Hannah McGee

Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commissions European Heart Health Charter in 2008 prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity and mortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the core components and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR can be delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A general table applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented.

Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey.

Background Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy. Design Postal survey of national CR-related organizations in European countries. Methods The European Cardiac Rehabilitation Inventory Survey assessed topics including national guidelines, legislation and funding mechanisms, phases of CR provided and characteristic of included patients. Results Responses were available for 28 of 39 (72%) countries; 61% had national CR associations; 57% national professional guidelines. Most countries (86%) had phase I (acute inhospital) CR, but with differing service availability. Only 29% reported provision to more than 80% patients. Phase II was also available, but 15 countries reported provision levels below 30%. Almost half (46%) had national legislation regarding phase II CR; three-quarters had government funding. Phase III was less supported: although available in most countries, 11 could not provide estimates of numbers participating. Thirteen reported that all costs were met by patients. Conclusion Fewer than half of eligible cardiovascular patients benefit from CR in most European countries. Deficits include absent or inadequate legislation, funding, professional guidelines and information systems in many countries. Priorities for improvement include promoting national laws and guidelines specific for CR and increasing both CR programme participation rates and CR infrastructure. The European Association of Cardiovascular Prevention and Rehabilitation can have an important coordinating role in sharing expertise among national CR-related agencies. Ultimately, such cooperation can accelerate CR delivery to the benefit of cardiac patients across Europe.

Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

The purpose of this statement is to provide specific recommendations in regard to evaluation and intervention in each of the core components of cardiac rehabilitation (CR) to assist CR staff in the design and development of their programmes; the statement should also assist health care providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of such programmes. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, at national or at individual centre level, need to consider where and how structured programmes of CR can be delivered to the large constituency of patients now considered eligible for CR.

Latent structure of the Hospital Anxiety And Depression Scale: A 10-year systematic review

OBJECTIVE To systematically review the latent structure of the Hospital Anxiety and Depression Scale (HADS). METHODS A systematic review of the literature was conducted across Medline, ISI Web of Knowledge, CINAHL, PsycInfo and EmBase databases spanning articles published between May 2000 and May 2010. Studies conducting latent variable analysis of the HADS were included. RESULTS Twenty-five of the 50 reviewed studies revealed a two-factor structure, the most commonly found HADS structure. Additionally, five studies revealed unidimensional, 17 studies revealed three-factor, and two studies revealed four-factor structures. One study provided equal support for two- and three-factor structures. Different latent variable analysis methods revealed correspondingly different structures: exploratory factor analysis studies revealed primarily two-factor structures, confirmatory factor analysis studies revealed primarily three-factor structures, and item response theory studies revealed primarily unidimensional structures. CONCLUSION The heterogeneous results of the current review suggest that the latent structure of the HADS is unclear, and dependent on statistical methods invoked. While the HADS has been shown to be an effective measure of emotional distress, its inability to consistently differentiate between the constructs of anxiety and depression means that its use needs to be targeted to more general measurement of distress.

Individual quality of life in the healthy elderly

Quality of life research with the elderly has usually focused on the impact of decline in function, and used a pre-determined model of quality of life in old age. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) allows individuals to nominate, weigh and assess those domains of greatest relevance to their quality of life. The SEIQoL was administered to 56 healthy elderly community residents at baseline and 12 months later. Quality of life levels were significantly higher at baseline (t=−2.04; p=0.04) than that of a previously studied sample of healthy adults below 65 years of age, and did not change significantly over the study period. The domains nominated by both samples as relevant to their quality of life differed notably. Health status was not correlated with the perceived importance of health at baseline, and showed only a low correlation (r=0.27) at 12 months. The weight placed on health did not increase over the study period despite a significant decline in health status. The value of allowing the individual to define personal quality of life values in a research context is explored.

Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention & Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology.

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic burden both in western and developing countries, in which this burden is increasing in close correlation to economic growth. Health authorities and the general population have started to recognize that the fight against these diseases can only be won if their burden is faced by increasing our investment on interventions in lifestyle changes and prevention. There is an overwhelming evidence of the efficacy of secondary prevention initiatives including cardiac rehabilitation in terms of reduction in morbidity and mortality. However, secondary prevention is still too poorly implemented in clinical practice, often only on selected populations and over a limited period of time. The development of systematic and full comprehensive preventive programmes is warranted, integrated in the organization of national health systems. Furthermore, systematic monitoring of the process of delivery and outcomes is a necessity. Cardiology and secondary prevention, including cardiac rehabilitation, have evolved almost independently of each other and although each makes a unique contribution it is now time to join forces under the banner of preventive cardiology and create a comprehensive model that optimizes long term outcomes for patients and reduces the future burden on health care services. These are the aims that the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation has foreseen to promote secondary preventive cardiology in clinical practice.

