Need for a paradigm shift: the importance of risk factor reduction therapy in treating patients with cardiovascular disease

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Clinical Trial of Herbal Formula on Weight Loss in Obese Korean Children

A traditional Korean herbal formula (KH), which is based on Taeumjowi-tang, is currently the most widely used herbal formula in Korea. In this study, KH was administered to obese children for 30 days, and was found to be clinically safe and effective. The subjects were children admitted to hospital to be treated for obesity with relative body weights (%RBW) of 20% or more. Originally, there were 31 subjects, but nine dropped out during the experiment. There were eight girls and 14 boys, whose average age was 11.00 ± 2.62 years, average weight was 53.37 ± 17.29 kg , and average period (30-day amount) of KH dosage was 51.18 ± 22.58 days.

The short-term effects of KH on obese children were the reduction of their BMI from 24.34 ± 3.10 to 23.26 ± 3.00 kg/m2, of %RBW from 34.41 ± 10.90 to 25.94 ± 11.18% ( p < 0.01), of body fat mass from 17.99 ± 5.37 to 16.50 ± 4.82 kg , and of body fat from 34.16 ± 3.75 to 32.08 ± 3.15% ( p < 0.01). Concerning anthropometrical measurements, abdominal skin-fold decreased from 26.16 ± 9.08 to 22.90 ± 8.35 mm , as did subscapular skin-fold from 20.86 ± 5.20 to 18.46 ± 5.31 mm ( p < 0.01). In terms of serum lipid levels, which are indices of heart disease, their total cholesterol decreased from 195.38 ± 31.39 to 183.25 ± 33.27 mg/dl , the arteriosclerosis index from 4.100 ± 0.81 to 3.84 ± 0.64 mg/dl ( p < 0.05), and serum leptin level from 14.91 ± 6.59 to 12.24 ± 4.98 ng/ml ( p < 0.01). Concerning the safety of KH, there were no significant changes in the subjects' livers, hearts, or kidneys. Nor were there any short-term signs of clinically serious side effects or withdrawal symptoms observed. The short-term effects of KH on obese children are weight loss and a decrease in obesity.

Physical therapy in the 21st century (Part II): evidence-based practice within the context of evidence-informed practice

Part II of this two-part introduction to this Special Issue on physical therapy practice in the 21st century outlines a health-focused strategy for physical therapists to lead in the assault on lifestyle conditions, global health care priorities, described in Part I. Consistent with contemporary definitions of physical therapy, its practice, professional education, and research, physical therapy needs to reflect 21st-century health priorities and be aligned with global and regional public health strategies. A proposed focus on health emphasizes clinical competencies, including assessments of health, lifestyle health behaviors, and lifestyle risk factors; and the prescription of interventions to promote health and well-being in every client or patient. Such an approach is aimed to increase the threshold for chronic conditions over the life cycle and reduce their rate of progression, thereby preventing, delaying, or minimizing the severity of illness and disability. The 21st-century physical therapist needs to be able to practice such competencies within the context of a culturally diverse society to effect positive health behavior change. The physical therapist is uniquely positioned to lead in health promotion and prevention of the lifestyle conditions, address many of their causes, as well as manage these conditions. Physical therapists need to impact health globally through public and social health policy as well as one-on-one care. This role is consistent with contemporary definitions of physical therapy as the quintessential noninvasive health care practitioner, and the established efficacy and often superiority of lifestyle and lifestyle change on health outcomes compared with invasive interventions, namely, drugs and surgery. A concerted commitment by physical therapists to health and well-being and reduced health risk is consistent with minimizing the substantial social and economic burdens of lifestyle conditions globally.

Meta-analysis of interventions to increase physical activity among cardiac subjects

BACKGROUND

Extensive primary research has tested interventions to increase physical activity (PA) among adults with cardiovascular disease. This meta-analysis integrates the extant research about how to increase PA in cardiac samples.

METHODS

Extensive literature searching located published and unpublished intervention studies that measured PA outcomes. Results were coded from primary studies. Fixed- and random-effects meta-analytic procedures included moderator analyses.

RESULTS

Data were synthesized across 11,877 subjects from 79 eligible research reports. The overall mean PA effect size for 2-group comparisons was 0.35 (higher mean for treatment than control), which is consistent with a difference of 1984 kcal/week for treatment subjects versus 1615 for control subjects. The fitness effect size for 2-group comparisons was .17. Other statistically significantly positive 2-group effect sizes were .24 for quality of life and .23 for subsequent cardiac events. Effect sizes for anthropometric measures and blood pressure did not differ significantly from 0. Exploratory moderator analyses found large effect sizes for PA among studies that had (1) an exclusive focus on PA versus diverse health behaviors, (2) more contact between interventionists and subjects, (3) supervised exercise sessions, (4) fitness testing, (5) face-to-face encounters versus mediated intervention delivery, and (6) more minutes of activity per week. Effect sizes were unrelated to funding status, dissemination vehicle, gender distribution, or attrition rate.

CONCLUSIONS

These findings document that interventions can be effective in increasing PA among patients with cardiovascular diseases. Primary research should compare interventions in randomized trials to confirm causal relationships.

Importance of geometry and refractory period in sustaining atrial fibrillation: testing the critical mass hypothesis

BACKGROUND

The critical mass hypothesis for atrial fibrillation (AF) was proposed in 1914. There has never been a systematic investigation defining the relationship between tissue geometry and AF. The purpose of this study was to determine the association among the probability of maintaining AF and the width, area, weight, effective refractory period (ERP), and wavelength in atrial tissue.

