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Nursing and Health Sciences (2014), ••, ••–••
Research Article
Effects of a comprehensive cardiac rehabilitation program in patients with coronary heart disease in Korea So-Sun Kim, PhD, RN, APRN,1 Sunhee Lee, PhD, RN,2 GiYon Kim, PhD, RN,3 Seok-Min Kang, PhD, MD4 and Jeong-Ah Ahn, PhD, RN5 1 College of Nursing, Nursing Policy Research Institute, 4Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, College of Medicine, Yonsei University, 2College of Nursing, the Catholic University of Korea, Seoul, 3Department of Nursing, Yonsei University, Wonju College of Medicine, Wonju, Korea and 5School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
Abstract
The purpose of this study was to develop a comprehensive cardiac rehabilitation program that considered patients’ learning needs and cultural context, and to identify the impact of this program on patients with coronary heart disease in Korea. We employed a quasi-experimental design to evaluate the effects of the developed program in 61 patients with coronary heart disease. The experimental group received education, counseling, educational materials, and telephone follow-ups by cardiac nurses for six months. Results showed that participants of the program exhibited reduced body mass index and waist circumference as well as improved left ventricular diastolic function and cardiac disease-related quality of life. There was no significant difference between the groups with the rate of recurring symptoms or cardiac events. This comprehensive cardiac rehabilitation program safely and effectively improved body composition, cardiac function, and quality of life in patients with coronary heart disease.
Key words
comprehensive health care, coronary disease, Korea, patient education, rehabilitation.
INTRODUCTION Cardiac disease is the third most common cause of death in Korea, causing 47 deaths per 100 000 individuals, and the incidence of cardiac disease is steadily increasing each year as individuals follow lifestyles which include an unhealthy diet, insufficient physical activity, tobacco use, and being overweight (Korea National Statistical Office, 2010). The leading cause of cardiac disease, especially coronary heart disease (CHD), is atherosclerosis, and extensive clinical and statistical studies have identified various factors like high blood cholesterol levels, high blood pressure, the presence of diabetes mellitus, heavy alcohol consumption, and stress as risk factors, in addition to the those mentioned above (American Heart Association, 2013). In addition to the use of percutaneous coronary angioplasty or coronary artery bypass grafting, which are popular methods of CHD treatment, individual lifestyle changes and management through the correction of various risk factors are essential for preventing CHD recurrence (Graham et al., 2007). Early pioneers like Hellerstein and Ford (1957) suggested the concept of cardiac rehabilitation (CR) that regular exercise does not increase mortality in patients with heart disease but improves physical function and prevents complications.
Correspondence address: Jeong-Ah Ahn, School of Nursing, Northeastern University, 360 Huntington Ave., Boston, MA 02115, USA. Email: [email protected] Received 21 December 2013; revision received 30 March 2014; accepted 13 May 2014
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Since then, the systematic application of CR programs as secondary prevention methods has been proven beneficial and is recommended by cardiovascular professional societies (Balady et al., 2007). Various studies have been adding to the existing evidence by reporting positive results of CR programs in physical parameters (lipid profile, blood pressure, body weight, cardiorespiratory fitness, and physical activity) and psychological parameters (quality of life [QOL], anxiety, and depression), and decreased symptoms, reinfarction, readmission, and mortality rates in patients with CHD (Heran et al., 2011; Lawler et al., 2011; Shepherd & While, 2012; Sandercock et al., 2013). However, in Korea, CR programs are not practical in clinical areas because of the lack of funding and unwillingness of medical personnel to run the programs. The cost of CR programs is not covered by government-initiated or private insurance and patients have to pay for themselves. Cardiac rehabilitation was introduced in the 1990s when the increased prevalence of CHD was recognized in Korea, but only four hospitals offered CR programs internally before 2007 (Kim et al., 2012). After a project by the Ministry of Health and Welfare, regional cardiocerebrovascular centers were created and CR programs were implemented. CR programs are currently operated in more institutions (five university hospitals in a metropolitan area, one hospital specializing in cardiac disease, and nine local university hospitals) (Kim et al., 2012). However, this has not yet been widely implemented. In addition, CR programs in Korea doi: 10.1111/nhs.12155
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focus mainly on therapeutic exercise, but this alone is not effective as a comprehensive program for managing the various risk factors of CHD mentioned previously (Song, 2009). Recently, our team of researchers have assessed and described the learning needs of Korean patients about their heart disease. Our findings showed that Korean patients had lower levels of knowledge about their heart disease compared to patients in Western countries. Also, they had relatively high learning needs related to worsening signs and symptoms and complications experienced (Kim et al., 2013). According to a nationwide survey of 6021 Korean adults, 74.8% have used complementary and alternative medicine (CAM) (Ock et al., 2009). It seems that the prevalence of CAM use in Korea is very high. This internal survey also reported that most CAM users tended to use CAM products after suggestion by their families or friends than after discussion with their physicians, despite the possibility of interactions between CAM supplements and other medications (Ock et al., 2009). Hence, we considered that it is important to encourage Korean patients with CHD to disclose their CAM use and include CAM education in the CR program. This study aimed to develop a comprehensive CR program for patients with CHD tailored to their specific learning needs and their cultural context in Korea, and to verify the program’s effects on physiological and psychosocial factors and recurrent symptoms or cardiac events.
METHODS Design A longitudinal and quasi-experimental design was used to sequentially collect data from patients in the control and experimental groups. The control group data were collected from February to August 2010, while the experimental group data were collected from September 2010 to March 2011. For both groups, data were collected three times: baseline and at three and six month follow-ups.
Participants and setting All participants were recruited through convenience sampling from the cardiovascular outpatient clinic at a large tertiary medical center in Seoul, Korea. Patients were included if they: (i) had been diagnosed with CHD by their primary cardiologist, treated with medication, percutaneous coronary angioplasty, or coronary artery bypass graft, and undergoing regular follow-up at the cardiovascular outpatient clinic; (ii) were at 20–79 years of age; and (iii) had the ability to perform regular physical activity according to the patients’ self-identification and the judgment of their primary cardiologist. We calculated the sample size adequacy using G*Power 3.1 analysis software (IBM Corp., Albany, NY, USA) and arrived at a required sample size of 55 according to an α level of 0.05, conventional medium effect size of 0.15 based on the cardiac disease-related QOL (CD-QOL) as the primary outcome, and a power of 0.80 for © 2014 Wiley Publishing Asia Pty Ltd.
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the linear model (Faul et al., 2009). Assuming a dropout rate of 20% during the trial, a total of 66 patients were required for the study.
Ethical consideration The protocol for the research project was approved by the institutional review board of Severance Hospital, Yonsei University Health System (IRB No. 08-0405). Before the data collection, two cardiac nurses trained by researchers explained the study purpose and methods in detail to each patient; upon agreement, they provided written informed consent. The trained nurses then administered the questionnaires, measured the baseline data, and were available to answer the patients’ questions.
