Engaging patients in managing their cardiovascular health

Psychological factors play a major part in the impact, course, and treatment of cardiovascular disease. Patients' cognitions and emotions feed into their responses to their illness and its treatments and can, for example, affect the likelihood of attendance at cardiac rehabilitation programmes. It is important to view the rehabilitation process from the perspective of the patient and to examine and assess patients' beliefs. Self management and self efficacy need to be encouraged. Depression and anxiety are common after myocardial infarction and can influence outcome. A patient's mood state should be assessed routinely and regularly.     

Effects of exercise and cardiac rehabilitation on cardiovascular outcomes

Cardiac rehabilitation was originally conceived to counteract the deconditioning and comorbidities associated with prolonged bed rest after a myocardial infarction. Contemporary cardiac rehabilitation has taken a more comprehensive approach, with a broader range of participating patients. Relevant cardiovascular outcomes of cardiac rehabilitation can be classified as primary clinical outcomes, intermediate clinical outcomes, and quality-of-life outcomes. In this article, the effects of exercise training alone and, more importantly, the value of comprehensive cardiac rehabilitation are reviewed from the point of view of individual cardiovascular outcomes.     

Factors associated with referral to outpatient cardiac rehabilitation services

BACKGROUND: Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low. PURPOSE: This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia. METHODS: The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral. RESULTS:: Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery. CONCLUSIONS: Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.     

Secondary Prevention After Acute Myocardial Infarction and Coronary Revascularisation: Focus on Angiotensin Converting Enzyme Inhibitors

INTRODUCTION: Cardiovascular disease (CVD) is responsible for an estimated one third of all deaths worldwide. PATIENTS AND METHODS: One group of patients who are at a particularly high risk of cardiovascular events and death are those with stable coronary artery disease (CAD), especially if they have had a previous myocardial infarction (MI) or revascularisation. DISCUSSION: Lifestyle changes (smoking, alcohol intake, diet, exercise) and cardiac rehabilitation play an important part in reducing risk of recurrent events. In patients with a history of MI and/or those who underwent myocardial revascularisation these have to be supplemented with medication. Several pharmacological agents are known to improve prognosis in these patients, i.e. beta-blockers, antiplatelet agents, statins, and angiotensin converting enzyme inhibitors (ACEi). The present article focuses mainly on the role of ACEi in the prevention of cardiovascular events in patients with a history of MI or myocardial revascularization.     

Wellness motivation in cardiac rehabilitation

Lack of patient adherence to prescribed regimens is a fundamental problem in cardiac rehabilitation programs. A causative factor in lack of patient adherence may be related to failure to address differences in individual health behavior motivation in cardiac rehabilitation. A group of 52 patients who had had myocardial infarction were sampled to test the relationship between social support systems, health locus of control, health value orientations, and wellness motivation. Pearson correlation coefficients indicated significant positive correlations between health locus of control variables, health value orientation variations, and wellness motivation. Health locus of control and health value orientation variables entered into a multiple regression equation to explain 32% of the variation in wellness motivation. Awareness of individual motivational responses that influence health behaviors in cardiac rehabilitation may enable nurses to develop intervention strategies for patients with cardiovascular disease who would benefit from modifying their risk-producing life-styles.     

Effectiveness of physical training in patients who have had a myocardial infarct

A study of the effects of exercise on cardiovascular function of myocardial infarction survivors showed their physical stress tolerance to increase as a result of improved myocardial contractility and the optimum adjustment of hemodynamic and oxygen support of exercise. Therefore, exercise should be used more extensively as part of the rehabilitation effort following myocardial infarction.     

心肺运动试验在心血管疾病中的诊疗和预后价值探讨

心血管疾病发病率和病死率持续增高,心肌缺血和心肌梗死是主要病因。心肺耐力反应了个体的心肺功能契合度以及对最大运动强度的耐受程度。心肺耐力为人体五大生命体征之一,可用于评价心血管疾病患病风险。心肺运动试验(CPET)作为新兴的心肺一体化客观无创检测技术,可以较早的推测出患者潜在的病理生理改变。CPET的数据解读相对复杂及未得到广泛普及,其在临床的应用潜力巨大。目前CPET应用领域包括疾病的诊断、病情及预后风险评估、运动处方制定等。用CPET对心血管疾病的早期风险予以评估和诊断,实现早干预、早治疗,符合心脏康复的主流。     

Efficacy of cardiac rehabilitation services. With emphasis on patients after myocardial infarction

During the 1970s, emphasis increased in clinical practice on early ambulation and exercise-based rehabilitation after myocardial infarction and other cardiac illnesses or procedures. This shift was based on the belief that exercise and improved conditioning would improve prognosis. We examine the evidence supporting this assertion. Most of the reports on cardiac rehabilitation are about patients who have coronary artery disease and a history of myocardial infarction. The review, therefore, is focused primarily on the patient who has had a myocardial infarction. Effects of cardiac rehabilitation, emphasizing exercise treatment and conditioning, are reviewed with regard to patient outcomes, including changes in functional (work) capacity, psychosocial functioning and health-related knowledge, risk factor modification, morbidity and mortality, and cardiac function. The safety of cardiac exercise programs is reviewed, and the use of telemetry monitoring is considered. We also discuss the role of cardiac rehabilitation in categories of patients other than those with myocardial infarction and the application of newer approaches to rehabilitation such as programs based in the patient's home.     

