SPEEDIER RECOVERY: The rehab team, comprising (from left) Mr Haja Mydin, Dr Tan Swee Yaw and Ms Tan Suan Choo, attending to Mr Dineshan Vallil Parampath.
AFTER surgery, heart patients need a cardiac rehabilitation programme to get back on track.
Mr Dineshan Vallil Parampath is not your typical heart patient. He is quite the opposite. He swims regularly, does yoga, does not smoke or drink, and dislikes oily food. Yet, this 44-year-old mechanical design engineer, with a son and daughter still in school, needed heart surgery in August last year.
The first sign that something was wrong came in December 2011, when he started having breathing difficulties while climbing stairs or swimming for a long time. “It was very uncomfortable as I was not getting enough oxygen,” he said.
A check-up revealed that his aortic valve had shrunk by around 40 per cent. “The doctor at the National Heart Centre Singapore (NHCS) told me it would be better to replace the valve immediately or it would continue to get smaller.”
Mr Dineshan believes his heart problem stems from a bout of rheumatic chorea he had when he was 16. Rheumatic chorea is a nervous disorder associated with rheumatic fever, occurring chiefly in childhood or during pregnancy.
Mr Dineshan had surgery to have a mechanical valve implanted. It went well and, after five days in the ward, it was time for the second phase of his recovery – cardiac rehabilitation – in which patients are slowly reintroduced to exercise, diet and a healthy lifestyle.
Initially, he was afraid of exercising so soon after surgery. “But the nurse and doctor told me not to lie down, but get up and walk, so I did.”
At the hospital, physiotherapists taught him breathing techniques to improve his lung function and helped him get out of bed and walk. They also gave him advice on things to do and avoid in the first two months after surgery, and how to exercise at home.
“After a while, I managed to sit by the bed. By the time I was discharged, I could walk a little with help,” he said.
Three weeks after discharge, he started his twice-weekly cardiac rehabilitation programme at NHCS.
Initially, he exercised on the stationary bicycle and was closely monitored by ECG (electrocardiogram) for vital signs. “After two sessions, I felt more comfortable, so I started exercising on the treadmill for 20 minutes and walking for five to 10 minutes,” he said.
Dr Tan Swee Yaw, Senior Consultant, Department of Cardiology, and Director, Cardiovascular Rehabilitation and Preventive Cardiology, NHCS, said cardiac rehabilitation is vital for recovery after heart operations, including coronary artery bypass graft surgery and valvular heart surgery.
Dr Tan said: “The standard of care 30 to 40 years ago after a heart attack was complete rest in bed for a month. Actually, that’s the worst thing someone can do. Now, usually one and half weeks after a heart attack, patients are encouraged to move about.
“Of course, it’s not very intense activity, but it’s for them to get mobile, regain their confidence and get back their full functional status as quickly as possible. Becoming mobile early reduces the risk of blood clots and helps speed up recovery.”
But cardiac rehabilitation does not involve just exercise. It also incorporates patient education. “We need to educate the patient so he understands his condition, how it happened and why.
“The next thing he must understand is what to do if it happens again, so he is empowered with the capability of preventing it from happening again. Studies show that attending a cardiac rehabilitation programme can reduce mortality by 25 per cent,” said Dr Tan. At NHCS, doctors review heart surgery patients two to three weeks after their discharge, and arrange for them to be on the cardiac rehabilitation programme, which consists of 16 sessions. There are usually about 15 patients per session.
Ms Tan Suan Choo, Senior Staff Nurse (Clinical), Cardiovascular Rehabilitation and Preventive Cardiology Unit, NHCS, said that at the start of the programme, patients attend an hour-long orientation and assessment session.
“They visit the rehabilitation unit and meet the physiotherapists and nurses there. Patients and their caregivers are taught to recognise the signs and symptoms of heart disease, the possible side effects of their medicines and risk factors such as obesity and smoking. We also give them dietary advice.”
Physiotherapists assess and group them into low-, moderate- or high-risk categories. Exercise regimes are prescribed to allow them to exercise at a safe maximum intensity with optimal benefit.
Those who complete all sessions are discharged with advice on exercise intensity and suitable exercise programmes, based on their recovery and progress during the sessions.
Mr Haja Mydin, Executive Physiotherapist, Cardiac Physiotherapy, NHCS, said joining a cardiac rehabilitation programme early allows patients to interact with others in the same situation.
He said: “It helps them overcome their fears and share ways of coping and managing pain, limited function and other symptoms. This helps them regain their confidence and function.”
• This story was first published in Singapore Health, May/Jun 2013.