Intervention The intervention design is shown in Figure 1. The comprehensive CR developed by the researchers is a structured program that consists of initial individual education, demonstration and counseling session, and regular follow-up phone calls, with continuing education and counseling, psychological support, and motivation for behavioral changes. We also developed an educational reference booklet and a selfreporting healthcare journal to support the patients’ ongoing self-management attempts. The educational booklet was developed after an assessment of learning needs of patients with CHD (Kim et al., 2013), and after factoring in multidisciplinary experts’ advice (from two cardiologists, one specialist in Oriental medicine, four nursing professors, two cardiac nurses, two nutritionists, and one exercise physiologist), as well as a review of earlier CR-related recommendations (Balady et al., 2007; Graham et al., 2007; Piepoli et al., 2010). The booklet contains the following details: (i) understanding CHD and its risk factors; (ii) information about cardiac medications as well as CAM supplements and practices; (iii) healthy eating guidelines; (iv) daily physical activity and aerobic exercise guidelines; (v) smoking cessation information; (vi) stress management and emotional stability information; and (vii) common disease-related misconceptions. In particular, this booklet emphasized management methods of the patients’ worsening signs and symptoms (i.e., recurrent chest pain or exacerbated dyspnea) and complications (i.e., side-effects of medications) to reflect their specific learning needs as well as CAM use and practices (i.e., supportive effects, sideeffects, and interactions of CAM with cardiac medications) to reflect the Korean cultural context. We covered the theme of CAM, including popular Korean herbal remedies with ingredients of pine needles, persimmon leaf, mature onion, garlic, ginger, and ginseng; the use of nutrient supplements with fish oils, omega-3 fatty acids, evening primrose oil, vitamin E, coenzyme Q10, L-carnitine, policosanol plus gugulipid, Echinacea, and propolis; hand and foot massage; and meditation and relaxation techniques under the supervision of the above experts’ advice and a review of earlier
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Figure 1.
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Description of the intervention design.
studies (Miller et al., 2004; Shin et al., 2004; Yeh et al., 2006; Whayne, 2010). The initial 1-h session for each person in the experimental group took place in a private room of the cardiovascular outpatient clinic. During that session, each person received education, demonstration of appropriate daily physical activity and exercise, and counseling on how to manage their personal risk factors and overcome their disease-related psychosocial problems based on the provided educational reference booklet. They were also encouraged to regularly record their weight changes, exercise and diet status, medication intake, general feelings, and any appearance of signs and symptoms in the self-reporting healthcare journal. After the initial session, follow-up phone calls (15–30 min each) were provided weekly for one month, biweekly for the next two months, and monthly for the next three months. All sessions were conducted by two cardiac nurses who were trained according to the study protocol prior to the study. The same nurse who performed a patient’s initial session also performed their regular telephone calls for a more efficient follow-up. Those in the control group were instructed to continue their usual daily activities and were provided their usual care at the cardiovascular outpatient clinic. This regimen consisted of meeting their cardiologist and cardiac nurse and receiving brief information about their medications and the course of their illness, which remained unchanged during the study. These individuals were offered the educational booklet and self-reporting healthcare journal at the end of the study.
Assessment of outcomes Baseline demographic and clinical information, including age, gender, duration of CHD, number of admissions, comorbidities, and medications was recorded. Physiological factors were recorded on a four-part form which included: (1) anthropometric measurements (body mass index [BMI], waist circumference, systolic and diastolic blood pressure [BP], and pulse rate [PR]); (2) blood biochemistry measurements (levels of fasting blood glucose, total cholesterol, triglycerides, and low density lipoprotein cholesterol); (3) evaluation of dyspnea assigned to New York Heart Association (NYHA) functional classes I–IV; and (4) transthoracic echocardiographic data (left ventricular ejection fraction [LVEF] for LV systolic function and early mitral inflow velocity/tissue Doppler-derived early diastolic mitral annular velocity [E/Ea ratio] for LV diastolic function) performed using Sonoace X8 (Samsung Medison Co., Seoul, Korea). Psychosocial factors were recorded on a two-part form which included: (1) perceived health status measured using one question asking about patients’ perception of how good they felt about their own health (score range, 1–5), which was developed by the researchers; and (2) CD-QOL assessed by a 21-item Likert scale self-report questionnaire with five subscales of daily physical activity, inter-relationship, emotional status, specific symptoms, and general symptoms (total score range, 0–100). This CD-QOL scale was developed and validated in patients with cardiovascular disease, including CHD in Korea, and the reliability of the instrument reported © 2014 Wiley Publishing Asia Pty Ltd.
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a Cronbach’s α value of 0.89 (Lee et al., 2007) (0.88 in this study). Patients’ recurrent symptoms and cardiac events related to CHD were monitored via a review of electronic medical records at the cardiovascular outpatient clinic. All patients underwent regular follow-ups with their primary cardiologist at the same cardiovascular outpatient clinic. All of the above data, except for transthoracic echocardiographic outcomes, were collected at baseline as well as three and six month follow-up for all participants at their usual follow-up visits. Transthoracic echocardiography was performed at baseline and at six month follow-up due to the high cost of the test.
Data analysis Data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive and inferential statistics (independent t-test and chi-square test) were used to define the participants’ baseline demographic and clinical profiles. Generalized estimating equations (GEE) (Huh et al., 2012) were used to determine the changes in physiological and psychosocial factors in time trends (baseline and three and six month follow-up), differences of variables between groups, and interactions between groups and time trends. Differences between groups in the recurrence of symptoms and cardiac events after six months were assessed using the chi-square test.
RESULTS Participants and baseline characteristics The study sample initially included 33 participants in each group. One patient in the experimental group failed to complete the program and was lost to follow-up, while four patients in the control group failed to complete the study because of withdrawal (n = 3) and loss to follow-up (n = 1), resulting in a final sample of 32 and 29 participants in the experimental and control groups, respectively. Baseline
Table 1.
demographic and clinical characteristics were comparable between the two groups (Table 1).
Effects of the program Most participants in the experimental group (n = 26, 81.3%) reported that they had improved overall CHD selfmanagement including participation of daily physical activity and aerobic exercise according to the guidelines by the six month follow-up. Evaluation of participants’ physiological factors indicated significant differences between groups in BMI, waist circumference, and LV diastolic function (E/Ea ratio) according to time trends (Table 2). Mean BMI decreased from 23.76 kg/m2 (baseline) to 23.15 kg/m2 (6 months) in the experimental group but increased from 24.36 kg/m2 (baseline) to 24.94 kg/m2 (6 months) in the control group (P = 0.020). Mean waist circumference decreased from 86.59 cm (baseline) to 85.56 cm (6 months) in the experimental group but increased from 86.32 cm (baseline) to 90.22 cm (6 months) in the control group (P < 0.001). E/Ea ratio for LV diastolic function improved significantly in the experimental group (from 13.99 to 8.40) compared with the control group (from 11.85 to 12.21) (P = 0.001). Other physiological variables, which were not significant, included systolic BP, PR, and blood biochemistry measurements (levels of fasting glucose and lipid profile). Regarding psychosocial factors, a significant difference was found for self-reported CD-QOL between groups; however, it improved in both the experimental group (from 84.50 to 90.38) and the control group (from 80.66 to 90.08) over time (P = 0.016) (Table 2). No significant difference in perceived health status was found between groups throughout the study. Regarding recurrent symptoms or cardiac events, two patients (6.3%) of the 32 who completed the CR program were readmitted because of severe recurrent symptoms. One of the patients complained of severe recurrent chest pain, was diagnosed with restenosis of a coronary artery, and subsequently underwent repeat percutaneous coronary
Homogeneity of demographic and clinical characteristics between groups
Characteristics Age (years) Gender
Male Female Duration of coronary heart disease (years) Number of admission history Comorbidity Yes No On medication† Hypertension Diabetes mellitus Hyperlipidemia †Overlapping response.
