Health-related quality of life in European women following myocardial infarction: a cross-sectional study

BACKGROUND

Coronary heart disease is a major contributor to women's health problems.

DESIGN

Self-perceived social support, well-being and health-related quality of life (HRQL) were documented in the cross-sectional HeartQoL survey of European women one and six months after a myocardial infarction.

METHODS

European women were recruited in 18 European countries and grouped into four geographical regions (Southern Europe, Northern Europe, Western Europe and Eastern Europe). Continuous socio-demographic variables and categorical variables were compared by age and region with ANOVA and χ(2), respectively; multiple regression models were used to identify predictors of social support, well-being and HRQL.

RESULTS

Women living in the Eastern European region rated social support, well-being and HRQL significantly lower than women in the other regions. Older women had lower physical HRQL scores than younger women. Eastern European women rated social support, well-being and HRQL significantly lower than women in the other regions. Prediction of the dependent variables (social support, well-being and HRQL) by socio-demographic factors varied by total group, in the older age group, and by region; body mass index and managerial responsibility were the most consistent significant predictors.

Health-related quality of life in patients with acute coronary syndromes and treated with ticagrelor or clopidogrel

Evaluation of: Levin LA, Wallentin L, Bernfort L et al. Health-related quality of life of ticagrelor versus clopidogrel in patients with acute coronary syndromes results from the PLATO trial. Value Health 16(4), 574-580 (2013). Antiplatelet therapy is considered essential treatment for acute coronary syndromes with or without ST-segment elevation and after stent procedures. The PLATelet inhibition and patient Outcomes (PLATO) trial compared ticagrelor or clopidogrel for the prevention of cardiovascular events. Prespecified substudies included a health-related quality of life (HRQL) study; the EQ-5D, a self-report, standardized, nondisease-specific utility measure with a single index value for health status, was used to assess HRQL. In the primary HRQL analysis, the mean 12-month HRQL score in 15,212 patients was reported to be 0.840 in the ticagrelor group and 0.832 in the clopidogrel group (p = 0.046). Excluding patients who died resulted in no difference in HRQL between patients treated with ticagrelor or clopidogrel (0.864 and 0.863, respectively; p = 0.69). The improved survival and reduction in cardiovascular events with ticagrelor as demonstrated in the main PLATelet inhibition and patient Outcomes trial are apparently obtained with no difference in quality of life.

Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited

Cardiac rehabilitation that includes either exercise training alone or exercise training in addition to psychosocial, risk factor management and/or educational interventions is considered a Class I indication [i.e., useful and effective] for patients with coronary heart disease. This overview of six independent cardiac rehabilitation meta-analyses published since 2000 includes a total of 71 randomized clinical trials (n = 13,824 patients) and clearly demonstrates significant clinical outcomes (reduced all-cause and cardiac mortality, nonfatal reinfarction and reduced hospitalization rates) and significant positive changes in modifiable risk factors (total cholesterol, triglycerides and systolic blood pressure). Despite the observation that the elderly, females, minority ethnic groups, low socioeconomic status patients and patients with comorbidities have not been well represented in the randomized clinical trials. Recent guidelines in the UK and USA have concluded with the recommendation that cardiac rehabilitation is reasonable and necessary and should be promoted by healthcare professionals, including senior medical staff.

The HeartQoL: part II. Validation of a new core health-related quality of life questionnaire for patients with ischemic heart disease

BACKGROUND

Evaluation of health-related quality of life (HRQL) is important in improving the quality of patient care. The aim of this study was to determine the psychometric properties of the HeartQoL in patients with ischemic heart disease (IHD), specifically angina, myocardial infarction (MI), or ischemic heart failure.

METHODS

Data for the interim validation of the HeartQoL questionnaire were collected in (a) a cross-sectional survey and (b) a prospective substudy of patients undergoing either a percutaneous coronary intervention (PCI) or referred to cardiac rehabilitation (CR) and were then analyzed to determine the reliability, validity, and responsiveness of the HeartQoL questionnaire.

RESULTS

We enrolled 6384 patients (angina, n = 2111, 33.1%; MI, n = 2351, 36.8%; heart failure, n = 1922, 30.1%) across 22 countries speaking 15 languages in the cross-sectional study and 730 patients with IHD in the prospective substudy. The HeartQoL questionnaire comprises 14-items with physical and emotional subscales and a global score (range 0-3 (poor to better HRQL). Cronbach's α was consistently ≥0.80; convergent validity correlations between similar HeartQoL and SF-36 subscales were significant (r ≥ 0.60, p < 0.001); discriminative validity was confirmed with predictor variables: health transition, anxiety, depression, and functional status. HeartQoL score changes following either PCI or CR were significant (p < 0.001) with effect sizes ranging from 0.37-0.64.

