The aim of the study was to assess the effectiveness of exercise training on depression, anxiety, physical capacity and sympatho-vagal balance in patients after myocardial infarction and compare differences between men and women.
Thirty-two men aged 56.3±7.6 years and 30 women aged 59.2±8.1 years following myocardial infarction underwent an 8-week training programme consisting of 24 interval trainings on cycloergometer, three times a week. Before and after completing the training programme, patients underwent: depression intensity assessment with the Beck depression inventory; anxiety assessment with the state–trait anxiety inventory; a symptom-limited exercise test during which were analysed: maximal workload, duration, double product.
In women the initial depression intensity was higher than in men, and decreased significantly after the training programme (14.8±8.7 vs. 10.5±8.8; P<0.01). The anxiety manifestation for state anxiety in women was higher than in men and decreased significantly after the training programme (45.7±9.7 vs. 40.8±0.3; P<0.01). Of note, no depression and anxiety manifestation was found in men. Physical capacity improved significantly after the training programme in all groups, and separately in men and in women. Moreover, an 8-week training programme favourably modified the parasympathetic tone.
Participating in the exercise training programme contributed beneficially to a decrease in depression and anxiety manifestations in women post-myocardial infarction. Neither depression nor anxiety changed significantly in men. The impact of exercise training on physical capacity and autonomic balance was beneficial and comparable between men and women.
No previous study has investigated the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after coronary artery bypass grafting (CABG).
This study aimed to identify the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after CABG.
This was a prospective cohort study performed at a cardiac university hospital in São Paulo, Brazil and 257 adult patients undergoing CABG were included. Potential risk factors for low cardiac output in the immediate post-operative period were investigated using the patients’ medical records. Univariate analysis and logistic regression were used to identify the predictive risk factors of decreased cardiac output. The area under the receiver operating characteristic curve was calculated as a measure of accuracy. The variables that could not be analysed through logistic regression were analysed through Fisher’s exact test.
One hundred and ninety-five patients had low cardiac output in the immediate post-operative period. The predictive risk factors included age >=60 years, decreased left ventricle ejection fraction, not using the radial artery graft, positive fluid balance and post-operative arrhythmia that differed from the pre-operative arrhythmia. This model predicted the outcome with a sensitivity of 62.9%, a specificity of 87.2% and an accuracy of 81.5%. The variables analysed through Fisher’s exact test included heart failure, re-exploration and bleeding-related re-exploration.
The predictive risk factors for the nursing diagnosis of risk for decreased cardiac output after CABG were found. These results can be used to direct nurses in patient monitoring, staff training and nursing team staffing.
Many patients with atrial fibrillation experience uncertainty and psychological distress. Internet support groups for atrial fibrillation have yet to be studied.
To determine the content and dialogue on an online message board for atrial fibrillation with the purpose of elucidating information and support needs from patient perspectives.
Interpretative description methodology was undertaken to explore conversation from a publicly available website for atrial fibrillation over a 3-month period.
Individuals interacted with the message board to make sense of their atrial fibrillation events by sharing experiences with medications, complementary and alternative medicine, trigger avoidance and ablation. The opinions of lay experts on the message board, anecdotal stories and hyperlinked Internet data were all highly valued sources of information in the messages. Using the learning gained from the board, individuals proceeded with strategies to treat their atrial fibrillation, often in a trial and error fashion. Throughout the process, individuals came back to the board, to update on their progress and gain assistance from others.
The studied atrial fibrillation population had unmet needs for education regarding non-pharmacological approaches to treat atrial fibrillation. In the absence of opportunity to discuss these needs with healthcare professionals, patients may be vulnerable to unproved approaches advocated by Internet peers. Further research is suggested to examine the prevalence of complementary and alternative medicine use in the atrial fibrillation population and to understand better how social media can be utilised to support atrial fibrillation patients.
Radial access is the preferential access route in patients undergoing diagnostic coronary angiography. We hypothesised that we could reduce hospital stay and improve patient comfort by accelerated deflation of the radial compression device (Terumo radial band).
The aim of this study was to compare accelerated pressure reduction with a standard Terumo radial band protocol with regard to local bleeding complications and reported pain scores after cardiac catheterisation.
We performed a single centre prospective randomised trial to compare accelerated care to standard care for patients undergoing diagnostic catheterisation through radial access. Patients in the accelerated care group started deflation after 1 hour, with a 2 ml/10-minute interval. Patients in the standard care group started after 2 hours with additional steps of deflation at 3 and 4 hours.
Of the 173 analysed patients 86 received accelerated care and 87 patients standard care. A total of 19 patients had pulsatile bleeding, which occurred similarly in the two groups (standard care 11 vs. accelerated care 8, P=0.47). The time to Terumo radial band removal was on average 129 minutes shorter for accelerated care patients compared to standard care (P<0.01). At 1 hour after Terumo radial band placement, accelerated care patients more often reported pain scores of 0 than standard care patients (89% vs. 74%, P=0.02).
There was no increase in local bleedings in the accelerated pressure reduction of the Terumo radial band after diagnostic cardiac catheterisation, increasing patient comfort and reducing hospital stay. These findings will further facilitate the widespread implementation of radial access.
Cardiac catheterization is the standard procedure for the diagnosis of coronary heart disease. The threat physically and emotionally from this procedure can affect the patient’s perception of their health. The heightened psychological distress associated with this diagnostic procedure can cause adverse patient outcomes. Non-pharmacologic interventions have been implemented to reduce psychological distress associated with cardiac catheterization.
The objective of this rapid review is to assess the efficacy of non-pharmacologic interventions (procedural education, relaxation techniques, psychological preparation) on psychological distress experienced by patients as they undergo a cardiac catheterization.
Published, peer-reviewed, English-language intervention studies from 1981 to 2014 were identified in a search of CINAHL, Medline, and Cochrane Library. Eligible studies included adults undergoing cardiac catheterization. Studies included in this review used experimental and quasi-experimental designs and assessed at least one primary outcome: anxiety, depression, and pain to test non-pharmacologic interventions pre and post-cardiac catheterization. Researchers independently extracted data from included studies and completed a quality assessment using a published tool. Data were synthesized as a narrative.
There were 29 eligible experimental and quasi-experimental studies that tested the three interventions (n=2504). Findings suggest that non-pharmacologic interventions were able to effectively reduce psychological distress in some patients undergoing cardiac catheterization.
Evidence is stronger in recent studies that non-pharmacologic interventions of procedural education and psychological preparation can reduce psychological distress in patients undergoing cardiac catheterization. Further research is needed to define the various relaxation techniques that can be effectively implemented for patients undergoing cardiac catheterization.
As heart failure (HF) is a progressive, debilitating condition, life-long self-care is required to achieve good outcomes. Rural residents with HF encounter more challenges with adherence to self-care than their urban counterparts because of rural–urban inequalities related to socioeconomic resources and access to health care. To date, investigators have focused on self-care in HF patients in urban settings, although factors related to self-care may be different between rural and urban residents.
The aim of this study was to explore the variables related to self-care in HF patients living in rural areas.
A total of 580 patients in the USA were included in this analysis. We included 12 variables reflecting four aspects that affect patients’ decisions to perform self-care: health literacy, psychosocial status, current symptom status, and aging status. We measured self-care using the European Heart Failure Self-Care Scale-9.
Depressive symptoms (β = 0.28, 95% confidence interval (CI): 0.16 to 0.45), lower perceived control (β = –0.15, 95% CI: –0.32 to –0.08), better symptom status (β = –0.11, 95% CI: –0.13 to –0.003), and annual income of <$20,000 (β = 0.11, 95% CI: 0.38–2.97) were negatively associated with self-care in rural residents with HF. The model with 12 variables explained 7.1% of the variance in self-care.
The variables included in the model did not sufficiently explain self-care among rural dwellers with HF. Given that all variables in the model were intrapersonal-level factors, more investigations that incorporate interpersonal factors (e.g. cultural beliefs and access to care) are needed in order to improve our understanding of self-care in HF patients living in rural areas.
To investigate whether phase II cardiac rehabilitation (CR) conducted by a community model of shared care CR (SC-CR) including health care centres and general practice was feasible and provided acceptable results and to compare SC-CR to hospital-based CR (H-CR) in a randomised controlled trial.
Patients were randomised to H-CR or SC-CR after admission for acute coronary syndrome. In SC-CR, the general practitioner took over the responsibility of the remaining rehabilitation, pharmacological treatment and risk factor management after the initial visit to the hospital outpatient clinic. The Municipal Health Care Centres provided courses on smoking cessation, nutrition, and exercise training and contributed to disease education and psychosocial support. The main endpoint was adherence to the CR programme and compliance with lifestyle modifications.
In total, 1364 patients were screened, 327 (24%) were eligible, and 212 (65%) accepted participation. Phase II CR was completed by 192 (91%) of the participants. Full adherence to the CR programme was seen in 53% in SC-CR versus 54% in H-CR (relative risk (RR): 0.98, 95% confidence interval: 0.73–1.32). In H-CR, patients had higher rates of adherence to dietary advice and health education. In SC-CR, 12% of patients did not attend the risk factor evaluation and clinical assessment with their general practitioner. No difference in risk factor improvement was found. Exercise training was declined by 25% in both groups.
Adherence to phase II CR was high in both groups. SC-CR did not improve adherence and efficacy, but had comparable effects on medication and risk factors. Thus, SC-CR was safe and effective.
Whether personality factors and depressive traits affect patients’ utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients’ personality factors and depressive symptoms.
We studied 366 myocardial infarction patients admitted to Malmö University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants’ health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis.
In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions.
Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts.
Barriers to exercise are common in people with coronary heart disease (CHD) and/or diabetes mellitus (DM), and may influence self-efficacy for exercise.
The purpose of this study was to describe the exercise barriers experienced by people who have CHD and/or DM participating in the Healthy Eating and Exercise Lifestyle Program and to determine whether these barriers influence self-efficacy.
Participants (n = 134) identified their barriers to exercise and completed the self-efficacy for exercise survey at baseline, at 4 months (following structured and supervised exercise) and at 12 months (following home-based exercise with three follow-up calls).
The sample mean age was 63.6 years (SD 8.5) and 58% were male. Barriers to exercise were reported by 88% at baseline, 76% at 4 months, and 47% at 12 months. The most common barriers were lack of motivation (40.3%), lack of time overall (30.6%), and lack of time due to family commitments (17.2%). Only motivation changed significantly over time from baseline (40%) to 4 months (23%, p = 0.040). Lower self-efficacy for exercise was associated with lack of motivation at 12 months only, more depressive symptoms at baseline and 4 months, and a CHD diagnosis and higher body mass index at 12 months. In contrast, male gender and having higher self-efficacy at baseline were associated with higher self-efficacy for exercise at 4 and 12 months.
Patients identified many exercise barriers despite participating in a lifestyle-change program. Lack of motivation negatively influenced self-efficacy for exercise at 12 months. Other factors needing attention include baseline self-efficacy, depressive symptoms, being female, being more overweight, and having CHD.
There is increasing evidence supporting the relationship between family support and patient outcomes. Therefore, involving families in the care of cardiovascular patients is expected to be beneficial for patients. The quality of the encounter with families highly depends on the attitudes of nurses towards the importance of families in patient care.
The aim of this study was to describe the attitudes of nurses towards family involvement in patient care and to investigate the individual contributions of demographic, professional and regional background characteristics.
A survey was distributed among cardiovascular nurses attending an international conference in Norway and a national conference in Belgium. Nurses were asked to complete a questionnaire, including the Families’ Importance in Nursing Care – Nurses’ Attitudes scale. The study population consisted of respondents from Belgium (n = 348) and from Scandinavian countries (Norway, Sweden and Denmark; n = 77).
In general, nurses viewed the family as important in care. However, attitudes towards actively inviting families to take part in patient care were less positive. Higher educational level and a main practice role in research, education or management were significantly associated with more positive attitudes. Furthermore, the attitudes of respondents living in Scandinavia were more positive as compared to the attitudes of respondents living in Belgium.
Education on the importance of families and active family involvement in patient care seems to be necessary in basic, undergraduate education, but also in clinical practice. More research is necessary in order to explore the cultural and regional differences in the attitudes of nurses towards the involvement of families in patient care.
Adolescents with congenital heart disease need to increase their resilience in the face of challenges in order to preserve their health and quality of life.
This study aimed to develop a resilience improvement program for adolescents with congenital heart disease and also to evaluate any change in resilience and quality of life as a measure of the effectiveness of the resilience improvement programs.
A nonequivalent control group pretest–posttest study was designed. Twenty-five adolescents who attended the first resilience improvement program were included in the experimental group, and 31 adolescents who took part in the second program were placed in the control group. Adolescents with congenital heart disease completed a self-report questionnaire on three separate occasions: the pretest, the first posttest and the second posttest. The self-report questionnaire included general characteristics and instruments to measure resilience and quality of life. For the longitudinal analysis, generalized estimating equations were used to evaluate the difference in the estimated average trajectories of resilience and quality of life changes.
Independent predictors of resilience improvement in adolescents with congenital heart disease were the experimental group (p=0.02) and middle and high school students (p=0.02). Quality of life was not associated with membership in the experimental group. However, males scored higher than females on quality of life measures (p=0.02).
It is essential for healthcare providers to apply various programs, including those targeted at accepting illness, improving autonomy and independently managing disease, to adolescents with congenital heart disease.
Home tele-monitoring (HTM) is used to monitor the clinical signs and symptoms of patients with chronic heart failure (CHF) in order to reduce unplanned hospital admissions. However, not all patients who are referred will agree to use HTM, and some patients choose to withdraw early from its use.
ADaPT-HF will investigate whether depression, anxiety, low perceived control, reduced technology capability, level of education, age or the severity or complexity of a patient’s illness can predict refusal of, or early withdrawal from, HTM in patients with CHF.
The study will recruit 288 patients who have been recently admitted to hospital with heart failure who have been referred for HTM. At the time of referral, patients will complete depression (nine-item Patient Health Questionnaire), anxiety (seven-item Generalised Anxiety Disorder questionnaire), perceived control (eight-item revised Controlled Attitudes Scale) and technology capability (ten-item Technology Readiness Index 2.0) screening questionnaires. In addition, data on demographics, diagnosis, clinical examination, socio-economic status, history of comorbidities, medication, biochemistry and haematology will be recorded. The primary outcome will be a composite of refusal of or early withdrawal from HTM. The principle analysis will be made using logistic regression.
By establishing which factors influence a patient’s decision to refuse or withdraw early from HTM, it may be possible to redesign HTM referral processes. It may be that patients with CHF who also have depression, anxiety, low control and poor technology skills should not be referred until they receive appropriate support or that they should be managed differently when they do receive HTM. The results of ADAPT-HF may provide a way of making more efficient and cost-effective use of HTM services.
Cardiac rehabilitation is often under-utilized despite its well-known benefits. Individuals with cardiac disease who exhibit a positive outlook often experience improved health outcomes. This study tried to explore the question: "What are the lived experiences of cardiac recovery in cardiac rehabilitation individuals with a predominantly positive outlook in the context of an acute cardiac event?"
Our primary aim explored the experiences of cardiac recovery in cardiac rehabilitation participants with a predominantly positive outlook, within the context of an acute cardiac event, including exploring barriers and facilitators of cardiac recovery. Our secondary aim explored how a positive outlook impacted completion of phase two of the cardiac rehabilitation program.
Husserlian phenomenology guided this study. A purposive sample of 10 individuals who had experienced an acute cardiac event and had a predominantly positive outlook were interviewed. Data were analyzed using Colaizzi’s method.
Three themes emerged from the data. The first was "choosing life over death," where participants discussed how they made a decision to improve their health. The second theme was "learning to live a new self," where participants described the changes they had to make in order to improve their health. The third theme was "a life-transforming cardiac event" where participants shared how the cardiac event had changed their life.
The participants’ decisions to choose to live, led them to embrace their cardiac recovery. It is important for nurses to identify individuals in cardiac rehabilitation that need additional support. In addition, alternative models of cardiac rehabilitation programs need to be explored.
Depression is common in patients with cardiovascular disease and is a risk marker for increased mortality. The valid and reliable detection of depression is fundamental to the appropriate management of these patients.
The aim of this study was to evaluate the psychometric characteristics of the Cardiac Depression Scale Short Form 1 (DS-SF1) and the Cardiac Depression Scale Short Form 2 (DS-SF2) for screening cardiac outpatients in clinical settings.
Adult cardiac outpatients attending a cardiovascular clinic completed the Cardiac Depression Scale (CDS), two versions of the DS-SF (DS-SF1 and DS-SF2) and the Physical Health Questionnaire 2 (PHQ2-Y/N) prior to their cardiac consultation.
Data from 326 patients (224 men; mean±SD age 66.25±14.39 years) were analysed. The DS-SF1 (mean score 16.28±5.70) had good construct validity with the CDS (r=0.77; p<0.0001), adequate convergence with the PHQ2-Y/N (r=0.59; p<0.0001) and good internal consistency (α=0.73). The DS-SF2 (mean score 15.80±6.80) had a better construct validity with the CDS (r=0.84; p<0.0001) and the PHQ2-Y/N (r=0.69; p<0.0001) and better internal consistency (α=0.82). The DS-SF2 showed strong criterion validity with the CDS with a DS-SF2 >=15 cut-point yielding 90% sensitivity and 73% specificity (area under the curve 0.92) for detecting depression (CDS >=95).
These findings confirm the excellent psychometric properties of the DS-SF2 as an ideal tool for screening depression in cardiac patients in clinical practice. The DS-SF2 should be regarded as the definitive version of the DS-SF.
Reducing patient delay for patients afflicted by an acute myocardial infarction is a task of great complexity, which might be alleviated if more factors that influence this delay could be identified. Although a number of self-reported instruments associated with patient delay exist, none of these taps the content of the appraisal process related to patients’ subjective emotions.
The aim of this study was to develop and validate a questionnaire aimed at assessing patients’ appraisal, emotions and action tendencies when afflicted by an acute myocardial infarction.
An item pool was generated based on themes conceptualized in a recent qualitative study of acute myocardial infarction patients’ thoughts, feelings and actions preceding the decision to seek medical care. The ‘Think-Aloud Protocol’ and test–retest analysis at item level were performed. The modified item pool was administered to 96 patients when treated for acute myocardial infarction. Explorative factor analysis and principal component analysis with the non-linear iterative partial least squares algorithm were performed to examine the underlying factor structure of the items.
The findings indicated three core dimensions corresponding to three subscales, namely, ‘symptom appraisal’; ‘perceived inability to act’; ‘autonomy preservation’. The results demonstrated acceptable measures of reliability and validity
The PA-AMI questionnaire demonstrated satisfactory psychometric properties. Assessment of the included core dimensions may contribute to greater understanding of the appraisal processes for patients afflicted by an acute myocardial infarction.
Little attention has focused on gender differences in cardiac comorbidities and outcomes in patients undergoing orthotropic heart transplant.
The objective of this study was to investigate gender differences at baseline and during follow-up among heart transplant patients.
An observational cohort within the NEW HEART study was evaluated to determine gender differences in relation to age, coexisting cardiac comorbidities, and outcomes. Differences were assessed by t-test, Fisher’s exact test, and logistic regression analysis.
Male transplant recipients (n = 238) were significantly older than female recipients (n = 92), with a greater percentage over 60 years of age (45% vs. 24%, p = 0.0006). Males were more likely to have hypertension (63% vs. 49%, p = 0.034), dyslipidemia (62% vs. 45%, p = 0.006), a history of smoking (52% vs. 35%, p = 0.009), and diabetes (42% vs. 21%, p = 0.0002). Analysis of endomyocardial biopsies obtained during the 1-year follow-up period demonstrated that women averaged more episodes of acute rejection than men (3.9 vs. 3.0, p = 0.009). While most episodes of rejection were mild, women were more likely than men to have episodes of moderate or severe rejection (14% vs. 5%, p = 0.012) and to be hospitalized for acute rejection (15% vs. 6%, p = 0.013). There were no significant differences in mortality.
Men were more likely than women to be older and to have diabetes, dyslipidemia, hypertension, and a history of smoking. Women were more likely to experience moderate or severe allograft rejection and to be hospitalized for acute rejection. Future investigation of the reasons for these gender differences is warranted and may improve clinical care of women undergoing cardiac transplantation.
Fluid restriction has long been considered one of the cornerstones in self-care management of patients with heart failure. The aim of this discussion paper is to discuss fluid restriction in heart failure and propose advice about fluid intake in heart failure patients.
Although there have been seven randomised studies on fluid restriction in heart failure patients, the effect of fluid restriction on its own were only evaluated in two studies. In both studies, a stringent fluid restriction compared to a liberal fluid intake was not more beneficial with regard to clinical stability or body weight. In the other studies fluid restriction was part of a larger study intervention including, for example, individualised dietary recommendations and follow-up by telephone. Thus, the effect of fluid restriction on its own has been poorly evaluated.
Fluid restriction should not be recommended to all heart failure patients. However, temporary fluid restriction can be considered in decompensated heart failure and/or patients with hyponatremia. Tailored fluid restriction based on body weight (30 ml/kg per day) seems to be most reasonable. To increase adherence to temporary fluid restriction, education, support and planned evaluations can be recommended.
Aortic stenosis is the most common valve disease in western countries and has poor prognosis without treatment. Surgical aortic valve replacement (SAVR) is the gold standard, and transcatheter aortic valve implantation (TAVI) is a new method that is used in high-risk patients who are denied surgery. The purpose of treatment is not only to save life, but also to reduce symptoms and increase health-related quality of life (HRQoL).
The aim of this study was to describe patients’ self-reported outcomes in terms of physical function, symptoms, dependence, HRQoL, and cognitive function after TAVI and SAVR.
All patients treated with TAVI during 1 year (n = 24) and age-matched patients treated with SAVR (n = 24) were included. Data were collected on the day before and at 6 months after treatment using structural questionnaires.
Self-rated function was low before treatment and increased at follow-up. A quarter of all patients reported syncope at baseline, and none reported this at follow-up. Breathlessness was reported by all patients to be the most limiting cardiac symptom, but the TAVI patients reported more severe symptoms. At 6 months’ follow-up, symptoms were reduced, but breathlessness and fatigue were still common, especially in the TAVI group. HRQoL, which was very low in the TAVI group at baseline, increased in all dimensions except social function.
We found no change in cognitive function or dependence at follow-up. There was no difference in the size of improvement between groups. The results could be helpful when informing future patients in order to give them realistic expectations.
Many patients experience the ‘cardiac blues’ at the time of an acute cardiac event, and one in five go on to develop severe depression. These emotional responses often go undetected and unacknowledged. We initiated the ‘Cardiac Blues Project’ in order to help support patients’ emotional recovery. As part of the project, we developed online training in order to support health professionals in the identification and management of the cardiac blues and depression. The aim of this study was to assess the acceptability of the training and its impacts on health professionals’ self-efficacy.
In July 2014, a ‘cardiac blues’ pack of patient resources, including access to health professional online training, was mailed to 606 centres across Australia. In the first 3 months after distribution, 140 health professionals registered to undertake the online training and participated in the present study. Participants provided information via a six-item pre- and post-training self-efficacy scale and on 10 post-training acceptability items.
Health professionals’ self-efficacy improved significantly after undertaking the online training across the six domains assessed and for the total score. Acceptability of the training was high across all 10 items assessed. Ratings of usefulness of the training in clinical practice were particularly favourable amongst those who worked directly with cardiac patients.
The health professional training significantly improves health professionals’ confidence in identifying and managing the ‘cardiac blues’ and depression. Monitoring of uptake is ongoing and future studies will investigate patient outcomes.
The results of research into the outcomes of physical rehabilitation and its relationship with post-myocardial ischaemia survival and readmissions are inconclusive. Our primary aim was to evaluate the efficacy of a supervised exercise training programme in terms of decreasing hospital cardiac readmission in patients with myocardial ischaemia.
We conducted a randomised controlled trial including patients with myocardial ischaemia. Eligible patients were assigned to a control group receiving standard care or to an intervention group that took part in a supervised exercise training programme. The follow-up period was 12 months after hospital discharge.
