Digital Telerehabilitation: A New Frontier in Cardiac Care for Post-PCI Patients

Can Digital Telerehabilitation Transform Cardiac Rehabilitation?

Digital Cardiac Telerehabilitation Shows Promise for Post-PCI Patients in Indonesia

The integration of digital health technologies into cardiac rehabilitation programs represents a significant advancement in cardiovascular care, particularly for patients who have undergone percutaneous coronary intervention (PCI). A groundbreaking pilot feasibility study from Indonesia is investigating whether a hybrid approach combining hospital visits with remotely monitored home-based exercise could improve patient outcomes and participation rates in cardiac rehabilitation programs.

Cardiovascular disease (CVD) remains the leading cause of death globally, with Indonesia reporting over 765,000 CVD-related deaths in 2021 alone. Despite the proven benefits of cardiac rehabilitation (CR) as a Class 1A recommendation for post-PCI patients, participation rates remain disappointingly low, with less than 35% of eligible patients completing recommended programs. This challenge is particularly pronounced in resource-limited settings like Indonesia, where CR facilities are predominantly concentrated in major urban centers, creating significant barriers for patients living in remote areas.

How Does the Hybrid Model Bridge Traditional and Digital Care?

The study, being conducted at Dr. Sardjito General Hospital in Yogyakarta, employs a quasi-experimental design to compare two approaches: traditional center-based cardiac rehabilitation (CBCR) versus a novel home-based exercise cardiac telerehabilitation (HBECTR) program. The HBECTR intervention leverages digital technology to enable patients to complete three of their five weekly exercise sessions at home while being remotely monitored through a smartwatch (CovWatch) connected to a web-based dashboard called "TEKAD" (Telerehabilitasi Kardiovaskular).

"This represents one of the first implementations of digitally-supported cardiac telerehabilitation in Indonesia," explains the research team. "By allowing patients to exercise at home while maintaining medical supervision through real-time monitoring, we aim to address several barriers to traditional cardiac rehabilitation, including transportation difficulties and limited availability of facilities."

Who Are the Participants and How Is Safety Monitored?

The study includes 63 post-PCI patients divided between intervention and control groups. Both groups receive individualized exercise prescriptions based on baseline 6-minute walk test results, with the control group completing two weekly sessions at the hospital for four weeks. The intervention group follows the same hospital schedule but adds three weekly home-based sessions with remote monitoring of vital signs including heart rate, blood pressure, and oxygen saturation.

Patient safety remains paramount in the study design, with comprehensive education provided about recognizing cardiovascular emergency signs and symptoms. The researchers have implemented strict safety protocols, including risk stratification screening prior to exercise, continuous monitoring during sessions, and clear communication channels for reporting adverse events. Only patients with low to moderate cardiovascular risk are included in the study, and the exercise intensity is carefully calibrated to moderate levels to minimize risks.

The primary outcome measure is patient adherence to the rehabilitation program, calculated as the percentage of prescribed sessions completed, with 80% attendance considered adherent. Secondary outcomes include changes in functional capacity as measured by the 6-minute walk test. Additional implementation outcomes are being assessed using the RE-AIM framework, examining aspects such as reach, effectiveness, adoption, implementation fidelity, and maintenance.

What Do Study Outcomes and Protocol Details Reveal?

While the study results are still being analyzed (expected completion by November 2025), the potential implications for cardiovascular care in Indonesia are significant. If successful, this hybrid approach could dramatically increase access to cardiac rehabilitation services, particularly for patients in remote areas or those facing transportation challenges. The integration of digital monitoring could also enhance safety while reducing the burden on healthcare facilities.

The researchers acknowledge several limitations, including the modest sample size, relatively short follow-up period, and challenges related to technology access and digital literacy. However, as a pilot feasibility study, these limitations are intentional design features focused on testing practicality and preliminary efficacy rather than providing definitive evidence of effectiveness.

The study also addresses methodological considerations inherent to its quasi-experimental design. Since randomization was not feasible due to logistical and resource constraints, the researchers implemented sequential, nonconcurrent enrollment with the intervention group recruited before the control group. To mitigate potential biases from this approach, they plan to use propensity score matching to balance characteristics across groups and will carefully document baseline demographic and clinical characteristics for statistical adjustment.

The exercise prescription follows established cardiac rehabilitation guidelines with both groups receiving moderate-intensity aerobic exercise. Each session consists of a 5-minute warm-up, 30 minutes of core exercise (treadmill walking in the hospital or flat ground walking at home), and a 10-minute cool-down. This structured approach aligns with Indonesia's national CR guidelines, although the current practice of twice-weekly sessions falls below the recommended 4-7 sessions per week. The HBECTR program helps bridge this gap by providing a feasible way for patients to complete additional sessions at home.

Cost-effectiveness analysis is also planned as part of this study, with researchers calculating the cost per patient, application development expenses, wearable device production, and internet provision requirements. This economic evaluation will be crucial for determining the scalability of the program within Indonesia's healthcare system, where the national health insurance scheme currently only reimburses center-based cardiac rehabilitation services.

What Are the Future Implications for Cardiac Care?

Could this innovative approach to cardiac rehabilitation represent a paradigm shift in how we deliver cardiovascular care in resource-limited settings? The integration of digital technologies into traditional rehabilitation models might offer a scalable solution to improve participation rates and outcomes, potentially influencing future healthcare policy and reimbursement structures. As healthcare systems worldwide grapple with increasing cardiovascular disease burden, such digitally-enhanced hybrid models could provide a template for more accessible, patient-centered care approaches.

How might the lessons learned from this Indonesian pilot study inform the development of cardiac rehabilitation programs in other low- and middle-income countries facing similar resource constraints? What additional strategies could further enhance patient adherence to both hospital-based and home-based exercise programs? The answers to these questions could reshape cardiovascular care delivery for millions of patients worldwide.

Summary

A pioneering pilot study in Indonesia is investigating whether digital telerehabilitation can improve cardiac rehabilitation outcomes for patients who have undergone percutaneous coronary intervention. The study at Dr. Sardjito General Hospital in Yogyakarta compares traditional center-based cardiac rehabilitation with a novel hybrid approach that combines hospital visits with remotely monitored home-based exercise sessions. The home-based exercise cardiac telerehabilitation program utilizes smartwatch technology and a web-based dashboard called TEKAD to enable patients to complete three of their five weekly exercise sessions at home under medical supervision. This approach addresses significant barriers to traditional cardiac rehabilitation in Indonesia, where participation rates remain below 35% despite proven benefits, largely due to limited facility availability and transportation challenges. The study includes 63 post-PCI patients and measures adherence as the primary outcome, with functional capacity changes assessed through 6-minute walk tests. Safety protocols include risk stratification, continuous vital sign monitoring, and comprehensive patient education about cardiovascular emergency signs. While results are expected by November 2025, the study's success could dramatically expand access to cardiac rehabilitation services in resource-limited settings. The research also includes cost-effectiveness analysis to determine scalability within Indonesia's healthcare system, where national health insurance currently only reimburses center-based rehabilitation. This innovative model could provide a template for improving cardiovascular care delivery in low- and middle-income countries worldwide facing similar healthcare resource constraints and rising cardiovascular disease burden.