Peter Tilkemeier

Neurocognitive functioning and improvement in quality of life following participation in cardiac rehabilitation

We investigated the relationship between neurocognitive functioning and quality of life/self-perceived health status (QOL) among cardiac rehabilitation (CR) patients to determine whether level of neurocognitive functioning is related to baseline QOL and improvement following CR. CR patients (n = 35) were given a neurocognitive screening before participation in CR, and also completed a behavioral inventory (SF-36) before and after CR to measure QOL associated with medical illness. At baseline, CR patients obtained relatively low SF-36 scores compared with published norms, and as reported previously, demonstrated inferior neurocognitive performance compared with healthy controls. Furthermore, neurocognitive performance was strongly positively correlated to SF-36 scores. Significant improvements were evident on many of the SF-36 subscales following rehabilitation. These improvements were relatively greater among SF-36 indexes of physical health status compared with SF-36 indexes of mental health status. Baseline neurocognitive performance also correlated strongly to the degree of improvement in SF-36 scores following rehabilitation. These findings indicate a strong relationship between baseline neurocognitive functioning and QOL before CR, and the degree to which QOL improves following this intervention.

Patient-Centered Imaging: Shared Decision Making for Cardiac Imaging Procedures With Exposure to Ionizing Radiation

The current paper details the recommendations arising from an NIH-NHLBI/NCI-sponsored symposium held in November 2012, aiming to identify key components of a radiation accountability framework fostering patient-centered imaging and shared decision-making in cardiac imaging. Symposium participants, working in 3 tracks, identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. The use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering, and reinforced by the performing provider team. An imaging protocol with effective dose ≤3 mSv is considered very low risk, not warranting extensive discussion or written informed consent. However, a protocol effective dose >20 mSv was proposed as a level requiring particular attention in terms of shared decision-making and either formal discussion or written informed consent. Laboratory reporting of radiation dosimetry is a critical component of creating a quality laboratory fostering a patient-centered environment with transparent procedural methodology. Efforts should be directed to avoiding testing involving radiation, in patients with inappropriate indications. Standardized reporting and diagnostic reference levels for computed tomography and nuclear cardiology are important for the goal of public reporting of laboratory radiation dose levels in conjunction with diagnostic performance. The development of cardiac imaging technologies revolutionized cardiology practice by allowing routine, noninvasive assessment of myocardial perfusion and anatomy. It is now incumbent upon the imaging community to create an accountability framework to safely drive appropriate imaging utilization.

Program Participation and Physical Activity Maintenance after Cardiac Rehabilitation

This study examined exercise maintenance among patients after completing cardiac rehabilitation. Subjects were men and women who had completed a Phase II Cardiac Rehabilitation Program approximately 12 months previously. Subjects were classified according to whether they had (a) never participated in a Phase III program (G-I) (N = 37), (b) enrolled and completed a Phase III program (G-II) (N = 30), or (c) were currently enrolled in a Phase III maintenance program (G-III) (N = 33). Subjects were significantly more likely to be participating in regular exercise if they had participated in a Phase III program (p < .05). Individuals in G-II and G-III engaged in more minutes of physical activity per week and were more likely to meet recommended levels of physical activity compared to G-I subjects. G-I individuals who had longer Phase II programs were more likely to maintain their exercise habits following graduation (p < .05). Results suggest that Phase III maintenance programs and longer Phase II participation improved exercise maintenance following rehabilitation.

Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes.

Multiple published studies have established erectile dysfunction (ED) as an independent risk marker for cardiovascular disease (CVD). In fact, incident ED has a similar or greater predictive value for cardiovascular events than traditional risk factors including smoking, hyperlipidemia, and family history of myocardial infarction. Here, we review evidence that supports ED as a particularly significant harbinger of CVD in 2 populations: men <60 years of age and those with diabetes. Although addition of ED to the Framingham Risk Score only modestly improved the 10-year predictive capacity of the Framingham Risk Score for myocardial infarction or coronary death data in men enrolled in the Massachusetts Male Aging Study, other epidemiologic studies suggest that the predictive value of ED is quite strong in younger men. Indeed, in the Olmstead County Study, men 40 to 49 years of age with ED had a 50-fold higher incidence of new-incident coronary artery disease than those without ED. However, ED had less predictive value (5-fold increased risk) for coronary artery disease in men 70 years and older. Several studies, including a large analysis of more than 6300 men enrolled in the ADVANCE study, suggest that ED is a particularly powerful predictor of CVD in diabetic men as well. Based on the literature reviewed here, we encourage physicians to inquire about ED symptoms in all men more than 30 years of age with cardiovascular risk factors. Identification of ED, particularly in men <60 years old and those with diabetes, represents an important first step toward CVD risk detection and reduction.