Of 478 patients assessed for eligibility, 86 were randomised to the control group (n = 44) or the intervention group (n = 42). Cardiac readmission rates were 14% versus 5% (p = 0.268) in the control and intervention groups, respectively, and all-cause readmission rates were 23% versus 15% (p = 0.34). There were no deaths in either group. More control patients were treated in the emergency services (50% vs. 24%; p = 0.015). In terms of health-related quality of life, patients in the intervention group presented with significant increases in functional capacity and mobility. More intervention patients returned to work (77.3% vs. 36.0%; p = 0.005).
The supervised physical exercise programme was effective at reducing the number of emergency room visits and at increasing the percentage of patients who returned to work. It also improved patients’ exercise capacity and increased their health-related quality of life. Although the results were promising, the programme was not associated with a significant reduction in cardiac and all-cause readmission rates.
As many as 88% of heart transplant recipients (HTRs) suffer from psychological distress. Both psychosocial factors and physical health are associated with increased psychological distress. However, the causes and impacts of psychological distress are unclear. HTRs strive for a sense of control over their health and daily lives in order to improve their psychological well-being. Perceived control was found to be related to the patients’ construction of normality, their emotional state, as well as their thoughts and feelings of uncertainty about the future.
An in-depth exploration of the meaning of uncertainty during the first year after a heart transplantation (HTX).
A phenomenological–hermeneutic method was employed. Interviews were conducted with 14 patients, four women and ten men, with a mean age of 51 years (range: 28–67 years).
Being in uncertainty after HTX means losing a sense of coherence, which shatters the HTR’s whole worldview. The HTRs search for meaning and strive for coherence, which is no longer achievable. By using a nursing theory, we understand that uncertainty should be seen as a natural state among HTRs. It constitutes the starting point from which the HTRs can reorganise their self-structure and find a new view of life. When striving for normality, certainty and predictability (i.e., the healthcare professional’s perspective), we block or prolong this process, thus causing distress among HTRs because they are unable to create a new orientation in life.
This study presents a hypothesis of the primary cause of psychological distress after HTX and provides a useful framework for how to approach this condition.
The objective of this study was to evaluate the effect of a training programme based on traditional Greek dance on the jumping ability, muscle strength and lower limb endurance in patients with chronic heart failure (CHF).
Forty Greek patients with CHF graded as NYHA <= II and aged 73.2±4.7 years were randomly divided into two groups. Group A (n=20) participated in a three-month physical rehabilitation programme based on Greek traditional dances, whereas group B (n=20) remained untrained and served as the control group. All patients were studied before and after the 12-week exercise training programme. At baseline and follow-up the exercise capacity of the patients was evaluated by the six-minute walking test, their lower extremity muscle strength was evaluated by an isokinetic dynamometer and their jumping ability by the Myotest-Pro test, which includes three types of jumps (plyometric, countermovement and squat jumps).
No significant difference was observed between the two groups at the baseline evaluation. At follow-up, group A showed significant improvements in walking distance calculated from the six-minute walking test (10.0% improvement; p<0.05), in lower limb strength (10.32% improvement; p<0.05), and in countermovement jump speed (6.9%; p<0.05) and squat jump speed (5.8%; p<0.05). Group A also increased their jump plyometry height by 13.86% (p<0.05), their counter jump height by 10.68% (p<0.05) and their squat jump height by 10.45% (p<0.05). Group A had a 6.85% (p<0.05) increased force of counter jump compared with group B.
The design and implementation of cardiac rehabilitation programmes using Greek traditional dances in patients with CHF are both safe and effective in improving lower limb function.
Harvest site infections after coronary artery bypass grafting (CABG) are a known complication which represent a serious problem for patients and an increased cost of health care. There is a discrepancy in routine care regarding use of a graduated compression stocking on the leg with the saphenous vein harvest site. Some wards apply a compression stocking postoperatively to all in-hospital patients, others do not. The deep vein thrombosis prevention effect of compression stockings is well documented, but there are no studies of their possible preventive effect on harvest site infections.
Our purpose was to examine whether the use of a graduated compression stocking for 4–6 weeks after CABG reduced the incidence of surgical wound infection at harvest sites.
Data on 377 consecutive CABG patients (September 2011–December 2012) were collected from the hospital’s patient registry and Surveillance System for Surgical Site Infections. Logistic regression was used to determine the odds of surgical site infection in patients at two surgical wards adhering to opposite practices regarding the use of compression stocking (stocking group n=296, no-stocking group n=155).
No significant relationship was found between post-operative infection rate and compression stocking routine.
In this ‘natural experiment’ no evidence was found that the use of a graduated compression stocking reduced the incidence of harvest site surgical wound infection. As the treatment of most Norwegian CABG patients involves the use of a graft leg compression stocking, a randomised controlled trial (RCT) is called for to decide which treatment is better.
The increasing survival of children with congenital heart disease (CHD) challenges healthcare systems regarding how to manage the many health needs of patients undergoing transitional care. A comprehensive understanding of the perspectives of patients, parents, and healthcare providers is required.
This study systematically identified the healthcare needs of adolescents with CHD transitioning into young adults by collecting the perspectives of patients, parents, and healthcare providers.
A sample of CHD patients (n = 29), parents of children with CHD (n = 29), and healthcare providers (n = 16) completed the two-round Delphi study, and 64 healthcare needs were identified. The central tendency and the level of dispersion were computed in order to establish a consensus.
A consensus was reached on 25 healthcare needs including health, family, individual, interpersonal interaction, and policy dimensions, which were classified as important with a moderate to high level of agreement by all three groups. The three groups were strongly agreed that "encouraging the patient to learn health self-management" and "cultivating a positive attitude toward the illness" were very important. The opinions of the three groups differed significantly on 12 needs (p < 0.05) related to health, family, and policy dimensions.
A consensus was reached on the needs that were identified as being potentially valid measures of the healthcare needs of adolescents with CHD transitioning into young adults. The identified needs can serve as the basis for establishing a transitional health passport and developing a clinical intervention for adolescents with CHD transitioning into young adults.
Atrial fibrillation (AF) is associated with cognitive impairment in heart failure (HF).
The purpose of this study was to examine whether AF independently predicted cognitive function in HF patients after controlling for more demographic, medical and psychological characteristics, and whether the timing of AF onset in relation to HF diagnosis independently contributed to cognitive function in HF patients with AF.
A total of 188 hospitalized HF patients (62.8% male, age 66.3±10.6 years) completed cognitive function assessment with the Montreal Cognitive Assessment (MoCA). A history of AF, along with other medical characteristics, was ascertained through a review of participants’ medical charts. The timing of AF onset in relation to HF diagnosis was categorized into AF occurring prior to HF diagnosis (i.e. prior AF) and AF developing after HF diagnosis (i.e. incident AF).
Altogether 72 participants had a positive diagnostic history of AF. Specifically, 41 had prior AF, and 31 developed AF subsequently. In HF patients, AF was associated with poorer performance on cognitive function after controlling for more confounders (β=–0.112, R2=0.010, p=0.046). Among HF patients with AF, incident AF independently predicted poorer cognitive function (β=–0.238, R2=0.027, p=0.047).
AF independently contributes to cognitive function in HF patients after adjusting for more confounding variables. The timing of AF onset in relation to HF diagnosis independently predicts cognitive function in HF patients with AF. Prospective studies are needed to elucidate possible mechanisms for the association between AF and cognitive function in HF populations.
In addition to favourable results regarding mortality and morbidity it is important to identify the impact transcatheter aortic valve implantation (TAVI) has on patients’ quality of life.
The aims were: (i) to describe clinical characteristics, self-reported health and quality of life in octogenarians before TAVI intervention; (ii) to determine changes in self-reported health and quality of life one month after TAVI; and (iii) to establish the clinical importance of the findings.
A prospective cohort study was conducted on consecutively enrolled octogenarians with severe aortic stenosis undergoing TAVI (N = 65). Self-reported health and quality of life were recorded at baseline and one month later using two global questions from the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF), the generic Short Form Health 12 and the disease-specific Minnesota Living with Heart Failure Questionnaire.
One month after TAVI, WHOQOL-BREF showed that self-reported health improved moderately (p < 0.001), while quality of life improved slightly, but not statistically significantly (p = 0.06). There were changes in all Short Form Health 12 domains, except social functioning and role emotional. The estimated changes were 3.6 to 5.8 with large confidence intervals. The Physical Component Summary increased statistically significantly from baseline to 30 days (30.6–34.7; p = 0.02), but the Mental Component Summary did not (46.9–50.0; p = 0.13).
Despite being an advanced treatment performed in a high risk population, TAVI in octogenarians improves short-term self-reported global health and generic physical health and quality of life. These patient-reported outcomes have importance, particularly in this age group.
Chronic heart failure (CHF) and atrial fibrillation (AF) are complex cardiogeriatric syndromes mediated by physical, psychological and social factors. Thromboprophylaxis is an important part of avoiding adverse events in these syndromes, particularly stroke.
This study sought to describe the clinical characteristics of a cohort of patients admitted to hospital with CHF and concomitant AF and to document the rate and type of thromboprophylaxis. We examined the practice patterns of the prescription of treatment and determined the predictors of adverse events.
Prospective consecutive participants with CHF and concomitant AF were enrolled during the period April to October 2013. Outcomes were assessed at 12 months, including all-cause readmission to hospital and mortality, stroke or transient ischaemic attack, and bleeding.
All-cause readmission to hospital was frequent (68%) and the 12-month all-cause mortality was high (29%). The prescription of anticoagulant drugs at discharge was statistically significantly associated with a lower mortality at 12 months (23 vs. 40%; p=0.037; hazards ratio 0.506; 95% confidence interval 0.267–0.956), but was not associated with lower rates of readmission to hospital among patients with CHF and AF. Sixty-six per cent of participants were prescribed anticoagulant drugs on discharge from hospital. Self-reported self-care behaviour and ‘not for cardiopulmonary resuscitation’ were associated with not receiving anticoagulant drugs at discharge. Although statistical significance was not achieved, those patients who were assessed as frail or having greater comorbidity were less likely to receive anticoagulant drugs at discharge.
This study highlights multi-morbidity, frailty and self-care to be important considerations in thromboprophylaxis. Shared decision-making with patients and caregivers offers the potential to improve treatment knowledge, adherence and outcomes in this group of patients with complex care needs.
Although individual symptoms and symptom trajectories for various cardiovascular conditions have been reported, there is limited research identifying the symptom clusters that may provide a better understanding of patients’ experiences with heart disease.
To summarize the state of the science in symptom cluster research for patients with acute coronary syndrome, myocardial infarction, coronary artery bypass surgery, and heart failure through systematic review and to provide direction for the translation of symptom cluster research into the clinical setting.
Databases were searched for articles from January 2000 through to May 2015 using MESH terms "symptoms, symptom clusters, acute coronary syndrome (ACS), myocardial infarction (MI), coronary heart disease (CHD), ischemic heart disease (IHD), heart failure (HF), coronary artery bypass surgery (CABS), cluster analyses, and latent classes." The search was limited to human studies, English language articles, and original articles investigating symptom clusters in individuals with heart disease. Fifteen studies meeting the criteria were included.
For patients with ACS and MI, younger persons were more likely to experience clusters with the most symptoms. Older adults were more likely to experience clusters with the lowest number of symptoms and more diffuse and milder symptom clusters that are less reflective of classic ACS presentations. For HF patients, symptom clusters frequently included physical and emotional/cognitive components; edema clustered in only three studies. Symptom expression was congruent across geographical regions and cultures.
The findings demonstrated similarities in symptom clusters during ACS, MI, and HF, despite multiple methods and analyses. These results may help clinicians to prepare at-risk patients for proper treatment-seeking and symptom self-management behaviors.
Health disparities are related to race/ethnicity, financial status and poor self-care behaviors, but the relationships between these factors remain unknown.
To explore the relationships between race/ethnicity, financial status and cardiac event-free survival, and the reasons for any disparities in patients with heart failure (HF).
We collected demographic data (e.g., race/ethnicity and financial status), clinical data (e.g., medication regimen) and self-care behaviors (by the Self-Care of Heart Failure Index) in 173 HF patients at baseline. Patients were grouped by race/ethnicity (African–American and Caucasian) and financial status (higher if they reported having "enough or more than enough to make ends meet" and lower if they "did not have enough to make ends meet"). Chi-square tests, t-tests and survival analyses were used to explore the relationships between race/ethnicity, financial status, self-care and survival.
African–American race/ethnicity and poor financial status were associated with poor outcomes (p < 0.005) when controlling for covariates. HF patients with lower financial status reported engaging in fewer self-care maintenance behaviors than those with higher financial status. African–American HF patients trended to report engaging in fewer self-care maintenance behaviors than Caucasian HF patients. African–Americans with lower financial status had a four- to six-times higher risk of experiencing cardiac events compared to patients who were Caucasian with higher financial status before and after controlling for covariates.
African–American HF patients and those with lower financial status had worse outcomes and reported fewer self-care maintenance behaviors. Interventions promoting self-care may decrease the disparity in outcomes and should be tailored to African–Americans and those with lower financial status.
Psychological resilience is associated with an improved capacity to cope with chronic health challenges such as cardiovascular disease.
The aim of this cross-sectional study was to examine the relationship between psychological resilience and symptoms of depression in a non-acute cardiac outpatient population.
A total of 419 adult cardiac outpatients (288 men; mean±SD age 66.26±14.04 years) attending cardiovascular clinics completed the Sense of Coherence (SOC13) scale as a measure of psychological resilience and the Cardiac Depression Scale (CDS26) prior to their consultation.
The total SOC13 score (mean±SD 64.02±14.24, range 19–91) was within the moderate range. Older patients (>=65 years) were significantly more resilient than those aged <65 (p<0.01). Psychological resilience (SOC13) was negatively correlated with depression (CDS26) (r=–0.79; p<0.001) and inversely associated with affective, cognitive and somatic symptoms of depression. Psychological resilience, particularly meaningfulness, accounted for more of the variance in affective features of depression than for somatic features.
These findings show that low psychological resilience was related to depression in this cohort of cardiac outpatients, particularly affective symptoms such as anhedonia and hopelessness. The SOC13 scale offers a complementary measure of psychological status that could be used to monitor, and possibly predict, patient coping and response to treatment throughout the cardiovascular disease trajectory.
Patients with atrial fibrillation often have an impaired quality of life (QoL). Practising yoga may decrease stress and have positive effects on mental and physical health. The aim of this study was to investigate whether yoga can improve QoL and decrease blood pressure and heart rate in patients with paroxysmal atrial fibrillation (PAF).
In this pilot study, 80 patients diagnosed with PAF were randomized to standard treatment (control group, n=40) or standard treatment in combination with yoga (yoga group, n=40) during a 12-week period. QoL, blood pressure and heart rate were evaluated at baseline and at the end of the study (12 (+2) weeks). EuroQoL-5D (EQ-5D) Visual Analogue Scale (VAS) and the two dimensions in Short-Form Health Survey (SF-36) were used to evaluate QoL.
At baseline there was a significant difference in QoL between the groups in EQ-5D VAS- scale (p=0.02) and SF-36 mental health score (p<0.001) in which the control group had higher scores. At the end of the study, the yoga group averaged higher SF-36 mental health scores. There was a significant difference between the two groups (p=0.016), but no differences in EQ-5D VAS- scale and physiological health score was seen between the two groups. At the end of the study, the yoga group had significantly lower heart rate (p=0.024) and systolic (p=0.033) and diastolic blood pressure (p<0.001) compared to the control group.
Yoga with light movements and deep breathing may lead to improved QoL, lower blood pressure and lower heart rate in patients with PAF compared to a control group. Yoga could be a complementary treatment method to standard therapy.
Health locus of control is a measure of an individual’s beliefs in factors that are thought to determine health experiences. Scores are generated and form a graduated linear scale from external to internal control, with respect to their views on health causality. Health locus of control has been considered to be a relatively stable entity. However, it is not clear if this status changes in the advent of serious health challenges, such as coronary artery bypass graft surgery. The aim of this study is to explore the variability of health locus of control and its association with postoperative health in this context.
In a longitudinal cohort study of patients undergoing coronary artery bypass graft surgery, a purposive sample (n=215) were recruited from the waiting list and followed up postoperatively, at approximately one year and seven years later.
Patients undergoing coronary artery bypass graft surgery demonstrated marked fluctuations in health locus of control in their peri-operative and rehabilitative phases. Mean health locus of control became more external (often associated with poorer outcomes) peri-operatively, and more internal (generally associated with better health outcomes) in the rehabilitative period.
Health locus of control scores were shown to be changeable during a major health care intervention, with possible consequences for patient outcomes and care needs. The significant health belief upheaval demonstrated in this cohort should be considered in assessing patients preoperatively, and managed as part of the patients’ clinical journey by both acute and rehabilitation staff. It is likely to have particular importance in individualised assessment and management of future prevention advice for patients.
Anxiety is a serious affective mood disorder that affects many chronic heart failure patients. While there is ample evidence that depression increases hospitalisations and mortality in chronic heart failure patients, it is unclear whether this association also exists for anxiety.
The purpose of this study was to report on prospective cohort studies investigating anxiety in chronic heart failure patients and its association with hospitalisations and mortality rates. This systematic review aims to improve the current knowledge of anxiety as a potential prognostic predictor in chronic heart failure populations.
This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by accessing electronic databases Embase, Medline, Cumulative Index to Nursing and Allied Health Literature and PsycINFO. Studies were included if they: employed a prospective cohort study design, included chronic heart failure participants with a confirmed clinical diagnosis plus anxiety confirmed by a validated anxiety assessment tool and/or clinical diagnosis and reported longitudinal hospitalisation rates and mortality data in chronic heart failure.
Six studies were identified for inclusion. A study investigating hospitalisations and mortality rates found a significant (p<0.05) association solely between hospitalisation and anxiety. Of four studies reporting on hospitalisations alone, only two reported significant associations with anxiety. One study reported rates of mortality alone and identified no significant associations between mortality and anxiety. There was some variation in quality of the studies in regards to their methodology, analysis and reported measures/outcomes, which may have affected the results reported.
It is possible that anxiety does predict hospitalisations in chronic heart failure populations, however further research is required to confirm this observation.
Multiple symptoms associated with chronic venous disease (CVD) are poorly understood, under-recognized, and ill-managed.
The aim of this study was to determine whether there are differences in symptoms and symptom clusters between men and women with stage C4 and stage C5 CVD.
Data were collected via interviews with 264 patients using a demographic survey and an 11-item VEINES-SYM questionnaire.
An intrinsic scoring algorithm was developed to calculate the overall t scores for each item by sex. Exploratory factor analysis identified symptom clusters using oblique rotation to account for correlations between factors.
The average age was 61.7 years; 54.5% of the patients were women, 58% were African American or black, and 60.6% had diabetes. The top three symptoms for women in order of frequency were achy legs, swelling, and pain; for men, these were swelling, achy legs, and heavy legs. For the total group, two symptom clusters emerged: distressful and discomfort. There was no statistically significant difference in factor score between the sexes. Different factor loadings for symptom clusters were observed: women reported hurting and annoying clusters; and men reported nagging and irritating clusters.
The data suggest differences in CVD symptoms and clusters by sex. Symptoms in the two clusters were different; however, there was consistency in the factors associated with each cluster. Co-morbid conditions and sex differences in pain responses may play a part in symptom presentation. This study supports the need for increased sex-delineated clinical assessment and consideration of the potential differences between the sexes in the management of CVD symptoms.
Despite the technical advancement of percutaneous coronary intervention, major adverse cardiac events after percutaneous coronary intervention are still a critical issue in Korea as well as in western society. Recently, low left ventricular ejection fraction and depressive symptoms have been regarded as independent predictors of adverse outcomes after successful primary percutaneous coronary intervention. However, there are few studies on the combined effect of left ventricular ejection fraction at baseline and post-cardiac depressive symptoms on major adverse cardiac events after percutaneous coronary intervention.
The aim of the current study is to examine the combined effect of low left ventricular ejection fraction and post-cardiac depressive symptoms on major adverse cardiac events after successful primary percutaneous coronary intervention.
A total of 221 patients who underwent successful percutaneous coronary intervention were assessed for left ventricular ejection fraction and depressive symptoms at baseline and 1 month after discharge, using the patient health questionnaire 9. Major adverse cardiac event-free survival rates during the 12-month follow-up period were analysed by Kaplan–Meier survival curves and Cox proportional hazard regression methods.
We found that the combined effect of baseline left ventricular ejection fraction less than 60% and depressive symptoms at 1 month after discharge were significantly correlated with increased incidence of major adverse cardiac events after successful primary percutaneous coronary intervention (hazard ratio 4.049; 95% confidence interval 1.365–12.011) after adjusting for sex, high sensitivity C-reactive protein, depressive symptoms at baseline and comorbidity.
Our results suggest that healthcare professionals should be aware of the necessity of early screening for post-cardiac depressive symptoms after discharge in percutaneous coronary intervention patients with a low left ventricular ejection fraction.
Relevant discharge information about the use of analgesic medication and other strategies may help patients to manage their pain more effectively and prevent postoperative persistent pain.
To examine patients’ pain characteristics, analgesic intake and the impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Concerns about pain and pain medication prior to surgery will also be described.
From March 2012 to September 2013, 416 participants (23% women) were consecutively enrolled in a randomized controlled trial. The intervention group received usual care plus an educational booklet at discharge with supportive telephone follow-up on postoperative day 10, and the control group received only usual care. The primary outcome was worst pain intensity (The Brief Pain Inventory – Short Form). Data about pain characteristics and analgesic use were collected at 2 weeks and at 1, 3, 6 and 12 months post-surgery. General linear mixed models were used to determine between-group differences over time.
Twenty-nine percent of participants reported surgically related pain at rest and 9% reported moderate to severe pain at 12 months post-surgery. Many participants had concerns about pain and pain medication, and analgesic intake was insufficient post-discharge. No statistically significant differences between the groups were observed in terms of the outcome measures following surgery.
Postoperative pain and inadequate analgesic use were problems for many participants regardless of group allocation, and the current intervention did not reduce worst pain intensity compared with control. Further examination of supportive follow-up monitoring and/or self-management strategies post-discharge is required.
We propose a new method for the early detection of metabolic syndrome in the working population, which was free of biomarkers (non-invasive) and based on anthropometric variables, and to validate it in a new working population.
Prevalence studies and diagnostic test accuracy to determine the anthropometric variables associated with metabolic syndrome, as well as the screening validity of the new method proposed, were carried out between 2013 and 2015 on 636 and 550 workers, respectively. The anthropometric variables analysed were: blood pressure, body mass index, waist circumference, waist–height ratio, body fat percentage and waist–hip ratio. We performed a multivariate logistic regression analysis and obtained receiver operating curves to determine the predictive ability of the variables. The new method for the early detection of metabolic syndrome we present is based on a decision tree using chi-squared automatic interaction detection methodology.
The overall prevalence of metabolic syndrome was 14.9%. The area under the curve for waist–height ratio and waist circumference was 0.91 and 0.90, respectively. The anthropometric variables associated with metabolic syndrome in the adjusted model were waist–height ratio, body mass index, blood pressure and body fat percentage. The decision tree was configured from the waist–height ratio (>=0.55) and hypertension (blood pressure >=128/85 mmHg), with a sensitivity of 91.6% and a specificity of 95.7% obtained.
The early detection of metabolic syndrome in a healthy population is possible through non-invasive methods, based on anthropometric indicators such as waist–height ratio and blood pressure. This method has a high degree of predictive validity and its use can be recommended in any healthcare context.
The available publications show that 50% of patients with hypertension discontinue their medications within the first 12 months after the beginning of treatment.
The aim of the study was to analyse the relationship between the acceptance of illness and the adherence to pharmacological and non-pharmacological therapy in patients with hypertension.
The study included 102 patients with hypertension examined with validated instruments: Acceptance of Illness Scale (AIS), Health Behavior Inventory (HBI) and Morisky Medication Adherence Scale (MMAS-8).
High (>30 points) and moderate (19–29 points) levels of AIS were presented respectively by 59 and 43 patients. In a univariate analysis, the level of AIS had a statistically significant, independent, positive influence on all domains of the HBI questionnaire: HBI (Spearman’s coefficient of rank correlation (rS) =+0.3997), healthy eating habits (rS=+ 0.376), preventive behaviours (rS=+0.242), positive mental attitude (rS=+0.504), health practices (rS=+0.264). In univariate analysis the level of MMAS-8 was influenced by female gender (rS=+0.325; p=0.001), higher education level (rS=+0.241; p=0.015), employment (rS=+0.217; p=0.029) and short duration of illness (rS=+0.229; p=0.022). Multiple regression analysis showed that female gender was an independent predictor of pharmacological adherence (β=+0.325; p=0.001). Illness acceptance was an independent predictor in two domains of the HBI: positive mental attitude HBI domain (β=+0.468; p<0.001) and healthy eating habits (β=+0.321; p=0.001).
