Marital status and cardiac rehabilitation attendance: a meta-analysis

Sex and gender specific pitfalls and challenges in cardiac rehabilitation: a working hypothesis towards better inclusivity in cardiac rehabilitation programmes

Notwithstanding its acknowledged pivotal role for cardiovascular prevention, cardiac rehabilitation (CR) is still largely under prescribed, in almost 25% of patients owing an indication for. In addition, when considering differences concerning the two sexes, female individuals are underrepresented in CR programmes with lower referral rates, participation, and completion as compared to male counterpart. This picture becomes even more tangled with reference to gender, a complex socio-cultural construct characterized by four domains (gender identity, relation, role, and institutionalized gender). Indeed, each of them reveals several obstacles that considerably penalize CR adherence for different categories of people, especially those who are not identifiable with a non-binary gender. Aim of the present review is to identify the sex- (i.e. biological) and gender- (i.e. socio-cultural) specific obstacles to CR related to biological sex and sociocultural gender and then envision a likely viable solution through tailored treatments towards patients' well-being.

Lower cardiac rehabilitation enrolment occurs in acute coronary syndrome patients who report low levels of physical activity at four weeks post-event: A prospective observational study using physical activity tracker data

BACKGROUND

Physical activity (PA) and cardiac rehabilitation (CR) attendance are important for recovery and prognosis following acute coronary syndrome (ACS). However, PA patterns early post-ACS are not well known.

OBJECTIVES

Investigate the level of PA at 4-weeks post-ACS and any potential associations with CR enrolment.

METHODS

We recruited patients admitted for ACS from cardiac wards and clinics at two hospital sites in Sydney, Australia. PA data were collected using wearable activity trackers worn at 4-weeks post-ACS, and CR enrolment was self-reported.

RESULTS

Participants (n = 61) were aged 66.7 ± 10.3 years, 74 % male, 61 % were married or partnered, and 33 % were diagnosed with ST-elevation myocardial infarction. Patients engaged in 7514±3355 steps per day and 44.6 ± 37.5 min of moderate-to-vigorous physical activity (MVPA). Patients who enrolled in CR exhibited higher daily step counts (p = 0.044), MVPA minutes (p = 0.001), and were more likely to meet PA guidelines. ACS patients who engaged in higher levels of MVPA were more likely to enrol in CR (odds ratio [OR] 1.46; 95 % confidence interval [CI] 1.08, 1.98). CR enrolment was also positively associated with being married or in an intimate partnership (OR 9.93; 95 % CI 1.83, 53.85) and absence of depressive symptoms (OR 11.86; 95 % CI 1.91, 73.74).

CONCLUSION

Lower CR enrolment rates were observed among less physically active patients at 4-weeks post-ACS. However, each 10 min increment in MVPA increased the odds of CR enrolment by 46 %. Future research should explore strategies to target this inactive and high-risk group, given the potential for a large prognostic gain with CR participation.

Acceptability, Preferred Medium, and Components of Nurse-Led Cardiac Telerehabilitation: A Cross-Sectional Study

Cardiac rehabilitation (CR) is a comprehensive and multidisciplinary secondary prevention care in coronary heart disease (CHD). There are barriers at the patient and health system levels that prevent CR from being utilized. Cardiac telerehabilitation led by nurses (Ne-CTR) can alleviate the obstacles to participation in CR. A patient perspective can improve CR access. This study was the first pre-program investigation to clarify the status of knowledge and participation in CTR. We sought to clarify the acceptability, the reasons for rejection, the desired form, components, and associated factors with the components needed for (Ne-CTR) in patients with CHD. The study aimed to help develop a protocol for Ne-CTR for Chinese patients with CHD. A cross-sectional study was conducted between 2020 and 2021. Hospitals in four provinces in China were included. The participants were 671 patients with CHD in hospitals located in three regions of China. A self-administered questionnaire collected information about demographics, knowledge, and participation in CTR, acceptability, preferred medium, and components of Ne-CTR. Student's t-test, analysis of variance, and multiple linear regression analyzed the factors associated with component needs. All the analyses were conducted using IBM SPSS version 25.0. Most participants (n = 434, 66.77%) had a poor understanding and participation in CTR. In addition, 65.38% (n = 439) of participants were willing to accept the Ne-CTR program, and 43.56% (n = 98) identified safety as reasons for not accepting such a program. In the group accepting Ne-CTR, 35% chose hospital-designed professional applications as a medium for Ne-CTR when offered. Education (4.44 ± 1.056) and drug information (4.44 ± 1.040) had the highest average need score. Education, monthly income, marital status, previous CTR participation, and health insurance were associated with the demand level scores of Ne-CTR. This study demonstrated high levels of need for Ne-CTR among patients with CHD and identified the desired medium, components, and associated factors of Ne-CTR. These findings provide reference information for the construction of a Ne-CTR program.

Comparisons of Patients Living Alone versus Living with Others in Acute Coronary Syndrome

We aimed to examine the relationship of living arrangements (i.e., living alone or living with others) with background, clinical severity, preintervention culprit lesion plaque morphology, and clinical outcomes in patients with acute coronary syndrome (ACS). Among 1,683 consecutive patients with ACS, we retrospectively compared patients living alone ( n  = 318) versus living with others ( n  = 1,362). Optical coherence tomography (OCT) findings, which are high-resolution intracoronary imaging devices, were analyzed in patients with preintervention OCT and compared between patients living alone ( n  = 174) versus those living with others ( n  = 665). Older (median; 69 vs. 67 y, p  = 0.046) and female (31 vs. 17%, p  < 0.001) patients more frequently lived alone. Frequency of achieving a time interval of 6 hours or less from ACS onset to admission was lower in patients living alone (56 vs. 63%, p  = 0.022). Clinical presentation was more severe in patients living alone (Killip II/III/IV; 27 vs. 22%, p  = 0.029). Plaque morphology evaluated by OCT was similar between groups (plaque rapture; 48 vs. 48%, p  = 0.171). Kaplan-Meier analyses revealed higher rates of cardiac mortality during 2-year follow-up period in patients living alone [13.9 vs. 8.5%, hazard ratio (HR) 1.604, 95% confidence interval (CI) 1.112-2.313, p  = 0.010]. After traditional cardiovascular risk factors and clinical severity upon admission had been adjusted, living alone was an independent predictor of cardiac mortality in ACS patients (HR 1.582, 95% CI 1.056-2.371, p  = 0.026). Living alone was independently associated with 2-year cardiacmortality in ACS patients after adjusting for background and presentation and might be unrelated to the development of atherosclerosis.

