Barriers to

Participation in Exercise Training Cardiac Rehabilitation:

A Serial Case Report

Lia Miranda

, Deddy Tedjasukmana

Physical Medicine and Rehabilitation Residency Program, Faculty of Medicine, Universitas Indonesia, Indonesia

Dr. Cipto Mangunkusumo National Hospital

Cardiorespiratory Division, Physical Medicine and Rehabilitation Department, Universitas Indonesia, Indonesia

Dr. Cipto Mangunkusumo National Hospital

li4mir4nd4@gmail.com, deddytedjasukmana60@gmail.com

Keywords: Recurrent Heart Attack, Exercise Training, Barriers in Cardiac Rehabilitation

Abstract: Acute coronary syndrome (ACS) is the most common cause of mortality in Coronary Artery Disease

(CAD) patients, 20% of ACS survivors will experience a recurrent heart attack. Exercise training as a part

of cardiac rehabilitation increases the quality of life, functional capacity, prevents recurrent heart attack

and reduces mortality but the participation rate is still very low. Among 36 patients who were admitted in

July 2019 in ICCU Ward, RSCM, 14 patients had recurrent heart attacks where 11 patients did not follow

phase II cardiac rehabilitation while 2 patients took part in cardiac rehabilitation. Recurrent heart attacks

are influenced by modifiable and unmodifiable factors and exercise training as a core of cardiac

rehabilitation is important to prevent this cardiac event because it has cardioprotective mechanisms.

Patients who got recurrent heart attacks had barriers to participate in exercise training included lack of

education, difficulty to arrange schedule, transportation or distance, no rehabilitation center and lack of

awareness. Exercise training in cardiac rehabilitation has beneficial effects in preventing recurrent heart

attacks and barriers to participate in it are challenges that we must overcome.

1 INTRODUCTION

In 2016, the American Heart Association (AHA)

reported 15.5 million Americans with age more

than 20 years had coronary heart disease, where per

42 seconds a person has suffered from myocardial

infarction (Heart Disease Fact, 2017). In Indonesia,

coronary heart disease is the second leading cause

of death after stroke, which is as much as 3.6% of

the age group most often occurs in the age group of

65-74 years followed by the age group of 75 years

and over (3.2%), age group 55-64 years (2.1%) and

age group 35-44 years (1.3%) (Penyakit Jantung

Penyebab Kematian Tertinggi, 2017). According to

the European Association for Cardiovascular

Prevention and Rehabilitation, coronary heart

disease remains a leading cause of mortality and

morbidity, although mortality of coronary heart

disease has declined considerably in the past 20

years.

However, the 1-year mortality rate is around

20% in patients with myocardial infarction (MI).

Among the patients who survive, 20% will

experience a recurrent MI within 1 year. It is

estimated that recurrent events caused by progression

of coronary and systemic atherosclerosis. Secondary

prevention including cardiac rehabilitation (CR) is

therefore essential to improve the long-term

prognosis of patients with MI and to improve their

quality of life and functional capacity (Hald, 2018).

The cardiac rehabilitation program for coronary

heart disease is a class 1 recommendation according

to the American Heart Association, the American

College of Cardiology and the European Society of

Cardiology (Kachur, 2017). In 1994, the AHA

declared that cardiac rehabilitation should not be

limited to an exercise training program but also

should include multifaceted strategies aimed at

reducing or controlling modifiable risk factors so it

can reduce morbidity and mortality. Cardiac

rehabilitation as secondary prevention programs

currently include baseline patient assessments,

nutritional counseling, aggressive risk factor

management (such as lipids, hypertension, weight,

diabetes, and smoking), psychosocial and

vocational counseling, and physical activity

counseling and exercise training, in addition to the

Miranda, L. and Tedjasukmana, D.

Observational Study of Recurrent Heart Attacks and Barriers to Participation in Exercise Training Cardiac Rehabilitation: A Serial Case Report.

DOI: 10.5220/0009066001350138

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 135-138

ISBN: 978-989-758-409-1

135

appropriate use of cardioprotective drugs that have

evidence-based efficacy for secondary prevention

(Leon, 2005).

However, an exercise in cardiac rehabilitation is

commonly underused throughout this process only

30% to 50% of eligible patients are typically

referred to outpatient cardiac rehabilitation, with

fewer still completing programs (Giuliano, 2017).

