A randomised controlled trial on the effectiveness of a home-based self-management programme for community-dwelling patients with myocardial infarction

Effectiveness of micro-lecture based cardiac rehabilitation education on health status in individuals with coronary artery disease: A randomized clinical trial

OBJECTIVE

To explore the effectiveness of the micro-lecture education on the ability of self-management and lifestyle changes in patients with coronary artery disease.

DESIGN

A randomized control trial with a 12-week follow-up.

SETTING

Cardiology wards of a large Chinese University Hospital.

SUBJECTS

One hundred eligible inpatients with coronary artery disease were recruited.

INTERVENTION

Intervention group received the micro-lecture education, while the control group received the traditional cardiac rehabilitation education.

MAIN MEASURES

Primary outcome of the ability of coronary self-management was assessed by the Coronary self-management scaleat baseline, 12-week after discharge. Secondary outcomes of smoking status, exercise status, and six-minute walk distance were evaluated at the baseline, week4 and week 12 after discharge. The chi-square test,Fisher's exact test, group t-test and the repeated measure variance were used for the data analysis.

RESULTS

Eighty-nine of 100 eligible participants responded, and mean age was 60.2 ± 11.3 years.After the intervention, the mean score of the coronary self-management scale (3.84 ± 0.36) was higher than that in the control group (2.78 ± 0.57).At week 12, the rate of re-smoked in the intervention group (6%) was significantly lower than that in the control group (43%),the frequency of the exercise (85%), and the 6MWD (495.55 ± 85.94) in the intervention group were better than the control group.

CONCLUSION

Micro-lecture education program presented a positive effect on promoting the ability of self-management, and apotential effect on the therapeutic lifestyle changes for the coronary artery disease patients.

Can Clinical and Functional Outcomes Be Improved with an Intelligent "Internet Plus"-Based Full Disease Cycle Remote Ischemic Conditioning Program in Acute ST-elevation Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention? Rationale and Design of the i-RIC Trial

BACKGROUND

Acute ST-elevation myocardial infarction (STEMI) is associated with a high incidence of complications as well as a considerable hospitalization rate and economic burden. Preliminary evidence suggests that remote ischemic conditioning (RIC) is a promising non-invasive intervention that may effectively and safely reduce myocardial infarct size, subsequent cardiac events and complications, and mortality. However, RIC's cardio-protective effect remains under debate, especially for single timepoint RIC programs. Adequately powered large-scale randomized controlled trials investigating clinical outcomes are thus needed to clarify the role of full disease cycle RIC programs.

METHODS

The intelligent "Internet Plus"-based full disease cycle remote ischemic conditioning (i-RIC) trial is a pragmatic, multicenter, randomized controlled, parallel group, clinical trial. The term, intelligent "Internet Plus"-based full disease cycle, refers to smart devices aided automatic and real-time monitoring of remote ischemic pre-, per- or post-conditioning intervention for patients with STEMI undergoing percutaneous coronary intervention (PCI). Based on this perspective, 4700 STEMI patients from five hospitals in China will be randomized to a control and an intervention group. The control group will receive PCI and usual care, including pharmacotherapy, before and after PCI. The intervention group will receive pre-, per-, and post-operative RIC combined with long-term i-RIC over a one-month period in addition. A smartphone application, an automated cuff inflation/deflation device and "Internet Plus"-based administration will be used in the long-term phase. The primary outcome is the combined cardiac death or hospitalization for heart failure rate. Secondary outcomes include clinical and functional outcomes: major adverse cardiac and cerebrovascular events rate, all-cause mortality, myocardial reinfarction rate, readmission rate for heart failure and ischemic stroke rate, unplanned revascularization rate, plasma concentration of myocardial infarction-related key biomarkers, infarct size, cardiac function, cardiopulmonary endurance, health-related quality of life, total hospital length of stay, total medical cost, and compliance with treatment regime.

DISCUSSION

The i-RIC trial is designed to test the hypothesis that clinical and functional outcomes can be improved with the i-RIC program in STEMI patients undergoing PCI. The concept of RIC is expected to be enhanced with this intelligent "Internet Plus"-based program focusing on the full disease cycle. If the i-RIC program results in superior improvement in primary and secondary outcomes, it will offer an innovative treatment option for STEMI patients and form the basis of future recommendations.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry ( http://www.chictr.org.cn ): ChiCTR2000031550, 04 April 2020.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Impact of technology-based patient education on modifiable cardiovascular risk factors of people with coronary heart disease: A systematic review

OBJECTIVE

To collect evidence on what types of technology and content are most effective in helping people with coronary heart disease (CHD) to change their modifiable cardiovascular risk factors.