Influence of exercise intensity on the presence, distribution, and size of thallium-201 defects☆

The effects of two levels of exercise intensity on the size and location of thallium-201 defects were compared in 22 patients with known ischemic coronary artery disease. A symptom-limited incremental exercise test was performed followed (greater than 48 hours) by submaximal steady-state exercise at 70% of the peak heart rate achieved during the incremental test. Planar thallium-201 myocardial scans obtained after each protocol were analyzed by means of both visual qualitative and computerized quantitative methods. After incremental exercise all patients exhibited reversible thallium-201 defects, and submaximal exercise still resulted in reversible defects in 20 (91%) patients. However, the size of the ischemic area and the degree of ischemia were significantly reduced by both qualitative and quantitative criteria after submaximal exercise. Therefore interpretation of thallium-201 scans with regard to severity of disease and prognosis should take into account exercise intensity.

Neuropsychological Functioning Among Cardiac Rehabilitation Patients

PURPOSE The underlying pathophysiology contributing to coronary heart disease also predisposes patients to cerebrovascular disease and associated cognitive disorders. Although prior studies have focused on the neuropsychological sequelae of specific cardiac problems, few have examined the associated cognitive capacities and limitations of typical cardiac patients. The current study was designed to examine neuropsychological functioning among a sample of cardiac rehabilitation (CR) patients. METHODS Using neuropsychological instruments, patients were compared in a CR program to age-matched outpatient control subjects who had no known history of cardiac or neurologic disease. Cardiac rehabilitation patients were then divided into dichotomous subgroups based on whether they had undergone coronary artery bypass grafting, had experienced a myocardial infarction, had hypertension, or had impaired ejection fraction. Neuropsychological functioning was examined relative to each of these factors. RESULTS Cardiac rehabilitation patients had poorer neuropsychological test performance than did control subjects, with subtle relative deficits on measures of response generation, memory, and verbal abstraction, and particularly verbal fluency. Low ejection fraction, hypertension, and prior coronary artery bypass graft were associated with greater relative neuropsychological impairments. CONCLUSIONS Although CR patients were not grossly neuropsychologically impaired as a group, it appears highly likely that many within a given program exhibit some degree of neuropsychological dysfunction. Including neuropsychological screening as part of pre-CR testing would help to identify such patients. This information may help staff to impart health care information in a manner that is most effective for the individual patient and may also be useful in the formation of realistic goals.

The Seamos Saludables study: A randomized controlled physical activity trial of Latinas.

BACKGROUND Latinas in the U.S. are less physically active than non-Latino white women and also report higher levels of diabetes, obesity, and other conditions related to inactivity. Interventions are needed to address disparities in this high-risk group. PURPOSE To evaluate the efficacy of a culturally adapted, Spanish-language, individually tailored, computer expert system-driven physical activity print-based intervention for adult Latinas. DESIGN RCT. SETTING/PARTICIPANTS Participants were 266 inactive adult Latinas who participated between 2009 and 2012. INTERVENTION Participants were randomized to one of two treatment arms: a 6-month tailored physical activity intervention condition or wellness contact control. For both conditions, print materials were delivered by mail. MAIN OUTCOME MEASURES The main outcome measure was change in weekly moderate-to-vigorous physical activity (MVPA) measured by the 7-Day Physical Activity Recall interview, which was administered at baseline and post-intervention (6 months). Participants also wore accelerometers for a week at baseline and follow-up. Analyses were conducted in 2013. RESULTS Increases in minutes/week of MVPA measured by the 7-Day PAR were significantly greater in the intervention group compared to the control group (mean difference=41.36, SE=7.93, p<0.01). This difference was corroborated by accelerometer readings (rho=0.44, p<0.01). Further, results indicate that intervention participants had greater increases in self-efficacy, cognitive processes, and behavioral processes at 3 months compared to control paricipants (ps<0.05). CONCLUSIONS The tailored Spanish-language intervention was effective in increasing MVPA among predominantly low-income, less-acculturated Latinas. Such print-based interventions are poised for widespread dissemination, and thus may help address health disparities.

