Factors related to functional status after percutaneous transluminal coronary angioplasty

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND

Little is known about the frequency of significant hypoglycemic events in actual practice. Limited health literacy (HL) is common among patients with type 2 diabetes, may impede diabetes self-management, and thus HL could increase the risk of hypoglycemia.

OBJECTIVE

To determine the proportion of ambulatory, pharmacologically-treated patients with type 2 diabetes reporting > or =1 significant hypoglycemic events in the prior 12 months, and evaluate whether HL is associated with hypoglycemia.

RESEARCH DESIGN

Cross-sectional analysis in an observational cohort, the Diabetes Study of Northern California (DISTANCE).

SUBJECTS

The subjects comprised 14,357 adults with pharmacologically-treated, type 2 diabetes who are seen at Kaiser Permanente Northern California (KPNC), a non-profit, integrated health care delivery system.

MEASURES

Patient-reported frequency of significant hypoglycemia (losing consciousness or requiring outside assistance); patient-reported health literacy.

RESULTS

At least one significant hypoglycemic episode in the prior 12 months was reported by 11% of patients, with the highest risk for those on insulin (59%). Patients commonly reported limited health literacy: 53% reported problems learning about health, 40% needed help reading health materials, and 32% were not confident filling out medical forms by themselves. After adjustment, problems learning (OR 1.4, CI 1.1-1.7), needing help reading (OR 1.3, CI 1.1-1.6), and lack of confidence with forms (OR 1.3, CI 1.1-1.6) were independently associated with significant hypoglycemia.

CONCLUSIONS

Significant hypoglycemia was a frequent complication in this cohort of type 2 diabetes patients using anti-hyperglycemic therapies; those reporting limited HL were especially vulnerable. Efforts to reduce hypoglycemia and promote patient safety may require self-management support that is appropriate for those with limited HL, and consider more vigilant surveillance, conservative glycemic targets or avoidance of the most hypoglycemia-inducing medications.

Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography

Background Little is known about illness-related uncertainty and decreased health-related quality of life in patients undergoing initial coronary angiography or about the long-term effects of uncertainty.

Objectives To compare patients with and without high levels of uncertainty before angiography and to examine the influence of uncertainty on health-related quality of life 1 year after angiography.

Methods In a prospective, longitudinal study, measurements of perceived control, uncertainty, affective distress, and health-related quality of life were collected from 93 patients before angiography (baseline) and 1 year later. At baseline, patients were classified into high- and low-uncertainty groups by median split. At 1 year, analysis of variance was used to compare health-related quality of life and psychological outcomes in the 2 groups, and multiple linear regression with stepwise entry was used to identify independent determinants of health-related quality of life.

Results Compared with patients with low baseline uncertainty, patients with high baseline uncertainty had higher levels of anxiety and depression and lower levels of perceived control and health-related quality of life 1 year after angiography. Baseline health-related quality of life, uncertainty, and life stress accounted for 54% of the variance in health-related quality of life, even when angiographic outcome was controlled for (P < .001). Baseline uncertainty was independently associated with health-related quality of life (β = −0.25; 95% confidence interval, −9.40 to −0.05; P = .02).

Conclusions At initial angiography, high levels of uncertainty about illness portend negative health-related quality of life outcomes up to 1 year later.

Changes in health-related quality of life following percutaneous coronary intervention: A longitudinal study

BACKGROUND

Coronary artery disease (CAD) is a major cause of mortality and morbidity in developed countries. The percutaneous coronary intervention (PCI) is a frequently used treatment for CAD. In order to manage the disease more effectively and to promote the health-related quality of life (HRQoL) of these patients, understanding the current status of HRQoL before and after PCI procedure is essential.

OBJECTIVES

This study was to examine the changes of HRQoL from before PCI to the first 3 months after PCI on Hong Kong Chinese.

DESIGN

A longitudinal, one-group observational design was used.

SETTING

Data collected from cardiac patients admitted into a regional public hospital at Hong Kong Island for PCI.

PARTICIPANTS

Between August 2003 and February 2004, all patients admitted for non-emergency PCI at the study site and met the inclusion criteria were invited to take part in the study. Seventy-eight out of 85 eligible patients agreed to participate. However, 13 patients dropped out during data collection period.

METHODS

HRQoL data using the Medical Outcomes Study 36-Item Short Form 36 (SF-36) and Seattle Angina Questionnaire (SAQ) were collected before PCI, 1 and 3 months after PCI.

RESULTS

Sixty-five patents completed the study. All domains in SF-36 and SAQ improved at 1 month but the improvements did not continue in all domains at 3 months. The HRQoL measured by SF-36 improved significantly over time (p<0.05) for six out of the eight domains. Scores of all domains of SF-36 improved at 3 months when compared with baseline. Moreover, all five domains of SAQ changed significantly over time (p<0.05); however, the score of angina stability at the third month was lower than that at baseline.