METHODS

A literature search was performed to find relevant studies published between 1 January 2008 and 31 December 2018 in PubMed, CINAHL, PROQUEST and Scopus databases. Selected outcomes were risk factors (exercise, diet, blood pressure, blood sugar, cholesterol, body mass index, tobacco use). The quality of the studies was evaluated according to Joanna Briggs Institute Reviewers Manual Checklists for risk for bias, TIDieR for quality of interventions, and PRISMA statement for presenting results.

RESULTS

Eighteen quantitative (17 RCT´s and one quasi-experimental) studies were included. Patient education delivered through telephone, text messaging, webpages, and smartphone applications resulted in significant changes in some risk factors of people with CHD. Sufficient descriptions of the content and intervention methods were lacking.

CONCLUSION

Patient education delivered with technology can help people with CHD to modify their risk factors. There is a need for better descriptions of the content and delivery of educational interventions in studies.

PRACTICE IMPLICATIONS

Patient education needs to be delivered with technological solutions that best support the multidimensional needs of CHD patients.

Effectiveness of a nurse-led multidisciplinary self-management program for patients with coronary heart disease in communities: A randomized controlled trial

OBJECTIVE

To examine the effectiveness of a nurse-led multidisciplinary self-management program (NMSP) on self-management behaviors, self-efficacy, health-related quality of life (HRQoL) and unplanned health service utilization (HSU) among Chinese patients with coronary heart disease (CHD) in communities.

METHODS

A randomized controlled trial with repeated measurements was used. A convenience sample of 144 participants was recruited from a community health center in China. All participants were randomly assigned to an intervention group (n = 72) in the newly developed NMSP or a control group (n = 72) in routine care. Outcome measurement was performed at baseline, 3 months and 6 months using Coronary Artery Disease Self-Management Scale (CADSs), Self-efficacy for Chronic Disease 6-item Scale (SECD6), and Short Form-12 health survey questionnaire (SF-12).

RESULTS

Over the six months, the two groups reported significant differences in disease medical and emotional management of CADSs, confidence in symptom and disease management of SECD6, physical and mental component summary of SF-12, as well as emergency and outpatient visits of unplanned HSU.

CONCLUSIONS

The NMSP improves self-management behaviors, self-efficacy, HRQoL and reduces unplanned HSU among CHD patients in communities.

PRACTICE IMPLICATIONS

This study provides an effective approach to empower CHD patients with emphasizing on collaboration support of health professionals in communities.

Effect of a nurse-led individualized self-management program for Chinese patients with acute myocardial infarction undergoing percutaneous coronary intervention

BACKGROUND

The study of the development and evaluation of self-management intervention among patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) is lacking, especially in China.

AIM

To examine the effects of a nurse-led individualized self-management program (NISMP) on health behaviors, control of cardiac risk factors, and health-related quality of life (HRQoL) among patients with AMI undergoing PCI.

METHODS

The quasi-experimental design included a convenience sample of 112 participants recruited from a tertiary hospital in China. The participants were assigned to the control group (n = 56) or the intervention group (n = 56). The intervention group underwent the NISMP, which includes six group-based education sessions, a face-to-face individual consultation, and 12-month telephone follow-ups. Data were collected at baseline and at the end of the 12-month program using the Health Promotion Lifestyle Profile, the Risk Factors Assessment Form, and the Short Form 36-item Health Survey.

RESULTS

The baseline sociodemographic and clinical characteristics of the two groups were comparable (p > 0.05). After the 12-month intervention, the health behaviors and HRQoL of the participants in the intervention group had significantly improved (p < 0.05 for both) compared to those of the control group. Compared to the control group, the participants in the intervention group also reported significantly better control of cardiac risk factors including smoking (χ² = 4.709, p = 0.030), low-density lipoprotein (χ² = 4.160, p = 0.041), body mass index (χ² = 3.886, p = 0.049) and exercise (χ² = 10.096, p = 0.001).

CONCLUSION

The NISMP demonstrated positive effects on health behaviors, control of cardiac risk factors, and HRQoL among Chinese patients with AMI undergoing PCI.

Role of Digital Games in Self-Management of Cardiovascular Diseases: A Scoping Review

OBJECTIVE

Examine research on the use of digital games to improve self-management (SM) behaviors in patients diagnosed with cardiovascular diagnoses of hypertension, coronary artery disease, heart failure, or myocardial infarction.

