Cardiovascular rehabilitation is nowadays a cornerstone of secondary prevention in the management of coronary artery disease [1]. Indeed, participation in a cardiac rehabilitation program has been correlated with a better quality of life as well as a decrease in morbidity and mortality associated with cardiovascular disease [2]. This intervention is a multicomponent and complex model of care. Consequently, the nature and the quality of services may vary significantly around the globe, according to the country’s income, the available professionals and other factors [3].

In sub-Saharan Africa, numerous technical progresses, interventional or surgical, are being made to reduce the burden of coronary artery disease. But cardiac rehabilitation remains almost non-existent in this area of the world. Very few African data are available on the impact of cardiac rehabilitation [4] [5] [6]. This fact could be due to several barriers identified in low- and middle-income countries such as socio-economic factors [4].

The aim of this work was to evaluate the results of a short cardiac rehabilitation program, performed by the first Senegalese outpatient center.

Cardiac rehabilitation cost-effectiveness has been widely proven around the world. But this intervention remains quasi inexistent in Africa, where several progresses have been made in the other fields of cardiovascular diseases management. Implementing the first Senegalese cardiac rehabilitation center was quite challenging due to many facts:

1) Lack of cardiorespiratory stress test equipment: we performed a simple exercise (treadmill) stress ECG without analysis of gas exchange. Therefore, we couldn’t determine the ventilatory threshold and the exact initial intensity of exercise training.

2) We performed exercise training with programmable treadmills and ergometers for domestic use (medical use treadmills were expensive). We didn’t have telemetry ECG; therefore, we only used a heart rate monitor chest strap.

3) Some medical insurance companies didn’t recognize this activity and only patients who had enough financial support accepted to be enrolled.

4) For these same economic reasons, we had to reduce the number of training sessions to the minimum required for each patient to be independent and enough self-confident to continue regular physical activity.

5) Patient education should have considered our cultural context: talking about sexual activity in a mixed audience of elderly and young people is taboo subject, but it was well appreciated at the end of sessions.

Socio-demographic data such as age, gender, marital status and level of education, were not significantly different between the two groups. The practice of a professional activity and the existence of health insurance were significantly higher in the rehabilitation group (p < 0.05). This difference could be explained by the cost of the rehabilitation which reduced the accessibility of the program to patients who have a low socioeconomic level or are without financial support. These two parameters are themselves linked to the existence of a professional activity.

The age in the rehabilitation group was a bit younger than that reported by Pavy (63.4 ± 10 years) [13] and by Adghar in Algeria (61 years) [6] in their series of coronary patients admitted to cardiac rehabilitation.

Our results show overall a remarkable improvement in the control of CVRF six months after the start of rehabilitation (Table 2).

Treatment compliance at inclusion in our series was low (30.00% in the rehabilitation group, 26.60% in the non-rehabilitation group). It is a challenge in the management of coronary artery disease. The most common non-compliance factors were forgetting to take medication and the high cost of medication in our cohort. These factors were also identified by Eagle as favoring non-compliance after ACS [14]. A positive impact of rehabilitation is suggested by our results. Peersen associated participation in a cardiovascular rehabilitation program with better treatment compliance (RR = 2.32) [15]. This impact would be largely linked to patient education which leads to a better knowledge of the disease and the benefit of the treatment by the patient. In their study, Burke associated this better knowledge of the disease acquired in a cardiac rehabilitation program with better treatment compliance in the management of cardiovascular diseases [16].

Our data show improvement and maintenance of physical activity in the rehabilitated group 6 months after the program. A 2017 meta-analysis by Dibben found similar results, associating participation in a rehabilitation program with an increase in the level of physical activity [17]. An increase in the Ricci Gagnon score was noted at 6 months by Pavy [13] and 77% of patients followed for 1 year by Denolle practiced physical activity regularly [18].

