Paul D. MacIntyre

Effect of subcutaneous sumatriptan, a selective 5HT1 agonist, on the systemic, pulmonary, and coronary circulation.

BackgroundSumatriptan (GR43175) is a selective 5-hydroxytryptamine (SHT1) receptor agonist effective in the acute treatment of migraine. Recent in vitro experiments suggest that it has vasoactive properties in vascular beds distinct from the cerebral circulation. The object of this study was to assess the vasoactive effects of the standard 6-mg subcutaneous dose of sumatriptan used in migraine on the systemic and pulmonary circulations and the coronary artery vasculature. Methods and ResultsTen patients undergoing diagnostic coronary arteriography were studied with digital subtraction angiography and invasive hemodynamic monitoring. After subcutaneous injection of sumatriptan, there was no significant change in heart rate or ECG morphology. There was a significant rise in the systemic (20%, p<0.05 by ANOVA) and pulmonary arterial (40%o, p<0.05 by ANOVA) pressures. There was no change in cardiac output, but there was a significant increase in total systemic (27%, p<0.05) and total pulmonary vascular resistance (40%, p<0.05). Sumatriptan caused a significant reduction (p<0.001 by ANOVA) in mean absolute coronary artery diameter, from 436±1.60 mm at baseline to 3.67±1.49 mm (16%) at 10 minutes and to 3.63+1.49 mm (17%) at 30 minutes after injection. There were no clinical sequelae. ConclusionSumatriptan, a SHT, receptor agonist administered by the subcutaneous route, causes a vasopressor response in the systemic and pulmonary arterial circulations and coronary artery vasoconstriction.

A randomized, controlled trial to study the effect of exercise consultation on the promotion of physical activity in people with Type 2 diabetes: a pilot study

Aim  To evaluate the effect of exercise consultation on promotion of physical activity in people with Type 2 diabetes.

Effect of an exercise consultation on maintenance of physical activity after completion of phase III exercise-based cardiac rehabilitation

Background Many patients do not maintain physical activity levels after completion of phase III exercise-based cardiac rehabilitation. Design This study determined the effect of an exercise consultation on maintenance of physical activity and cardiorespiratory fitness 12 months after completion of a phase III exercise programme. Seventy cardiac patients were randomized to the experimental (exercise consultation and exercise information) or control groups (exercise information only). Methods Outcomes recorded at baseline, 6 and 12 months were: physical activity (stage of change, 7-day recall, accelerometer), cardiorespiratory fitness, lipids, quality of life, anxiety and depression. Results Both groups were regularly active at baseline. The between-group difference for the change in total activity (min/week) assessed by the 7-day recall was significant from baseline to 12 months [98% confidence interval (CI) −295, −20]. Total activity was maintained in the experimental group (98% CI −63, 154) and significantly decreased in the control group (115 min/week; 98% CI −228, −28) from baseline to 12 months. The between-group difference for the change in accelerometer counts/week was not significant from baseline to 6 (98% CI −1143 720, 607430) or 12 months (98% CI −1131 128, 366 473). A comparable, significant decrease in peak oxygen uptake occurred from baseline to 12 months in experimental (1.8 ml/kg per min; 98% CI −3.2, −0.3) and control participants (2.3 ml/kg per min; −3.8, −0.8). Lipids, quality of life, anxiety and depression were normal at baseline and did not significantly change in either group over time. Conclusion Exercise consultation was effective in maintaining self-reported physical activity, but not peak oxygen uptake, for 12 months after completion of phase III. Eur J Cardiovasc Prev Rehabil 14: 114-121

Overcoming barriers to engaging socio-economically disadvantaged populations in CHD primary prevention: a qualitative study.