可穿戴设备在心肌梗死患者随访管理中的应用

主动健康要求个体主动获得持续的健康能力,要求慢性病患者自发和积极地关注自身健康,参与到疾病的管理中来.然而,常规随访手段不能满足心肌梗死患者的长期管理要求,患者对自己生命体征的把握,以及心血管健康状况、药物优化治疗方案和康复锻炼效果缺乏足够的了解手段.具有多种传感器的可穿戴设备为心肌梗死患者危险因素的管理、病情的监测和...     

Social support and its relationship to morbidity and mortality after acute myocardial infarction: systematic overview

Among the commonly understood socioeconomic determinants of health, social change, disorganization, and poverty have been associated with an increased risk of morbidity and mortality. One of the postulated mechanisms through which these determinants have been linked to health and illness is their relationship to social support. The health determinant, social isolation or lack of a social support network (SSN), and its effects on premature mortality after acute myocardial infarction mandate further scrutiny by the cardiovascular community for several reasons. First, as a predictor of 1-year mortality, low SSN is equivalent to many of the classic risk factors, such as elevated cholesterol level, tobacco use, and hypertension. Second, treatment of acute myocardial infarction is costly. Because low social support is associated with an increased 1-year mortality, neglecting the role of the SSN may diminish the possible gains accrued during acute-phase treatment. Therefore, lack of an SSN should be considered a risk factor for subsequent morbidity and mortality after a myocardial infarction. Finally, cardiac rehabilitation programs and other extant prevention strategies can be better used to reduce mortality after myocardial infarction. This article systematically reviews recent evidence related to SSNs to provide an update on the role of social support in cardiovascular disease-related outcomes.     

Results of the residential cardiac rehabilitation in patients after myocardial infarction treated with percutaneous coronary intervention (PCI)

Patients after cardiac infarct and primary PCI are mainly people shortly immobilized with slight damage of the heart muscle with good condition and low consciousness of the disease. Development of the cardiology gives new goals for a cardiac rehabilitation. Traditional rehabilitation targets just like preventation results of immobilization and raising of efficiency are now not so important. Main task of modern rehabilitation, except function improvement of life quality, is preventation of progress coronary disease and reduction of mortality by changing health behavior, especially consent to regular physical activity. The purpose of this study was to evaluate physical efficiency and life quality of life in patients after myocardial infarction treated with PCI who participated in residential cardiac rehabilitations according to age and time of beginning this process. 167 patients (male) after myocardial infarction treated with primary PCI in age 33-82 years, mean age 57,1 +/- 8,92 (years). All patients participated in a 20 +/- 2 (days) comprehensive residential cardiac rehabilitation. ECG treadmill exercise test according Bruce protocol was performed after beginning and at the end of rehabilitation process. Quality of life was evaluated according to SF-36 questionnaire completed at the beginning and after rehabilitation programm. Residential cardiac rehabilitation increases physical efficiency and improves quality of life in patients who undergo primary PCI after myocardial infarction. Effects of cardiac rehabilitation dose not depend on age or on time of beginning of rehabilitation. Most significant increase of physical efficiency was observed in patients who were referend to cardiac rehabilitation no longer then 6 weeks after cardiac event.     

Factors which influence attendance at a rural Australian cardiac rehabilitation program

This study investigated factors that are associated with and predict attendance of patients following acute myocardial infarction, at the cardiac rehabilitation program of Wimmera Health Care Group, Horsham, Australia. Previous research suggested age, gender, distance from cardiac rehabilitation and lack of social support were associated with non-attendance at a cardiac rehabilitation program. A survey form was compiled to collect demographic data, cardiac risk factor information and cardiac rehabilitation referral and attendance details. Seventy-nine of 115 patients discharged alive with a diagnosis of acute myocardial infarction completed and returned the survey form. The results indicated that being older, living further away, living alone and not having access to private transport were significantly associated with cardiac rehabilitation non-attendance. The factors that predicted cardiac rehabilitation attendance in 93.59% of cases were being referred to the program, living an average of 27 km away compared to an average of 47 km, living with a partner and being male.     

