1. WALK IN THE COMMUNITY a Community Partnership Cardiac Rehabilitation Program co-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

2. 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)

3. 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

4. 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)

5. 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

6. Methods  A collaboration program between TWEH and Care for Your Heart Training sessions 1 2 3 4 5 6 7 8 Community 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 Exercise prescription All patients said to be actively exercising in community

7. 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)

8. Exercise Test  No previous cardiac rehab (n= 12) Symptom-limited exercise test to determine maximum heart rate (HR max )  Had previous cardiac rehab (n= 28) HR max at post-program exercise test was taken as reference

9. Calculation of heart rate training zone Target HR range = ([HR max – HR rest ] x % intensity) + HR rest Example: HR max 140 / min, HR rest 70 / min Intensity 40% to 80% Target HR range = ([140 – 70] x 40% - 80%) + 70 = (28 – 56) + 70 = 98 / min – 126 / min

10. Community Walking Class Date / Time: every Thursday (7:00am- 8:30am) Venue: Victoria Park (600m jogging path) Components: 10 minsStretching & Warm-up Exercise 40-60 minsBrisk Walking Exercise 10 minsCool-down & Stretching Exercise Equipments: HR monitor (POLAR), BP monitor, Automated External Defibrillator (AED), Basic First Aid Kit Manpower: 2 nurses, 1 physiotherapist, 2 volunteers

11. 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)

12. Results Demographic data for completed cases, n= 40 Sessions8 Total Number of Attendance 320 Averaged Age of the Patients62.8 ± 10.7 Gender : Male 63% Diagnosis: CAD 32 (PCI 25, CABG 3) Post valvular replacement2 CHF6

13. Field Test n= 40

14. Percentage of Subjects of which the Exercise Heart Rate is within the Recommended Target Exercise HR Training Zone Percentage of subjects (%) P<0.001

15. n= 40 Field Test

16. p < 0.001 3.3 ± 0.8 4.0 ± 0.8 Averaged Exercise Intensity (METs) before and after the Community Walking Class

17. Percentage of subjects who were able to establish a regular exercise habit in the community Percentage of subjects (%) p < 0.001

18. 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

19. 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

20. 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

21. 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

23. Acknowledgement Cardiac Rehabilitation and Resource Center, Tung Wah Eastern Hospital Dr. LEUNG Kei Pui Deputy Hospital Chief Executive Chief of Service (Department of Medicine and Rehabilitation) Tung Wah Eastern Hospital Ms TANG Siu Wai Nurse 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, Cat Exeuctive Sectetary, Registered Social Worker Care for Your Heart

24. - Thank You - Looking forward for Further Collaborations with more Community Partners