Physical health status assessed during hospitalization for acute coronary syndrome predicts mortality 12 months later

Preoperative Assessment of a Patient Undergoing Bariatric Surgery

Over the past few decades, obesity rates in the United States have risen drastically, and with this, there has been a rising demand for bariatric surgery. As such, anesthesiologists need to be familiar with the challenges presented by patients seeking bariatric surgery. Obesity causes pathophysiologic changes which may affect decision-making during the management of these patients. Patients seeking bariatric surgery also have a long, prescribed preoperative course that offers anesthesiologists the opportunity to be involved earlier during the pre-surgical evaluation and optimization process.

Health-Related Quality of Life Scores and Values as Predictors of Mortality: A Scoping Review

Health-related quality of life (HRQoL) can be assessed through measures that can be generic or disease specific, encompass several independent scales, or employ holistic assessment (i.e., the derivation of composite scores). HRQoL measures may identify patients with differential risk profiles. However, the usefulness of generic and holistic HRQoL measures in identifying patients at higher risk of death is unclear. The aim of the present study was to undertake a scoping review of generic, holistic assessments of HRQoL as predictors of mortality in general non-patient populations and clinical sub-populations with specified conditions or risk factors in persons 18 years or older. Five databases were searched from 18 June to 29 June 2020 to identify peer-reviewed published articles. The searches were updated in August 2022. Reference lists of included and cited articles were also searched. Of 2552 articles screened, 110 met criteria for inclusion. Over one-third of studies were from North America. Most studies pertained to sub-populations with specified conditions and/or risk factors, almost a quarter for people with cardiovascular diseases. There were no studies pertaining to people with mental health conditions. Nearly three-quarters of the studies used a RAND Corporation QoL instrument, predominantly the SF-36, and nearly a quarter, a utility instrument, predominantly the EQ-5D. HRQoL was associated with mortality in 67 of 72 univariate analyses (92%) and 100 of 109 multivariate analyses (92%). HRQoL was found to be associated with mortality in the general population and clinical sub-populations with physical health conditions. Whether this relationship holds in people with mental health conditions is not known. HRQoL assessment may be useful for screening and/or monitoring purposes to understand how people perceive their health and well-being and as an indicator of mortality risk, encouraging better-quality and timely patient care to support and maximize what may be a patient's only modifiable outcome.

A risk model for decline in health status after acute myocardial infarction among older adults

BACKGROUND

Health status is increasingly recognized as an important patient-centered outcome after acute myocardial infarction (AMI). Yet drivers of decline in health status after AMI remain largely unknown in older adults. We sought to develop and validate a predictive risk model for health status decline among older adult survivors of AMI.

METHODS

Using data from a prospective cohort study conducted from 2013 to 2017 of 3041 patients age ≥75 years hospitalized with acute myocardial infarction at 94 U.S. hospitals, we examined a broad array of demographic, clinical, functional, and psychosocial variables for their association with health status decline, defined as a decrease of ≥5 points in the Short Form-12 (SF-12) physical component score from hospitalization to 6 months post-discharge. Model selection was performed in logistic regression models of 20 imputed datasets to yield a parsimonious risk prediction model. Model discrimination and calibration were evaluated using c-statistics and calibration plots, respectively.

RESULTS

Of the 2571 participants included in the main analyses, 30% of patients experienced health status decline from hospitalization to 6 months post-discharge. The risk model contained 14 factors, 10 associated with higher risk of health status decline (age, pre-existing AMI, pre-existing cancer, pre-existing COPD, pre-existing diabetes, history of falls, presenting Killip class, acute kidney injury, baseline health status, and mobility impairment) and four associated with lower risk of health status decline (male sex, higher hemoglobin, receipt of revascularization, and arrhythmia during hospitalization). The model displayed good discrimination (c-statistic = 0.74 in validation cohort) and calibration (p > 0.05) in both development and validation cohorts.

CONCLUSIONS

We used split sampling to develop and validate a risk model for health status decline in older adults after hospitalization for AMI and identified several risk factors that may be modifiable to mitigate the threat of this important patient-centered outcome. External validation of this risk model is warranted.

Barriers and Facilitators in Rehabilitation in Chronic Diseases and After Surgery: Is It a Matter of Adherence?