BackgroundPreventative medicine has become increasingly important in efforts to reduce the burden of chronic disease in industrialised countries. However, interventions that fail to recruit socio-economically representative samples may widen existing health inequalities. This paper explores the barriers and facilitators to engaging a socio-economically disadvantaged (SED) population in primary prevention for coronary heart disease (CHD).MethodsThe primary prevention element of Have a Heart Paisley (HaHP) offered risk screening to all eligible individuals. The programme employed two approaches to engaging with the community: a) a social marketing campaign and b) a community development project adopting primarily face-to-face canvassing. Individuals living in areas of SED were under-recruited via the social marketing approach, but successfully recruited via face-to-face canvassing. This paper reports on focus group discussions with participants, exploring their perceptions about and experiences of both approaches.ResultsVarious reasons were identified for low uptake of risk screening amongst individuals living in areas of high SED in response to the social marketing campaign and a number of ways in which the face-to-face canvassing approach overcame these barriers were identified. These have been categorised into four main themes: (1) processes of engagement; (2) issues of understanding; (3) design of the screening service and (4) the priority accorded to screening. The most immediate barriers to recruitment were the invitation letter, which often failed to reach its target, and the general distrust of postal correspondence. In contrast, participants were positive about the face-to-face canvassing approach. Participants expressed a lack of knowledge and understanding about CHD and their risk of developing it and felt there was a lack of clarity in the information provided in the mailing in terms of the process and value of screening. In contrast, direct face-to-face contact meant that outreach workers could explain what to expect. Participants felt that the procedure for uptake of screening was demanding and inflexible, but that the drop-in sessions employed by the community development project had a major impact on recruitment and retention.ConclusionSocio-economically disadvantaged individuals can be hard-to-reach; engagement requires strategies tailored to the needs of the target population rather than a population-wide approach.

Exercise consultation improves short-term adherence to exercise during phase IV cardiac rehabilitation: a Randomized, controlled trial

This randomized-controlled trial demonstrates that an exercise consultation, based on the transtheoretic model of exercise behavior change, significantly improves short-term adherence to exercise.

Exercise consultation and physical activity in patients with type 1 diabetes

34 patients with type 1 diabetes were randomly assigned to either an intervention group, who received an exercise consultation, or to a control group, who received an ‘exercise and diabetes’ information leaflet. Physical activity was measured by the Scottish Physical Activity Questionnaire. At a follow-up of 3 weeks, the intervention group had increased their leisure time physical activity level (LTPA) by 64.8% (p=0.045 compared to baseline). This group were significantly different from the controls at 3 weeks (p=0.025 compared to the control group). Most of this increase in LTPA came from individuals at stages 4 and 5 (action and maintenance) of exercise behaviour. In the intervention group the number of individuals reporting sport or exercise participation increased from four out of 11 (36%) at baseline to eight out of 11 (73%) at 3 weeks. This increase was contributed by both males and females, who came from stages 2 and 3 (contemplation and preparation) of exercise behaviour. This study has demonstrated the effectiveness of the exercise consultation process in increasing short-term physical activity levels in a small group of individuals with type 1 diabetes. The intervention has been shown to be significantly more effective than information provided in a leaflet. Copyright

Peer support to promote physical activity after completion of centre-based cardiac rehabilitation: evaluation of access and effects.

Background: Patients with heart disease receive little support for sustaining physical activity over the long-term. This study compared the characteristics of patients choosing to join a peer support program to promote use of physical activity and assessed its effects on physical activity. Aims: To compare characteristics of those choosing to join the peer support (PS) program versus those who did not, and to assess the effect on physical activity patterns at 12 months of the PS program. Methods: Based on health status from 225 people who completed centre-based cardiac rehabilitation, 109 patients with heart disease who had completed a program of hospital-based cardiac rehabilitation were suitable for the peer support program. Health status and characteristics of patients opting to join the program (n = 79) were compared to patients who did not wish to join (n = 30). A longitudinal study was then conducted to determine the objective effects on physical activity levels of program membership at 12 months as measured by self-report and pedometers. Results: Patients who joined the peer support program tended to be older (p < 0.001), and female compared to those who were eligible but did not join (p = 0.04). Over the next 12 months, those who did not participate in the peer support program reported a decline of 211 min in the total amount of physical activity accumulated in an average week (1382.5 ± 238.2 to 1171.5 ± 220.1 min week−1 p = 0.003), whereas program members sustained similar levels of physical activity as was recorded at the completion of cardiac rehabilitation (1021.1 ± 141.9 to 1070 ± 127.8 min week− 1). Objective measures of physical activity indicated that groups increased moderately total step count per week (p = 0.68 and p = 0.25) and in their average steps per day (p = 0.68 and p = 0.25 respectively) from baseline to 12 months. Conclusion: Peer support programs have good potential to help people with heart disease maintain physical activity after cardiac rehabilitation. Importantly, they may offer particular benefits for older patients and females.

