Short-term patient-reported outcomes after different exercise-based cardiac rehabilitation programmes.

BACKGROUND: An objective of exercise-based cardiac rehabilitation is improvement in patient-reported outcomes such as health-related quality of life as well as anxiety and depressive symptoms. There are no direct comparisons of the effectiveness of inpatient and outpatient exercise-based cardiac rehabilitation programmes on patient-reported outcomes. METHODS: In this non-randomized study we collected patient-reported outcomes data with the MacNew Heart Disease health-related quality of life questionnaire and the Hospital Anxiety and Depression Scale at baseline, 1 month and again 3 months after admission to exercise-based cardiac rehabilitation in a cohort of 216 consecutive patients enrolled either in a 4-week inpatient exercise-based cardiac rehabilitation (n=62) or a 3-month outpatient exercise-based cardiac rehabilitation (n=87) and in a usual care group (n=67) to document the natural course in patient-reported outcome variables without exercise-based cardiac rehabilitation. RESULTS: Although MacNew health-related quality of life scores improved more with inpatient than outpatient exercise-based cardiac rehabilitation by month 1, the improvement was still significant in both groups at month 3 and also in the usual care group when compared to baseline. The health-related quality of life scores in the inpatient group, however, decreased between month 1 and 3 whereas they continued to improve in the outpatient group. The significant reduction in both anxiety and depressive symptoms in both exercise-based cardiac rehabilitation groups by month 1 was maintained at month 3 only with outpatient exercise-based cardiac rehabilitation. No significant changes over the 3 months were observed in the usual care group. CONCLUSION: Significant improvements of 1-month patient-reported outcomes are achieved in patients attending inpatient as well as outpatient exercise-based cardiac rehabilitation when compared with no exercise-based cardiac rehabilitation. In contrast to inpatient exercise-based cardiac rehabilitation, however, outpatient exercise-based cardiac rehabilitation leads to a further improvement of patient-reported outcomes. These results suggest that, if patients have to be admitted for inpatient exercise-based cardiac rehabilitation, this programme should be followed by an outpatient exercise-based cardiac rehabilitation to further improve and stabilize these patient-reported outcome variables.     

Predictive factors of daily opioid use and quality of life in adults with sickle cell disease

ABSTRACT

Objectives: In adults with sickle cell disease (SCD), pain often necessitates opioid use. Few studies have examined the relationship between opioid use and health-related quality of life (HRQOL) in adults with SCD. We tested the hypothesis that higher doses of opioids are associated with worse HRQOL.

Methods: A cross-sectional cohort study was performed in adults with SCD who completed standardized and validated HRQOL questionnaires: Patient Health Questionnaire-15 (PHQ-15), Patient Health Questionnaire-9 (PHQ-9), Medical Outcome Study 36 Item Short Form (SF-36), and Generalized Anxiety Disorder questionnaire (GAD-7). Daily outpatient opioid dose was converted into morphine milligram equivalents (MME) and categorized as <?90?mg/day or ≥?90?mg/day. Subject's questionnaire scores were compared by opioid dose.

Results: Ninety-nine adults completed questionnaires. The majority had HbSS and median age was 30 years. The median MME was 80?mg/day. When the association between HRQOL and opioid dose was compared, those prescribed ≥?90 MME had significantly lower SF-36 subscale scores in 7 of 8 domains, and significantly higher severity scores in the PHQ-15, GAD-7, and the PHQ-9 in comparison those prescribed <?90 MME. Using a multivariable regression tree analysis, in addition to the presence of chronic pain, mental health, physical health, and somatic burden were key predictors of ≥?90 MME opioid use.

Conclusion: Higher daily opioid dose is associated with chronic pain. Among those with chronic pain, opioid dose ≥?90 MME is associated with worse HRQOL.     

Literacy education as treatment for depression in patients with limited literacy and depression

BACKGROUND: Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame. OBJECTIVE: To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone. DESIGN: Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment. PARTICIPANTS: Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM). MEASUREMENTS: Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups. RESULTS: The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group. CONCLUSIONS: There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.     