(1) Correlation analysis shows that illness acceptance is an important factor contributing to a higher level of adherence to non-pharmacological therapy of hypertension (total index of health behaviours: healthy eating habits, preventive behaviours, positive mental attitude, health practice) but has no influence on adherence to pharmacological treatment. (2) Female gender, higher levels of education, and the short duration of the disease significantly improve patients’ adherence to the prescribed pharmacological and non-pharmacological therapy of hypertension.
Impaired emotional well-being has detrimental effects on health outcomes in patients with chronic heart failure (CHF).
To evaluate a nurse-led Coping Effectiveness Training (CET) group intervention for patients with CHF. It was hypothesized that CET would increase emotional well-being (primary outcome) and health-related quality (HRQoL) of life and improve clinical outcomes. Furthermore, changes in appraisal and coping as mediators of the intervention effect were examined.
Participants were randomized to either control group (n=51) receiving standard health care or CET intervention group (n=52). Self-assessments of positive affect, negative affect, depression, anxiety, HRQoL, illness perception, coping strategies and social support were performed pre- and post-intervention and after six weeks, six months and 12 months. Time to death and hospitalizations were measured during the entire follow-up (median 35 months, interquartile range 11 months).
No significant improvements for emotional well-being and HRQoL in the intervention group compared with the control group were found. After excluding patients with clinical anxiety and depression at baseline the intervention group had significantly lower negative affect (p = 0.022). There were no significant differences regarding cardiovascular events between the groups. The intervention group had greater sense of control over their illness in the short-term (p = 0.036).
CET intervention was found to increase sense of control over the illness in the short term. Psychosocial support programmes, like CET, for patients with CHF is currently lacking evidence for implementing in clinical practice. However, the results provide a basis for future studies with a modified CET intervention design and increased study size.
Adults with congenital heart disease seem to be more distressed than their healthy counterparts, which might render them even more susceptible to developing detrimental health outcomes. Previous research has confirmed the relationship between the perceived impact of stress on health and self-rated health. However, it remains unknown whether sense of coherence, a person’s capacity to cope with stressors, moderates this relationship.
This cross-sectional study aims to explore: the relationship between demographic and clinical characteristics, sense of coherence, and the perceived impact of stress on health; the relationship between the perceived impact of stress on health and self-rated health; and the moderating effect of sense of coherence in a sample of adults with congenital heart disease.
Patients were recruited from the database of congenital and structural cardiology of a university hospital. The analytic sample included 255 patients (median age 35 years; 50% men). Data were obtained using self-report questionnaires and through medical record view. Univariate analyses and multiple regression analysis were conducted.
The perceived impact of stress on health was negatively associated with sense of coherence (P<0.01), but there was no significant association with demographic or clinical characteristics. The perceived impact of stress on health and self-rated health were negatively associated (P<0.001), but sense of coherence did not moderate this relationship.
Our findings support the need for further research on the perceived impact of stress on health. Such insights can be valuable for developing interventions aimed at reducing the negative health consequences of stress in patients with congenital heart disease.
Patient views are especially important in patient education, as patient involvement is essential. However, no empirical research clarifies what knowledge, skills and competencies are needed for health professionals to competently serve as a good educator according to the patients themselves.
To explore what qualities patients with coronary heart disease perceive in a good educator.
A qualitative research method, with semi-structured individual interviews, was used in this study. Purposeful sampling was used to recruit participants from a general hospital in Iceland and in Norway. The data were analysed using systematic text condensation.
The participants included 17 patients who had been through a percutaneous coronary intervention and participated in formal patient education after discharge from hospital. The patients saw a good educator as one who they feel is trustworthy and who individualizes the education to patients’ needs and context and translates general information to their personal situation in lay language. Building trust was dependent on the patients’ perceiving the educator to be knowledgeable and good at connecting with the individual patient, so that the patients feel they are being treated as a whole person with equality and respect.
The patients perceived the capability of building trust and tailoring the education to the individual as the most prominent characteristics of a good educator. Training skills that facilitate patients’ trust, being observant of the patient and his learning needs and adjusting the patient education to individual needs and situations should be key objectives in health professionals’ training in patient education.
The connection between stress and disease has been part of folk wisdom for a long time and has even made its way into our language with phrases such as ‘scared to death’ and ‘a broken heart’. Takotsubo syndrome is a form of acute, reversible heart failure characterized by ballooning of the left ventricle. Post-menopausal women are primarily affected, but cases have been described in both sexes and at all ages. The complete pathophysiology is unknown, but the disease has been connected to psychological or physical stress and a surge in catecholamines. Despite the strong connection with stress, knowledge about the life of patients before the onset of Takotsubo syndrome is lacking.
The aim of this study was to describe and interpret patients’ narratives about long-term stress experienced before the onset of Takotsubo syndrome.
Nineteen people diagnosed with Takotsubo syndrome were interviewed. The narrative interviews were recorded and transcribed verbatim. The resulting texts were analysed using phenomenological hermeneutics.
The analysis revealed that the interviewees lived under stressful circumstances, characterized by feeling burdened by responsibilities, injustice and uncertainty, long before the onset of Takotsubo syndrome. This long-term stress wore down the defences of the interviewees to the degree that their capacity was exhausted and the smallest stressor could ‘tip them over the edge’. The findings indicated that the social structure of gender possibly contributed to the interviewees’ condition.
These findings indicated that long-term stressful circumstances may cause vulnerability to acute psychological or physical stressors and, subsequently, to the onset of Takotsubo syndrome.
In heart failure, a holistic approach incorporating the patient’s perspective is vital for prognosis and treatment. Self-rated health has strong associations with adverse events and short-term mortality risk, but long-term data are limited. We investigated the predictive value of two consecutive self-rated health assessments with regard to long-term mortality in a large, well characterised sample of elderly patients with stable chronic heart failure.
We measured self-rated health by asking ‘In general, would you say your health is: 1, excellent; 2, very good; 3, good; 4, fair; 5, poor?’ twice: at baseline and the end of a 12-week beta-blocker up-titration period in the CIBIS-ELD trial. Mortality was assessed in an observational follow-up after 2–4 years. A total of 720 patients (mean left ventricular ejection fraction 45±12%, mean age 73±5 years, 36% women) rated their health at both time points. During long-term follow-up, 144 patients died (all-cause mortality 20%). Fair/poor self-rated health in at least one of the two reports was associated with increased mortality (hazard ratio 1.42 per level; 95% confidence interval 1.16–1.75; P<0.001). It remained independently significant in multiple Cox regression analysis, adjusted for N-terminal pro B-type natriuretic peptide (NTproBNP), heart rate and other risk prediction covariates. Self-rated health by one level worse was as predictive for mortality as a 1.9-fold increase in NTproBNP.
Poor self-rated health predicts mortality in our long-term follow-up of patients with stable chronic heart failure, even after adjustment for established risk predictors. We encourage clinicians to capture patient-reported self-rated health routinely as an easy to assess, clinically meaningful measure and pay extra attention when self-rated health is poor.
Myocardial infarction (MI) patients may find it challenging to adhere to lifestyle advice and medications. Understanding motivational factors and barriers to change is crucial. However, empirical evidence on patients’ ability to effect lifestyle changes at the time of discharge is limited.
The aim of this study was to identify at the time of hospital discharge the goals, resources, and barriers to future change in MI patients.
We conducted a qualitative interview study with a purposive sample of 20 MI patients (eight women) in a cardiac department at a university hospital in Norway. All interviews were conducted before hospital discharge, transcribed verbatim, and analysed using qualitative content analysis.
Three themes suggested that, at the time of discharge, patients’ views of their MI were complex and diverse. Patients were motivated to change their lifestyle and contemplated taking their life in new directions, adopting a change of life perspective. Frequently, patients struggled to understand the context of living with an MI, manage symptoms, and understand the precipitating causes of MI. There were also patients who wanted to maintain their present lifestyle and live as normal as possible. They just wanted to keep going.
There is a need for a different approach to communicating with MI patients at the time of discharge. Person-centred care that allows personal narratives to emerge may enable health-care professionals to offer more individualised guidance to MI patients that will help them cope with the everyday challenges they experience after discharge.
Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe symptomatic aortic stenosis at increased surgical risk and likely to derive benefit. Multimodality and multidisciplinary assessment is required for the heart team to determine eligibility for TAVI in a primarily older population. Little is known about patients’ motivation and perspectives on making the decision to undergo the complex assessment.
To explore factors influencing patients’ decision making to undergo TAVI eligibility assessment to inform practice, programme development, health policy and future research.
An exploratory qualitative approach was used. Semistructured interviews were conducted with 15 patients at the time of their referral for assessment to a quaternary cardiac and high volume TAVI centre.
Multiple, intersecting factors that included biomedical, functional, social and environmental considerations influenced patients’ decision. The six distinct factors were symptom burden, participants’ perception as ‘experienced’ patients, expectations of benefit and risks, healthcare system and informal support, logistical barriers and facilitators, and obligations and responsibilities.
The decision to undergo TAVI eligibility assessment is multifaceted and complex. Programmatic processes of care must be in place to facilitate appropriate and patient-centered decision making and access to TAVI. Strategies are required to mitigate the risks associated with the rapid deterioration of severe aortic stenosis, address patient and referring physicians’ education needs, and provide individualised care and equitable access. Future research must focus on patients’ experiences throughout the trajectory of TAVI care.
Depression is common in patients with coronary heart disease, and together these conditions significantly affect health outcomes. Impaired social support is also considered an important predictor of coronary heart disease prognosis and, as there is a complex interplay between social isolation and depression, interventions to address both may be required. This review aimed to assess the effectiveness of psychosocial interventions addressing both depression and social support for people with coronary heart disease and depression.
PRISMA guidelines were used to search major health databases to identify randomised controlled trials that evaluated psychosocial interventions compared with usual care in patients with coronary heart disease and depression; the primary outcome was depressive symptoms and secondary outcomes were mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety, social support and quality of life. Data, when suitable, were pooled using a random-effects meta-analysis model.
Five studies (n=1358 participants) were eligible and included. The psychosocial intervention group had significantly lower levels of depressive symptoms (standardised mean difference (SMD) –0.15, 95% confidence interval (CI) –0.27 to –0.03; P=0.02) and higher levels of social support (SMD 0.17; 95% CI 0.04 to 0.30; P=0.01) but no differences were found for mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety or quality of life.
Psychosocial interventions for patients with coronary heart disease and depression result in modest reductions in depressive symptoms and improvements in social support. However, caution is warranted in view of the small number of studies included in the review and potential heterogeneity in outcomes and in differences in treatment.
Delay in seeking treatment for symptoms of atrial fibrillation (AF) at onset results in a missed opportunity for vital early treatment of AF which is important for reducing stroke, tachycardia induced heart failure, and treatment-resistant AF. Little is known about factors that contribute to treatment-seeking delay for symptoms of AF.
The purpose of this study was to identify factors associated with treatment-seeking delay for symptoms of AF before diagnosis.
For this descriptive study, 150 participants with recently detected AF completed structured interviews to collect data about symptoms, symptom characteristics, symptom representation regarding cause, seriousness, controllability of symptoms, responses to symptoms before diagnosis, and time from symptom onset to treatment-seeking. Chi-square analysis was used to identify factors associated with delay (>1 week) versus no delay (<=1 week) in treatment-seeking after symptom onset.
Participants were 51% female (n=76) with a mean age of 66.5 (standard deviation (SD)±11.1) years. A majority (70%, n=105) delayed treatment-seeking. Factors associated with delay included experiencing fatigue, dyspnea, intermittent symptoms, attributing symptoms to deconditioning, overwork, inadequate sleep, and perceiving symptoms as not very serious and amenable to self-management. Responses such as a wait and see approach, working through symptoms, reporting no fear of symptoms, or attempting to ignore symptoms were associated with delay.
Experiencing fatigue, dyspnea and intermittent symptoms produced symptom representations and emotional and behavioral responses associated with treatment-seeking delay. There is a critical need to develop and test educational interventions to increase awareness of the spectrum and characteristics of AF symptoms and appropriate treatment-seeking behaviors.
The effect of preoperative education on anxiety and postoperative outcomes of cardiac surgery patients remains unclear.
The aim of the study was to estimate the effectiveness of a nurse-led preoperative education on anxiety and postoperative outcomes.
A randomised controlled study was designed. All the patients who were admitted for elective cardiac surgery in a general hospital in Athens with knowledge of the Greek language were eligible to take part in the study. Patients in the intervention group received preoperative education by specially trained nurses. The control group received the standard information by the ward personnel. Measurements of anxiety were conducted on admission-A, before surgery-B and before discharge-C by the state–trait anxiety inventory.
The sample consisted of 395 patients (intervention group: 205, control group: 190). The state anxiety on the day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease in state score during the follow-up period was greater in the intervention group (P=0.001). No significant difference was found in the length of stay or readmission. Lower proportions of chest infection were found in the intervention group (10 (5.3) versus 1 (0.5); P=0.004). Multivariate linear regression revealed that education and score in trait anxiety scale on admission are independent predictors of a reduction in state anxiety.
Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients undergoing cardiac surgery, but it was not effective in reducing readmissions or length of stay.
Transcatheter aortic valve replacement (TAVR) is a less invasive treatment option for patients that are deemed too high a risk for surgical aortic valve replacement (SAVR). The aim of this review is to evaluate the frailty tools currently being used in patients referred for TAVR.
Using a literature search involving database search engines from CINAHL, PubMed, SAGE publications and European Society of Cardiology conducted from 2010 to the present, a critical evaluation of studies dealing with frailty assessment in patients referred for TAVR/SAVR is discussed.
Eight studies met the criteria using frailty assessment in TAVR/SAVR patients. In all reviewed studies the impact of frailty on clinical outcome has been proved. Different instruments for measurements of frailty were used that have not been robustly evaluated. Frailty was defined differently and results may not be comparable. All reviewed studies used different cutoffs and scales and some a composite scoring system, although validity was limited.
For frailty assessment implementation of validated standardized test protocols based on well-established assessment tools, covering all domains of frailty among TAVR centers is crucial for patient selection. Secondly, validated cutoffs and scoring systems are essential.
Anglophone nurses face the challenge of communicating health information to patients who do not speak or understand English. Limited English-proficient patients are at higher risk of misinterpreting health information teaching. Successful recovery after coronary artery bypass graft surgery requires patients’ engagement with healthcare professionals and active participation in therapies and related undertakings. Determination of whether limited English-proficient patients undergoing coronary artery bypass graft surgery recover at the same pace as the general population is of interest.
This study examined whether limited English-proficient patients had prolonged post-operative length of stay following coronary artery bypass graft surgery. The patients’ length of stay with regard to a clinical pathway target was also examined.
A retrospective medical record review of all patients undergoing isolated coronary artery bypass graft surgery in a 2-year period was conducted. A screening tool was developed to identify limited English-proficient patients through examination of their medical records.
A total of 691 of 712 (97.1%) patients met the inclusion criteria; 103 (14.9%) patients were identified as limited English-proficient. The post-operative median length of stay of limited English-proficient patients was 7 days compared with 6 days for the English-proficient patients (p = 0.007). Limited English-proficient patients had higher infection rates (29.1%) vs. English-proficient patients (16.7%) (odds ratio = 2.05 (95% confidence intervals 1.27–3.30)). Post-operative infection was the strongest predictor of length of stay and fully mediated the relationship between language proficiency and length of stay.
When compared with English-proficient patients, limited English-proficient patients had greater infection rates, which were associated with longer length of stay. These findings warrant examination of the mechanisms through which post-operative infections are acquired by limited English-proficient patients.
Patients undergoing coronary artery bypass graft surgery often experience a range of problems and symptoms such as immobility, pain and insufficient sleep. Results from trials investigating testing in-hospital physical exercise or psychological intervention have been promising. However, no randomized clinical trials have tested a comprehensive rehabilitation programme consisting of both physical exercise and psycho-education in the early rehabilitation phase.
The aims of the present SheppHeart pilot randomized clinical trial were to evaluate the feasibility of patient recruitment, patient acceptance of the intervention, safety and tolerability of the intervention.
Sixty patients admitted for coronary artery bypass graft were randomized 1:1:1:1 to: 1) physical exercise plus usual care, or 2) psycho-educational intervention plus usual care, or 3) physical exercise and psycho-educational plus usual care, or 4) usual care alone during a four week period after surgery.
The acceptability of trial participation was 67% during the three month recruitment period. In the physical exercise groups, patients complied with 59% of the total expected training sessions during hospitalization. Nine patients (30%) complied with >75% and nine patients (30%) complied with 50% of the planned exercise sessions. Eleven patients (42%) participated in >=75% of the four consultations and six patients (23%) participated in 50% of the psycho-educational programme.
Comprehensive phase one rehabilitation combining physical exercise and psycho-education in coronary artery bypass graft patients shows reasonably high inclusion, feasibility and safety.
Depression after cardiac surgery (CS) is associated with increased pain and decreased sleep quality. While cognitive behavioral therapy (CBT) aimed at depression is effective in relieving depressive symptoms after cardiac surgery, little is known about its ability to ameliorate other common postoperative problems that affect recovery and quality of life.
The purpose of this study was to evaluate the effects of CBT for depression on pain severity, pain interference, sleep, and perceived control in patients recovering from CS.
Depressed patients recovering from CS were randomized to receive either eight weeks of CBT or usual care. At baseline and post-intervention, patients completed questionnaires for depressive symptoms, pain, sleep, and perceived control. Group comparisons were conducted using t-tests or chi square analysis. Repeated measures analysis was used to assess the effect of the intervention in changes over time.
The sample (n=53) included 16.9% women and had a mean age of 67.8±9.2 years. CBT for depression increased perceived control (p<0.001) and decreased pain interference (p=0.02) and pain severity (p=0.03). Group effects remained significant (p<0.05) for perceived control and pain interference and a trend was observed for pain severity (p<0.10) after controlling for variables that differed at baseline. There were no group differences in sleep disturbance over time.
A depression-focused CBT intervention yields benefits in other common postoperative problems, specifically improved perceived control and decreased pain in depressed cardiac surgery patients.
Blood pressure targets in individuals treated for hypertension in primary care remain difficult to attain.
To assess the role of practice nurses in facilitating intensive and structured management to achieve ideal BP levels.
We analysed outcome data from the Valsartan Intensified Primary carE Reduction of Blood Pressure Study. Patients were randomly allocated (2:1) to the study intervention or usual care. Within both groups, a practice nurse mediated the management of blood pressure for 439 patients with endpoint blood pressure data (n=1492). Patient management was categorised as: standard usual care (n=348, 23.3%); practice nurse-mediated usual care (n=156, 10.5%); standard intervention (n=705, 47.3%) and practice nurse-mediated intervention (n=283, 19.0%). Blood pressure goal attainment at 26-week follow-up was then compared.
Mean age was 59.3±12.0 years and 62% were men. Baseline blood pressure was similar in practice nurse-mediated (usual care or intervention) and standard care management patients (150 ± 16/88 ± 11 vs. 150 ± 17/89 ± 11 mmHg, respectively). Practice nurse-mediated patients had a stricter blood pressure goal of <=125/75 mmHg (33.7% vs. 27.3%, p=0.026). Practice nurse-mediated intervention patients achieved the greatest blood pressure falls and the highest level of blood pressure goal attainment (39.2%) compared with standard intervention (35.0%), practice nurse-mediated usual care (32.1%) and standard usual care (25.3%; p<0.001). Practice nurse-mediated intervention patients were almost two-fold more likely to achieve their blood pressure goal compared with standard usual care patients (adjusted odds ratio 1.92, 95% confidence interval 1.32 to 2.78; p=0.001).
There is greater potential to achieve blood pressure targets in primary care with practice nurse-mediated hypertension management.
Sudden cardiac arrest (SCA) survivors can develop posttraumatic stress disorder (PTSD) which is associated with worse clinical outcomes. The purpose of this study was to evaluate the prevalence and predictors of PTSD in a large sample of SCA survivors. Prior history of psychological trauma and the effects of repeated trauma exposure on subsequent PTSD and symptom severity after SCA were also explored.
A retrospective, cross-sectional study of 188 SCA survivors from the Sudden Cardiac Arrest Association patient registry completed an online questionnaire that included measures of PTSD, trauma history, sociodemographics, general health, and cardiac history.
Sixty-three (36.2%) SCA survivors in this sample scored above the clinical cutoff for PTSD. Female gender, worse general health, and younger age predicted PTSD symptoms after SCA. Additionally, 50.2% of SCA survivors (n = 95) reported a history of trauma exposure and 25.4% (n = 48) of the total sample endorsed a traumatic stress response to a historic trauma. Results indicated that a traumatic stress response to a historic trauma was a stronger predictor of PTSD after SCA (odds ratio = 4.77) than all other variables in the model.
PTSD symptoms are present in over one-third of SCA survivors. While demographic or health history variables predicted PTSD after SCA, a history of traumatic stress response to a previous trauma emerged as the strongest predictor of these symptoms. Routine assessment and interdisciplinary management are discussed as potential ways to expedite survivors’ recovery and return to daily living.
To examine the effectiveness of a four-week home-based self-management rehabilitation programme on health-related quality of life, anxiety and depression levels, cardiac risks and unplanned visits to the health services among community-dwelling patients with myocardial infarction.
A randomised controlled trial with repeated measurements was used. A convenience sample of 128 patients with myocardial infarction was recruited from outpatient cardiology clinics at a tertiary hospital in Singapore. Participants were randomly assigned to the intervention group or control group. The outcomes were measured using Short Form 12-item Health Survey Version 2, Myocardial Infarction Dimensional Assessment Scale, and Hospital Anxiety and Depression Scale. The cardiac physiological risk parameters and number of unplanned health service use were also assessed. Data were collected at baseline, and at four weeks and 16 weeks from the baseline.
Over the 16 weeks, the two groups reported significant differences in physical activity (F = 4.23, p = 0.02), dependency (F = 5.16, p = 0.01), concerns over medication (F = 3.47, p = 0.04) on MIDAS, anxiety level (F = 3.41, p = 0.04) and body mass index (F = 3.12, p = 0.04). A significant difference was also found in unplanned cardiac-related emergency room visits (2 = 6.64, p = 0.036) and medical consultation (2 = 9.67, p = 0.046) at the 16-week study point.
The study may provide a useful tool to help health care professionals to meet the cardiac rehabilitative care needs of community-dwelling patients with myocardial infarction in Singapore.
This study aimed to evaluate the effectiveness of a home-based educational strategy using community health volunteers (CHVs) in improving self-care of patients with chronic heart failure (CHF) in comparison with an educational strategy using formal health professionals (FHPs) at hospital, and also with a control group receiving usual care in western Iran.
A three-arm controlled trial randomly allocated 231 patients with CHF into a control group and two intervention groups undertaking two different educational approaches – a face-to-face education program by CHVs at the patients’ homes and a formal education program using paid FHPs at hospital. Data obtained through interviewing patients before and two months after interventions were analyzed. Self-care components significantly increased after the intervention in both interventional groups compared to the control group (p<0.001). Differences between the two strategies were not significant, except for self-care confidence being greater in the groups exposed to the health professionals (p=0.004). The mean and standard deviation (SD) of the changes in self-maintenance, self-management and self- confidence score (each with a maximum score of 100) for the CHVs group were 26.2±12.7, 29.4±11 9.5±17; for the health professional group were 29.5±12, 31.3±12, 18.1±17; and for the control group were 2.7±9, 10.2±10, –0.30±11 respectively.
The home-based face-to-face education by CHVs improved self-care maintenance and self-care management in patients with CHF as effectively as the education provided by health professionals in a formal health education program, and much better than the usual care.
In 2005, the UK Department of Health recommended that a new role, the arrhythmia care coordinator (ACC), be created to guide patients through the diagnosis and treatment for arrhythmia. The belief was that this would improve the efficiency of care and improve their quality of life. The British Heart Foundation provided funding for 32 such posts, all of which were filled by arrhythmia specialist nurses, and commissioned an evaluation of the new service to assess its impact on patients.
