R. Zecchin

Double-blind trial of lignocaine versus sotalol for acute termination of spontaneous sustained ventricular tachycardia

The efficacy of antiarrhythmic drugs for terminating sustained ventricular tachycardia (VT) has been disappointing. Lignocaine is the traditional drug but it is not very effective. Sotalol, one of the most effective drugs in suppressing spontaneous or induced VT, should theoretically be useful in this setting. We have compared lignocaine with sotalol for the acute termination of spontaneous sustained VT not causing cardiac arrest in 33 patients (26 males, 7 females, aged 21-90) whose underlying heart disease was old myocardial infarction (28), acute myocardial infarction (2), dilated cardiomyopathy (1), or idiopathic cardiomyopathy (2). Left-ventricular ejection fraction was 35% (range 18-76%). Patients were randomly allocated in a double-blind fashion to lignocaine 100 mg (n = 17) or sotalol 100 mg (n = 16) given intravenously over 5 min. Those with persistent VT 15 min after onset of administration of the first drug were crossed over to the other drug. Sotalol was significantly more effective than lignocaine whether analysed on an intention-to-treat basis (69% vs 18%; 95% confidence interval for absolute difference of 51% 22-80%, p = 0.003) or by analysis limited to the 31 patients with subsequent electrophysiologically proven VT (69% vs 20%). 1 patient in each group required cardioversion after the first drug. Tachycardia persisted in 14 patients in the lignocaine group and 4 in the sotalol group after 15 min. Tachycardia ceased in 7 (50%) patients who crossed over to sotalol, and in 1 patient who crossed over to lignocaine. There was 1 death in each group after the first drug and 1 death after both drugs. We conclude that sotalol was superior to lignocaine for the acute termination of sustained VT. The incidence of adverse effects was similar for the two drugs.

A Cardiac Rehabilitation Program to Improve Psychosocial Outcomes of Women with Heart Disease

BACKGROUND AND AIMS Heart disease in women is characterised by greater disability and a higher rate of morbidity and early death after an acute coronary event compared with men. Women also have lower participation rates than men in cardiac rehabilitation. This study sought to describe development of a nurse-directed cardiac rehabilitation program tailored to the needs of women following an acute cardiac event to address their psychological and social needs. METHODS The Heart Awareness for Women program (HAFW) commenced in 2003 with phase I involving development of program elements and seeking validation through consumers and clinical experts. The program was then trialed in an 8-week program in a convenience sample of 6 women. Phase II applied the revised program using action research principles focusing on enabling clinical staff to implement the ongoing program. A total of 54 women participated in this phase, 48 of whom completed baseline questionnaires. A mixed-method evaluation, using questionnaires, interviews, and observation, assessed the impact of the intervention on psychological and social aspects of womens recovery following an acute coronary event. RESULTS Women welcomed the opportunity to discuss their individual stories, fears, and challenges and to derive support from contact with other women. Via health professional facilitation, women were able to develop strategies collectively to address risk factor modification and achieve optimal cardiovascular health. No statistically significant changes in depression, anxiety, stress, cardiac control, role integration, or perceived social support were found; however, descriptive and qualitative findings revealed decreases in anxiety and an increased sense of social support. CONCLUSIONS On the basis of this study, a cardiac rehabilitation program tailored to the needs of women appears to be feasible and acceptable. The efficacy of this intervention to improve health-related outcomes needs to be tested in a randomized, controlled trial.

Single-Ring Posterior Left Atrial (Box) Isolation Results in a Different Mode of Recurrence Compared With Wide Antral Pulmonary Vein Isolation on Long-Term Follow-Up Longer Atrial Fibrillation–Free Survival Time but Similar Survival Time Free of Any Atrial Arrhythmia

Background—Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions (single-ring isolation [SRI]) may result in fewer atrial fibrillation (AF) recurrences than wide antral pulmonary vein isolation (wide antral isolation [WAI]) by abolishing extravenous AF triggers. The effect of mitral isthmus line (MIL) ablation on outcomes after SRI has not previously been assessed. Methods and Results—We randomly assigned 220 consecutive patients (58±10 years old; 82% men) with highly symptomatic AF (61% paroxysmal, 39% persistent/longstanding persistent) to undergo either SRI or WAI. Half of each cohort was also randomly allocated to have left lateral MIL ablation (2×2 factorial study design). Patients were followed clinically and with 7-day Holter studies for arrhythmia recurrences. The primary end points were recurrence of AF and organized atrial tachyarrhythmias. AF-free survival at 2 years was better after SRI (74% [95% CI, 65%–82%]) than WAI (61% [51%–70%]; P=0.031). Organized atrial tachyarrhythmia–free survival was similar after SRI and WAI (67% [57%–75%] ersus 64% [54%–72%], respectively, at 2 years; P=0.988). MIL ablation resulted in better 2-year organized atrial tachyarrhythmia–free survival (71% [62%–79%] versus 60% [50%–69%]; P=0.07), which approached statistical significance. Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation. Conclusions—SRI resulted in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias. MIL ablation may reduce organized atrial tachyarrhythmia recurrences. Clinical Trial Registration—http://www.anzctr.org.au; ACTRN12606000467538.

