Brian Garavalia

Symptom Recognition and Healthcare Experiences of Young Women With Acute Myocardial Infarction

Background—Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ⩽55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population. Methods and Results—We conducted a qualitative study using in-depth interviews with 30 women (aged 30–55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease. Conclusions—Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women’s elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

“I'm Not Just a Heart, I'm a Whole Person Here”: A Qualitative Study to Improve Sexual Outcomes in Women With Myocardial Infarction

Background Little is known about recovery of female sexual function following an acute myocardial infarction (MI). Interventions to improve sexual outcomes in women are limited. Methods and Results Semistructured, qualitative telephone interviews were conducted with 17 partnered women (aged 43 to 75 years) purposively selected from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status Registry to deepen knowledge of recovery of female sexual function following an acute myocardial infarction (MI) and to improve sexual outcomes in women. Sixteen women had a monogamous relationship with a male spouse; 1 had a long‐term female partner. Most women resumed sexual activity within 4 weeks of their MI. Sexual problems and concerns were prevalent, including patient and/or partner fear of “causing another heart attack.” Few women received counseling about sexual concerns or the safety of returning to sex. Most women who discussed sex with a physician initiated the discussion themselves. Inquiry about strategies to improve sexual outcomes elicited key themes: need for privacy, patient‐centeredness, and information about the timing and safe resumption of sexual activity. In addition, respondents felt that counseling should be initiated by the treating cardiologist, who “knows whether your heart is safe,” and then reinforced by the care team throughout the rehabilitation period. Conclusions Partnered women commonly resume sexual activity soon after an MI with fear but without directed counseling from their physicians. Proactive attention to womens concerns related to sexual function and the safety of sexual activity following an MI could improve post‐MI outcomes for women and their partners.

Clinician-patient discord: exploring differences in perspectives for discontinuing clopidogrel.

Background: Premature stopping of anti-platelet therapy has potentially fatal consequences for myocardial infarction (MI) patients who have received a drug-eluting stent (DES). Exploring multiple perspectives to identify contributing factors to the problem is essential. Aim: We gained patient and clinician perspectives as to why MI patients prematurely stop anti-platelet therapy (clopidogrel) after DES implantation. Methods: This qualitative, descriptive study of DES-treated MI patients (n = 22) and of clinicians (physicians and nurse practitioners; n = 17) from multiple U.S. cities used content analysis of interview data. Findings across patients and clinicians were then compared to examine congruent and contrasting reasons for premature clopidogrel discontinuance. Findings: Patients frequently identified communication and education (e.g. unaware they should be taking clopidogrel, unaware of intended duration of therapy) as the primary reasons for having stopped. Patients rarely cited cost, while clinicians most commonly cited cost as a reason for premature stopping. Conclusions: The discrepancy in perceptions of patients and clinicians as to the primary reason for early discontinuance suggests an important opportunity for improving persistence. Rather than focusing on the high costs of medications, something outside of their control, physicians should consider communicating more effectively the importance and intended duration of clopidogrel to their patients.

Clopidogrel-taking behavior by drug-eluting stent patients: Discontinuers versus continuers

Background Each day, patients make choices whether or not to take their prescribed medications. Previous research has shown that 1 in 7 myocardial infarction (MI) patients discontinued thienopyridines within 1 month of receiving a drug-eluting stent (DES) with serious consequences. This qualitative research study explored in depth the clopidogrel-taking behavior among DES-treated patients who quit taking clopidogrel 1 month after treatment and those who continued therapy. Methods Sequential patients from a prospective MI registry who reported discontinuing clopidogrel within 30 days of DES treatment (N = 11) were matched with continuers (N = 11). Both groups underwent detailed qualitative phone interviews. Coding and thematic representation using directed qualitative content analysis by 3 PhD researchers was done. Results Patients were 41–77 years old and the majority was Caucasian and male. Multiple barriers were described by discontinuers that were not reported by continuers. The most frequently cited barrier was misunderstanding the intended duration of treatment. Discontinuers also described system weaknesses that contributed to early discontinuance such as gaps in the transition to primary care. Conclusions While premature discontinuation of a prescribed therapy is viewed by clinicians as a willful disregard for medical advice, early stopping of clopidogrel is influenced greatly by processes of care and system issues.

Patient-Centered Decision Support in Acute Ischemic Stroke: Qualitative Study of Patients' and Providers' Perspectives.