This paper focuses on the impact of the ACCs on their patients’ levels of anxiety and depression, hospital readmissions and costs to the National Health Service (NHS).
From 2008 to 2010, using questionnaires, we conducted a longitudinal audit of the psychological status of the patients referred to the ACCs; we also assessed the ACCs’ impact on readmissions and cost benefits to the NHS using UK Hospital Episode Statistics.
We found high levels of anxiety and depression amongst patients. Nearly one-third were at the ‘borderline’ or ‘clinically anxious’ and 18% were at the ‘borderline’ or ‘clinically depressed’ level at their first assessment with small changes at follow-up. In arrhythmia specialist nurse sites, readmission rates were reduced by half. After deducting the cost of the ACCs and their support, the estimated annual saving was £29,357 per ACC.
This evaluation has shown that the NHS saves £29,357 per year over and above the costs of employing a British Heart Foundation ACC and that all arrhythmia centres should be encouraged to employ an appropriate number of such specialists.
Depression is common among patients with coronary heart disease (CHD) and has a major impact on their quality of life, morbidity and mortality.
The aim of this study was to map the 12-month psychosocial outcomes of patients with CHD who were screened positive for depression in an acute cardiac ward.
A prospective cohort study was conducted of the psychosocial trajectory (depression, anxiety, wellbeing, social support, mental health service access) of 212 patients with CHD who were screened for depression after being admitted to acute cardiac wards of a major metropolitan hospital. Outcomes were assessed before hospital discharge and at one, three, six and 12 months post-discharge.
Linear mixed models identified that those patients screened at ‘moderate to high’ risk of depression at baseline had higher levels of depression (F(1,173)=53.93, p<0.0001) and anxiety (F(1,180)=67.01, p<0.001), and lower levels of wellbeing (F(1,186)=42.47, p<0.001) and social support (F(1,177)=25.40, p<0.0001), compared to those at ‘no to low’ risk of depression. Levels of depression and wellbeing remained fairly constant over the 12-month trajectory. Surgical and medical treatment groups were of similar psychological composition over the 12-month period.
These findings attest to the effectiveness and predictive validity of a simple nurse-administered screening tool designed to identify depression in hospital patients with CHD and also indicate that a screening and referral tool alone is not sufficient to achieve optimal disease management. A collaborative care model involving family members and integrated pathways to primary care is recommended.
As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted.
To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland.
Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified.
Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance.
The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.
Fatigue is a debilitating and highly prevalent symptom in patients with chronic heart failure (HF) possibly complicating HF self-care behaviour which is crucial for maintaining health.
The purpose of this study was to examine whether general and exertion fatigue are distinctively associated with self-care in patients with chronic HF.
In total, 545 outpatients with chronic HF (mean age=66.2 years; 75% male) completed measures of general fatigue (i.e. a sustained sense of exhaustion including mental efforts), exertion fatigue (i.e. fatigue directly related to physical activity), sleep problems, mood symptoms and HF self-care behaviour at baseline, 12-, and 18-month follow-up.
Linear mixed modelling results showed that general and exertion fatigue were significantly associated with poor HF self-care (estimate=0.10, p=0.004; estimate=0.06, p=0.01, respectively) and poor consulting behaviour (estimate=0.05, p=0.04; estimate=0.04, p=0.007, respectively) over time, independent of sleep and mood problems, and other clinical covariates. Exertion fatigue was associated with supplementary determinants.
This is the first prospective study demonstrating that general and exertion fatigue were both associated with poor HF self-care, which could not be explained by sleep problems or mood symptoms, and was independent of clinical indicators of disease severity. Treatment of fatigue problems may improve HF self-care skills and ultimately quality of life and cardiovascular outcomes. Further research is needed to examine this potential causal relationship.
In-depth analysis of emergency medical services (EMSs) performances in out-of-hospital cardiac arrest (OHCA) promotes quality improvement.
The purpose of this study was to identify the improvable factors of the EMS response to OHCA through the description and analysis of OHCA incidence, characteristics, management and outcome.
This was a retrospective cohort study on all OHCA patients treated by the EMSs of the district of Trieste, Italy (236,556 inhabitants) in 2011.
A total of 678 OHCAs occurred and 142 (20.1%) underwent cardiopulmonary resuscitation (CPR), with a respective incidence of 287/100,000/year and 60/100,000/year. The incidence of shockable rhythms in the CPR group was 13/100,000. OHCAs occurred mainly during daytime, though the proportion of patients receiving CPR was significantly higher by night-time (p=0.01). Thirty-four CPR patients (23.9%) restored spontaneous circulation on scene; 12 (8.5%) survived to hospital discharge (11 with good neurological recovery). Survival was not correlated with age, while was significantly higher for patients with shockable rhythms (32.3%; p<0.001). Mean response time was 8 min. Direct intervention of physician-staffed units did not improve the outcome when compared with two-tiered activation. Patients immediately identified as OHCA by dispatch nurses and those undergoing therapeutic hypothermia showed a non-significant trend towards improved survival (p=0.09 and 0.07, respectively).
OHCA identification by dispatch nurses and reduction of response time were the factors most susceptible to improvement.
Heart failure self-care requires confidence in one’s ability and motivation to perform a recommended behavior. Most self-care occurs within a family context, yet little is known about the influence of family on heart failure self-care or motivating factors.
To examine the association of family functioning and the self-care antecedents of confidence and motivation among heart failure participants and determine if a family partnership intervention would promote higher levels of perceived confidence and treatment self-regulation (motivation) at four and eight months compared to patient–family education or usual care groups.
Heart failure patients (N=117) and a family member were randomized to a family partnership intervention, patient–family education or usual care groups. Measures of patient’s perceived family functioning, confidence, motivation for medications and following a low-sodium diet were analyzed. Data were collected at baseline, four and eight months.
Family functioning was related to self-care confidence for diet (p=0.02) and autonomous motivation for adhering to their medications (p=0.05) and diet (p=0.2). The family partnership intervention group significantly improved confidence (p=0.05) and motivation (medications (p=0.004; diet p=0.012) at four months, whereas patient–family education group and usual care did not change.
Perceived confidence and motivation for self-care was enhanced by family partnership intervention, regardless of family functioning. Poor family functioning at baseline contributed to lower confidence. Family functioning should be assessed to guide tailored family–patient interventions for better outcomes.
The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS.
The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken.
A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation.
From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01–2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7–5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03–2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9–3.2%). Nearly half (n=103, 46%; 95% CI: 39.5–52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3–52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7–20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3–16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1).
Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.
Pulmonary arterial hypertension (PAH) is a devastating disease characterized by elevated pulmonary pressures that lead to right heart failure and premature mortality. Patients experience multiple symptoms including dyspnea, fatigue and chest pain, but little is known about sleep disturbance, PAH symptoms, psychological distress and health-related quality of life (HRQOL) in PAH.
The purpose of this study was to describe the occurrence of sleep disturbance and compare PAH symptoms, psychological distress, and HRQOL across severity of sleep disturbance.
One hundred and ninety-one participants completed a socio-demographic and clinical data form, PAH Symptom Severity Scale, Profile of Mood States (POMS) short form and the Medical Outcomes Short Form-36 (SF-36). Descriptive statistics were used to describe sleep disturbances; analysis of variance models were used to quantify differences in PAH symptoms, psychological distress and HRQOL by sleep disturbance groups.
The majority of participants (n=162, 85%) were women with a mean age of 53 years. Sixty-five (34%) reported no sleep disturbance; 54 (28%) mild sleep disturbance; 41 (22%) moderate sleep disturbance; and 31 (16%) severe sleep disturbance. Those reporting higher sleep disturbance severity reported worse PAH symptoms, psychological distress, and HRQOL.
Sleep disturbance is a significant finding in PAH. Increasing levels of sleep disturbance are associated with worse PAH symptoms, psychological states, and health-related quality of life. Interventions that decrease sleep disturbances may improve symptoms and HRQOL.
The most common manifestation of heart failure is physical capacity impairment resulting in dyspnoea and fatigue. The disease deteriorates the quality of life (QoL). Its consequences restrict not only functioning in the physical aspect of QoL but also patients’ emotional condition.
The study is aimed to assess QoL changes in HF patients after home-based telemonitored cardiac rehabilitation (HTCR Group) versus outpatient-based standard cardiac rehabilitation (SCR Group).
The study comprised 131 heart failure patients (aged 56.4±10.9 years; II/III NYHA) rehabilitated for eight weeks in two random groups: HTCR Group (n=75), participating in home-based rehabilitation supervised telemedically based on walking training; SCR Group (n=56), participating in traditional outpatient-based rehabilitation (cycloergometer training). QoL parameters were assessed with a Polish version of the Medical Outcomes Study Short Form 36 Health Survey Questionnaire (SF-36).
After rehabilitation, both groups achieved a significant QoL improvement, both physically and mentally. HTCR Group patients improved in QoL physical categories in one subscale (physical function), and in two subscales in the mental categories (mental health, vitality). In SCR Group, three physical subscales improved (physical function, role limitation caused by physical problems, bodily pain). In the mental categories, also three subscales improved (social function, mental health, vitality).
The study demonstrated that in heart failure patients HTCR provided a similar improvement in total QoL index as SCR. Yet it differed in QoL subscales. Patients who underwent home-based telerehabilitation observed an improvement mainly in the mental categories. Patients in SCR Group improved their general physical well-being.
Medication adherence is a complex behavior that is influenced by numerous factors. Applying self-efficacy theory, the primary aim of this randomized controlled trial was to compare medication self-efficacy among patients with coronary heart disease who received: (a) text messages (TMs) for medication reminders and education, (b) TMs for education, or (c) no TMs. The second aim was to identify the personal (sociodemographic and clinical characteristics) and psychosocial factors that were associated with and predicted medication adherence.
Customized TMs were delivered over 30 days. Repeated measures analysis of variance was used to analyze medication self-efficacy. A multiple regression analysis was performed at baseline and follow-up to determine variables that were associated with and predicted self-reported medication adherence.
Among 90 subjects with mean age 59.2 years (standard deviation (SD) 9.4, range 35–83), total scores for medication self-efficacy improved over 30 days; however, there was no significant difference in this improvement as a function of the different treatment groups (p=0.64). Controlling for other variables in the model (age, education, depression, and social support), less depression (p=0.004) and higher social support (p=0.02) positively predicted higher medication adherence in the final model.
TM medication reminders and/or health education did not improve medication self-efficacy. Further theory testing of current and future models and interventions are required to understand variables related to self-efficacy and medication adherence. Addressing psychosocial factors such as depression and social support should be a priority to improve medication adherence among patients with coronary heart disease.
Regional-dwelling adults have higher levels of cardiovascular disease (CVD) risk.
To determine the potential benefits of a nurse-led, self-management intervention program to reduce CVD and diabetes risk.
A six-month pre/post observational study was conducted in a high risk, under-serviced regional community. A nurse-led heart health clinic was established and 530 self-selected adult individuals (mean age 54±14 years, 62% female) were subject to standardized screening. Individual targets and multidisciplinary strategies to reduce risk factors were individually tailored according to the Green Amber Red Delineation of rIsk And Need (GARDIAN) system. Changes in participants’ CVD risk factors and lifestyle behaviors were compared and independent correlates of improvements in blood pressure (BP), total cholesterol, weight and absolute CVD risk were evaluated. Baseline risk factors for CVD were highly prevalent. Participants required low (43%), moderate (34%) or high (23%) levels of surveillance and management according to GARDIAN criteria. Clinically significant changes in 326 (76%) participants were observed. Average BP decreased by 4 mmHg (systolic) and 1 mmHg (diastolic), weight by almost 1 kg, total cholesterol by 0.6 mmol/l and body mass index (BMI) by 0.3 kg/m2. A change in absolute CVD risk scores of –0.4% was observed. Primary physician attendance independently predicted improvements in BP (odds ratio (OR) 1.67; 95% confidence interval (CI) 1.08–2.58, p=0.022) whereas GARDIAN status, age, physical activity and nurse guidance positively influenced cholesterol, absolute CVD risk and weight outcomes.
The feasibility and short-term benefits of a dedicated "heart health" service for high risk regional-dwelling individuals was shown.
The reported cost effectiveness of cardiovascular disease management programs (CVD-MPs) is highly variable, potentially leading to different funding decisions. This systematic review evaluates published modeled analyses to compare study methods and quality.
Articles were included if an incremental cost-effectiveness ratio (ICER) or cost-utility ratio (ICUR) was reported, it is a multi-component intervention designed to manage or prevent a cardiovascular disease condition, and it addressed all domains specified in the American Heart Association Taxonomy for Disease Management. Nine articles (reporting 10 clinical outcomes) were included.
Eight cost-utility and two cost-effectiveness analyses targeted hypertension (n=4), coronary heart disease (n=2), coronary heart disease plus stoke (n=1), heart failure (n=2) and hyperlipidemia (n=1). Study perspectives included the healthcare system (n=5), societal and fund holders (n=1), a third party payer (n=3), or was not explicitly stated (n=1). All analyses were modeled based on interventions of one to two years’ duration. Time horizon ranged from two years (n=1), 10 years (n=1) and lifetime (n=8). Model structures included Markov model (n=8), ‘decision analytic models’ (n=1), or was not explicitly stated (n=1). Considerable variation was observed in clinical and economic assumptions and reporting practices. Of all ICERs/ICURs reported, including those of subgroups (n=16), four were above a US$50,000 acceptability threshold, six were below and six were dominant.
The majority of CVD-MPs was reported to have favorable economic outcomes, but 25% were at unacceptably high cost for the outcomes. Use of standardized reporting tools should increase transparency and inform what drives the cost-effectiveness of CVD-MPs.
There are few data regarding the effectiveness of remote monitoring for older people with heart failure. We conducted a post-hoc sub-analysis of a previously published large Cochrane systematic review and meta-analysis of relevant randomized controlled trials to determine whether structured telephone support and telemonitoring were effective in this population.
A post hoc sub-analysis of a systematic review and meta-analysis that applied the Cochrane methodology was conducted. Meta-analyses of all-cause mortality, all-cause hospitalizations and heart failure-related hospitalizations were performed for studies where the mean or median age of participants was 70 or more years.
The mean or median age of participants was 70 or more years in eight of the 16 (n=2659/5613; 47%) structured telephone support studies and four of the 11 (n=894/2710; 33%) telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63–1.00) and telemonitoring (RR 0.56; 95% CI=0.41–0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67–0.99).
Despite a systematic bias towards recruitment of individuals younger than the epidemiological average into the randomized controlled trials, older people with heart failure did benefit from structured telephone support and telemonitoring. These post-hoc sub-analysis results were similar to overall effects observed in the main meta-analysis. While further research is required to confirm these observational findings, the evidence at hand indicates that discrimination by age alone may be not be appropriate when inviting participation in a remote monitoring service for heart failure.
Cognitive impairment is common in heart failure. Obesity is a known risk factor for cognitive dysfunction in heart failure, though the mechanisms remain unclear. Obesity increases risk for conditions like hypertension and type 2 diabetes mellitus (T2DM) as well as poor fitness levels, and this may serve as one possible pathway accounting for association between obesity and cognitive dysfunction.
We used structural equation modeling to test whether the combination of hypertension, T2DM, and reduced fitness mediate the association between obesity and cognitive dysfunction.
Two hundred heart failure patients completed neuropsychological testing and a physical fitness assessment. Hypertension and T2DM were ascertained via self-report and medical records. Body mass index (BMI) was calculated.
Forty-three percent of the sample was obese. Hypertension (70%) and T2DM (36%) were common, and fitness levels were reduced. The structural equation model with these factors as mediators between BMI and cognitive function demonstrated excellent fit (comparative fit index = 0.98; root mean-square error of approximations = 0.03). Higher BMI correlated with hypertension, T2DM, and poorer fitness. Each of these factors predicted worse cognition. Models that isolated medical comorbidities and physical fitness as the mediator were weaker than the full model.
Increased risk for medical comorbidities and reduced fitness levels helped to explain the negative effects of obesity on cognitive dysfunction in heart failure. Prospective studies should confirm this pattern and examine how weight loss benefits cognitive function in heart failure.
Depressive symptoms in people with heart failure (HF) are highly prevalent. Caring for patients with both HF and depression may be more burdensome than caring for patients with HF alone.
The purpose of this study was to examine differences in caregivers’ outcomes (i.e. caregiving burden, difficulty and time spent on caregiving, perceptions of life change as a result of caregiving, and quality of life) between caregivers who take care of HF patients with depressive symptoms and without depressive symptoms.
Patient-caregiver dyads at an outpatient clinic completed survey questionnaires. Patients’ depression was assessed using the Beck Depression Inventory-II (BDI-II); primary caregivers completed caregiving outcome questionnaires. Differences in caregiving outcomes between patients with and without depressive symptoms (BDI-II≥14) were examined using t-tests, Chi-square, and Mann-Whitney U-test.
Of 102 patients (64% male, mean age 61, 41% NYHA Class III–IV, mean ejection fraction 35.8±13.9), 26.5% had clinically significant depressive symptoms. Of the primary caregivers (78% female; mean age 56.7), 42% reported severe burden (the Zarit Burden Interview (ZBI)≥17). Caregivers of patients with depressive symptoms had a higher level of burden (25±13 vs 13.5±12 on the ZBI; p<0.001), spent more time caregiving (37±12 vs 30±11 on the Oberst Caregiving Burden Scale; p=0.004), and reported worse mental quality of life (46±10 vs 51±10 on the SF-12v2; p=0.026) than those of patients without depressive symptoms.
Family members caring for HF patients with depressive symptoms had significantly higher levels of caregiving burden and worse quality of life compared to those caring for patients without depressive symptoms.
Quality of life is included in the economic evaluation of health services by measuring the preference for health states, i.e. health state utilities. However, most intervention studies include a disease-specific, not a utility, instrument. Consequently, there has been increasing use of statistical mapping algorithms which permit utilities to be estimated from a disease-specific instrument. The present paper provides such algorithms between the MacNew Heart Disease Quality of Life Questionnaire (MacNew) instrument and six multi-attribute utility (MAU) instruments, the Euroqol (EQ-5D), the Short Form 6D (SF-6D), the Health Utilities Index (HUI) 3, the Quality of Wellbeing (QWB), the 15D (15 Dimension) and the Assessment of Quality of Life (AQoL-8D).
Heart disease patients and members of the healthy public were recruited from six countries. Non-parametric rank tests were used to compare subgroup utilities and MacNew scores. Mapping algorithms were estimated using three separate statistical techniques.
Mapping algorithms achieved a high degree of precision. Based on the mean absolute error and the intra class correlation the preferred mapping is MacNew into SF-6D or 15D. Using the R squared statistic the preferred mapping is MacNew into AQoL-8D.
The algorithms reported in this paper enable MacNew data to be mapped into utilities predicted from any of six instruments. This permits studies which have included the MacNew to be used in cost utility analyses which, in turn, allows the comparison of services with interventions across the health system.
Coronary heart disease is a major contributor to women’s health problems.
Self-perceived social support, well-being and health-related quality of life (HRQL) were documented in the cross-sectional HeartQoL survey of European women one and six months after a myocardial infarction.
European women were recruited in 18 European countries and grouped into four geographical regions (Southern Europe, Northern Europe, Western Europe and Eastern Europe). Continuous socio-demographic variables and categorical variables were compared by age and region with ANOVA and 2, respectively; multiple regression models were used to identify predictors of social support, well-being and HRQL.
Women living in the Eastern European region rated social support, well-being and HRQL significantly lower than women in the other regions. Older women had lower physical HRQL scores than younger women. Eastern European women rated social support, well-being and HRQL significantly lower than women in the other regions. Prediction of the dependent variables (social support, well-being and HRQL) by socio-demographic factors varied by total group, in the older age group, and by region; body mass index and managerial responsibility were the most consistent significant predictors.
Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery.
The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings.
In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI).
Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4–8.7) and 7.6 (6.6–8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.
The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital’s cardiac surgery pathway or applied in home care.
Ethnicity and gender may influence acute coronary syndrome patients recognizing symptoms and making the decision to seek care.
To examine these potential differences in European (Caucasian), Chinese and South Asian acute coronary syndrome patients.
In-depth interviews were conducted with 20 European (Caucasian: 10 men/10 women), 18 Chinese (10 men/eight women) and 19 South Asian (10 men/nine women) participants who were purposively sampled from those participating in a large cohort study focused on acute coronary syndrome. Analysis of transcribed interviews was undertaken using constant comparative methods.
Participants followed the process of: having symptoms; waiting/denying; justifying; disclosing/ discovering; acquiescing; taking action. The core category was ‘navigating the experience’. Certain elements of this process were in the forefront, depending on participants’ ethnicity and/or gender. For example, concerns regarding language barriers and being a burden to others varied by ethnicity. Women’s tendency to feel responsibility to their home and family negatively impacted the timeliness in their decisions to seek care. Men tended to disclose their symptoms to receive help, whereas women often waited for their symptoms to be discovered by others. Finally, the thinking that symptoms were ‘not-urgent’ or something over which they had no control and concern regarding potential costs to others were more prominent for Chinese and South Asian participants.
Ethnic- and gender-based differences suggest that education and support, regarding navigation of acute coronary syndrome and access to care, be specifically targeted to ethnic communities.
The four-item Control Attitudes Scale (CAS) was developed to measure control perceived by patients with cardiac disease and their family members, but extensive psychometric evaluation has not been performed.
The aim was to translate, culturally adapt and psychometrically evaluate the CAS in a Swedish sample of implantable cardioverter defibrillator (ICD) recipients, heart failure (HF) patients and their partners.
A sample (n=391) of ICD recipients, HF patients and partners were used. Descriptive statistics, item-total and inter-item correlations, exploratory factor analysis, ordinal regression modelling and Cronbach’s alpha were used to validate the CAS.
The findings from the factor analyses revealed that the CAS is a multidimensional scale including two factors, Control and Helplessness. The internal consistency was satisfactory for all scales (α=0.74–0.85), except the family version total scale (α=0.62). No differential item functioning was detected which implies that the CAS can be used to make invariant comparisons between groups of different age and sex.
The psychometric properties, together with the simple and short format of the CAS, make it to a useful tool for measuring perceived control among patients with cardiac diseases and their family members. When using the CAS, subscale scores should be preferred.
Depressive symptoms are prevalent in patients with chronic heart failure, but information about the relationship between depressive symptoms and dyspnea in chronic heart failure patients is limited.
To assess the prevalence and mutual association between depressive symptoms and dyspnea in Chinese patients with chronic heart failure.
A cross-sectional design was used in this study. One hundred and fifty-two patients with chronic heart failure (mean age 67 years, 57% female) were recruited from cardiovascular wards of hospitals. Depressive symptoms were measured with the Beck Depression Inventory, whereas dyspnea was evaluated with the Modified Pulmonary Functional Status and Dyspnea Questionnaire. Other data were obtained via patient interview and/or medical record review.
Out of 152 patients with chronic heart failure, 136 patients (89.5%) experienced dyspnea, whereas depressive symptoms were observed in 67 patients (44.1%). The transformed Beck Depression Inventory score correlated with dyspnea score positively (r = 0.54, p < 0.01). Multiple regression analysis revealed that gender, monthly income, body mass index, New York Heart Association class and dyspnea score contributed to depressive symptoms in Chinese patients with chronic heart failure. In addition, Beck Depression Inventory score and ejection fraction were identified as independent factors that contributed to dyspnea.
In Chinese patients with chronic heart failure, the prevalence for both depressive symptoms and dyspnea is high and depressive symptoms and dyspnea are related to each other. Our results implicate that managing depressive symptoms and dyspnea appropriately is of great importance to patients with chronic heart failure.
Heart valve replacement surgery is undertaken to improve cardiac function and health-related quality of life (HRQoL). Mechanical valves are typically used for younger people (aged <65 years). Implantation of these valves comes with life-long health self-management requirements which potentially impact on HRQoL.
The purpose of this study was to identify the short and long-term impact on HRQoL after mechanical valve replacement surgery.
Multiple electronic databases were searched for peer-reviewed studies published between 2000–2013, which focused on patients who had mechanical valve replacement, aged <65 years, and used a valid measure of HRQoL.