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Experimental group (n = 32)
Control group (n = 29)
M ± SD or n (%)
M ± SD or n (%)
t or χ2
P
63.64 ± 12.26 21 (65.6) 11 (34.4) 8.28 ± 6.98 1.24 ± 1.15 24 (75.0) 8 (25.0) 20 (62.5) 10 (31.3) 14 (43.8)
60.39 ± 16.97 15 (51.7) 14 (48.3) 5.83 ± 6.62 0.96 ± 1.02 21 (72.4) 8 (27.6) 18 (62.1) 8 (27.6) 13 (44.8)
−0.882 0.947
0.381 0.448
−1.338 −0.987 0.088
0.187 0.328 1.000
0.001 0.098 0.007
0.972 0.754 0.933
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Table 2. Effects of a comprehensive cardiac rehabilitation program
Factors Physiological factors Anthropometric measurements Body mass index (kg/m2) Waist circumference (cm)† Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Pulse rate (beat/min) Blood biochemistry measurements Fasting glucose (mg/dL) Total cholesterol (mg/dL) Triglycerides (mg/dL) Low density lipoprotein cholesterol (mg/dL) NYHA functional class Echocardiographic data LVEF (%)† E/Ea ratio Psychosocial factors Perceived health status (range: 1–5) CD-QOL (range: 0–100)
Baseline
3-month
6-month
Group
M ± SD
M ± SD
M ± SD
P*
Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont.
23.76 ± 2.82 24.36 ± 3.41 86.59 ± 7.21 86.32 ± 7.86 114.94 ± 16.18 116.03 ± 17.77 70.94 ± 10.38 73.86 ± 12.39 72.16 ± 12.15 76.66 ± 13.08
23.20 ± 2.53 24.72 ± 3.65 84.81 ± 6.65 94.03 ± 9.85 111.58 ± 19.04 121.79 ± 18.48 68.96 ± 10.97 74.04 ± 11.99 68.18 ± 10.86 76.55 ± 11.74
23.15 ± 3.01 24.94 ± 3.70 85.56 ± 7.30 90.22 ± 10.14 114.91 ± 18.69 124.25 ± 21.63 69.81 ± 10.26 75.92 ± 13.62 73.86 ± 14.70 76.53 ± 13.62
0.127
0.860
0.020
0.001
< 0.001
< 0.001
0.066
0.316
0.106
0.048
0.723
0.640
0.075
0.098
0.106
Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont.
114.03 ± 33.82 110.33 ± 31.13 169.03 ± 40.23 176.33 ± 38.05 113.66 ± 59.57 119.19 ± 50.11 101.19 ± 29.23 102.21 ± 35.21 1.75 ± 0.88 1.52 ± 0.63
128.13 ± 78.91 104.64 ± 32.50 168.07 ± 39.88 162.99 ± 37.08 126.95 ± 63.03 112.36 ± 56.02 98.01 ± 34.67 88.46 ± 25.57 1.69 ± 0.60 1.21 ± 0.42
103.73 ± 23.54 122.58 ± 65.09 164.61 ± 49.67 162.90 ± 33.93 114.11 ± 59.55 105.04 ± 29.01 98.74 ± 37.83 88.86 ± 24.52 1.65 ± 0.76 1.17 ± 0.38
0.784
0.831
0.323
0.986
0.166
0.436
0.634
0.455
0.359
0.416
0.160
0.477
0.003
0.143
0.445
Exp. Cont. Exp. Cont.
39.25 ± 10.14 39.83 ± 13.65 13.99 ± 5.94 11.85 ± 3.91
46.45 ± 14.71 46.14 ± 11.39 8.40 ± 2.85 12.21 ± 6.93
0.943
< 0.001
0.780
0.539
0.005
0.001
Exp. Cont. Exp. Cont.
2.70 ± 0.97 2.69 ± 0.93 78.87 ± 13.36 80.66 ± 10.73
2.59 ± 0.92 3.15 ± 0.58 81.31 ± 10.39 90.08 ± 4.66
0.339
0.413
0.413
0.015
< 0.001
0.016
2.82 ± 1.19 2.86 ± 0.95 81.86 ± 12.98 86.92 ± 11.15
P**
P***
*P-value for statistical significance of the group difference (between effect); **P-value for statistical significance of the time difference (within effect); ***P-value for statistical significance of the group X time interaction. †Adjusted for baseline waist circumference and LVEF. CD-QOL, cardiac disease-related quality of life; Cont., contol group; E/Ea, early mitral inflow velocity/early diastolic mitral annular velocity; Exp., experimental group; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.
angioplasty. The other patient complained of exacerbated dyspnea and was treated with medication in the hospital. Two patients (6.9%) of the 29 in the control group reported exacerbated dyspnea and were treated with medication as inpatients. There was no significant difference between groups in the frequency or rate of recurrent symptoms and cardiac events secondary to CHD.
DISCUSSION Internationally, people with CHD are managed mostly with cardiac medication, percutaneous intervention, and surgical management. However, the scope of CR programs has shifted to the use of multifaceted and comprehensive secondary prevention strategies managing cardiac risk, psychological, behavioral, and social factors to effectively impact patient outcomes (Mampuya, 2012).The comprehensive CR program developed in this study included diverse information with
multidisciplinary advice and reflected the patients’ specific educational needs. We assume that the initial face-to-face educational session, educational booklet, and self-reporting healthcare journal, as well as the regular follow-up telephone calls for six months supported and encouraged the patients’ continuous self-management intentions. This program was a relatively safe and effective intervention, as it reduced BMI and waist circumference and improved LV diastolic function and CD-QOL, and demonstrated no difference between groups in terms of symptom or cardiac event recurrence. Similar to our results that the CR program reduced BMI and waist circumference, Silberman et al. (2010) reported a significant reduction in BMI after CR treatment in 2974 CHD patients from 24 diverse hospital sites, while Duarte et al. (2011) reported that a cohort of 101 cardiac patients’ BMI and waist circumferences decreased significantly after CR program implementation. Profiles of patients with CHD have recently changed as the prevalence of obesity has increased; © 2014 Wiley Publishing Asia Pty Ltd.