穴位按摩联合心脏康复操在冠状动脉支架植入患者中的应用效果

目的 探讨穴位按摩联合心脏康复操对冠状动脉支架植入术（PCI）患者血脂水平、心功能、情绪状态、睡眠及生活质量的影响。 方法 选择我院2017年1月～2019年12月收治的冠心病PCI患者120例,采用随机数字法将其分为对照组和干预组（每组60例）。对照组PCI术后采取常规运动康复治疗,干预组在常规运动康复治疗基础上,采取穴位按摩联合心脏康复操治疗。比较两组治疗前后血脂指标[总胆固醇（TC）、三酰甘油（TG）、低密度脂蛋白胆固醇（LDL-C）、高密度脂蛋白胆固醇（HDL-C）]、心功能指标[左室射血分数（LVEF）、氨基末端脑钠尿肽前体（NT-proBNP）、6分钟步行距离（6MWT）]、焦虑抑郁[汉密尔顿焦虑量表（HAMA）、汉密尔顿抑郁量表（HAMD）]、睡眠质量[匹兹堡睡眠质量指数（PSQI）]及生活质量[采用西雅图生活质量量表（SAQ）,包括躯体活动受限程度（PL）、心绞痛稳定情况（AS）、心绞痛发作情况（AF）、治疗满意程度（TS）、疾病认识程度（DS）]评分情况。 结果 两组治疗前血脂指标、心功能指标、焦虑抑郁、睡眠质量及生活质量评分比较差异均无统计学意义;干预组治疗后TC、TG、LDL-C、HDL-C、NT-proBNP、HAMA、HAMD、PSQI均较本组治疗前和对照组治疗后显著下降,LVEF、6MWT、PL、AS、AF、TS、DS均较本组治疗前和对照组治疗后显著升高（均P<0.05）。 结论 穴位按摩联合心脏康复操可显著改善PCI术后患者血脂水平,提高心功能,缓解焦虑、抑郁等不良情绪,提高睡眠及生活质量,临床疗效满意。     

The PHQ-9: validity of a brief depression severity measure

OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.     

Discordant hemodynamic and fibrinolytic adaptations following a 6-week cardiac rehabilitation program

The present study evaluated changes in hemodynamics and fibrinolysis during 6 weeks of participation in an exercise-based cardiac rehabilitation program. Fourteen patients trained for 3 days per week for 6 weeks using American College of Sports Medicine guidelines for intensity and duration. Blood samples were taken at baseline and after 3 and 6 weeks of participation and analyzed for tissue plasminogen activator (t-PA) activity and antigen, plasminogen activator inhibitor-1 (PAI-1) activity and antigen, and relative quantification of t-PA and PAI-1 RNA. Data were analyzed using repeated measures analysis of variance. Training elicited significant decreases in submaximal exercise heart rate and systolic blood pressure and resting systolic blood pressure (p<.05). There were no significant changes in plasma concentrations of t-PA or PAI-1, and no change was observed in t-PA or PAI-1 gene expression. The present findings suggest that favorable hemodynamic adaptations may occur after only 6 weeks of exercise-based cardiac rehabilitation, but longer training periods may be needed to elicit positive hemostatic adaptations.     

Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited

OBJECTIVE—To identify factors associated with the uptake of cardiac rehabilitation following acute myocardial infarction.
DESIGN—Retrospective analysis using multivariate logistic regression modelling.
SETTING—Two large teaching hospitals in Nottingham.
PATIENTS—Cohorts of patients admitted with acute myocardial infarction in 1992 and 1996.
INTERVENTIONS—None.
MAIN OUTCOME MEASURES—Factors in multivariate analysis found to be associated with attendance at cardiac rehabilitation. Use of secondary prevention in those who were and were not invited and those who did and did not attend cardiac rehabilitation.
RESULTS—58% of all patients were offered cardiac rehabilitation. Attendance rates were 60% in 1992 and 74% in 1996. Invitations were more likely to be offered to younger patients, those who had received thrombolysis, and to patients admitted to one of the two Nottingham hospitals. Use of secondary prevention was only 48% in 1992 but this increased to 80% in 1996. Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no difference in the use of secondary prevention between those who did and did not attend cardiac rehabilitation.
CONCLUSION—Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.


Keywords: cardiac rehabilitation; acute myocardial infarction; thrombolysis     

Peplau人际关系理论结合康复护理治疗老年冠心病的临床分析

目的 探究Peplau人际关系理论结合康复护理对老年冠心病患者心脏康复和心理状态的影响,为治疗该病提供临床方法.方法 选取2016年6月-2019年7月南京鼓楼医院老年科收治的老年冠心病患者196例,采用随机数字表法将患者分为对照组及观察组,每组各98例.对照组给予常规康复护理,观察组则予以基于Peplau人际关系理论...     