Eight papers were included, all of which used the Short-Form 36 Health Survey (SF-36). Preoperatively, HRQoL was impaired, particularly in the SF-36 health domains of role-physical, physical-functioning, vitality and role-emotional. Postoperatively, most people had positive and sustained HRQoL improvement. In the early postoperative period all data showed significant improvement in at least four of eight health domains (physical function, role-physical, vitality, social function). Two-thirds of people also had significant improvement in an additional two health domains (general and mental-health). Whilst most people sustained HRQoL over time, one-third of younger adults (age <24 years) showed impairment in three domains (physical-function, mental-health and general-health).
Mechanical valve replacement surgery results in important and sustained improvements in HRQoL. Future research should include investigation of HRQoL outcomes after mechanical valve replacement for specific groups such as younger adults and people in developing countries, and include evaluations of the potential impact of valve-specific factors and health self-management requirements.
Conventional treatment for patients with severe symptomatic aortic stenosis is surgical aortic valve replacement (SAVR), but transcatheter aortic valve implantation (TAVI) has become a reliable alternative in high-risk patients.
The aim of our study was to describe the post-operative patient response to TAVI on the evening of the procedure and the following day before discharge from the coronary care unit. A secondary aim was to compare responses of patients younger and older than 80 years of age.
A prospective, comparative observational study triangulating nurse assessment and structured interviews on a cohort of 54 Danish patients: 28/26 male/female, 26/28 younger/older than 80. Mean age in the younger/older group was 73/85 years.
After TAVI pain was experienced by 47 (87%) patients; 29 (62%) were restricted by pain, and 24 (44%) had discomfort at the femoral insertion site. Disturbed sleep/rest were reported by 34 (63%)/29 (55%) patients; nausea/vomiting by 14 (26%)/5 (9%) patients, restricting eating/drinking in 11 (21%)/8 (15%) patients. Sinus rhythm/atrial fibrillation/paced rhythm were observed in 35 (65%)/8 (15%)/21 (39%) patients; bleeding/haematoma/oozing from femoral insertion site in 23 (45%)/10 (19%)/23 (43%) patients.
Patients older than 80 years did as well as the younger patients in our study; the main complaints were post-operative pain and disrupted sleep. Our numbers are small, but most patients experienced considerable pain, predominantly continuous and at rest. We recommend the development of an evidence-based pathway to address the immediate post-operative issues in TAVI patients. Non-pharmacological interventions to prevent pain and promote sleep need to be explored.
Patients’ treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.
We reviewed the English-language literature from 1998–2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.
We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.
This study explores if nightly hypoxia (i.e. percentage of sleep time with oxygen saturation lower than 90% (SaO2<90%)) contributed to the association between sleep-disordered breathing (SDB) and insomnia in community-dwelling elderly with and without cardiovascular disease (CVD). A second aim was to explore a potential cut-off score for hypoxia to predict insomnia and the association of the cut-off with clinical characteristics and cardiovascular mortality.
A total of 331 community-dwelling elderly aged 71–87 years underwent one-night polygraphic recordings. The presence of insomnia was recorded by a self-report questionnaire. The presence of CVD was objectively established and mortality data were collected after three and six years.
In both patients with CVD (n=119) or without CVD (n=212) SDB was associated with hypoxia (p<0.005). Only in the patients with CVD was hypoxia associated with insomnia (p<0.001) which mediated an indirect effect (p<0.05) between SDB and insomnia. Hypoxia of more than 1.5% of sleep time with SaO2<90% was found to be a critical level for causing insomnia. According to this criterion 32% (n=39) and 26% (n=55) of those with and without CVD had hypoxia, respectively. These groups did not differ with respect to age, gender, body mass index, diabetes, hypertension, respiratory disease or levels of SDB. However, in the CVD group, hypoxia was associated with cardiovascular mortality at the three-year follow-up (p=0.008) and higher levels of insomnia (p=0.002).
In the elderly with CVD, SDB mediated by hypoxia can be associated with more insomnia and a worse prognosis.
Due to medical advances, most children with congenital heart disease (CHD) are expected to survive into adulthood. Establishing adequate physical self-concept and cardiopulmonary tolerance during the adolescent period can primarily enhance overall well-being.
The purpose of this study was to undertake a gender-specific evaluation of the domain of physical self-concept among adolescents with mild CHD, and to examine the relationships between physical self-concept and cardiopulmonary exercise tolerance among adolescents with mild CHD.
Four hundred and thirteen adolescents 12–20 years of age, whose cardiologists had not recommended any limitation of exercise, completed Physical Self-Description Questionnaires and three-minute step tests in two outpatient cardiology departments.
The male participants had significantly greater scores in measures of overall physical self-concept, competence in sports, physical appearance, body fat, physical activity, endurance, and strength than did the female participants. More than 80% of the participants had at least an average cardiopulmonary exercise tolerance index. The perception of not being ‘too fat’ and being more physically active were significant correlates of better cardiopulmonary exercise tolerance for adolescents with mild CHD.
The results provided evidence for gender-specific evaluation of domains of physical self-concept among adolescents with mild CHD. The three-minute step test to measure cardiopulmonary exercise tolerance in adolescents with mild CHD may be an appropriate objective measure for use in future research. Continued efforts are needed in early intervention to promote cardiopulmonary exercise tolerance.
The aim of this randomised clinical trial was to assess a comprehensive cardiac rehabilitation intervention including exercise training and psycho-education vs ‘treatment as usual’ in patients treated with an implantable cardioverter defibrillator (ICD).
In this study 196 patients with first time ICD implantation (mean age 57.2 (standard deviation (SD)=13.2); 79% men) were randomised (1:1) to comprehensive cardiac rehabilitation vs ‘treatment as usual’. Altogether 144 participants completed the 12 month follow-up. The intervention consisted of twelve weeks of exercise training and one year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes. Two primary outcomes, general health score (Short Form-36 (SF-36)) and peak oxygen uptake (VO2), were used. Post-hoc analyses included SF-36 and ICD therapy history.
Comprehensive cardiac rehabilitation significantly increased VO2 uptake after exercise training to 23.0 (95% confidence interval (CI) 20.9–22.7) vs 20.8 (95% CI 18.9–22.7) ml/min/kg in the control group (p=0.004 (multiplicity p=0.015)). Comprehensive cardiac rehabilitation significantly increased general health; at three months (mean 62.8 (95% CI 58.1–67.5) vs 64.4 (95% CI: 59.6–69.2)) points; at six months (mean 66.7 (95% CI 61.5–72.0) vs 61.9 (95% CI 56.1–67.7) points); and 12 months (mean 63.5 (95% CI 57.7–69.3) vs 62.1 (95% CI 56.2–68.0)) points (p <0.05). Explorative analyses showed a significant difference between groups in favour of the intervention group. No significant difference was seen in ICD therapy history.
Comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves VO2-uptake and general health. Furthermore, mental health seems improved. No significant difference was found in the number of ICD shocks or anti-tachycardia pacing therapy.
Patients with heart failure (HF) experience difficulty performing activities of daily living. As impaired functional status is adversely associated with outcomes, it is important to accurately evaluate patient functional status. The Duke Activity Status Index (DASI) is a 12-item, self-administered questionnaire to measure functional status. However, its psychometric properties have not been determined in patients with HF. The purpose of this study was to examine the psychometric properties of the DASI in patients with HF.
We used data from 297 patients with a diagnosis of HF (age 61±11 years, 31% female) for psychometric testing. Internal consistency reliability of the DASI was high (Cronbach’s alpha=0.86). Criterion-related validity was supported by significantly different DASI scores for each New York Heart Association classification. Construct validity was supported by significant correlation of DASI scores with health-related quality of life (r = –0.64), depressive symptoms (r = –0.44), and N-terminal B-type natriuretic peptide (r = –0.14).
Our data support the psychometric properties of the DASI as a measure of functional status in patients with HF. This instrument can be used to evaluate functional status and enhance health care provider understanding of functional status related to daily living from the patient perspective.
Medication non-adherence leads to a vast range of negative outcomes in patients with coronary artery disease. An automated web-based system managing short message service (SMS) reminders is a telemedicine approach to optimise adherence among patients who frequently forget to take their medications or miss the timing.
This paper sought to investigate the effect of automated SMS-based reminders on medication adherence in patients after hospital discharge following acute coronary syndrome (ACS).
An interventional study was conducted at a tertiary teaching hospital in Malaysia. A total of 62 patients with ACS were equally randomised to receive either automated SMS reminders before every intake of cardiac medications or only usual care within eight weeks after discharge. The primary outcome was adherence to cardiac medications. Secondary outcomes were the heart functional status, and ACS-related hospital readmission and death rates.
There was a higher medication adherence level in the intervention group rather than the usual care group, (2 (2)=18.614, p<0.001). The risk of being low adherent among the control group was 4.09 times greater than the intervention group (relative risk =4.09, 95% confidence interval (CI) 1.82–9.18). A meaningful difference was found in heart functional status between the two study groups with better results among patients who received SMS reminders, (2 (1) = 16.957, p<0.001).
An automated SMS-based reminder system can potentially enhance medication adherence in ACS patients during the early post-discharge period.
Sleep disturbances, including insomnia and sleep-disordered breathing, are a common complaint in people with heart failure and impair well-being. Exercise training (ET) improves quality of life in stable heart failure patients. ET also improves sleep quality in healthy older patients, but there are no previous intervention studies in heart failure patients.
The aim of this study was to examine the impact of ET on sleep quality in patients recently discharged from hospital with heart failure.
This was a sub-study of a multisite randomised controlled trial. Participants with a heart failure hospitalisation were randomised within six weeks of discharge to a 12-week disease management programme including exercise advice (n=52) or to the same programme with twice weekly structured ET (n=54). ET consisted of two one-hour supervised aerobic and resistance training sessions, prescribed and advanced by an exercise specialist. The primary outcome was change in Pittsburgh Sleep Quality Index (PSQI) between randomisation and week 12.
At randomisation, 45% of participants reported poor sleep (PSQI≥5). PSQI global score improved significantly more in the ET group than the control group (–1.5±3.7 vs 0.4±3.8, p=0.03). Improved sleep quality correlated with improved exercise capacity and reduced depressive symptoms, but not with changes in body mass index or resting heart rate.
Twelve weeks of twice-weekly supervised ET improved sleep quality in patients recently discharged from hospital with heart failure.
Stroke is the leading cause of disability in adults, and has a significant impact on individuals, families, and society. Returning home after a stroke represents a challenging experience for patients who struggle to adapt to their new life conditions. Although many studies have been conducted on stroke survivors, few studies have focused on the lived experience of patients at three months after they came home after rehabilitation.
The aim of this study was to describe the experience of stroke survivors three months after being discharged home from rehabilitation hospitals.
A phenomenological methodology was used to conduct the study. Participants were enrolled from rehabilitation hospitals in the cities of Rome and Naples. Interviews were conducted at the patients’ house and data were analysed with a phenomenological approach
Fifteen stroke survivors were interviewed (mean age 70 years; 12 males). Five themes emerged from the phenomenological analysis of the interviews and the field notes: deeply changed life, vivid memory of the acute phase of the stroke, slowed lives, relief after recovering from stroke, being a burden for family members.
The results of this study give an overview of the experience of stroke survivors three months after being discharged home. From a clinical perspective, health care providers need to provide more interventions to help survivors to cope better with life changes and encourage them to adapt to daily life limitations caused by stroke. Also, health care providers should improve support provided to family members of stroke patients.
The study assessed the effects of a counselling intervention on lifestyle changes in certain-aged people at risk of cardiovascular disease.
This was an intervention study at baseline and six- and 12-month follow-ups. The participants were 40 years old (n= 53 at baseline, n=33 at six months and n=34 at 12 months). The main outcomes were cardiovascular health parameters, such as weight, BMI, waist circumference, blood pressure, cholesterol (total, high density lipoprotein, low density lipoprotein), blood glucose, and self-assessed and reported lifestyle and adherence to lifestyle changes. The counselling intervention was Internet-based and carried out via Skype or face-to-face in small groups (on average, six participants).
There were statistically significant differences between the baseline and the 12-month follow-up with respect to the consumption of fat and snacks. Some positive cardiovascular health improvements were detected between baseline and six months, but not as clearly between baseline and 12 months. The participants reported having a healthier diet at 12 months than at baseline. At 12 months, BMI measurements indicated that all participants were overweight (mean BMI 29.8), but according to the self-assessed data, only 25% considered themselves to be so.
Changes in lifestyle were detected as a result of the intervention. These lifestyle changes may improve cardiovascular health in the long term. Discrepancies were found between the measured indicators of cardiovascular health and information obtained from questionnaires and diary records. In order to achieve sustainable lifestyle changes, long-term support is required.
The purpose of this study was to assess whether changes in self-rated physical activity and diet during a type 2 diabetes (T2D) prevention program were associated with changes in estimated 10-year risk for cardiovascular disease (CVD) events and mortality in people at high risk for T2D.
Individuals were identified and offered lifestyle counseling as part of the Finnish diabetes prevention program. Ten-year risk for estimated CVD events and mortality were calculated with Framingham Risk Score (FRS) and Systematic Coronary Risk Evaluation (SCORE) formula. FRS was available for 774 men and 1474 women and SCORE for 961 men and 1766 women.
During the one-year follow-up, 9.6% of the men reported both an increase in physical activity and improved dietary pattern, 4.1% an increase in physical activity, 39.3% an increase in improved dietary pattern, while 47.0% reported no lifestyle changes. Corresponding numbers for women were 14.2%, 3.8%, 39.2% and 42.7%. Estimated 10-year risk for CVD events decreased 3.5% in men and 1.5% in women reporting an increase in physical activity and improvement in diet, compared to an increase of 0.15% in men (p<0.001, between groups) and decrease of 0.43% (p=0.027, between groups) in women with no lifestyle changes after adjustment for age and baseline FRS. Numbers needed to treat to prevent one CVD event by lifestyle changes were 25 for men and 59 for women. Lifestyle changes had no effect on estimated CVD mortality risk.
Lifestyle counseling offered in primary health care for one year results in favorable changes in lifestyle, and lowered the estimated 10-year risk for CVD events.
The aim of our study was to compare Euroqol-5D (EQ-5D) outcomes in coronary heart disease (CHD) patients with those from the general population. We aimed to identify those dimensions which were mostly impaired.
EQ-5D results (both the dimensions and the EQ-5D visual analogue scale (EQ-VAS)) from a European sample (11 countries) of coronary patients were compared with published age- and gender-specific normative data.
EQ-5D outcomes differed across countries and gender. Overall, the age-adjusted EQ-VAS scores were significantly lower in coronary patients compared with the general population, both in males (mean difference (MD)= –5.24(–7.59 to –2.88)) and in females (MD= –8.32 (–11.69 to –4.95)). Coronary patients had a significantly higher risk to report moderate or severe problems related to anxiety/depression (odds ratio (OR) male=1.84 (1.14–2.95); OR female=3.20 (2.32–4.40)). Furthermore, female coronary patients reported more problems on the mobility (OR=2.00 (1.38–2.90)), usual activity (OR= 2.54 (1.81–3.57)) and pain/discomfort dimension (OR=1.73 (1.23–2.43)) whereas in males, a borderline significant OR was found on the mobility (OR=1.43 (0.97–2.11)) and usual activity dimension (OR=1.44 (0.94–2.20)). The difference between the general population and the CHD patients attenuated as age increased.
CHD has a negative influence on patient’s self-reported health status, both the EQ-VAS as well as the EQ-5D dimensions (with the exception of self-care in both genders and pain/discomfort in males) were impaired. The relative impairment was the greatest in female patients and the differences in the proportion of reported problems diminished with increasing age. The EQ-5D instrument is appropriate in capturing problems related to anxiety/depression, pain/discomfort, mobility and usual activities. Within clinical practice, particular attention should be given to females and younger CHD patients.
Health-related quality of life (HRQOL) is as important as survival to patients with heart failure (HF). Perceptions of loss of control are common in HF and negatively affect HRQOL. Knowledge of modifiable factors associated with perceived control could guide the development of interventions to improve perceived control and thus HRQOL. Accordingly, this study examined factors related to perceived control and the relationship between perceived control and HRQOL.
Patients (N=232, mean age 61±12, 67% male, 78% Caucasian) provided data on HRQOL (Minnesota Living with Heart Failure questionnaire), perceived control (Control Attitudes Scale-Revised), and factors possibly associated with perceived control (knowledge and barriers (Heart Failure Knowledge and Barriers to Adherence Scale), attitudes (Dietary Sodium Restriction Questionnaire), and social support (Multidimensional Scale of Perceived Social Support)). Patients also provided data on depressive symptoms, which were a covariate of HRQOL. Hierarchical multiple regression analysis was used to analyze the data.
Fewer barriers to following a low sodium diet, more positive attitudes toward following a low sodium diet, and better social support were related to higher perceived control (F=7.54, R2=0.17, p<0.001). Perceived control was independently associated with HRQOL, controlling for depressive symptoms, New York Heart Association functional class, age, gender, and all variables possibly associated with perceived control (F=29.67, R2=0.55, p<0.001).
Interventions targeting attitudes and barriers to a low sodium diet and social support may improve perceived control and, in turn, HRQOL.
Self-care improves outcomes in patients with heart failure; however, no studies have been conducted on this topic in Italy.
We aimed to describe self-care in Italian adults with heart failure and to identify sociodemographic and clinical determinants of self-care.
A cross-sectional design was used to study 1192 heart failure patients enrolled across Italy. We measured self-care using the Self-Care of Heart Failure Index version 6.2, which measures self-care maintenance, management and confidence. Sociodemographic and clinical data were tested as potential determinants of self-care.
The mean age of the sample was 72 (SD = 11) years; 58% were male. In the three areas of self-care, scores ranged from 53.18 to 55.26 and few people were adequate in self-care (14.5% to 24.4% of the sample). Self-care behaviours particularly low in this population were symptom monitoring, exercise, use of reminders to take medicines and symptom recognition. Confidence in the ability to keep oneself free of symptoms and relieve symptoms was low. Taking fewer medications, poor cognition, older age, having a caregiver, being male and having heart failure for a shorter time predicted poor self-care maintenance. Poor cognition, not being employed, being male, and having worse New York Heart Association class predicted poor self-care management. Poor cognition, taking fewer mediations, older age, and male gender predicted poor self-care confidence.
Self-care is poor in Italian heart failure patients. Determinants of poor self-care identified in this study can help to target patients’ education. Male gender and poor cognition were consistently associated with poor self-care maintenance, management and confidence.
With typically fewer than 35% of eligible patients attending outpatient cardiac rehabilitation (CR), more accessible provision is required. Community-based cardiac rehabilitation is one option but its effects need to be compared with those of hospital-based CR.
The purpose of this study was to compare changes in health-related quality of life (HRQOL), anxiety and depression, and exercise and smoking rates, between attendees at community-based and hospital-based CR programmes.
A prospective comparative cohort design was used. Consecutive patients admitted to Aberdeen Royal Infirmary and eligible for CR were recruited and followed up by self-report questionnaire. Outcomes were health status (RAND-36), Hospital Anxiety and Depression Scale (HADS), Godin Leisure-Time Exercise and smoking status.
There were 136 of 179 (75%) attenders at community-based CR, compared to 169 of 209 (80%) at hospital-based CR (p=0.242). In univariate analysis, there were no significant differences between the two groups in health status, HADS, and frequency or intensity of exercise immediately after the CR programme or six months later. Adjusting for other significant factors, patients who attended community CR reported higher RAND-36 energy scores at six months compared with attenders at hospital CR (p=0.020), but were less likely to undertake frequent exercise (p=0.041).
Community-based CR appears to achieve similar attendance rates and effects on health status and health behaviour as hospital-based CR. This option might help overcome the poor attendance of patients with long travelling times to hospital-based CR.
The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients’ self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care?
MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords ‘careers’, ‘family members’ and ‘lay persons’ for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients–either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted.
Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients’ self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs’ activities on patients’ self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research.
To our knowledge, this is the first systematic review to examine CGs’ contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs’ contributions on patient self-care outcomes.
Ambulatory blood pressure monitoring (ABPM) was implemented in our primary care setting four years ago. Since then, 450 ABPMs have been performed and 69 riser subjects identified. The riser pattern is an independent risk factor for both incidence of cardiovascular events and their associated mortality.
The purpose of this study was to assess the amount of control of essential hypertension (EH) among riser patients and to evaluate how our health professionals manage therapeutic changes in riser individuals.
This retrospective study involved 34,289 inhabitants served in a centre in the Barcelona metropolitan area. EH individuals (450) were recruited and ABPM was performed following guidelines of the MAPAPRES (www.cardiorisc.com/MP/index_MP.asp).
Good control of blood pressure was observed in 46% of dipper and non-dipper subjects but only 35% of riser subjects had blood pressures within good control ranges. The measured cardiovascular risk was either high or very high in 35% of riser individuals. Changes in medication were introduced in riser patients with both good and poor blood pressure control. A second follow-up ABPM was done in only 27% of the riser individuals. In these subjects, therapeutic changes successfully modified ABPM patterns in 87% of cases.
Therapeutic changes in riser patients were introduced when these subjects were poorly controlled and these changes were highly effective. Additional ABPM to confirm the effectiveness of therapeutic changes was only performed in some individuals. Thus, for management of riser patients, more specific training of health professionals is needed.
Patients with heart failure (HF) vary in their ability to respond to symptoms when they occur. The goal of this study was to classify common patterns of symptom response behaviors among adults with HF and identify biobehavioral determinants thereof.
Consulting behaviors (i.e. contacting a provider for guidance) were measured using the European Heart Failure Self-care Behavior Scale consulting behaviors subscale, and self-care management (i.e. recognizing and engaging in self-initiated treatment of symptoms) was measured with the Self-Care of HF Index self-care management scale in a prospective cohort study. Latent class mixture modeling was used to identify distinct profiles of consulting and of self-care management behaviors.
The mean age (n=146) was 57±13 years, 30% were female, and 59% had class III/IV HF. Two distinct profiles of consulting behaviors (novice and expert) and three distinct profiles of self-care management (novice, inconsistent and expert) were identified. There was a weak association between profiles of consulting behaviors and self-care management (Kendall’s tau-b=0.211). Higher levels of anxiety were associated with worse consulting behaviors (β=1.67±0.60) and worse self-care management (β= –5.82±3.12) and lower odds of exhibiting expert level consulting behaviors (odds ratio (OR)=0.50; 95% confidence interval (CI)=0.26–0.95) and self-care management (OR=0.47; 95% CI=0.24–0.92) (all p<0.05). Higher levels of physical symptoms were associated with better self-care management (β=0.50±0.12; OR =1.02, 95% CI=1.00–1.05; both p<0.05).
Expertise in consulting behaviors does not necessarily confer expertise in symptom self-care management and vice versa. Physical and psychological symptoms are strong determinants of symptom response behaviors.
Despite a growing recognition that a strict low sodium diet may not be warranted in compensated heart failure (HF) patients, the link between sodium restriction below 2 g/day and health outcomes is unknown in patients at different levels of HF severity.
The purpose of this study was to compare differences in event-free survival among patients with <2 g/day, 2–3 g/day, or >3 g/day sodium intake stratified by New York Heart Association (NYHA) class.
A total of 244 patients with HF completed a four-day food diary to measure daily sodium intake. All-cause hospitalization or death for a median of 365 follow-up days and covariates on age, gender, etiology, body mass index, NYHA class, ejection fraction, total comorbidity score, the presence of ankle edema, and prescribed medications were determined by patient interview and medical record review. Hierarchical Cox hazard regression was used to address the purpose.
In NYHA class I/II (n=134), patients with <2 g/day sodium intake had a 3.7-times higher risk (p=0.025), while patients with >3 g/day sodium intake had a 0.4-times lower risk (p=0.047) for hospitalization or death than those with 2–3 g/day sodium intake after controlling for covariates. In NYHA class III/IV (n=110), >3 g/day sodium intake predicted shorter event-free survival (p=0.044), whereas there was no difference in survival curves between patients with <2 g/day and those with 2–3 g/day sodium intake.
Sodium restriction below 2 g/day is not warranted in mild HF patients, whereas excessive sodium intake above 3 g/day may be harmful in moderate to severe HF patients.
A low-sodium diet is a core component of heart failure self-care but patients have difficulty following the diet.
The aim of this study was to identify predictors of higher than recommended sodium excretion among patients with heart failure.
The World Health Organization Five Dimensions of Adherence model was used to guide analysis of existing data collected from a prospective, longitudinal study of 280 community-dwelling adults with previously or currently symptomatic heart failure. Sodium excretion was measured objectively using 24-hour urine sodium measured at three time points over six months. A mixed effect logistic model identified predictors of higher than recommended sodium excretion.
