Listening to patients: choice in cardiac rehabilitation.

BACKGROUND: The benefits of cardiac rehabilitation (CR) after myocardial infarction (MI) are increasingly recognised and is recommended in national guidelines. AIMS: To explore patients' experience of MI and to identify the factors which influence the choice patients make given the option of hospital or home-based CR after MI. METHOD: Qualitative study using semi-structured interviews and interpretive phenomenological analysis (IPA). This study was embedded within a randomised trial with preference arms. RESULTS: Seventeen participants were interviewed before their rehabilitation programme. Ten expressed a preference for home-based and seven for hospital-based rehabilitation. Common to both groups was shock and disbelief, which led to a loss of confidence. They expressed a strong desire to make lifestyle changes and looked for specific advice, guidance and support from knowledgeable experts. The hospital-based group had an emphasis on supervision during exercise, needed the camaraderie of a group, were willing to make travel arrangements and believed they lacked self-discipline. The home-based group believed that their CR should fit in with their lives rather than their lives fitting in with the rehabilitation programme and were self-disciplined. They disliked groups and expressed practical concerns. CONCLUSIONS: Understanding the factors that influence patient's choices may help professionals guide them to the most appropriate CR method and hence improve uptake.     

早期心脏康复程序对急性心肌梗死患者经皮冠状动脉介入术后心脏收缩功能的影响

目的:通过三维斑点追踪成像技术评估急性心肌梗死患者(AMI)经皮冠状动脉介入术(PCI)后的左室整体及局部收缩功能变化,探讨以社区为主的早期心脏康复训练对AMI患者的心功能影响。方法:根据是否愿意参加心脏康复,将急性心肌梗死术后患者分为康复组(25例)和对照组(25例)。其中,康复组参与12周的心脏康复程序,进行早期心脏康复训练。对照组仅接受常规护理。在研究开始前、结束后,所有患者均接受三维斑点追踪成像(Three-dimensional speckle tracking imaging,3D-STI)检查,获得左心室整体及各节段纵向、径向、周向及面积应变值(LS、RS、CS、AS)。结果:经过12周的康复程序后,康复组的整体纵向应变(global longitudinal strain,GLS)、整体圆周应变(global circumferential strain,GCS)、整体径向应变(global radial strain,GRS)、整体面积应变(global area strain,GAS)及左室射血分数(left ventricular ejection fraction,LVEF)较对照组显著增加(P0.01)。根据左室心肌节段分区法,两组间左前降支供血区域各有150节段,左回旋支供血区域各有125节段,右冠脉供血区域各有125节段。经过12周的康复程序后,康复组不同冠脉供血区域的LS、RS、CS、AS较对照组显著增加(P0.05)。结论:早期心脏康复治疗可以改善经PCI术后患者的心脏收缩功能。     

Health care and social welfare costs in home-based and hospital-based rehabilitation after stroke

During the 1990s most western European and Organization of Economic Cooperation and Development (OECD) countries experienced financial difficulties and were forced to cut back on or restrain health care expenditures. Home rehabilitation has received attention in recent years because of its potential for cost containment. Often forgotten, however, is the redistribution of costs from one caregiver to another. The aim of this study was to analyse whether a redistribution of costs occurs between health care providers (the County councils) and social welfare providers (the municipalities) in a comparison of home-based rehabilitation and hospital-based rehabilitation after stroke. The study population included 123 patients, 53 in the home-based rehabilitation group and 68 in the hospital-based rehabilitation group. The patients were followed up at 6 and 12 months after onset of stroke. Resource use over a 12-month period included acute hospital care, in-hospital rehabilitation, home rehabilitation and use of home-help service as well as nursing home living. The hospital-based rehabilitation group had significantly fewer hospitalization days after a decision was made about rehabilitation at the acute care ward and consequently the cost for the acute care period was significantly lower. The cost for the rehabilitation period was significantly lower in the home-based rehabilitation group. However, the cost for home help service was significantly higher in the home-based rehabilitation group. The total costs for the care episode did not differ between the two groups. The main finding of this study is that there seems to occur a redistribution of costs between health care providers and social welfare providers in home rehabilitation after stroke in a group of patients with mixed degree of impairment.     