An intervention to promote physical activity and self-management in people with stable chronic heart failure The Home-Heart-Walk study: study protocol for a randomized controlled trial

BackgroundChronic heart failure (CHF) is a chronic debilitating condition with economic consequences, mostly because of frequent hospitalisations. Physical activity and adequate self-management capacity are important risk reduction strategies in the management of CHF. The Home-Heart-Walk is a self-monitoring intervention. This model of intervention has adapted the 6-minute walk test as a home-based activity that is self-administered and can be used for monitoring physical functional capacity in people with CHF. The aim of the Home-Heart-Walk program is to promote adherence to physical activity recommendations and improving self-management in people with CHF.Methods/DesignA randomised controlled trial is being conducted in English speaking people with CHF in four hospitals in Sydney, Australia. Individuals diagnosed with CHF, in New York Heart Association Functional Class II or III, with a previous admission to hospital for CHF are eligible to participate. Based on a previous CHF study and a loss to follow-up of 10%, 166 participants are required to be able to detect a 12-point difference in the study primary endpoint (SF-36 physical function domain).All enrolled participant receive an information session with a cardiovascular nurse. This information session covers key self-management components of CHF: daily weight; diet (salt reduction); medication adherence; and physical activity. Participants are randomised to either intervention or control group through the study randomisation centre after baseline questionnaires and assessment are completed. For people in the intervention group, the research nurse also explains the weekly Home-Heart-Walk protocol. All participants receive monthly phone calls from a research coordinator for six months, and outcome measures are conducted at one, three and six months. The primary outcome of the trial is the physical functioning domain of quality of life, measured by the physical functioning subscale of the Medical Outcome Study Short Form -36. Secondary outcomes include physical functional capacity measured by the standard six minute walk test, self-management capacity, health related quality of life measured by Medical Outcome Study Short Form -36 and Minnesota Living With Heart Failure Questionnaire, self-efficacy and self-care behaviour.DiscussionA self-monitoring intervention that can improve individuals exercise self-efficacy, self-management capacity could have potential significance in improving the management of people with chronic heart failure in community settings.Trial RegistrationAustralian New Zealand Clinical Trial Registry 12609000437268

Is nurse-supervised exercise stress testing safe practice?

OBJECTIVE Nurses have been performing exercise stress tests (EST) without medical supervision since 1978 in our hospital-based cardiac rehabilitation unit. This study was conducted to examine the incidence of cardiovascular complications and to describe the competency-based training program for the nurses performing the EST. DESIGN Descriptive, retrospective audit of prospective data. SETTING Single comprehensive cardiac rehabilitation center in a large tertiary referral hospital in western Sydney, Australia. SUBJECTS Seventeen thousand, four hundred and sixty-seven patients were included in this study over a 12-year period. METHOD Data were collected on all ESTs performed by the cardiac rehabilitation nurses from January 1986 to December 1997 in relation to serious cardiovascular complications and other EST parameters. RESULTS In this study, 17,467 ESTs were performed on 5054 patients who had 6273 separate presentations. The most common entry diagnosis was after an acute myocardial infarction (50%). The mean age was 58 +/- 10.5 years (range 15 to 87 years; 80% male). The left ventricular ejection fraction (n = 2822) was 49% +/- 14%. In a subgroup analysis of 14,454 patients, 14% had a positive EST (ST segment >1.9 mm depression). There were no deaths associated with the EST, and there were 13 major complications in 12 patients. This figure included no cardiac arrests, 11 episodes of conscious sustained ventricular tachycardia, 1 reinfarction, and 1 mitral valve rupture, representing a 0% mortality rate and a 0.075% major morbidity rate. CONCLUSION This study shows that nurse-supervised EST of higher risk patients in the hospital-based cardiac rehabilitation setting has been a safe practice from a mortality and morbidity rate perspective. This finding may be accounted for by the high training standard and reaccreditation of the nurses on the advanced practice of performing EST.