Design matters in secondary prevention: individualization and supervised exercise improves the effectiveness of cardiac rehabilitation

Background: Hospital or centre-based cardiac rehabilitation (CR) can lengthen and improve life. However, most existing trials do not examine the effects of design characteristics. To examine the effects of these characteristics, this study compared an individualized cardiac rehabilitation programme to a standardized programme and examined what factors contributed most to programme effects. Design: A prospective cohort analysis was done comparing patients using an individualized centre-based cardiac rehabilitation programme (ICR) in a mixed urban-rural region of the west of Scotland, to a standardized cardiac rehabilitation programme (SCR) provided at the same site three years previously. Both inter- and intra-programme differences in outcomes were explored. Results: More patients were referred to ICR than SCR (749 versus 414 patients, p = 0.002) and the proportion of patients who subsequently attended was around 30% higher (p < 0.0001) although the overall rate of referral to ICR was lower (70% versus 62%, p = 0.002). ICR was associated with a reduction in hospital admission compared to SCR (HR: 0.664: 95% confidence interval (CI) 0.554 to 0.797). ICR patients also had significantly shorter hospitalizations (mean: 8.02 days versus 5.84 days, p < 0.05). ICR patients who attended at least 75% of the exercise sessions were significantly less likely to be hospitalized than individuals who partially attended (HR 2.39, 95% CI: 1.659 to 3.488) or did not participate in exercise sessions (HR 2.16, 95% CI: 1.482 to 3.143). Conclusions: Individualized content and supervised exercise components are key design characteristics for improving outcomes from centre-based CR in clinically representative populations.

The role of age in moderating access to cardiac rehabilitation in Scotland

Access to health care should be determined by clinical need and not by age. Older people form an increasing proportion of the general population and of those with coronary heart disease, but compared with younger people they are less likely to be invited for cardiac rehabilitation programmes and more likely not to complete them. This study examined the factors that contribute to these trends in Scotland. A national survey of rehabilitation centres (n = 30) found that the majority of their programme co-ordinators believe that age does influence access to rehabilitation. While only one programme used an overt age criterion, age was widely perceived to influence access, both during initial assessment and in assessments for exercise components; and while the respondents acknowledged that other criteria influenced selection, the factors cited most often were all more common during old age, e.g. the presence of other medical ailments, lower initial exercise tolerance, and poor access to private or public transport. Focus groups undertaken with a sub-sample of the co-ordinators revealed that staff appeared to have knowledge of the benefits of cardiac rehabilitation for older people, but that the scarcity of resources prevented them from offering more accessible and appropriate services.

Prior psychiatric hospitalization is associated with excess mortality in patients hospitalized with non-cardiac chest pain: a data linkage study based on the full Scottish population (1991-2006)

AIMS Non-cardiac chest pain (NCCP) is considered a benign condition. We investigate case-fatality following an incident hospitalization for NCCP and determine whether previous psychiatric hospitalization is associated with short-term mortality. METHODS AND RESULTS This was a population-based retrospective cohort study of 159 888 patients discharged from hospital in Scotland (1991-2006) following a first NCCP hospitalization, using routinely collected morbidity and mortality data. All-cause and cardiovascular disease (CVD) mortality at 1 year following hospitalization was examined. A total of 3514 (4.4%) men and 3136 (3.9%) women with a first NCCP hospitalization had a psychiatric hospitalization in the 10 years preceding incident NCCP hospitalization. Those with a previous psychiatric hospitalization were younger and more socioeconomically deprived (SED). Overall, crude case fatality at 1 year was 4.4% in men and 3.7% in women. This was higher in patients with a previous psychiatric hospitalization compared with those without (overall: men 6.3 vs. 4.3%; women: 5.3 vs. 3.6%), in all age groups and all SED quintiles. Following adjustment (year of NCCP hospitalization, SED, co-morbid diabetes, and hypertension), the hazard of all-cause and CVD-specific death at 1 year was higher in men and women with a previous psychiatric hospitalization than without, with effect modification according to age group. CONCLUSION Non-cardiac chest pain is not an entirely benign condition. Individuals with a hospital discharge diagnosis of NCCP who have a previous psychiatric hospitalization have a greater risk of death, all-cause, and CVD-specific, at 1 year, than those without. A NCCP hospitalization is an opportunity to engage, and where appropriate, intervene to modify cardiovascular risk in this difficult-to-reach and high-risk group.