The Potential of Home-based Cardiac Rehabilitation Via Telehealth in Patients with the Post-Acute Coronary Syndrome in Indonesia: A Literature Review Study

Patients with post-acute coronary syndrome (ACS) require cardiac rehabilitation. However, there were obstacles in in-hospital cardiac rehabilitation (IHCR), so that it impacts on recurrence and a decreased quality of life. This paper analyzes the potential of home-based cardiac rehabilitation (HBCR) via Telehealth in post-ACS patients in Indonesia. It was a literature review study. We used articles from electronic media through the keywords home-based cardiac rehabilitation, Telehealth, and acute coronary syndrome. Journals were obtained through search sites on Google Scholar, Science Direct, PubMed, and ProQuest. The identification criteria were using Indonesian and English with the year of publication from 2015 to 2020. Then, we analysed and synthesized eligible publications using the PRISMA method. Findings from eight journals showed that the most common barriers for patients in in-hospital cardiac rehabilitation were logistical barriers (distance, time, functional status) and the patient's insufficient knowledge regarding the importance of cardiac rehabilitation. HBCR is an implementation model that has the potential as an effective solution in overcoming logistical limitations between patients and doctors. Care providers in several developed countries have implemented HBCR. It significantly improved medication adherence, outcome, and safety profile in patients. Furthermore, virtual cardiac rehabilitation provided the same outcome and safety profile as IHCR. Indonesia needs to develop HBCR via Telehealth for secondary prevention management in patients after heart events, especially ACS. Developing Telehealth could reduce complications and recurrence, improve lifestyle and physical activity, lower the risk of rehospitalization, and reduce treatment costs.


INTRODUCTION
Heart disease is one type of catastrophic disease requiring comprehensive treatment. However, cardiac rehabilitation in several parts of Indonesia has not been directly proportional to the high number of patients. Patients after acute cardiovascular events require cardiac rehabilitation because it is an effective intervention and can reduce mortality and morbidity (Smolderen, 2017). Cardiac rehabilitation can allow post-cardiovascular patients to adapt to cardiac physiologic changes. It is one of the aspects of selfmanagement and is essential in implementing discharge planning and a continuum of care (Wolf et al., 2016).
In Indonesia, ischemic heart disease such as acute coronary syndrome (ACS) is the number one cause of increased mortality and morbidity rates. The number of ischemic heart disease patients with Disability Adjusted Life Years (DALY's) increased by 10.5%, from 5.9 million in 2006 to 6.25 million in 2016. In addition, The estimated incidence of DALYs was 200 per 100,000 population (Sunjaya, Sunjaya, and Priyana, 2019). Meanwhile, only 11.35% of patients with coronary heart disease (CHD) underwent cardiac rehabilitation in a hospital in Bandung (Saripudin, Emaliyawati en Somantri, 2018). Suboptimal https://doi.org/10. 33086/jhs.v15.i1.2457 Lutfian -The Potential of Home-based Cardiac Rehabilitation Via Telehealth in Patients with the Post-Acute Coronary Syndrome in Indonesia: A Literature Review Study cardiac rehabilitation causes decreased quality of life and increased average claim for financing treatment in heart disease.
Several obstacles can cause low patient participation in the cardiac rehabilitation program. This condition impacts disease recurrence and decreases the quality of life. A prior study reveals the number 1 barrier to cardiac rehabilitation in CHD patients is logistical barriersdistance, transportation, and time (Saripudin et al., 2018). The obstacles are because Indonesia is an archipelagic region. In addition, cardiac rehabilitation centers in 2019 had not reached all areas in Indonesia.
According to the American Heart Association (AHA), screening in patients with heart disease is crucial to assess the severity and typical symptoms of cardiovascular disorders. The vital point of the screening is working with the patient to identify a specific individualized treatment plan and further monitor the patient's symptoms (Smolderen, 2017). One potential resource to support self-management and navigation of health care is Telehealth.
Telehealth has the potential to develop home-based cardiac rehabilitation (HBCR) as an effort to overcome logistical barriers for patients. It includes symptom monitoring without reducing the frequency of access to health facilities. In addition, it is supported by an accessible 24-hour service. Thus, Telehealth can be a strategy to change behavior in the community. This paper analyzes the potential of home-based cardiac rehabilitation (HBCR) via Telehealth in post-ACS patients in Indonesia.

METHOD
This study was a literature review. We used articles from electronic media through the keywords home- Adherence to cardiac rehabilitation is one indicator that can improve patients' quality of life with CHD. Saripudin (2018) found that the most common barriers for patients in in-hospital cardiac rehabilitation that provided the same outcome and safety profile as IHCR (Wolf et al., 2016;Sunjaya, Sunjaya and Priyana, 2019; Thomas et al., 2019;Wakefield et al., 2019;Moulson et al., 2020).