CONCLUSION

The HeartQoL questionnaire is reliable, valid, and responsive to change allowing clinicians and researchers to (a) assess baseline HRQL, (b) make between-diagnosis comparisons of HRQL, and (c) evaluate change in HRQL in patients with angina, MI, or heart failure with a single IHD-specific HRQL instrument.

Psychometric properties of the Flemish version of the MacNew heart disease health-related quality of life questionnaire

BACKGROUND

Assessment of health-related quality of life, increasingly being used as an outcome measure in cardiovascular disease research studies and clinical practice, requires questionnaires with sound psychometric properties. The aim of this study was to evaluate the psychometric properties of the Flemish version of the MacNew Heart Disease Health-related Quality of Life questionnaire in Flemish-speaking Belgian patients.

METHOD

Between 2002 and 2008, as part of the international HeartQol Project, 344 Belgian patients with a diagnosis of angina, ischaemic heart failure or myocardial infarction completed the Flemish versions of the MacNew, the Short-Form 36 and the Hospital Anxiety and Depression Scale. Ceiling and floor effects of the MacNew were analysed. Internal consistency was assessed by Cronbach's a and reproducibility (intra-class correlation coefficients) was assessed in a subsample of patients over a 2-3 week period with repeated tests. Convergent validity (Pearson's correlation between MacNew and Short-Form 36 constructs) and discriminant validity ('known-group' approach) were tested.

RESULTS

The Flemish version of the MacNew appears to be a reliable instrument with a high internal consistency, demonstrating strong discriminative validity and satisfactory construct validity. The results of factor analysis are similar to the factor structure of the original MacNew explaining 59.8% of the total variance.

CONCLUSION

The Flemish version of the MacNew demonstrates good psychometric properties. It can be recommended as a specific instrument for assessing and evaluating health-related quality of life in Flemish-speaking patients in each of the three major ischaemic heart disease diagnoses: angina, ischaemic heart failure and myocardial infarction. However, responsiveness to change could not be tested in this cross-sectional study and should be further investigated in a larger sample of patients following an intervention likely to induce a change in health-related quality of life.

The MacNew Heart Disease Health-Related Quality of Life Questionnaire in patients with angina and patients with ischemic heart failure

OBJECTIVE

Patient-reported outcomes including health-related quality of life are important in clinical care and research studies. The MacNew Heart Disease Health-Related Quality Of Life Questionnaire has been validated in English-speaking patients with myocardial infarction. The aim of this study was to validate the MacNew in English-speaking patients with angina or ischemic heart failure.

METHODS

Canadian and American patients with angina or ischemic heart failure completed the MacNew, the Short Form-36 Health Survey, and the Hospital Anxiety and Depression Scale.

RESULTS

We administered questionnaires to 276 patients with angina (mean age, 65.9 years) and 155 patients with ischemic heart failure (mean age, 70.3 years). The mean ± SD MacNew global score in patients with ischemic heart failure (5.1 ± 1.2) was statistically (P < 0.001), but not clinically, poorer than in patients with angina (5.3 ± 1.1). The three-factor measurement model explained 46.1% of the observed variance in the MacNew in patients with angina and 46.5% in patients with ischemic heart failure. Internal consistency was ≥0.90, and test-retest reliability was ≥0.70 for each MacNew scale and the a priori convergent and discriminative validity hypotheses were confirmed in both diagnoses. The MacNew was highly accepted by patients with little respondent or administrative burden.

CONCLUSIONS

The English version of the MacNew is reliable and valid in patients with angina or ischemic heart failure. This permits health-related quality of life outcome comparisons in patients with angina, ischemic heart failure, and myocardial infarction with the MacNew and provides a better understanding of the full range of health-related quality of life outcomes.

Cross-cultural analysis of type D (distressed) personality in 6222 patients with ischemic heart disease: a study from the International HeartQoL Project

BACKGROUND

Type D (distressed) personality, the conjoint effect of negative affectivity (NA) and social inhibition (SI), predicts adverse cardiovascular outcomes, and is assessed with the 14-item Type D Scale (DS14). However, potential cross-cultural differences in Type D have not been examined yet in a direct comparison of countries.

