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61
ORIGINAL ARTICLE
Adherence in Following Phase II Cardiac Rehabilitation Program among
Patients with Coronary Artery Disease Post-Revascularization
Arnengsih Nazir1, Badai Bhatara Tiksnadi2, Fahreza Pradana3
1
Department of Physical and Rehabilitation Medicine, Dr. Hasan Sadikin General Hospital/Faculty of
Medicine Universitas Padjadjaran, Bandung, Indonesia,
2
Department of Cardiology and Vascular Medicine, Dr. Hasan Sadikin General Hospital/Faculty of
Medicine Universitas Padjadjaran, Bandung, Indonesia,
3
Faculty of Medicine Universitas Padjadjaran, Bandung, Indonesia
ABSTRACT
Purpose: This study aimed to describe the adherence of patients with coronary artery disease (CAD) in
initiating, sustaining, and completing phase II cardiac rehabilitation (CR) program after revascularization
with Coronary Artery Bypass Graft (CABG) and Percutaneous Coronary Intervention (PCI).
Methods: This study was conducted using a descriptive cross-sectional design and secondary data were
taken retrospectively from medical records. The population was post-revascularization CAD patients
undergoing phase II CR at Dr. Hasan Sadikin General Hospital from 2019-2020 and all samples were
selected using the total sampling method. Adherence was defined as the ability to initiate, sustain, and
complete CR program in the CABG and PCI groups, and it was expressed in percentage.
Results: A total of 96 subjects were found to meet the inclusion and exclusion criteria. The adherence
for initiating the CR program was 94.6% and 100% in the CABG and PCI groups respectively. A total of
50 (67.56%) and 16 people (72.72%) in the respective groups completed each training session on time
as programmed. About 57 (77.02%) and 16 people (72.72%) in each group respectively completed 12
training sessions regardless of the specified time.
Conclusion: Overall, the level of adherence to following phase II CR in the CABG and PCI groups was
relatively high. Adherence to initiating and sustaining phase II CR in the PCI was higher than in the
CABG group.
Keywords: adherence, cardiac rehabilitation, Coronary Artery Bypass Graft, Percutaneous Coronary
Intervention
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ABSTRAK
Pendahuluan: Penelitian ini bertujuan untuk menggambarkan kepatuhan pasien dengan penyakit arteri
koroner (PAK) setelah revaskularisasi dengan bedah pintas arteri koroner (BPAK) dan intervensi koroner
perkutan (IKP) dalam memulai, menjalani, dan menyelesaikan program rehabilitasi jantung (RJ) fase II.
Metode: Penelitian ini bersifat deskriptif dengan desain potong lintang. Data sekunder retrospektif
diambil dari rekam medis. Populasi penelitian ini adalah pasien PAK yang menjalani revaskularisasi dan
mengikuti RJ fase II di Rumah Sakit Umum Dr. Hasan Sadikin pada tahun 2019-2020. Pengumpulan
sampel dilakukan dengan metode sampling total. Kepatuhan digambarkan sebagai kepatuhan memulai,
menjalani, dan menuntaskan program RJ pada kelompok BPAK dan IKP serta dijabarkan dalam persentase.
Hasil: Sembilan puluh enam subjek memenuhi kriteria inklusi dan eksklusi. Kepatuhan memulai program
RJ setinggi 94,6% pada kelompok BPAK dan 100% pada kelompok IKP. Lima puluh subjek (67,56%)
pada kelompok BPAK dan enam belas (72,72%) pada kelompok IKP menjalani sesi latihan sebagaimana
terjadwal. Sebanyak 57 subjek (77,02%) pada kelompok BPAK dan 16 subjek (72,72%) dari kelompok
IKP menyelesaikan 12 sesi latihan, tanpa memandang waktu yang diperlukan untuk menuntaskannya.
Simpulan: Secara keseluruhan, kepatuhan mengikuti program RJ fase II pada kelompok BPAK dan IKP
cukup tinggi. Kepatuhan untuk memulai dan menjalani program RJ fase II pada kelompok IKP lebih
tinggi dari kelompok BPAK.
Kata kunci: bedah pintas arteri koroner, intervensi koroner perkutan, kepatuhan, rehabilitasi jantung.