Acute Coronary Syndrome in Indonesia
In Indonesia, ischemic heart disease such as acute coronary syndrome (ACS) is the number one cause of increased mortality and morbidity rates. The number of ischemic heart disease patients with Disability Adjusted Life Years (DALY's) increased by 10.5%, from 5.9 million in 2006 to 6.25 million in 2016. The Strong Heart Study by the American Heart Association in 2019 revealed that women aged 45 years had a higher incidence of cardiovascular disease than men (Muller et al., 2019). day. In contrast, The IHCR is only done a few hours weekly (Thomas, 2019). Telehealth allows patients to consult with health workers via smartphones to overcome logistical barriers in IHCR.
The core components of HBCR are patient assessment, physical exercise, dietary counseling, risk factor management (smoking, blood pressure, weight, diabetes mellitus), and psychological intervention (Thomas, 2019). The outcome of HBCR is to help reduce the recurrence of secondary cardiovascular events after hospitalization. In addition, it helps restore optimal physical, mental, social, vocational, and sexual life after changes in health status (Nuraeni, 2016). The following are components of home-based cardiac rehabilitation:

1) Pain Management
Patients after cardiovascular events often complain of chest pain. The pain is different because it is above the pain threshold and tolerance. In addition, there is a decrease in circulating endorphins and enkephalins hormones released by the pituitary. There are pharmacological and non-pharmacological interventions in HBCR. The goal of pharmacological intervention is to increase blood flow by increasing the oxygen supply and reducing the myocardium's demand for oxygen. While non-pharmacological interventions prevent pain, reduce the risk of decreased cardiac output, increase self-care ability, reduce anxiety, and prevent complications.
Non-pharmacological interventions include rest and thermotherapy. Rest serves to reduce oxygen consumption by the myocardium. In addition, thermotherapy uses hot packs warmed at a temperature of 50ºC for 20 minutes per day or according to the patient's comfort. Thermotherapy can manage pain through surface tissue (skin) and muscle tissue. Stimulation of heat receptors will increase the secretion of endorphins so that it can reduce pain levels. In addition, endothelial duplication and increased nitric oxide (NO) will help myocardial perfusion, thereby reducing pain (Moradkhani en Baraz, 2018).

2) Stress Management / Psychological Traumatic Healing
Management of traumatic stress in post-acute coronary syndromes is rarely known, but it can have longterm effects on adopting healthy behaviors. Patients after cardiovascular events experience varying levels of stress, but the probability is higher than that of the general population (Tulloch, Greenman en Tassé, 2015). One of the most extreme of traumatic stress is Post Traumatic Stress Disorder (PTSD). PTSD is associated with cardiovascular reactivity, such as increased proinflammatory and endothelial dysfunction.
Furthermore, it can develop into an exacerbation of heart disease (Tulloch, Greenman en Tassé, 2015).
Primary Care PTSD Screen (PC: PTSD) is a Valid posttraumatic stress screening to detect anxiety (Roberts et al., 2016). In addition, psychoeducation about the signs and symptoms of PTSD and other psychological disorders related to heart disease is essential. techniques (such as diaphragmatic breathing and progressive muscle relaxation). Furthermore, it is a nursing intervention to minimize stress (Tulloch, Greenman en Tassé, 2015).
3) Physical activity management Support for staying physically active at home requires measurements of speed and distance. So it takes a particular device in a phone to measure these things. The target heart rate in independent physical exercise is 60-75%. Developing an android system such as an accelerometer system can be a solution for tracking location and measuring mobile phone motion's speed and direction. In addition, the accelerometer in the mobile phone can calculate the average daily energy expenditure level, which is visualized on a statistical graph. As a result, it can monitor the patient's physical activity.

4) Diet management
Diet management in CHBR is focused on the history of the food consumed and the time of daily consumption. Sources of nutrition can be adjusted to the patient's resources and can be monitored by health workers. In diet management, there is a modification of protein intake and a reduction in salt, saturated fat, and alcohol intake (Quiles en Miralles-vicedo, 2014). Telehealth allows patients to input the type of food consumed. Then the care provider will evaluate and modify their food and measure the patient's BMI every week or month.

5) Patient assessment
The Seattle Angina Questionnaire -7 (SAQ-7) is an assessment to evaluate the frequency of angina recurrence. It has 7 question items to measure the domains of physical limitations, angina stability, angina frequency, satisfaction with treatment, and perception of the disease. The instrument is valid for coronary artery disease and has high reliability and accurate predictive power (Chan et al., 2014). Care providers can use this assessment to evaluate the success of CHBR.

Daily Monitoring of ACS patients via Telehealth
The growth of internet users in Indonesia in 2017 increased to 143.26 million from the previous year of 132.7 million users. There was a shift in the productive age generation of internet users.  (Thomas et al., 2019). Telehealth via web and online applications in patients with cardiovascular disorders has been studied in several countries like Sweden and Japan. Daily activity measurements will be measured automatically in the mobile application. In addition, there is a questionnaire containing patient data and complaints every day. Furthermore, there are data on patient compliance in carrying out the intervention. Thus the care provider can evaluate the cardiac rehabilitation program (Wolf et al., 2016).

CONCLUSION
Indonesia needs to develop HBCR via Telehealth for secondary prevention management in patients after heart events, especially ACS. Developing Telehealth could reduce complications and recurrence, improve lifestyle and physical activity, lower the risk of rehospitalization, and reduce treatment costs.