Ann Kirkness

Age-specific differences in women with implantable cardioverter defibrillators: an international multi center study.

Background: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers.

A pre-test post-test study of a brief educational intervention demonstrates improved knowledge of potential acute myocardial infarction symptoms and appropriate responses in cardiac rehabilitation patients

BACKGROUND Patient delay in recognizing and responding to potential acute myocardial infarction (AMI) symptoms is an international issue. Cardiac rehabilitation provides an ideal opportunity to deliver an intervention. AIMS This study examines an individual educational intervention on knowledge of heart attack warning signs and specific chest pain action plans for people with coronary heart disease. METHODS Cardiac rehabilitation participants at five hospitals were assessed at program entry and tailored education was provided using the Heart Foundation of Australias Heart Attack Warning Signs campaign educational tool. Participants (n=137) were reassessed at program conclusion (six to eight weeks). RESULTS Study participants had a mean age of 64.48 years (SD 12.22), were predominantly male (78%) and most commonly presented with a current referral diagnosis of a percutaneous coronary intervention (PCI) (80%) and/or AMI (60%). There were statistically significant improvements in the reporting of 11 of the 14 warning signs of heart attack, with patients reporting 2.56 more warning signs on average at outcome (p<.0001). Patients reported more heart attack warning signs if they had completed high school education (β=1.14) or had better knowledge before the intervention (β=.57). There were statistically significant improvements in reporting of all appropriate actions in response to potential AMI symptoms, with patients reporting an average of 1.3 more actions at outcome (p<.001), with no change in the median time they would tolerate symptoms (p=.16). CONCLUSIONS A brief education session using a single standardised tool and adapted to a patient assessment is effective in improving knowledge of potential AMI symptoms and appropriate responses in cardiac rehabilitation up to two months following.

Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram.

OBJECTIVES Postoperative atrial fibrillation (POAF) occurs in 25-40% of patients following cardiac surgery, and is associated with a significant increased risk of stroke and mortality. Routine surveillance is not performed post-discharge; however, recurrence of POAF can occur in up to 30% of patients discharged in sinus rhythm. This study aimed to determine the feasibility of patients self-monitoring with an iPhone handheld electrocardiogram (iECG) to identify recurrence of POAF in the post-discharge period following cardiac surgery. METHODS Patients with POAF following cardiac surgery were eligible for participation if they had no prior history of atrial fibrillation (AF) and were discharged home in stable sinus rhythm. Participants were provided with an iECG and asked to record a 30-s iECG, four times per day for 4 weeks post-discharge. iECGs were automatically transmitted to a secure server, and reviewed for the presence of AF by the research team and a validated algorithm. All participants also received brief education on AF. RESULTS Forty-two participants completed the intervention (mean age 69 ± 9 years, 80% male). Self-monitoring for POAF recurrence using an iECG was feasible and acceptable, and participants felt empowered. Self-monitoring identified 24% (95% confidence interval, 12-39%) with an AF recurrence within 17 days of hospital discharge. These participants were significantly younger than those without AF recurrence (64 ± 7 vs 70 ± 10 years; P = 0.025), and had a significantly lower CHA2DS2-VASc score (2.3 ± 1.2 vs 3.7 ± 2.3; P = 0.007). However, 80% were at high enough stroke risk to warrant consideration of anticoagulation, i.e. CHA2DS2-VASc score ≥2. Only 30% of recurrences were associated with palpitations. Participation also improved AF knowledge from 6.4 ± 1.8 to 7.3 ± 1.8 (P = 0.02), of a total score of 10. CONCLUSIONS Providing patients with an iECG is a non-invasive, inexpensive, convenient and feasible way to monitor for AF recurrence in post-cardiac surgery patients. It also provides a mechanism to provide knowledge about the condition and also potentially reduce anxiety. The success of patients using this technology also has implications for extending the use of iECG self-monitoring to other patient groups such as those undergoing antiarrhythmic interventions for AF.

Impact of the Healthy Eating and Exercise Lifestyle Programme on depressive symptoms in overweight people with heart disease and diabetes

Background: The Healthy Eating and Exercise Lifestyle Program (HEELP) is a secondary risk factor intervention programme for people with heart disease and/or type 2 diabetes, which has proven benefits for weight loss and exercise. This secondary analysis evaluated the effects of HEELP on achieving recommended levels of exercise and the prevalence of depressive symptoms, and whether meeting exercise recommendations had an independent effect on depressive symptoms. Design: A randomized parallel controlled trial of patients (n = 147) with body mass index 27–39 kg/m2 were recruited from cardiac rehabilitation and diabetes education programmes. Methods: HEELP participants received a 16-week group-based lifestyle intervention of twice-weekly supervised exercise and five information sessions; the control group received usual care. At 16 weeks, achievement of recommended levels of exercise (≥5 days/week, moderate or higher intensity, and total duration of ≥150 minutes/week) and depressive symptoms (Hospital Anxiety and Depression Scale) were assessed. Results: More HEELP participants met the recommendations for exercise frequency (71 vs. 50%, p = 0.036), intensity (76 vs. 60%, p = 0.05), and total duration (65 vs. 43%, p = 0.047). The prevalence of depressive symptoms in HEELP was half that of the control group (17 vs. 34%; OR 0.397, 95% CI 0.18–0.86). Participants who met recommendations for total duration of exercise were less likely to report depressive symptoms (OR 0.29, 95% CI 0.112–0.717) after adjusting for treatment group and weight change. Conclusions: A group-based lifestyle intervention improves exercise and reduces depressive symptoms despite multiple risk factors.