Measuring health-related quality of life in older patient populations: a review of current approaches

The changing demographic profile of the world’s population towards old age and evidence of people living for longer with less time spent in ill health highlight the importance of addressing quality-of-life (QOL) assessment issues for older people. The assessment of health-related QOL (HR-QOL) has received considerable attention in the last 2–3 decades, with a wide variety of assessment instruments available. These instruments can be either generic or disease specific, health profiles or preference based.The literature was reviewed systematically to identify studies measuring HR-QOL in older patient groups. A total of 37 studies were identified, 11 of which were randomised, controlled trials/evaluations, 14 were prospective studies that did not involve a randomised, controlled intervention, and 12 were cross-sectional studies. Studies were summarised in terms of the study aim, patient population characteristics, the instrument used to measure HR-QOL, and HR-QOL findings. A majority of studies used a generic HR-QOL instrument, the single most commonly used being the 36-Item Short-Form Health Survey. In many cases, a second disease-specific measure was used in combination with the generic measure. In a majority of studies involving interventions, significant improvements in HR-QOL were noted. In prospective studies, a negative impact of health conditions (e.g. myocardial infarction and chronic heart failure) was also identified using HR-QOL assessments.None of the studies in this review used HR-QOL measurement instruments that were old-age specific. Using instruments that are not specific to a particular age group enables comparisons to be made with other age groups, i.e. younger or middle-aged groups. However, the questionnaire items of HR-QOL instruments tend to be phrased predominantly in relation to physical function and thus may inadvertently discriminate against older persons, whose physical function is likely to be not as good as that of younger people. Particular issues in the assessment of HR-QOL in older patient populations include the persistent finding of a poor relationship between QOL and disability/disease severity, the dynamic nature of QOL, and the importance of valid proxy ratings for those unable to make decisions or communicate for themselves.It is important, therefore, that assessment of HR-QOL incorporates issues of importance to individual older people by broadening the scope of the measurement instruments, thus representing more validly the HR-QOL status of older patient groups. Future research in HR-QOL must incorporate the perspective of the individual in order to enable valid conclusions to be derived based on content that is relevant to the individual being assessed, thus informing management decisions, policy and practice more meaningfully.

Development of a direct weighting procedure for quality of life domains

The Schedule for the Evaluation of Individual Quality of Life allows individuals to nominate the domains they consider most important to their quality of life and to use their own value system when describing the functional status and relative importance of those domains. The weights for domain importance are derived through a procedure called judgement analysis. As judgement analysis is impractical for individuals with cognitive impairment and in many clinical situations, a shorter, direct weighting procedure has been developed. To test the new procedure, 40 healthy individuals completed both direct and judgement analysis weightings, at t1 and 7-10 days later (t2). After a further 7-10 days (t3), they were asked to identify the weight profiles they had previously produced using each method. The weights produced by the two methods differed on average by 7.8 points at t1 and 7.2 points at t2. The direct weights changed on average by 4.5 points from t1 to t2, while the judgement analysis weights changed by 8.4 points. At t3, 55% of individuals were able to identify the direct weights they had previously produced. The new procedure demonstrates stability and validity but is not interchangeable with judgement analysis. The most appropriate ways of using and interpreting both procedures are discussed.

Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology.

There is now clear scientific evidence linking regular aerobic physical activity to a significant cardiovascular risk reduction, and a sedentary lifestyle is currently considered one of the five major risk factors for cardiovascular disease. In the European Union, available data seem to indicate that less than 50% of the citizens are involved in regular aerobic leisure-time and/or occupational physical activity, and that the observed increasing prevalence of obesity is associated with a sedentary lifestyle. It seems reasonable therefore to provide institutions, health services, and individuals with information able to implement effective strategies for the adoption of a physically active lifestyle and for helping people to effectively incorporate physical activity into their daily life both in the primary and the secondary prevention settings. This paper summarizes the available scientific evidence dealing with the relationship between physical activity and cardiovascular health in primary and secondary prevention, and focuses on the preventive effects of aerobic physical activity, whose health benefits have been extensively documented. Eur J Cardiovasc Prevention Rehab 10:319-327

Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular risk factors: recommendations from the EACPR (Part II)

In a previous paper, as the first of a series of three on the importance of characteristics and modalities of physical activity (PA) and exercise in the management of cardiovascular health within the general population, we concluded that, in the population at large, PA and aerobic exercise capacity clearly are inversely associated with increased cardiovascular disease risk and all-cause and cardiovascular mortality and that a dose–response curve on cardiovascular outcome has been demonstrated in most studies. More and more evidence is accumulated that engaging in regular PA and exercise interventions are essential components for reducing the severity of cardiovascular risk factors, such as obesity and abdominal fat, high BP, metabolic risk factors, and systemic inflammation. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit for each separate risk factor. The present paper, therefore, will review and make recommendations for PA and exercise training in the management of cardiovascular health in individuals with cardiovascular risk factors. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and individual members of the public. Based on previous and the current literature overviews, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and regarding appropriate risk evaluation during exercise in individuals with cardiovascular risk factors.