Although it has been generally acknowledged that participating in rehabilitation programs is better for chronic diseases or post-surgery, the adherence rates of these programs remain lower than expected. According to the World Health Organization (WHO), adherence has been defined as follows: "the extent to which a person's behavior corresponds with agreed recommendations from a healthcare provider." In general, rehabilitation is well investigated, and in chronic diseases like chronic obstructive pulmonary disease (COPD), cardiovascular disease, neuromuscular disease, cancer, and even psychiatric diseases like depression, it has been shown that exercise therapy, in particular, has beneficial effects on morbidity, mortality, and convalescence of these patients. The aim of this review is to give an overview of the barriers and facilitators in rehabilitation practices and possible reasons why adherence rates remain low. Regarding potential future research, barriers and facilitators also need to be taken into account. Despite promising research in the field of preoperative exercise therapy (PET) and preoperative rehabilitation (prehab) and the enormous body of evidence in postoperative rehabilitation or rehabilitation in chronic diseases, it is also needed to take into account the accessibility of these prehab facilities in research and in clinical practice.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.

Increased risk of mortality and readmission associated with lower SF-12 scores in cardiac patients: Results from the national DenHeart study

BACKGROUND

The SF-12v2 health survey (SF-12) is widely used as a generic measure of health-related quality of life. However, interpretation of score differences can be difficult.

AIM

To estimate benchmarks for interpretation of score differences on the SF-12 for readmission and all-cause mortality in cardiac patients.

METHODS

Data from the DenHeart study, a national cross-sectional survey including one year follow-up register data, were used. Patients with ischaemic heart disease, arrhythmia, heart failure and heart valve disease answered the survey at hospital discharge. Cox proportional hazards models were used to regress readmission and all-cause mortality.

RESULTS

A total of 10,813 cardiac patients completed the SF-12. For patients with ischaemic heart disease and arrhythmia, a one point lower physical component summary score was associated with a 2% increase in risk in readmission (hazard ratio (HR) 1.022 (95% confidence interval 1.017;1.027) and HR 1.024 (1.018; 1.029), respectively) and a 3% increase in risk for patients with heart failure (HR 1.027 (1.015; 1.038)). A one point lower mental component summary score was associated with a 2% increase in the risk of readmission (HR 1.017 (1.013; 1.022)) across diagnoses. For both the physical and mental component summary score, a one point lower score meant a 5% increase in the risk of all-cause mortality (HR 1.046 (1.031; 1.060) and HR 1.046 (1.029; 1.065), respectively) across diagnoses.

CONCLUSION

In a large group of cardiac patients, a one point lower physical or mental component summary score was associated with an up to 3% increased risk of readmission and a 5% increased risk of mortality in the first year after discharge.

Association between illness perception and health-related quality of life in patients with preexisting premature coronary artery disease

OBJECTIVES

Illness perception in younger age differs from that in older age. We aimed to examine the association between illness perception and health-related quality of life (HRQoL) in patients with premature coronary artery disease (CAD).

METHODS

In a cross-sectional design, between November 2016 and September 2017, a total of 779 adults (52.5% female) with premature CAD (diagnosed in men aged ≤ 45 y and women aged ≤ 55 y) completed the Beck Depression Inventory-II, the Beck Anxiety Inventory, the Brief Illness Perception, and the Short-Form Health Survey 36 questionnaires in an outpatient clinic 8 years after the diagnosis.

RESULTS

The patients were treated with coronary artery bypass graft surgery (24.6%), percutaneous coronary intervention (39.5%), and medical treatment (35.8%). The cognitive, emotional, and comprehension aspects of illness perception had significant associations with both physical and mental health in univariable analysis (all Ps < 0.001). After adjustments for potential confounding factors, higher cognitive perception was independently associated with greater physical health [OR = 4.13, Confidence interval (CI): 3.53-4.72] and mental health (OR = 3.17, CI: 2.57-3.77). Additionally, emotional perception was also directly associated with higher physical (OR = 1.62, CI: 1.17-2.06) and mental (OR = 1.52, CI: 1.07-1.96) health; all Ps < 0.001.

CONCLUSIONS

Of the 3 different aspects of illness perception, cognitive perception appeared to have the greatest influence on HRQoL, either physical or mental health. Further studies are needed to investigate whether cognitive interventions can improve HRQoL in premature CAD patients and, thus, their outcome.

