Research has always been an integral part of the activities of the department of Cardiac Rehabilitation. The goal of this research is to ensure that patient outcomes are optimal and in keeping with the latest evidence based medical findings. Patient data is also analyzed so that existing guidelines can be appropriately modified and checked for effectiveness with special regard for the Indian patient population.

We accept interns and observers who would like to participate in this exciting field of research. We are also happy to co-ordinate with other organizations or hospitals. For more information please feel free to contact us on acontractor@ahirc.com.

The Asian Heart Institute's dept. of Cardiac Rehabilitation is one of the busiest in the country. It stresses the fact that there is a significant increase in awareness amongst people with respect to prevention of chronic diseases. In fact 17% of patients who enter the program are patients who have risk factors of heart disease, but haven't yet become prey to heart disease. They are health conscious individuals who want to prevent a problem which is going to take a massive toll on the health system of India in the years to come.

Average distribution (by diagnosis) of patients entering cardiac rehabilitation

*CABG - Bypass surgery, PTCA - Angioplasty, CAD - Patients with coronary artery disease (blockages) on medical management, 1° Prevention- Preventive cardiology

Scientific data presented by the department at the Cardiology Society of India Annual Meetings

December 2004: Bangalore

1. Implementation of A Cardiac Rehabilitation And Cardiovascular Risk Reduction Program
   
   Authors: Aashish Contractor, Tilak Suvarna, Vijay Surase, Anuja Parekh, Jigar Shah, Ramakanta Panda.

   Worldwide there have been documented clinical benefits of cardiac rehabilitation. Despite this very few hospitals in India offer these services. At the Asian Heart Institute we implemented an inpatient and outpatient cardiac rehabilitation program. Components of the program, include: 1.mobilization and education of inpatients, post cardiac event.2. outpatient exercise under telemetry supervision. 3.aggressive control of multiple coronary heart disease (CHD) risk factors. 4. nutritional and psychosocial counseling. Yoga was an optional component of the program. During the first year the outpatient program had 201 patients. 143 had undergone coronary artery bypass graft (CABG) surgery; 35 PTCA; 23 had CHD on medical management. Mean age was 57 years;184 were males and 17 females; average ejection fraction =53%. Patients enrolled on a monthly basis and the mean duration was 25 sessions over 77 days. Their risk factor status was evaluated at baseline and at exit from the program. There were no adverse events reported. For patients with abnormal baseline CHD risk factors, clinically relevant improvements were observed as follows (all values statistically significant unless otherwise mentioned) : total cholesterol - 35mg/dl; triglycerides -38mg/dl; LDL -25mg/dl; HDL - 1mg/dl (NS); fasting glucose -33mgdl; BP -14/-8 mmHg.

   Conclusion: These data serve to demonstrate the safety and effectiveness of a cardiac rehabilitation and risk factor reduction program in those with CHD.
   
   
2. Safety and Efficacy of Exercise Training In Coronary Heart Disease Patients With Low Ejection Fraction
   
   Authors: Aashish Contractor, Sudhir Vaishnav, Dhiraj Narula, Vijay Surase, Pradnya Salgaonkar, Ramakanta Panda.

   A low ejection fraction (EF) risk stratifies an individual in the high risk category for cardiac events. It is a widespread belief that these patients should not engage in intense physical activity. In this study we looked at 34 coronary heart disease (CHD) patients with EF<35% who were enrolled in the cardiac rehabilitation program at the Asian Heart Institute. There were 28 males and 6 females;mean age=57 years(range 40-75 years);mean EF=28%; 25 had undergone CABG surgery, 5 PTCA, and 4 had triple vessel disease on medical management. They exercised under telemetry supervision for an average duration of 25 sessions over 77 days. They started at low intensity (< 3 METS) for 5 minutes (mins), and progressed to a mean intensity of 4 METS for 45 mins. Exercise was prescribed at 60-80% of maximum heart rate and a rating of perceived exertion of 11-13 on the Borg scale. Participants were evaluated at baseline and at completion. During the training period there were no adverse events reported. On exit, improvement was observed in multiple CHD risk factors for those who had abnormal baseline risk factor values (based on international clinical guidelines)as follows: Systolic/diastolic blood pressure -15/-8 mmHg(p<.05); total cholesterol -40mg/dl(p<.05); triglycerides -50 mg/dl(p<.05); LDL cholesterol -32mg/dl(p<.05); HDL cholesterol +2mg/dl(p=NS); fasting glucose -70mgdl(p<.05); BMI -0.18 kg/m2(p=NS).