Correspondent Detail:
Arnengsih Nazir
Department of Physical and Rehabilitation
Medicine, Faculty of Medicine Universitas
Padjadjaran, Dr. Hasan Sadikin General
Hospital, Bandung, Indonesia
Email: arnengsih@unpad.ac.id
INTRODUCTION
Heart disease is one of the major health problems
worldwide, including in Indonesia. According
to the Basic Health Research data (Riskesdas)
in 2018, the prevalence of heart disease based
on the diagnosis of the physician among all
ages in all provinces was 1.5% of the 1 million
population.1 The most common cause of death
from heart disease is coronary artery disease
(CAD). Indonesian Sample Registration System
(SRS) survey in 2014 showed that CAD is the
second-leading cause of death among all ages
after stroke, accounting for 12.9%.2
The medical assessment of CAD patients is
generally implemented by pharmacologic therapy
either with or without surgery. The most common
non-surgical procedure is Percutaneous Coronary
Intervention (PCI) and the surgical option is
Coronary Artery Bypass Graft (CABG). After a
successful medical intervention, patients usually
undergo a cardiac rehabilitation program (CR)
to restore their functional abilities and gradually
return to normal daily activities.3
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CR program is well-organized and consists of
several core components such as prescribing
physical exercises, controlling risk, and managing
psychosocial factors. It is a secondary prevention
program and aims to prevent the deterioration of
disease or recurrence.4-6 This program consists
of 3 phases, namely 1 (inpatient), 2 (outpatient),
and 3 (community).5-8 A study reported that
participation in CR could support a healthy
lifestyle, alleviate risk factors, improve quality of
life, and reduce the mortality rate.9-10
Supporting patients to modify their lifestyle by
controlling risk factors and providing appropriate
exercise prescriptions can mitigate the disease.11
Pouche et al. found that completion of CR program
reduced both mortality and hospital admission
rate. Furthermore, identifying and controlling
individualized risk factors can be more effective
in planning interventions for each CAD patient.12
Other studies suggested that CR was associated
with a 20-30% reduction in cardiac hospitalization
and a 26% decline in cardiac mortality. Pack et
al. also reported that participation in CR was
associated with a 45% reduction in all-cause
mortality.14 Sjolin et al. showed that patients
attending CR had mitigated cardiovascular risk
factors, including rates of smoking cessation
and improvement in physical activity, as well as
a greater reduction in triglyceride levels, body
weight, and cholesterol levels.15
Although the benefits of CR are widely known,
several factors have become concerned barriers
to implementing the program. These common
barriers include low referral rates, limited
transportation, tight schedule, aversion to
group therapy, economic conditions, and lack
of insight.13 Another significant factor is the
adherence of patients in undergoing phase II
63
CR. Patients’ adherence is a crucial condition
that can be amplified to improve cooperation.
Implementing CR program in hospitals, at home,
or through telerehabilitation has culminated in
enhancing functional capacity, physical activity,
and the quality of life in post-CABG patients.16
Based on the above explanation, this study aims
to examine the adherence of CAD patients after
revascularization to initiating, sustaining, and
completing phase II CR program at Dr. Hasan
Sadikin General Hospital (RSHS) which has
integrated cardiac services. The results are
expected to be used as a reference in improving the
services for CAD patients undergoing phase II CR.
METHODS
This was a descriptive, cross-sectional
study carried out using secondary data taken
retrospectively from medical records. This
study was conducted after obtaining approval
from the Ethics Committee of the Faculty of
Medicine, Universitas Padjadjaran No.75/UN6.
KEP/EC/2020. The population was patients with
CAD who underwent revascularization using the
PCI and CABG methods as well as phase II CR
at RSHS in 2019-2020. The inclusion criteria
were patients with CAD post-revascularization
and undergoing phase II CR from September
1st, 2019 – February 29th, 2020. Subjects were
excluded when the medical record data were
inaccessible, damaged, or illegible. Sample
selection was carried out with the total sampling
method by taking all medical record data that met
the inclusion and exclusion criteria.
Data were processed using Microsoft Excel 2016
as well as IBM SPSS Statistics version 22, and
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presented descriptively. The characteristics of
subjects were described based on age, gender,
level of education, occupation, domicile, type of
revascularization measures, residential address,
and insurance. These characteristic data were
grouped based on the type of revascularization
performed, namely PCI and CABG.