Highly Purified Omega-3 Fatty Acids for Secondary Prevention of Sudden Cardiac Death After Myocardial Infarction—Aims and Methods of the OMEGA-Study

Introduction

During the last decades a large body of data has been accumulated indicating omega-3 fatty acids to exert beneficial effects on the prognosis of patients with cardiovascular disease. Especially, omega-3 fatty acids are regarded to be effective in reducing the risk of sudden cardiac death after acute myocardial infarction. However, treatment of acute myocardial infarction and secondary prevention considerably have been improved within the past years including early revascularization by PCI, the routine use of beta-blockers, statins and ACE-inhibitors as well as cardiac rehabilitation for improving life style measures. To date, there exists no controlled randomized trial testing the prognostic effect of omega-3 fatty acids after acute myocardial infarction in a double blind regimen under the conditions of modern treatment of myocardial infarction.

Materials and methods

The present study therefore evaluates the effect of highly purified omega-3 fatty acid ethylesters (omega-3-acid ethyl esters 90=Zodin®) on the rate of sudden cardiac death within 1 year after acute myocardial infarction. Secondary endpoints are total mortality, non-fatal cardiovascular events, rhythm abnormalities in holter monitoring and depression score.

Result and conclusion

The recruitment-period started in October 2003 and is expected to last until December 2006. The results of the study are therefore expected for the beginning of 2008, when all patients will have completed the 12-months follow up-period.     

Safety of cardiac rehabilitation in a medically supervised, community-based program

The time to occurrence of cardiovascular complications after the beginning of an exercise rehabilitation program is variable. It is not clear whether such complications are related to the duration in the program. The aim of the present study was to assess the timing of cardiovascular events occurring during the activity and the long-term safety of a medically supervised cardiac rehabilitation program performed in the community, in a large cohort. We retrospectively evaluated 3,511 patients with a history of myocardial infarction, coronary artery bypass grafting and risk factors for coronary artery disease, participating in exercise training, for 69 months. The total number of patient-hours was 338,688 with an event rate of 1/58,902 patient-hours/year (0.02%). Non-fatal events occurred in 11 patients and fatal cardiovascular events in 2 patients; 1 was successfully resuscitated. Most of the non-fatal events (62%) occurred during the first 4 weeks from the beginning of the exercise program. One third of the patients who experienced cardiovascular events, resumed the exercise program with no further complications. Medically supervised cardiac rehabilitation program is accompanied by a very low incidence of cardiovascular events. Nevertheless, special caution should be undertaken during the first sessions of the program.     

抗阻运动对老年心脏康复作用的研究进展

心血管疾病已成为我国居民致残致死的首要病因,心脏康复对心血管疾病患者十分重要,可以提高生活质量、运动能力和体力活动能力,降低再住院率和病死率。抗阻运动是心脏康复的重要组成部分,可以提高肌肉力量、耐力和身体活动能力。本综述旨在总结抗阻运动对老年人群心脏康复的作用,为更好的改善老年心血管病患者的预后提供帮助。     

Cardiovascular complications during exercise training of cardiac patients

The occurrence of major cardiovascular complications during exercise training of cardiac patients in 30 cardiac rehabilitation programs in North America was determined by questionnaire. These programs conducted medically supervised cardiac exercise classes in 103 locations and reported information on 13,570 participants who accumulated a total of 1,629,634 patient hours of supervised exercise. Cardiovascular complications were reported as nonfatal or fatal and included cardiac arrest, myocardial infarction and other. A total of 50 cardiac arrests were observed during exercise, 42 of which were successfully resuscitated while eight were fatal. Seven myocardial infarctions were reported; five were nonfatal and two were fatal. Four other fatalities were reported due to acute cardiopulmonary disorders. The average complication rate for all programs was one nonfatal and one fatal event every 34,673 and 116,402 patient hours of participation, respectively. Complication rates are lower in programs which continuously monitor the electrocardiogram during exercise and are lower when only the experience since 1970 is evaluated. These data support the recommendation that medically prescribed and supervised exercise can be performed reasonably safely by medically selected cardiac patients.     

Procedural Guidance Using Advance Imaging Techniques for Percutaneous Edge-to-Edge Mitral Valve Repair

Human sexuality is an important aspect of health and quality of life. Many patients with ischemic heart disease – and their partners – are concerned that sexual activity could exacerbate their cardiac condition, possibly causing myocardial infarction or cardiac death. Patients with ischemic heart disease who wish to initiate or resume sexual activity should be evaluated with a thorough medical history and physical examination. Sexual activity is reasonable for individuals with no or mild angina and those who can exercise ≥3-5 METS without angina, excessive dyspnea, or ischemic ST segment changes. For the patient who is considered not be at low cardiovascular (CV) risk or in whom the CV risk is unknown, an exercise stress test is reasonable in order to determine his or her exercise capacity and to ascertain if symptoms or ischemia may occur. Regular exercise and cardiac rehabilitation can be effective in reducing the risk of CV complications associated with sexual activity for the patient with ischemic heart disease.     