   Conclusions: Low EF patients with CHD can safely participate in a medically supervised exercise program and experience significant gains in multiple CHD risk factors.
   
   
3. Effectiveness of Cardiac Rehabilitation of blood pressure reduction in cardiac patients
   
   Authors: Contractor Aashish, Parekh Anuja

   Material & Method: Hypertension is recognized as one of the major risk factors for coronary heart disease (CHD). In this study we looked at the effect of a phase 2 cardiac rehabilitation programs on the blood pressure (BP) in 197 patients with CHD. The program involved telemetry monitored exercise 3 times a week and cardiac risk factor modification at the Asian Heart Institute. BP was evaluated at baseline and at 2.5 months. Patients were categorized into hypertensive (BP > 140/90; n=44) or non-hypertensive (BP <140/90; n=153).

   Results:

   HTN Non-HTN All   Syst Dias Syst Dias Syst Dias Pre-BP 142 88 115 75 121 78 Post BP 128 80 116 73 118 75 Change - 14 - 8 +1 -2 -3 - 3 P value < 0.5 < 0.5 NS NS < 0.5 < 0.5

   These findings suggest that the program had a significant impact on the BP of all participants and those with hypertension at baseline. Also, it's more important to assess changes in those with abnormal baseline risk as compared to looking at overall results. At the end of the program 27 patients (61%) moved from the hypertensive to non-hypertensive classification.

   Conclusions: A cardiac rehabilitation and risk factor modification program is effective in lowering the BP of CHD patients; especially those who are hypertensive.

4. Participation In A Marathon Soon After Bypass Surgery: The Asian Experience
   
   Author's: Aashish Contractor, Sudhir Vaishnav, Sandip Rane, Vijay Surase Pradnya Salgaonkar, Meghna Kadakia, Ramakanta Panda.

   After a cardiac event, especially coronary artery bypass graft (CABG) surgery, patients are extremely wary of participating in physical activity, which is perceived as strenuous. 22 patients, who were enrolled in the Asian Heart Institute cardiac rehabilitation program were trained to participate in the Dream Run (7 kilometres)of the Mumbai International Marathon, in which over 20,000 people took part. 14 participants had undergone CABG surgery, 3 PTCA, and 5 had triple vessel disease on medical management. Mean age was 54 years; mean ejection fraction was 54%; 21 were males and 1 female. Mean time from surgery to the race was 7 months (range 2-10 months). The rehabilitation program included exercise training with telemetry monitoring three times a week. Each participant started with 10 minutes and was gradually built up to 60 minutes of symptom limited aerobic exercise. As the event approached, outdoor training was included with a gradual increase in distance from 4 km to 7 km. Prior to the race, subjects completed a stress test with a mean time of 10.5 minutes (range 8.5 to 12) on the Bruce protocol. During the training period there were no adverse events reported.

   Results: All participants successfully completed the distance on marathon day and none required emergency medical care. The average time was 61 minutes (53min being the fastest and 75min being the slowest).
   
   Conclusion: with appropriate medical supervision patients can safely participate in endurance events after CABG surgery.