MATERIALS AND METHODS

For this scoping review, the CINAHL, PubMed, and Web of Science databases were searched for studies published from January 1, 2008 to December 20, 2017 using terms relevant to digital games and cardiovascular diseases (CVDs).

RESULTS

Eight articles met the inclusion/exclusion criteria, seven of which presented studies with participants 50 years or older. Five of the eight studies assessed physical activity. Only two studies included a control group. Digital games significantly improved exercise capacity and energy expenditure but did not affect quality of life, self-efficacy, anxiety, or depression. Digital games were found enjoyable by 79%-93% of participants, including those with lower education or age; however, barriers to game use included being tired or bored, lack of interest in digital games, poor perception of fitness through games, sensor limitations, conflicts with daily life routine, and preferences for group exercise. Average adherence ranged from 70% to 100% over 2 weeks to 6 months of study duration, with higher adherence rates in studies that included human contact through supervision or social support.

CONCLUSION

Paucity of studies about digital games for CVD SM behaviors precludes the need to undertake a full systematic review. Future studies examining digital games should include larger sample sizes, longer durations, game-design guided by behavioral change theoretical frameworks, and CVD SM behaviors in addition to physical activity behaviors.

The effect of a self-help psychoeducation programme for people with coronary heart disease: A randomized controlled trial

AIM

To examine the effect of a self-help psychoeducation program for people with coronary heart disease in Singapore.

BACKGROUND

Cardiac rehabilitation has shown benefits for mitigating many cardiac risk factors and can lead to improvement in health-related quality of life and psychological well-being in people with heart disease. However, traditional hospital-based cardiac rehabilitation faces substantial challenges. A self-management cardiac rehabilitation program offers an avenue to increase uptake and empowers patients to manage their condition at home.

DESIGN

A two-arm, randomized controlled trial.

METHODS

A total of 129 patients with coronary heart disease were recruited from an outpatient clinic in a public hospital in Singapore from April 2015-January 2016. They were randomly assigned to the intervention group or the control group. Participants in the intervention group received the 4-week home-based self-help psychoeducation program. Outcomes were measured at baseline and at 4 weeks and 16 weeks from the baseline.

RESULTS

There were no significant differences in health-related quality of life, psychological status (i.e., perceived stress level, anxiety, and depression levels), or cardiac physiological risk parameters between the intervention and the control groups immediately after the program or at different time points. There was also no significant difference in unplanned health service use at the 16 week posttest point between the two groups.

CONCLUSIONS

This study did not find any significant effect of our program on outpatients with coronary heart disease. Nonetheless, findings on participant characteristics may offer healthcare professionals valuable insights to help facilitate future development of an effective cardiac rehabilitation program catered to outpatients with coronary heart disease.

TRIAL REGISTRATION

The study has been registered with ISRCTN registry. The trial registration number is ISRCTN15839687.

Treatment of Anxiety in Patients With Coronary Heart Disease: A Systematic Review

BACKGROUND

Anxiety is common in patients with coronary heart disease (CHD) and is associated with an increased risk for adverse outcomes. There has been a relative paucity of studies concerning treatment of anxiety in patients with CHD.

OBJECTIVE

We conducted a systematic review to organize and assess research into the treatment of anxiety in patients with CHD.

METHODS

We searched CCTR/CENTRAL, MEDLINE, EMBASE, PsycINFO, and CINAHL for randomized clinical trials conducted before October 2016 that measured anxiety before and after an intervention for patients with CHD.

RESULTS

A total of 475 articles were subjected to full text review, yielding 112 publications that met inclusion criteria plus an additional 7 studies from reference lists and published reviews, yielding 119 studies. Sample size, country of origin, study quality, and demographics varied widely among studies. Most studies were conducted with nonanxious patients. The Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were the most frequently used instruments to assess anxiety. Interventions included pharmacological, counseling, relaxation-based, educational, or "alternative" therapies. Forty (33% of total) studies reported that the interventions reduced anxiety; treatment efficacy varied by study and type of intervention. Elevated anxiety was an inclusion criterion in only 4 studies, with inconsistent results.

CONCLUSION

Although there have been a number of randomized clinical trials of patients with CHD that assessed anxiety, in most cases anxiety was a secondary outcome, and only one-third found that symptoms of anxiety were reduced with treatment. Future studies need to target anxious patients and evaluate the effects of treatment on anxiety and relevant clinical endpoints.

Cardiac rehabilitation and physical activity: systematic review and meta-analysis

Objective

To undertake a systematic review and meta-analysis to assess the impact of cardiac rehabilitation (CR) on physical activity (PA) levels of patients with heart disease and the methodological quality of these studies.