Self-compassion, attitudes to ageing and indicators of health and well-being among midlife women

OBJECTIVES

Attitudes to ageing exert a powerful influence on health and well-being, yet surprisingly little research has examined factors that contribute to the formation of these attitudes. The aim of this study was to consider the potential role of self-compassion in predicting attitudes to ageing, which in turn contribute to positive and negative mental well-being and self-reported health.

METHOD

This was a cross-sectional study using data from 517 midlife women aged between 40 and 60. Structural equation modelling was used to examine the relationships between self-compassion, three facets of attitudes to ageing and well-being outcomes.

RESULTS

Together, self-compassion and attitudes to ageing explained between 36% and 67% of the variance in well-being. Self-compassion was a strong predictor of attitudes towards psychosocial loss, physical change and psychological growth (β range: .22-.51). Furthermore, the relationship between self-compassion and well-being outcomes was partially mediated by attitudes to physical change.

CONCLUSION

Self-compassion may be a modifiable internal resource to promote healthy attitudes to ageing in midlife, when ageing becomes personally relevant. Moreover, attitudes towards physical change may help explain how self-compassion promotes well-being among midlife women.

Cardiac rehabilitation using the Family-Centered Empowerment Model versus home-based cardiac rehabilitation in patients with myocardial infarction: a randomised controlled trial

Objective

To determine if a hybrid cardiac rehabilitation (CR) programme using the Family-Centered Empowerment Model (FCEM) as compared with standard CR will improve patient quality of life, perceived stress and state anxiety of patients with myocardial infarction (MI).

Methods

We conducted a randomised controlled trial in which patients received either standard home CR or CR using the FCEM strategy. Patient empowerment was measured with FCEM questionnaires preintervention and postintervention for a total of 9 assessments. Quality of life, perceived stress, and state and trait anxiety were assessed using the 36-Item Short Form Health Survey (SF-36), the 14-item Perceived Stress, and the 20-item State and 20-item Trait Anxiety questionnaires, respectively.

Results

70 patients were randomised. Baseline characteristics were similar. Ejection fraction was significantly higher in the intervention group at measurements 2 (p=0.01) and 3 (p=0.001). Exercise tolerance measured as walking distance was significantly improved in the intervention group throughout the study. The quality of life results in the FCEM group showed significant improvement both within the group over time (p<0.0001) and when compared with control (p<0.0001). Similarly, the perceived stress and state anxiety results showed significant improvement both within the FCEM group over time (p<0.0001) and when compared with control (p<0.0001). No significant difference was found either within or between groups for trait anxiety.

Conclusions

The family-centred empowerment model may be an effective hybrid cardiac rehabilitation method for improving the physical and mental health of patients post-MI; however, further study is needed to validate these findings. Clinical Trials.gov identifier NCT02402582.

Trial registration number

NCT02402582.

Is self-rated health an independent prognostic factor of six-week mortality in older patients hospitalized for an acute condition?

PURPOSE

To determine whether self-rated health is a prognostic factor of six-week mortality, independently of other known objective prognostic factors.

METHODS

The SAFMA study was a prospective cohort, which recruited patients from the University Hospital of Martinique Acute Care for Elders unit (French West Indies) from January to June 2012. Patients aged 75 or older and hospitalized for an acute condition were eligible. The outcome was time to death within the six-week follow-up. The main explanatory variable was self-rated health. Sociodemographic and clinical characteristics were considered as covariates. Cox's proportional hazards model was used.

RESULTS

The mean age of the 223 patients included was 85.1 ± 5.5 years. Six-week mortality rate was 14.8 %; none were lost to follow-up. In total, 123 claimed "very good to good" health, and 100 "medium to very poor" health. Self-rated health was the only independent prognostic factor associated with 6-week mortality (hazard ratio 2.61; 95 % confidence interval 1.18-5.77; p = .02), when adjusting for known prognostic factors such as age, dimensions of the comprehensive geriatric assessment and comorbidity burden.

CONCLUSION

The association between self-rated health and short-term mortality could have implications for clinical practice, particularly in helping in the estimation of prognosis in acute care setting.

Self-reported health following percutaneous coronary intervention: results from a cohort followed for 3 years with multiple measurements

Objective

Improvements in the treatment of coronary heart disease have increased the number of patients living with a chronic heart disease. Patient-reported outcomes are required to adequately describe prognosis. We report self-rated health in a population-based cohort of patients with coronary heart disease treated with percutaneous coronary intervention (PCI).