Clinical implications of high‐sensitivity cardiac troponins

Cardiac troponin assays have become more sensitive over the years leading to the clinical introduction of high‐sensitivity cardiac troponin assays in 2010. Their use has revolutionized the assessment of patients with chest pain in the emergency department by allowing earlier rule‐in and rule‐out of myocardial infarction leading to shorter stays in the emergency department and reduced admissions for chest pain. The incidence of myocardial infarction has increased slightly, and patients with myocardial infarction diagnosed with high‐sensitivity cardiac troponins have been found to have a reduced risk of reinfarction, though without an impact on survival. High‐sensitivity cardiac troponins are powerful predictors of long‐term mortality and cardiovascular disease in the general population as well as in patients with chest pain with or without cardiovascular disease. The increase in risk for death and cardiovascular disease associated with high‐sensitivity cardiac troponins is graded and starts already at detectable levels, well below the upper normal level. The aim of this review was to describe the clinical use and consequences of the introduction of high‐sensitivity cardiac troponins. In addition, the importance of persistently elevated troponin levels for prognosis and what investigations may be appropriate to perform in patients with stable troponin elevations are discussed.     

Economic evaluation of cardiac rehabilitation: a systematic review.

BACKGROUND: Economic evaluation is an important tool in the evaluation of competing healthcare interventions. Little is known about the economic benefits of different cardiac rehabilitation program delivery models. DESIGN: The goal of this study was to review and evaluate the methodological quality of published economic evaluations of cardiac rehabilitation services. METHODS: Electronic databases were searched for English language evaluations (trials, modeling studies) of the economic impact of cardiac rehabilitation. A review of study characteristics and methodological quality was completed using standardized tools. All costs are adjusted to 2004 US dollars. RESULTS: Fifteen economic evaluations were identified which met eligibility criteria but which displayed wide variation in the use of comparators, evaluation type, perspective and design. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation in myocardial infarction and heart failure patients was identified. The range of cost per life year gained was estimated as from 2193 dollars to 28,193 dollars and from - 668 dollars to 16,118 dollars per quality adjusted life year gained. The level of evidence supporting the economic value of home-based cardiac rehabilitation interventions is limited to partial economic analyses. CONCLUSIONS: Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. Further trials are required to support the cost-effectiveness of cardiac rehabilitation in cardiac patients who have under gone revascularization. The literature evaluating home-based and alternative delivery models of cardiac rehabilitation was insufficient to draw conclusions about their relative cost-effectiveness. The overall quality of published economic evaluations of cardiac rehabilitation is poor and further well-designed trials are required.     

Participation in Cardiac Rehabilitation,Readmissions, and Death After Acute Myocardial Infarction

Background

Participation in cardiac rehabilitation has been shown to decrease mortality after acute myocardial infarction, but its impact on readmissions requires examination.

Methods

We conducted a population-based surveillance study of residents discharged from the hospital after their first-ever myocardial infarction in Olmsted County, Minnesota, from January 1, 1987, to September 30, 2010. Patients were followed up through December 31, 2010. Participation in cardiac rehabilitation after myocardial infarction was determined using billing data. We used a landmark analysis approach (cardiac rehabilitation participant vs not determined by attendance in at least 1 session of cardiac rehabilitation at 90 days post-myocardial infarction discharge) to compare readmission and mortality risk between cardiac rehabilitation participants and nonparticipants accounting for propensity to participate using inverse probability treatment weighting.

Results

Of 2991 patients with incident myocardial infarction, 1569 (52.5%) participated in cardiac rehabilitation after hospital discharge. The cardiac rehabilitation participation rate did not change during the study period, but increased in the elderly and decreased in men and younger patients. After adjustment, cardiac rehabilitation participants had lower all-cause readmission (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.65-0.87; P < .001), cardiovascular readmission (HR, 0.80; 95% CI, 0.65-0.99; P = .037), noncardiovascular readmission (HR, 0.72; 95% CI, 0.61-0.85; P < .001), and mortality (HR, 0.58; 95% CI, 0.49-0.68; P < .001) risk.

Conclusions

Cardiac rehabilitation participation is associated with a markedly reduced risk of readmission and death after incident myocardial infarction. Improving cardiac rehabilitation participation rates may have a large impact on post-myocardial infarction healthcare resource use and outcomes.