Long-term outcomes from Healthy Eating and Exercise Lifestyle Program for overweight people with heart disease and diabetes

Background: The benefits of exercise and weight reduction for overweight or obese people with coronary heart disease and/or diabetes mellitus are well recognised. The Healthy Eating and Exercise Lifestyle Program demonstrated these outcomes at 4 months, but longer-term outcomes are not yet reported. Aim: To determine whether positive weight, body mass index, waist and exercise duration outcomes were sustained in the long term (12 months) and to identify the independent predictors of these outcomes at 4 and 12 months. Methods: Longitudinal design, combining data of all Healthy Eating and Exercise Lifestyle Program participants (intervention and wait-list control, n = 134). Participants had a body mass index between 27 and 39 kg/m2 and had completed cardiac rehabilitation and/or diabetes education programmes. Healthy Eating and Exercise Lifestyle Program intervention included an active phase of two 1-hour group-based supervised structured exercise sessions every week for 4 months and four 90-minute group information and support sessions. The maintenance phase included one 90-minute group-based booster information session and three 15-minute goal-focused telephone follow-up calls over 8 months. Results: Participants had statistically significant reductions from baseline in weight, body mass index and waist circumference and improvements in exercise duration and capacity at 4 and 12 months. Time, self-efficacy, depressive symptoms and male gender were independent predictors for body mass index, waist and/or exercise duration (p < 0.05). Conclusion: The Healthy Eating and Exercise Lifestyle Program was an effective programme to achieve and sustain weight loss and increase exercise participation over 1 year.

Exercise barriers and the relationship to self-efficacy for exercise over 12 months of a lifestyle-change program for people with heart disease and/or diabetes

Background: Barriers to exercise are common in people with coronary heart disease (CHD) and/or diabetes mellitus (DM), and may influence self-efficacy for exercise. Purpose: 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. Methods: 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). Results: 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. Conclusion: 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.

Sublingual nitroglycerin practices in patients with coronary artery disease in Australia.

Background and Research Objective:Sublingual nitroglycerin (SLNTG) medications are a recommended treatment for people with coronary artery disease (CAD); however, prescription and knowledge may be suboptimal. This study set out to determine how often SLNTG is prescribed and the knowledge and factors associated in patients with CAD. Subjects and Methods:Patients (n = 142) were recruited from cardiac rehabilitation and surveyed regarding SLNTG prescription and key knowledge areas related to SLNTG in those prescribed (n = 89). Multiple regression analysis was used to determine independent predictors of knowledge. Results and Conclusions:Despite having CAD, 37% were not prescribed SLNTG, and of those prescribed, only 43% received related instruction. Knowledge of SLNTG was low at a mean 7.11 (SD, 2.05) points of a possible 14. Most participants (96%) knew to use SLNTG to treat chest pain/discomfort, and no participant described inappropriate symptoms for treatment. Although most patients (80%) knew to have the SLNTG available at all times, only 46% did so in reality. One in 5 participants reported that they would not call an ambulance if chest pain was unrelieved by SLNTG. Participants had more SLNTG knowledge if they were married, were male, and had been instructed about SLNTG and had less knowledge if their hospital discharge diagnosis included angina. The reporting of calling an ambulance for unrelieved symptoms was increased by having more knowledge of SLNTG, but decreased if participants had prior use of SLNTG, were married, or had more comorbidities. Consideration of prescription for SLNTG and related instruction, particularly for their chest-pain action plan, needs to be provided more systematically for patients with CAD.

Who Gets Stroke Prevention? Stroke Prevention in Atrial Fibrillation Patients in the Inpatient Setting

BACKGROUND Current guidelines strongly recommend antithrombotic therapy, particularly warfarin, for stroke prevention in atrial fibrillation (AF) patients at high risk of stroke. Despite this, use of these medications is far from optimal. The aim of this study was to describe the use of stroke prevention medication in inpatients and identify factors associated with prescription in one local health district in Sydney, Australia. METHODS A prospective audit of medical records for patients admitted with an AF diagnosis to five hospitals in the health district and excluding cardiac surgery patients was undertaken. Patients were classified as high or low for stroke risk as well as for risk of bleeding and predictors were identified by logistic regression. RESULTS A total of 204 patients were enrolled from July 2012 to April 2013, with a mean age of 75 years (SD 13) and half (50%) were male. Valve disease was present in 17% and 15% received a procedure for their AF (cardioversion/ablation/pulmonary vein isolation). Patients were least likely to be prescribed warfarin/novel oral anticoagulant (NOAC) if they were non-valvular and did not undergo cardioversion/ablation (p=.03), and least likely to be prescribed aspirin if they had no AF procedure (p=.01). In non-valvular patients who did not have cardioversion/ablation the odds of being prescribed warfarin/NOAC were increased by being classified at high risk of stroke (OR 3.1, 95% CI 1.0 -9.5) and decreased if there was a prescription for aspirin (OR .3. 95% CI .1 -.6). CONCLUSIONS Overall use of stroke prevention medication indicates that gaps remain in translation of evidence into clinical practice.

Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol

Introduction Postoperative atrial fibrillation (AF) occurs in 30–40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. Methods and analysis This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patients use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. Ethics and dissemination Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. Trial registration number ACTRN12614000383662.

Evaluation of a brief educational intervention to improve knowledge of sublingual nitroglycerin in cardiac rehabilitation patients.

Objective: This study aimed to evaluate the impact of a brief educational intervention delivered in cardiac rehabilitation (CR) on patients’ knowledge of sublingual nitroglycerin (SLN). Methods: 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). Results: 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). Conclusion: 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.