CONCLUSIONS

The results of this study quantify the benefits of PCI procedure on HRQoL of patients. Although PCI improved the HRQoL 1 month after PCI, the effect did not last long. Nursing interventions are needed to maintain and further enhance the HRQoL of these patients and the interventions should be introduced immediately post-PCI.

Patterns of recovery following percutaneous coronary intervention: a pilot study

Percutaneous coronary intervention (PCI) is the most common type of cardiac revascularization performed. However, there has been limited research examining the recovery of PCI patients after their hospital discharge. This descriptive, longitudinal study examined patterns of recovery (cardiac symptoms experienced, impact of cardiac symptoms on physical functioning and enjoyment of life, postprocedure problems experienced, and functioning) of 37 PCI patients at 2, 4, and 6 weeks following PCI. Fatigue was the most frequent and persistent symptom, and significantly, F(2, 26) = 3.6, p < .05, it impacted physical functioning at 4 weeks following PCI. Both physical and psychosocial functioning improved over time. Coronary restenosis and heart rhythm disturbance were the most common self-reported heart-related problems. Understanding normal variation in recovery patterns can assist clinicians in developing interventions to facilitate optimal outcomes.

Work-related outcomes after a myocardial infarction

STUDY OBJECTIVE

To evaluate work-related outcomes of patients at 7 months after a myocardial infarction and to identify patient, disease, and intervention characteristics associated with these outcomes.

DESIGN

Cross-sectional survey analysis.

SETTING

Large Midwestern academic health system.

PATIENTS

Eighty-nine patients with the discharge diagnosis of acute myocardial infarction during a 1-year index period.

INTERVENTION

Work performance questionnaire administered by telephone, and medical record review.

MEASUREMENTS AND MAIN RESULTS

Seven months after discharge, 232 patients were interviewed by telephone to determine work status before and after myocardial infarction, work-related outcomes (absenteeism and perceived work performance, assessed by the Work Performance Scale [WPS] of the Functional Status Questionnaire), and health-related quality of life. Univariate analyses were used to determine the association between individual characteristics and work-related outcomes. Of the 89 patients who had worked before the index myocardial infarction, 21 (23.6%) did not return to work. Variables associated with the outcome of not returning to work were past myocardial infarction (before the index myocardial infarction), coronary artery bypass graft surgery, heart failure, positive stress test, and low score on the Physical Component Summary (PCS-12) scale of the Short Form-12. Patients who did not return to work also tended to have more comorbidities and take more prescribed drugs than those who returned to work. Median WPS scores were higher for patients who had higher ejection fractions at discharge, had not experienced a myocardial infarction before the index event, underwent a percutaneous revascularization intervention at the time of hospitalization, and had not recently been absent from work. Workers reporting absences had lower PCS-12 scores than their counterparts or reported a rehospitalization before the survey.

CONCLUSION

Preexisting cardiac disease and poorer physical functioning were consistently related to worse work-related outcomes. This small study demonstrates the need for a larger, broader study that includes health beliefs, treatment, and other job and patient factors that may influence work-related outcomes.

Nursing Outcomes

Percutaneous coronary interventional (PCI) procedures are commonly performed in the United States. The process of caring for this patient population has changed dramatically over the last 10 years, with many of the changes being driven by an evolution in the knowledge base underlying nursing practice. The purpose of this article is to provide a summary and critique of nurse-sensitive outcomes related to patients undergoing PCI procedures and to identify gaps in the literature to provide recommendations for future research. Nursing research on indicators related to costs of care, morbidity, symptom management, functional status, patient/family knowledge, patient responses, behavior, and home/occupational function following PCI are discussed in this review.

Modeling predictors of quality of life after coronary angioplasty

Psychological predictors of quality of life in patients undergoing coronary angioplasty were investigated using a prospective model based on self-regulation and stress-coping theories. Predictors (chest pain, disturbance of personal goals, stress perception, approach coping, avoidant coping, and optimism) and three quality of life indicators (disease-specific quality of life, positive affect, and negative affect) were measured with questionnaires in 158 patients both when they were admitted on the waiting list for angioplasty and 3 months after angioplasty. The results were congruent with expectations based on the theories and indicated that the models predicting disease-specific quality of life and negative affect fit the data well. Avoidant Coping and Stress Perception predicted all quality of life indicators. Goal Disturbance predicted only negative quality of life variables, and Approach Coping predicted only positive quality of life variables. Chest Pain predicted Disease-Specific Quality of Life and Positive Affect. Optimism served as a coping resource. Individualized behavior modification interventions were recommended, but the data suggest that patients may not be easily persuaded to engage in health behavior.

