C. Ellis

Changing Illness Perceptions After Myocardial Infarction: An Early Intervention Randomized Controlled Trial

Objective This study was designed to examine whether a brief hospital intervention designed to alter patients’ perceptions about their myocardial infarction (MI) would result in a better recovery and reduced disability. Design In a prospective randomized study, 65 consecutive patients with their first MI aged were assigned to receive an intervention designed to alter their perceptions about their MI or usual care from rehabilitation nurses. Patients were assessed in hospital before and after the intervention and at 3 months after discharge from hospital. Results The intervention caused significant positive changes in patients’ views of their MI. Patients in the intervention group also reported they were better prepared for leaving hospital (p < .05) and subsequently returned to work at a significantly faster rate than the control group (p < .05). At the 3-month follow-up, patients in the intervention group reported a significantly lower rate of angina symptoms than control subjects (14.3 vs. 39.3, p < .03). There was no significant differences in rehabilitation attendance between the two groups. Conclusions An in-hospital intervention designed to change patients’ illness perceptions can result in improved functional outcome after MI.

Further development of an illness perception intervention for myocardial infarction patients: A randomized controlled trial

OBJECTIVE To further develop and trial a brief in-hospital illness perception intervention for myocardial infarction (MI) patients. METHODS One hundred and three patients admitted with acute MI were randomized to receive either standard care or standard care plus an illness perception intervention, which consisted of three half-hour patient sessions and one half-hour patient-and-spouse session delivered in hospital. Patients were followed up to 6 months. The main outcome was the difference between groups in rate of return to work. RESULTS The intervention group had a faster rate of return to work than the control group, and more patients in the intervention group had returned to full time work by 3 months than in the control group. At discharge, patients in the intervention group demonstrated changes in causal attributions regarding their MI and higher perceived understanding of their condition, which remained at the 6-month follow-up. They also reported a better understanding of the information given in hospital, higher intentions to attend cardiac rehabilitation classes, lower anxiety about returning to work, greater increases in exercise, and made fewer phone calls to their general practitioner about their heart condition at follow-up. CONCLUSION This study replicates the findings of an earlier trial that a brief in-hospital illness perception intervention can change perceptions and improve rates of return to work in MI patients. It increases the generalizability of the intervention to the current broader definition of MI and to patients who have had previous infarcts.

Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction.

Abstract Objective: To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy. Design: Cohort follow up study. Setting: The four coronary care units in Auckland, New Zealand. Subjects: All 3014 patients presenting to the units with suspected myocardial infarction in 1993. Main outcome measures: Eligibility for reperfusion with thrombolytic therapy (presentation within 12 hours of the onset of ischaemic chest pain with ST elevation >/=2 mm in leads V1-V3, ST elevation >/=1 mm in any other two contiguous leads, or new left bundle branch block); proportions of (a) patients eligible for reperfusion and (b) patients with contraindications to thrombolysis; death (including causes); definite myocardial infarction. Results: 948 patients had definite myocardial infarction, 124 probable myocardial infarction, and nine ST elevation but no infarction; 1274 patients had unstable angina and 659 chest pain of other causes. Of patients with definite or probable myocardial infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite contraindications to thrombolysis (risk of bleeding). Hence 49.7% of patients (537/1081) were eligible for thrombolysis and 43.5% (470) received this treatment. Hospital mortality among patients eligible for reperfusion was 11.7% (55/470 cases) among those who received thrombolysis and 17.0% (18/106) among those who did not. Conclusions: On current criteria about half of patients admitted to coronary care units with definite or probable myocardial infarction are eligible for thrombolytic therapy. Few eligible patients have definite contraindications to thrombolytic therapy. Mortality for all community admissions for myocardial infarction remains high. Key messages Less than 10% of patients eligible for reperfusion have contraindications to thrombolysis The hospital mortality for all patients with acute myocardial infarction remains high (14%) Better treatments are required to reduce mortality in both reperfusion eligible and reperfusion ineligible patients

Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study.

Objectives: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published guidelines.

Changes in patient drawings of the heart identify slow recovery after myocardial infarction.

Objective: The objective of this study was to investigate how changes in heart attack patients’ drawings of their heart over the recovery period relate to psychological and functional recovery. Methods: Sixty-nine inpatients admitted for acute myocardial infarction at the coronary care unit at a metropolitan hospital completed questionnaires at discharge, including a drawing of what they thought had happened to their heart after their heart attack. Fifty-six patients returned follow-up questionnaires at 3 and 6 months, including heart drawings, cardiac anxiety, time to return to work, changes in exercise frequency, and healthcare use. Results: Increases in the size of the heart drawn at the 3-month follow-up relative to discharge were related to slower return to work (r = 0.48, p < .01), higher cardiac anxiety (r = 0.35, p < .05), and more phone calls to health services (r = 0.37, p < .05) as well as increases in worry about another myocardial infarction (r = 0.39, p < .01), increased activity restriction (r = 0.34, p < .05), higher use of alternative medicines (r = 0.40, p < .05), and less frequent exercise (r = −0.39, p < .05) relative to before the myocardial infarction. Conclusions: Drawings of the heart may be useful in identifying patients who have experienced heart attacks who are likely to develop greater heart-focused anxiety, complaints of ill health, and higher use of health care. Increases in the size of the patient’s drawing of the heart may reflect increases in the extent to which their heart condition plays on their mind and directs their daily activities. MI = myocardial infarction; CAQ = Cardiac Anxiety Questionnaire.