Trends in Unhealthy Lifestyle Factors among Adults with Stroke in the United States between 1999 and 2018

BACKGROUND: Unhealthy lifestyle factors are risk factors for stroke, and they play a key role in stroke secondary prevention. A better understanding of these factors may aid with improvements in public health policy. OBJECTIVE: Our objective was to comprehensively understand the trends in unhealthy lifestyle factors in people who have previously had a stroke in the US. METHODS: Utilizing data from the biannual United States National Health and Nutrition Examination Surveys (NHANESs) between 1999 and 2018, we collated data on unhealthy lifestyle factors (smoking, alcohol drinking, depression, unhealthy diet, high BMI, physical inactivity, and sedentary behavior) in adults with a history of stroke. The Joinpoint Regression model was used to calculate the annual percentage change (APC) and average annual percentage change (AAPC) to identify trends. Logistic regression modeling was used to identify the influence of sociodemographic factors (age, sex, race/ethnicity, marital status, employment status, family income, and highest education level). RESULTS: The analysis included 2017 respondents with a history of stroke. Current alcohol drinking (39.3% (95% confidence interval: 29.8, 48.7) to 57.4% (45.7, 69.0) p = 0.008) and obesity (39.2% (28.3, 50.2) to 49.4% (38.9, 59.8) p = 0.029) increased significantly from 1999 to 2018. The prevalence of smoking and depression remained generally stable. The proportion of respondents with an unhealthy diet decreased from 1999 (44.5% (32.4, 56.5)) to 2011 (29.0% (17.5, 40.4) p = 0.019), but then returned to its original prevalence in 2018 (42.0% (31.4, 52.7)). From 2007 to 2018, the proportion of respondents who were physically inactive decreased significantly, from 70.4% (64.4, 76.3) to 55.1% (46.1, 64.2; p = 0.017). After a gradual increase in sedentary activity from 2007 to 2012, this declined from 2013 to 2018, with no statistical significance. We found stroke survivors who were widowed, divorced, separated, or unemployed were at a higher risk of having unhealthy lifestyles than those who were employed or had other marital statuses. CONCLUSIONS: A modest reduction in the prevalence of physical inactivity was observed in Americans with a history of stroke between 1999 and 2018. The prevalences of smoking, drinking, depression, poor diet, obesity, and sedentary behavior were stable or increasing.

The Association between Marital Status and Outcomes of Patients Hospitalized with Heart Failure

BACKGROUND

Little is known about the association between marital status and long-term outcomes of patients hospitalized with heart failure (HF). We aimed to examine the association between marital status and early as well as long-term outcomes of patients hospitalized with HF.

METHOD

We analyzed data of 4089 patients hospitalized with HF and were enrolled in the multicenter national survey in Israel between March and April 2003 and were followed until December 2014. Patients were classified into married (N = 2462, 60%) and unmarried (N = 1627, 40%).

RESULTS

Married patients were more likely to be males, younger, and more likely to have past myocardial infarction and previous revascularization. Also, they tended to have higher rates of diabetes mellitus (DM) and dyslipidemia, as well as smokers. Survival analysis showed that unmarried patients had higher mortality rates at 1 and 10 years (33% vs. 25%, at 1 year, 89% vs. 80% at 10 years, all p < 0.001). Consistently, multivariable analysis showed that unmarried patients had independently 44% and 35% higher risk of mortality at 1- and 10-year follow-up respectively (1-year HR = 1.44; 95%CI 1.14-1.81; p = 0.002, 10-year HR = 1.35; 95%CI 1.19-1.53; p ≤ 0.001). Other consistent predictors of mortality at both 1- and 10-year follow-up include age, renal failure, and advanced HF.

CONCLUSIONS

Being unmarried is independently associated with worse short- and long-term outcomes, particularly among women. Thus, attempts to intensify secondary preventive measures should focus mainly on unmarried patients and mainly women.

Intimate Relationships and Coronary Heart Disease: Implications for Risk, Prevention, and Patient Management

PURPOSE OF REVIEW

Research and clinical services addressing psychosocial aspects of coronary heart disease (CHD) typically emphasize individuals, focusing less on the context of intimate relationships such as marriage and similar partnerships. This review describes current evidence regarding the role of intimate relationships in the development, course, and management of CHD.

RECENT FINDINGS

Having an intimate partner is associated with reduced risk of incident CHD and a better prognosis among patients, but strain (e.g., conflict) and disruption (i.e., separation, divorce) in these relationships are associated with increased risk and poor outcomes. These associations likely reflect mechanisms involving health behavior and the physiological effects of emotion and stress. Importantly, many other well-established psychosocial risk and protective factors (e.g., low SES, job stress, depression, and optimism) are strongly related to the quality of intimate relationships, and these associations likely contribute to the effects of those other psychosocial factors. For better or worse, intimate partners can also affect the outcome of efforts to alter health behaviors (physical activity, diet, smoking, and medication adherence) central in the prevention and management CHD. Intimate partners also influence-and are influenced by-stressful aspects of acute coronary crises and longer-term patient adjustment and management. Evidence on each of these roles of intimate relationships in CHD is considerable, but direct demonstrations of the value of couple assessments and interventions are limited, although preliminary research is promising. Research needed to close this gap must also address issues of diversity, disparities, and inequity that have strong parallels in CHD and intimate relationships.