Reliability, validity, and responsiveness of a 2-min walk test to assess exercise capacity of COPD patients

PURPOSES: To investigate the reliability, validity, and responsiveness of a 2-min walk test (2MWT) in Chinese COPD patients with moderate-to-severe disease. METHODS: This study consisted of two parts. Forty-seven stable COPD patients with moderate-to-severe disease participated in the first part of study for the investigation of reliability and validity. The demographic and anthropomorphic data collected included age, gender, body weight, height, and body mass index. Each subject performed a pulmonary function test, a cardiopulmonary exercise test, three trials of a 2MWT, and two trials of 6-min-walk test (6MWT) in random order within a 5-day period. Fifteen of these subjects participated in the second part of study for the evaluation of the responsiveness of the 2MWT following pulmonary rehabilitation. The 2MWT and 6MWT were conducted before and after the program for comparison. RESULTS: Forty-five subjects (mean [+/- SD] age, 71.8 +/- 8.3 years; mean FEV1, 0.88 +/- 0.27 L) completed the first part of study, and 9 subjects (mean age, 74 +/- 8.7 years; mean FEV1, 0.94 +/- 0.28 L) completed the second part of study. The intraclass correlation coefficient of the repeated 2MWTs was high (R = 0.9994; p < 0.05), mean differences across trials ranged from 0.3 to 0.8 m (95% confidence interval, -3.1 to 4.6 m) demonstrated its high test-retest reliability. Significant correlations were found between the 2MWT and the 6MWT, the maximum oxygen uptake (V(O2)max) in milliliters per minute, and the V(O2)max in milliliters per kilogram per minute (r = 0.937, 0.454, and 0.555 respectively; p < 0.0125). Following rehabilitation, there were significant improvements in the mean 2MWT and 6MWT walking distance of 17.2 +/- 13.8 m and 60.6 +/- 35.5 m, respectively, with moderate effect sizes (0.61 and 0.53, respectively) and large standardized mean responses (1.25 and 1.70, respectively). High correlation was found between changes in the 2MWT and the 6MWT (r = 0.70; p < 0.05). CONCLUSION: The 2MWT was shown to be a reliable and valid test for the assessment of exercise capacity and responsive following rehabilitation in patients with moderate-to-severe COPD. It is practical, simple, and well-tolerated by patients with severe COPD symptoms.     

Effect of cardiac rehabilitation on cardiovascular risk factors in chronic heart failure patients

Introduction

Cardiac rehabilitation improves disease-related symptoms, quality of life, and clinical outcomes. This study was done to evaluate the effect of cardiac rehabilitation program on cardiovascular risk factors in chronic heart failure patients as well as functional capacity and health related quality of life.

心肺康复运动训练对中度IPF患者肺功能的影响

目的评价应用心肺康复运动训练对中度IPF患者的肺功能和生活质量的影响。方法选取中度IPF患者30例随机分为两组,常规组按IPF疾病诊治指南进行正规药物治疗,实验组在常规组基础上进行规律康复运动训练。两组患者均于治疗前及12周时行肺功能检查、6分钟步行实验(6MWT)及生活质量量表(ATAQ-IPF)以评价疗效。结果实验组治疗12周时肺功能(FVC%预计值、TLC%预计值、DLCO%预计值)、6MWT、ATAQ-IPF评分较前明显改善,较对照组变化有统计学意义(P0.05)。结论在IPF患者疾病早期,应用心肺康复运动训练,能提高肺功能,同时也可明显改善患者的运动耐力及生活质量。     

Relatives’ quality of life and psychological disturbance: a new concern of SLE management