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therefore, a focus on risk reduction that promotes greater weight loss along with BMI and waist circumference reductions through increased physical activity and exercise for patients with CHD is a noteworthy part of CR (Ades et al., 2009). Several studies have shown that CR improves the cardiac function of patients with CHD. However, its improvement in cardiac function (systolic or diastolic) is controversial. Depending on study methodology and patient selection, LVEF for LV systolic function has been shown to be either increased or unchanged after CR. Yu et al. (2004) reported that in patients with CHD, the effect of CR on LV systolic function was neutral but it prevented the progression of LV diastolic dysfunction. This study showed that the E/Ea ratio for the LV diastolic function significantly improved after the CR program compared with the control group. The LV diastolic function is known as the condition associated with patients’ physical activity and exercise capacity (Grewal et al., 2009). As such, the increases in physical activity and exercise of the patients in the experimental group are considered helpful for improving their LV diastolic function. This study showed a significant improvement in CD-QOL of the experimental group, but this value also improved in the control group over time. Some studies have shown that CR improves QOL (Dalal et al., 2007; Lie et al., 2009; Kitzman et al., 2010; Yohannes et al., 2010), while others have shown some partially positive effects on QOL (Belardinelli et al., 2001; Jolly et al., 2007), and others have reported no significant difference between experimental and control groups (Hage et al., 2003; Briffa et al., 2005; Hanssen et al., 2009). Considering these results, ongoing management and longterm observations may be needed to ensure further improvement in QOL in addition to the improved physiological factors in patients with CHD. The results, however, did not support the hypothesis that participants who completed the CR program would have reduced BP, PR, and glucose levels and improved lipid profile and NYHA functional classes. One possible explanation for this is the effect of the continuous intake of prescribed medications and other routine approaches on disease management in both groups. This finding is consistent with that of Choi et al. (2008), in which the physiological variables (BP, PR, and lipid profile) did not differ between the experimental and control groups after CR. The findings also did not support the positive effect of the CR program on perceived health status. Patients in the experimental group reported their health as being of medium to low quality both before and after the CR program. We suspect that this is because their disease requires life-long management, and this uncertain thought influences their health status self-perception. In an earlier study, patients with CHD perceived less control over their health and high level of health-related uncertainty that tended to persist even after one year of follow-up (Eastwood et al., 2008). Alternatives to physician-led inpatient or outpatient care for CHD, such as this tested comprehensive and multidisciplinary outpatient CR model considering patients’ learning needs and cultural context regarding the use of CAM, especially with nurse-led program aspects, should be utilized with © 2014 Wiley Publishing Asia Pty Ltd.
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a larger patient population in Korea. It is likely that continuous follow-up by nurses helped improve and maintain CHD patients’ physiological and psychosocial factors, including cardiac function and CD-QOL, and we hope that the CR program becomes an important part of the secondary prevention method for patients with CHD, and it can be used easily and efficiently throughout the general healthcare system.
Study limitations This study has some limitations. First, a quasi-experimental design was used rather than a randomized controlled trial design. Second, it did not track whether patients were taking multiple medications. This variable might help control possible confounding factors, particularly with regard to physiological outcomes. Third, this study did not directly assess the experimental group patients’ degree of knowledge improvement after the intervention. Finally, because this study was conducted at only one medical center in South Korea, its findings may have limited generalizability. Future investigations should consider using a larger and randomized sample and including a longer tracking period, other influential factors, and various regions to increase its statistical power.
CONCLUSION The patients in the experimental group, who were provided a comprehensive CR program, including education, demonstration, counseling, telephone call follow-ups, and six month support by cardiac nurses, improved significantly in terms of BMI, waist circumference, LV diastolic function, and CD-QOL. This program’s safety was evidenced by the similar symptom and cardiac event recurrence rate between the experimental and control groups. We hope that a comprehensive CR program for secondary prevention in patients with CHD becomes more widely available in Korea.
ACKNOWLEDGMENTS This work was supported by College of Nursing, Yonsei University, Seoul, Republic of Korea. We are grateful to all patients who participated in this project. No conflict of interest has been declared by the authors.
CONTRIBUTIONS Study Design: SSK, SL, GYK, SMK, JAA. Data Collection and Analysis: SMK, JAA. Manuscript Writing: SSK, SL, GYK, JAA.
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Balady GJ, Williams MA, Ades PA et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. a scientific statement from the American Heart Association; Exercise, Cardiac Rehabilitation, and Prevention Committee; the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the Americal Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115: 2675–2682. Belardinelli R, Pailini I, Cianci G et al. Exercise training intervention after coronary angioplasty: The ETICA trial. J. Am. Coll. Cardiol. 2001; 37: 1891–1900. Briffa TG, Eckermann SD, Griffiths AD et al. Cost-effectiveness of rehabilitation after an acute coronary event: A randomized controlled trial. Med. J. Aust. 2005; 183: 450–455. Choi MA, Kim KS, Yi M et al. Effects of cardiac rehabilitation education for coronary artery bypass grafting patients during their hospitalization. J. Korean Biol. Nurs. Sci. 2008; 10: 69–79. Dalal HM, Evans PH, Campbell JL et al. Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms – Cornwall Heart Attack Rehabilitation Management Study (CHARMS). Int. J. Cardiol. 2007; 119: 202–211. Duarte FP, Haida A, Bousquet M et al. Short-term impact of a 4-week intensive cardiac rehabilitation program on quality of life and anxiety-depression. Ann. Phys. Rehabil. Med. 2011; 54: 132– 143. Eastwood JA, Doering L, Roper J et al. Uncertainty and healthrelated quality of life 1 year after coronary angiography. Am. J. Crit. Care 2008; 17: 232–242. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: Test for correlation and regression analyses. Behav. Res. Methods 2009; 41: 1149–1160. Graham I, Atar D, Borch-Johnsen K et al. European guidelines on cardiovascular disease prevention in clinical practice: Full text. Fourth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur. J. Cardiovasc. Prev. Rehabil. 2007; 14 (Suppl. 2): S1–113. Grewal J, McCully RB, Kane GC et al. Left ventricular function and exercise capacity. JAMA 2009; 301: 286–294. Hage C, Mattsson E, Ståhle A. Long-term effects of exercise training on physical activity level and quality of life in elderly coronary patients – a three- to six-year follow up. Physiother. Res. Int. 2003; 8: 12–22. Hanssen TA, Nordrehaug JE, Eide GE et al. Does a telephone follow-up intervention for patients discharged with acute myocardial infarction have long-term effects on health-related quality of life? A randomised controlled trial. J. Clin. Nurs. 2009; 18: 1334– 1345. Hellerstein HK, Ford AB. Rehabilitation of the cardiac patient. JAMA 1957; 164: 225–231. Heran BS, Chen JM, Ebrahim S et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst. Rev. 2011; (6): CD001800. Huh D, Flaherty BP, Simoni JM. Optimizing the analysis of adherence interventions using logistic generalized estimating equations. AIDS Behav. 2012; 16: 422–431. Jolly K, Taylor R, Lip GY et al. The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: Cost-effectiveness and patient adherence. Health Technol. Assess. 2007; 11: 1–118.
