Tammy Cosman

Caregivers’ contributions to heart failure self-care: A systematic review:

Aims: The purpose of this study was to conduct a systematic review answering the following questions: (a) what specific activities do caregivers (CGs) contribute to patients’ self-care in heart failure (HF)?; and (b) how mature (or developed) is the science of the CG contribution to self-care? Methods: MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Cochrane Library and ClinicalTrials.gov were searched using the terms heart failure and caregiv* as well as the keywords ‘careers’, ‘family members’ and ‘lay persons’ for studies published between 1948 and September 2012. Inclusion criteria for studies were: informal CGs of adult HF patients–either as dependent/independent variable in quantitative studies or participant in qualitative studies; English language. Exclusion criteria for studies were: formal CGs; pediatric, adult congenital, or devices or transplant CGs; mixed diagnosis; non-empiric reports or reports publishing duplicate results. Each study was abstracted and confirmed by two authors. After CG activities were identified and theoretically categorized, an analysis across studies was conducted. Results: Forty papers were reviewed from a pool of 283 papers. CGs contribute substantively to HF patients’ self-care characterized from concrete (weighing the patient) to interpersonal (providing understanding). Only two studies attempted to quantify the impact of CGs’ activities on patients’ self-care reporting a positive impact. Our analysis provides evidence for a rapidly developing science that is based largely on observational research. Conclusions and implications of key findings: To our knowledge, this is the first systematic review to examine CGs’ contributions in depth. Informal caregivers play a major role in HF self-care. Longitudinal research is needed to examine the impact of CGs’ contributions on patient self-care outcomes.

Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines

Refractory angina (RFA) is a debilitating disease characterized by cardiac pain resistant to conventional treatments for coronary artery disease including nitrates, calcium-channel and β-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions, and coronary artery bypass grafting. The mortality rate of patients living with RFA is not known but is thought to be in the range of approximately 3%. These individuals suffer severely impaired health-related quality of life with recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, and activity restriction. Effective care for RFA sufferers in Canada is critically underdeveloped. These guidelines are predicated upon a 2009 Canadian Cardiovascular Society (CCS) Position Statement which identified that underlying the problem of RFA management is the lack of a formalized, coordinated, interprofessional strategy between the cardiovascular and pain science/clinical communities. The guidelines are therefore a joint initiative of the CCS and the Canadian Pain Society (CPS) and make practice recommendations about treatment options for RFA that are based on the best available evidence. Concluding summary recommendations are also made, giving direction to future clinical practice and research on RFA management in Canada.

Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial

Background: A hip fracture causes bleeding, pain and immobility, and initiates inflammatory, hypercoagulable, catabolic and stress states. Accelerated surgery may improve outcomes by reducing the duration of these states and immobility. We undertook a pilot trial to determine the feasibility of a trial comparing accelerated care (i.e., rapid medical clearance and surgery) and standard care among patients with a hip fracture. Methods: Patients aged 45 years or older who, during weekday, daytime working hours, received a diagnosis of a hip fracture requiring surgery were randomly assigned to receive accelerated or standard care. Our feasibility outcomes included the proportion of eligible patients randomly assigned, completeness of follow-up and timelines of accelerated surgery. The main clinical outcome, assessed by data collectors and adjudicators who were unaware of study group allocations, was a major perioperative complication (i.e., a composite of death, preoperative myocardial infarction, myocardial injury after noncardiac surgery, pulmonary embolism, pneumonia, stroke, and life-threatening or major bleeding) within 30 days of randomization. Results: Of patients eligible for inclusion, 80% consented and were randomly assigned to groups (30 to accelerated care and 30 to standard care) at 2 centres in Canada and 1 centre in India. All patients completed 30-day follow-up. The median time from diagnosis to surgery was 6.0 hours in the accelerated care group and 24.2 hours in the standard care group (p < 0.001). A major perioperative complication occurred in 9 (30%) of the patients in the accelerated care group and 14 (47%) of the patients in the standard care group (hazard ratio 0.60, 95% confidence interval 0.26–1.39). Interpretation: These results show the feasibility of a trial comparing accelerated and standard care among patients with hip fracture and support a definitive trial. Trial registration: ClinicalTrials.gov, no. NCT01344343.

Recommendations for advancing the care of Canadians living with refractory angina pectoris: a Canadian Cardiovascular Society position statement.

Refractory angina (RFA) is a debilitating disease characterized by severe, unremitting cardiac pain (1,2). This pain or discomfort, by definition, is resistant to all conventional treatments for coronary artery disease (CAD) including nitrates, calcium channel and beta-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions and coronary artery bypass grafting (1,2). Patients living with RFA have a low annual mortality rate of 3% but suffer from a severely impaired health-related quality of life (3). They typically experience recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, activity restriction and inability to self-manage (4–7). As more patients survive primary and subsequent cardiac events, the global prevalence of RFA is ever increasing (1,2,8,9).