AIM

To examine the cross-cultural validity of the Type D construct and its relation with cardiovascular risk factors, cardiac symptom severity, and depression/anxiety.

METHODS

In 22 countries, 6222 patients with ischemic heart disease (angina, 33%; myocardial infarction, 37%; or heart failure, 30%) completed the DS14 as part of the International HeartQoL Project.

RESULTS

Type D personality was assessed reliably across countries (αNA>.80; αSI>.74; except Russia, which was excluded from further analysis). Cross-cultural measurement equivalence was established for Type D personality at all measurement levels, as the factor-item configuration, factor loadings, and error structure were not different across countries (fit: CFI=.91; NFI=.88; RMSEA=.018), as well as across gender and diagnostic subgroups. Type D personality was more prevalent in Southern (37%) and Eastern (35%) European countries compared to Northern (24%) and Western European and English-speaking (both 27%) countries (p<.001). Type D was not confounded by cardiac symptom severity, but was associated with a higher prevalence of hypertension, smoking, sedentary lifestyle, and depression.

CONCLUSION

Cross-cultural measurement equivalence was demonstrated for the Type D scale in 21 countries. There is a pan-cultural relationship between Type D personality and some cardiovascular risk factors, supporting the role of Type D personality across countries and cardiac conditions.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health.

OBJECTIVES

To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD.

SEARCH STRATEGY

RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009).

SELECTION CRITERIA

Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography.

DATA COLLECTION AND ANALYSIS

Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care.

AUTHORS' CONCLUSIONS

Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.

Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation

BACKGROUND

Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required.

DESIGN

A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group.

METHOD

One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization.

RESULTS

Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µ(add) = 0.69, p < 0.05).

CONCLUSION

Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.

Reprint--AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)

Endorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons.

This document was approved by the American College of Cardiology Foundation Executive Committee in April 2010, by the American Heart Association Science Advisory and Coordinating Committee in April 2010, and by the AACVPR Document Oversight Committee and Board of Directors in June 2010.

The American College of Cardiology Foundation requests that this document be cited as follows: Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J. AACVPR/ACC/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. J Am Coll Cardiol 2010;56:1159–1167.

This article is copublished in Circulation and the Journal of Cadiopulmonary Rehabilitation and Prevention.

Copyright ©2010 by the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology Foundation, and American Heart Association, Inc. Published by Elsevier Inc.

CPT™ contained in the online data supplement is ©2009 American Medical Association.

Impact of 24-hr in-hospital interventional cardiology team on timeliness of reperfusion for ST-segment elevation myocardial infarction

OBJECTIVE

We studied the effect of 24 hr a day, 7 days a week interventional cardiology staff on door-to-balloon (D2B) time and mortality in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Any delay in PPCI in acute STEMI is associated with higher mortality and, therefore, time to treatment should be as short as possible. Despite the use of several strategies, goal D2B time of <90 min remains elusive.

METHODS

The study examined 790 consecutive STEMI patients treated with PPCI as the reperfusion therapy of choice. Patients were grouped into a pre-24 x 7 and post-24 x 7 cohort to study the impact of the new protocol on D2B time and major adverse cardiovascular events (MACE) and mortality.

RESULTS

Median D2B time decreased from 99 min in the pre-24 x 7 group to 55 min in the post-24 x 7 group (P = 0.001) and was not influenced by time of day or day of week. Adjusted for patient and clinical characteristics, the pre-24 x 7 group had increased in-hospital cardiovascular mortality (odds ratio 1.94, 95% confidence interval 0.95-3.94; P = 0.048) and MACE (odds ratio 1.66, 95% confidence interval 1.10-2.49; P = 0.009) compared with the post-24 x 7 group. Prolonged D2B time was also associated with higher 1-year overall mortality in the pre-24 x 7 group compared with the post-24 x 7 group (12.8% vs. 8.1%; hazard ratio 1.17, 95% confidence interval 1.04-2.66; P = 0.044).

CONCLUSIONS

Round-the-clock, in-hospital interventional cardiology team consistently and significantly reduces D2B time, in-hospital cardiovascular mortality, MACE, and 1-year mortality in patients with STEMI.