December 2005: Mumbai

1. ONE YEAR FOLLOW-UP OF PATIENTS WITH TRIPLE VESSEL DISEASE (RECOMMENDED CABG) ON INTENSE MEDICAL MANAGEMENT
   
   Authors: Aashish Contractor, Pradnya Salgaonkar, Jigar Shah, Sangeetha Subramanium, Siddhartha Angadi, Ramakanta Panda

   48 patients who were diagnosed with triple vessel coronary heart disease (CHD), and advised coronary artery bypass graft (CABG) surgery by their interventional cardiologist, consulted our cardiovascular surgeon. On reviewing the angiography the surgeon opined that surgery could be deferred and instead recommended intense medical management, for which the patients enrolled in the cardiac rehabilitation program. In the program their risk factors were aggressively controlled both pharmacologically and with lifestyle modification, according to international guidelines: BP below 120/80 mmHg; total cholesterol < 200 mg/dl; triglycerides < 150 mg/dl; LDL cholesterol < 100 mg/dl; HDL cholesterol > 40 mg/dl. Other goals included smoking cessation, tight blood glucose control in diabetics, daily physical activity of at least 30 minutes, and a diet low in saturated fat and high in complex carbohydrates, fruits and vegetables. Patients followed up three times a week for an average duration of 33 sessions (~3 months). They were made to exercise under telemetry supervision, for duration of 45-60 minutes at an intensity of 60-80% of maximal heart rate. Their diets were analyzed through a three-day food recall and appropriate recommendations made, to keep their total fat intake below 30%, and saturated fat intake less than 7%. Their blood pressure was evaluated at each visit, both at rest and during exercise. Diabetics had their blood sugar measured before and after exercise. Their anti-diabetic medications were titrated according to their responses. Lipid profiles were measured every three months and were treated to goal. To achieve these risk reduction targets, medication changes were made in conjunction with the patient's cardiologist.

   Results: At the time of reporting all 48 patients were stable and had not experienced a cardiac event, including MI or coronary intervention. Of these patients 18 of them had completed one year from the time of their initial angiography.

   Conclusion: With aggressive medical management and lifestyle modification, coronary intervention can be avoided in selected cases of patients with triple vessel CHD.

2. Marathon participation in heart disease patients
   
   Authors: Aashish Contractor, Pradnya Salgaonkar, Jigar Shah, Sangeetha Subramanium, Ramakanta Panda

   Physical inactivity is an established risk factor for coronary heart disease (CHD). After a cardiac event, patients are made to begin low-level physical activity immediately after they are clinically stabilized. This is increased to a moderate level of physical activity within a few weeks, which should then be maintained life-long. Low-risk patients may even participate in strenuous physical activity provided they increase their activity level in a graded symptom-limited manner. 22 CHD patients took part and successfully completed the 7km dream run in the 2004 Mumbai Marathon. In 2005, we enrolled a total of 45 patients to take part in the Standard Chartered International Mumbai Marathon. Of these, 30 had undergone coronary artery bypass graft surgery, 9 had undergone angioplasties, and 6 had stable CHD disease on medical management. These individuals were placed in an endurance-training program at the Asian Heart Institute where-in the patients exercised 3 times/week with telemetry monitoring in the cardiac rehabilitation department. They were taken for training sessions outdoors once every three weeks as well. At the end of the training period they were subjected to a pre-participation stress test. Average time from the coronary event to marathon participation was 104 days. Their details are as given below:

   Mean Age Mean Ejection Fraction Bruce protocol time (in secs) Avg. time from coronary event to participation 59yrs 53% 9mins 47 secs 104 days

   2 patients had a positive stress test (for which they were further evaluated) and were not allowed to participate. All the remaining patients completed the 7km dream run with an average time of 63 minutes and 30 seconds (fastest time was 53 minutes and the slowest was 74 minutes). No adverse events were recorded during or after the marathon. All of them reported a boost in their self-confidence levels and reported a high level of motivation to continue with their previous levels of physical activity.

   Conclusion: Strenuous physical activity is safe for CHD patients, provided they are appropriately screened and activity is increased in a graded symptom-limited fashion.