*8.3. Cardiac Rehabilitation during Ramadan*

Ramadan is one of the five pillars of Islam, during which Muslims are not allowed to eat or drink between sunrise and sunset. Ramadan affects Muslims' diets, levels of physical activity, sleeping patterns, and adherence to medications [16]. Decreases in physical activity may be attributed to dehydration, fasting, or disturbed sleeping cycles [16]. Therefore, to prevent functional capacity impairment, adequate hydration, and the maintenance of exercise regimens are essential. Physical activity during Ramadan should preferably be performed in air-conditioned facilities—e.g., in fitness centers. The optimal timing of exercise is debated, with it being suggested that exercise be performed before the main meal (Iftar) or at night (1–2 a.m.). Each training session should consist of a 5–10 min warm-up, a main session of 20–30 min, and 5–10 min of cool-down. Endurance training intensity should be reduced (at a light-to-moderate level) and be performed at intervals. Strength training intensity should not exceed 50% of 1-RM. Adequate fluid replacement and wearing suitable clothing are essential [17].

Adherence to cardiac rehabilitation programs during Ramadan is poor due to participants' fasting and disturbed sleep patterns. According to the authors' experiences, only 15%–20% of patients regularly attend supervised exercise sessions during Ramadan. Thus, the authors suggest the following strategies:

For patients already enrolled in exercise sessions before Ramadan, the use of a light-to-moderate-intensity home- or community-based exercise program that is adjusted to the participant's sleep–wake-up cycle should be discussed. A detailed exercise plan should be prescribed that takes into account the training heart rate range, and cardiac rehabilitation personnel should stay in touch with patients.

For patients needing to commence exercise sessions during Ramadan, a home-based light-intensity exercise program should be discussed, with the commencement of supervised exercise training sessions beginning after Ramadan.

### *8.4. Development of Cardiac Rehabilitation in the Kingdom of Saudi Arabia*

Considering the high prevalence of obesity, diabetes, and physical inactivity in the Kingdom of Saudi Arabia, efficient cardiovascular prevention and cardiac rehabilitation programs are of paramount importance. Cardiac rehabilitation has gradually evolved into a multi-factorial program that involves managing cardiovascular risk factors and delivering nutritional, psychological, and social support to improve patient outcomes. Most of these steps have been implemented at the Prince Sultan Cardiac Center (PSCC) in Riyadh from 2009 by Dr. Fahad AlNouri, an outstanding expert on familiar hypercholesterolemia who has been serving as the President of the Saudi Group for Cardiovascular Prevention and Rehabilitation. Dr. AlNouri graduated with a Master of Science diploma in preventive cardiology, with merit for his dissertation, from the Imperial College London in 2009. Upon completion of his degree and his return to Riyadh, Dr. Alnouri set up the first ever Cardiovascular Prevention and Rehabilitation Unit within the Kingdom of Saudi Arabia. This unit employs a unique preventive cardiology clinic team comprising a cardiologist, dietician, physical activity specialist, clinical pharmacist, and health education nurse. One of the routine components of the clinic's practice is patient physical activity counseling. In February 2018, the first exercise training program in the Kingdom of Saudi Arabia was established by Dr. Adam Staron. Dr. Staron, serving as the Head of the Cardiac Rehabilitation Unit at Prince Sultan Cardiac Center, implemented the protocols of the Polish School of Cardiac Rehabilitation, modified later with regards to the local conditions. Over one thousand patients completed a supervised exercise training program (October 2021), achieving excellent outcomes (average improvement of physical capacity by 2.78 MET). In 2019, a separate female exercise area was created by Dr. Jadwiga Wolszakiewicz (Figures 19 and 20).

(A)

(B)

19

**Figure 19.** Male (**A**) and female (**B**) exercise areas at Prince Sultan Cardiac Center. Source: Photos by authors.

In addition, in 2020 the curriculum of the Cardiac Rehabilitation Fellowship Program for certified cardiologists was approved by the Saudi Commission for Health Specialties (authors: Wolszakiewicz, Staron, AlSulaimi). The same authors are being involved (June 2022) in writing Saudi Cardiac Rehabilitation guidelines and curriculum of the Cardiac Rehabilitation Fellowship for physiatrists. Supervised cardiac rehabilitation is currently being delivered in other healthcare facilities in the Kingdom (Sultan bin Abdulaziz Humanitarian City Riyadh, Dr. Soliman Fakeeh Hospital in Jeddah), with several other hospitals planning to establish cardiac rehabilitation services in a near future. cardiac rehabilitation is currently being delivered in other healthcare facilities in the Kingdom (Sultan bin Abdulaziz Humanitarian City Riyadh, Dr. Soliman Fakeeh Hospital in Jeddah), with several other hospitals planning to establish cardiac rehabilitation services in a near future.

Figure 20. Cardiac rehabilitation staff—Prince Sultan Cardiac Center (November 2019). Source: Photo by authors. **Figure 20.** Cardiac rehabilitation staff—Prince Sultan Cardiac Center (November 2019). Source: Photo by authors.

#### References **References**


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Adam Staron, MD, PhD, is a consultant cardiologist with over 20 years of experience in clinical cardiology who is currently working as a Director of Cardiac Rehabilitation in Prince Sultan Cardiac Center, Riyadh. Dr. Staron established the Cardiac Rehabilitation Unit in December 2017 and implemented in 2018 the first exercise training program in the Kingdom of Saudi Arabia. Dr. Staron is a member of the European Society of Cardiology. Previously, Dr. Staron had worked for several years in the Upper Silesian Cardiac Center in Katowice, Poland. He served as the Head of the Cardiac Rehabilitation Department in Katowice, implementing yoga and tai-chi. Dr. Staron was awarded a European Society of Cardiology training grant in the field of 3-dimensional echocardiography in 2008, and he was a cofounder of the International Summit on Imaging and Interventions in Cardiology (ISIIC) conference in 2011. Dr. Staron is the main author of the cardiac rehabilitation policy and procedures manual for Saudi Arabian military hospitals.

Jadwiga Wolszakiewicz, MD, PhD, is a cardiologist and physical medicine and rehabilitation specialist, with 30 years of experience in cardiac rehabilitation, who is currently working as a consultant in the Cardiac Rehabilitation Unit in Prince Sultan Cardiac Center, Riyadh. Dr. Wolszakiewicz established in 2019 the female section of cardiac rehabilitation in PSCC. Dr. Wolszakiewicz is a member of the European Society of Cardiology and Saudi Heart Association. Previously, Dr. Wolszakiewicz worked at the National Institute of Cardiology in Warsaw, Poland. She served as the Chairman of the Board of the Cardiac Rehabilitation Section of the Polish Cardiac Society and currently serves as a board member of the Saudi Group for Cardiovascular Prevention and Rehabilitation. Dr. Wolszakiewicz is an author and co-author of many cardiac rehabilitation papers. She is the main author of the Cardiac Rehabilitation Fellowship Program for certified cardiologists in the Kingdom of Saudi Arabia.

Meteb AlSulaimi has held a BSc in rehabilitation sciences (physical therapy) from King Saud University, Saudi Arabia, since 2002. Mr. AISulaimi is a physical therapist who specializes in cardiac rehabilitation at the Prince Sultan Cardiac Center and is an active member of the Saudi Physical Therapy Association. Mr. AlSulaimi is currently serving as the Supervisor of Physiotherapy at the Prince Sultan Cardiac Center, where he is responsible for inpatient and outpatient cardiac rehabilitation.

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