Tom Briffa

Telehealth interventions for the secondary prevention of coronary heart disease: a systematic review

Coronary heart disease (CHD) is a leading cause of death globally. Despite proven health benefits and international recommendations, attendance at cardiac rehabilitation programs is poor. Telehealth (phone, Internet, and videoconference communication between patient and health-care provider) has emerged as an innovative way of delivering health interventions. This review aimed to determine telehealth effectiveness in CHD management. Study design includes systematic review with meta-analysis. Randomized controlled trials evaluating telehealth interventions in patients with CHD were identified by searching multiple electronic databases, reference lists, relevant conference lists, gray literature, and key-word searching of the Internet. Studies were selected if they evaluated a telephone, videoconference, or web-based intervention, provided objective measurements of mortality, changes in multiple risk factor levels or quality of life. In total, 11 trials were identified (3145 patients). Telehealth interventions were associated with nonsignificant lower all-cause mortality than controls [relative risk = 0.70, 95% confidence interval (CI) = 0.45-1.1; P = 0.12]. These interventions showed a significantly lower weighted mean difference (WMD) at medium long-term follow-up than controls for total cholesterol (WMD = 0.37mmol/l, 95% CI = 0.19-0.56, P < 0.001), systolic blood pressure (WMD = 4.69 mmHg, 95% CI = 2.91-6.47, P < 0.001), and fewer smokers (relative risk = 0.84, 95% CI = 0.65-0.98, P = 0.04). Significant favorable changes at follow-up were also found in high-density lipoprotien and low-density lipoprotein. In conclusion, telehealth interventions provide effective risk factor reduction and secondary prevention. Provision of telehealth models could help increase uptake of a formal secondary prevention by those who do not access cardiac rehabilitation and narrow the current evidence-practice gap.

Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study

Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be

Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data

AUD5,988 (€3,142;

Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial

USD4,066) per Quality Adjusted Life Year gained and

Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005

AUD30,481 (€15,993;

Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study.

USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

A specific activity questionnaire to measure the functional capacity off cardiac patients

Background: Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature. Methods: Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data. Results: From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR. Conclusions: There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

Population Trends of Recurrent Coronary Heart Disease Event Rates Remain High

Objective: To determine the effect of a new CHOICE (Choice of Health Options In prevention of Cardiovascular Events) programme on cardiovascular risk factors in acute coronary syndrome (ACS) survivors. Design: Single-blind randomised controlled trial. Setting: Tertiary referral hospital in Sydney Australia. Patients: 144 ACS survivors who were not accessing standard cardiac rehabilitation. Data were also collected on a further 64 ACS survivors attending standard cardiac rehabilitation. Intervention: The CHOICE group (n = 72) participated in a brief, patient-centred, modular programme comprising a clinic visit plus telephone support, encompassing mandatory cholesterol lowering and tailored preferential risk modification. The control group (n = 72) participated in continuing conventional care but no centrally coordinated secondary prevention. Main outcome measures: Values for total cholesterol, systolic blood pressure, smoking status and physical activity. Results: CHOICE and control groups were well matched at baseline. At 12 months, the CHOICE group (n = 67) had significantly better risk factor levels than controls (n = 69) for total cholesterol (TC) (mean (SEM) 4.0 (0.1) vs 4.7 (0.1) mmol/l, p<0.001), systolic blood pressure (131.6 (1.8) vs 143.9 (2.3) mm Hg, p<0.001), body mass index (28.9 (0.7) vs 31.2 (0.7) kg/m2, p = 0.025) and physical activity (1369.1 (167.2) vs 715.1 (103.5) METS/kg/min, p = 0.001) as well as a better knowledge of risk factor targets. Also at 1 year, fewer CHOICE participants (21%) had three or more risk factors above widely recommended levels then controls (72%) (p<0.001). Conclusions: Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months. CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes. Trial registration number: ISRCTN42984084

National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016.

Objective To examine trends in long term survival in patients alive 28 days after myocardial infarction and the impact of evidence based medical treatments and coronary revascularisation during or near the event. Design Population based cohort with 12 year follow-up. Setting Perth, Australia. Participants 4451 consecutive patients with a definite acute myocardial infarction according to the World Health Organization MONICA (monitoring trends and determinants in cardiovascular disease) criteria admitted to hospital during 1984-7, 1988-90, and 1991-3. Main outcome measures All cause mortality identified from official mortality records and the hospital morbidity data, with death from cardiovascular disease as a secondary end point. Results In the 1991-3 cohort, 28 day survivors of acute myocardial infarction had a 7.6% absolute event reduction (95% confidence interval 4% to 11%) or a 28% lower relative risk reduction (16% to 38%), unadjusted for risk of death, over 12 years after the incident admission compared with the 1984-7 cohort, similar to the survival of the 1988-90 cohort. The improved survival for the 1991-3 cohort persisted after adjustment for demographic factors, coronary risk factors, severity of disease, and event complications with an adjusted relative risk reduction of 26% (14% to 37%), but this was not apparent after further adjustment for medical treatments in hospital and coronary revascularisation procedures within 12 months of the incident myocardial infarction. Conclusion The improving trends in 12 year survival after a definite acute myocardial infarction are associated with progressive use of evidence based treatments during the initial admission to hospital and in the 12 months after the event. These changes in the management of acute myocardial infarction are probably contributing to the continuing decline in mortality from coronary heart disease in Australia.

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

Objectives: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published guidelines.