Alan J. Goble

Cardiac rehabilitation programmes: predictors of non-attendance and drop-out:

Background Despite evidence of its benefits, attendance at cardiac rehabilitation (CR) programmes is poor. Past studies to identify predictors of non-attendance have been limited by their small sample size, particularly for female patients. The present study was designed to identify socio-demographic and clinical predictors of non-attendance and drop-out separately for men and women automatically referred to CR programmes. Method and subjects Prospective study of CR programme attendance amongst 808 patients consecutively admitted over an 11-month period to one of two hospitals in Melbourne, Australia, after acute myocardial infarction (AMI), or to undergo coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI). Results Of the 652 eligible patients, 573 (88%) were successfully tracked at 4 months. Of these, 284 (49.6%) had attended a CR programme, while 272 (47.5%) had not. Using logistic regression, the significant predictors of programme non-attendance among men were having had a PCI, being a non-driver, and being aged 70 or more. The only factor predictive of non-attendance for women was being aged 70 or more. Amongst attenders, 67 (23.6%) patients discontinued the programme. Being a smoker, having diabetes and being unemployed at the time of hospital admission were predictive of programme drop-out by men. Being physically inactive at admission was predictive of programme drop-out by women. Conclusions The present study demonstrated a relatively high rate of CR programme attendance. Special attention needs to be directed towards males who are older, PCI patients, smokers, unemployed or non-drivers, and females who are older or inactive.

Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up

Objective To investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose–response relationship between the proportion of CR sessions attended and long-term mortality. Design Retrospective cohort study. Setting CR programmes in Victoria, Australia Patients The sample comprised 544 men and women eligible for CR following myocardial infarction, coronary artery bypass surgery or percutaneous interventions. Participants were tracked 4 months after hospital discharge to ascertain CR attendance status. Main outcome measures All-cause mortality at 14 years ascertained through linkage to the Australian National Death Index. Results In total, 281 (52%) men and women attended at least one CR session. There were few significant differences between non-attenders and attenders. After adjustment for age, sex, diagnosis, employment, diabetes and family history, the mortality risk for non-attenders was 58% greater than for attenders (HR=1.58, 95% CI 1.16 to 2.15). Participants who attended <25% of sessions had a mortality risk more than twice that of participants attending ≥75% of sessions (OR=2.57, 95% CI 1.04 to 6.38). This association was attenuated after adjusting for current smoking (OR=2.06, 95% CI 0.80 to 5.29). Conclusions This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose–response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation.

Mortality Reduction in a Coronary Care Unit

reveals an overall mortality rate of 5.7%. Two hundred and fifty patients are in normal health leading active lives. Con version to total ileostomy has been necessary in 14 cases (5% of operative survivors), because of the development of carcinoma of the rectum, stricture, incontinence, or other complications. The indications for this type of operation in acute and chronic diseases are discussed. It is suggested that the best results in the surgical management of patients with ulcerative colitis can be achieved only in special centres. Acknowledgement is due to Lille Chirurgical for permission to publish Figs. 2 and 3.

Anxiety and depression after coronary artery bypass graft surgery: most get better, some get worse.

Background To target interventions, patients at risk for poor outcomes after a cardiac event need to be identified. We investigated trajectories of anxiety and depression after coronary artery bypass graft surgery (CABGS) and identified patients at risk of persistent or worsening anxiety and depression. Methods A consecutive sample of 184 patients on the waiting list for CABGS at The Royal Melbourne Hospital completed self-report questionnaires before surgery, and at 2 and 6 months postsurgery. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale. Growth mixture modelling identified trajectories of anxiety and depression. Results Two possible trajectories emerged for anxiety, whereas three trajectories emerged for depression. Most patients (92%) followed a trajectory of minor presurgical anxiety that remitted in 6 months after CABGS, with the remainder (8%) following a trajectory of major anxiety that remitted in the same period. Minor remitted depression was also common (72% patients). Two less common depression trajectories indicated worsening or unresolved depression. One trajectory began with major presurgical depression that partially remitted by 6 months (14% patients) and the other began with minor presurgical depression that worsened by 6 months (14% patients). Unpartnered patients, smokers, those with presurgical anxiety, high cholesterol, angina, more severe disease or having repeat CABGS were at increased risk for a poor depression trajectory. Conclusion Although initial anxiety and depression resolved or lessened for most patients, some patients experienced persistent or worsening depression after CABGS. Interventions can be targeted toward ‘at risk’ patients. Eur J Cardiovasc Prev Rehabil 15:434-440© 2008 The European Society of Cardiology

