The Effect of Dhikr Therapy on the Cardiac Chest Pain of Acute Coronary Syndrome (ACS) Patients

Background: Cardiac chest pain is a typical complaint experienced by patients with Acute Coronary Syndrome (ACS) in Emergency Departments (EDs). Pharmacological therapy is one major intervention used to reduce cardiac chest pain due to ACS. However, this therapy does not optimally and completely reduce cardiac chest pain; therefore, additional therapy is greatly required. Purpose: This study aimed to examine the effect of Dhikr therapy as one of the additional therapies for the cardiac chest pain experienced by patients with ACS in EDs. Methods: This quasi-experimental research was conducted using a pretest-posttest control group design. As many as 52 patients with ACS were recruited using a consecutive sampling technique and then equally divided into the intervention and control group. The intervention group received both pharmacological and Dhikr therapy approximately for 17 minutes, while the control group only received the pharmacological therapy based on the hospital’s protocol. The Numeric Pain Rating Scale (NPRS) was used to measure the intensity of cardiac chest pain, and both paired and independent ttests were utilized to analyze the data. Results: The results showed that there was a significant difference in pain reduction in both groups (p=0.000), although the decrease in the intervention group was higher than that in the control group. Furthermore, the pain reduction was significantly different between groups (p=0.021) Conclusion: Dhikr combined with pharmacological therapy reduced the intensity of cardiac chest pain in ACS patients better than the use of pharmacological therapy alone. Therefore, this study recommends the combination of pharmacological and Dhikr therapy for patients with ACS.


BACKGROUND
Ischemic Heart Disease (IHD) is the most common heart disease in the world. Research showed that the prevalence of Cardiovascular Disease (CVD) was approximately 422.7 million cases with 17.92 million deaths (Roth et al., 2017). Data from the Ministry of Health of the Republic of Indonesia (2018) reported that the prevalence of heart disease in Indonesia in 2015 rose by 15 per 1,000 people, or approximately 2,784,064 people; West Java has become the big 10 provinces with the highest number of people suffering from heart disease. In the Asia Pacific, Acute Coronary Syndrome (ACS) was the most common coronary heart disease with the prevalence of death reaching for more than 5% (Chan et al., 2016).
ACS is a heart disease with a typical symptom of cardiac chest pain. This cardiac chest pain is described as a symptom that is mostly complained by patients; the characteristics of the pain, include a sensation of being struck by a heavy object or burning sensation that spreads from chest, shoulders, and neck to arms, as well as breathing difficulty (Malik, Khan, Safdar, & Taseer, 2013). The pain occurs due to the imbalance of blood supply to the coronary arteries which require oxygen and nutrients in the myocardium. The imbalance of blood supply may be caused by the presence of plaque in the coronary arteries resulting in ischemia. Once ischemia occurs for more than 20 minutes, myocardial infarction may be resulted and lead to the decreasing cardiac output. To deal with these conditions, the heart will perform anaerobic metabolism and produce lactic acid which eventually results in cardiac chest pain (McCance, 2010).
The prolonged cardiac chest pain may physically and psychologically affect patients' conditions. The physical impact is associated with the instability of electrical activity caused by the failure of the heart to pump the blood (McCance, 2010), while the psychological impacts as reported by those suffering from cardiac chest pain include depression and anxiety (Kim et al., 2016;Meneghetti, Guidolin, Zimmermann, & Sfoggia, 2017). Thus, this life-threatening pain requires immediate treatment. Another study also explained that patients with constant anxiety might have more complications than those without anxiety. Thus, controlling anxiety in patients with ACS is greatly important to maintain their health (AbuRuz, 2018).
Cardiac chest pain management for patients with ACS is mostly conducted using the pharmacological therapy, such as nitroglycerin, Isosorbide Dinitrate (ISDN), β-blockers, calcium antagonists, and morphine (Association of Indonesian Cardiovascular Specialist, 2018). However, the implementation of pharmacological therapy may also result in some negative impacts, such as gastrointestinal problems (nausea, vomiting), respiratory depression, and hypoxia at high dosages (Mccarthy, Mullins, Sidhu, Schulman, & Mcevoy, 2016). Thus, ACS patients require a complementary intervention to optimally reduce their cardiac chest pain. A spiritual approach was selected since many patients suffering from heart disease considerably decide to get closer to God as their coping strategy (Herawati, Keliat, Waluyo, 2019). Furthermore, Abuatiq (2015) also explained that nurses in the area of critical care nursing only focused on improving the patients' physical conditions, such as oxygenation, perfusion, and nutrition rather than their spiritual needs.
One complementary therapy which might be used to reduce the cardiac chest pain is Dhikr therapy. Some studies have shown the effect of Dhikr therapy in the clinical setting (Nasiri, Fayazi, Ghaderi, Naseri, & Adarvishi, 2014;Sulistyawati, Probosuseno, & Setiyarini, 2019;Wahyuni, Soejoenoes, Putra, & Syukur, 2018). Sulistyawati et al. (2019) used Dhikr therapy to reduce anxiety in patients suffering from cancer. Wahyuni et al. (2018) claimed that Dhikr therapy reduced stress and depression on primigravida women, while Nasiri et.al. (2014) used Dhikr therapy for post-operative pain. The effect of Dhikr therapy to overcome cardiac chest pain in ACS patients is related to their psychological conditions. Anxiety, depression, and stress may increase the sympathetic nervous activity resulting in an increasing level of catecholamine, cortisol, and inflammatory mediators, which influenced the required oxygen (DeJongh, Birkeland, Brenner, 2015). Dhikr therapy is a form of relaxation that can be used to reduce sympathetic nervous system activity and increase the parasympathetic nervous system activity. Parasympathetic nerves may decrease oxygen consumption, respiration, pulse, and result in relaxation (O'Donnell & Glasgow, 2011). Many researchers have carried out studies related to the effect of Dhikr therapy on some clinical purposes; yet Dhikr therapy on cardiac chest pain is still rarely conducted.

