Robert Lewin

Living with Heart Failure; Patient and Carer Perspectives

Patients with heart failure have multiple readmissions to hospital, a poor prognosis and varying quality of life. This paper explores how patients with heart failure and their family carers cope with daily life. 36 patients and 20 family caregivers were interviewed in five centres in the UK. Analysis showed that living with heart failure can be frightening, restrictive and distressing for both patients and their family carers. Patients found most difficulty coping with functional limitation and adapting to living with heart failure, but also reported particular problems due to side effects of medications, co-morbidities and a lack of psychosocial support and rehabilitation services. Those with less socio-economic resources found it harder to cope. Patients from minority ethnic groups held different beliefs about the illness and its treatment, and some had profound problems communicating with health and social care professionals that made managing the disease even more difficult. Caring for a person with heart failure often has a considerable impact on the psychological and physical health of family caregivers. Psychosocial support and rehabilitation services provided at diagnosis and after an acute episode would enable families to better manage living with this syndrome.

A confirmatory factor analysis of the Hospital Anxiety and Depression Scale in coronary care patients following acute myocardial infarction

The utility of the Hospital Anxiety and Depression Scale (HADS) as a screening instrument for coronary care patients following acute myocardial infarction (MI) was investigated. A confirmatory factor analysis was conducted on the HADS to determine its psychometric properties in 335 MI patients over three observation points (1 week, 6 weeks and 6 months). Internal and test-retest reliabilities of the HADS total and HADS sub-scale scores were generally found to be acceptable. The underlying factor structure of the HADS comprised three distinct factors. Support was found for the use of the HADS sub-scales to assess dimensions of anhedonia, psychic anxiety and psychomotor agitation. The HADS may be a useful screening instrument to assess post-MI patients for symptoms of psychological distress. Further research is required to determine the three-factor structure of the HADS in other clinical groups.

Cognitive‐behavioural rehabilitation programme for patients with an implanted cardioverter defibrillator: A pilot study

OBJECTIVES The effectiveness of a comprehensive 12-week CR programme for ICD patients was evaluated. DESIGN All surviving and suitable ICD patients being cared for by a regional implantation centre were invited to attend a 12-week cognitive-behavioural cardiac rehabilitation programme that had been modified to meet the needs of this group. Patients assenting were randomized to either an immediate treatment or a waiting treatment group. Measures were taken prior to randomization, at the end of the treatment or waiting period, at the end of the second treatment group for that group only and at three months post-treatment for both groups. OUTCOME MEASURES The Hospital Anxiety and Depression Scale, the Total Concerns Questionnaire, the Quality of Life after Myocardial Infarction Questionnaire, the EuroQual (subjective health rating scale), the Shuttle Test and a number of ICD shocks and ATP episodes were used in this study. RESULTS For those patients willing and able to attend, the cognitive-behavioural CR programme produced significant benefits in terms of psychological and functional adaptation to living with the device. CONCLUSIONS A comprehensive 12-week CR programme that incorporated both psychological and exercise-based components significantly reduced anxiety and depression and improved quality of life of ICD patients. It is not clear if these benefits are sustained.

Cardiac rehabilitation in the United Kingdom

Cardiac rehabilitation (CR) is a cost-effective, life-enhancing and life-saving treatment for patients recovering from cardiac illness—from myocardial infarction, revascularisation, angina, heart failure, etc. Its main aims are to help the patient to recover as quickly and completely as possible and then to reduce to a minimum the chance of recurrence of the cardiac illness—it should be an integral step in the management of the patient’s condition. Despite the inclusion of CR in the National Service Framework for coronary heart disease only a minority of cardiac patients join CR programmes. Suggestions are made for increasing the uptake.

A brief cognitive behavioural preimplantation and rehabilitation programme for patients receiving an implantable cardioverter-defibrillator improves physical health and reduces psychological morbidity and unplanned readmissions

Objective: To assess the clinical and cost effectiveness of a brief home-based cognitive behavioural rehabilitation programme (the ICD Plan) for patients undergoing implantation of a cardiac defibrillator. Design: A prospective multicentred, intention-to-treat, cluster-randomised controlled trial. Setting: Eight implantable cardioverter-defibrillator (ICD) implantation centres in the UK. Patients: Consecutive series of patients undergoing implantation with an ICD. Interventions: The control group received usual care and advice from an experienced healthcare professional. The intervention group received usual care plus the ICD Plan. The plan was introduced before implantation, with three further brief telephone contacts with the nurse over the next 12 weeks. Main outcome measures: Health-related quality of life (Short Form Health Survey (SF-12)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), activity limitations (subscale from the Seattle Angina Questionnaire (SAQ)), unplanned admissions and other economic data using a questionnaire developed for the study. Results: 192 patients were recruited to the study (71 intervention, 121 control). At 6 months after surgery the intervention group had better physical health (37.83 vs 34.24; p<0.01), fewer limitations in physical activity (34.02 vs 31.72; p = 0.04), a greater reduction in the proportion of patients with a borderline diagnosis of anxiety (21% vs 13%; p = 0.60) and depression (13% vs 2%; p = 0.30), more planned ECGs (89% vs 66%; p = 0.04) and 50% fewer unplanned admissions (11% vs 22%; p<0.01). Conclusions: The ICD Plan improved health-related quality of life, reduced the incidence of clinically significant psychological distress and significantly reduced unplanned readmissions. It is a cost effective and easily implemented method for delivering rehabilitation and psychological care to patients undergoing ICD implantation. Trial registration number: ISRCTN70212111.