Trajectories and predictors of anxiety and depression in women during the 12 months following an acute cardiac event

OBJECTIVES Many previous investigations of the recovery of emotional well-being, particularly the resolution of depression, following an acute cardiac event assume that all patients follow a similar, linear trajectory. However, it is possible that there are different groups of patients who follow different trajectories. This study tested for multiple trajectories of anxiety and depression and identified the characteristics of patients most at risk for persistent or worsening anxiety and depression in the 12 months following their cardiac event. METHOD A consecutive sample of 226 women was interviewed following either acute myocardial infarction (AMI) or coronary artery bypass graft surgery (CABGS). The Hospital Anxiety and Depression Scale were administered on four occasions over 12 months. Growth curve and growth mixture modelling were used to identify trajectories of change and univariate tests were employed to establish predictors of each trajectory. RESULTS Most women began with relatively low levels of anxiety and/or depression that improved over the 12 month period (84% women showed this trajectory for anxiety, 89% for depression). A smaller group began with relatively high levels of anxiety and/or depression that worsened over time (16% for anxiety, 11% for depression). Patients in the latter group were more likely to report high levels of loneliness, have a first language other than English, perceive their cardiac disease as more severe (anxiety group only) and have diabetes (depression group only). Trajectories were non-linear, with most change occurring in the initial 2-month period. CONCLUSION Growth modelling techniques highlight that change in anxiety and depression following an acute event follows neither a single nor linear trajectory. Most women showed early resolution of anxiety and depression following their event, indicative of a normal bereavement or adjustment response. A minority of women reported worsening anxiety and/or depression in the year following their cardiac event, particularly those who lacked social support or were from non-English speaking backgrounds. Intervention studies to explore support options for these women are warranted, both prior to and following their event.

Causal attributions for coronary heart disease among female cardiac patients.

PURPOSE Beliefs about the etiology of coronary heart disease (CHD) can influence patient outcomes following an acute cardiac event. However, past research has focused predominantly on male patients. The present study investigated causal attributions and their associations with actual risk profiles in female cardiac patients. METHODS Female cardiac patients consecutively admitted to hospital after an acute myocardial infarction (AMI) or for coronary artery bypass graft surgery (CAGS) were interviewed in hospital at 2, 4, and 12 months postdischarge. RESULTS Among 260 women (mean age = 68.6, SD = 10.4), there was little correspondence between actual and perceived risk factors. Hypertension was least recognized: only 5% of the 180 women who had hypertension acknowledged it as a cause of their CHD. High cholesterol, obesity, and high-fat diet were also underacknowledged, with only 14%, 15%, and 17% of women with these risk factors implicating them in their CHD. A higher percentage, 44%, of smokers and 40% of women with a positive family history acknowledged these risk factors as a cause of their CHD. Women who had no idea about the cause of their CHD constituted 20%. There was little change in causal attributions over the 12-month study period and little apparent impact of cardiac rehabilitation (CR) program attendance on causal beliefs. CONCLUSIONS Women were more likely to attribute their CHD to smoking or positive family history than to other major modifiable risk factors. The lack of correspondence between actual and perceived risk factors and the lack of impact of CR attendance on causal attributions highlight the need for personalized advice and support regarding risk factor modification.

Survival after resuscitation from cardiac arrest in acute myocardial infarction

Abstract The results of attempted resuscitation of 38 patients who suffered cardiac arrest after acute myocardial infarction are presented. Resuscitation was successful in 17 patients, with limited survival in 9, and long-term survival in 8. Ventricular fibrillation was responsible for cardiac arrest in 24 patients, including the 8 long-term survivors. Asystole was responsible in 14 patients, with no long-term survivors. Of the 8 long-term survivors, 7 showed no evidence of circulatory embarrassment prior to cardiac arrest. The conclusion is that immediate resuscitation will usually lead to long-term survival in those patients with myocardial infarction in whom circulatory embarrassment is not evident prior to cardiac arrest. Failure of resuscitation can be predicted in most cases in which hypotension, cardiac failure, or cardiogenic shock precede cardiac arrest. Special units, to which patients with acute myocardial infarction should be admitted, for monitoring, management, and resuscitation are required in all large general hospitals.

