Modular prevention of heart disease following acute coronary syndrome (ACS) [ISRCTN42984084]

Clinical care standards: appropriate care everywhere - acute coronary syndromes as an example

Audit data show that despite clinical practice guidelines, some patients miss out on evidence-based care, which is not explained by individual needs or preferences. Clinical care standards are small sets of concise recommendations that focus on known gaps in evidence-based care for a particular clinical condition. They aim to ensure that all patients with the same clinical condition are offered appropriate care, regardless of their location. Clinical care standards are nationally agreed standards and are developed to maximise engagement of consumers, clinicians, health services, and state and territory health departments and agencies. They complement clinical practice guidelines and other initiatives for improving quality of health care. As an example, the Acute Coronary Syndromes (ACS) Clinical Care Standard is a significant step forward in supporting clinicians and health services to realise all of the gains promised by the ACS evidence base. The ACS Clinical Care Standard focuses on the areas of care that are known to be most associated with variation in outcome. It supports patient involvement in critical decisions that affect their care, refocuses clinicians on the priority areas of ensuring appropriate ACS care, and informs health services about the systems required to deliver evidence-based care.

Correlates of health behaviors in patients with coronary artery disease

PURPOSE

To investigate the effect of cardiac knowledge and cardiac self-efficacy on health behaviors after controlling for influences from associating factors of health behaviors in patients with coronary artery diseases (CADs).

METHODS

A descriptive correlational and cross-sectional design was used. Subjects with CADs were recruited from outpatient clinics of three academic medical centers. The cardiac knowledge, cardiac self-efficacy, and health behaviors were measured by Coronary Heart Disease Awareness and Knowledge Questionnaire, Cardiac Self-Efficacy Scale, and Health-Promoting Lifestyle Profile II respectively. The data collected were statistically analyzed by descriptive statistics, t test, Kruskal-Wallis test, analysis of variance, Pearson's correlation analysis, and the hierarchical multiple regression analysis.

RESULTS

A total of 157 subjects were recruited for this study. The mean age of subjects was 59.38 ± 10.04 years, and three-fourths (75.2%) were male. Subjects showed relatively low cardiac knowledge, moderately high cardiac self-efficacy, and moderate level of health behaviors. The overall model significantly explained 48% of variance in health behaviors (F = 14.52, p < .001). Among predictors, age, education, smoking status, experience of receiving patient education, and cardiac self-efficacy significantly affected health behaviors, and cardiac self-efficacy had the greatest effect on health behaviors (β= .39). However, cardiac knowledge had no statistically significant influence on health behaviors after controlling for the other factors.

CONCLUSION

The findings suggested that cardiac self-efficacy was shown to be the most influencing factor on health behaviors but cardiac knowledge had no influence on health behaviors. The nursing interventions tailored on the patient characteristics should be developed in order to improve the health behaviors of patients with CADs.

Obstacles and alternative options for cardiac rehabilitation in Nanjing, China: an exploratory study

BACKGROUND

Coronary heart disease (CHD) is a major cause of morbidity and mortality, and cardiac rehabilitation (CR) is still not well developed in mainland China. The objective of this study is to investigate the barriers associated with those seeking cardiac rehabilitation (CR) and to explore appropriate secondary prevention modalities tailored to the needs of Chinese patients with coronary heart disease (CHD).

METHODS

A consecutive series of eligible patients was recruited from the cardiac department of a teaching hospital in Nanjing, located in southeast China. Structured face-to-face interviews were conducted with 328 patients prior to hospital discharge. Patient preferences for seeking an outpatient CR program or an alternative outpatient self-choice, minimal-cost educational program were evaluated. Socio-demographic characteristics and clinical data were assessed. Additionally, patients were asked to provide the reasons affecting their choice.