Adherence to CR program was determined by
adopting the 2013 American Association of
Cardiovascular and Pulmonary Rehabilitation
(AACVPR) guidelines for cardiovascular
rehabilitation and secondary prevention. It
was calculated from the time patients were
discharged from phase 1 CR (hospital care)
until their revisit for phase II CR which begins
1-2 weeks or 8 weeks post-treatment.17 In this
study, subjects were considered to be adherent
when they initiated phase II CR within 1 week
to 2 months after discharge. Adherence in
sustaining the program was determined based
on the attendance to complete phase II CR as
assisted by the doctor 2 times a week for 6-12
weeks. Meanwhile, adherence to completing the
program was determined based on the number
of subjects who have completed phase II CR, as
declared by the doctor and proven by the final
evaluation data. The adherence to initiating,
sustaining, and completing CR program was
expressed in percentage. The results obtained
were then grouped based on the characteristics
of each subject to obtain a description of
adherence.
RESULTS
A total of 96 subjects met the inclusion and
exclusion criteria in this analysis with 12 or
12.5% being females and 84 or 87.5% males.
Table 1 presents the demographic characteristics
of the subjects divided into 2 groups based on the
type of revascularization, with 74 and 22 people
for CABG and PCI, respectively.
Based on age characteristics, the majority of
the subjects were aged 55-64 years both in the
CABG and PCI groups with 28 people (37.8%)
and 10 people (45.5%), respectively. The
majority of subjects were domiciled around
Bandung City which has convenient access
to RSHS, namely 49 (66.2%) and 14 (63.6%)
people in the CABG and the PCI groups,
respectively. Based on job characteristics, most
of the subjects in the CABG group namely
22 people (29.7%) were private employees,
while in the PCI group, more than 7 people
(31.8%) were entrepreneurs or self-employed.
Additionally, most of the subjects had
health insurance, namely 69 (93.2%) and 22
(100%) people in the CABG and PCI groups,
respectively.
Table 2 provides an overview of patients’
adherence in following phase II CR. It was
found that the level of adherence in initiating
the program was high, with 94.6% in the
CABG and 100% in the PCI group. A total
of 50 (67.56%) and 16 (72.72%) subjects in
both groups respectively participated in each
training session prescribed. All subjects were
given 1 episode of CR for 6 weeks or 12
training sessions. About 57 (77.02%) subjects
in the CABG and 16 (72.72%) in the PCI group
completed the 12 training sessions regardless
of the time needed.
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Table 1. Demographic Characteristics
Total
Characteristics
CABG
n= 74
PCI
n=22
35-44
3 (4.1%)
5 (22.7 %)
45-54
23 (31.8%)
3 (13.6 %)
55-64
28 (37.8%)
10 (45.5 %)
65-75
19 (25.6%)
2 (9 %)
1 (1.4%)
1 (4.5 %)
Male
66 (89.2%)
18 (81.8 %)
Female
8 (10.8%)
4 (18.2 %)
49 (66.2%)
14 (63.6%)
Bandung Regency
3 (41%)
3 (13.6%)
Bandung Barat Regency
2 (27%)
2 (9%)
Outside Bandung City
3 (41%)
3 (13.6%)
Elementary School
0
0
Middle High School
4 (5.4%)
0
Senior High School
21(28.3%)
3 (13.6 %)
7(9.5%)
4 (18.2 %)
41(55.4%)
15 (6.2%)
Entrepreneur
18 (24.3%)
7 (31.8%)
Housemaid
1 (13.5%)
2 (9 %)
Civil Servant
18 (24.3%)
3 (13.6 %)
Retiree
21 (28.3%)
6 (27.3%)
Employee
22 (29.7%)
4 (18.2%)
4 (5.4%)
0
Yes
69 (93.2%)
22 (100%)
No
5 (6.75%)
0
Age, n (%)1
75+
Gender, n (%)
Domicile, n (%)
Bandung City
Educational Stage, n (%)
Diploma
Bachelor or higher
Occupation, n (%)
Laborer
Health Assurance, n (%)
65
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Table 2. Adherence in Following Phase II Cardiac Rehabilitation
Adherence Characteristic
Adherence to initiate, n (%)
Yes
No
Adherence to sustain, n (%)
Yes
No
Adherence to complete, n (%)
Yes
No
DISCUSSION
This study showed that, in general, the adherence
in following phase II CR at RSHS was relatively
high, above 65%. It was found that 94.6% and
100% of subjects in the CABG and PCI groups,
respectively, initiated phase II CR. According
to Soroush A et al., the referral rate for postCABG patients to undergo phase II CR was very
low (8.3%) and lower than the general referral
rate in Iran, which was below 15%. Most of the
cardiologists in Iran noted that the main reasons
for the low referral rate were lack of awareness
about the benefits of CR and health insurance, high
costs, and difficulty in accessing CR centers.18
However, this study did not assess referral rate
as one of the factors to analyze the adherence to
phase II CR. Regardless of the referral rate, it was
found that 94.6% - 100% of patients started phase
II CR as scheduled. This indicated that the low
level of coverage can be determined by external
factors such as low referral rates.