Methods

Databases (MEDLINE, EMBASE, CENTRAL, CINAHL, PsychINFO and SportDiscus) were searched without language restriction from inception to January 2017 for randomised controlled trials (RCTs) comparing CR to usual care control in adults with heart failure (HF) or coronary heart disease (CHD) and measuring PA subjectively or objectively. The direction of PA difference between CR and control was summarised using vote counting (ie, counting the positive, negative and non-significant results) and meta-analysis.

Results

Forty RCTs, (6480 patients: 5825 CHD, 655 HF) were included with 26% (38/145) PA results showing a statistically significant improvement in PA levels with CR compared with control. This pattern of results appeared consistent regardless of type of CR intervention (comprehensive vs exercise-only) or PA measurement (objective vs subjective). Meta-analysis showed PA increases in the metrics of steps/day (1423, 95% CI 757.07 to 2089.43, p<0.0001) and proportion of patients categorised as physically active (relative risk 1.55, 95% CI 1.19 to 2.02, p=0.001). The included trials were at high risk of bias, and the quality of the PA assessment and reporting was relatively poor.

Conclusion

Overall, there is moderate evidence of an increase in PA with CR participation compared with control. High-quality trials are required, with robust PA measurement and data analysis methods, to assess if CR definitely leads to important improvements in PA.

Efficacy of an early home-based cardiac rehabilitation program for patients after acute myocardial infarction: A three-dimensional speckle tracking echocardiography randomized trial

BACKGROUND

The effect of an early short-term home-based cardiac rehabilitation (CR) program on ventricular function in acute myocardial infarction (AMI) patients is not yet clear. The purpose of this study was to evaluate the efficacy of our CR program on the improvement of myocardial function using three-dimensional speckle tracking echocardiography (3D-STE) in AMI patients.

METHODS

Fifty-two AMI patients were randomly assigned to 2 groups after discharge: the rehabilitation group, which participated in an early, home-based CR program, and the control group, which received only usual care. All subjects in both groups underwent 3D-STE examinations of the left ventricle within 48 hours of percutaneous coronary intervention and again 4 weeks after discharge. Global longitudinal strain (GLS), global radial strain (GRS), global area strain (GAS), global circumferential strain (GCS), left ventricular ejection fraction (LVEF), and segmental strains were computed. The CR program was initially conducted with supervised inpatient training, followed by an unsupervised home-based training program during a 4-week follow-up.

RESULTS

We obtained segmental strains from 832 segments, of which 319 were defined as interventional segments, 179 as ischemic segments, and the remaining segments as normal segments. At the 4-week follow-up, when controlling for baseline values, the rehabilitation group showed significant improvements in GLS, GRS, GCS, GAS, LVEF, and in all of the segmental strains of the 3 subgroups compared with the control group (P <0.05).

CONCLUSION

Our study suggests that an early, home-based CR program can greatly improve the ventricular function of AMI patients in a short period of time.

The efficacy of a supervised exercise training programme on readmission rates in patients with myocardial ischemia: results from a randomised controlled trial

BACKGROUND

The results of research into the outcomes of physical rehabilitation and its relationship with post-myocardial ischaemia survival and readmissions are inconclusive. Our primary aim was to evaluate the efficacy of a supervised exercise training programme in terms of decreasing hospital cardiac readmission in patients with myocardial ischaemia.

METHODS

We conducted a randomised controlled trial including patients with myocardial ischaemia. Eligible patients were assigned to a control group receiving standard care or to an intervention group that took part in a supervised exercise training programme. The follow-up period was 12 months after hospital discharge.

RESULTS

Of 478 patients assessed for eligibility, 86 were randomised to the control group ( n = 44) or the intervention group ( n = 42). Cardiac readmission rates were 14% versus 5% ( p = 0.268) in the control and intervention groups, respectively, and all-cause readmission rates were 23% versus 15% ( p = 0.34). There were no deaths in either group. More control patients were treated in the emergency services (50% vs. 24%; p = 0.015). In terms of health-related quality of life, patients in the intervention group presented with significant increases in functional capacity and mobility. More intervention patients returned to work (77.3% vs. 36.0%; p = 0.005).

CONCLUSIONS

The supervised physical exercise programme was effective at reducing the number of emergency room visits and at increasing the percentage of patients who returned to work. It also improved patients' exercise capacity and increased their health-related quality of life. Although the results were promising, the programme was not associated with a significant reduction in cardiac and all-cause readmission rates.