RESULTS

Overall, only 14.3% patients preferred the standard CR program. Factors associated with non-participating were female gender (odds ratios [ORs], 6.05, 95% CI, 1.30-28.19), older age (ORs, 1.11, 95% CI, 1.04-1.19, per year), less education (ORs, 8.13, 95% CI, 2.83-23.38), low income (ORs, 3.26, 95% CI, 1.24-8.54), and having either basic medical care or a lack of health insurance (ORs, 10.01, 95% CI, 3.90-25.68). The most common reason for refusing to participate in CR was that patients could not afford it. Of the remaining patients, 65.8% patients chose self-choice educational programs, especially for female (ORs, 5.84, 95% CI, 2.67-12.79), older (ORs, 1.06, 95% CI, 1.02-1.11, per year), and low income (ORs, 2.14, 95% CI, 1.12-4.10) patients. The main reasons for their preferences were their desires for more information about disease and risk factors, the low cost, feasibility, and saving time.

CONCLUSIONS

Multiple barriers, which may occur at the patient, health system, and societal levels, have prevented eligible patients from participating in CR programs. Self-choice educational programs, an alternative model incorporating more information, would strongly meet the needs of most patients. A feasible delivery format for secondary prevention should be provided for all CHD patients.

Effects of a psychoeducational intervention for secondary prevention in Korean patients with coronary artery disease: a pilot study

This intervention study was designed to examine whether a 12-week psychoeducational intervention influenced recurrent cardiac events, symptom experience and treatment adherence of patients with coronary artery disease. Fifty-eight patients were randomized to either the intervention or the control group. Measures were taken at baseline, after intervention, and at 6-month follow-up. Recurrent cardiac events included revascularization, rehospitalization, emergency room visits and mortality. Symptom experiences were measured using the Seattle Angina Questionnaire-Korean and Hospital Anxiety and Depression Scale. Treatment adherence included health behaviours, routine check-up and medication adherence. At 6-month follow-up, the intervention group had significantly better physical functions and lower anxiety and depressive symptoms. Treatment adherence was also significantly higher in the intervention group than the control group. No significant difference was noticed in the incidence of recurrent cardiac events between the groups. A longer follow-up study is needed to determine the long-term effects on the prevention of recurrent cardiac events.

Poor use of cardiac rehabilitation among older adults: a self-regulatory model for tailored interventions

BACKGROUND

A greater number of older adults now live with coronary heart disease (CHD). This poses a significant public health problem, because older adults are at high risk for CHD-related mortality and morbidity. Overwhelming data support the benefits of cardiac rehabilitation for secondary prevention, yet only a small portion of eligible older adults receive it.

METHODS AND RESULTS

Whereas many studies examined factors that affect the use of cardiac rehabilitation among older adults, few interventions aimed to improve their cardiac rehabilitation participation rates. A substantial body of evidence indicates that an individual's illness perceptions play a pivotal role in health behavior, and may be a promising target for intervention. Drawing from the theoretic and empiric findings of others, a self-regulatory model is proposed that explicates how CHD perceptions of older adults may influence participation in cardiac rehabilitation.

CONCLUSION

The model may provide a useful guide for the development of effective interventions tailored to older adults.

Impact of medical consultation frequency on modifiable risk factors and medications at 12 months after acute coronary syndrome in the CHOICE randomised controlled trial

BACKGROUND

We aimed to determine whether the frequency of General Practitioner and Cardiologist consultations impacted on improvements in risk factors in Choice of Health Options in Reducing Cardiovascular Events (CHOICE) randomised controlled trial.

METHODS

Retrospective subgroup analysis of single-blind randomised controlled trial. We included acute coronary syndrome survivors not accessing cardiac rehabilitation in the CHOICE trial whose General Practitioner or Cardiologist returned a visit frequency survey. The CHOICE group participated in tailored risk factor reduction packaged as clinic visit plus 3 months telephone support. Controls participated in physician-directed usual medical care. We compared total cholesterol, systolic blood pressure, smoking status, physical activity, number of modifiable risk factors and medications with frequency of medical consultations at baseline and 12 months.

RESULTS

Most control and CHOICE patients saw their General Practitioner≥5 times (85% vs 90%) and Cardiologist at least once (65% vs 57%). CHOICE patients had a significantly better modifiable risk profile (factor levels and multiples) and more patients were on evidence-based medications at 12 months compared to controls. In CHOICE, the significant reduction in total cholesterol was unrelated to medical visits but lower systolic blood pressure was significant in patients who saw their General Practitioner≥5 compared with ≤4 times. In controls, frequency of medical visits was not associated with any changes in risk profile.