The adjusted odds of higher sodium excretion were 2.90, (95% confidence interval (CI): 1.15–4.25, p<0.001) for patients who were obese; 2.80 (95% CI: 1.33–5.89, p=0.007) for patients with diabetes; and 2.22 (95% CI: 1.09–4.53, p=0.028) for patients who were cognitively intact.
Three factors were associated with excess sodium excretion and two factors, obesity and diabetes, are modifiable by changing dietary food patterns.
Addressing sexual concerns of cardiac patients is integral to comprehensive patient-centered nursing care, and instruments for use across cardiac populations are needed to promote this activity. Knowing the factors that contribute to sexual concerns provides insights that help to promote inclusion of assessment of relevant sexual activity and provide sexual counseling as a standard of care.
This study examined demographic factors, comorbid conditions, and sexual activities as predictive of sexual concerns. Specific sexual activities and demographic variables were also examined for their relation to sexual concerns.
This study was a sub-analysis of a cross-sectional observational study testing a regression model of factors that predicted sexual concerns in a broad sample of cardiac patients in the United States, using a self-report survey method.
More comorbidities and types of sexual activities contributed to greater sexual concerns reported by respondents. Sexual activities resulting in overall sexual concerns included hugging/kissing, oral sex, and finger penetration. Non-Whites reported more sexual concerns, sexual fears, and symptoms related to sexual activity. Those who were not working/retired from employment reported significantly more sexual concerns and dysfunction, whereas, those who had a smoking/tobacco use history reported more sexual concerns, symptoms, and dysfunction.
This study underscores that cardiac patients across a variety of diagnoses and comorbidities often experience sexual concerns, fears, symptoms, and dysfunction. The strongest predictors of sexual concerns were the number of cardiac and noncardiac comorbidities, thus illustrating the importance of a thorough assessment of these factors when examining sexual concerns of cardiac patients.
Nurses represent the largest sector of the workforce caring for people with cardiovascular disease in Europe. Little is known about the post-registration education provided to nurses working within this specialty. The aim of this descriptive cross sectional survey was to describe the structure, content, teaching, learning, assessment and evaluation methods used in post-registration cardiovascular nurse education programmes in Europe.
A 24-item researcher generated electronic questionnaire was sent to nurse representatives from 23 European countries. Items included questions about cardiovascular registered nurse education programmes.
Forty-nine respondents from 17 European countries completed questionnaires. Respondents were typically female (74%) and educated at Masters (50%) or doctoral (39%) level. Fifty-one percent of the cardiovascular nursing education programmes were offered by universities either at bachelor or masters level. The most frequently reported programme content included cardiac arrhythmias (93%), heart failure (85%) and ischaemic heart disease (83%). The most common teaching mode was face-to-face lectures (85%) and/or seminars (77%). A variety of assessment methods were used with an exam or knowledge test being the most frequent. Programme evaluation was typically conducted through student feedback (95%).
There is variability in the content, teaching, learning and evaluation methods in post-registration cardiovascular nurse education programmes in Europe. Cardiovascular nurse education would be strengthened with a stronger focus upon content that reflects current health challenges faced in Europe. A broader view of cardiovascular disease to include stroke and peripheral vascular disease is recommended with greater emphasis on prevention, rehabilitation and the impact of health inequalities.
Left ventricular assist device (LVAD) therapy is increasingly used in patients with advanced heart failure, and may have a significant psychological impact on both patients and their partners. Hence, we examined the distress levels of LVAD patients and their partners.
Anxiety, depression and post-traumatic stress disorder (PTSD) were assessed at 3–4 weeks after implantation, and at 3 and 6 months follow-up in 33 LVAD patients (73% men; mean age=54±10 years) and 33 partners (27% men; mean age=54±11 years).
The prevalence of anxiety in LVAD partners was significantly higher compared to LVAD patients at baseline (48% vs. 23%, p=0.03) and 3 months follow-up (44% vs. 15%, p=0.02), but not at 6 months follow-up (p=0.43). No differences were found for depression and PTSD (ps>0.05). Scores between the LVAD patients and partners showed only a significant correlation at baseline between the anxiety, depression and PTSD score of the patient and the depression score of the partner (ranx=0.40, p=0.04; rdep=.40, p=0.04; rPSTD=0.46, p=0.05). Multivariable analyses showed no significant association between the role (patient vs. partner) and anxiety, depression and PTSD over time after correction for age, gender and clinical covariates. However, after correction for Type D personality and the use of psychotropic medication the LVAD partners showed significantly higher anxiety (F=6.95, p=0.01) and depression (F=3.94, p=0.04) scores over time compared to LVAD patients.
LVAD partners had significantly higher levels of anxiety than LVAD patients. Emotional distress of LVAD partners should gain more attention, as partners are an essential source of support for LVAD patients.
In patients undergoing coronary angiography or percutaneous coronary intervention (PCI), the standard post procedure regime includes immobilization and bed rest despite the use of vascular closure devices.
In the Mobilization after Coronary Angiography or Percutaneous Coronary Intervention (MOBS) study we compared bleeding complications after cardiac catheterization with femoral artery access after mobilization immediately off the angiographic table or standard care with1 hour (MOBS I after a diagnostic angiogram) or 2 hours of bed rest before mobilization (MOBS II after PCI).
Bleeding complications were defined as major (requiring surgery of the femoral artery, transfusion or increased hospital stay) and minor (hematoma <5x5 cm2, oozing from the puncture site or minor bleeding that could be compressed manually).
In the MOBS I cohort (100 patients were mobilized immediately and 100 patients followed standard care) no major bleeding complications were seen. In the immediate mobilization group 2.0% experienced minor bleeding compared to 4.0% in the standard care group (p=0.41). In the MOBS II cohort after PCI (158 patients were mobilized immediately and 161 patients followed standard care), major bleeding complication rates did not differ significantly between the two groups: immediate mobilization group 26.6% vs. standard care group 28.0%, p=0.78. The majority of bleeding complications were due to oozing: immediate mobilization group 22.8% vs. standard care group 20.5%, p=0.62.
Immediate mobilization after a coronary angiogram or PCI with the femoral access site closed by the closure device AngioSeal was not associated with increased bleeding risk compared to standard care with bed rest.
The use of fitness testing for the identification of women at high-risk of metabolic syndrome (MS), and therefore of cardiovascular disease, is clinically relevant.
The purpose of this study was to determine the ability of a set of physical fitness tests to establish the risk of MS in perimenopausal Moroccan women.
The study comprised 151 women (45–65 years) from the North of Morocco. We used standardized field-based fitness tests to assess cardiorespiratory fitness, muscular strength, flexibility and balance. Fatness was assessed by impedanciometry and anthropometry. We also measured resting heart rate, blood pressure and plasma fasting glucose, total cholesterol, low density lipoprotein (LDL)-cholesterol, high density lipoprotein (HDL)-cholesterol and triglycerides.
Women with MS performed worse in most of the fitness tests studied. Among the fitness test studied, the six-minute walk test was the most associated to MS. Receiver operating characteristics curve analyses revealed that the six-minute walk test threshold that best discriminated between the presence and absence of MS was 480.5 m (area under curve (AUC): 0.719, 95% confidence interval (CI): 0.62–0.82; p<0.001). Logistic regression after adjustment for age and weight showed that a distance ≤480 m is associated with 2.9 times higher risk (95% CI: 1.56–7.65; p<0.05) for having MS.
Including cardiorespiratory fitness as a MS risk factor may improve early identification of at-risk Moroccan women. Fitness testing provides useful information and is cheap, easy to perform, and not time-consuming, which makes its use in this specific clinical settings feasible.
In-hospital telemetry monitoring is important for diagnosis and treatment of patients at risk of developing life-threatening arrhythmias. It is widely used in critical and non-critical care wards. Nurses are responsible for correct electrode placement, thus ensuring optimal quality of the monitoring. The aims of this study were to determine whether a complex educational intervention improves (a) optimal electrode placement, (b) hygiene, and (c) delivery of critical information to patients (reason for monitoring, limitations in cellular phone use, and not to leave the ward without informing a member of staff).
A prospective interventional study design was used, with data collection occurring over two six-week periods: before implementation of the intervention (n=201) and after the intervention (n=165). Standard abstraction forms were used to obtain data on patients’ clinical characteristics, and 10 variables related to electrode placement and attachment, hygiene and delivery of critical information.
At pre-intervention registration, 26% of the electrodes were misplaced. Twelve per cent of the patients received information about limiting their cellular phone use while monitored, 70% were informed of the purpose of monitoring, and 71% used a protective cover for their unit. Post-intervention, outcome measures for the three variables improved significantly: use of protective cover (p<0.001), information about the purpose of monitoring (p=0.005) and information about limitations in cellular phone use (p=0.003). Nonetheless, 23% of the electrodes were still misplaced.
The study highlights the need for better, continued education for in-hospital telemetry monitoring in coronary care units, and other units that monitor patients with telemetry.
Breathlessness is a cardinal symptom of pulmonary arterial hypertension (PAH); yet no breathlessness instrument has been previously tested for reliability and validity for this population. Using a cross-sectional design, we tested the psychometric properties of the Dyspnoea-12 (D-12), for the assessment of breathlessness in PAH. Pearson’s correlations with World Health Organization functional class (WHO FC), Minnesota Living with Heart failure – pulmonary hypertension modified version (MLHF-PH), Hospital Anxiety and Depression scale (HADS) and 6-minute walk distance test (6MWD) were conducted. Participants (n = 176) were mostly female (70.5%), mean age 54.3±14 years; diagnosed with idiopathic PAH (48.9%), congenital heart disease (27.8%) and connective tissue disease (23.3%); and most were WHO FC II (32.4%) and III (52.3%). The D-12 showed excellent internal consistency for the total and two-component scores for physical and emotional (Cronbach’s α 0.95, 0.93 and 0.94, respectively). D-12 total score was significantly associated with MLHF-PH (r = 0.70), HADS (anxiety r = 0.54 and depression r = 0.68), WHO FC (r = 0.49), and 6MWD (r = -0.26). In patients with PAH, the D-12 - a short patient reported measure of breathlessness severity that taps the physical and emotional components, is a reliable and valid instrument.
Cardiovascular disease is a leading cause of death worldwide and genetic risk factors play a role in nearly all such cases. In the UK, health service capacity to meet either current or future estimated needs of people affected by inherited cardiac conditions (ICCs) is inadequate. In 2008 the British Heart Foundation funded nine three-year Cardiac Genetics Nurse (CGN) posts across England and Wales to enhance ICC services. The CGNs were experienced cardiac nurses who had additional training in genetics and acted to coordinate cardiac and genetics service activities.
To create and apply a framework against which progress in ICC service improvement could be measured over time following the CGN appointments.
A performance grid (Maturity Matrix, MM) articulating standards in five domains against stages of ICC service development was created by stakeholders through a consensus approach. The MM was used to guide staged self-assessments by the CGNs between 2009 and 2011. A six-point scale was used to locate progress from ‘emerging’ to ‘established’, represented graphically by spider diagrams.
Progress in all domains was significant for new, emerging and established services. It was most notable for effective utilisation of care pathways and efficient running of clinics. Commitment to family-centred care was evident.
The ICC-MM provided a comprehensive framework for assessing ICC services and has merit in providing guidance on development. CGNs can help integrate care across specialisms, facilitating the development of effective and sustainable ICC services at new, developing, and more established ICC service locations.
Physical activity can improve exercise capacity, quality of life and reduce mortality and hospitalization in patients with heart failure (HF). Adherence to exercise recommendations in patients with HF is low. The use of exercise games (exergames) might be a way to encourage patients with HF to exercise especially those who may be reluctant to more traditional forms of exercise. No studies have been conducted on patients with HF and exergames.
This scoping review focuses on the feasibility and influence of exergames on physical activity in older adults, aiming to target certain characteristics that are important for patients with HF to become more physically active.
A literature search was undertaken in August 2012 in the databases PsychInfo, PUBMED, Scopus, Web of Science and CINAHL. Included studies evaluated the influence of exergaming on physical activity in older adults. Articles were excluded if they focused on rehabilitation of specific limbs, improving specific tasks or describing no intervention. Fifty articles were found, 11 were included in the analysis.
Exergaming was described as safe and feasible, and resulted in more energy expenditure compared to rest. Participants experienced improved balance and reported improved cognitive function after exergaming. Participants enjoyed playing the exergames, their depressive symptoms decreased, and they reported improved quality of life and empowerment. Exergames made them feel more connected with their family members, especially their grandchildren.
Although this research field is small and under development, exergaming might be promising in order to enhance physical activity in patients with HF. However, further testing is needed.
In older patients undergoing elective cardiac surgery, the timely identification and preparation of patients at risk for frequent postoperative hospital complications provide opportunities to reduce the risk of these complications.
We developed an evidence-based, multi-component nursing intervention (Prevention of Decline in Older Cardiac Surgery Patients; the PREDOCS programme) for application in the preadmission period to improve patients’ physical and psychosocial condition to reduce their risk of postoperative complications. This paper describes in detail the process used to design and develop this multi-component intervention.
In a team of researchers, experts, cardiac surgeons, registered cardiac surgery nurses, and patients, the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed, including identifying existing evidence, identifying and developing theory and modelling the process and outcomes. Additionally, the criteria for reporting the development of complex interventions in healthcare (CReDECI) were followed.
The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients, a second part in which patients with an increased risk are identified, and a third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk.
Following the MRC guidelines, an extended, stepwise, multi-method procedure was used to develop the multi-component nursing intervention to prepare older patients for cardiac surgery, creating transparency in the assumed working mechanisms. Additionally, a detailed description of the intervention is provided.
Self-care is important for heart failure (HF) management and may be influenced by the patient’s educational level.
We assessed the relationship of educational level with baseline self-care behaviour and changes one year after a nursing intervention in HF outpatients attending a HF unit.
Three hundred and thirty-five HF patients were studied, with a median age of 67 years (P25–75 57–75) and a median HF duration of six months (P25–75 1–36). HF aetiology was mainly ischaemic heart disease (53.4%). Median ejection fraction was 30% (P25–75 24–37%). The functional class was mainly II (66.3%) and III (25.7%). Educational levels were: very low 17.3%; low 62.1%; medium–high 20.6%. Patients were evaluated at the first visit (baseline) and one year after the educational intervention with the nine-item European Heart Failure Self-care Behaviour Scale.
Median patient scores differed in the baseline (19 (P25–75 15–26) vs. 16 (P25–75 13–21) vs. 15 (P25–75 12.5–15.5)) and the one-year evaluation (15 (P25–75 13–17) vs. 13 (P25–75 11–15) vs. 12 (P25–75 10–14)) for the three educational levels, respectively, with statistically significant differences between levels (p=0.007 to p<0.001) except between low and medium-high education at one year (p=0.057). In the one-year evaluation, self-care behaviour significantly improved in the three educational groups (p<0.001), with a similar, albeit not statistically significant, magnitude of improvement in all groups.
Self-care behaviour at baseline and one year after a nursing intervention was better in patients with a higher education, although the improvement with the intervention was similar irrespective of the educational level.
A systematic method of symptom assessment in patients with acute coronary syndromes is important for disease recognition and initiation of early treatment. However, such assessment in Chinese people is hindered by the lack of a psychometrically sound instrument.
To develop the Chinese version of the Symptoms of Acute Coronary Syndromes Inventory (SACSI-C) and to evaluate its psychometric properties for Chinese patients.
SACSI was translated from English into Chinese according to Brislin’s model. Its content validity and face validity were evaluated. A sample of 114 acute coronary syndromes patients was recruited from the cardiac units of two hospitals in Hong Kong. The reliability was assessed by one-day test-retest reliability. The known-groups validity was evaluated by its ability to differentiate patients with typical versus atypical symptom presentation in older (≥75 years) and younger (<75 years) groups.
The Item-Content Validity Index of the SACSI-C was computed as 0.88–1.00. The Scale-Content Validity Index was computed as 0.99. The intraclass correlation coefficients of all items of the symptom subscale were above 0.75, except for item 16. The kappa values of all items in the symptom location and quality subscales were above 0.663. The test-retest reliability was good. The known-groups validity was evident, as demonstrated by the results of Chi-square test (p=0.007) and logistic regression analysis (odds ratio=2.9, p=0.039), showing that older patients were significantly more likely to have atypical symptom presentation.
The psychometric properties of the SACSI-C are satisfactory and could be used to assess acute coronary syndromes symptomatology in Chinese.
Pre-hospital delay has a significant impact on patients’ mortality and morbidity in ST segment elevation myocardial infarction (STEMI). Internationally many factors including female gender have been implicated, but no research has been conducted in Arab cultures. We aimed to explore the factors contributing to pre-hospital delay among female STEMI patients in Saudi Arabia.
This sequential, explanatory mixed methods study comprised a consecutive sample of 311 patients, presenting with STEMI to three hospitals in Riyadh, from March 2011–August 2011. Of these, 189 patients (36 females) were eligible and interviewed using the Response to Symptoms Questionnaire. A purposive sample of 18 patients (9 females) then participated in qualitative interviews that were taped and transcribed prior to thematic analysis.
The median pre-hospital delay for males was 5 h and 12.9 h for females (p<0.002). Standard multiple regression determined female gender as the strongest predictor of transfer delay–from decision to seek help to hospital arrival. Qualitative analysis produced five gender-related themes: (a) women require a male relative’s permission to seek medical help; (b) women cannot travel to hospital unless accompanied by a male relative; (c) women prioritise family responsibilities over seeking help; (d) women lack knowledge of myocardial infarction (MI) symptoms and treatment; and (e) perception that women should not attract attention.
This study provides new insight into how cultural factors increase pre-hospital delay for women within Saudi Arabia. While the quantitative data demonstrates that women experience much longer delays, the qualitative interviews confirm that cultural factors are implicated. Further research is urgently required.
Over the last two decades the UK health service has endeavoured to place patient and public involvement at the heart of its modernisation agenda. Despite these aspirations the role of patients in the development of nursing curricula remains limited.
A descriptive qualitative design was used to explore the views of cardiac patients about the educational preparation of cardiac nurses.
Eight participants attending an annual conference of a patient and carer support group were recruited to the study. A focus group was conducted to explore their views on how the educational preparation of cardiac nurses in the UK should develop. Tape-recorded data were transcribed and a thematic analysis was undertaken.
Four themes were identified: contradictions around practice and education; demonstrating compassion; delivering rehabilitation expertise; leadership in practice. Participants perceived that they had a valuable role in the educational development of nurses, enhancing nurses’ understanding of how individuals live and adjust to living with cardiovascular disease.
Cardiac patients believe that the education of cardiac nurses should be driven by experiences in practice, nevertheless they want nurses to be equipped to deliver care that is underpinned by a strong knowledge base and skills combined with an ability to engage, educate and deliver high quality care that is both compassionate and individualised.
Inflammation may be a link between depressive symptoms and outcomes in patients with heart failure. It is not clear whether inflammatory markers are independently related to depressive symptoms in this population.
To determine which inflammatory biomarkers are independently associated with depressive symptoms in heart failure.
We analyzed data from 428 outpatients enrolled in a heart failure registry (32% female, 61 ± 12 years, 48% New York Heart Association Class III/IV). Depressive symptoms were measured with the Beck Depression Inventory-II. Serum C-reactive protein (CRP), cytokines (interleukin 1 receptor antagonist, 2, 4, 6, 8, 10), tumor necrosis alpha, and soluble receptors sTNFR1 and sTNFR2 were measured with enzyme immunoassay. Multiple regressions were used to determine which biomarkers were associated with depressive symptoms controlling for demographics, heart failure severity, and clinical variables. Twenty-seven percent (n = 119) had depressive symptoms. CRP was related to depressive symptoms after controlling for age and gender, but no inflammatory biomarkers were associated with depressive symptoms after controlling for all variables in the model.
There was no relationship between inflammatory biomarkers and depressive symptoms. Our findings, in combination with prior researchers’, suggest there is not a robust relationship between depressive symptoms and individual biomarkers of inflammation in heart failure.
Nurse-led interventions have proven beneficial to reduce estimated cardiovascular risk.
The purpose of this study was to evaluate the effect of systematic, nurse-led individual lifestyle counseling sessions on the reduction of 10-year cardiovascular risk scores in patients with coronary artery disease (CAD).
This was a randomized clinical trial of CAD patients treated at a tertiary referral hospital. The intervention group received nurse-led guidance by means of five face-to-face sessions and telephone contact over the course of one year, starting three months after hospital discharge. Exercise and dietary goals were set for each patient and monitored at each session. The control group received standard medical advice. Patients were stratified by Framingham risk score and compared at the end of the follow-up period.
The final sample comprised 74 patients, 38 in the intervention group and 36 in the control group. Mean age was 58±9 years; 74% of patients were male. A 1.7 point (–13.6%) reduction in risk score was recorded in the intervention group, vs a 1.2 point increase in risk score (+11%) in the control group (p=0.011). Significant between-group differences were detected for weight (intervention, 78±14 kg at baseline vs 77±14 kg at study end; control, 78±15 kg vs 79±15 kg; p=0.04), systolic blood pressure (intervention, 136±22 mm Hg vs 124±15 mm Hg; control, 126±15 mm Hg vs 129±16 mm Hg; p=0.005), and diastolic blood pressure (intervention, 82±10 mm Hg vs 77±09 mm Hg; control, 79±09 mm Hg vs 80±10 mm Hg; p=0.02).
Structured and systematic nurse-led lifestyle counseling effectively reduced cardiovascular risk score.
Sudden cardiac arrest (SCA) is an event that has tremendous impact on the physical, cognitive and emotional well-being of individuals. Clinical experience and results of various studies indicate that survivors, in addition to having problems related to the underlying disease, have unique needs as a result of the cardiac arrest.
The main purpose of this study was to describe survivors’ experiences following SCA and resuscitation in order to gain knowledge of the effect of this experience on the needs and concerns of the survivors.
This qualitative study draws on interpretive phenomenology. The sample was purposive and data were generated through two semi-structured interviews.
Seven men aged 50 to 54 years participated. Participants’ experience is reflected in the following themes: feelings of insecurity and the need for support; striving to regain former life; emotional challenges; responding to symptoms; and a new view on life.
The findings illustrate complex effects of the cardiac arrest on the survivor’s life. Support after hospital discharge needs to be organized in a more structured fashion. The need for security and support was fundamental and should be addressed with continuity and vigilance in health care.
The use of endovascular aneurysm repair (EVAR) as a treatment for abdominal aortic aneurysm (AAA) has started to become popular in Taiwan. Quality of life is considered an indicator of clinical outcome, and self-management and health literacy have been identified as significant contributors to quality of life. However, the research on these three variables, and relationships among them in AAA patients who have undergone EVAR, is limited.
The purpose of this study is to examine the relationship between self-management, health literacy and quality of life in AAA patients who have undergone EVAR in Taiwan.
This study uses a cross-sectional design with convenience sampling. A total of 105 patients were sampled in the outpatient clinic when they returned for a follow-up visit to a veterans’ general hospital in Taiwan between May 2011 and June 2012. Four questionnaires (demographic, self-management, health literacy, quality of life) were used to collect data. Regarding the relationship among these variables, Pearson correlations and hierarchical logistic regression were used to analyze the relationship.
Self-management has a 73% mediation effect and an indirect effect of 13.51 on the relationship between health literacy and quality of life, while education and exercise habit has a 57% mediation effect and an indirect effect of 6.20 on this same relationship.
These findings can be used to identify specific populations who have more risk for worse outcomes. They can then be provided with education to promote exercise behavior and to enhance self-management to achieve better quality of life.
Screening for self-care capacity is advocated before applying educational strategies. No screening tool has been specifically developed to assess barriers that impede engagement in self-care in people with heart failure. Earlier conceptual work (InCOGNITO) identified NYHA class, mild cognitive impairment and depressive symptoms as barriers that impede engagement in HF self-care.
Study aims were: 1) to develop the Heart Failure Screening Tool (Heart-FaST) as a means of assessing three critical barriers to self-care; 2) to assess the content validity of the Heart-FaST; and 3) to test the feasibility of implementing the Heart-FaST in clinical practice.
The Heart-FaST was developed from barriers identified in previous research (InCOGNITO) and from expert panel consensus. Content validity was assessed by examining the proportion of experts who scored each item as relevant.