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Kim C, Moon CJ, Lim MH. Safety of monitoring exercise for early hospital-based cardiac rehabilitation. Ann. Phys. Rehabil. Med. 2012; 36: 262–267. Kim SS, Ahn JA, Kang SM, Kim GY, Lee SH. Learning needs of patients with heart failure: A descriptive, exploratory study. J. Clin. Nurs. 2013; 22: 661–668. Kitzman DW, Brubaker PH, Morgan TM et al. Exercise training in older patients with heart failure and preserved ejection fraction: A randomized, controlled, single-blind trial. Cir. Heart Fail. 2010; 3: 659–667. Korea National Statistical Office. Korea National Statistical Office Statistics: the cause of death. 2010. [Cited 1 May 2013.] Available from URL: http://www.kostat.go.kr/. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. Am. Heart J. 2011; 162: 571–584. Lee EH, Tahk SJ, Shin JH et al. Development and a psychometric evaluation of cardiovascular disease-specific quality of life scale for Koreans. J. Korean Acad. Nurs. 2007; 37: 313–323. Lie I, Arnesen H, Sandvik L et al. Health-related quality of life after coronary artery bypass grafting: The impact of a randomized controlled home-based intervention program. Qual. Life Res. 2009; 18: 201–207. Mampuya WM. Cardiac rehabilitation past, present and future: An overview. Cardiovasc. Diagn. Ther. 2012; 2: 38–49. Miller KL, Liebowitz RS, Newby LK. Complementary and alternative medicine in cardiovascular disease: A review of biologically based approaches. Am. Heart J. 2004; 147: 401–411. Ock SM, Choi JY, Cha YS et al. The use of complementary and alternative medicine in a general population in South Korea: Results from a National Survey in 2006. J. Korean Med. Sci. 2009; 24: 1–6. Piepoli MF, Corrà U, Benzer W et al. Secondary prevention through cardiac rehabilitation: From knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur. J. Cardiovasc. Prev. Rehabil. 2010; 17: 1–17. Sandercock G, Hurtado V, Cardoso F. Changes in cardiorespiratory fitness in cardiac rehabilitation patients: A meta-analysis. Int. J. Cardiol. 2013; 167: 894–902. Shepherd CW, While AE. Cardiac rehabilitation and quality of life: A systematic review. Int. J. Nurs. Stud. 2012; 49: 755–771. Shin KR, Park SY, Shin SJ. A study on the use patterns of alternative therapy in the elderly. Korean J. Adult Nurs. 2004; 16: 111–122. Silberman A, Banthia R, Estay IS et al. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am. J. Health Promot. 2010; 24: 260–266. Song Y. Analyses of studies on cardiac rehabilitation for patients with cardiovascular disease in Korea. J. Korean Acad. Nurs. 2009; 39: 311–320. Whayne TF Jr. What should medical practitioners know about the role of alternative medicines in cardiovascular disease management? Cardiovasc. Ther. 2010; 28: 106–123. Yeh GY, Davis RB, Phillips RS. Use of complementary therapies in patients with cardiovascular disease. Am. J. Cardiol. 2006; 98: 673– 680. Yohannes AM, Doherty P, Bundy C et al. The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. J. Clin. Nurs. 2010; 19: 2806–2813. Yu CM, Li LS, Lam MF et al. Effect of a cardiac rehabilitation program on left ventricular diastolic function and its relationship to exercise capacity in patients with coronary heart disease: Experience from a randomized, controlled study. Am. Heart J. 2004; 147: 11–18.
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Nursing and Health Sciences (2014), ••, ••–••
Research Article
Effects of a comprehensive cardiac rehabilitation program in patients with coronary heart disease in Korea So-Sun Kim, PhD, RN, APRN,1 Sunhee Lee, PhD, RN,2 GiYon Kim, PhD, RN,3 Seok-Min Kang, PhD, MD4 and Jeong-Ah Ahn, PhD, RN5 1 College of Nursing, Nursing Policy Research Institute, 4Division of Cardiology, Severance Cardiovascular Hospital and Cardiovascular Research Institute, College of Medicine, Yonsei University, 2College of Nursing, the Catholic University of Korea, Seoul, 3Department of Nursing, Yonsei University, Wonju College of Medicine, Wonju, Korea and 5School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
Abstract
The purpose of this study was to develop a comprehensive cardiac rehabilitation program that considered patients’ learning needs and cultural context, and to identify the impact of this program on patients with coronary heart disease in Korea. We employed a quasi-experimental design to evaluate the effects of the developed program in 61 patients with coronary heart disease. The experimental group received education, counseling, educational materials, and telephone follow-ups by cardiac nurses for six months. Results showed that participants of the program exhibited reduced body mass index and waist circumference as well as improved left ventricular diastolic function and cardiac disease-related quality of life. There was no significant difference between the groups with the rate of recurring symptoms or cardiac events. This comprehensive cardiac rehabilitation program safely and effectively improved body composition, cardiac function, and quality of life in patients with coronary heart disease.
Key words
comprehensive health care, coronary disease, Korea, patient education, rehabilitation.
INTRODUCTION Cardiac disease is the third most common cause of death in Korea, causing 47 deaths per 100 000 individuals, and the incidence of cardiac disease is steadily increasing each year as individuals follow lifestyles which include an unhealthy diet, insufficient physical activity, tobacco use, and being overweight (Korea National Statistical Office, 2010). The leading cause of cardiac disease, especially coronary heart disease (CHD), is atherosclerosis, and extensive clinical and statistical studies have identified various factors like high blood cholesterol levels, high blood pressure, the presence of diabetes mellitus, heavy alcohol consumption, and stress as risk factors, in addition to the those mentioned above (American Heart Association, 2013). In addition to the use of percutaneous coronary angioplasty or coronary artery bypass grafting, which are popular methods of CHD treatment, individual lifestyle changes and management through the correction of various risk factors are essential for preventing CHD recurrence (Graham et al., 2007). Early pioneers like Hellerstein and Ford (1957) suggested the concept of cardiac rehabilitation (CR) that regular exercise does not increase mortality in patients with heart disease but improves physical function and prevents complications.
Correspondence address: Jeong-Ah Ahn, School of Nursing, Northeastern University, 360 Huntington Ave., Boston, MA 02115, USA. Email: [email protected] Received 21 December 2013; revision received 30 March 2014; accepted 13 May 2014
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Since then, the systematic application of CR programs as secondary prevention methods has been proven beneficial and is recommended by cardiovascular professional societies (Balady et al., 2007). Various studies have been adding to the existing evidence by reporting positive results of CR programs in physical parameters (lipid profile, blood pressure, body weight, cardiorespiratory fitness, and physical activity) and psychological parameters (quality of life [QOL], anxiety, and depression), and decreased symptoms, reinfarction, readmission, and mortality rates in patients with CHD (Heran et al., 2011; Lawler et al., 2011; Shepherd & While, 2012; Sandercock et al., 2013). However, in Korea, CR programs are not practical in clinical areas because of the lack of funding and unwillingness of medical personnel to run the programs. The cost of CR programs is not covered by government-initiated or private insurance and patients have to pay for themselves. Cardiac rehabilitation was introduced in the 1990s when the increased prevalence of CHD was recognized in Korea, but only four hospitals offered CR programs internally before 2007 (Kim et al., 2012). After a project by the Ministry of Health and Welfare, regional cardiocerebrovascular centers were created and CR programs were implemented. CR programs are currently operated in more institutions (five university hospitals in a metropolitan area, one hospital specializing in cardiac disease, and nine local university hospitals) (Kim et al., 2012). However, this has not yet been widely implemented. In addition, CR programs in Korea doi: 10.1111/nhs.12155
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focus mainly on therapeutic exercise, but this alone is not effective as a comprehensive program for managing the various risk factors of CHD mentioned previously (Song, 2009). Recently, our team of researchers have assessed and described the learning needs of Korean patients about their heart disease. Our findings showed that Korean patients had lower levels of knowledge about their heart disease compared to patients in Western countries. Also, they had relatively high learning needs related to worsening signs and symptoms and complications experienced (Kim et al., 2013). According to a nationwide survey of 6021 Korean adults, 74.8% have used complementary and alternative medicine (CAM) (Ock et al., 2009). It seems that the prevalence of CAM use in Korea is very high. This internal survey also reported that most CAM users tended to use CAM products after suggestion by their families or friends than after discussion with their physicians, despite the possibility of interactions between CAM supplements and other medications (Ock et al., 2009). Hence, we considered that it is important to encourage Korean patients with CHD to disclose their CAM use and include CAM education in the CR program. This study aimed to develop a comprehensive CR program for patients with CHD tailored to their specific learning needs and their cultural context in Korea, and to verify the program’s effects on physiological and psychosocial factors and recurrent symptoms or cardiac events.