PURPOSE
This study aimed to investigate the effect of the pharmacological and Dhikr therapy on the intensity of cardiac chest pain of ACS patients in the EDs.

METHOD Research design and samples
This quasi-experimental research used a pretest-posttest control group design. The population and samples of this study were patients with cardiac chest pain entering the ED of an Islamic hospital in Bandung, East Java. The total samples were 52 respondents equally divided into two groups: the control group and the intervention group. Respondents were divided evenly in which the intervention group was completed first, and then allocated the remaining to the control group. The inclusion criteria were ACS patients with cardiac chest pain, Muslim, and receiving pharmacological therapies such as anti-angina, analgesics, or beta-blockers. Meanwhile, the exclusion criteria were patients of post-open heart surgery and losing consciousness. This study was conducted in the ED of one Islamic hospital in Bandung in 2017. The data were collected in two weeks. Prior to the administration of pharmacological therapies according to the hospital protocol, the pain scores were measured as the pre-test. The intervention group then obtained Dhikr therapy for 17 minutes, while the control group received standard care. Dhikr therapy was given through earphones which was connected with sound recorder. Respondents were asked to say dhikr sentences namely Subhanalah, Alhamdulillah, Allahuakbar, La hawla wala kuwata illa billah 33 times slowly. The pain scores then were re-measured as post-test 27 minutes after the medication administration. The procedures to collect data were described in Figure 1.

Data analysis
The data were analyzed using the dependent t-test to determine the mean difference score of cardiac chest pain experienced by each group before and after receiving the therapy. Before a further analysis with the dependent t-test, the data were tested for normality, and the result showed that the pain scores before and after the therapy were normally distributed. The hypothesis was examined using the independent t-test to determine the differences in pain reduction between the control and intervention groups.

Ethical considerations
This research had obtained the ethical clearance from the Ethical Commission of Universitas Padjajaran (No. LB.04.01/A05/EC/057/III/2017). Some ethical principles were ensured in this study. All respondents were consented to participate in this research.
Considering the principle of justice, after re-measuring cardiac chest pain in the control group, the control group patients also received Dhikr therapy for 17 minutes. Table 1 showed the characteristics of respondents involved in this study. The dominant age in the intervention group was 57-67 years old (46.15%), while in the control group was 46-56 years old (46.15%). The majority of respondents in the intervention group suffered from Unstable Angina Pectoris (UAP) (38.5%) and mostly received nitroglycerin (65.4%). In contrast, STEMI/AMI was the most prominent disease in the control group (65.4%), and morphine was mostly given as the pharmacological therapy (38.5%). Furthermore, both groups were dominated by males. The homogeneity of respondents was tested to each characteristic, and the results showed that both groups were homogenous. Pain scale distribution Figure 2 shows the pain scale distribution before and after the treatment in the intervention and control group. The most striking feature was that the majority of respondents in the intervention group experienced a higher decrease of pain scales from scale 6 to 2 compared to the respondents in the control groups who experienced a decreased scale from 5 to 3.