The InCOGNITO study indicated that four cognitive tasks, seven emotional questions and NYHA functional class were significantly correlated with the self-care scales: maintenance, management and confidence. These factors were used to create the Heart-FaST items. Consensus on wording and items to be included in the Heart-FaST was reached after two rounds of panel discussion. All items had an item-level content validity index ≥0.78. High scores on each barrier (physical, cognitive and emotional functioning) suggest poor self-care and the need for more intensive disease management efforts.
The Heart-FaST measures three critical barriers that impede engagement in self-care. In clinical practice this tool may assist in individually tailoring educational and support strategies to promote effective heart failure self-care.
This paper is a report of a narrative review examining the current state of knowledge regarding adherence with cardiac medication among South Asian cardiac patients.
South Asians experience higher rates of cardiovascular disease than any other ethnic group. South Asians may be less adherent with a cardiac medication regimen than Caucasians. The factors contributing to adherence are important to discover to assist South Asians to optimize their cardiac health.
CINAHL, Medline (Ovid), PsychINFO, EMB Reviews-(Cochrane), and EMBASE were accessed using the key words: ‘South Asian’, ‘Asia’, ‘East India’, ‘India’, ‘Pakistan’, ‘Bangladesh’, ‘Sri Lanka’, ‘medication compliance’, ‘medication noncompliance’ and ‘medication adherence’. English language papers published from January 1980 to January 2013 were eligible for inclusion.
Abstracts were reviewed for redundancy and eligibility by the primary author. Manuscripts were then retrieved and reviewed for eligibility and validity by the first and last authors. Content analysis strategies were used for the synthesis.
Thirteen papers were in the final data set; most were conducted in India and Pakistan. Medication side-effects, cost, forgetfulness and higher frequency of dosing contributed to non-adherence. South Asian immigrants also faced language barriers, which contributed to non-adherence. Knowledge regarding the medications prescribed was a factor that increased adherence.
South Asians’ non-adherence to cardiac medications is multifaceted. How South Asians who newly immigrate to Western countries make decisions regarding their cardiac medication adherence ought to be explored in greater detail.
A high sense of coherence (SOC) has been found to be associated with favourable health-related behaviours. However, evidence is for the most part lacking on the influence of SOC on health-related behaviours among coronary heart disease patients. The aim of this study was to explore the association between SOC at baseline and smoking status, nutrition behaviour, physical exercise and alcohol consumption of coronary heart disease patients 12–28 months after they had undergone different cardiac treatments.
A total of 179 coronary heart disease patients (mean age 58.32±6.54 years, 19% female) were interviewed before coronary angiography and 12–28 months after. Self-report data about health-related behaviours were obtained via a structured interview. SOC was measured using the 13-item Orientation to Life Questionnaire. The relationship between SOC and health-related behaviours was examined using regression and cross-lagged path analyses.
SOC at baseline predicted non-smoking and quitting smoking: odds ratio (OR) (95% confidence interval (CI)) per unit increase (over range 38–91) was 1.11 (1.03–1.19) and 1.09 (1.01–1.17), respectively. Moreover, baseline SOC predicted healthy nutrition behaviour among percutaneous coronary intervention patients: the OR per unit increase was 1.08 (95% CI: 1.01–1.15). Lastly, SOC at baseline predicted improvement in alcohol consumption at follow-up among coronary artery bypass grafting patients (standard score result: –0.15, p<0.05).
Coronary heart disease patients with a low SOC before treatment are less likely to improve health behaviours after cardiac treatment and should thus get additional attention in health promotion.
Cardiac rehabilitation (CR) programmes have increased their availability and expanded their eligibility criteria. This study sought to identify current predictors and reasons influencing myocardial infarction patients’ pre-discharge intentions to attend CR.
Patients in this longitudinal, prospective, five site study completed questionnaires that surveyed their intentions to attend, attendance and main reasons for non-attendance at CR.
84% of the 1172 patients indicated that they intended to attend CR. Multivariate analyses revealed that age, employment and earlier history of myocardial infarction were significant predictors of intention to attend CR, yet contributed to only a small proportion of the variance. The main reasons given for not intending to attend CR were lack of interest and perception that the programme would not be beneficial. Other obstacles included work, transport or time. A total of 708 (60%) patients responded at 12 months, and of these, 44% who did not intend to attend CR had attended.
Patient sociodemographic and clinical profile, although significant, are not major predictors of intention to attend CR. Lack of interest and misconceptions regarding CR are cited as key barriers. Some of these seem to have been addressed post discharge as a good proportion of patients who had not intended to attend CR did change their minds and attended. Motivation of patients to participate in CR, including the identification of barriers and the provision of comprehensive information about the purpose and varied formats of CR programmes, could be used to help further address barriers to attendance.
The study objective was to evaluate the relationship of health-related quality of life (HRQoL) with fatigue and exercise capacity in coronary artery disease (CAD) patients.
A total of 1072 consecutive CAD patients on admission to a cardiac rehabilitation program were evaluated for HRQoL (36-item Short Form Medical Outcome Questionnaire; SF-36), body mass index, clinical characteristics (New York Heart Association (NYHA) class, angina pectoris class, coronary interventions, treatment with beta blockers, hypertension and diabetes), symptoms of depression and anxiety (Hospital Anxiety and Depression Scale), fatigue (Multidimensional Fatigue Inventory-20; MFI-20), and exercise capacity (bicycle ergometer test).
In univariate regression analyses lower scores on all SF-36 domains were associated with greater scores on all MFI-20 subscales. Exercise capacity was associated with all SF-36 domains, except for social functioning and mental health domains. In multivariate regression analyses, after adjusting for age, gender, body mass index, NYHA class, angina pectoris class, hypertension, diabetes, coronary interventions, treatment with betablockers, and symptoms of depression and anxiety, greater limitation due to physical and due to emotional problems, poor social functioning, decreased energy/vitality, worse general health perception, reduced mental component summary and lower global SF-36 score were independently associated with higher MFI-20 general fatigue score. Reduced physical functioning, greater pain, and reduced physical component summary SF-36 scores were associated with greater MFI-20 physical fatigue score. Lower SF-36 mental health score was associated, with greater MFI-20 mental fatigue score.
In CAD patients undergoing rehabilitation, poor HRQoL is associated with greater fatigue and decreased exercise capacity independently from mental distress and CAD severity score.
Depression is common in patients with heart failure. The prevalence of depression is known to differ in male and female patients with heart failure, but little is known about whether these patients differ in predictors of depression. The purposes of this study were to: (1) determine whether the prevalence of depression in patients with heart failure differed by gender: (2) examine if predictors of depression differed by patient gender.
In this cross-sectional observational study, 147 patients with a primary diagnosis of heart failure completed five self-report questionnaires: demographic and clinical characteristic questionnaire, Mishel Uncertainty in Illness Scale, Beck Depression Inventory-II, Social Support Scale and Minnesota Living with Heart Failure Questionnaire. Data were analyzed with logistic regression.
The majority of subjects were male (54.4%), with a mean age of 71.04 ± 13.29 years and mean ejection fraction of 46.42 ± 17.02%. About two-thirds of male patients (65%) and of female patients (65.7%) had significant depressive symptoms (Beck Depression Inventory-II score ≥14). More female than male patients had moderate or severe depressive symptoms. Stratified analyses revealed that significant independent predictors of depressive symptoms among males were being unemployed (odds ratio=.09, 95% confidence intervals=.02– .54), lower ejection fraction (odds ratio=.96, 95% confidence intervals=.92–1.00), and worse quality of life (odds ratio=1.09, 95% confidence intervals=1.05–1.14); among females, predictors were uncertainty (odds ratio=1.09, 95% confidence intervals=1.04–1.32) and worse quality of life (odds ratio=1.17, 95% confidence intervals=1.08–1.48).
Different variables predicted the presence of significant depressive symptoms in male and female patients with heart failure, but quality of life was an important factor in predicting depression in both genders.
Dietary supplement use is widespread; patterns of use and perceptions about supplements in individuals with heart failure (HF) are not well understood.
The purpose of this study was to describe the prevalence, patterns and reasons for use of dietary supplements, and to compare characteristics of, and perceptions about, safety and efficacy between dietary supplement user and non-user participants with HF.
Patients with HF (n=99) completed a Dietary Supplement Questionnaire. Descriptive statistics were used to analyze the data. Independent sample t-tests, Fisher’s exact test, and Chi square analyses compared dietary supplement users to non-users.
More than half of the participants used at least one dietary supplement and almost all patients using dietary supplements reported they had informed their healthcare provider. Dietary supplements were taken to improve intake of dietary components and better individual health state. Participants thought that dietary supplements in general were safer and more effective than current evidence suggests. Users and non-users expressed similar perceptions. Patients who used dietary supplements were older (64±10 years vs 53±12 years) and had a lower body mass index (30.0±6.5 kg/m2 vs 34.1±8.3 kg/m2) compared with patients who did not.
Dietary supplement use was common in these participants with HF; global perceptions about safety and efficacy of dietary supplements were similar between users and non-users of dietary supplements. Systematic evaluation of dietary supplement use, with discussion about safety and efficacy may be constructive for patients with HF.
Occurrences of impaired activities of daily living (ADL) are common in heart failure (HF) patients and contribute to the elevated mortality and hospitalization rates in this population. Cognitive impairment is also prevalent in HF, though its ability to predict functional decline over time is unknown.
This study examined the longitudinal pattern of activities of daily living (ADL) in HF persons and whether reduced baseline cognitive status predicts functional decline in this population.
Altogether 110 persons with HF completed the Lawton-Brody Instrumental Activities of Daily Living (IADL) scale and were administered the Modified Mini-Mental Status Examination (3MS) at baseline and a 12-month follow-up. Three composite scores were derived from the Lawton-Brody scale, including total, instrumental, and basic ADL.
HF patients reported high rates of baseline impairments in instrumental ADL, including shopping, food preparation, housekeeping duties, laundry, among others. Repeated measures analyses showed significant declines in total and instrumental ADL from baseline to the 12-month follow-up in HF (p<0.05). Hierarchical regression analyses showed that poorer baseline performance on the 3MS predicted worse total ADL performance at 12-months (β=0.15, p=0.049), including greater dependence in shopping, driving, feeding, and physical ambulation (p<0.05 for all).
The current results show that HF patients report significant functional decline over a 12-month period and brief cognitive tests can identify those patients at highest risk for decline. If replicated, such findings encourage the use of cognitive screening measures to identify HF patients most likely to require assistance with ADL tasks.
Despite well-established evidence of benefit from cardiac rehabilitation, typically fewer than 35% of eligible patients attend.
The purpose of this study was to evaluate whether theory-based invitations increase attendance at cardiac rehabilitation.
The study was a randomized controlled trial (RCT) with two by two factorial design. A total of 375 participants with acute myocardial infarction or coronary revascularization was recruited from medical and surgical cardiac wards at Aberdeen Royal Infirmary (ARI). They were randomly assigned to receive either the standard invitation letter or a letter with wording based on the ‘theory of planned behavior (TPB)’ and the ‘common sense model of illness perception’, and either a supportive leaflet with motivational messages or not. The primary outcome was one or more attendances at cardiac rehabilitation.
The theory-based letter increased attendance at cardiac rehabilitation compared to the standard letter (84% versus 74%, odds ratio (OR) 2.93, 95% confidence interval (CI) 1.54–5.56), independent of age, gender, working status, hypertension, identity and TPB constructs. The number needed to treat (NNT) was 9 (95% CI 7–12). The motivational leaflet had no significant effect on attendance at rehabilitation (OR 1.02, 95% CI 0.57–1.83).
The use of theory-based wording in invitation letters is a simple method to improve attendance at cardiac rehabilitation. Our letter, reproduced in this paper, could provide a template for practitioners and researchers.
There are considerable differences in the type of treatments offered to patients presenting with acute myocardial infarction (AMI), in terms of the speed and urgency with which they are admitted, treated and discharged from hospital. The impact of these different treatment experiences on patients’ illness perception and motivation for behavioural changes is unknown.
The aim of this study was to explore and compare patients’ illness perception and motivation for behavioural change following myocardial infarction (MI) treated by different methods.
Semi-structured, domiciliary interviews (n=15) based on the common sense model of self regulation, were conducted with three groups of MI patients within four weeks of diagnosis: (a) primary percutaneous coronary intervention (PPCI) (n=5); (b) thrombolysis (n=5); (c) non ST elevation MI (NSTEMI) (n=5). Framework analysis was used to identify and compare themes between groups.
Patients presenting with a ST-elevation MI (STEMI) receiving either PPCI or thrombolysis had similar perceptions of their illness as a serious, life-threatening event and were determined to make lifestyle changes. In contrast, patients with a NSTEMI experienced uncertainty about symptoms and diagnosis, causing misconceptions about the severity of their condition and less determination for lifestyle changes.
Patients with NSTEMI in this study expressed very different perceptions of their illness compared to those experiencing STEMI. Patients’ clinical presentation and treatment experience during an AMI can impact on their illness perception, motivation for behavioural change and uptake of cardiac rehabilitation. Nurses should consider the patients’ illness experience and perception when planning secondary prevention interventions.
People with heart failure have difficulty with self-care management. We do not know if patients with heart failure have difficulty with self-care management due to underlying, mild cognitive impairment (MCI). The purpose of this study was to determine whether MCI, as identified on a simple screening tool, is significantly associated with self-care management in a sample of community dwelling older patients with heart failure.
Using a cross-sectional design, heart failure patients (n=100, mean age 72 SD 10 years) attending an outpatient heart failure clinic completed the Montreal Cognitive Assessment tool (MoCA), Self-Care in Heart Failure Index (SCHFI) and Geriatric Depression Scale. The presence of MCI, as defined by a MoCA score <26, was present in 73% patients; 21% had an adequate self-care management SCHFI score; and 12% reported symptoms of depression. Participants with a MoCA score <26 vs. ≥ 26 scored significantly lower on the self-care management subscale of the SCHFI (48.1 SD 24 vs. 59.3 SD 22 respectively, p=0.035). Using backward regression, the final model was fitted to self-care management while controlling for age and sex and was significant, with (F= 7.04 df (3, 96), and p<0.001), accounting for 18% of the total variance in self-care management (R2 = 18.03%). The MoCA score was the only variable which remained in the model significantly with p= 0.001.
Findings from this study highlight the difficulty older heart failure patients have with self-care management and the need to include formal screening for MCI when exploring variables contributing to self-care management in heart failure patients.
Patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) are at risk of early death. This may be reduced by timely assessment and treatment.
The purpose of this study was to evaluate if Nurse-led Early Triage (NET) in the coronary care unit (CCU) can improve time to assessment and management of NSTE-ACS patients.
Data on 79 consecutive chest pain patients admitted pre-NET to the acute admissions unit (AAU) and on 103 patients admitted in the first six months of the NET service in CCU, was re-examined and compared to subsequent data obtained on 92 patients admitted via NET five years later, in order to re-evaluate the service.
NET resulted in significant improvements in: the number of patients with chest pain who had their 12-lead electrocardiogram (ECG) performed within 10 min of admission (94% vs 32%, p<0.001); the number of high-risk NSTE-ACS patients prescribed clopidogrel (72% vs 42%, p<0.01); and the number being managed in CCU (82% vs 34%, p<0.01). Comparison of the NET service at five years with the pre-NET service demonstrated measurable benefits were sustained (p<0.01) for the same comparative end points. There were no significant differences in these end-points of time to ECG, clopidogrel prescription nor management in CCU for high-risk patients between the NET groups at six months and five years, demonstrating that current triage is as effective as when first introduced.
This study demonstrated the positive impact of nurse-led early triage for NSTE-ACS patients and that initial benefits have been sustained.
The education of patients with heart failure (HF) is an essential part of disease management. The perspectives of an increasing number of patients and a shortage of professionals force healthcare to explore new strategies in supporting patients to be better informed and more active.
Three hundred and eighty-two patients with HF (age 71±SD 11.2 years) were randomly assigned to either a telemonitoring or a usual care group. Patients received four postal questionnaires to assess their levels of self-reported knowledge, self-care, self-efficacy and adherence. Generalized estimating equations analysis was performed to assess the effects of telemonitoring during the 1-year follow-up. Corrections for baseline were performed if needed.
Baseline differences between groups were found for self-care (p=0.001) and self-efficacy (p=0.024). Knowledge of patients in the telemonitoring group significantly improved with 0.9 point on a 15-points scale (p<0.001). Their self-care abilities improved with 1.5 point on a 10-item scale whereas no changes were found in patients receiving usual care (p<0.001). Self-efficacy of patients in the intervention group improved significantly after 6 months yet was not significantly different after 3 months and 1 year. For patients in the intervention group adherence improved for daily weighing (p<0.001) during the whole follow-up and for fluid intake (p=0.019) after 3 months and after 12 months (p=0.086). Adherence for activity recommendations improved (p=0.023) after 3 months and importance of medication adherence increased after 6 (p=0.012) and 12 months (p=0.037). No effects were found regarding appointments, diet, smoking and use of alcohol.
Tailored telemonitoring was found to educate patients with HF and to improve their self-care abilities and sense of self-efficacy.
Memory and executive function may be associated with poorer self-care management behaviors (indicators of self-care decision making). Dysfunction of self-care decision making processes often results in worsening of heart failure symptoms that necessitates hospitalization for acute management.
The purposes of this literature review are to (a) synthesize the published literature (2000–2012) examining the relationship between cognitive dysfunction (CD) (executive function and memory) and self-care management decisions in heart failure (HF) patients; (b) identify gaps in knowledge; and (c) provide recommendations for future research to fill this gap.
Literature from January 2000–September 2012 was reviewed to determine the relationship between cognitive dysfunction and self-care decision making in patients with HF. Studies were included that used measures to examine the relationship between cognitive dysfunction and self-care decision making in patients with HF.
The ability to identify a significant relationship between CD and self-care decision making processes was limited by the paucity of studies, small sample sizes, use of convenience samples and the use of single center recruitment sites.
Despite the importance of memory and executive function in decision making, there is a paucity of studies describing the relationship between CD and self-care decision making processes. A knowledge gap exists regarding the relationship between CD and self-care decision making processes. The influence of executive function and memory on self-care decision making abilities needs further study in diverse populations, using standardized and valid measures for CD and self-care decision making processes.
Patients with heart failure managed by community heart failure specialist nurses (CHFSNs) may have episodes of (often unrelated) ill-health managed separately in hospital. Inadequate communication and multi-disciplinary working between these different providers can impact on the effectiveness of care.
This service improvement project explored the potential of patient-held alert cards to improve communication and continuity of care for heart failure patients moving between CHFSNs and hospital settings.
Alert cards were distributed to 119 patients on a community case load for presentation at hospital or emergency department. Follow-up data were obtained from practitioners and patients at 12 months.
At 12 months, 38 patients from the CHFSN caseload experienced 61 hospital admissions. CHFSNs were informed of 80% of admissions by practitioners (61%) and family members (38%). They were also informed of 59% of discharges. Notification of admission by hospital staff increased from zero in the previous 12 months, to 19 notifications. CHFSNs were more involved with hospital care, and patients reported increased confidence with the alert cards.
The study has shown that alert cards can increase the involvement of CHFSNs in the ongoing care and discharge planning process. They can also empower patients and carers to take an active role in their own care.
Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia.
An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h).
Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event.
Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.
Psychological and physiological effects of chronic heart failure (CHF) can influence sexuality. Both CHF patients and their partners may experience changes and have questions about sexuality. Despite this, healthcare professionals give little information regarding sexuality. This may be due to the paucity of literature describing patients’ concerns and questions about sexuality and CHF.
The aims of this study were to describe the sexuality of patients and their partners and to describe their needs for information regarding sexuality.
A prospective, descriptive cross-sectional design was used. A convenience sample was obtained in three hospitals (Belgian and the Netherlands). Patients and partners completed two questionnaires: Sexual Adjustment Scale (SAS) and the Needs of Sexual Counseling Scale for Chronic Heart Failure (NSCS-CHF).
There were 52 patients and 32 partners who participated in the study. No or slight disturbance was seen in sexual discussions and intimacy. Marked or serious disturbance was reported in sexual activity. A mixed profile was seen in sexual performance, sexual interest and sexual pleasure. The majority of patients with CHF and their partners want information regarding sexuality. The NSCS-CHF clearly identified the information needs of patients and partners and most needs concerned the areas of symptoms, the relationship and relaxation.
The questionnaires were easy to complete and changes in sexuality and information needs were identified. The NSCS-CHF needs further validation as a research instrument. Healthcare professionals can use both questionnaires to bring up the topic of sexuality and to identify topics that require further discussion or counselling with patients and partners.
Sudden cardiac death (SCD) in the young is a devastating event and often due to an underlying genetic heart disease. Managing these families is complicated by uncertainty regarding clinical management and profound grief. This study sought to evaluate psychological wellbeing and experiences of at-risk relatives following SCD in the young.
Relatives who attended a specialized clinic following the SCD of a relative were invited to complete the Hospital Anxiety and Depression Scale (HADS) and a series of open-ended questions. Primary outcome measures were the HADS anxiety and depression subscales and a thematic qualitative analysis of the open-ended responses was performed. Clinical and genetic data were collected from the medical record.
Fifty relatives from 29 families returned surveys. The mean time since death was 4±2 years (mean age at death 23±10 years, 79% males). There was significant impairment in mean anxiety (8.7±4.3, p<0.0001) and depression (5.8±3.6, p<0.0001) scores compared to the general population. Mothers showed significantly impaired anxiety (10.9±4.0, p=0.001) and depression (7.3±3.3, p=0.001) scores, with 53% having an anxiety score above 11 suggesting probable anxiety disorder. Participants revealed a number of factors that have helped and hindered their ability to cope with the death, and their decisions relating to clinical screening.
The SCD of a young relative has significant and long-term emotional implications for the family, particularly for the mother.
Pain and discomfort in relation to vascular closure are the predominant patient complaints after coronary angiography (CAG). No large-scale randomized studies have evaluated pain and discomfort after CAG with access site closure by manual compression versus a vascular closure device (VCD).
To compare pain and discomfort after femoral artery closure by manual compression versus FemoSeal® VCD.
The study is a sub study to the CLOSE-UP study, a randomized, single centre comparison of FemoSeal® VCD versus manual compression after CAG. Pain and discomfort score was assessed immediately after the closure procedure, at time for mobilization, at discharge and after 14 days.
1014 patients were included and 1001 patients entered analysis. In-hospital follow-up was obtained for all patients and 14-day follow-up was completed for 96% of patients. The closure procedure lasted 1 (1–1) min in the FemoSeal®VCD group and 8 (6–10) min in the manual compression group. Pain and discomfort score at the procedure was significantly higher in the FemoSeal®VCD group. No differences in pain and discomfort were detected after leaving the catheterization laboratory.
Closure of femoral access after CAG by the FemoSeal®VCD was associated with significantly more pain and discomfort compared with closure by manual compression. No difference in pain and discomfort was found at follow-up.
To improve patients’ quality of life (QoL) we need to identify modifiable determinants, such as illness perceptions. Patients’ illness perceptions are known to regulate emotional responses and health-behaviour. Illness perceptions comprise several components: consequences, control, coherence, changeability and emotional representations.
To examine (a) the relation between patient characteristics and illness perceptions, and (b) the independent predictive value of illness perceptions for future QoL.
A longitudinal study in 845 patients with congenital heart disease was conducted. Patients completed three questionnaires: the IPQ-R (illness perceptions) and two years later the SF-36 and TAAQOL-CHD (QoL). Linear regression analyses were performed relating illness perceptions to patient characteristics (sex, age, disease complexity and functional status) and QoL.
Patients with a complex defect or poor functional status reported poor illness perceptions. Independent of patient characteristics, poor illness perceptions (i.e. a strong belief that the illness has severe consequences; a weak belief that you have a coherent illness understanding and that the illness can be controlled by treatment; and a strong belief that the illness is changeable and causes negative emotions) were predictive of future QoL.
Illness perceptions independently predict QoL, suggesting that QoL may be improved by altering patients’ beliefs about their illness. For example, increasing patients’ knowledge regarding their disease and informing them about treatment opportunities may enhance their QoL.