Methods

Over 3 years, we followed 1,726 patients under 65 years treated with PCI with eight repetitive questionnaires. With the use of multiple imputation, we described the course of self-rated health using the short form 12-item survey’s mental component summary (MCS) and physical component summary (PCS) and analyzed adjusted differences by sex, age, educational level, indication for PCI, and left ventricular ejection fraction along with an analysis of decrease in health status.

Results

MCS scores increased during follow-up, while PCS scores were stable over time. Men rated higher in MCS and PCS than women, and older patients rated higher in MCS than younger. Other differences were negligible. Younger age was identified as a risk factor for marked decrease in mental health over time.

Conclusion

In a complete population-based cohort of PCI patients with multiple measurements, we found improvements in mental, but not physical health over time. Demographic differences in health were larger than disease-related differences.

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

BACKGROUND

Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.

METHODS AND RESULTS

Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes.

CONCLUSIONS

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

Preoperative exercise therapy for elective major abdominal surgery: a systematic review

OBJECTIVES

The impact of postoperative complications after Major Abdominal Surgery (MAS) is substantial, especially when socio-economical aspects are taken into account. This systematic review focuses on the effects of preoperative exercise therapy (PEXT) on physical fitness prior to MAS, length of hospital admission and postoperative complications in patients eligible for MAS, and on what is known about the most effective kind of exercise regime.

METHODS

A systematic search identified randomised controlled trials on exercise therapy and pulmonary physiotherapy prior to MAS. The methodological quality of the included studies was rated using the 'Delphi List For Quality Assessment of Randomised Clinical Trials'. The level of agreement between the two reviewers was estimated with Cohen's kappa.

RESULTS

A total of 6 studies were included, whose methodological quality ranged from moderate to good. Cohen's kappa was 0.90. Three studies reported on improving physical fitness prior to MAS with the aid of PEXT. Two studies reported on the effect of training on postoperative complications, showing contradictory results. Three studies focused on the effect of preoperative chest physiotherapy on postoperative lung function parameters after MAS. While the effects seem positive, the optimal training regime is still unclear.

CONCLUSION

Preoperative exercise therapy might be effective in improving the physical fitness of patients prior to major abdominal surgery, and preoperative chest physiotherapy seems effective in reducing pulmonary complications. However consensus on training method is lacking. Future research should focus on the method and effect of PEXT before high-risk surgical procedures.

Perioperative exercise training in elderly subjects

The association between physical fitness and outcome following major surgery is well described - less fit patients having a higher incidence of perioperative morbidity and mortality. This has led to the idea of physical training (exercise training) as a perioperative intervention with the aim of improving postoperative outcome. Studies have started to explore both preoperative training (prehabilitation) and postoperative training (rehabilitation). We have reviewed the current literature regarding the use of prehabilitation and rehabilitation in relation to major surgery in elderly patients. We have focussed particularly on randomised controlled trials, systematic reviews and meta-analyses. There is currently a paucity of high-quality clinical trials in this area, and the evidence base in elderly patients is particularly limited. The review indicated that prehabilitation can improve objectively measured fitness in the short time available prior to major surgery. Furthermore, for several general surgical procedures, prehabilitation using inspiratory muscle training may reduce the risk of some specific complications (e.g., pulmonary complications and predominately atelectasis), but it is unclear whether this translates into an improvement in overall surgical outcome. There is clear evidence that rehabilitation is of benefit to patients following cancer diagnoses, in terms of physical activity, fatigue and health-related quality of life. However, it is uncertain whether this improved physical function translates into increased survival and delayed disease recurrence. Prehabilitation using continuous or interval training has been shown to improve fitness but the impact on surgical outcomes remains ill defined. Taken together, these findings are encouraging and support the notion that pre- and postoperative exercise training may be of benefit to patients. There is an urgent need for adequately powered randomised control studies addressing appropriate clinical outcomes in this field.

Depression and self-reported functional status: impact on mortality following acute myocardial infarction

OBJECTIVE

The cause of increased post-AMI (acute myocardial infarction) mortality associated with depression remains poorly elucidated. The objective of this study was to examine the extent to which self-reported cardiac functional status accounted for depression-mortality associations following AMI.