Psychometric properties of the MacNew heart disease health-related quality of life instrument in patients with heart failure

RATIONALE, AIMS AND OBJECTIVES

Heart failure (HF) is a severe chronic disease and impairs health-related quality of life (HRQL). While validated specific HRQL instruments are required for evaluation of treatment and rehabilitation in patients with HF, a single validated measure to document changes in HRQL for patients with different heart disease diagnoses would be invaluable. The purpose of this analysis was the psychometric analysis of the German MacNew Heart Disease Questionnaire (MacNew) in HF patients, which has previously been shown to be reliable and valid in patients with myocardial infarction, angina pectoris and arrhythmia.

METHODS

We recruited 89 patients (61.7+/-11.5 years; 84.3% male) in two Austrian and one Swiss cardiology department with documented HF (effect sizes 28.9+/-10.1%). The self-administered MacNew, the Short Form-36 (SF-36) and the Hospital Anxiety and Depression Scale were completed. Internal consistency reliability (Cronbach's alpha), discriminative and evaluative validity were assessed.

RESULTS

Cronbach's alpha exceeded 0.80. Each MacNew scale differentiated between patients with and without anxiety (3.9+/-1.0 vs. 5.3+/-0.8, all P<0.001), with and without depression (4.2+/-1.2 vs. 5.2+/-0.9 all P<0.03) and by the SF-36 health transition item (deteriorate=4.39, no change=4.95, improve=5.45, all P<0.02). Evaluative validity was demonstrated with effect sizes >0.70 for a subsample attending a 12-week outpatient rehabilitation programme.

CONCLUSIONS

The German language version of the MacNew demonstrates consistently acceptable psychometric properties of reliability, validity and responsiveness in patients with documented HF. Together with previous documentation of reliability, validity and responsive, these findings strengthen the argument for the MacNew as a potential 'core' HRQL measure, at least in the German language.

The validity and reliability of the Turkish version of the MacNew Heart Disease Questionnaire in patients with angina

AIMS AND OBJECTIVES

Health-related quality of life (HRQL) is an important patient-reported outcome when identifying the effects of the angina and evaluating the efficacy of treatment. The aim of this study was to determine the reliability and validity of the Turkish version of the MacNew Heart Disease HRQL Questionnaire (MacNew) in patients with angina.

METHOD

The Short Form SF-36, the MacNew, and the Hospital Anxiety and Depression Scale were completed by the 125 patients in first 2-3 days after admission to the coronary care unit. Internal consistency reliability (Cronbach's alpha) and reproducibility (intraclass correlation coefficients, ICC) of the MacNew were assessed, and test-retest reproducibility was evaluated over a 2-month period in 25 clinically stable patients.

RESULTS

The original three-factor structure for the Turkish MacNew was confirmed, with construct validity only partially confirmed; reliability statistics show that Cronbach's alpha exceeded 0.80 and the ICC exceeded 0.60 for all MacNew scales. Discriminative validity of the MacNew was confirmed.

CONCLUSION

The MacNew appears to be reliable and valid in Turkish patients with angina.

Elective percutaneous coronary intervention without on-site surgical backup: a community hospital experience

CONTEXT

The American College of Cardiology guidelines consider elective percutaneous coronary intervention (PCI) without on-site surgical backup (OSB) a Class-III indication.

OBJECTIVE

Our objective was to determine the safety of elective PCI without OSB.

DESIGN

The study is a prospective analysis of a cohort of patients who underwent elective PCI without OSB at our institution. All patients were at our community satellite institution in Beloit, Wis. Three hundred twenty-one elective interventions were performed (mean age 64 +/-12, 68% male). The prevalence of diabetes and hypertension was 28% and 82.5% respectively.

INTERVENTION

A predefined protocol was designed to transfer patients to a cardiac surgical facility if necessary. An experienced interventional cardiologist reviewed the diagnostic angiograms. Patients with complex lesions were excluded from the study.

MAIN OUTCOME MEASURE

Any procedure-related death or emergency coronary artery bypass graft surgery.

RESULTS

Three hundred eighty-two vessels were stented. Multi-vessel intervention was performed in 61 patients (19%). Only 5% of lesions were type C. Four hundred thirty-seven stents were deployed. IIb-IIIa inhibitors were used in 77 (24%) cases. Procedural success was 99.7%. There were no deaths, myocardial infarctions nor need for urgent target vessel revascularization at 6 months.

CONCLUSION

With careful patient/lesion selection, an experienced interventional cardiologist and a predefined transfer protocol, elective PCI without OSB can be performed safely.