WALK IN THE COMMUNITY

a Community Partnership

Cardiac Rehabilitation Programco-organized by

Cardiac Rehabilitation and Resource Center

Tung Wah Eastern Hospital

and

Care for Your Heart

Dr. Leung Kei Pui

Deputy Hospital Chief Executive

Chief of Service (Medicine and Rehabilitation)

Tung Wah Eastern Hospital

23rd September, 2006

Introduction

Exercise-based rehabilitation for coronary heart disease shown to decrease all cause mortality by 27% and total cardiac mortality by 31%

(Cochrane Review 2003)

Even in PCI era, exercise training shown to lower significantly the event rate and hospital readmission rate in addition to the improvement of functional capacity and QOL

( ETICA Trial 2001)

Introduction

Many cardiac patients claimed to be engaged

in physical activities

Whether such physical activities can achieve

exercise intensity levels sufficient to improve

aerobic fitness or slow progression of CAD is

unknown

Introduction

The recommended exercise goal for secondary

prevention is 30 to 60 min of moderate-intensity

aerobic activity, such as brisk walking in most,

preferably all, days of the week

(AHA/ACC Joint Guideline 2006 Update)

Objectives

To determine self-selected exercise intensity of

cardiac patients who reported walking as their most

frequent form of exercise

To examine whether a community walking class

can improve the percentage of patients to exercise

at the target heart rate training zone

Methods A collaboration program between TWEH and Care

for Your Heart

Training sessions

1 2 3 4 5 6 7 8Community cardiac pts

n= 24

TWEH, RH completed phase II CRP > 6 months

n= 41

Completed 8 sessions of CWC, n= 40

Continue exercise in CWC, n= 25

Field test

Field test

Exercise prescription

All patients said to be actively exercising in community

Check-point 2

Check-point 1

Runner

Field Test:

Polar was used to monitor HR

Walk at their self-selected (usual) pace

Walking path : 600m per lap

HR taken in 2 check points at each lap

8 lap walking (40 - 60 min) (excluded warm up & stretching exercise)

HRs were averaged and intensity were calculated as metabolic equivalents (METs)

Exercise Test

No previous cardiac rehab (n= 12)

Symptom-limited exercise test to determine

maximum heart rate (HRmax)

Had previous cardiac rehab (n= 28)

HRmax at post-program exercise test was taken

as reference

Calculation of heart rate training zone

Target HR range =

([HRmax – HRrest] x % intensity) + HRrest

Example:

HRmax 140 / min, HRrest 70 / min

Intensity 40% to 80%

Target HR range = ([140 – 70] x 40% - 80%) + 70

= (28 – 56) + 70

= 98 / min – 126 / min

Community Walking Class

Date / Time: every Thursday (7:00am- 8:30am)

Venue: Victoria Park (600m jogging path)

Components: 10 mins Stretching & Warm-up Exercise

40-60 mins Brisk Walking Exercise

10 mins Cool-down & Stretching Exercise

Equipments: HR monitor (POLAR), BP monitor,

Automated External Defibrillator (AED),

Basic First Aid Kit

Manpower: 2 nurses, 1 physiotherapist, 2 volunteers

Individualized Exercise Prescription

Pre-Walking Class Briefing

Patients know Training HR zone

How to monitor the HR

How to titrate the exercise intensity

How fast they should walk

Take precautions (eg, adequate hydration, emergency response)

Results

Demographic data for completed cases, n= 40

Sessions 8

Total Number of Attendance 320

Averaged Age of the Patients 62.8 ± 10.7

Gender : Male 63%

Diagnosis:

CAD 32 (PCI 25, CABG 3)

Post valvular replacement 2

CHF 6

60

80

100

120

140

160

180

Exe

rcis

e H

eart

Rat

e

Subject

Exercise HR before and after the community walking class

pre post

Field Testn= 40

22.5

82.5

77.5

17.5

0

10

20

30

40

50

60

70

80

90

100

pre post

patient who are

unable to achieve

the target HR

patient who are able

to achieve the target

HR (i.e. 40% - 80% HR

reserve)

Percentage of Subjects of which the Exercise Heart Rate is within the Recommended Target Exercise HR Training Zone

Per

cen

tag

e o

f s u

bje

cts

(%)

P<0.001

1

2

3

4

5

6

7

8

9

ME

Ts

Subject

Exercise Intensity in Metabolic Equivalents (METs)before and after the Community Walking Class

pre post

n= 40

Field Test

1

2

3

4

pre post

Met

abo

lic

Eq

uiv

alen

ts (

ME

Ts)

p < 0.001

3.3 ± 0.8

4.0 ± 0.8

Averaged Exercise Intensity (METs) before and after the

Community Walking Class

Percentage of subjects who were able to establish a regular exercise habit in the community

Per

cen

tag

e o

f s u

bje

cts

(%)

37.5

82.5

62.5

17.5

0

10

20

30

40

50

60

70

80

90

100

pre post

patient who are unableto establish a regularexercise habit in thecommunity

patient who are able toestablish a regularexercise habit in thecommunity

p < 0.001

Discussion

Recent epidemiological studies shown that each

1-MET increase in exercise capacity confers 8%

to 17% reduction in cardiovascular and all cause

mortality

The exercise intensity of our patient study group

was 3.3 METs in average, which is at the lower

end of the recommended intensity of 3- to 6-

METs, and less than ¼ could exercise within the

target HR training zone

Discussion

Even for patients who had undergone CRP training

and continued to exercise in the community, they

frequently could not maintain the exercise intensity

achieved during the rehabilitation

Community maintenance program might be helpful

to keep them exercising at adequate intensity to

maintain health benefits

Discussion

Benefits of walking class

Walking is the most-preferred mode of exercise

Large scale participation, accommodates 50 to 100

clients, if suitable area is available

An enjoyable event and in a healthy environment

Could intake patients with CHD in lower risk

(exercise capacity >8 METs or uncomplicated MI)

Decrease resources use compared with formal

CRP hospital-based program

Conclusion

Many cardiac patients failed to attain the recommended target exercise heart rate while walking at their self-selected paces

A community walking program that partnered with community organisations could increase the exercise intensity which might be associated with better health outcomes

AcknowledgementCardiac Rehabilitation and Resource Center, Tung Wah Eastern Hospital

Dr. LEUNG Kei PuiDeputy Hospital Chief ExecutiveChief of Service (Department of Medicine and Rehabilitation)Tung Wah Eastern Hospital

Ms TANG Siu WaiNurse Specialist Department of Medicine and Rehabiliataion, Cardiac Rehabilitation and Resource Center, Tung Wah Eastern Hospital

Mr. CHAN Kin Ming Clement Physiotherapist Department of Physiotherapy, Cardiac Rehabilitation and Resources Center,Tung Wah Eastern Hospital

Care for Your Heart

Ms. HUI Yuen Ting, CatExeuctive Sectetary, Registered Social WorkerCare for Your Heart

- Thank You -

Looking forward for

Further Collaborations with more

Community Partners