Epidemiologic and viral predictors of antiretroviral drug resistance among persons living with HIV in a large treatment program in Nigeria

BACKGROUND

Expanded access to combination antiretroviral therapy (cART) throughout sub-Saharan Africa over the last decade has remarkably improved the prognosis of persons living with HIV (PLWH). However, some PLWH experience virologic rebound after a period of viral suppression, usually followed by selection of drug resistant virus. Determining factors associated with drug resistance can inform patient management and healthcare policies, particularly in resource-limited settings where drug resistance testing is not routine.

METHODS

A case-control study was conducted using data captured from an electronic medical record in a large treatment program in Nigeria. Cases PLWH receiving cART who developed acquired drug resistance (ADR) and controls were those without ADR between 2004 and 2011. Each case was matched to up to 2 controls by sex, age, and education. Logistic regression was used estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with ADR.

RESULTS

We evaluated 159 cases with ADR and 299 controls without ADR. In a multivariate model, factors associated with ADR included older age (OR = 2.35 [age 30-40 years 95% CI 1.29, 4.27], age 41 + years OR = 2.31 [95% CI 1.11, 4.84], compared to age 17-30), higher education level (secondary OR 2.14 [95% CI 1.1.11-4.13]), compared to primary and tertiary), non-adherence to care (OR = 2.48 [95% CI 1.50-4.00]), longer treatment duration (OR = 1.80 [95% CI 1.37-2.35]), lower CD4 count((OR = 0.95 [95% CI 0.95-0.97]) and higher viral load (OR = 1.97 [95% CI 1.44-2.54]).

CONCLUSIONS

Understanding these predictors may guide programs in developing interventions to identify patients at risk of developing ADR and implementing prevention strategies.

Impact of Marital Status on the Outcome of Acute Coronary Syndrome: Results From the Acute Coronary Syndrome Israeli Survey

Background

Marriage is one of the common forms of social support. Conflicting evidence exists about the impact of marital status on the outcomes of patients with acute coronary syndrome (ACS). It is further not clear if sex disparity exists in the outcome of married and nonmarried patients with ACS.

Methods and Results

Data from the ACS Israeli Survey, collected between 2004 and 2016, were used to compare baseline characteristics, clinical indexes, and outcomes of married and nonmarried patients with ACS. Cox regression analysis and propensity score matching were used to explore if marital status was independently associated with long‐term outcome. Of 7233 patients included with reported marital status, 5643 (78%) were married. Married patients were younger (62.69±12.07 versus 68.47±14.84 years; P<0.001), more frequently men (83.1% versus 54.8%; P<0.001), and less likely to be hypertensive (61.1% versus 69.3%; P<0.001). All‐cause mortality incidence at 30 days and at 1 year was lower in married patients (3.1% versus 7.6% [P<0.001]; and 7.1% versus 15.3% [P<0.001], respectively). After adjusting for multiple covariates, the hazard ratio for 5‐year all‐cause mortality for married patients was 0.74 (95% CI, 0.62–0.88). Similar results were observed after propensity score matching. Kaplan‐Meier estimates for all‐cause mortality at 5 years demonstrated the best prognosis for married men and the worst for nonmarried women.

Conclusions

Marriage is independently associated with better short‐ and long‐term outcomes across the spectrum of ACS. Attempts to intensify secondary prevention measures should focus on nonmarried patients and especially nonmarried women.

Interplay of Self-efficacy and Social Support in Predicting Quality of Life in Cardiovascular Patients in Pakistan

The primary objective of the present study was to assess independent and interactive relations of perceived social support and self-efficacy with four quality of life (QOL) domains namely physical, psychological, social, and environmental in cardiovascular disease (CVD) patients from a South Asian region. Participants were 172 (age 22-60 years) patients recruited from three major government sector hospitals from the fifth biggest city of South Asia. It was found that overall CVD patients had a better QOL in psychological and environmental domains compared to social and psychological. Furthermore, findings from hierarchical regression analyses indicated that perceived social support and self-efficacy were positively associated with the four QOL domains. Besides main effects, a synergistic interaction between social support and self-efficacy emerged indicating that perceived social support was strongly associated with physical and social QOL in CVD patients who had higher self-efficacy levels, while, perceived social support was weakly associated with the physical and social QOL in CVD patients who had lower self-efficacy levels.

Marital status and outcomes in patients with cardiovascular disease

The national burden of cardiovascular disease (CVD) continues to impose significant risk of morbidity, mortality and increased costs. While traditional risk factors have been well-established, the evolving role of non-traditional risk factors, including socioeconomic and psychosocial factors, is increasingly being recognized. Several studies have acknowledged an association between marital status and the presence of CVD and its associated adverse outcomes. Across multiple U.S. and international cohorts, patients who are unmarried, including those who are divorced, separated, widowed, or never married, have an increased rate of adverse cardiovascular events when compared to their married counterparts. Some studies suggest that marriage may have a more protective role for men compared to women. Furthermore, dissatisfaction in a marriage and marriage quality have significant impact on cardiovascular risk. Psychosocial and socioeconomic factors, as well as other acute stressors, may contribute to the association between marital status and CVD outcomes, but the underlying mechanisms are not completely clear. Further investigation is required to identify potential targets for intervention and to determine whether more aggressive targeting of standard anti-atherosclerotic therapies can favorably impact CVD risk in unmarried patients.

Factors influencing change in walking ability in patients with heart failure undergoing exercise-based cardiac rehabilitation

OBJECTIVES

Exercise-based cardiac rehabilitation (CR) is an effective intervention for patients with heart failure (HF), in which one of the main targets is to increase physical capacity. In the HF population this is traditionally assessed using distance covered during a walking test. This study aims to establish the extent to which change in walking ability, in HF patients attending CR, is determined by patient characteristics and service provision.

METHODS

The study utilised routine clinical data from the National Audit of Cardiac Rehabilitation to perform a robust analysis. Change, in metres, between pre- and post-CR six-minute walk tests was calculated. Multivariate linear regression models were used to explore the relationship between patient characteristics, service-level variables, and change in metres walked.