METHODS Design A longitudinal and quasi-experimental design was used to sequentially collect data from patients in the control and experimental groups. The control group data were collected from February to August 2010, while the experimental group data were collected from September 2010 to March 2011. For both groups, data were collected three times: baseline and at three and six month follow-ups.
Participants and setting All participants were recruited through convenience sampling from the cardiovascular outpatient clinic at a large tertiary medical center in Seoul, Korea. Patients were included if they: (i) had been diagnosed with CHD by their primary cardiologist, treated with medication, percutaneous coronary angioplasty, or coronary artery bypass graft, and undergoing regular follow-up at the cardiovascular outpatient clinic; (ii) were at 20–79 years of age; and (iii) had the ability to perform regular physical activity according to the patients’ self-identification and the judgment of their primary cardiologist. We calculated the sample size adequacy using G*Power 3.1 analysis software (IBM Corp., Albany, NY, USA) and arrived at a required sample size of 55 according to an α level of 0.05, conventional medium effect size of 0.15 based on the cardiac disease-related QOL (CD-QOL) as the primary outcome, and a power of 0.80 for © 2014 Wiley Publishing Asia Pty Ltd.
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the linear model (Faul et al., 2009). Assuming a dropout rate of 20% during the trial, a total of 66 patients were required for the study.
Ethical consideration The protocol for the research project was approved by the institutional review board of Severance Hospital, Yonsei University Health System (IRB No. 08-0405). Before the data collection, two cardiac nurses trained by researchers explained the study purpose and methods in detail to each patient; upon agreement, they provided written informed consent. The trained nurses then administered the questionnaires, measured the baseline data, and were available to answer the patients’ questions.
Intervention The intervention design is shown in Figure 1. The comprehensive CR developed by the researchers is a structured program that consists of initial individual education, demonstration and counseling session, and regular follow-up phone calls, with continuing education and counseling, psychological support, and motivation for behavioral changes. We also developed an educational reference booklet and a selfreporting healthcare journal to support the patients’ ongoing self-management attempts. The educational booklet was developed after an assessment of learning needs of patients with CHD (Kim et al., 2013), and after factoring in multidisciplinary experts’ advice (from two cardiologists, one specialist in Oriental medicine, four nursing professors, two cardiac nurses, two nutritionists, and one exercise physiologist), as well as a review of earlier CR-related recommendations (Balady et al., 2007; Graham et al., 2007; Piepoli et al., 2010). The booklet contains the following details: (i) understanding CHD and its risk factors; (ii) information about cardiac medications as well as CAM supplements and practices; (iii) healthy eating guidelines; (iv) daily physical activity and aerobic exercise guidelines; (v) smoking cessation information; (vi) stress management and emotional stability information; and (vii) common disease-related misconceptions. In particular, this booklet emphasized management methods of the patients’ worsening signs and symptoms (i.e., recurrent chest pain or exacerbated dyspnea) and complications (i.e., side-effects of medications) to reflect their specific learning needs as well as CAM use and practices (i.e., supportive effects, sideeffects, and interactions of CAM with cardiac medications) to reflect the Korean cultural context. We covered the theme of CAM, including popular Korean herbal remedies with ingredients of pine needles, persimmon leaf, mature onion, garlic, ginger, and ginseng; the use of nutrient supplements with fish oils, omega-3 fatty acids, evening primrose oil, vitamin E, coenzyme Q10, L-carnitine, policosanol plus gugulipid, Echinacea, and propolis; hand and foot massage; and meditation and relaxation techniques under the supervision of the above experts’ advice and a review of earlier
Cardiac rehabilitation program in Korea
Figure 1.
3
Description of the intervention design.
studies (Miller et al., 2004; Shin et al., 2004; Yeh et al., 2006; Whayne, 2010). The initial 1-h session for each person in the experimental group took place in a private room of the cardiovascular outpatient clinic. During that session, each person received education, demonstration of appropriate daily physical activity and exercise, and counseling on how to manage their personal risk factors and overcome their disease-related psychosocial problems based on the provided educational reference booklet. They were also encouraged to regularly record their weight changes, exercise and diet status, medication intake, general feelings, and any appearance of signs and symptoms in the self-reporting healthcare journal. After the initial session, follow-up phone calls (15–30 min each) were provided weekly for one month, biweekly for the next two months, and monthly for the next three months. All sessions were conducted by two cardiac nurses who were trained according to the study protocol prior to the study. The same nurse who performed a patient’s initial session also performed their regular telephone calls for a more efficient follow-up. Those in the control group were instructed to continue their usual daily activities and were provided their usual care at the cardiovascular outpatient clinic. This regimen consisted of meeting their cardiologist and cardiac nurse and receiving brief information about their medications and the course of their illness, which remained unchanged during the study. These individuals were offered the educational booklet and self-reporting healthcare journal at the end of the study.
Assessment of outcomes Baseline demographic and clinical information, including age, gender, duration of CHD, number of admissions, comorbidities, and medications was recorded. Physiological factors were recorded on a four-part form which included: (1) anthropometric measurements (body mass index [BMI], waist circumference, systolic and diastolic blood pressure [BP], and pulse rate [PR]); (2) blood biochemistry measurements (levels of fasting blood glucose, total cholesterol, triglycerides, and low density lipoprotein cholesterol); (3) evaluation of dyspnea assigned to New York Heart Association (NYHA) functional classes I–IV; and (4) transthoracic echocardiographic data (left ventricular ejection fraction [LVEF] for LV systolic function and early mitral inflow velocity/tissue Doppler-derived early diastolic mitral annular velocity [E/Ea ratio] for LV diastolic function) performed using Sonoace X8 (Samsung Medison Co., Seoul, Korea). Psychosocial factors were recorded on a two-part form which included: (1) perceived health status measured using one question asking about patients’ perception of how good they felt about their own health (score range, 1–5), which was developed by the researchers; and (2) CD-QOL assessed by a 21-item Likert scale self-report questionnaire with five subscales of daily physical activity, inter-relationship, emotional status, specific symptoms, and general symptoms (total score range, 0–100). This CD-QOL scale was developed and validated in patients with cardiovascular disease, including CHD in Korea, and the reliability of the instrument reported © 2014 Wiley Publishing Asia Pty Ltd.