Caring for Others, but Not Themselves: Implications for Health Care Interventions in Women with Cardiovascular Disease

Cardiovascular disease is the largest killer of women internationally and women often suffer inferior outcomes following an acute cardiac event as compared to men. A gendered approach to investigating cardiovascular disease in women incorporates the unique social, cultural, and economic circumstances that being a woman brings to the health encounter. The multiple roles enacted by many women may be important factors in this health discrepancy. In order to more fully understand the impact of the roles of women on health, a questionnaire was administered to participants of the Heart Awareness for Women group cardiac rehabilitation program which assessed womens role perceptions followed by discussions. We found that caregiving can be both positive and negative. It gives a sense of purpose, meaning, and community connection as well as burden and conflict. Emphasis must be placed on promoting strategies in women to achieve a balance between caregiving responsibilities and prioritisation of cardiovascular health.

Assessment of a Self‐administered Adapted 6‐Minute Walk Test

PURPOSE This study assessed the reliability and viability of the Home-Heart-Walk (HHW) test, adapting a standardized 6-minute walk test protocol for self-administration. METHODS Twenty-nine volunteers with documented coronary heart disease (CHD) undertook a structured 7-day program using the HHW. RESULTS The intervention was well received by participants. The intraclass correlation coefficient of the test distance over 7 days was 0.98, and the correlations between investigator and participant measures were high (r = 0.99 for day 1 [first test], r = 0.99 for day 1 [second test], and r = 0.99 on day 7). CONCLUSION These data demonstrate the potential of the HHW as a tool to promote and monitor physical activity in community-based settings. These observations require further investigation and testing in other populations.

Correlation between a self-administered walk test and a standardised Six Minute Walk Test in adults.

This study was undertaken to assess the correlation between a self-administered, adapted Six Minute Walk Test (the Home-Heart-Walk) and the standard Six Minute Walk Test based on the American Thoracic Society guideline. A correlational study was conducted at a university campus in Sydney, Australia. Thirteen healthy volunteers underwent the Home-Heart-Walk and the standard Six Minute Walk Test on a single occasion. The distance that participants walked during the two tests was assessed using Pearsons correlation. The correlation between the Home-Heart-Walk and the Six Minute Walk Test distance was 0.81. The Home-Heart-Walk distance was highly correlated to the standard Six Minute Walk Test distance in this study. This relationship provides confidence for further research in populations to facilitate monitoring and evaluation.

Making Sense of the Unfavourable Systematic Review of Exercise-Based Cardiac Rehabilitation in the Modern Era: How Should We Proceed?

International guidelines recommend exercise-based cardiac rehabilitation (EBCR) to promote secondary prevention and support recovery following cardiovascular disease (CVD) events [1]. Although the effectiveness of EBCR has been questioned due to poor delivery and participation [2], the efficacy of EBCR for reducing mortality and morbidity has not been challenged given the Class 1A evidence available [3]. However, in January 2018, BMJ Open published a well-performed and well-reported systematic review that questions the efficacy of EBCR for reducing mortality in the contemporary era [4]. Powell et al.’s work is important because shortcomings of previous reviews may have led to overestimates of the benefits of EBCR for current practice given improvements in intervention delivery and the evolving management of CVD and its associated risk factors. The results reported in Powell et al.’s systematic review challenge cardiac health professionals to consider the value of EBCR for CVD patients, however, we encourage readers to consider several important caveats when reflecting on the results and conclusions of the review...

Development of Quality Indicators for Cardiac Rehabilitation in Australia: A Modified Delphi Method and Pilot Test

BACKGROUND International guidelines recommend cardiac rehabilitation (CR) for secondary prevention of cardiovascular disease, however, it is underutilised and the quality of content and delivery varies widely. Quality indicators (QIs) for CR are used internationally to measure clinical practice performance, but are lacking in the Australian context. This study reports the development of QIs for minimum dataset (MDS) for CR and the results of a pilot test for feasibility and applicability in clinical practice in Australia. METHODS A modified Delphi method was used to develop initial QIs which involved a consensus approach through a series of face-to-face and teleconference meetings of an expert multidisciplinary panel (n=8), supplemented by an environmental scan of the literature and a multi-site pilot test. RESULTS Eight QIs were proposed and sent to CR clinicians (n=250) electronically to rate importance, current data collection status, and feasibility of future collection. The top six of these QIs were selected with an additional two key performance indicators from the New South Wales (NSW) Ministry of Health and two QIs from international registers for a draft MDS. The pilot test in 16 sites (938 patient cases) demonstrated median performance of 93% (IQR 47.1-100%). All 10 QIs were retained and one further QI related to diabetes was added for a final draft MDS. CONCLUSIONS The MDS of 11 QIs for CR provides an important foundation for collection of data to promote the quality of CR nationally and the opportunity to participate in international benchmarking.