RESULTS

Complete and valid data from 633 patients was analysed, and a mean change of 51.30 m was calculated. Female gender (-34.13 m, p = 0.007), being retired (-36.41 m, p = 0.001) and being married/in a relationship (-32.54 m, p = 0.023) were all significant negative predictors of change. There was an additional negative relationship with body mass index (BMI) whereby for every unit increase in BMI, predicted change reduces by 2.48 m (p = 0.006).

CONCLUSIONS

This study identified significant patient-level characteristics strongly associated with limited improvement in walking ability following CR. Improving physical capacity is a core component of CR, therefore services should aim to account for baseline characteristics identified in this study as part of tailoring the CR intervention around the individual. Pre- and post-CR physical capacity assessments, which constitute minimum standards for CR, are worryingly low and should be given high priority.

Socioeconomic status predicts second cardiovascular event in 29,226 survivors of a first myocardial infarction

Background

Risk assessment post-myocardial infarction needs improvement, and risk factors derived from general populations apply differently in secondary prevention. The prediction of subsequent cardiovascular events post-myocardial infarction by socioeconomic status has previously been poorly studied.

Design

Swedish nationwide cohort study.

Methods

A total of 29,226 men and women (27%), 40–76 years of age, registered at the standardised one year revisit after a first myocardial infarction in the secondary prevention quality registry of SWEDEHEART 2006–2014. Personal-level data on socioeconomic status measured by disposable income and educational level, marital status, and the primary endpoint, first recurrent event of atherosclerotic cardiovascular disease, defined as non-fatal myocardial infarction or coronary heart disease death or fatal or non-fatal stroke were obtained from linked national registries.

Results

During the mean 4.1-year follow-up, 2284 (7.8%) first recurrent manifestations of atherosclerotic cardiovascular disease occurred. Both socioeconomic status indicators and marital status were associated with the primary endpoint in multivariable Cox regression models. In a comprehensively adjusted model, including secondary preventive treatment, the hazard ratio for the highest versus lowest quintile of disposable income was 0.73 (95% confidence interval 0.62–0.83). The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was stronger in men as was the risk associated with being unmarried (tests for interaction P < 0.05).

Conclusions

Among one year survivors of a first myocardial infarction, first recurrent manifestation of atherosclerotic cardiovascular disease was predicted by disposable income, level of education and marital status. The association between disposable income and first recurrent manifestation of atherosclerotic cardiovascular disease was independent of secondary preventive treatment but further study on causal pathways is needed.

Social inequality in phase II cardiac rehabilitation attendance: The impact of potential mediators

BACKGROUND

Cardiac rehabilitation participation is an essential component of the contemporary management of coronary heart disease. However, patients with low socioeconomic position are less likely to attend the rehabilitation programme.

AIM

We aimed to explore the effect of potential mediators between socioeconomic position defined by educational attainment and cardiac rehabilitation attendance.

METHODS

Prospective observational study of patients with acute coronary syndrome ( N=302). Logistic regression and mediation analysis was conducted to explore mechanisms of non-attendance.

RESULTS

Thirty per cent attended full cardiac rehabilitation. Patients with low educational attainment, comorbidities, long commute to cardiac rehabilitation centre, and lone dwelling were less likely to attend full cardiac rehabilitation, whereas patients with high anxiety and depression score were more likely to attend full cardiac rehabilitation. Patients with low educational attainment had lower self-efficacy and longer commute compared with patients with high educational attainment. The potential mediators included in the study, however, did not have a significant mediation effect.

CONCLUSION

Our study demonstrated a variety of mechanisms contributing to cardiac rehabilitation non-attendance. Further, the study demonstrated that non-attendance was especially related to the cardiac rehabilitation elements involving lifestyle modifications. However, the mechanisms explaining social inequality in full cardiac rehabilitation are still not fully understood.

Divorce and Severity of Coronary Artery Disease: A Multicenter Study

The association between marital status and coronary artery disease (CAD) is supported by numerous epidemiological studies. While divorce may have an adverse effect on cardiac outcomes, the relationship between divorce and severe CAD is unclear. We conducted a multicenter, observational study of consecutive patients undergoing coronary angiography during the period between April 1, 2013, and March 30, 2014. Of 1,068 patients, 124 (12%) were divorced. Divorce was more frequent among women (27%) compared to men (6%). Most divorced patients had been divorced only once (49%), but a subset had been divorced 2 (38%) or ≥3 (12%) times. After adjusting for baseline differences, there was no significant association between divorce and severe CAD in men. In women, there was a significant adjusted association between divorce and severe MVD (OR 2.31 [1.16, 4.59]) or LMD (OR 5.91 [2.19, 15.99]). The modification of the association between divorce and severe CAD by gender was statistically significant for severe LMD (Pinteraction 0.0008) and marginally significant for CAD (Pinteraction 0.05). Among women, there was a significant adjusted association between number of divorces and severe CAD (OR 2.4 [95% CI 1.2, 4.5]), MVD (OR 2.0 [95% CI 1.4, 3.0]), and LMD (OR 3.4 [95% CI 1.9, 5.9]). In conclusion, divorce, particularly multiple divorces, is associated with severe CAD, MVD, and LMD in women but not in men.

Widowhood and severity of coronary artery disease: a multicenter study

OBJECTIVES

The aim of this study was to assess the association of widowhood with the severity and extent of coronary artery disease (CAD), and whether it is modified by sex or socioeconomic status.

PATIENTS AND METHODS

A total of 1068 patients undergoing coronary angiography at five centers in Saudi Arabia and the United Arab Emirates were included in the study. CAD was defined as more than 70% lumen stenosis in a major epicardial vessel or more than 50% in the left main coronary artery. Multivessel disease was defined as more than one diseased vessel.