Impact of self-management interventions on stable angina symptoms and health-related quality of life: a meta-analysis

BackgroundChronic stable angina (CSA) has a major negative impact on health-related quality of life (HRQL) including poor general health status, psychological distress, and inability to self-manage.MethodsWe used meta-analysis to assess the effectiveness of self-management interventions for improving stable angina symptoms, HRQL and psychological well-being. Nine trials, involving 1,282 participants in total, were included. We used standard inverse-variance random-effects meta-analysis to combine the trials. Heterogeneity between trials was evaluated using chi-square tests for the tau-squared statistic and quantified using the I2 statistic.ResultsThere was significant improvement in the frequency of angina symptoms (Seattle Angina Questionnaire [SAQ], symptom diary) across trials, standardized mean difference (SMD): 0.30 (95% Confidence interval [CI] 0.14, 0.47), as well as reduction in the use of sublingual (SL) nitrates, SMD: -0.49 (95% CI -0.77, -0.20). Significant improvements for physical limitation (SAQ), SMD: 0.38 (95% CI 0.20, 0.55) and depression scores (Hospital Anxiety and Depression Scale), SMD: -1.38 (95% CI -2.46, -0.30) were also found. The impact of SM on anxiety was uncertain due to statistical heterogeneity across trials for this outcome, I2 = 98%. SM did not improve other HRQL dimensions including angina stability, disease perception, and treatment satisfaction.ConclusionsSM interventions significantly improve angina frequency and physical limitation; they also decrease the use of SL nitrates and improve depression in some cases. Further work is needed to make definitive conclusions about the impact of SM on cardiac-specific anxiety.

Nonischemic Chest Pain Following Successful Percutaneous Coronary Intervention at a Regional Referral Centre in Southern Ontario

BACKGROUND The purpose of this study was to identify factors that predispose individuals to nonischemic chest pain following successful percutaneous coronary intervention (PCI). METHODS We prospectively followed, for 6 months, a cohort of 110 patients who underwent PCI. We determined baseline factors associated with post PCI pain via nonlinear mixed model regression; a binomial distribution with logit link was used. RESULTS The mean age of participants (n = 110) was 64 (SD ± 11.19), 69% were male. The majority had 1 coronary vessel dilated (88%) and a single stent placement (67%). During follow-up, chest pain was prevalent in 54% (95% confidence interval [CI], 44.8-63.7) and 45% (95% CI, 36.0-54.8) of patients, at 3 and 6 months respectively. Less than half of those with chest pain were evaluated for ischemia. Of those evaluated, tests were negative for the majority; 74% and 61% at 3 and 6 months respectively. Higher baseline depression (odds ratio 1.50; 95% CI, 1.13-1.99) scores (Hospital Anxiety Depression Scale) were significantly associated with nonischemic chest pain during follow-up. CONCLUSION Higher baseline depression scores were found to be significant risk factors for chest pain of nonischemic origin following successful PCI. A larger study is needed to confirm the predictive value of this and other factors that may contribute to this elusive pain problem. Further research is also required to develop pain management strategies for patients whose chest pain persists in the absence of discernible ischemic causes.

Prevalence of bruising at the vascular access site one week after elective cardiac catheterisation or percutaneous coronary intervention

AIM To identify the prevalence and predictors of VAS bruising in the 5-7 days following cardiac catheterisation or percutaneous coronary intervention. BACKGROUND Complication(s) of cardiac catheterisation and/or percutaneous coronary intervention (PCI) occur commonly at the vascular access site (VAS). While major complications, such as retroperitoneal bleeding, are evident before hospital discharge, the prevalence of VAS bruising in the early post-discharge period is undocumented. DESIGN Prospective observational study. METHOD Data were collected on 172 patients following cardiac catheterisation and/or PCI through (1) chart review, (2) pre-discharge assessment and (3) telephone follow up 5-7 days post-discharge. RESULTS At the time of telephone follow up bruising was reported in 68.6% of all patients (n = 118), with 47% of those patients (n = 56) reporting bruises larger than 7.5 cm (3 inches). Incidence of bruising varied by access site; 73% of patients (n = 86) who had femoral access, 83% (n =  5) with femoral access plus closure device and 60% (n = 17) of patients with radial access reported bruising 5-7 days post-discharge. Bivariate analysis revealed a significant association between female sex and post discharge bruising (χ(2) 10.490, p = 0.001), with a likelihood ratio of 11.20. Abciximab use during the procedure was associated with post discharge bruising (Fishers exact test, p = 0.045). Logistic regression analysis revealed female sex as a significant predictor of bruising after discharge (p = 0.001). CONCLUSION This study suggests that the majority of patients will experience significant bruising at the VAS following discharge and that women may be more at risk. RELEVANCE TO CLINICAL PRACTICE The high prevalence of post-discharge bruising after cardiac catheterisation and/or PCI has important implications for nursing education and preparation of patients prior to hospital discharge.

Caregiver Contribution to Heart Failure Self-Care (CACHS).

While caregivers (CGs) make an important contribution to the self‐care of heart failure (HF) patients, there are no reliable and valid tools for measuring such contributions. Current interventions that strive to optimize patient outcomes through self‐care strategies neglect to account for CG contributions, a potential confounder on outcomes. The aim of the study was to develop an instrument that measures CG contributions to HF patients’ self‐care.

Reliability of vascular access site bruise measurement.

Background and Purpose: Vascular access site (VAS) bruising is common following invasive cardiac procedures. The extent of VAS bruising is underreported because of the lack of reliable measurement methods. This study examined the reliability of linear measurement and planimetry to measure VAS bruise size. Methods: There were 40 participants with VAS bruising after invasive cardiac procedures who completed VAS bruise measurement. Participants, a principal investigator, and a research assistant completed measurements independently. Inter-rater reliability was determined using intraclass correlation coefficient (ICC), 2-way random effects model. Results: The ICC for linear measurement and planimetry was high (.929 and .914 respectively). Both methods were reliable measures of VAS bruise size. Conclusions: Linear measurement or planimetry can be used with confidence to measure VAS bruising in clinical and research contexts.

RELIABILITY OF BRUISE MEASUREMENT FOLLOWING INVASIVE CARDIAC PROCEDURES

The most common complication following invasive cardiac procedures is the development of vascular access site (VAS) bruising. Research into this post-procedure complication is hindered by the lack of a reliable and practical bruise measurement tool. Linear measurement and planimetry, used in wound