Gert-Jan Lauret

Lifestyle interventions in patients with coronary heart disease: A systematic review

CONTEXT Coronary heart disease (CHD) is responsible for about 15% of all deaths worldwide and is identified as a top priority for decision makers. Both primary and secondary prevention are considered key strategies in the prevention of CHD. The aim of this study was to assess the efficacy of nonpharmacologic interventions with multiple lifestyle components in patients with established CHD in comparison to usual care. For this reason, a systematic review and meta-analysis of RCTs were performed. EVIDENCE ACQUISITION The Cochrane Library, MEDLINE, and EMBASE databases were examined until March 31, 2012 (without start date) in order to identify studies addressing patient-tailored multifactorial lifestyle interventions aimed at reducing more than one cardiovascular risk factor in patients with established CHD. Primary endpoints were fatal and nonfatal cardiovascular events. Secondary outcomes were overall mortality and cardiovascular disease-associated hospital readmissions. EVIDENCE SYNTHESIS The search strategy yielded 14 unique RCTs, which were considered in the qualitative analysis. Nine of them contributed to the meta-analysis. A random effects model was used to pool the data. The meta-analysis showed a significant risk reduction of 18% (relative risk 0.82, 95% CI=0.69, 0.98) of fatal cardiovascular events in patients undergoing multifactorial lifestyle interventions. Further, a nonsignificant reduction of nonfatal events, overall mortality and hospital readmissions was found. CONCLUSIONS Multifactorial lifestyle interventions aimed at improving modifiable risk factors in patients with established CHD reduce the risk for fatal cardiovascular events. Therefore, they may have added value in secondary prevention of CHD.

Multidisciplinary treatment for peripheral arterial occlusive disease and the role of eHealth and mHealth

Increasingly unaffordable health care costs are forcing care providers to develop economically viable and efficient health care plans. Currently, only a minority of all newly diagnosed peripheral arterial occlusive disease (PAOD) patients receive efficient and structured conservative treatment for their disease. The aim of this article is to introduce an innovative effective treatment model termed ClaudicatioNet. This concept was launched in The Netherlands as a means to combat treatment shortcomings and stimulate cohesion and collaboration between stakeholders. The overall goal of ClaudicatioNet is to stimulate quality and transparency of PAOD treatment by optimizing multidisciplinary health care chains on a national level. Improved quality is based on stimulating both a theoretical and practical knowledge base, while eHealth and mHealth technologies are used to create clear insights of provided care to enhance quality control management, in addition these technologies can be used to increase patient empowerment, thereby increasing efficacy of PAOD treatment. This online community consists of a web portal with public and personal information supplemented with a mobile application. By connecting to these tools, a social community is created where patients can meet and keep in touch with fellow patients, while useful information for supervising health care professionals is provided. The ClaudicatioNet concept will likely create more efficient and cost-effective PAOD treatment by improving the quality of supervised training programs, extending possibilities and stimulating patient empowerment by using eHealth and mHealth solutions. A free market principle is introduced by introducing transparency to provided care by using objective and subjective outcome parameters. Cost-effectiveness can be achieved using supervised training programs, which may substitute for or postpone expensive invasive vascular interventions.

Supervised exercise therapy for intermittent claudication: current status and future perspectives

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

The ClaudicatioNet concept: design of a national integrated care network providing active and healthy aging for patients with intermittent claudication.

Introduction: Intermittent claudication (IC) is a manifestation of peripheral arterial occlusive disease (PAOD). Besides cardiovascular risk management, supervised exercise therapy (SET) should be offered to all patients with IC. Outdated guidelines, an insufficient number of specialized physiotherapists (PTs), lack of awareness of the importance of SET by referring physicians, and misguided financial incentives all seriously impede the availability of a structured SET program in The Netherlands. Description of care practice: By initiating regional care networks, ClaudicatioNet aims to improve the quality of care for patients with IC. Based on the chronic care model as a conceptual framework, these networks should enhance the access, continuity, and (cost) efficiency of the health care system. With the aid of a national database, health care professionals will be able to benchmark patient results while ClaudicatioNet will be able to monitor quality of care by way of functional and patient reported outcome measures. Discussion: The success of ClaudicatioNet is dependent on several factors. Vascular surgeons, general practitioners and coordinating central caregivers will need to team up and work in close collaboration with specialized PTs. A substantial task in the upcoming years will be to monitor the quality, volume, and distribution of ClaudicatioNet PTs. Finally, misguided financial incentives within the Dutch health care system need to be tackled. Conclusion: With ClaudicatioNet, integrated care pathways are likely to improve in the upcoming years. This should result in the achievement of optimal quality of care for all patients with IC.

Physical Activity Monitoring in Patients with Intermittent Claudication

OBJECTIVES Reduced physical activity (PA) is associated with a higher mortality rate and more rapid functional decline in patients with intermittent claudication (IC). The newest generation of accelerometers can assess both direction and intensity of activities three-dimensionally and may also adequately calculate energy expenditure in daily life. The aim of this study was to quantify daily PA level and energy expenditure of newly diagnosed patients with IC and healthy controls. PA outcomes are compared with contemporary public health physical activity guidelines. METHODS Before initiating treatment, 94 patients with newly diagnosed IC and 36 healthy controls were instructed to wear a tri-axial seismic accelerometer for 1 week. Daily PA levels (in metabolic equivalents, METs) were compared with the ACSM/AHA public health PA minimum recommendations (≥64 METs·min·day, in bouts of ≥10 minutes). A subgroup analysis assessed the effect of functional impairment on daily PA levels. RESULTS Data from 56 IC patients and 27 healthy controls were available for analysis. Patients with IC demonstrated significantly lower mean daily PA levels (±SD) than controls (387 ± 198 METs·min vs. 500 ± 156 METs·min, p = .02). This difference was solely attributable to a subgroup of IC patients with the largest functional impairment (WIQ-score < 0.4). Only 45% of IC patients met the public health physical activity guidelines compared with 74% of the healthy controls (p = .01). CONCLUSIONS More than half of patients with IC do not meet recommended standards of PA. Considering the serious health risks associated with low PA levels, these findings underscore the need for more awareness to improve physical exercise in patients with IC.

Persisting pain after endovascular treatment of a symptomatic aortic aneurysm

INTRODUCTION Usually patients are admitted to hospital with a single diagnosis, but if complaints persist it is important to consider a synchronous secondary diagnosis. PRESENTATION OF CASE A 74-year-old woman presented with severe abdominal and back pain. On physical examination, a tender abdominal aortic aneurysm (AAA) was noted. Following endovascular treatment of the AAA, pain in the right lower abdomen persisted. Review of the pre-EVAR CT images revealed a foreign body in the terminal ileum, which was surgically removed. DISCUSSION Patients with foreign-body-related intestinal pain present with complaints of abdominal pain at initial presentation. The accompanied back pain and abdominal tenderness of the abdominal aorta in our case could indicate another diagnosis. CONCLUSION Persisting complaints post-intervention should not only arouse suspicion of an intervention-related complication, but also of a synchronous second diagnosis.