The low participation in cardiac rehabilitation is

influenced by many things including transportation

problems or long distance to the heart rehabilitation

center, time problems such as difficulty in arranging

schedules due to work, economic factors, other

health factors and lack of awareness about the

importance of cardiac rehabilitation (Haddadzadeh,

2011)

From this study, we predicted that patients who

participated in the exercise program of cardiac

rehabilitation had a lower risk for recurrent cardiac

events.

2 METHODS

This is an observational study of patients who were

admitted to the Intensive Cardiology Care Unit

(ICCU) at Cipto Mangunkusumo National General

Hospital for recurrent heart attacks. Data were

obtained from patients' register in July 2019,

medical record and information by phone.

Information about patients' characteristics, risk

factors, heart attack frequency, and cardiac

rehabilitation program were gotten from patients'

registration, medical records and confirmation by

phone.

3 RESULT

Among 36 patients who were admitted in July 2019

in ICCU ward, RSCM because heart attacks, 14

patients had recurrent heart attacks consisted of 10

men and 4 women with age range 42-74 years old.

One patient had 8 times recurrent heart attacks, 2

patients had 4 times recurrent heart attacks, 1 patient

had 3 times recurrent heart attacks and 10 patients

had 2 times recurrent heart attacks (Table 1). Among

them, 9 patients had uncontrolled hypertension, 5

patients had uncontrolled diabetes mellitus, 8

patients had overweight or obesity, 9 patients have a

history of the smoking habit, 11 patients had a

sedentary lifestyle and 8 patients had genetic history.

Twelve (85.7%) of 14 patients who got recurrent

heart attacks did not a joint exercise in cardiac

rehabilitation because of many reasons. Five Patients

(41.7%) said that there were no information or

education about exercise in cardiac rehabilitation, 2

(16.7%) patients because difficulty to arrange

schedule, 2 (16.7%) patients because lack of

awareness, 1 (8.3%) patient had other medical

problems, 1 patient did not participate exercise in

cardiac rehabilitation because there was no

rehabilitation center and 1 patient because

transportation problem.

Among 14 patients who got recurrent heart

attacks, 2 patients followed cardiac rehabilitation but

1 patient was not compliance in phase II cardiac

rehabilitation because a musculoskeletal problem

that is limb pain because the history of neglected

fracture of the right femur and 1 patient did not

continue to phase III cardiac rehabilitation because

of lack of motivation.

Table 1: Patients’ Characteristic.

Characteristic

Number (%)

Age

42 – 74 y. o

Gender

Female

Male

4 (28.6 %)

10 (71.4 %)

Risk Factor

Hypertension

Diabetes

Obesity

Dyslipidemia

Smoking

Sedentary Lifestyle

9 (64.3 %)

5 (35.7 %)

8 (57.1 %)

9 (64.3 %)

11 (78.6 %)

Number of recurrent heart

attack

2 times

3 times

4 times

>4 times

Phase II and III Cardiac

Rehabilitation Exercise

Participation

Yes

2 (14.3%)

12 (85.7%)

Reasons not following CR

Lack of education

Lack of awareness

Schedule problem

Distance/transport problem

No Rehabilitation center

Other medical problems

5 (41.7 %)

2 (16.7%)

1 (8.3%)

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

136

4 DISCUSSION

Recurrent heart attacks are influenced by

unmodifiable risk factors such as genetics, age,

gender and modifiable risk factors such as

hypertension, diabetes mellitus, obesity, smoking,

dyslipidemia, and physical inactivity or sedentary

lifestyle (Humal, 2012) All of the patients who got

recurrent heart attacks was more than 40 years old

with higher prevalence in man than woman with

ratio 5:2 and 8 (57.1%) patients had genetic risk

factor. All of these increased unmodifiable risk

factors of patients to get recurrent heart attacks

(Foussas, 2016). More than 50% of patients had

uncontrolled modifiable risk factors such as

hypertension, diabetes mellitus, dyslipidemia,

smoking, overweight or obesity, and a sedentary

lifestyle. All of these also increased the risk of

getting recurrent heart attacks.