METHODS AND RESULTS

Isolated canine atria (n=20) were perfused with Krebs-Henseleit solution. Baseline ERPs were obtained with and without acetylcholine (10E-3.5 mol/L) using single extra-stimulus pacing while unipolar electrograms were recorded from 250 sites. The tissue was then partitioned using bipolar radiofrequency ablation, and the ERPs were measured again with and without acetylcholine. Any section of tissue that maintained AF was divided until the arrhythmia was no longer inducible. ERPs and conduction velocities were measured in all of the sections after each ablation, and the wavelengths were calculated. The probability of AF was found to be correlated with increasing tissue areas, widths, and weights (P<0.001). The probability of AF was significantly associated with the length of the ERP and the wavelength (P<0.001). With shorter ERPs and shorter wavelengths, there was an increased probability of sustained AF.

CONCLUSIONS

The probability of sustained AF was significantly associated with increasing tissue area, width, and weight and decreasing ERPs and wavelengths. These data may lead to a better understanding of the mechanism of AF and, thus, help to design more-effective interventional procedures in the future.

Development of a self-efficacy instrument for coronary artery bypass graft patients

Research related to self-efficacy has demonstrated that measures of this concept need to be specific to the behavior of interest. Self-efficacy is the degree of confidence one has to perform an activity. This article describes the development and testing of the Barnason Efficacy Expectation Scale (BEES). The instrument is a 15-item tool that uses a Likert scale to determine the coronary-artery-bypass-graft (CABG) patient's self-efficacy related to the risk-reduction-related aspects of recovery and lifestyle adjustment following CABG surgery (physical functioning, psychosocial functioning, coronary artery disease risk factor modification and self-care management). Internal consistency reliability of the instrument was 0.93, and principal components analysis revealed a single factor (Eigenvalue = 10.59, percent variance = 70.61%). Three phases of tool development are described in the article that document satisfactory reliability and validity (face, content, criterion, and construct).

Biochemical risk factors for cardiovascular disease in an aged male population: emerging vascular pathogens

The progressive increase of deaths and morbidity from cardiovascular disease (CVD) in most developed societies has led to the formulation of preventive strategies and application of several diagnostic guidelines. However, there is emerging evidence that most panels and algorithms are inadequate and require urgent revision and updating. Therefore, the aim of this study was the evaluation of a wide cardiovascular risk profile in elderly male patients with acute myocardial infarction (AMI) or peripheral occlusive disease (POD). The risk profile was assessed by measuring conventional serum lipid and lipoprotein levels and emerging parameters: lipoprotein(a) (Lp[a]), homocysteine (Hcy), and C-reactive protein (CRP). The concentration of triglycerides, Lp(a), Hcy and the total cholesterol/high-density lipoprotein (TC/HDL) ratio were significantly higher in both classes of patients than in a population of matched healthy controls and, similarly, patients with CVD displayed lower plasma values of HDL. No significant differences were observed for TC, low-density lipoprotein (LDL), and CRP. Patients with POD exhibited a marked atherogenic profile, as attested by substantially increased values of Hcy, Lp(a), triglycerides, and TC/HDL ratio. The frequency distributions of Lp(a) and Hcy concentrations were markedly shifted toward upper values in both classes of patients than in controls. In multivariate regression analysis, Lp(a) and Hcy were the best predictors for AMI, whereas Lp(a), Hcy, and the TC/HDL ratio were the best predictors for POD. Taken together, these data suggest that Lp(a) and Hcy excesses might exert a central role in the development of atherosclerotic disease in elderly male patients. Thereby, the inclusion of those tests, along with the TC/HDL ratio and other more conventional analyses in panels for the evaluation of the cardiovascular risk might be profitable in terms of effectual prevention.

SSM Health Care clinical collaboratives: improving the value of patient care in a health care system

BACKGROUND

In 1998 SSM Health Care (St Louis) began a series of clinical collaboratives modeled after The Institute of Healthcare Improvement (Boston) Breakthrough Series. There are now four collaboratives, with 46 teams in progress, and four additional collaboratives are scheduled.

COLLABORATIVE TOPICS AND STRUCTURE

Each collaborative consists of three phases: the prework, active, and the continuous improvement phases. The structure of the collaboratives is quite similar to that of the Institute for Healthcare Improvement Breakthrough Series. However, the SSMHC collaboratives include a continuous improvement phase, which was designed to help maintain gains from the projects and to involve entities not originally involved in the collaborative. RESULTS OF COLLABORATIVES IN PROGRESS: Entity teams participating in multiple collaboratives seem to ascend a learning curve and become progressively more skilled in subsequent collaborative work. In Collaborative 1--Improving the Secondary Prevention of Ischemic Heart Disease--the participating entities showed significant improvement in cholesterol screening and treatment. In Collaborative 2--Improving Prescribing Practices--the collaborative teams also showed significant improvement, with a combined cost savings of approximately $450,000 per year. Collaboratives 3--Using Patient Information to Improve Care and Assure Success-and-4--Enhancing Patient Safety Through Safe Systems--are under way.

SUMMARY

The collaboratives accelerate improvement work through sharing of successes and failures and peer influence within a reinforcing environment. Most of the collaborative teams have reached their project goals, and the pace of clinical improvement work has accelerated since the start of the collaboratives. The collaboratives provide an environment for clinicians to constructively participate in improvement of patient care.