RESULTS

Of 1068 patients, 65 (6%) were widowed. Widowed patients were older (65±15 vs. 59±12), more likely to be female (75 vs. 25%), less likely to be smokers (18 vs. 47%), of lower economic and education status, and more likely to have undergone coronary angiography for urgent/emergent indications (75 vs. 61%) (P<0.05 for all). There was a significant association between widowhood and the number of coronary arteries with more than 70% lumen stenosis. Consequently, such a high degree of lumen stenosis in those who were widowed was more likely to require coronary artery bypass graft surgery (38 vs. 16%; P<0.01). After adjusting for baseline differences, widowhood was associated with a significantly higher odds of CAD [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI) 1.2-10.5] and multivessel disease (adjusted OR 4.6; 95% CI 2.2-9.6), but not left main disease (adjusted OR 1.3; 95% CI 0.5-3.1). All associations were consistent in men and women and not modified by age, community setting (urban vs. rural), employment, income, or educational levels (Pinteraction>0.1 for all).

CONCLUSION

Widowhood is associated with the severity and extent of CAD. The association is not modified by sex or socioeconomic status.

Experience of exclusion: A framework analysis of socioeconomic factors affecting cardiac rehabilitation participation among patients with acute coronary syndrome

Background:

The Danish public healthcare system provides comprehensive care based on the principle of equal access. However, it is well documented that patients with low socioeconomic position are less likely to participate in cardiac rehabilitation. More knowledge is needed to understand this phenomenon. The aim of the study was to explore the patient experience of barriers to completion of phase II cardiac rehabilitation, and to investigate the impact of socioeconomic factors on completion of cardiac rehabilitation.

Methods:

The study had a qualitative explorative design using semi-structured individual or dyadic interviews with patients ( n = 24) and close relatives ( n = 12). Informants were sampled from a quantitative prospective study of 302 patients with acute coronary syndrome and data were analyzed using the framework method.

Results:

Patients in different socioeconomic groups were challenged by a rigid and non-individualized rehabilitation program. A total of five themes were identified that might explain non-participation in cardiac rehabilitation: exclusion by time and place, exclusion by health beliefs, exclusion from counseling, exclusion by alienation, and exclusion of relatives. The themes were described in a matrix of socioeconomic factors of age, sex, education and employment.

Conclusions:

Patients in various socioeconomic subgroups felt excluded from cardiac rehabilitation for different reasons. This study supports earlier findings and provides examples of real-life issues that need to be addressed to prevent attrition and encourage participation. Equal access to cardiac rehabilitation can only be reached if the physical and psychological needs of patient and family are met by tailoring therapy to consider age, sex, education and employment groups.

Polygamy and Risk of Coronary Artery Disease in Men Undergoing Angiography: An Observational Study

Epidemiologic evidence suggests a link between psychosocial risk factors such as marital status and coronary artery disease (CAD). Polygamy (multiple concurrent wives) is a distinct marital status practiced in many countries in Asia and the Middle East, but its association with CAD is not well defined. We conducted a multicenter, observational study of consecutive patients undergoing coronary angiography during the period from April 1, 2013, to March 30, 2014. Of 1,068 enrolled patients, 687 were married men. Polygamy was reported in 32% of married men (1 wife: 68%, 2 wives: 19%, 3 wives: 10%, and 4 wives: 3%). When stratified by number of wives, significant baseline differences were observed in age, type of community (rural versus urban), prior coronary artery bypass grafting (CABG), and household income. After adjusting for baseline differences, there was a significant association between polygamy and CAD (adjusted OR 4.6 [95% CI 2.5, 8.3]), multivessel disease (MVD) (adjusted OR 2.6 [95% CI 1.8, 3.7]), and left main disease (LMD) (adjusted OR 3.5 [95% CI 2.1, 5.9]). Findings were consistent when the number of wives was analyzed as a continuous variable. In conclusion, among married men undergoing coronary angiography for clinical indications, polygamy is associated with the presence of significant CAD, MVD, and LMD.

Marital Status, Cardiovascular Diseases, and Cardiovascular Risk Factors: A Review of the Evidence

BACKGROUND

There is evidence showing that marital status (MS) and marital disruption (i.e., separation, divorce, and being widowed) are associated with poor physical health outcomes, including for all-cause mortality. We checked for the available evidence on the association between MS and cardiovascular (CV) diseases, outcomes, and CV risk factors.

METHODS

A search across the PubMed database of all articles, including the term "marital status" in their title, was performed. All articles were then manually checked for the presence of the following terms or topic: CV diseases, acute myocardial infarction, acute coronary syndrome, coronary artery disease, cardiac arrest, heart failure, heart diseases, and CV mortality. Moreover, other search terms were: CV risk factors, hypertension, cholesterol, obesity, smoking, alcohol, fitness and/or physical activity, and health. Systematic reviews, meta-analyses, controlled trials, cohort studies, and case-control studies were potentially considered pertinent for inclusion. Case reports, comments, discussion letters, abstracts of scientific conferences, articles in other than English language, and conference abstracts or proceedings were excluded.

RESULTS

In total, 817 references containing the title words "marital status" were found. After elimination of articles dealing with other topics, 70 records were considered pertinent. Twenty-two were eliminated for several reasons, such as old articles, no abstract, full text unavailable, other than English language, comments, and letters. Out of the remaining 48 articles, 13 were suitable for the discussion, and 35 (accounting for 1,245,967 subjects) were included in this study.

CONCLUSIONS

Most studies showed better outcomes for married persons, and men who were single generally had the poorest results. Moreover, being married was associated with lower risk factors and better health status, even in the presence of many confounding effects.

Marital History and Survival After Stroke

BACKGROUND

Stroke is among the leading causes of disability and death in the United States, and nearly 7 million adults are currently alive after experiencing a stroke. Although the risks associated with having a stroke are well established, we know surprisingly little about how marital status influences survival in adults with this condition. This study is the first prospective investigation of how marital history is related to survival after stroke in the United States.

