Cardiovascular disease takes the lead as the primary global cause of mortality, claiming around 17.9 million lives annually1, accounting for a striking 32% of all global deaths. A substantial 85% of these cases are from heart attacks and strokes.
Shifting our focus to Singapore, the daily toll paints a serious picture: 23 lives succumb to cardiovascular disease due to heart conditions and strokes. In 20222, this condition contributed to 31.4% of all recorded deaths, highlighting that over one-third of mortalities are attributed to heart ailments and strokes.
Think of your heart as a never-tiring muscle pumping life-sustaining blood to ensure your body functions seamlessly throughout your lifetime. However, as one ages, subtle shifts akin to the wear and tear on an engine are introduced, affecting both the heart and blood vessels. As the years advance, your heart's response to physical activity and stress may slightly diminish compared to your youthful vigor. Nevertheless, the heart rate during periods of rest remains remarkably steadfast, unaffected by the passage of time.
These changes to your heart and blood vessels can amplify the risk of heart disease, a significant contributor to disabilities that limit daily activities and can negatively affect the quality of life in older individuals. But here's the silver lining: There are things you can do to delay, lower, or even avoid and reverse your risk through cardiac rehabilitation. It is a therapeutic approach that offers a tailored strategy to regain and enhance heart health, encompassing exercise, dietary modifications, and lifestyle adjustments. By embracing such modifiable risk factors, individuals can delay, lower, or even reverse their risk of heart disease.
At its core, the overarching aim of cardiac rehabilitation is to elevate heart health and overall well-being, safeguarding against the recurrence of cardiac events. While the program elements are simple, and some are common knowledge, they must be guided and monitored.
“Cardiac rehabilitation is a medically supervised holistic program designed to improve your cardiovascular health if you have experienced a heart attack, heart failure, angioplasty, or heart surgery,” Dr. William Kristanto explained.
In addition to physical exercise-based activity to strengthen the heart, the programs also include patient education sessions focusing on heart disease conditions and risk factors, treatment, and risk factor modification to empower patients to care for themselves.
“As the lead in cardiac rehabilitation, I work very closely with my colleagues from allied health, especially the physiotherapist, in helping our patients get back to physical activities. We also work with the dieticians to provide our patients with nutritional advice on a heart-healthy diet to lower their low-density lipoprotein (LDL) to target and control their diabetes," he added.
LDL is also known as “bad cholesterol”, and a high LDL level leads to a build-up of cholesterol in the arteries, which raises the risk of heart disease and stroke. Beyond the lifestyle modifications and depending on the patient's lifestyle choices and emotional state, Dr. Kristanto said the program also includes stress reduction, psychological support, optimal adherence to medication, and smoking cessation.
The program can be broken down into the following phases: the hospitalization phase, the outpatient phase, and the maintenance phase3. It can start while the patient is still in the hospital or right after they leave the hospital. In most cases, the program takes place post-surgery. Hence, initiating earlier at the hospitalization phase to assist patients' cardiovascular system adaptation to physical activity. It also has an essential role in terms of discharge planning. The advantage is that since the cardiac episode is still fresh in the patients' minds, their reception of patient education about risk factors and lifestyle changes is better, and they are more likely to commit to a long-term secondary prevention plan tailored for them while they are still in the hospital.
The main part of the outpatient program is monitoring physical exercise and calibrating the intensity based on personalized clinical assessment, with inputs from exercise stress testing, stimulation from favorable lifestyle changes, adherence to secondary prevention measures, and patient participation.
The maintenance phase is to keep up with the established lifestyle changes to stabilize health under minimal professional supervision. If their participation during the outpatient phase is active, the patient will likely continue lifelong behavior involving lifestyle changes that may minimize the risk of further cardiac symptoms or events.
“In general, we can target the modifiable cardiovascular risk factors by controlling our diet to reduce our LDL levels, engaging in more physical activities, avoiding smoking, and reducing stress,” Dr. Kristanto explained.
“There has been increasing evidence in the medical literature that patients who enroll in cardiac rehabilitation have lower mortality and morbidity compared to those who did not, especially amongst patients who underwent cardiac surgery or coronary intervention,” he added.
He said the most critical factor is patients' commitment to the program, which helps ensure their adherence to their medications, does their exercises, and sticks to their dietary plan.
“These modifiable factors involve quite a change in their lifestyle and formation of good habits, which goes a long way,” he said.
A further point on cardiac rehabilitation benefits outcome is an improved psychosocial function resulting from the prospect of being able to return to work and joining other social and recreational activities4. Psychological distress and poor social support have been shown to affect heart health rehabilitation of poor outcomes. Through monitoring, cardiac rehabilitation may screen heart patients for signs of depression and anxiety and offer patients counseling. It helps to address the patient's health beliefs and concerns and clarify their cardiac misconceptions.
Despite the numerous advantages it offers, cardiac rehabilitation services often remain underutilized. The reasons behind this are multifaceted and involve various hurdles. For instance, some patients need more motivation or willingness to modify their lifestyle. Work commitments, financial limitations, and the limited availability of outpatient rehabilitation centers also pose significant barriers.
“It starts with awareness amongst doctors and patients, followed by enabling factors like overcoming logistical issues and finally cost issues,” Dr. Kristanto explained.
Specialized cardiac rehabilitation services are available at Farrer Park Hospital. These services span both the inpatient wards and the Medical Centre. Beyond that, once discharged, patients can transition to private practices referred by their heart specialists to continue the regime. Referrals can also be made to continue cardiac rehabilitation at restructured hospitals and community-based centers, which may be closer to their home.
The Singapore Heart Foundation has also expanded its reach, establishing community-driven cardiac rehabilitation programs for patients who have concluded their hospital inpatient and outpatient rehab journeys. The three Heart Wellness Centres are strategically positioned across Singapore, serving as hubs for additional rehabilitation services in the maintenance phase, support groups, and heart health lectures to further educate and aid patients on their path to recovery.
The COVID-19 pandemic saw the suspension of conventional center-based cardiac rehabilitation activities. This situation accentuated the necessity for alternatives, particularly home-based cardiac rehabilitation, either through therapist home visits or telerehabilitation. These alternative modes of service delivery are convenient, especially for patients with limited mobility.