叙事护理在急诊经皮冠状动脉介入术后病人心脏康复中的应用

[目的]探讨叙事护理干预急性心肌梗死行急诊经皮冠状动脉介入(PCI)术后病人在心脏康复中的应用效果。[方法]选取2017年2月—2019年1月在医院心血管内科收治的急性心肌梗死行急诊PCI术病人106例,按照入院顺序分为观察组和对照组各53例。在心脏康复的心理处方中,对照组按常规给予健康教育和心理疏导,观察组在常规护理基础上采取叙事疗法,比较两组的干预效果。[结果]干预2周后观察组病人焦虑自评量表(SAS)、抑郁自评量表(SDS)、总体生活质量评分优于对照组,两组干预后SAS、SDS、总体生活质量评分优于干预前(P<0.05)。[结论]将叙事护理应用到急性心肌梗死PCI术后病人中减轻了病人焦虑、抑郁症状,生活质量得到明显改善,有益于病人早日康复。     

早期康复治疗对无并发症急性心肌梗死患者QT间期离散度的影响

目的探讨早期康复治疗对无合并症急性心肌梗死 (acute myocardial infarction ,AMI )患者 QT间期离散度( QTd)的影响. 方法 113例研究对象前瞻性随机分为早期康复治疗组 (组 1, 54例 )及对照组 (组 2, 59例 ). 2组主要基线资料具可比性.组 1采用早期康复治疗方案,组 2采用传统康复方案.所有研究对象分别在入院当时 [平均( 9.3± 1.9) h]第 1周末、第 2周末、第 3周末记录标准 12导联心电图. QT 间期的测量从 QRS 波起点至 T波终点,同一导联测量 3个心动周期,取其平均值.不同导联最大减去最小 QT值为 QTd 值. 结果早期康复组入院当时、第 1 周末、第 2 周末、第 3周末 QTd[分别为 (64± 14)ms,(46± 15)ms,(43± 12)ms,(39± 13)ms]与对照组 [分别为 (67± 12)ms,(48± 16)ms,(41± 13)ms,(40± 15)ms]比较统计学上无显著性差异( t分别为 0.81,0.68,0.85,0.38, P >0.05). 结论无合并症 AMI 患者实行早期康复治疗不影响 QTd 值,因而不影响心肌电稳定性,提示该组患者早期康复治疗安全可行.     

循证护理在急性心肌梗死后心律失常护理中的应用研究

目的:探讨循证护理在急性心肌梗死(AM I)后心律失常护理中的应用效果。方法:将患者随机分为研究组32例,对照组30例。研究组重点从“AM I后心律失常时相分布特征、AM I后心律失常可控因素、AM I后心理干预措施、AM I后康复训练”四个方面进行循证,并用以指导临床护理;对照组按常规护理。结果:两组患者心律失常发生率、平均住院日、心功能分级比较有显著性差异(P<0.05)。结论:应用循证护理能显著降低AM I后心律失常的发生。     

心理干预结合运动训练对冠脉搭桥患者术后恢复及心功能的影响

目的:观察心理干预联合运动训练对冠状动脉搭桥(CABG)患者术后恢复及心功能的影响。方法:52例拟行CABG的住院患者随机分为康复组(n=27)和对照组(n=25)。康复组给予心理干预治疗和强度渐增的运动。主要观察指标为:焦虑自评量表(SAS)、抑郁自评量表(SDS)、6min步行试验(6MWT)、肿瘤坏死因子α(TNFα)、左室射血分数(LVEF)、术后插管时间、重症护理时间与术后住院时间。结果:与对照组比较,康复组患者术后SAS与SDS评分下降显著(P<0.01);康复组患者6min步行距离(6MWD)明显加长(P<0.005);康复组TNF-α浓度明显降低(P<0.01);康复组患者术后呼吸机辅助通气时间及重症监护时间较对照组缩短(P<0.05);与术前比较,康复组LVEF明显改善(P<0.005);将康复组患者的上述观察指标进行相关性分析,结果显示SAS、SDS评分的下降分别与6MWD的加长(rSAS=0.46,P<0.01;rSDS=0.48,P<0.01)成明显正相关。结论:心理干预联合运动训练可以改善CABG术后患者的焦虑及抑郁程度,提高运动能力,促进心脏功能的恢复。     

Outcomes of inappropriate prescribing of beta-blockers after an acute myocardial infarction in a Medicaid population