Figure 2. Pain scale distribution
Cardiac chest pain differences Table 3 shows that the pre-test mean score in the intervention group was higher than that in the control group (5.73+1.54 and 5.27+1.25, respectively). Although both groups showed significant pain scale differences before and after the treatment (p=0.000), the intervention group (2.77) had higher pain reduction than the control group (2.08). There was a significant difference in the pain reduction between the intervention and the control group (p=0.000), indicating that Dhikr combined with pharmacological therapies decreased cardiac chest pain.

DISCUSSION
The main result of this study showed that the combination of pharmacological and Dhikr therapy significantly reduced cardiac chest pain compared to the pharmacological therapy alone. This result is congruent with some previous studies. Dhikr therapy could reduce the pain experienced by patients after surgery (Haryani, Arifudin, & Nurhayati, 2015;Beiranvand, Noparast, Eslamizade, & Saeedikia, 2014), AMI patients (Nasiri et al., 2014), and primigravida women who experienced depression (Wahyuni et al., 2018). The decreasing pain scale is related to the patients' psychological conditions. Patients with ACS have anxiety symptoms, such as fear of death, losing personal control, and inability to normally work (Abu Ruz et al., 2010), leading to the production of catecholamine hormone causing hypertension, tachycardia, and shortness of breath that requires more oxygen (Smeltzer, Bare, Hinkle, & Cheever, 2010). One way to reduce anxiety and oxygen demand is Dhikr therapy. This is consistent with the research conducted by Sukarni, Mardiyono, & Parwati (2014), explaining that Dhikr therapy may reduce the anxiety of patients with ACS.
The effect of Dhikr therapy may be associated with the patients' relaxation. In this study, the patients received Dhikr therapy through an audio recorder for 17 minutes, and breathing slowly was aimed at relaxing and encouraging patients to concentrate well. Both pharmacological and Dhikr therapy simultaneously worked. Pharmacological therapy reduced the cardiac chest pain through an adequate function of endothelium which influences the bloodstream (Boden, Padala, Cabral, Buschmann, & Sidhu, 2015), leading to the increased oxygen supply and decreasing the oxygen demand, while Dhikr therapy may reduce the oxygen consumption by controlling some predictor factors, like anxiety and fear. However, it is interesting to note that both groups had significant pain decreasing after the therapies. This result might be caused by the fact that most patients in the control group received morphine as the main pain reliever. Theoretically, pharmacological therapy alone can reduce chest pain significantly. According to Wick (2016), morphine can reduce pulse, blood pressure, and venous return, leading to decreased demand for oxygen. On the other hand, the intervention group used a combination of pharmacological and Dhikr therapy which facilitated pain reduction more effectively.
The cardiac chest pain before the pharmacological therapy in both groups was dominated by moderate pain (4-6 scale). This study has a limitation that the ACS type and pharmacological therapy were not the same in both groups, which might affect pain reduction. In the intervention group, most patients suffered from UAP, while those in the control group suffered from AMI, the most dominant ACS type. The pharmacological therapy used in this study was also different.
In the intervention group, nitroglycerin was used as the most dominant medicine, while morphine was mostly used in the control group. The pharmacological choices were based on the pain scale following the hospital's regulation. The morphine was used more in the control group and possibly highly decreased the pain scale. However, the intervention group had a higher mean pain reduction than the control group. Therefore, it can be concluded that the combination of pharmacological and Dhikr therapy is more effective to reduce the pain intensity of patients with ACS patients although most control group patients were given morphine.

CONCLUSION
This study concluded that the combination of pharmacological and Dhikr therapy significantly reduced pain compared to pharmacological therapy alone. In clinical practice, Dhikr therapy can be considered as a complementary therapy to reduce chest pain in ACS, especially for Muslim patients. For further research, the characteristics of respondents especially the ACS and pain relief types should be controlled. Implementing Dhikr therapy to patients with ACS undergoing treatment in the Intensive Care Unit (ICU) may also become one alternative choice for the next research.