METHODS AND RESULTS

Data from a nationally representative sample of older adults who experienced a stroke (n=2351) were used to examine whether and to what extent current marital status and past marital losses were associated with risks of dying after the onset of disease. Results showed that the risks of dying following a stroke were significantly higher among the never married (hazard ratio [HR], 1.71; 95% CI, 1.31–2.24), remarried (HR, 1.23; 95% CI, 1.06–1.44), divorced (HR, 1.23; 95% CI, 1.01–1.49), and widowed (HR, 1.25; 95% CI, 1.10–1.43) relative to those who remained continuously married. We also found that having multiple marital losses was especially detrimental to survival-regardless of current marital status and accounting for multiple socioeconomic, psychosocial, behavioral, and physiological risk factors.

CONCLUSIONS

Marital history is significantly associated with survival after stroke. Additional studies are needed to further examine the mechanisms contributing to the associations and to better understand how this information can be used to personalize care and aggressively treat vulnerable segments of the population.

"I'm No Superman": Understanding Diabetic Men, Masculinity, and Cardiac Rehabilitation

Exercise-based cardiac rehabilitation (CR) programs help patients with coronary heart disease (CHD) reduce their risk of recurrent cardiac illness, disability, and death. However, men with CHD and Type 2 diabetes mellitus (T2DM) demonstrate lower attendance and completion of CR despite having a poor prognosis. Drawing on gender and masculinity theory, we report on a qualitative study of 16 Canadian diabetic men recently enrolled in CR. Major findings reflect two discursive positions men assumed to regain a sense of competency lost in illness: (a) working with the experts, or (b) rejection of biomedical knowledge. These positions underscore the varied and sometimes contradictory responses of seriously ill men to health guidance. Findings emphasize the priority given to the rehabilitation of a positive masculine identity. The analysis argues that gender, age, and employment status are powerful mechanisms of variable CR participation.

Association between divorce and risks for acute myocardial infarction

BACKGROUND

Divorce is a major life stressor that can have economic, emotional, and physical health consequences. However, the cumulative association between divorce and risks for acute myocardial infarction (AMI) is unknown. This study investigated the association between lifetime exposure to divorce and the incidence of AMI in US adults.

METHODS AND RESULTS

We used nationally representative data from a prospective cohort of ever-married adults aged 45 to 80 years (n=15,827) who were followed biennially from 1992 to 2010. Approximately 14% of men and 19% of women were divorced at baseline and more than one third of the cohort had ≥1 divorce in their lifetime. In 200,524 person-years of follow-up, 8% (n=1211) of the cohort had an AMI and age-specific rates of AMI were consistently higher in those who were divorced compared with those who were continuously married (P<0.05). Results from competing-risk hazard models showed that AMI risks were significantly higher in women who had 1 divorce (hazard ratio, 1.24; 95% confidence interval, 1.01-1.55), ≥2 divorces (hazard ratio, 1.77; 95% confidence interval, 1.30-2.41), and among the remarried (hazard ratio, 1.35; 95% confidence interval, 1.07-1.70) compared with continuously married women after adjusting for multiple risk factors. Multivariable-adjusted risks were elevated only in men with a history of ≥2 divorces (hazard ratio, 1.30; 95% confidence interval, 1.02-1.66) compared with continuously married men. Men who remarried had no significant risk for AMI. Interaction terms for sex were not statistically significant.

CONCLUSIONS

Divorce is a significant risk factor for AMI. The risks associated with multiple divorces are especially high in women and are not reduced with remarriage.

Secondary prevention of acute coronary syndrome. Socio-economic and lifestyle determinants: a literature review

Although cardiovascular disease mortality rates seem to decline, especially among middle-aged people in developed countries, the prevalence of acute coronary syndrome (ACS) increases, representing the most common cause of morbidity in both developed and developing countries and generating large economic burden. It is estimated that one fifth of the ACS patients die suddenly and half of them belong to a fast growing popula- tion age-group, i.e., those between 70 and .80 years. A substantial number of these deaths has been attributed to various lifestyles, modifiable factors; therefore, it can be prevented. However, factors such as dietary habits and behaviours, physical activity, life stress and smoking habits, although thoroughly discussed, are not well understood and appreciated in the spectrum of secondary ACS prevention. The latter deserves further attention under the prism of socio-economic status that has changed dramatically in the last years in some populations. The aim of this review was to discuss the role of lifestyle factors on secondary ACS prevention under the prism of individual's socio-economic status. Based on the retrieved information it was revealed that there is vast evidence that secondary prevention of cardiovascular events cannot be accomplished simply through medical treatment, but it requires a multifaceted approach incorporating lifestyle modifications, too. Therefore, public health policy endeavours should be directed towards multifocal strategies, i.e., to motivate and support cardiac patients to consistently follow treatment regimens and to establish more effective and efficient community lifestyle interventions.

Psychosocial experiences in the context of life-threatening illness: The cardiac rehabilitation patient

Objective:

One of the most prevalent life-threatening illnesses is heart disease. The initial trauma of being diagnosed with a life-threatening illness or having a cardiac event can begin a psychosocial chain reaction that results in a transformation of the lives of these patients. The goal of our study was to investigate the lived experiences of psychosocial healing in rehabilitation of cardiac patients using a qualitative written interview.

Method:

A purposive sample of 14 cardiac event survivors was recruited. Participants were interviewed after informed consent and screening. We used a qualitative analysis and model-revision approach similar to the procedure outlined by Charmaz (2006).

Results:

Participants consistently mentioned that a heightened awareness of mortality was a motivating factor that led to participants focusing more on their family and relationships, having an enhanced outlook on life, and making healthy lifestyle changes.

Significance of results:

If clinicians are able to employ a measure to better understand the nature of a patient's progression from cardiac event to successful recovery, interventions such as cardiac rehabilitation can be implemented earlier and more effectively during the course of the illness and recovery phases of treatment. Theoretically, this early detection of a patient's progression could reduce the time spent recovering from a cardiac event, and it would allow treatments for these conditions to better alleviate the psychosocial concerns faced by patients.

Factors that affect readiness to change lifestyle: a 22-country survey from primary care

BACKGROUND

The family physician's task in prevention is not only an assessment of patients' health risks but also counselling individual patients.

AIM

Aim of this primary care based study was to find how patients' characteristics relate to their readiness to change.