It is known that the quality of life (QOL) and psychological status of patients with systemic lupus erythematosus (SLE) are severely impaired. However, a few reports have assessed the QOL and psychological status in relatives of these patients. This study aimed to assess the QOL and psychological status in relatives of patients with SLE and their impact on patients. A total of 104 patient–relative dyads were evaluated using a 36-Item Short-Form Survey (SF-36), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and Social Support Rating Scale (SSRS). Relatives of patients with SLE exhibited an impaired QOL compared with the general population (69.59 ± 22.78 vs 78.18 ± 15.88, P < 0.001) and suffered from depression (5.8 ± 5.4) and anxiety (5.8 ± 6.0). GAD-7 of relatives was positively correlated with GAD-7 of patients (r = 0.210, P < 0.05). Patients reported a lower global SF-36 score when their relatives had lower global SF-36 scores (50.13 ± 19.18 vs 58.44 ± 19.67, P < 0.05) and significantly higher SSRS when their relatives had lower PHQ-9 (41.9 ± 8.7 vs 36.3 ± 6.2, P < 0.01) or GAD-7 scores (42.8 ± 7.4 vs 36.7 ± 6.6, P < 0.01). The QOL and psychological status in relatives of patients with SLE were adversely impaired. Associations exist between the QOL and psychological status of relatives and patients with SLE. Therefore, both patients and their relatives should be taken into account when making management decisions.     

Efeitos a longo prazo de um programa de reabilitação cardíaca no controlo dos fatores de risco cardiovasculares

IntroductionCardiac rehabilitation programs are designed to improve patients’ functional capacity, as well as to educate them and to monitor their cardiovascular risk factors.AimThe study aims to evaluate the effects of cardiac rehabilitation programs in patients with coronary disease over a 12-month follow-up period with regard to control of cardiovascular risk factors.MethodsThis was a prospective study of patients diagnosed with coronary disease who completed an exercise-based cardiac rehabilitation program between January 2008 and December 2009 and who were not lost to follow-up. Patients were evaluated at an early stage (first medical consultation in phase II of the program) and 3, 6 and 12 months later, the following parameters being assessed: weight and body mass index, waist circumference, lipid profile, HbA1c in diabetic patients, blood pressure, smoking status and physical activity (using the International Physical Activity Questionnaire).ResultsIn the sample of 256 patients (76.2% male, mean age 67 years), dyslipidemia proved to be the most prevalent risk factor (74.2%), followed by overweight (71.5%). There was a statistically significant improvement (p<0,05) in all risk factors studied at the end of phase II of the program, which was maintained at 6 and 12 months of follow-up, with the exception of body mass index (loss of statistical significance at 6-month assessment, p=0,92).ConclusionThis study highlights the need for cardiac rehabilitation programs in the context of secondary prevention of cardiovascular disease and the importance of implementing strategies that promote long-term maintenance of their benefits.     

心房颤动患者心脏康复中国专家共识

心房颤动(AF)是最常见的心律失常之一,其危险因素控制和多学科综合管理逐渐受到人们重视。多项研究证明,AF心脏康复行之有效,但目前国内尚缺乏AF心脏康复的统一管理方案。结合近年来国内外相关指南,择其更新的重要学术内容,制订AF(包括瓣膜病性AF和非瓣膜病性AF)患者心脏康复中国专家共识,以期推动我国AF康复的发展。共识内容主要包括AF的上游管理,多维度康复评估和处方制定。     

Improvement in heart rate recovery after cardiac rehabilitation

PURPOSE: Exercise-based cardiac rehabilitation has been shown to reduce mortality in patients with coronary artery disease. Although the exact mechanisms by which exercise reduces mortality are unclear, one hypothesis invokes the effect of exercise on autonomic tone. Heart rate recovery (HRR) immediately after exercise is a marker of vagal tone that findings have shown to be a powerful predictor of all-cause mortality. This study aimed to evaluate the effect of exercise-based cardiac rehabilitation on HRR. METHODS: A retrospective study was performed. Patients who completed phase 2 cardiac rehabilitation and had entry and exit exercise stress tests (n = 34) were included in the study. A control sample was identified by review of the exercise stress laboratory database (n = 35). Then HRR at baseline and on follow-up were compared. RESULTS: After completion of phase 2 cardiac rehabilitation, the HRR improved from 18 +/- 7 bpm to 22 +/- 8 bpm (P <.001). Among controls, the HRR on serial testing were 21 +/- 10 bpm and 21 +/- 9 bpm (P =.649). The mean difference in HRR on follow-up testing was different between those enrolled in a cardiac rehabilitation program and those who were not (P =.002). CONCLUSION: Exercise training in a cardiac rehabilitation program results in HRR improvement. As a simple parameter for assessing autonomic tone, HRR may be used in a cardiac rehabilitation facility to identify patients with higher risk profiles, and can be useful for evaluating patient outcomes.     

Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials

PURPOSE: To review the effectiveness of exercise-based cardiac rehabilitation in patients with coronary heart disease. METHODS: A systematic review and meta-analysis of randomized controlled trials was undertaken. Databases such as MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2003. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise training alone or in combination with psychological or educational interventions. RESULTS: We included 48 trials with a total of 8940 patients. Compared with usual care, cardiac rehabilitation was associated with reduced all-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) and cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96); greater reductions in total cholesterol level (weighted mean difference, -0.37 mmol/L [-14.3 mg/dL]; 95% CI: -0.63 to -0.11 mmol/L [-24.3 to -4.2 mg/dL]), triglyceride level (weighted mean difference, -0.23 mmol/L [-20.4 mg/dL]; 95% CI: -0.39 to -0.07 mmol/L [-34.5 to -6.2 mg/dL]), and systolic blood pressure (weighted mean difference, -3.2 mm Hg; 95% CI: -5.4 to -0.9 mm Hg); and lower rates of self-reported smoking (OR = 0.64; 95% CI: 0.50 to 0.83). There were no significant differences in the rates of nonfatal myocardial infarction and revascularization, and changes in high- and low-density lipoprotein cholesterol levels and diastolic pressure. Health-related quality of life improved to similar levels with cardiac rehabilitation and usual care. The effect of cardiac rehabilitation on total mortality was independent of coronary heart disease diagnosis, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date. CONCLUSION: This review confirms the benefits of exercise-based cardiac rehabilitation within the context of today's cardiovascular service provision.     

Feasibility of a multi-state outcomes program for cardiopulmonary rehabilitation

BACKGROUND: Outcomes validate program performance and patient benefits received from cardiac and pulmonary rehabilitation. However, outcomes have little meaning without test standardization and the ability to benchmark data with other programs. The purpose of this article is to demonstrate the feasibility for measuring standardized outcomes in a large number of rehabilitation programs. METHODS: The subjects included 928 cardiac patients and 222 pulmonary patients from 35 cardiac and 31 pulmonary rehabilitation programs. The SF-36 Health Survey, patient knowledge test, and 6-minute distance walk were administered before and after completion of the rehabilitation program. The patients completed rehabilitation according to the program guidelines at their respective site. RESULTS: Significant (P < 0.05) improvements were demonstrated for cardiac and pulmonary rehabilitation in each of the eight health concepts within the SF-36. In addition, patient knowledge and distance walked significantly (P < 0.05) improved for both cardiac and pulmonary rehabilitation. CONCLUSIONS: Although this study does not document the effectiveness of rehabilitation for patients, it does demonstrate that the collection and analysis of standardized outcomes among many cardiac and pulmonary rehabilitation sites is feasible.     

Plasma B-type natriuretic peptide predicts atrial fibrillation during rehabilitation after cardiac surgery

BACKGROUND: B-type natriuretic peptide (BNP) levels are known to predict atrial fibrillation (AF) occurrence short-term after cardiac surgery, but no information is available on their predictive potential at a later time point. We evaluated whether BNP levels predict postcardiac surgery AF events occurring during rehabilitation program. AF impact on hospitalization length and rehabilitation program have also been evaluated. METHODS AND RESULTS: One hundred and forty-nine patients who underwent cardiac surgery were monitored for 'late' AF, defined as AF occurring during the rehabilitation period (20+/-5 days) in contrast to 'early' AF defined as AF documented in the surgical department soon after surgery. BNP was determined at rehabilitative hospital admission (10+/-5 days after surgery). Late AF was observed in 17% of patients. AF patients had higher BNP levels than event-free patients (459+/-209 vs. 401+/-449 pg/ml, P=0.01). Lower kaliemia values (P=0.048), early AF (P<0.001), and combined surgery (coronary artery by pass graft and valve replacement; P=0.016) were also associated with late AF. At multivariate analysis, BNP levels more than 322 pg/ml (P=0.02), and early AF (P=0.003) showed an independent association with late AF occurrence, which did not interfere with the physical training program but prolonged hospitalization (22+/-5 vs. 20+/-5 days, P=0.062) and telemetry monitoring (6+/-5 vs. 1+/-3 days, P<0.001). CONCLUSION: BNP levels measured at the beginning of the rehabilitation program are independent predictors of late AF after cardiac surgery. These results suggest a more aggressive therapeutical approach during the rehabilitation period in patients with elevated BNP levels who have already experienced AF in the surgical department.