At baseline, even if difference may be apparent looking at percentages of diabetes control, p value was not significant at M0 between the two groups. The most relevant result is that at M6 and this might be due to better treatment adherence, low rate of sedentary lifestyle and improvement in diet found at M6 in the rehabilitated group. These results confirm those of EUROACTION [19] and Denolle [18], who found 73.00% of patients controlled at 1 year of the program.

Participation in the rehabilitation program was associated with an improvement in lipid balance with significantly higher LDL-C control in the group rehabilitation at M6 at 33.00% (p = 0.02) and a significant increase in the rate of HDL-C at M6 (p = 0.01). These findings were similar to those of Denolle [18] and in EUROACTION [19] who respectively revealed 30.00% and 32.00% of LDLc control. It was better, by 76.00% in the Pavy series [13], due to a less severe therapeutic target, in accordance with the recommendations at the time of his survey (LDL less than 1 g/l).

Sexual dysfunction is a common issue among cardiac patients and can be predictive of future cardiovascular events and poorer quality of life [20]. Nearly half of these patients report a sexual problem, whether it is erectile dysfunction, lack of orgasm, or lack of interest [21] [22]. Age, male gender, BMI, hyperlipidemia, poor initial functional capacity are known to be independent factors of recovery of sexual activity [22] [23]. In our study, very few men confessed sexual dysfunction, probably because it is a taboo subject in our Senegalese culture. Women of our sample did not complain and some Senegalese series reveal their decency and resignation when it comes to sexual concerns [24]. Other reasons could be the size and the younger age of our sample, given that all the other factors (BMI, functional capacity, anxiety and depression) were quite similar to other studies. “Sexual life after coronary artery disease” is a component of our collective educational sessions available for all patients, as this is demonstrated by Lindau [25] be a significant predictor of resuming this activity.

Return to work is a major goal of cardiac rehabilitation, which improves health related quality of life, physical work capacity and resuming work [26] [27]. We found a little proportion of disabled patients at baseline and they all returned to work at 6-month follow-up. Female gender depression, limited secondary education, or low income are associated with decreased return to work rates after coronary artery bypass grafting surgery (CABG) [28] [29]. After a cardiac rehabilitation program following a CABG, persistent negative predictors to return to work are depression, age and negative subjective occupational prognosis [30]. The little size of our cohort did not allow us to do this analysis.

These psychosocial factors (symptoms of anxiety and/or depression) were reported by half of the intervention group at baseline but it decreased significantly at 3 then at 6 months. Assessment of psychosocial factor is very variable and some references suggest a better screening including vital exhaustion, type D personality, chronic stress at work, social support [31] [32]. However, our findings are consistent with those of Alqahtani who found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR programs [33]. Indeed, cardiac rehabilitation can help the patients to have better understanding of the influence of psychobiological risk factors and the way to manage their stress [34].

Our cardiac rehabilitation program in patients with coronary artery disease, resulted in good outcomes in a short period of time and with low cost equipment. It was efficient in controlling CVRF, reducing anxiety and depression symptoms, and improving treatment and diet compliance. Further investigations with larger population should be conducted to better assess the benefits of resuming sexual activity and returning to work.

The authors declare no conflicts of interest regarding the publication of this paper.

Ka, M.M., Mboup, W.N., Ndao, S.C.T., Abadassi, S.P.A., Ba, D.M., Dia, K., Fall, P.D. and Mboup, M.C. (2021) Low Cost Equipment and Short Duration Program Are Not Barriers to Good Outcomes of Cardiac Rehabilitation in Senegalese Patients with Coronary Artery Disease. World Journal of Cardiovascular Diseases, 11, 421-433. https://doi.org/10.4236/wjcd.2021.119039

WHO: World Health Organization

CVRF: Cardiovascular Risk Factors

BP: Blood Pressure

HR: Heart Rate

HDL: High Density Lipoprotein

LDL: Low Density Lipoprotein

ESC: European Society of Cardiology

ACS: Acute Coronary Syndrome

CCS: Chronic Coronary Syndrome

BMI: Body Mass Index