How goal disturbance, coping and chest pain relate to quality of life: A study among patients waiting for PTCA

This article describes psychological correlates of quality of life (QOL) in patients on a waiting list for percutaneous transluminal coronary angioplasty (PTCA). Variables were selected based on a theoretical model describing psychological correlates of QOL in PTCA patients. This model was based on self-regulation and stress-coping theories. The variables in the model are stress appraisal, coping, coping resources, and general and disease-specific QOL variables. Respondents were 122 patients on a 3-month waiting list for a PTCA. Results indicated that PTCA patients had a poorer QOL than matched healthy controls. Using a path analysis approach to regression analysis, it appeared that goal disturbance, avoidant coping, approach coping, and chest pain were related to QOL. More specifically, chest pain and goal disturbance were only related to health-related QOL and negative affect. Both approach and avoidant coping were related to QOL variables. Results could be explained adequately using self-regulation theory. Recommendations for future research and for form and content of rehabilitation programmes were made.

Rehabilitation outcomes following percutaneous coronary interventions (PCI)

This prospective study evaluated the effect of an individualized, comprehensive, home-based cardiac rehabilitation program combining exercise training with risk factor modification and psychosocial counseling on risk factors, psychological well-being, functional capacity, and work resumption in 99 post-percutaneous coronary interventions (PCI) patients randomized to control (standard care plus telephone follow-up, n=49) or intervention (individualized, comprehensive, home-based cardiac rehabilitation, n=50) groups. Data were collected at time 1 (T(1)) during hospital admission, time 2 (T(2)) approximately 2 months post-PCI, and time 3 (T(3)) approximately 12 months post-PCI. Results suggest that the allocation to an individualized, comprehensive, home-based cardiac rehabilitation program provided more advantageous outcomes. At both follow-ups, the intervention group showed within-group improvement in serum cholesterol levels (P<0.02; P<0.01) and exercise participation (P<0.001; P<0.001) with differences in exercise participation favoring the intervention group (P<0.01) at T(2). Repeated measures ANOVA showed significant improvements over time in body mass index (BMI) (P<0.01), psychological well-being (P<0.001), and functional capacity (P<0.001) for both groups. More patients in the intervention group had returned to work at T(2) (P<0.001) and did so more quickly (P<0.01). These findings suggest that an individualized, comprehensive, home-based cardiac rehabilitation program improves risk factor profiles and work resumption patterns for patients following PCI.

Quality of life comparisons after coronary angioplasty and coronary artery bypass graft surgery

OBJECTIVE

To examine the differences in realization of expected benefits, complications, and quality of life (QOL) 3 months after percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery.

DESIGN

Nonexperimental, prospective, and comparative. Before discharge, participants listed benefits expected from the procedure, as well as comorbid health problems (Charlson Comorbidity Index) and complications. At 3 months, they quantified their realization of expected benefits, reported postdischarge complications, and completed Ferrans and Powers' Quality of Life Index-Cardiac Version III.

SAMPLE

36 patients who had PTCA; 38 patients who had CABG.

RESULTS

There were no differences between groups in realization of expected benefits or QOL. Patients who had CABG reported a greater number of complications after discharge, and a greater proportion of patients who had PTCA reported angina. Patients who had PTCA and then recurrent angina had significantly lower health QOL and psychologic and spiritual QOL.

CONCLUSIONS

Patients who undergo CABG need guidance regarding what complications to expect, and patients who undergo PTCA need to know that recurrent angina is possible and how to manage it.

Prediction of functional and psychological status after percutaneous transluminal coronary angioplasty

OBJECTIVE

To examine symptom, functional status, and psychological status profiles after percutaneous transluminal coronary angioplasty (PTCA) and determine indicators of outcome.

DESIGN

Descriptive and correlational with repeated measures.

SETTING

Hospital or home (2.1 days before PTCA) and home (3.9 and 10.2 months after discharge).

MEASURES

Self-administered questionnaires (developed for study) for functional status (personal and instrumental activities of daily living), and cardiac symptoms (chest pain and shortness of breath at rest and on exertion). General Health Questionnaire(16) for psychological status.

PATIENTS

One hundred thirty with PTCA (mean age 57 years, 84% male, 15% with prior PTCA).

RESULTS

Chest pain and shortness of breath at rest and on exertion decreased and functional and psychological status improved 3.9 months after PTCA, with measures maintained at 10.2 months. At 3.9 months after PTCA, poorer psychological status was predicted by having had a longer duration of coronary artery disease before PTCA. Post-PTCA indicators of poor psychological status were continued chest pain and shortness of breath on exertion and not working. The presence of post-PTCA chest pain on exertion and not working were also correlated with reduced functional status.

CONCLUSIONS

Although pre-PTCA variables such as duration of coronary artery disease can predict post-PTCA outcome, the use of variables measured after PTCA may also provide clinicians with accurate estimates of functional and psychological status after PTCA.