METHODS

This multinational cross-sectional survey was conducted in primary care in 22 European countries, coordinated by EUROPREV. Consecutive attenders from randomly selected family practices answered a questionnaire about attitudes towards prevention and about lifestyle.

RESULTS

The questionnaire was answered by 7947 patients in 224 primary care practices in 22 European countries. Smoking was reported by 828 women (23.2%) versus 1238 (32.57%) men, unhealthy diet by 637 (11.6%) women versus 830 men (17.62%), risky alcohol consumption by 348 women (8.19%) versus 1009 men (23.07%) and the lack of physical activity by 617 women (12.68%) versus 614 men (16.45%). The need for change was declared by 432 (31.8%) of 1357 risky drinkers, 612 (29.6%) of 2066 smokers, 1210 (82.4%) of 1467 patients with unhealthy diet and by 2456 (30.9%) of all participants, 1231 of them were not physically active at all. Among patients with unhealthy dietary habits, 681 (56.3%) were confident of successfully changing their behaviour, among physically inactive it was 1561 (63.6 %), among smokers 284 (46.4%), and among risky drinkers 214 (49.5%).

CONCLUSION

More likely to be ready to change unhealthy lifestyles are frequent attenders, European Union citizens, women and patients under 50 years of age.

Marital status and ischemic heart disease incidence and mortality in women: a large prospective study

BACKGROUND

Being married has been associated with a lower mortality from ischemic heart disease (IHD) in men, but there is less evidence of an association for women, and it is unclear whether the associations with being married are similar for incident and for fatal IHD. We examined the relation between marital status and IHD incidence and mortality in the Million Women Study.

METHODS

A total of 734,626 women (mean age 60 years) without previous heart disease, stroke or cancer, were followed prospectively for hospital admissions and deaths. Adjusted relative risks (RRs) for IHD were calculated using Cox regression in women who were married or living with a partner versus women who were not. The role of 14 socio-economic, lifestyle and other potential confounding factors was investigated.

RESULTS

81% of women reported being married or living with a partner and they were less likely to live in deprived areas, to smoke or be physically inactive, but had a higher alcohol intake than women who were not married or living with a partner. During 8.8 years of follow-up, 30,747 women had a first IHD event (hospital admission or death) and 2,148 died from IHD. Women who were married or living with a partner had a similar risk of a first IHD event as women who were not (RR = 0.99, 95% confidence interval (CI) 0.96 to 1.02), but a significantly lower risk of IHD mortality (RR = 0.72, 95% CI 0.66 to 0.80, P <0.0001). This lower risk of IHD death was evident both in women with and without a prior IHD hospital admission (respectively: RR = 0.72, 95% CI 0.60 to 0.85, P <0.0001, n = 683; and 0.70, 95% CI 0.62 to 0.78, P <0.0001, n = 1,465). These findings did not vary appreciably between women of different socio-economic groups or by lifestyle and other factors.

CONCLUSIONS

After adjustment for socioeconomic, lifestyle and other factors, women who were married or living with a partner had a similar risk of developing IHD but a substantially lower IHD mortality compared to women who were not married or living with a partner.

Relation of patients living without a partner or spouse to being physically active after acute coronary syndromes (from the PULSE accelerometry substudy)

Living alone is associated with adverse outcomes after acute coronary syndromes (ACS). One potential mediator of the relation between partner status and outcomes after ACS is physical activity. To evaluate the association of partner status with physical activity after ACS, data from 107 participants enrolled in the Prescription Use, Lifestyle, and Stress Evaluation (PULSE) study, a prospective observational study of post-ACS patients, were analyzed. Accelerometers were used to measure physical activity after hospital discharge. The primary outcome measure was a maximum 10 hours of daytime activity 1 month after discharge. One month after discharge from ACS hospitalizations, participants without a partner or spouse exhibited 24.4% lower daytime activity than those with a partner or spouse (p = 0.003). After controlling for age, gender, body mass index, Charlson co-morbidity index, and traditional psychosocial and clinical cardiovascular correlates of post-ACS physical activity, partner status remained an independent predictor of post-ACS physical activity (20.5% lower daytime activity among those without a partner or spouse, p = 0.008). In conclusion, in this study of accelerometer-measured physical activity after an ACS hospitalization, those without a partner or spouse exhibit significantly less physical activity than those with a partner or spouse 1 month after discharge from the hospital. Low physical activity may be an important mediator of the prognosis associated with partner status after ACS.

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

BACKGROUND

Healthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes.

METHODS

A systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework.

RESULTS

374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes.

CONCLUSION

There are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support.

Primary relationships, HIV treatment adherence, and virologic control

To identify factors associated with antiretroviral therapy (ART) adherence and virologic control among HIV-positive men on ART in primary relationships, data were collected from 210 male couples (420 men). Dyadic actor-partner analyses investigated associations with three levels of adherence-related dependent variables: self-efficacy (ASE), self-reported adherence, and virologic control. Results indicated that higher patient ASE was related to his own positive beliefs about medications, higher relationship autonomy and intimacy, and fewer depressive symptoms. Fewer depressive symptoms and less relationship satisfaction in the partner were linked to higher ASE in the patient. Better self-reported adherence was related to the patient's positive appraisal of the relationship and the partner's positive treatment efficacy beliefs. Greater medication concerns of both patient and partner were associated with less adherence. The partner's higher relationship commitment was associated with lower viral load in the patient. Findings suggest that depressive symptoms, treatment beliefs, and relationship quality factors of both partners may influence adherence-related outcomes.

Tai Chi as an adjunct physical activity for adults aged 45 years and older enrolled in phase III cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation improves physical, cognitive and psychosocial functioning, yet services are greatly underutilized with increasing patterns of attrition over time. Tai Chi has been suggested as a possible adjunct to cardiac rehabilitation exercise training.

AIM

To describe differences in physical, cognitive and psychosocial functioning among adults ≥ 45 years old attending phase III cardiac rehabilitation, who have or have not self-selected Tai Chi exercise as an adjunct physical activity.