Exercise training as a core of cardiac

rehabilitation is really important to prevent these

recurrent cardiac events (Leon, 2005). Exercise in

cardiac rehabilitation has 3 phases that are a phase I

for inpatient, phase II for outpatient as long as 8-12

weeks and phase III as a maintenance phase for

lifetime exercise (Basuni, 2016). Exercise training,

as part of a comprehensive rehabilitation program,

has cardioprotective mechanisms that can slow the

progression or partially reduce the severity of

coronary atherosclerosis. Multiple factors directly or

indirectly appear to contribute to this anti-

atherosclerotic effect. Increased flow-mediated shear

stress on artery walls during exercise results in

improved endothelial function which is associated

with enhanced synthesis, release, and duration of

action of nitric oxide. Nitric oxide is responsible for

endothelium-dependent vasodilatation and inhibits

multiple processes involved in atherogenesis and

thrombosis. Chronic inflammation plays a major role

in the pathogenesis of CAD and plaque stability. The

plasma level of C-reactive protein, a nonspecific

biomarker of inflammation, is associated with an

increased risk of CAD. Aerobic exercise training

and improved cardiorespiratory endurance are

associated with reduced C-reactive protein levels,

which suggests that exercise training has anti-

inflammatory effects. Besides, exercise training and

regular physical activity can result in moderate

losses in body weight and adiposity (Leon, 2005).

Endurance exercise also can promote decreases

in blood pressure and serum triglycerides, increases

in high-density lipoprotein cholesterol and

improvements in insulin sensitivity and glucose

homeostasis which along with modest weight

reduction have been shown to reduce the risk of type

2 diabetes mellitus in individuals with glucose

intolerance. Endurance exercise training also has

potential anti-ischemic effects. it can reduce

myocardial ischemia decreasing myocardial oxygen

demands during physical activity and exercise

thereby raising the ischemic threshold. Also,

exercise training can increase coronary flow by

improving coronary artery compliance or elasticity

and endothelium-dependent vasodilatation and by

increasing the luminal area of conduit vessels

through remodeling or arteriogenesis and myocardial

capillary density by angiogenesis (Leon, 2005).

Many meta-analyses studies showed the

effectiveness of exercise in cardiac rehabilitation in

coronary heart disease. Existing data indicated that

comprehensive cardiac rehabilitation after

myocardial infarction will reduce mortality by 15%

to 28% and the mortality rate of patients undergoing

an exercise in cardiac rehabilitation decreases 26%

to 31% when compared to patients who do not

participate in cardiac rehabilitation. Guidelines

issued by the American Heart Association and the

American College of Cardiology recommend cardiac

rehabilitation in patients after a heart attack

(Stephens, 2009).

Exercise in cardiac rehabilitation is safe to do.

The incidence of side effects in supervised exercises

is very small, namely 1/50,000 to 1 /120,000 (Leon,

2005). Cardiac rehabilitation is a class I

recommendation for all patients with CAD based on

a growing body of evidence that participation can

reduce hospital bed usage, cardiovascular mortality,

as well as improve functional capacity and quality of

life but participation rate of exercise is still very low

at around 30% - 50%, and influenced by various

factors (Giuliano, 2017). This agrees with this study

where among 14 patients who got recurrent heart

attacks, 12 (85.7%) patients did not participate in

phase II cardiac rehabilitation and 2 (14,3%) patients

participated in phase II cardiac rehabilitation but 1

patient was not compliance in phase II cardiac

rehabilitation because musculoskeletal problem and

1 patient did not continue to phase III cardiac

rehabilitation because lack of motivation.

The low participation in cardiac rehabilitation is

influenced by many things including transportation

problems or long distance to the heart rehabilitation

training center, time such as difficulty arranging

schedules due to work, economic factors, other

health problems and lack of awareness that the

importance of cardiac rehabilitation (Haddadzadeh,

2011). In this study, lack of information or education

(41.7%) as being the most reason patients did not

Observational Study of Recurrent Heart Attacks and Barriers to Participation in Exercise Training Cardiac Rehabilitation: A Serial Case

Report

137

participate in cardiac rehabilitation, followed by

difficulty to arrange schedule (16.7%), lack of

awareness (16.7%), no rehabilitation center (8.3%)

and transportation or distance problem (8.3%) and