METHODS

Using a prospective cohort design (n = 1941), the authors obtained self-reported measures of depression and developed profiles of the patients' pre-hospitalization cardiac risks, co-morbid conditions and drugs and revascularization procedures during or following index AMI hospitalization. To create these profiles, the patients' self-reports were retrospectively linked to no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, income, cardiovascular risk, co-morbid conditions, selected process-of-care factors and self-reported cardiac functional status.

RESULTS

Depression was strongly correlated with 2-year mortality rate [crude hazard ratio (HR) of severe vs. minimal depression category, 2.48 (95% CI 1.20-5.15); P = 0.01]. However, after sequential adjustment for age, sex, income and self-reported cardiac functional status, the effect of depression was greatly attenuated [adjusted HR for severe vs. minimal depression category, 1.35 (95% CI 0.63-2.87); P = 0.44]. Cardiac risk factors and non-cardiac co-morbidities had negligible explanatory effect.

DISCUSSION

The main factor determining the increased mortality rate in depressed patients is self-reported cardiac functional status. Efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status.

The mechanisms linking health literacy to behavior and health status

OBJECTIVE

To examine the mechanisms linking health literacy to physical activity and self-reported health.

METHODS

From 2005-2007, patients (N = 330) with hypertension were recruited from safety net clinics. Pathanalytic models tested the pathways linking health literacy to physical activity and self-reported health.

RESULTS

There were significant paths from health literacy to knowledge (r = 0.22, P < 0.001), knowledge to self-efficacy (r = 0.13, P < 0.01), self-efficacy to physical activity (r = 0.17, P < 0.01), and physical activity to health status (r = 0.17, P < 0.01).

CONCLUSIONS

Health education interventions should be literacy sensitive and aim to enhance patient health knowledge and self-efficacy to promote self-care behavior and desirable health outcomes.

The effects of preoperative exercise therapy on postoperative outcome: a systematic review

OBJECTIVE

To summarize the current evidence on the effects of preoperative exercise therapy in patients awaiting invasive surgery on postoperative complication rate and length of hospital stay.

DATA SOURCES

A primary search of relevant key terms was conducted in the electronic databases of PubMed, EMBASE, PEDro and CINAHL.

REVIEW METHODS

Studies were included if they were controlled trials evaluating the effects of preoperative exercise therapy on postoperative complication rate and length of hospital stay. The methodological quality of included studies was independently assessed by two reviewers using the PEDro scale. Statistical pooling was performed when studies were comparable in terms of patient population and outcome measures. Results were separately described if pooling was not possible.

RESULTS

Twelve studies of patients undergoing joint replacement, cardiac or abdominal surgery were included. The PEDro scores ranged from 4 to 8 points. Preoperative exercise therapy consisting of inspiratory muscle training or exercise training prior to cardiac or abdominal surgery led to a shorter hospital stay and reduced postoperative complication rates. By contrast, length of hospital stay and complication rates of patients after joint replacement surgery were not significantly affected by preoperative exercise therapy consisting of strength and/or mobility training.

CONCLUSION

Preoperative exercise therapy can be effective for reducing postoperative complication rates and length of hospital stay after cardiac or abdominal surgery. More research on the utility of preoperative exercise therapy and its long-term effects is needed as well as insight in the benefits of using risk models.

Depressive Symptoms, Self-Reported Physical Functioning, and Identity in Community-Dwelling Older Adults

OBJECTIVE: To examine the relationship between self-reported physical functioning and depressive symptoms by testing the mediation of identity processes in linking this relationship. METHODS: Sixty-eight older adults (mean age= 74.4) participated in this cross-sectional study. Participants completed measures of physical functioning (Physical Symptoms Checklist), depressive symptoms (CESD-20) and identity processes (IES-G). RESULTS: The relationship between physical functioning and depressive symptoms was partially mediated by sensitivity of older adults to feedback from experiences, the process known as identity accommodation (Whitbourne, Sneed, & Skultety, 2002). CONCLUSION: Not only are physical changes relevant to negative psychological outcomes in later adulthood, but it is the interpretation of these changes that seems to have particular relevance for aging individuals. Though preliminary based on cross-sectional data, the findings suggest that examining individual differences in sensitivity to aging stereotypes may help identify factors related to depressive symptoms in later adulthood. Future research is needed to disentangle these interrelated concepts.