BACKGROUND: Acute myocardial infarction (AMI) is associated with high mortality. beta-Blockers are known to reduce mortality and reinfarction rates when used for long-term prevention following an AMI. OBJECTIVE: To assess the prescribing patterns of beta-blockers in patients after experiencing an AMI in the West Virginia Medicaid program and examine its impact on patient outcomes. METHODS: One-year pre- and post-AMI data were extracted for 488 Medicaid patients. Prescribing of beta-blockers within 90 days after discharge was evaluated among these patients. Based on American Heart Association/American College of Cardiology guidelines, patients were divided into 2 groups: those prescribed therapy appropriately and those prescribed therapy inappropriately (underuse, misuse). One-year all-cause mortality, cardiac mortality, and cardiac morbidity were compared between the groups using survival analysis. RESULTS: Approximately 64% of the patients were appropriately prescribed beta-blockers and illustrated significantly (p = 0.035) lower all-cause mortality rates compared with the inappropriately prescribed group at the one-year follow-up. Cardiac mortality evaluation showed no significant findings. The groups differed significantly in morbidity outcome (time to first cardiac hospitalization), with the inappropriate group exhibiting later hospitalization at the end of the year (p = 0.019). However, the appropriate group had a higher proportion of hypertensive patients, suggesting more severity compared with the inappropriate group. CONCLUSIONS: Inappropriate prescribing of beta-blockers following AMI was observed in this Medicaid population. Data suggest that there were overall survival benefits associated with appropriate beta-blocker prescribing. However, cardiac morbidity associated with inappropriate prescribing needs to be evaluated after adjusting for disease severity between the 2 groups.     

A predominantly home-based progressive resistance exercise program increases knee extensor strength in the short-term in people with chronic obstructive pulmonary disease: a randomised controlled trial

QUESTIONS: Does a 12-week, predominantly home-based program of progressive resistance exercises reduce impairments, activity limitations, and participation restrictions in people with chronic obstructive pulmonary disease? Are any gains maintained 12 weeks after the cessation of the program? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: 54 people with moderately severe chronic obstructive pulmonary disease not undergoing pulmonary rehabilitation. INTERVENTION: The experimental group performed six progressive resistance exercises three times per week (once a week hospital-based, twice a week home-based) for 12 weeks. Exercise intensity was three sets of 8 to 12 repetition maximum progressed against elasticised bands of increasing resistance. The control group received no intervention. OUTCOME MEASURES: Primary outcomes were strength (knee extensor, hip abductor, shoulder horizontal flexor, shoulder flexor) measured using hand-held dynamometry, and walking capacity measured by the 6-minute Walk Test performed before and after intervention and again at 12 weeks after the cessation of intervention. RESULTS: The experimental group increased their knee extensor strength by 4.9 kg (95% CI 1.1 to 8.7) more than the control group by Week 12. However, this gain was not maintained at Week 24. No difference between the groups was found for any of the other primary outcomes. CONCLUSIONS: A predominantly home-based progressive resistance exercise program led to modest improvements in knee extensor strength in people with chronic obstructive pulmonary disease. However, 44% of the experimental group were unable to complete the exercise program, highlighting the need to understand factors influencing adherence to exercise in this population.     

2周住院心脏康复程序对急性心肌梗死患者血脂、生存质量及精神心理状态的影响

目的：探讨2周住院心脏康复程序对急性心肌梗死（AMI）患者血脂、生存质量及精神心理状态（焦虑）的影响。方法：选择轻度AMI患者40例，随机分为对照组20例，康复组20例。对照组进行常规内科治疗．康复组在常规内科治疗的同时进行2周住院心脏康复程序治疗，出院后继续康复治疗3个月。康复前及康复3个月后分别评价血脂水平，生存质量（QOL）、状态-特质焦虑（state-trait anxiety inventory，STAI）及体力活动程度，与对照组及康复前进行比较。结果：康复前，两组间的各项指标比较差异无显著性意义。康复组，与康复前比较．康复3个月后HDL-C（P〈0．01）、TC／HDL-C（P〈0．05）均得到明显改善：康复后QOL总分和社会态度与主观幸福感评分均比康复前明显增加（P均〈0．05）；状态焦虑（S-AI）和特质焦虑（T-AI）均比康复前明显降低（P均〈0．05）；康复后体力活动程度明显改善（P〈0．01）。结论：2周住院心脏康复程序能明显改善轻度AMI患者的血脂．改善体力活动程度，改善精神心理状态（焦虑）．提高生存质量。     

Patients' experience of home and hospital based cardiac rehabilitation: A focus group study

Background

New cardiac rehabilitation (CR) programmes, such as home programmes using the Heart Manual, are being introduced but little is known about patients' experiences of these.

Aims

To compare the views of patients who had completed a home or hospital-based CR programme and explore the benefits and problems of each programme.

Methods

16 patients from 4 hospital programmes attended one of 3 focus groups; 10 home programme patients attended one of 2 focus groups.

Results

Some themes were common to all focus groups: loss of confidence; continuing to exercise and lifestyle changes; understanding of heart disease. Hospital programme patients particularly enjoyed exercising in a group and mixing with other people, and gained motivation and support from others. Home programme patients spoke very highly of the Heart Manual and valued the one-to-one support of the nurse facilitators. They described the home programme as a lifestyle change compared to the hospital programme which they suggested was more like a treatment.