Health related quality of life trajectories and predictors following coronary artery bypass surgery

BackgroundMany studies have demonstrated that health related quality of life (HRQoL) improves, on average, after coronary artery bypass graft surgery (CABGS). However, this average improvement may not be realized for all patients, and it is possible that there are two or more distinctive groups with different, possibly non-linear, trajectories of change over time. Furthermore, little is known about the predictors that are associated with these possible HRQoL trajectories after CABGS.Methods182 patients listed for elective CABGS at The Royal Melbourne Hospital completed a postal battery of questionnaires which included the Short-Form-36 (SF-36), Profile of Mood States (POMS) and the Everyday Functioning Questionnaire (EFQ). These data were collected on average a month before surgery, and at two months and six months after surgery. Socio-demographic and medical characteristics prior to surgery, as well as surgical and post-surgical complications and symptoms were also assessed. Growth curve and growth mixture modelling were used to identify trajectories of HRQoL.ResultsFor both the physical component summary scale (PCS) and the mental component summary scale (MCS) of the SF-36, two groups of patients with distinct trajectories of HRQoL following surgery could be identified (improvers and non-improvers). A series of logistic regression analyses identified different predictors of group membership for PCS and MCS trajectories. For the PCS the most significant predictors of non-improver membership were lower scores on POMS vigor-activity and higher New York Heart Association dyspnoea class; for the MCS the most significant predictors of non-improver membership were higher scores on POMS depression-dejection and manual occupation.ConclusionIt is incorrect to assume that HRQoL will improve in a linear fashion for all patients following CABGS. Nor was there support for a single response trajectory. It is important to identify characteristics of each patient, and those post-operative symptoms that could be possible targets for intervention to improve HRQoL outcomes.

Expressed preferences for health education of patients after percutaneous coronary intervention

Background Percutaneous coronary intervention patients may require further education to increase their uptake of lifestyle change. Little is known, however, about their preferences for health education. This study aimed to investigate percutaneous coronary intervention patients’ preferences regarding information provision and to identify patient characteristics associated with specific preferences. Design and methods A consecutive series of eligible patients was recruited from three metropolitan hospitals in Melbourne, Australia after their first percutaneous coronary intervention. Structured telephone interviews were conducted with 218 patients shortly after discharge from hospital. Patient preferences for source and format of information about both heart disease and lifestyle change were ascertained. Data regarding demographic characteristics and rehabilitation attendance were also collected. Results Cardiac rehabilitation programme staff were the most frequently nominated preferred source for information delivery. Cardiac rehabilitation was also the most frequently nominated preferred format for information delivery. Half the patients nominated alternative formats, most commonly individual consultation with a health professional and self-education. Not surprisingly, patients who preferred alternatives to group cardiac rehabilitation were significantly less likely to attend rehabilitation. Conclusions It is important to cater for patients who express a desire for alternative information formats. A flexible model of cardiac rehabilitation delivery which incorporates non-group alternatives would meet the needs of these patients.

An evaluation of self-report physical activity instruments used in studies involving cardiac patients.

PURPOSE Given the importance of physical activity (PA) in cardiac rehabilitation and prevention, measuring it in a valid and reliable manner is a practical challenge. Measuring self-reported PA in elderly cardiac patients can be problematic because of the need to assess many activities of short duration that may occur as part of routine daily functions. The primary purpose of this article was to identify and evaluate instruments that have been used over the last 15 years in studies of cardiac patients. METHODS A comprehensive MEDLINE search was carried out to identify articles from studies undertaken to assess PA in cardiac patients. The self-report PA instruments were subjected to evaluation concerning suitability for use with cardiac patients. RESULTS The initial electronic and hand searches yielded 203 articles. After removing articles that did not meet the inclusion criteria, a total of 86 articles were selected. Twenty-three self-report instruments were identified for evaluation. Most of the instruments had problems associated with inadequate validation methods or suitability for cardiac patients. Many of the instruments failed to demonstrate adequate validity or reliability, particularly when measuring low-intensity PA. CONCLUSIONS Some instruments are more suited to epidemiologic research than to clinical interventions where responsiveness to interventions is crucial. Recommendations for the constituents of an acceptable self-report PA instrument for cardiac patients are presented and the most suitable existing instruments are identified.