METHODS

A cross-sectional design compared subjects attending group-based Wu style Tai Chi classes plus cardiac rehabilitation, with cardiac rehabilitation only. Subjects had a battery of physical and cognitive functioning tests administered to examine aerobic endurance, balance, strength, and flexibility, verbal retrieval/recall, attention, concentration and tracking. Subjects completed a health survey to ascertain cardiac event information, medical history, and psychosocial functioning (i.e. health-related quality of life, stress, depressive symptoms, social support, and Tai Chi self-efficacy).

RESULTS

A total of 51 subjects (75% married, 84% college-educated, 96% White/European-American) participated. Subjects were on average 70 (± 8) years old and had attended cardiac rehabilitation for 45 (± 37) months. Approximately 45% (n = 23) attended Tai Chi classes plus cardiac rehabilitation, while 55% (n = 28) attended cardiac rehabilitation only. Subjects attending Tai Chi plus cardiac rehabilitation had better balance, perceived physical health, and Tai Chi self-efficacy compared to those attending cardiac rehabilitation only (p ≤ 0.03).

CONCLUSION

Tai Chi can be easily implemented in any community/cardiac rehabilitation facility, and may offer adults additional options after a cardiac event.

Social network resources and management of hypertension

Hypertension is one of the most prevalent chronic diseases among older adults, but rates of blood pressure control are low. In this article, we explore the role of social network ties and network-based resources (e.g., information and support) in hypertension diagnosis and management. We use data from the National Social Life, Health, and Aging Project to identify older adults with undiagnosed or uncontrolled hypertension. We find that network characteristics and emotional support are associated with hypertension diagnosis and control. Importantly, the risks of undiagnosed and uncontrolled hypertension are lower among those with larger social networks-if they discuss health issues with their network members. When these lines of communication are closed, network size is associated with greater risk for undiagnosed and uncontrolled hypertension. Health care utilization partially mediates associations with diagnosis, but the benefits of network resources for hypertension control do not seem to stem from health-related behaviors.

The shifting landscape of health care: toward a model of health care empowerment

In a rapidly changing world of health care information access and patients' rights, there is limited conceptual infrastructure available to understand how people approach and engage in treatment of medical conditions. The construct of health care empowerment is defined as the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty regarding health care. I present a model in which health care empowerment is influenced by an interplay of cultural, social, and environmental factors; personal resources; and intrapersonal factors. The model offers a framework to understand patient and provider roles in facilitating health care empowerment and presents opportunities for investigation into the role of health care empowerment in multiple outcomes across populations and settings, including inquiries into the sources and consequences of health disparities.

Marital status and heart rate variability in patients with suspected coronary artery disease

BACKGROUND

Married individuals are at reduced risk of cardiovascular disease morbidity and mortality. Recent research indicates that impaired heart rate variability (HRV) may contribute to cardiovascular disease morbidity and mortality and has also been associated with social isolation.

PURPOSE

We investigated associations between HRV and marital status in patients with suspected coronary artery disease (CAD).

METHODS

Eighty-eight patients who were being investigated for suspected CAD (28 women, 60 men, mean age 61.6, 60% married) were recruited from three rapid access chest pain clinics in London. Heart rate variability was measured using 24-h electrocardiograms and analyzed using frequency and time-domain measures.

RESULTS

Unmarried marital status was associated with reduced heart rate variability as indexed by both frequency and time-domain measures, independently of age, gender, beta-blocker use, depression ratings, and subsequent diagnosis of significant CAD.

CONCLUSION

These findings suggest that reduced heart rate variability is associated with not being married and may contribute to the reliably observed relationship between marital status and cardiovascular disease morbidity and mortality.

Marital status, gender and cardiovascular mortality: behavioural, psychological distress and metabolic explanations

The intermediate processes through which the various unmarried states can increase the risk of subsequent cardiovascular disease mortality are incompletely understood. An understanding of these processes and how they may vary by gender is important for understanding why marital status is strongly and robustly associated with subsequent cardiovascular disease. In a prospective study of 13,889 Scottish men and women (mean age 52.3, Standard Deviation: 11.8 yrs, range 35–95, 56.1% female) without a history of clinically diagnosed cardiovascular disease, we examined the extent to which health behaviours (smoking, alcohol, physical activity), psychological distress (General Health Questionnaire-12 item) and metabolic dysregulation (obesity levels, and the presence of hypertension and diabetes) account for the association between marital status and cardiovascular mortality. There were 258 cardiovascular deaths over an average follow up of 7.1 (Standard Deviation = 3.3) years. The risk of cardiovascular mortality was greatest in single, never married men and separated/divorced women compared with those that were married in gender stratified models that were adjusted for age and socio-economic group. In models that were separately adjusted, behavioural factors explained up to 33%, psychological distress explained up to 10% and metabolic dysregulation up to 16% of the relative change in the hazard ratios in the observed significant associations between marital status and cardiovascular mortality. Behavioural factors were particularly important in accounting for the relationship between being separated/divorced and cardiovascular mortality in both men and women (33% and 21% of the relative change in the hazard ratios, respectively). The findings suggest that health behaviour, psychological distress and metabolic dysregulation data have varying explanatory power for understanding the observed relationship between cardiovascular disease mortality and unmarried states.

Cardiac rehabilitation: Adding years to life and life to years

Abstract

Cardiac rehabilitation is an integral component of comprehensive cardiac care and is effective in reducing morbidity and mortality and improving quality of life. However, despite a 50-year-history and extensive evidence base attesting to its clinical and cost-effectiveness, including adding years to life and life to years, and exhortations that its implementation should be a key priority, the majority of cardiac patients do not receive rehabilitation. There is a comparative dearth of funding and wide variation in service provision, with a health care system that often fails to address issues such as sub-optimal referral, enrolment and completion, particularly amongst certain potential user groups that could benefit. This paper reviews these issues and suggests ways of overcoming the obstacles identified. It also highlights some of the knowledge gaps and areas that warrant further research.