Conclusions

Patients in the hospital programme enjoyed the camaraderie of group exercise and patients in the home programme valued the wealth of information and advice in the Heart Manual and this gave them a feeling of being in control of their health.     

心理行为干预对急性心肌梗死急诊PTCA及支架术后康复的影响

目的：探讨心理行为干预对急诊经皮冠状动脉内成形（PTCA）及支架术后患者康复的影响。方法：84例接受急诊PTCA及支架植入术成功的急性心肌梗死（AMI）患者随机分为干预组和对照组各42例,均常规药物治疗和AMI常规护理,干预组同时配合系统的心理行为干预,包括心理支持、康复锻炼及院外指导等。结果：经过6个月观察,干预组患者的焦虑、抑郁（SAS、SDS）评分与干预前及对照组比较均明显下降;血糖、血脂、体质量及再住院率均低于对照组;患者用药依从性、戒烟率及恢复工作率均明显高于对照组（P〈0.05,0.01）。结论：系统心理行为干预能明显缓解急诊PTCA及支架术后患者的负面情绪,促进心脏康复和提高生存质量。     

Broadening the reach of cardiac rehabilitation to rural and remote Australia.

BACKGROUND: Cardiac rehabilitation (CR) has an evidence base but traditional models may not readily apply to people living in rural and remote regions. AIM:: To outline published comprehensive and non-hospital based CR models used for people discharged from hospital after a cardiac event that have potential relevance to those living in rural and remote areas in Australia. METHODS: The PubMed database was searched using Medical subject headings (MeSH) terms and the key word 'cardiac rehabilitation' limited to clinical trials. Articles were retrieved if they included at least two components of CR and were not based in an outpatient setting. RESULTS: No CR models specifically developed for rural and remote areas were identified. However, 14 studies were found that outlined 11 non-conventional comprehensive CR models. All provided CR in a home-based setting. Health professionals provided support via telephone contact or home visits, and via resources such as the Heart Manual. Reported outcomes from these CR programs varied: ranging from an increase in knowledge of risk factors, to improvements in physical activity, decreased risk factor profile, improved psychological and social functioning and reductions in health service costs and mortality. CONCLUSION: Home-based, CR models have the most substantive evidence base and, therefore the greatest potential to be developed and made accessible to eligible people living in rural and remote areas.     

Psychology in coronary care

Psychological stress has been implicated in the onset and progression of coronary heart disease (CHD). Recent research has highlighted the importance of depression and anxiety as independent risk factors for mortality in cardiac patients. Accordingly, it is critical that clinically significant levels of distress are identified, both in-hospital and after discharge, to target patients who require specific psychological intervention, in addition to conventional cardiac rehabilitation. Ameliorating distress has been shown to improve adherence to treatment advice, such as modifying cardiac risk factors, compliance with medication regimens, and attendance at exercise programmes, which in turn should reduce cardiac morbidity and mortality. The emphasis within cardiac rehabilitation should be on tailoring provision to meet individual patients' needs.     

Effects of cardiac rehabilitation program on exercise capacity and chronotropic variables in patients with orthotopic heart transplant

AIM: To evaluate the effects of home- and hospital-exercise programs on exercise capacity and chronotropic variables in patients with heart transplantation. METHODS: Forty patients were randomized into two groups either hospital- or home-based exercise program. The patients were compared, before and after the rehabilitation program, with respect to maximal oxygen uptake (pVO(2)), chronotropic variables [heart rate reserve (HRR(e)), heart rate recovery (HRR(1)), and chronotropic response index (CRI)] and Duke Treadmill Score (DTS). RESULTS: Hospital-based exercise group has shown a significant recovery in post-exercise pVO(2) (pre-exercise 16.73 +/- 3.9 ml/kg/min, post-exercise 19.53 +/- 3.89 ml/kg/min, P = 0.002) and DTS (pre-exercise 4.74 +/- 1.17, post-exercise 5.61 +/- 1.11, P = 0.002). A significant recovery in favor of the hospital-based exercise group was found in HRR(e) (pre-exercise 26.9 +/- 14.6, post-exercise 34.6 +/- 14.6, P = 0.01). No significant change was observed in HRR(1) (pre-exercise -1.38 +/- 1.04, post-exercise -1.21 +/- 1.89, P = 0.49) and CRI (pre-exercise 0.44 +/- 0.23, post-exercise 0.48 +/- 0.20, P = 0.15) in hospital-based exercise group. No significant change was observed in any parameters of home-based group (P > 0.05). CONCLUSION: A significant recovery was observed both in the functional capacity and the chronotropic response in hospital-based exercise program. Exercise programs that are planned to be performed under supervision in rehabilitation units are useful for the patients with heart transplant in terms of the exercise capacity and chronotropic variables.     