CONCLUSIONS

Acute coronary syndrome survivors receiving frequent medical follow-up without packaged secondary prevention had no improvement in multiple risk factors over 12 months. CHOICE patients who saw their doctors frequently were more likely to have significantly reduced systolic blood pressure and be on evidence-based medications.

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background.The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model. Methods.A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented. Results.Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis. Conclusions.Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community. What is known about this topic?Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known. What does this paper add?This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness. What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.

The last mile: improving patient outcomes within modern cardiovascular medicine

It is now well recognised that, in many areas of medicine, substantial gaps in clinical care exist despite robust clinical trial data and the careful assimilation of this information into clinical practice guidelines. Those at greatest risk are patients presenting with multiple co-morbidities, and those with advanced age in whom the issues of complexity and limited time available for careful assessment, potentially lead to sub-optimal clinical practice and outcomes. Greater efforts are needed to move the acquired knowledge across the "last mile", that is from clinical guidelines and best practice to nationwide routine practice. This article will discuss some of issues faced in operationalizing "clinical effectiveness" in cardiovascular care in Australia.

The CHOICE (Choice of Health Options In prevention of Cardiovascular Events) replication trial: study protocol

Background

Although morbidity and mortality from coronary heart disease (CHD) are high, only a minority of acute coronary syndrome (ACS) survivors accesses an effective secondary prevention program. We aim to determine whether the previously proven CHOICE program can be replicated at multiple sites and whether ongoing reinforcement further improves risk factor modification.

Methods/design

Participants eligible for but not accessing standard cardiac rehabilitation will be randomly allocated to either a previously tested 3-month CHOICE program or a 30-month CHOICE program (CHOICE-plus). Both groups will participate in individualised risk factor modules of differing duration that involve choice, goal setting and telephone follow-up for three months. CHOICE-plus will also receive additional face-to-face and telephone reinforcement between three and 30 months. At one site we will recruit a randomised control group, receiving conventional care. Primary outcomes are lipid levels, blood pressure, physical activity levels and smoking rates. Secondary outcomes include readmission rates, death, the number of risk factors, other modifiable risk factors, quality of life and process evaluation measures over three years.

Discussion

We present the rationale and design of a multi-centre, replication study testing a modular approach for the secondary prevention of CHD following an ACS.

Trial Registration

[Clinical Trial Registration Number, ACTRN12608000182392]

Low utilisation of cardiovascular risk reducing therapy in patients with acute coronary syndromes and non-obstructive coronary artery disease

BACKGROUND

Between 6-25% of patients undergoing coronary angiography for acute coronary syndrome (ACS) have non-obstructive coronary artery disease (NOCAD).

METHODS

One-hundred and eighty patients presenting with an ACS who were taking part in a risk factor modification study and had undergone coronary angiography were examined. We compared baseline characteristics, medical treatment and 12-month outcome in patients with NOCAD (<50% lumen diameter stenosis at coronary angiography) and obstructive CAD (> or = 50% lumen diameter stenosis at coronary angiography).

RESULTS

There were 29 (16%) patients with NOCAD and 151 (84%) with obstructive CAD (CAD). Patients with NOCAD were significantly younger, more likely to be female, had higher mean total cholesterol and LDL levels, and fewer received cardiac rehabilitation, treatment with statins, aspirin, ACE inhibitors, beta-blockers or clopidogrel. Over the next 12-months, there was no mortality or myocardial infarction in the NOCAD group compared to 2% in the CAD group, but 14% with NOCAD were readmitted for a cardiovascular cause including 2 patients (7%) who underwent percutaneous coronary intervention (PCI).

CONCLUSIONS

Patients presenting with ACS and NOCAD may not have a completely benign prognosis, and preventative strategies and therapies such as statins in this group of patients appear to be under-utilised.

High risk-factor level and low risk-factor knowledge in patients not accessing cardiac rehabilitation after acute coronary syndrome

OBJECTIVE

To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.

DESIGN AND SETTING

Cross-sectional comparison in a tertiary hospital.

PARTICIPANTS

Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).

MAIN OUTCOME MEASURES

Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.

RESULTS

Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (+/- SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 +/- 0.1 v 2.3 +/- 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).

CONCLUSIONS

Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.