Systematic review of interventions to reduce delay in patients with suspected heart attack

Objectives: To evaluate the effectiveness of interventions aiming to reduce time from onset of signs and symptoms of an acute myocardial infarction (AMI) to seeking medical help/arrival at hospital. Methods: A systematic review was conducted. Fifteen electronic databases, the internet, and bibliographies of included studies were searched, and experts in the field of cardiac care were contacted. Randomised controlled trials (RCTs), controlled trials, and before and after studies conducted in any setting that assessed an intervention aimed at reducing time from onset of signs and symptoms of an AMI to seeking medical help and/or arrival in hospital were eligible for inclusion. Results: Eleven media/public education intervention studies met the inclusion criteria. Five (one controlled and four before and after studies) reported the intervention to have a statistically positive effect on delay time and six (two RCTs and four before and after studies) reported no statistically significant effect. Three (one RCT and two before and after studies) of five studies evaluating the effect of the intervention on emergency department visits reported an increase in this outcome as a result of the intervention, and both studies (one RCT and one before and after study) examining calls made to emergency switchboards reported an increase in this outcome after the intervention. Conclusions: There was little evidence that media/public education interventions reduced delay. There is some evidence that they may result in an increase in emergency switchboard calls and emergency department visits. Despite substantial expenditure of time and effort, methodological deficiencies of the studies mean that it is not possible to make definitive recommendations.

Prehabilitation prior to CABG surgery improves physical functioning and depression.

Background Many patients demonstrate psychological distress and reduced physical activity before coronary artery bypass graft surgery (CABG). Here we evaluated the addition of a brief, cognitive-behavioural intervention (the HeartOp Programme) to routine nurse counselling for people waiting for CABG surgery. Methods Randomised controlled trial comparing nurse counselling with the HeartOp programme to routine nurse counselling in 204 patients awaiting first time elective CABG. Primary outcome measures were: anxiety and length of hospital stay; secondary outcome measures were: depression, physical functioning, cardiac misconceptions and cost utility. Measures were collected prior to randomisation and after 8 weeks of their intervention prior to surgery, excepting length of hospital stay which was collected after discharge following surgery. Results 100 patients were randomised to intervention, 104 to control. At follow-up there were no differences in anxiety or length of hospital stay. There were significant differences in depression (difference = 7.79, p = 0.008, 95% CI = 2.04–13.54), physical functioning (difference = 0.82, p = 0.001, 95%CI = 0.34–1.3) and cardiac misconceptions (difference = 2.56, p < 0.001, 95%CI = 1.64–3.48) in favour of the HeartOp Programme. The only difference to be maintained following surgery was in cardiac misconceptions. The HeartOp Programme was found to have an Incremental Cost Effectiveness Ratio (ICER) of £288.83 per Quality-Adjusted Life Year. Conclusions Nurse counselling with the HeartOp Programme reduces depression and cardiac misconceptions and improves physical functioning before bypass surgery significantly more than nurse counselling alone and meets the accepted criteria for cost efficacy.

Development of the York Angina Beliefs Questionnaire

It is known that people who have suffered a heart attack can hold misconceived or maladaptive beliefs and that these can have a deleterious effect on quality of life and functioning. It has also been noted that clinicians do not routinely elicit these maladaptive beliefs. It is probable that angina sufferers also hold such beliefs. As angina is a great burden in the western world, with over two million people with angina in the UK alone, there may be large numbers of people who suffer from these frightening and unhelpful misconceptions. We believe that there is a need for a simple questionnaire that could assist the delivery of tailored education directed at dispelling common misconceptions. This article details the development and psychometric properties of just such a brief questionnaire, designed for use both in research and in clinical practice.

Exploring health‐related experiences of children and young people with congenital heart disease

Objective  To determine the health‐related experiences of children with congenital heart disease.

Development and validation of a short measure of health status for individuals with acute myocardial infarction: The myocardial infarction dimensional assessment scale (MIDAS)

The purpose of this study was to develop and validate a disease-specific health status measure for individuals with myocardial infarction (MI). The development of the myocardial infarction dimensional assessment scale (MIDAS) followed three main stages. Stage 1 consisted of in-depth, semi-structured, exploratory interviews conducted on a sample of 31 patients to identify areas of salience and concern to patients with MI. These interviews generated 48 candidate questions. In stage 2 the 48-item questionnaire was used in a postal survey to identify appropriate rephrasing/shortening, to determine acceptability and to help identify sub-scales of the instrument addressing different dimensions of MI. Finally, in stage 3 the construct validity of MIDAS subscales was examined in relation to clinical and other health outcomes. A single centre (district general hospital) in England was used to stages 1 and 3 and a national postal survey was conducted for stage 2. A total of 410 patients were recruited for the national survey (stage 2). Full data were available on 348 (85%) patients. One hundred and fifty-five patients were recruited to test construct validity (stage 3). The MIDAS contains 35 questions measuring seven areas of health status: physical activity, insecurity, emotional reaction, dependency, diet, concerns over medication and side effects. The measure has high face, internal and construct validity and is likely to prove useful in the evaluation of treatment regimes for MI.