信息-动机-行为模型在冠心病患者经皮冠状动脉介入术后心脏康复中的应用研究

目的 探讨信息-动机-行为(information-motivation-behavioral,IMB)模型在冠状动脉粥样硬化心脏病(冠心病)患者经皮冠状动脉介入治疗(percutaneous coronary intervention, PCI)术后心脏康复中的应用效果。方法 选取2021年1月-12月在心血管内科行PCI术的120例冠心病患者。按照随机数字表法将其分为对照组和研究组,各60例。对照组给予心脏康复健康教育,研究组在对照组基础上应用IMB模型进行个体化教育,比较2组干预3个月后的心脏康复信息需求和依从性。结果 干预3个月后,研究组心脏基础知识、营养知识、药物知识、心理压力、紧急与安全、风险因素评分及心脏康复依从性各条目评分均高于对照组(P＜0.05)。结论 应用IMB模型进行个体化教育,能改善冠心病PCI术后患者的心脏康复信息需求和依从性。     

心脏康复训练对冠心病患者生活质量的影响

目的探讨护士指导与支持下的病人自我管理型家庭心脏康复训练对改善冠心病患者生活质量的效果.方法将167名符合纳入与排除标准的冠心病患者随机分配到干预组与对照组.对照组84例接受常规治疗护理,干预组83例接受为期12周的患者自我管理型家庭心脏康复训练,包括药物管理、心绞痛管理、运动锻炼、饮食管理、戒烟等.生活质量用SF-36中文版测评.资料收集时间为干预前、干预后,以及干预结束后3个月随访时.结果接受心脏康复训练的干预组患者在一般健康状况、生理机能、生理职能、躯体疼痛、心理健康和精力方面的改善均显著优于对照组.三个月后随访时,其生理功能和生理职能的改善亦显著优于对照组.结论护士指导与支持下的患者自我管理型家庭心脏康复训练对改善冠心病患者的生活质量有积极作用.     

居家老年冠心病伴衰弱患者心肺运动康复效果评价

目的:观察心肺运动康复对居家老年冠心病伴衰弱患者心肺功能和生活质量的影响。方法:便利选取郑州市航海东路社区卫生服务中心的98例患者为研究对象,按照居住地分成两组,干预组与对照组各49例患者。对照组接受心肺康复健康教育,干预组接受心肺康复健康教育+心肺运动康复。比较干预前后两组患者衰弱得分、心肺功能和生活质量变化情况。结果:干预后,干预组患者衰弱总分及各维度得分低于对照组,差异具有统计学意义(P<0.05);干预组患者心率、收缩压、舒张压及心脏负荷量好于对照组,差异具有统计学意义(P<0.05);干预组患者用力肺活量、第一秒用力肺活量和一秒率水平好于对照组,差异具有统计学意义(P<0.05);干预组患者生活质量总分及各维度得分高于对照组,差异有统计学意义(P<0.05)。结论:心肺运动康复可以改善居家老年冠心病患者心肺功能及衰弱情况,提高患者生活质量。     

局部应用苯妥英治疗各类创口效果的系统评价

目的探讨局部应用苯妥英治疗各类创口的有效性和安全性.方法计算机检索MEDLINE(1966～2002.10)、EMBASE(1984～2002.10)、Cochrane 图书馆(2002年第4期)、Biologic Abstract(1993～1996)、Cancerlit(1997～2002.9)、Life Science Collection(1982～1995.3)、The International Pharmaceutical Abstract(1970～2002)和中国生物医学文献数据库(1978～2003.1),收集局部应用苯妥英治疗各类创口的对照试验.逐篇评价纳入研究的质量后,对研究结果进行描述性分析.结果共纳入9篇文献(1篇RCT、8篇同期非随机对照研究),共507例各类创口.文献质量评价结果显示,纳入文献的方法学质量均较低.多数研究的结果表明,局部应用苯妥英在健康肉芽组织的生长、痊愈率、痊愈时间以及降低创口细菌培养阳性率方面较对照药疗效好,但由于各种创口形成原因、对照干预措施以及结局评价指标上存在差异,未能进行Meta分析.仅一个研究报道有轻微的不良反应.结论评价者认为纳入论证强度低于随机对照试验的研究,其结论可能引起误导,因此要得出苯妥英治疗各类创口肯定有效的结论,尚需进行更多设计、执行和报告都良好的随机对照试验.