Exhaustion, a consequence of prolonged stress characterized by unusual fatigue, is associated with increased risk of cardiac morbidity and mortality. In patients recovering from coronary artery bypass (CABG), little is known about the relationship of 1) immune-mediated inflammation and resultant endothelial activation, and 2) cumulative exposure to infectious pathogens (pathogen burden (PB)) implicated in coronary atherosclerosis to exhaustion.
The aim of this exploratory study was to investigate the association of PB, inflammatory markers (interleukin (IL)-6, IL-10) and a marker of endothelial activation (soluble intercellular adhesion molecule-1 (sICAM-1)) to exhaustion.
One to two months post-CABG, 42 individuals who met inclusion criteria were assessed for exhaustion using the Maastricht Interview for Vital Exhaustion. Serum IgG antibodies to herpes simplex virus (HSV)-1, HSV-2, cytomegalovirus, Epstein Barr virus, and inflammatory and endothelial activation markers were measured by enzyme-linked immunosorbent assay. Pathogen burden was defined as the total number of seropositive exposures: low (0-1), moderate (2-3), and high (4).
Prevalence of exhaustion was 40.5%. Relative to non-exhausted patients, exhausted patients demonstrated a higher frequency of moderate PB (h=0.73, p=0.04) but lower frequency of high PB (h=1.05, p=0.03). Exhaustion showed a non-significant trend for positive correlations with IL-6 and sICAM-1 levels, and inverse relation to PB. In subgroup analysis, exhausted patients had stronger correlations with IL-6 and IL-6:IL-10 and a tendency towards higher serum IL-10 concentrations compared with their non-exhausted counterparts.
This hypothesis-generating study provides preliminary evidence that elevated post-CABG exhaustion may be associated with PB, inflammation, and endothelial activation.
Age-adjusted stroke mortality rates in Israel are higher among Arabs compared with Jews; therefore, knowledge of stroke signs and prevention strategies is especially important in the Arab population. Data on stroke knowledge among Arabs in Israel are lacking.
We aimed to examine knowledge, perceptions and thoughts of stroke among Arab-Muslim Israelis.
A complementary mixed method design was used. Ninety-nine Arab Muslims living in Israel, older than 40 years, with no history of stroke, were personally interviewed. Knowledge of stroke was assessed using quantitative analysis by a semi-structured interview. Information on perceptions and thoughts evoked by stroke was analyzed using qualitative analysis by the constant comparative method. Rates of reported knowledge-related variables were presented.
Mean (SD) age of participants was 50.1 (8.0) years, 52.5% were women. Most of the participants (84.8%) knew the causes of stroke but only 29.3% mentioned sudden weakness or paralysis in one side of the body as a warning sign and other warning signs were even less known. The main known risk factor was hypertension (43.3%). Although knowledge of stroke prevention was poor, 89% were interested in learning about stroke and its prevention. The qualitative findings showed that stroke evokes negative thoughts of mental and physical burden and is associated with death, disability, dependence and depression.
Levels of stroke knowledge among Arab-Muslim Israelis are low to moderate. Healthcare professionals should assist high risk populations in controlling and treating risk factors in order to reduce mortality and disability following a stroke.
Patients with congenital heart disease (CHD) have poor understanding of their heart condition, treatment and prevention of complications. To improve their level of health-related knowledge, a structured education program was implemented in the adult congenital heart disease program. This study aimed (a) to evaluate the level of knowledge of patients who received structured CHD education as compared to patients who did not receive this education; (b) to explore if the provision of structured education is an independent determinant of knowledge; and (c) to evaluate whether patients who received structured education reached the educational target (>80% correct answers).
A total of 317 patients were included: 226 in the education group, and 91 in the comparison group. Knowledge was assessed using the ‘Leuven Knowledge Questionnaire for Congenital Heart Disease’. The mean total knowledge score in the education group (57%) was significantly higher as compared to the comparison group (43%) (p<0.001). However, only 24 patients (11%) in the education group reached the educational target of the program. After adjusting for patient’s age, educational level and disease complexity, hierarchical multivariable linear regression analysis showed that the provision of structured CHD education was an independent determinant of higher levels of knowledge.
A structured education program was associated with a higher level of knowledge. However, the educational target for sufficient knowledge was reached in a very limited number of patients. Hence, continuous efforts in educating patients and developing alternative education methods are needed.
Nurses and nurse practitioners play an integral role in initiating and managing antithrombotic prophylaxis in patients with atrial fibrillation (AF). Since the advent of warfarin in the 1950s, there have been few changes in this field until recently. Warfarin has been used for decades and has well-demonstrated efficacy. However, it also has well-known drawbacks, including an unpredictable dose response, need for anticoagulation monitoring, frequent dose adjustments, and many drug and food interactions. A new generation of anticoagulants, which includes direct thrombin inhibitors and selective Factor Xa inhibitors, shows the potential to significantly improve options for antithrombotic prophylaxis and to positively affect patient outcomes. The objective of this review is to update nurses on the new oral anticoagulants, other recent developments, such as improved risk-assessment techniques, and the role of over-the-counter products, including aspirin.
Since survival rates of patients with congenital heart disease (CHD) have improved, issues beyond the quantity of life have become more important. Quality of life (QOL) has mainly been investigated in adults with CHD. Hence, research about QOL among adolescents with CHD is much needed.
To compare the QOL of adolescents with CHD with that of control subjects from the general population and to explore whether sense of coherence (SOC) explains differences in QOL between patients and controls.
In this cross-sectional, comparative study, we included 429 patients (229 boys; 200 girls) aged 14–18 years, who were matched to control subjects for age and sex. QOL was measured with a Linear Analogue Scale; SOC was measured using the SOC-13.
Median QOL score in patients was 82 (Q1=75; Q3=90). The QOL of patients was significantly (Z=–5.888; p<0.001) better than that of controls (median=80; Q1=70; Q3=85.5). Adjusted for other potentially confounding factors, linear mixed modelling showed that the better QOL in patients was explained by a higher SOC (mean=61.4±12.0 vs. 53.6±10.4) and better perceived physical health (mean=87.0±13.8 vs. 85.3±13.2).
This study found that adolescents with CHD have a good QOL, one that is better than that of control subjects from the general population. A stronger SOC and better perceived physical health are potential resources for better QOL in patients.
Sexual problems are common among cardiac patients. Further information is required on patients’ experiences of sexuality and preferences for sexual counselling.
To characterise sexual dysfunction and related factors among patients following cardiac rehabilitation and examine related treatment delivery.
Telephone interviews with 382 patients (32% response rate) recruited from six hospital rehabilitation centres.
Seventy-nine per cent were male; average age was 64 years (SD 9.8). Forty-seven per cent of the total sample reported no sexual relations in the previous year, and nearly a half of sexually active respondents reported at least one sexual problem. Erectile dysfunction (reported by 33%) and lack of interest in sex (reported by 10%) were the most common problems for men and women respectively. Twenty-three per cent reported that sex had deteriorated for them since their cardiac event, and for half of these this was considered a serious problem. In logistic regression analysis, higher anxiety (Hospital Anxiety and Depression Scale) and being male were associated with reporting a sexual problem (2 = 37.85, p<0.001). Sixty-six per cent reported that sex was never discussed by a health professional and satisfaction with this aspect of care was low. Patients wanted these issues to be addressed and the majority (63%) claimed they would find it easy to discuss sexual problems with a health professional.
Sexual inactivity and sexual problems are common in this group. Health professionals should address sexual issues with their patients, ideally in a private setting and within the broader context of addressing psychological wellbeing.
This study aimed to explore and identify the relationship between health-related quality of life (HRQoL) and perceived social support among Chinese patients with coronary heart disease (CHD) in mainland China.
A descriptive correlational study was conducted with a convenience sample of 200 Chinese patients with CHD recruited from the cardiac outpatient departments of two university-affiliated hospitals in Xi’an, China. The Chinese Mandarin versions of the Short-form 36-item health survey (CM:SF-36) and the Medical Outcomes Study Social Support Survey (CM:MOS-SSS) were administered to assess HRQoL and perceived social support.
The results indicated that Chinese patients with CHD reported a poorer HRQoL and lower social support compared with their Western and Hong Kong counterparts. Multiple regression analyses identified four significant predictors of deteriorated physical health (increasing age, co-morbidity with heart failure or hypertension, and smoking status) and two significant predictors of poor mental health (co-morbidity with heart failure and perceived social support).
Health status and social support in Chinese people with CHD should be routinely assessed and, where feasible, addressed through appropriate individually tailored interventions.
Despite the established benefits of cardiac rehabilitation (CR) attendance rates remain variable. Physical barriers to attendance have been extensively investigated but relatively less is known about the relationship between attendance at CR and psychosocial variables such as illness perceptions and social isolation.
To examine the influence of socio-demographic factors, illness perceptions and social isolation on patient attendance at cardiac rehabilitation.
All individuals offered CR over a two-year period were invited to take part in a postal survey. The survey collected socio-demographic data and included completion of the Friendship Scale, to assess social isolation, and the Brief Illness Perceptions Questionnaire. Parametric and non-parametric statistical tests were used as appropriate.
One hundred and twenty-eight (47%) questionnaires were returned. Non-attendees reported higher total illness perception scores and those who attributed their illness to non-modifiable factors were significantly less likely to attend CR (p = 0.042). Attendees reported lower levels of social isolation; however, this finding was not statistically significant. No differences were found between attendees and non-attendees in terms of their age, gender, educational status or proximity to cardiac rehabilitation centre.
Psychosocial barriers, specifically illness perceptions and attributions, were found to be significant with patients who did not attend CR reporting more negative illness perceptions. Distance to CR was not a significant factor influencing attendance. Early screening of perceived causal attributions may help to identify those who would benefit from early and targeted intervention to increase participation in CR. Future prospective studies would permit testing of screening approaches and early interventions.
To optimize long-term outcomes, patients with congenital heart disease (CHD) should adopt health-promoting behaviors. Studies on health behavior in afflicted patients are scarce and comparability of study results is limited. To enlarge the body of evidence, we have developed the Health Behavior Scale-Congenital Heart Disease (HBS-CHD).
We examined the psychometric properties of the HBS-CHD by providing evidence for (a) the content validity; (b) validity based on the relationships with other variables; (c) reliability in terms of stability; and (d) responsiveness.
Ten experts rated the relevance of the HBS-CHD items. The item content validity index (I-CVI) and the averaged scale content validity index (S-CVI/Ave); the modified multi-rater Kappa and proportion of missing values for each question were calculated. Relationships with other variables were evaluated using six hypotheses that were tested in 429 adolescents with CHD. Stability of the instrument was assessed using Heise’s method; and responsiveness was tested by calculating the Guyatt’s Responsiveness Index (GRI).
Overall, 86.3% of the items had a good to excellent content validity; the S-CVI/Ave (0.81) and multi-rater Kappa (0.78) were adequate. The average proportion of missing values was low (1.2%). Because five out of six hypotheses were confirmed, evidence for the validity of the HBS-CHD based on relationships with other variables was provided. The stability of the instrument could not be confirmed based on our data. The GRI showed good to excellent capacity of the HBS-CHD to detect clinical changes in the health behavior over time.
We found that the HBS-CHD is a valid and responsive questionnaire to assess health behaviors in patients with CHD.
In acute myocardial infarction the risk of death and loss of myocardial tissue is at its highest during the first few hours. However, the process from symptom onset to the decision to seek medical care can take time. To comprehend patients’ pre-hospital delay, attention must be focused on the circumstances preceding the decision to seek medical care.
To add a deeper understanding of patients’ thoughts, feelings and actions that preceded the decision to seek medical care when afflicted by an acute myocardial infarction.
Fourteen men and women with a first or second acute myocardial infarction were interviewed individually in semi-structured interviews. Data were analysed by qualitative content analysis.
Four themes were conceptualized: ‘being incapacitated by fear, anguish and powerlessness’, ‘being ashamed of oneself’, ‘fear of losing a healthy identity’ and ‘striving to avoid fear by not interacting with others’. Patients were torn between feelings such as anguish, fear, shame and powerlessness. They made an effort to uphold their self-image as being a healthy person thus affected by an unrecognized discomfort. This combined with a struggle to protect others from involvement, strengthened the barriers to seeking care.
The present study indicates that emotional reactions are important and influence patients’ pre-hospital behaviour. Being ashamed of oneself stood out as a novel finding. Emotions might be an important explanation of undesired and persisting patient delays. However, our findings have to and should be evaluated quantitatively. Such a study is in progress.
This study aimed to evaluate the impact of a brief educational intervention delivered in cardiac rehabilitation (CR) on patients’ knowledge of sublingual nitroglycerin (SLN).
Patients (n=86) commencing CR were provided with a brief educational intervention tailored to deficits identified in an assessment of SLN knowledge using the Sublingual Nitroglycerin Questionnaire, with reassessment at the end of program completion (6–8 weeks).
The mean age of patients was 64.95 years (standard deviation (SD) 10.87); 74% were male, 78% were married and 60% had not completed high school. Most (70%) had no prior coronary heart disease (CHD) history and 80% had been referred to CR following percutaneous coronary intervention. SLN knowledge scores increased from baseline to outcome. Patients were significantly more likely to know: the name of their SLN medication (11% increase, p=0.001), the recommended timing between doses (29% increase, p=0.02), the maximum number of doses (27% increase, p=0.005), to have SLN on their person at the time of the interview (25% increase, p<0.001) and to know the interaction between SLN and sildenafil (36% increase, p=0.001). The independent predictors of SLN knowledge included having better knowledge at baseline (β=0.28) and having consulted a general practitioner post discharge and before commencing CR (β=1.48).
A brief standardised knowledge intervention, individually tailored to identified deficits in a knowledge screen and delivered during CR, shows promise for improving patient knowledge of SLNs. The role of general practitioners in delivering medication education needs further investigation.
Self-care is a key principle in the management of chronic heart failure (HF). The common sense model (CSM) of illness cognitions and behaviour provides a theoretical framework within which relationships between beliefs and behaviour can be examined.
The aim of this study was to determine relationships between illness representations, treatment beliefs and the performance of self-care in community HF patients.
A cross-sectional survey was carried out in 169 patients with HF in South East England. Illness representations, treatment beliefs and self-care were measured using an adapted Revised Illness Perception Questionnaire (IPQ-R); the Beliefs about Medicines Questionnaire (BMQ) and the Looking After Yourself with Heart Failure Questionnaire (LAYHFQ), according to the CSM. Relationships between these specific concepts were determined using Pearson’s correlation co-efficients (r) and stepwise multiple regression.
Perceived medication knowledge (r=0.51, p≤0.01), beliefs about the necessity of medication (r=0.45, p≤0.01) and illness coherence (r=0.39, p≤0.01) were moderately correlated with self-care. Multiple regression analysis revealed that 46% of the variance in self-care could be explained by illness representations and treatment beliefs (adjusted R2=0.46, F=9.93, p=0.00). Three factors were significant predictors of self-care – medication knowledge (β=0.319, p=0.003), a belief in the illness having serious consequences (β=0.258, p=0.008) and the impact of medication use on lifestyle (β= –0.231, p=0.03).
Illness representations and treatment beliefs should be explored in patients with HF in order to inform the development of targeted interventions designed to correct misconceptions and enhance self-care. This has the potential to improve clinical outcomes in this population.
There is a lack of data about the information preferences of patients and their partners after a myocardial infarction.
This paper explores anxiety, depression, coping and the desire to be actively involved in care in relation to age, gender and education level in myocardial infarction patients and partners.
One hundred and twenty-eight patients and their partners answered the Swedish version of the Krantz Health Opinion Survey, the Hospital Anxiety and Depression Scale, and the Mastery Scale one year after the patient’s myocardial infarction.
More active roles in decision-making during care were desired by females, younger patients and partners, and patients and partners with higher education levels. Female partners reported more anxiety than male partners, and female patients reported more depression than male patients. No differences between groups were detected in coping; overall coping was rated high.
Secondary prevention should consist of person-centred support to both the patients and their partners, since factors such as age, gender and education level can influence information preferences during patient care.
Many patients with chronic heart failure (CHF) experience uncertainty regarding the treatment and characteristics of their illness. Person-centred care (PCC) emphasizes patient involvement in care. We have previously shown that PCC improved outcomes such as length of hospital stay and activities of daily living in patients with CHF. The impact of PCC on self-reported uncertainty in illness among patients hospitalized for CHF is still unknown.
To evaluate whether PCC is associated with less self-reported uncertainty in illness compared with usual care in patients hospitalized for worsening CHF.
Using a controlled before-and-after design, eligible CHF patients were assigned to either a usual care group or a PCC intervention group. Patient-reported uncertainty in illness was assessed at hospital discharge with the Cardiovascular Population Scale (CPS). The CPS consists of two domains: 1) Ambiguity (about illness severity); and 2) Complexity (of treatment and system of care).
Two hundred and forty-eight patients were included in the study; 123 in the usual care group and 125 in the PCC intervention. The PCC group had better scores than the usual care group in the CPS domains complexity (M=15.2, SD=4.7 vs. M=16.8, SD=4.7; p=0.020) and ambiguity (M=27.8, SD=6.6 vs. M=29.8, SD=6.9; p=0.041).
Patients with CHF were less uncertain in their illness after PCC, which may help to equip and empower patients to manage their illness. Together with earlier findings of shortened hospital stay and improved activities of daily living, this indicates that PCC should be a standard approach for hospital care of patients with worsening CHF.
To provide a critical review and analysis of heart failure (HF)-specific symptom measures
A systematic search using the PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases and reference lists of relevant papers was undertaken to identify symptom measures that were primarily designed for patients with HF.
The systematic search yielded seven instruments that included three or more symptoms. Of the seven instruments, only five had psychometric properties available and these were reviewed. Levels of comprehensiveness of symptom measures varied including the number of symptoms assessed (13–32 symptoms/signs) and symptom dimensions (e.g. frequency and severity). Information about reading levels, time to completion, and completion rates was limited. Psychometric properties of the five measures have not been extensively investigated or reported.
The development and use of the HF symptoms instruments is at a relatively early stage. Thus, further investigation of the psychometric characteristics of existing HF-specific symptom instruments is necessary before one can be recommended for research and clinical use.
Studies show that patients with implantable cardioverter defibrillators (ICD) frequently experience sexual dysfunction. These experiences are often linked to exercise intolerance, side-effects of medication, and psychological problems.
To describe (a) the level of information given about sexual activity, (b) the areas of patient concerns related to sexual function and the ICD, and (c) changes in sexual behavior.
A randomized controlled trial including 196 patients (1:1) was designed, including 12 weeks of exercise training and 1 year of psycho-educational follow-up focusing on modifiable factors associated with poor outcomes, including sexual functioning. The Sex After ICD Survey was administered 6 months after the randomization as part of the planned explorative outcomes. 141 patients responded.
The analyses showed that 37 of the 69 (55.2%) patients of the intervention group and 16 of the 72 (24.6%) patients of the control group received information (p<0.001). The areas of greatest concern reported by many patients were: lack of interest in sex, erectile dysfunction, and an over-protective partner. Fewer patients were sexually active 6 months after the ICD implantation than before the ICD implant: 51.8% versus 66.7%. In the intervention group, patients had sexual intercourse a mean of 4.9 times during the previous 2 months versus 4.0 in the control group (p=0.4).
Despite having received more information, no interventional effect was found between groups in terms of sexual concerns or activity.
Poor adherence is a significant nursing and public health concern because it affects patients’ quality of life. It compounds the disease burden of the growing coronary heart disease population. Promoting optimal patient adherence to cardiac-health enhancing recommendations by healthcare providers can reduce mortality and morbidity risk after acute coronary syndrome (ACS).
This paper sought to examine rates and predictors of patient adherence to health recommendations after ACS.
A cross-sectional survey of 210 Malaysian patients using consecutive sampling was conducted in early 2009 at a tertiary teaching hospital. The Medical Outcome Study Specific Adherence Scale (MOSSAS) questionnaire was adapted to measure the extent of patient adherence to recalled health recommendations. Logistic regression modelling was applied to determine odds ratio and factors of suboptimal adherence.
The suboptimal adherence rate was 65.2% (95% CI 58.8–71.7%). Recall of recommendation rates varied from 38.1% to 95.3%, whereas the adherence rates varied from 22.1% to 95.1% across the six aspects of health recommendation namely medication taking, dietary modification, regular physical exercise, stress reduction, gathering social support and avoidance of substance abuse. Those who had to adhere to more than three aspects of recommendations, active smokers and the Malay ethnic race had higher odds of suboptimal adherence.
Monitoring of patient recall and adherence rate may provide information on the effectiveness of patient care management and outcomes. Identifying patients with higher risk for poor adherence is recommended for more targeted interventions.
Patients with heart failure (HF) have poor health-related quality of life (HRQOL). The vast majority of patients have physical symptoms, and about 30–40% have depressive symptoms. The combined effects of physical and depressive symptoms on HRQOL have not been examined fully in HF.
To examine the combined effects of physical and depressive symptoms on HRQOL using repeated measures, controlling for covariates (i.e. age, education level, New York Heart Association (NYHA) functional class, financial status, and health perception).
Patients (N = 224, 62 ± 12 years old, 67% male, 38% NYHA functional class III/IV) provided data on physical (Symptom Status Questionnaire) and depressive symptoms (Beck Depression Inventory II) at baseline and HRQOL (Minnesota Living with Heart Failure Questionnaire) at baseline and 12 months. Patients were divided into three groups based on presence of physical and depressive symptoms: a) no symptom group, b) one symptom group (dyspnea or fatigue), and c) two symptom group (physical and depressive symptoms). Repeated measures ANOVA was used to analyze the data.
The least squares mean scores of baseline and 12-month HRQOL differed significantly in the three groups after controlling for the covariates (26.4 vs. 36.6 vs. 53.1, respectively, all pairwise p values < 0.001). There was no time-by-group interaction or time main effect.
Physical and depressive symptoms have a dose–response relationship with HRQOL. Further research is needed to provide effective interventions to improve physical and depressive symptoms, in turn, HRQOL.
Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure.
To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure.
A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS).
Cronbach’s alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22–.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman’s rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t318 = –5.05, p < .001) supported construct validity.
The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.
Refractory angina pectoris (AP) is a persistent, painful condition characterized by angina caused by coronary insufficiency in the presence of coronary artery disease. It has been emphasized that there are possible underlying neuropathophysiological mechanisms for refractory AP but chronic ischemia is still considered to be the main problem. These patients suffer from severe AP and cannot be controlled by a combination of pharmacological therapies, angioplasty or coronary bypass surgery. AP has a negative impact on quality of life and daily life. Enhanced external counterpulsation (EECP) is a therapeutic option for these patients.
The aim of this study was to evaluate EECP after six months regarding physical capacity and health-related quality of life (HRQoL) in patients with refractory AP.
This was a study with single case research experimental design involving 34 patients treated with EECP. Six minute walk test (6MWT), functional class with Canadian Cardiological Society (CCS) classification and self-reported HRQoL questionnaires as Short Form 36 (SF-36) were collected at baseline and after treatment. CCS class and SF-36 were repeated at six months follow-up.
Patients enhanced walk distance on average by 29 m after EECP (p<0.01). CCS class also improved (p<0.001) and persisted at six months follow-up (p<0.001). HRQoL improved significantly and the effects were maintained at follow-up after the treatment.
Patients with refractory AP receive beneficial effects from EECP both in physical capacity and HRQoL. As other treatment options for this patient group are scarce, EECP should be offered to improve physical health and HRQoL in these patients.
Purpose: This study systematically examined previous studies on the effect of early ambulation on vascular complications in subjects who had just undergone a percutaneous coronary intervention (PCI), and analyzed the effects of early ambulation on both hemorrhage and hematoma formation at the puncture site.
Methods: Study data were analyzed using the R (version 2.13.1) program. Publication bias was verified via regression analysis, using the logarithm of the odds ratio (OR) and sample size, and a funnel plot using sample size. The risk ratio of the incidence of bleeding and hematoma formation at the puncture site, relative to early ambulation, was confirmed using ORs and the forest plot.
Results: The PCI recipients’ bed rest time had no significant effect on the risk ratio of hematoma formation (OR = 0.89; 95% CI = 0.68–1.17) nor the incidence of bleeding (OR = 1.14; 95% CI = 0.77–1.7) at the puncture site.
Conclusions: This retrospective study’s findings show that early ambulation following PCI had no effect on the incidence of either hematoma formation nor bleeding at the puncture site; however, differences in demographic factors should be considered carefully, in order to avoid interpreting the results too broadly.