Power Walking in Cardiac Patients Who Underwent Post-coronary Angioplasty
Condition: Heart Diseases, Ischemic; Coronary Artery Disease; Coronary Arteriosclerosis; Coronary Syndrome; Coronary Disease
MeSH terms: Coronary Artery Disease; Myocardial Ischemia; Coronary Disease; Heart Diseases; Arteriosclerosis
Study type: Interventional

Summary: 
      The risk and prevalence of cardiovascular disease in United Arab Emirates (UAE) is high with
      ischemic heart disease ranks first in terms of major cause of mortality. Large number of
      patients undergoes coronary angioplasty but very few participate in cardiac rehabilitation
      because its awareness is not widespread in middle east region.

      The objectives was to find the influence of standardized outpatient cardiac rehabilitation
      program along with power walking on Heart quality of life (Heart QoL), functional exercise
      capacity, Left Ventricular Ejection Fraction and metabolic equivalent task (MET's) among
      patients with post coronary angioplasty.

      The investigators conducted a randomized clinical trail in out patient physiotherapy
      department at Thumbay hospitals Dubai, on patients who underwent coronary artery angioplasty.
      After meeting the inclusion criteria, participants were randomized into standardized
      outpatient cardiac rehabilitation program along with power walking (intervention group) or
      standardized outpatient cardiac rehabilitation program (control group).

      A 4 weeks of 12 outpatient cardiac rehabilitation sessions consisting of 3 sessions per week
      was provided to both the groups. Intervention group received standardized outpatient cardiac
      rehabilitation program along with power walking based on targeted heart rate and weekly
      steps, whereas control group received only standardized outpatient cardiac rehabilitation
      program based on American College of Sports Medicine (ACSM) Guidelines.

      The investigators measured Quality Of Life (HRQoL) by HeartQoL questionnaire, Exercise
      Capacity by 6 min walk test (6MWT), Left ventricle Ejection fraction (LVEF) using
      Echocardiogram, Metabolic Equivalent Task (MET'S) using Symptom-limited exercise stress test
      and Average number of steps walked daily using step up smartphone Pedometer App.
    

Detailed description: 
      Approximately 17.8 million worldwide deaths per year are due to cardiovascular disease (CVD).
      Arab countries are at higher risk of CVD in which middle income countries are mostly at
      burden. "The threshold for cardiac arrests and cardiovascular disease (CVD) worldwide is 65
      years, while people in the UAE are suffering from the CVD at the age of 45" reported by
      Emirates Cardiac Society. One of the most common causes of cardiovascular deaths is coronary
      artery disease (CAD). Coronary angioplasty one of the most common non-surgical approach for
      the treatment of ischemic coronary artery disease. It is widely accepted that cardiac
      rehabilitation can be beneficial for patients with heart diseases. Most of the patients won't
      achieve adequate functional improvement, if rehabilitation exercises are not done on regular
      basis post-coronary angioplasty.

      In cardiac rehabilitation (CR) programs, psychosocial function and the assessment of quality
      of life (QOL) are the major objective parameters commonly used by researchers. Physical
      activity and emotional status influence health related quality of life (HRQOL) in patient
      underwent coronary angioplasty. It is important to find effectiveness of CR on health related
      quality of life (HRQOL). Studies has shown that tailored exercise training helped to improve
      Left Ventricle Ejection Fraction (LVEF) in patients post coronary angioplasty. A systematic
      review highlighted the effectiveness of using 6MWT to show improvement of functional capacity
      in patients undergoing cardiac rehabilitation.

      It is well known that walking exercise reduces cardiovascular disease-related mortality and
      predicts longevity in patients with established CAD. One of the integral components of
      cardiac rehabilitation is treadmill walking. A meta-analysis demonstrated that physical
      activity could be enhanced in patients with the use of pedometer. Recent evidence shows that
      smartphone apps are effective at promoting physical activity. Studies also shows that
      smartphone Apps are more accurate in tracking steps as compared to fitness trackers.

      Power walking is an effective part of phase II cardiac rehabilitation. Running is preferred
      over walking since oxygen consumption while running is less as compared to walking.

      It was reported that up to 1 year, cardiac rehabilitation improves QOL in patients with acute
      myocardial infarction (AMI) or revascularization procedures. Four weeks of short CR course
      provides better attendance, improvement in quality of life and exercise capacity.

      Accordingly, the current study was conducted for 4 weeks, a shorter period of rehabilitation
      and documented the effectiveness on cardiac fitness including health related quality of life,
      functional exercise capacity, ejection fraction and metabolic equivalent task (MET's) of
      patients with post angioplasty.

      Although the advantages of CR are well known to most of the physicians, still one third of
      the patients do not receive CR post coronary angioplasty due to poor referral trends. Higher
      rates of quality-of-care measures were found among patients who were referred for CR compared
      to those who were not referred. Post coronary angioplasty patients need to continue with
      cardiac rehabilitation in a progressive manner to attain the overall improvement. In a
      comparative study where 5 and 39 CR programs participated from Arab countries and Canada
      respectively showed that in Arab countries CR programs are very limited. Recent statistics in
      UAE has shown that 30% deaths are due to cardiovascular diseases, 30-70% population has
      cardiovascular diseases or are at risk and 37% population do not exercise and are physical
      inactive.

      The concept is very clear that significant number of eligible patients with cardiac
      conditions is not referred for outpatient CR. Although most patients post coronary
      angioplasty are encouraged by cardiologist to gradually increase their activity levels,
      limited data are available on the amount of physical and walking activity and regular aerobic
      exercises done by patients with post coronary angioplasty at phase II CR.

      Power walking has an advantage that it consumes 55% more energy in comparison to just walking
      alone or running at a speed of 6 to 8 km/h, while being at a lower intensity. Despite the
      advantages of power walking, the exercise effects have not been reported in cardiac
      rehabilitation programs.

      This study will help to fulfill great need for referral and awareness of out patient cardiac
      rehabilitation by proving outcomes of standardized outpatient cardiac rehabilitation program.
      The investigators utilized power walking along with standardized cardiac rehabilitation to
      find effectiveness on health related quality of life, functional exercise capacity, ejection
      fraction and metabolic equivalent task (MET's) of patients with post coronary angioplasty.
      Henceforth, the need for research is to prove the effectiveness of cardiac rehabilitation in
      UAE population.
    

Intervention name(s): Power walking; Standardised outpatient cardiac rehabilitation
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Exercise in the form of Power walking at hospital for 10-20 minutes on treadmill with various exercise intensities. Weekly Steps at home 30 minutes walking with target to reach 1000 steps daily.
It is a form of exercise where active upper body movement is performed along with usual walking. It is a fast walking exercise done at a speed of 6 to 8 km/h. During power walking the back is kept straight with the centre of gravity moving from heal, sole, and to hallux. There is active swing back and forth movement of elbow joint with 90 degrees of flexion while walking.
Weekly protocol for power walking
Week 1 60-65 % of the target heart rate (THR) 5,000 to 7,499 steps/day
Week 2 65-70 % of the target heart rate (THR) 7,500 to 9,999 steps/day
Week 3 70-75 % of the target heart rate (THR) >=10,000 steps/day
Week 4 75-80 % of the target heart rate (THR) >12,500 steps per day; Standardised Outpatient Cardiac Rehabilitation based on ACSM Guidelines the intervention group received the following four weeks of intense training program
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A 4-Week, Single-Blind, Parallel-Group Study
Masking: Double (Participant, Investigator)
Primary purpose: Treatment
Keywords: cardiac rehabilitation; coronary angioplasty; power walking; heart quality of life; metabolic equivalents task