Abnormal Coronary Flow in Infarct Arteries 1 Year After Myocardial Infarction Is Predicted at 4 Weeks by Corrected Thrombolysis in Myocardial Infarction (TIMI) Frame Count and Stenosis Severity

Because 24% to 30% of patent infarct-related arteries occlude in the year following thrombolytic therapy for acute myocardial infarction, angiographic factors including corrected Thrombolysis in Myocardial Infarction (TIMI) frame count which may predict abnormal infarct-artery flow, require definition. We examined changes in coronary flow and infarct-artery lesion severity by computerized quantitative angiography over 1 year in 154 patients with a patent infarct-related artery 4 weeks after myocardial infarction. These patients were randomized to receive either ongoing daily therapy of 50 mg aspirin and 400 mg dipyridamole, or placebo. All angiograms were interpreted blind in our core angiographic laboratory. Infarct-artery flow, assessed by corrected TIMI frame counts, was normal (< or = 27) in 46% and 45% of patients at 4 weeks and 1 year, respectively. At 4 weeks, patients with corrected TIMI frame counts < or = 27 had higher ejection fractions (60+/-11% vs 56+/-12%; p = 0.04) than those with corrected TIMI frame counts >27. On multivariate analysis, corrected TIMI frame count and stenosis severity were predictive of late abnormal infarct-artery flow (TIMI 0 to 2 flow, both p <0.01). Only stenosis severity at 4 weeks predicted reocclusion at 1 year (p <0.0001). Aspirin and dipyridamole had no effect on flow or reocclusion. Thus, corrected TIMI frame count and stenosis severity at 4 weeks was highly correlated with infarct-artery flow at 1 year.

Symptom expectations and delay in acute myocardial infarction patients

The efficacy of the timely administration of thrombolytic treatment in the clinical management of acute myocardial infarction (MI) is well established. Large scale clinical trials have conclusively shown that the earlier the administration of such treatment, the greater the morbidity and mortality advantage.1 The demonstration of this time dependent relation has prompted research into factors that contribute to the delay interval between symptom onset and hospital presentation. The failure of sociodemographic and clinical factors to be consistently related to pre-hospital delay2 has recently focused attention on how patients make sense of their symptoms and determine whether they need urgent medical help. Building on a recent study which found that patient delay was associated with a discrepancy between symptom experience and prior symptom expectation of MI,3 we extended the scope of this research by also investigating whether delay was related to having a family member present or to behaviours such as self medication before calling for help. We evaluated a consecutive sample comprising 47 participants with a confirmed diagnosis of acute MI (38 men and nine women with a mean (SD) age of 62 (13.4) years). Thirty eight per cent of the sample had a family history of MI and 15% of participants had experienced a previous MI. Patients were required to recall both the symptoms experienced as part of their …

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

Objective To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care. Methods All patients hospitalised bi-nationally with ACS were identified between 14–27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care. Results For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88–3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52–2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67–6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21–3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06–1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35–0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42–0.84]; p=0.003) were associated with lower exposure to preventive care. Conclusions Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.

Association of genetic variation in the natriuretic peptide system with cardiovascular outcomes

Polymorphisms within individual natriuretic peptide genes have been associated with risk factors for cardiovascular disease, but their association with clinical outcomes was previously unknown. This study aimed to investigate the association between genetic variants in key genes of the natriuretic peptide system with cardiovascular outcomes in patients with coronary artery disease. Coronary disease patients (n=1810) were genotyped for polymorphisms within NPPA, NPPB, NPPC, NPR1 and NPR2. Clinical history, natriuretic peptide concentrations, echocardiography, all-cause mortality and cardiovascular hospital readmissions were recorded over a median 2.8 years. Minor alleles of NPPA rs5068, rs5065 and rs198358 were associated with less history of hypertension; minor alleles of NPPA rs5068 and rs198358 was also associated with higher circulating natriuretic peptide levels (p=0.003 to p=0.04). Minor alleles of NPPB rs198388, rs198389, and rs632793 were associated with higher circulating BNP and NT-proBNP (p=0.001 to p=0.03), and reduced E/E(1) (p=0.011), or LVESVI (p=0.001) and LVEDVI (p=0.004). Within NPPC, both rs11079028 and rs479651 were associated with higher NT-proBNP and CNP (p=0.01 to p=0.03), and rs479651 was associated with lower LVESVI (p=0.008) and LVEDVI (p=0.018). NPR2 rs10758325 was associated with smaller LVMI (p<0.02). A reduced rate of cardiovascular readmission was observed for minor alleles of NPPA rs5065 (p<0.0001), NPPB rs632793 (p<0.0001), rs198388 (p<0.0001), rs198389 (p<0.0001), and NPR2 rs10758325 (p<0.0001). There were no associations with all-cause mortality. In established cardiovascular disease, natriuretic peptide system polymorphisms were associated with natriuretic peptide levels, hypertension, echocardiographic indices and the incidence of hospital readmission for cardiovascular events.

Patients with acute myocardial infarction have an inaccurate understanding of their risk of a future cardiac event

Background: Accurate perceptions of future cardiac risk are important to ensure informed treatment choices and lifestyle adaptation in patients following myocardial infarction (MI). The aim of this study was to investigate whether risk perceptions of patients with MI were accurate compared with an established clinical risk model.