Comparison of chest pain, electrocardiographic changes and thallium-201 scintigraphy during varying exercise intensities in men with stable angina pectoris

This study was performed to evaluate the presence of angina pectoris, electrocardiographic changes and reversible thallium-201 defects resulting from 2 different levels of exercise in 19 patients with known coronary artery disease and evidence of exercise-induced ischemia. The exercise protocols consisted of a symptom-limited incremental exercise test (Bruce protocol) followed within 3 to 14 days by a submaximal, steady-state exercise test performed at 70% of the maximal heart rate achieved during the Bruce protocol. The presence and time of onset of angina and electrocardiographic changes (greater than or equal to 0.1 mV ST-segment depression) as well as oxygen uptake, exercise duration and pressure-rate product were recorded. Thallium-201 (2.5 to 3.0 mCi) was injected during the last minute of exercise during both protocols, and the images were analyzed using both computer-assisted quantitation and visual interpretations. Incremental exercise resulted in anginal symptoms in 84% of patients, and electrocardiographic changes and reversible thallium-201 defects in all patients. In contrast, submaximal exercise produced anginal symptoms in only 26% (p less than 0.01) and electrocardiographic changes in only 47% (p less than 0.05), but resulted in thallium-201 defects in 89% of patients (p = not significant). The locations of the thallium-201 defects, when present, were not different between the 2 exercise protocols. These findings confirm the sequence of the ischemic cascade using 2 levels of exercise and demonstrate that the cascade theory is applicable during varying ischemic intensities in the same patient.

Nationwide Laboratory Adherence to Myocardial Perfusion Imaging Radiation Dose Reduction Practices: A Report From the Intersocietal Accreditation Commission Data Repository.

OBJECTIVES This study sought to examine current laboratory practices for radiation effective doses for myocardial perfusion imaging (MPI) and laboratory adherence to guideline-directed radiation reduction practices. BACKGROUND A recent focus on radiation dose reduction for cardiovascular imaging has led to several published guidelines and consensus statements detailing performance metrics for laboratory practices. We sought to examine laboratory adherence to optimized radiation dose protocol recommendations among 5,216 submitted cases from 1,074 MPI laboratories evaluated for Intersocietal Accreditation Commission accreditation. METHODS Eligible imaging centers included MPI laboratories enrolled in the Intersocietal Accreditation Commission data repository of accreditation applications from 2012 to 2013. Accreditation requires submission of 3 to 5 cases for evaluation of a range of representative cases. Based on standard dosimetry for rest and stress MPI, an effective dose (in millisieverts) was calculated. Model simulations were performed to estimate guideline-directed effective doses. RESULTS The average effective dose was 14.9 ± 5.8 mSv (range 1.4 to 42.4 mSv). A 1-day technetium Tc 99m protocol was used in 82.9% of cases, whereas a 2-day technetium Tc 99m and dual isotope protocol was used in 7.5% of submitted cases. Only 1.5% of participating imaging centers met current guidelines for an average laboratory radiation exposure ≤9 mSv, whereas 10.1% of patient effective doses were >20.0 mSv. A model simulation replacing the radiation exposure of dual isotope MPI with that of a 1-day technetium Tc 99m protocol reduced the proportion of patients receiving an effective dose >20 mSv to only 2.7% of cases (p < 0.0001). CONCLUSIONS Mandatory laboratory accreditation for MPI allows for examination of current radiation dosimetry practices. Current guidelines for reduced patient-specific radiation exposure are rarely implemented, with few laboratories meeting recommendations of ≤9 mSv for 50% of patients. Increased educational efforts and the development of performance measures for laboratory accreditation may be required to meet current radiation dose-reduction standards.

Rationale, design, and baseline findings from Seamos Saludables: A randomized controlled trial testing the efficacy of a culturally and linguistically adapted, computer- tailored physical activity intervention for Latinas

BACKGROUND Latinos are now the largest (and fastest growing) ethnic minority group in the United States. Latinas report high rates of physical inactivity and suffer disproportionately from obesity, diabetes, and other conditions that are associated with sedentary lifestyles. Effective physical activity interventions are urgently needed to address these health disparities. METHOD/DESIGN An ongoing randomized controlled trial will test the efficacy of a home-based, individually tailored physical activity print intervention for Latinas (1R01NR011295). This program was culturally and linguistically adapted for the target population through extensive formative research (6 focus groups, 25 cognitive interviews, iterative translation process). This participant feedback was used to inform intervention development. Then, 268 sedentary Latinas were randomly assigned to receive either the Tailored Intervention or the Wellness Contact Control arm. The intervention, based on Social Cognitive Theory and the Transtheoretical Model, consists of six months of regular mailings of motivation-matched physical activity manuals and tip sheets and individually tailored feedback reports generated by a computer expert system, followed by a tapered dose of mailings during the second six months (maintenance phase). The main outcome is change in minutes/week of physical activity at six months and one year as measured by the 7-Day Physical Activity Recall (7-Day PAR). To validate these findings, accelerometer data will be collected at the same time points. DISCUSSION High reach, low cost, culturally relevant interventions to encourage physical activity among Latinas could help reduce health disparities and thus have a substantial positive impact on public health.