Background—National guidelines endorse recombinant tissue-type plasminogen activator (r-tPA) in eligible patients with acute ischemic stroke to improve patients’ functional recovery. However, 23% to 40% of ideal candidates with acute ischemic stroke for reperfusion are not treated, perhaps because of the difficulty in explaining the benefits and risks of r-tPA within the frenetic pace of emergency department care. To support better knowledge transfer and creation of a shared decision-making tool, we conducted qualitative interviews to define the information needs and preferred presentation format for stroke survivors, caregivers, and clinicians considering r-tPA treatment. Methods and Results—A multidisciplinary team used qualitative research methods to identify informational needs and strategies for describing the benefits and risks of r-tPA in a clinical setting. Through focus groups (n=10) of stroke survivors (n=39) and caregivers (n=24) and individual interviews with emergency physicians (n=23) and advanced practice nurses (n=20), several themes emerged. Survivors and caregivers preferred a broader definition of a good outcome (independence, rather than no significant disability), simpler graphs as compared with detailed pictographs, and presentation of both population and individualized benefits (framed positively) and risk of receiving r-tPA. Some physicians expressed skepticism with the data and the ability to present risk/benefit information emergently, whereas other physicians and most advanced practice nurses thought such information would improve care. Physicians stressed the importance of presenting the risk of thrombolytic-related intracranial hemorrhage. Conclusions—This study suggests that a positively framed risk–benefit tool with graphical presentations of general and patient-specific risk estimates could support patients and providers in considering r-tPA for acute ischemic stroke. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01864928.

Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians.

Background Warfarin, the most commonly used antithrombotic agent for stroke prophylaxis in atrial fibrillation (AF), requires regular monitoring, frequent dosage adjustments, and dietary restrictions. Clinicians’ perceptions of barriers to optimal AF management are an important factor in treatment. Anticoagulation management for AF is overseen by both cardiology and internal medicine (IM) practices. Thus, gaining the perspective of specialists and generalists is essential in understanding barriers to treatment. We used qualitative research methods to define key issues in the prescription of warfarin therapy for AF by cardiology specialists and IM physicians. Methods and results Clinicians were interviewed to identify barriers to warfarin treatment in a large Midwestern city. Interviews were conducted until thematic saturation occurred. Content analysis yielded several themes. The most salient theme that emerged from clinician interviews was use of characteristics other than the patient’s CHADS2 score to enact a treatment plan, such as the patient’s social situation and past medication-taking behavior. Other themes included patient knowledge, real-world problems, breakdown in communication, and clinician reluctance. Conclusion Warfarin treatment is associated with many challenges. The barriers identified by clinicians highlight the unmet need associated with stroke prophylaxis in AF and the opportunity to improve anticoagulation treatment in AF. Social and lifestyle factors were important considerations in determining treatment.

SP2 Clinician-Patient Discord: Exploring Differences in Perspectives for Clopidogrel Persistence

Reduction of cardiovascular risk (CVR) is one of the most important role in advanced cardiovascular nursing. There has been no research to date evaluating CVR in patients with permanent cardiac pacing including the role of selected risk factors. We assessed the hypothesis that continuous nursing care and health promotion during regular follow-up visits after pacemaker implantation can add value such as reduction of CVR as well as reducing risk factors. Aim: Evaluate which of the modified CVR factors are most visibly reduced by health promotion provided by cardiovascular nurses during follow–up of patients after pacemaker implantations. Methods: 763 patients (aged 59.47±10.29; 397 males) with heart rhythm disorders hospitalized for first-time implantation (60,55%) or pacemaker exchange procedures (39,45) were included in the trial. The main reasons for implantation were sinus node dysfunction SND (65.27%) or AV blocks (34.73%). Average follow-up was 10.53±3.58 years. The SCORE cardiovascular risk for high risk countries was evaluated using the CVD Risk Calculator LN-10eu (PhaRma-Cat) for all patients. The analyzed parameters were: age, sex, total cholesterol (mg/dl), systolic blood pressure SBP (mmHg) and smoking. Results: Average CVR for the general population qualified for a pacemaker exchange procedure (3,01±2,99%) is significantly lower (p=0.000) when compared to the population of first implantation (4,62±2,90%). Detailed results for the analyzed risk factors are presented in the table below. The introduction of new nursing care for patients after pacemaker implantation did not result in a significant reduction in smoking (p=0,1491) nor in a reduction of average SBP (p=0,2422). Unfortunately, the level of total cholesterol increased (p=0,2965).