Home Based Cardiac Rehabilitation: Development, Implementation, and Outcome Evaluation in Patients with Coronary Artery Diseases in Lahore, Pakistan. A Mixed Methods Study

Phase 1 In this phase, a few hours after the procedure, patients’ capacity to mobilize, risk factors and education, and possible facilitation into the program will be assessed. Furthermore, the researcher will initiate phase 1 by examining the cardiac risk factors for all eligible patients by blood pressure, heart rate, New York Heart Association (NYHA) Classification for dyspnea, and present symptoms. Along with that, the patient’s cognitive function, readiness for a lifestyle change, and overall health needs will also be evaluated. The complete assessment will be done in approximately 1 hour during hospitalization, at a private room in the hospital. Few hours after the event or procedure is a critical window in which patients often feel highly motivated to initiate lifestyle changes. Phases 2 and 3 Phase 2 includes functional capacity, physical activity and exercise, risk-factor modification, tobacco/smoking cessation, nutritional guidance, psychological counseling, and medication adherence. Before entering into this phase, a submaximal exercise test; the 6-minute Walk Test (6MWT) will be used as qualifying as well as for initiating the exercise prescription. The minimum distance required to qualify will be 150 meters for non-surgical patients (Rohrbach, 2017). The 6MWT will be performed at first follow-up i.e. within 7 days after the procedure in a hospital setting for patients with stable angina, post Percutaneous Coronary Intervention (PCI), and with following myocardial infarction. On the same visit, each patient in the HBCR Group will receive a hard copy of booklet as a guide to physical activity and exercise, strategies for risk-factor modification, nutritional guidance, and the importance of medication adherence. The booklet will be developed specifically for this study by exploring experiences and Opinions from the patients and experts, respectively. An electronic/soft copy of booklet (pdf) will also be shared on their WhatsApp number. A reminder through a text message will be given every week to ensure their compliance with the educational module. Additionally, a structured personal health journal will be developed and provided to document daily activities such as blood pressure, heart rate, physical activity, and dietary intake. After subsequent assessment and enrollment into phase two, patients will be followed physically in the clinics on their scheduled appointment/follow-up i.e at 1 week, 4 week, 8 week, and 12 week post-discharge and will be compensated for these visits. The topics mentioned in the handbook will be covered in these sessions and they will also be taught about self-monitoring the exercise with a targeted heart rate between 60%-75% and Borg dyspnea scale for perceived exertion, respectively. The aim is to achieve a minimum 150 minutes of moderate activity level each week as determined by a targeted heart rate between 60%-75% and Borg dyspnea scale for perceived exertion. The targeted heart rate will be calculated by the researcher for the individual patient. The patients will be taught to take caution and stop physical activity/exercise if they feel chest discomfort, chest pain, unexpected Shortness of breath, nausea, dizziness, palpitations, excess sweating, or feeling of being unwell. For the risk-factor modification, patients will be motivated to avoid smoking and tobacco use, weight management, and diabetes control (if applicable). For nutritional guidance, patients will be counselled to avoid food that contain high saturated fat and cholesterol, such as processed meat, fired food, baked goods sweets etc. These counseling sessions of 45-50 minutes will be conducted on their scheduled appointment/follow-up at the hospital private rooms on their physical follow-ups post-discharge. Furthermore, a total of seven 5-10 minutes telephonic follow-up sessions will be conducted by the Researcher and a trained cardiac nurse within 12 weeks (weekly for the initial 3 weeks (2nd, 3rd, and 4th weeks), and then biweekly (5th, 7th, 9th, 11th weeks) until the 12th week). Upon completion of phase 2 CR after the 12th week, they will be continuing the CR as phase 3. Phase 3 will be the long-term maintenance program that will include monthly phone calls for a total of seven 5-10 minutes telephonic follow-up sessions by the Researcher and a trained cardiac nurse up to 6 months from the date of discharge (16th , 20th, and 24th weeks). Patients will be encouraged to continue the personal health journal until 24 weeks of enrollment. The goal of HBCR is to support each patient to adopt a healthy lifestyle in a long run by putting each part of the intervention into their daily lives such as physical activity, healthy diet, etc.