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a Cronbach’s α value of 0.89 (Lee et al., 2007) (0.88 in this study). Patients’ recurrent symptoms and cardiac events related to CHD were monitored via a review of electronic medical records at the cardiovascular outpatient clinic. All patients underwent regular follow-ups with their primary cardiologist at the same cardiovascular outpatient clinic. All of the above data, except for transthoracic echocardiographic outcomes, were collected at baseline as well as three and six month follow-up for all participants at their usual follow-up visits. Transthoracic echocardiography was performed at baseline and at six month follow-up due to the high cost of the test.
Data analysis Data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive and inferential statistics (independent t-test and chi-square test) were used to define the participants’ baseline demographic and clinical profiles. Generalized estimating equations (GEE) (Huh et al., 2012) were used to determine the changes in physiological and psychosocial factors in time trends (baseline and three and six month follow-up), differences of variables between groups, and interactions between groups and time trends. Differences between groups in the recurrence of symptoms and cardiac events after six months were assessed using the chi-square test.
RESULTS Participants and baseline characteristics The study sample initially included 33 participants in each group. One patient in the experimental group failed to complete the program and was lost to follow-up, while four patients in the control group failed to complete the study because of withdrawal (n = 3) and loss to follow-up (n = 1), resulting in a final sample of 32 and 29 participants in the experimental and control groups, respectively. Baseline
Table 1.
demographic and clinical characteristics were comparable between the two groups (Table 1).
Effects of the program Most participants in the experimental group (n = 26, 81.3%) reported that they had improved overall CHD selfmanagement including participation of daily physical activity and aerobic exercise according to the guidelines by the six month follow-up. Evaluation of participants’ physiological factors indicated significant differences between groups in BMI, waist circumference, and LV diastolic function (E/Ea ratio) according to time trends (Table 2). Mean BMI decreased from 23.76 kg/m2 (baseline) to 23.15 kg/m2 (6 months) in the experimental group but increased from 24.36 kg/m2 (baseline) to 24.94 kg/m2 (6 months) in the control group (P = 0.020). Mean waist circumference decreased from 86.59 cm (baseline) to 85.56 cm (6 months) in the experimental group but increased from 86.32 cm (baseline) to 90.22 cm (6 months) in the control group (P < 0.001). E/Ea ratio for LV diastolic function improved significantly in the experimental group (from 13.99 to 8.40) compared with the control group (from 11.85 to 12.21) (P = 0.001). Other physiological variables, which were not significant, included systolic BP, PR, and blood biochemistry measurements (levels of fasting glucose and lipid profile). Regarding psychosocial factors, a significant difference was found for self-reported CD-QOL between groups; however, it improved in both the experimental group (from 84.50 to 90.38) and the control group (from 80.66 to 90.08) over time (P = 0.016) (Table 2). No significant difference in perceived health status was found between groups throughout the study. Regarding recurrent symptoms or cardiac events, two patients (6.3%) of the 32 who completed the CR program were readmitted because of severe recurrent symptoms. One of the patients complained of severe recurrent chest pain, was diagnosed with restenosis of a coronary artery, and subsequently underwent repeat percutaneous coronary
Homogeneity of demographic and clinical characteristics between groups
Characteristics Age (years) Gender
Male Female Duration of coronary heart disease (years) Number of admission history Comorbidity Yes No On medication† Hypertension Diabetes mellitus Hyperlipidemia †Overlapping response.
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Experimental group (n = 32)
Control group (n = 29)
M ± SD or n (%)
M ± SD or n (%)
t or χ2
P
63.64 ± 12.26 21 (65.6) 11 (34.4) 8.28 ± 6.98 1.24 ± 1.15 24 (75.0) 8 (25.0) 20 (62.5) 10 (31.3) 14 (43.8)
60.39 ± 16.97 15 (51.7) 14 (48.3) 5.83 ± 6.62 0.96 ± 1.02 21 (72.4) 8 (27.6) 18 (62.1) 8 (27.6) 13 (44.8)
−0.882 0.947
0.381 0.448
−1.338 −0.987 0.088
0.187 0.328 1.000
0.001 0.098 0.007
0.972 0.754 0.933
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Table 2. Effects of a comprehensive cardiac rehabilitation program
Factors Physiological factors Anthropometric measurements Body mass index (kg/m2) Waist circumference (cm)† Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Pulse rate (beat/min) Blood biochemistry measurements Fasting glucose (mg/dL) Total cholesterol (mg/dL) Triglycerides (mg/dL) Low density lipoprotein cholesterol (mg/dL) NYHA functional class Echocardiographic data LVEF (%)† E/Ea ratio Psychosocial factors Perceived health status (range: 1–5) CD-QOL (range: 0–100)
Baseline
3-month
6-month
Group
M ± SD
M ± SD
M ± SD
P*
Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont.
23.76 ± 2.82 24.36 ± 3.41 86.59 ± 7.21 86.32 ± 7.86 114.94 ± 16.18 116.03 ± 17.77 70.94 ± 10.38 73.86 ± 12.39 72.16 ± 12.15 76.66 ± 13.08
23.20 ± 2.53 24.72 ± 3.65 84.81 ± 6.65 94.03 ± 9.85 111.58 ± 19.04 121.79 ± 18.48 68.96 ± 10.97 74.04 ± 11.99 68.18 ± 10.86 76.55 ± 11.74
23.15 ± 3.01 24.94 ± 3.70 85.56 ± 7.30 90.22 ± 10.14 114.91 ± 18.69 124.25 ± 21.63 69.81 ± 10.26 75.92 ± 13.62 73.86 ± 14.70 76.53 ± 13.62
0.127
0.860
0.020
0.001
< 0.001
< 0.001
0.066
0.316
0.106
0.048
0.723
0.640
0.075
0.098
0.106
Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont. Exp. Cont.
114.03 ± 33.82 110.33 ± 31.13 169.03 ± 40.23 176.33 ± 38.05 113.66 ± 59.57 119.19 ± 50.11 101.19 ± 29.23 102.21 ± 35.21 1.75 ± 0.88 1.52 ± 0.63
128.13 ± 78.91 104.64 ± 32.50 168.07 ± 39.88 162.99 ± 37.08 126.95 ± 63.03 112.36 ± 56.02 98.01 ± 34.67 88.46 ± 25.57 1.69 ± 0.60 1.21 ± 0.42
103.73 ± 23.54 122.58 ± 65.09 164.61 ± 49.67 162.90 ± 33.93 114.11 ± 59.55 105.04 ± 29.01 98.74 ± 37.83 88.86 ± 24.52 1.65 ± 0.76 1.17 ± 0.38
0.784
0.831
0.323
0.986
0.166
0.436
0.634
0.455
0.359
0.416
0.160
0.477
0.003
0.143
0.445
Exp. Cont. Exp. Cont.