Subject adherence in sustaining phase II CR was
67.56% in the CABG and 72.72% in the PCI
group. This was better than the result obtained by
Types of Revascularizations
CABG
PCI
n=74
n=22
70 (94.6%)
4 (5.04 %)
22 (100%)
0
50 (67.56%)
24 (32.43%)
16 (72.72%)
6 (27.7%)
57 (77.02%)
17 (22.97 %)
16 (72.72%)
6 (27.27%)
Chai Li Sze et al. wherein 72.6% of patients were
absent and 12.1% dropped out before completing
the program.19 According to Pardaens S et al.,
patients who withdrew from CR prematurely had
twice the risk of cardiovascular events or death
than those who attended more than half of the
sessions. In either the group of patients with acute
coronary syndrome or post-PCI, withdrawal was
associated with an adverse outcome in CR.20
The adherence in completing CR program was
relatively high, namely 77.02% in the CABG
and 72.72% in the PCI group. Several studies
suggested that the health benefits of CR were
related to patients’ commitment and participation
in completing the program for 12 weeks. Sze
et al. found that the completion rate of CR
among the referred and enrolled patients was
low at 15.3%. Most of patients were absent or
dropped out before completing all sessions. This
was mainly due to the lack of motivation and
encouragement to join and complete the program.
19 Heydarpour et al. reported that only 49% of
patients completed CR program due to illiteracy,
old age, employment status, low exercise
capacity, depression, mild anxiety, and cessation
IndoJPMR Vol.12 - 1st Edition - JUNE 2023 |
of smoking.21 Additionally, Bustamante J et
al. found that adherence in completing the 36
training sessions given was low at 33% but it was
better in the age group over 50, non-smokers, and
previously active individuals.22
67
adherence in initiating and sustaining phase II
CR in post-PCI was higher than in post-CABG
patients.
CONFLICT OF INTEREST
There have been no comparisons made in studies
regarding adherence to CR between post-CABG
and post-PCI patients. In this study, it was found
that adherence to completing the program was
high. Comparing the two groups, the adherence in
initiating and sustaining phase II CR was higher
in the post-PCI group. Post-CABG patients
usually have more severe disabilities, older
age, comorbidities, as well as a longer healing
period,23 which may have affected the adherence
in following phase II CR.
The author declares that there is no conflict of
interest.
ACKNOWLEDGEMENT
The authors are grateful to Kurnia Wahyudi, MD
for the contribution provided to data analysis.
REFERENCES
This study has several limitations, including 1)
it did not assess referral and registration levels
which are important components in analyzing
barriers in phase II CR, 2) retrospective data
collection based on medical records is a limited
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about 6 months culminating in a fewer number
of subjects compared to other studies. Therefore,
further study is needed to specifically assess
the factors affecting compliance in completing
phase II CR in Indonesia. Investigations on the
reference level and the factors influencing them
are also needed. Both are required to increase the
coverage of services and overcome obstacles in
the implementation of phase II CR.
CONCLUSION
The level of adherence to initiating, sustaining, and
completing phase II CR in post-revascularization
CAD patients was relatively high. The level of
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