ACADEMIA Letters Cardiac rehabilitation care for post COVID-19 survivors Sherldine Tomlinson, Staffordshire University - Life Science and Education As the novel coronavirus (COVID-19) pandemic persists in causing mortalities worldwide, even with the vaccine availability, the research is highlighting the impact of the virus. For instance, we now understand how COVID-19 attacks the body’s systems. With discoveries still emerging, a considerable amount of data suggests that in addition to identifying risks for disease (i.e., comorbidities and respiratory conditions), COVID-19 survivors experience cardiac injuries even though they never had underlying heart problems [1-4]. Heart health experts notice that recovered COVID-19 patients suffer major prolonged complications and require ongoing support and treatment. Insufficient oxygen, myocarditis, myocardial infarction, and cardiomyopathy are a few constellations of conditions described with post-COVID19 patients. With the use of cardiovascular magnetic resonance (CMR) imaging, one study reported cardiac injury in 78% of COVID-19 survivors, while 60% had ongoing myocardial inflammation [5]. Another study applying echocardiography measurements noted damage in left ventricular (LV) diastolic and right ventricular (RV) function [6]. The cardiac sequelae from COVID-19 experience with recovered individuals significantly compromise their cardiorespiratory system to function properly. Unfortunately, this can cause them to suffer long-term disabilities. In addition to cardiac damage, the persistence of symptoms known as COVID long haul after months of being free from the virus leaves a tremendous effect on the health of some recovered individuals, but not all. Headaches, breathing difficulties, muscle aches and pain, brain fog, chronic cough, loss of olfactory sensation and taste are just several ongoing symptoms with former COVID-19 patients [7]. With the high number of post-COVID-19 survivors experiencing cardiovascular damage and the long-lasting effects, should health services in partnership with other healthcare sectors support COVID19 patients with their recovery? Without proper treatment in place, survivors’ life expectancy could significantly decline compared to the general population. It is then appropriate because Academia Letters, August 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Sherldine Tomlinson, tr902550@student.staffs.ac.uk Citation: Tomlinson, S. (2021). Cardiac rehabilitation care for post COVID-19 survivors. Academia Letters, Article 3028. https://doi.org/10.20935/AL3028. 1 of the ongoing care post-COVID-19 survivors require to recommend cardiac rehabilitation (CR) exercise prescription in regaining their health. Evidence-based research demonstrates CR programmes efficacy, yielding positive outcomes where cardiac participants reduce their cardiovascular risks and improve their quality of life, well-being, and functional capacity after completing the programme. The programme’s impact is well established for decades and is the care model for cardiac patients [8]. It is a multifaceted service offering health education and lifestyle changes to enhance the cardiovascular system and lower cardiac mortality risk [8]. Usually, the program is 12 weeks, with psychosocial support teaching participants the risk factors and lifestyle counselling [8-9]. The lifestyle coaching or psychosocial component would significantly benefit COVID-19 survivors because they will learn healthy behaviours and habits and self-care strategies, helping them get back to their regular daily routines. Recovery from COVID-19 takes a considerable toll on the entire body, both physically and mentally. Without appropriate available treatment, the virus will continue to impact former patients’ health significantly. Cardiac rehabilitation health coaching can therefore support and inspire them to better health. Core elements to CR treatment start with exercise tolerance testing’s in assessing patients’ prognosis, functional capacity such as blood pressure, total oxygen consumption and aerobic capacity, rate pressure product, cardiac output measurements, and metabolic equivalent and risk stratification. These tests are appropriate to administer with COVID-19 patients, but because of severe lung damage with some, performing tests with a cycle ergometer in a semi-recumbent position instead of the upright bike test may be more suited. Another testing option would be to have the patient slowly walk on the treadmill as an alternative to the typical graded tests. Exercise testing guides the training prescription, consisting of a structured workout plan tailored to the patient’s needs and supervised by an exercise physiologist, kinesiologist, or fitness specialist. Although there are no evidence-based on the standard training prescription for cardiac patients, the American College of Sports Medicine designed specific exercise prescriptions guidelines for cardiac patients. The prescription can be practical for post-COVID-19 survivors with cardiac damage or even individuals suffering long-haul symptoms [10]. Moreover, a low-impact walking regiment is preferred with a gradual increase in intensity as it is safe and straightforward. As indicated in the research among people who have heart attacks or stroke, those who have participated in a CR walking exercise prescription program are more likely to survive the heart attack than individuals who have not engaged in exercise or have been active in clinical trials [9]. Indeed, CR exercise prescription is worth the chance because of the success with traditional cardiac patients. Cardiac rehabilitation is a sensible solution for recovered COVID-19 individuals with enAcademia Letters, August 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Sherldine Tomlinson, tr902550@student.staffs.ac.uk Citation: Tomlinson, S. (2021). Cardiac rehabilitation care for post COVID-19 survivors. Academia Letters, Article 3028. https://doi.org/10.20935/AL3028. 