39.25 ± 10.14 39.83 ± 13.65 13.99 ± 5.94 11.85 ± 3.91
46.45 ± 14.71 46.14 ± 11.39 8.40 ± 2.85 12.21 ± 6.93
0.943
< 0.001
0.780
0.539
0.005
0.001
Exp. Cont. Exp. Cont.
2.70 ± 0.97 2.69 ± 0.93 78.87 ± 13.36 80.66 ± 10.73
2.59 ± 0.92 3.15 ± 0.58 81.31 ± 10.39 90.08 ± 4.66
0.339
0.413
0.413
0.015
< 0.001
0.016
2.82 ± 1.19 2.86 ± 0.95 81.86 ± 12.98 86.92 ± 11.15
P**
P***
*P-value for statistical significance of the group difference (between effect); **P-value for statistical significance of the time difference (within effect); ***P-value for statistical significance of the group X time interaction. †Adjusted for baseline waist circumference and LVEF. CD-QOL, cardiac disease-related quality of life; Cont., contol group; E/Ea, early mitral inflow velocity/early diastolic mitral annular velocity; Exp., experimental group; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.
angioplasty. The other patient complained of exacerbated dyspnea and was treated with medication in the hospital. Two patients (6.9%) of the 29 in the control group reported exacerbated dyspnea and were treated with medication as inpatients. There was no significant difference between groups in the frequency or rate of recurrent symptoms and cardiac events secondary to CHD.
DISCUSSION Internationally, people with CHD are managed mostly with cardiac medication, percutaneous intervention, and surgical management. However, the scope of CR programs has shifted to the use of multifaceted and comprehensive secondary prevention strategies managing cardiac risk, psychological, behavioral, and social factors to effectively impact patient outcomes (Mampuya, 2012).The comprehensive CR program developed in this study included diverse information with
multidisciplinary advice and reflected the patients’ specific educational needs. We assume that the initial face-to-face educational session, educational booklet, and self-reporting healthcare journal, as well as the regular follow-up telephone calls for six months supported and encouraged the patients’ continuous self-management intentions. This program was a relatively safe and effective intervention, as it reduced BMI and waist circumference and improved LV diastolic function and CD-QOL, and demonstrated no difference between groups in terms of symptom or cardiac event recurrence. Similar to our results that the CR program reduced BMI and waist circumference, Silberman et al. (2010) reported a significant reduction in BMI after CR treatment in 2974 CHD patients from 24 diverse hospital sites, while Duarte et al. (2011) reported that a cohort of 101 cardiac patients’ BMI and waist circumferences decreased significantly after CR program implementation. Profiles of patients with CHD have recently changed as the prevalence of obesity has increased; © 2014 Wiley Publishing Asia Pty Ltd.
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therefore, a focus on risk reduction that promotes greater weight loss along with BMI and waist circumference reductions through increased physical activity and exercise for patients with CHD is a noteworthy part of CR (Ades et al., 2009). Several studies have shown that CR improves the cardiac function of patients with CHD. However, its improvement in cardiac function (systolic or diastolic) is controversial. Depending on study methodology and patient selection, LVEF for LV systolic function has been shown to be either increased or unchanged after CR. Yu et al. (2004) reported that in patients with CHD, the effect of CR on LV systolic function was neutral but it prevented the progression of LV diastolic dysfunction. This study showed that the E/Ea ratio for the LV diastolic function significantly improved after the CR program compared with the control group. The LV diastolic function is known as the condition associated with patients’ physical activity and exercise capacity (Grewal et al., 2009). As such, the increases in physical activity and exercise of the patients in the experimental group are considered helpful for improving their LV diastolic function. This study showed a significant improvement in CD-QOL of the experimental group, but this value also improved in the control group over time. Some studies have shown that CR improves QOL (Dalal et al., 2007; Lie et al., 2009; Kitzman et al., 2010; Yohannes et al., 2010), while others have shown some partially positive effects on QOL (Belardinelli et al., 2001; Jolly et al., 2007), and others have reported no significant difference between experimental and control groups (Hage et al., 2003; Briffa et al., 2005; Hanssen et al., 2009). Considering these results, ongoing management and longterm observations may be needed to ensure further improvement in QOL in addition to the improved physiological factors in patients with CHD. The results, however, did not support the hypothesis that participants who completed the CR program would have reduced BP, PR, and glucose levels and improved lipid profile and NYHA functional classes. One possible explanation for this is the effect of the continuous intake of prescribed medications and other routine approaches on disease management in both groups. This finding is consistent with that of Choi et al. (2008), in which the physiological variables (BP, PR, and lipid profile) did not differ between the experimental and control groups after CR. The findings also did not support the positive effect of the CR program on perceived health status. Patients in the experimental group reported their health as being of medium to low quality both before and after the CR program. We suspect that this is because their disease requires life-long management, and this uncertain thought influences their health status self-perception. In an earlier study, patients with CHD perceived less control over their health and high level of health-related uncertainty that tended to persist even after one year of follow-up (Eastwood et al., 2008). Alternatives to physician-led inpatient or outpatient care for CHD, such as this tested comprehensive and multidisciplinary outpatient CR model considering patients’ learning needs and cultural context regarding the use of CAM, especially with nurse-led program aspects, should be utilized with © 2014 Wiley Publishing Asia Pty Ltd.
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a larger patient population in Korea. It is likely that continuous follow-up by nurses helped improve and maintain CHD patients’ physiological and psychosocial factors, including cardiac function and CD-QOL, and we hope that the CR program becomes an important part of the secondary prevention method for patients with CHD, and it can be used easily and efficiently throughout the general healthcare system.
Study limitations This study has some limitations. First, a quasi-experimental design was used rather than a randomized controlled trial design. Second, it did not track whether patients were taking multiple medications. This variable might help control possible confounding factors, particularly with regard to physiological outcomes. Third, this study did not directly assess the experimental group patients’ degree of knowledge improvement after the intervention. Finally, because this study was conducted at only one medical center in South Korea, its findings may have limited generalizability. Future investigations should consider using a larger and randomized sample and including a longer tracking period, other influential factors, and various regions to increase its statistical power.
CONCLUSION The patients in the experimental group, who were provided a comprehensive CR program, including education, demonstration, counseling, telephone call follow-ups, and six month support by cardiac nurses, improved significantly in terms of BMI, waist circumference, LV diastolic function, and CD-QOL. This program’s safety was evidenced by the similar symptom and cardiac event recurrence rate between the experimental and control groups. We hope that a comprehensive CR program for secondary prevention in patients with CHD becomes more widely available in Korea.
ACKNOWLEDGMENTS This work was supported by College of Nursing, Yonsei University, Seoul, Republic of Korea. We are grateful to all patients who participated in this project. No conflict of interest has been declared by the authors.
CONTRIBUTIONS Study Design: SSK, SL, GYK, SMK, JAA. Data Collection and Analysis: SMK, JAA. Manuscript Writing: SSK, SL, GYK, JAA.
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