2 couraging results and the multifaceted services available. Unfortunately, though, a significant challenge for this approach is the inaccessibility, gross underfunding, and underuse of the programme [11]. Cardiac rehabilitation, for example, is available only in 25% of low and middle-income countries [12]. The shortage of patients is also because there is no advocacy for the service despite the high prevalence of cardiovascular diseases and little government support resulting in underappreciated service. Another concern is the limited access to quality healthcare services in low economies of the world; CR delivery is lacking. There is not much research indicating the status of CR care in these countries but what is known is the availability of heart health services, including resources (such as specialise diagnostic tests and performing heart surgery) [13]. Because of the economic conditions in these regions, supporting CR care for COVID-19 survivors would be a challenge, likewise for the uninsured. One resolution can be to look at communitybased health promotion offering free of charge exercise training. Perhaps, further research can explore this unique approach. A significant challenge for support CR lies in persuading physicians to refer COVID-19 patients to CR. Clinical practice guideline recommendations to prescribe heart patients are a massive challenge with a low rate of physicians making referrals [10]. The research cited that healthcare professionals, specifically medical doctors, have very little knowledge about or are unaware of the importance of exercise prescription contributes to the low referral numbers for CR [10-11]. Sanctions for CR for patients are the physician’s responsibility and, without their endorsement, the numbers of patients entering CR will continue to be small. Perhaps establishing an automatic referral system for eligible patients might be the answer to support the increase in CR enrolment. In addition to heart patients discharging from a hospital heart unit, COVID-19 patients could also thoroughly inform CR care. This approach can boost attendance retention and participants adhering to their CR plan. However, without the proper guidance or clinicians’ knowledge about CR programs, qualified patients will not be interested in enrolling in the programme. It is key then that these medical specialists clearly understand the CR clinical exercise prescription and are open to supporting the atypical heart patients, in this case, post-COVID-19 patients with long haul cardiovascular complications. There is no known research on exercise response with post COVID-19 survivors, but the programme can be helpful because exercise carries many benefits to care for cardiac patients. We know from the literature that living an active lifestyle, including habitual exercise, could potentially lower the risk of severe COVID-19 illness and even death [14]. The robust cardiovascular response to exercise training yields optimistic outcomes, as demonstrated in the research. Regular exercise training, for example, produces positive reactions within the body. For one, exercise has anti-inflammatory protection that shields the heart from a potential heart Academia Letters, August 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Sherldine Tomlinson, tr902550@student.staffs.ac.uk Citation: Tomlinson, S. (2021). Cardiac rehabilitation care for post COVID-19 survivors. Academia Letters, Article 3028. https://doi.org/10.20935/AL3028. 3 attack and improves blood vessels’ elasticity, to name a few [15]. Thus, physical training could considerably reduce post-COVID-19 symptoms, including breathlessness, chest discomfort, and other severe complications identified in some people. Thus, exercise is the champion of good health and positively is medicine for the entire body systems alongside healthy eating. A favourable consideration for supporting innovation is promoting home-based or community care exercise prescriptions targeting post COVID-19 survivors with or without symptoms. In addition to slowing or disease prevention, physical activity helps one feel good with more energy and a positive mind. Furthermore, structured exercise intervention outside of a traditional CR setting makes even more sense given the coronavirus pandemic. Studies are quickly emerging supporting the protective advantages of exercise response to COVID-19. In one recent study, the authors found exercise beneficial for people infected with COVID-19 [16]. Future research and data are needed to explore the delivery model and evaluate appropriate CR exercise prescription for recovered COVID-19 individuals. In this framework, equity and culture must also be part of the plan. The program planning could consist of restructuring and making room for flexibility. These additional strategies would significantly increase the diversity of participants attending CR and perhaps establish higher retention rates. Finally, a critical matter to keep in mind is patient follow up. All healthcare providers involved in the treatment plan must also be part of the follow-up process to ensure patient satisfaction and check if they require more treatment or support. References 1. Guzik, T. J., Mohiddin, S. A., Dimarco, A., Patel, V., Savvatis, K., Marelli-Berg, F. M.,…& McInnes, I. B. (2020). COVID-19 and the cardiovascular system: implications for risk assessment, diagnosis, and treatment options. Cardiovascular Research, 116(10), 1666-1687. 2. Zheng, Y. Y., Ma, Y. T., Zhang, J. Y., & Xie, X. (2020). COVID-19 and the cardiovascular system. Nature Reviews Cardiology, 17(5), 259-260. 3. Long, B., Brady, W. J., Koyfman, A., & Gottlieb, M. (2020). Cardiovascular complications in COVID-19. The American journal of emergency medicine, 38(7), 1504-1507. 4. Rey, J. R., Caro‐Codón, J., Rosillo, S. O., Iniesta, Á. M., Castrejón‐Castrejón, S., Marco‐Clement, I.,…& Buño, A. (2020). Heart failure in COVID‐19 patients: prevalence, incidence and prognostic implications. 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Academia Letters, Article 3028. https://doi.org/10.20935/AL3028. 5 15. Ruby, M. B., Dunn, E. W., Perrino, A., Gillis, R., & Viel, S. (2011). The invisible benefits of exercise. Health Psychology, 30(1), 67. 16. Sallis, R., Young, D. R., Tartof, S. Y., Sallis, J. F., Sall, J., Li, Q.,…& Cohen, D. A. (2021). Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. British journal of sports medicine. Academia Letters, August 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Sherldine Tomlinson, tr902550@student.staffs.ac.uk Citation: Tomlinson, S. (2021). Cardiac rehabilitation care for post COVID-19 survivors. Academia Letters, Article 3028. https://doi.org/10.20935/AL3028. 6