Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery

Background— Cardiac rehabilitation (CR) is effective in prolonging survival and reducing disability in patients with coronary heart disease. However, national use patterns and predictors of CR use have not been evaluated thoroughly.

Methods and Results— Using Medicare claims, we analyzed outpatient (phase II) CR use after hospitalizations for acute myocardial infarctions or coronary artery bypass graft surgery in 267 427 fee-for-service beneficiaries aged ≥65 years who survived for at least 30 days after hospital discharge. We used multivariable analyses to identify predictors of CR use and to quantify geographic variations in its use. We obtained unadjusted, adjusted-smoothed, and standardized rates of CR use by state. Overall, CR was used in 13.9% of patients hospitalized for acute myocardial infarction and 31.0% of patients who underwent coronary artery bypass graft surgery. Older individuals, women, nonwhites, and patients with comorbidities (including congestive heart failure, previous stroke, diabetes mellitus, or cancer) were significantly less likely to receive CR. Coronary artery bypass graft surgery during the index hospitalization, higher median household income, higher level of education, and shorter distance to the nearest CR facility were important predictors of higher CR use. Adjusted CR use varied 9-fold among states, ranging from 6.6% in Idaho to 53.5% in Nebraska. The highest CR use rates were clustered in the north central states of the United States.

Conclusions— CR use is relatively low among Medicare beneficiaries despite convincing evidence of its benefits and recommendations for its use by professional organizations. Use is higher after coronary artery bypass graft surgery than with acute myocardial infarctions not treated with revascularization procedures and varies dramatically by state and region of the United States.

Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years

Gender-related differences in cardiac rehabilitation referral patterns and response to an aerobic conditioning program were examined in 226 hospitalized older coronary patients (aged greater than or equal to 62 years). Overall, the outpatient cardiac rehabilitation participation rate in this population was 21%. Older women were less likely to enter cardiac rehabilitation than were older men (15 vs 25%; p = 0.06), despite similar clinical profiles. This was explained primarily by a greater likelihood of primary physicians to strongly recommend cardiac rehabilitation to men. Before conditioning, women who entered cardiac rehabilitation were less fit than were men; peak oxygen consumption was 18% lower in women (16 +/- 5 vs 20 +/- 5 ml/kg/min; p = 0.02). However, both groups improved aerobic capacity similarly in response to a 12-week aerobic conditioning program, with maximal oxygen consumption increasing by 17% in women and by 19% in men. Thus, older female coronary patients are less likely to be referred for cardiac rehabilitation, despite a similar clinical profile and improvement in functional capacity from the training component.

Fast-track recovery of the coronary bypass patient

A new approach termed "fast-track recovery" ws undertaken at both the Baystate Medical Center and Hartford Hospital. The fast-track protocol involves the following principles: (1) preoperative education; (2) early extubation; (3) methylprednisolone sodium succinate before bypass followed by dexamethasone for 24 hours postoperatively; (4) prophylactic digitalization, metoclopramide HCl, docusate sodium, and ranitidine HCl; (5) accelerated rehabilitation; (6) early discharge; (7) a dedicated fast-track coordinator to perform both daily telephone contact and a 1-week postoperative examination; and (8) a routine 1-month postoperative visit with a PA or MD. To evaluate the effects of this approach on patient care, a retrospective 1-year analysis was undertaken in both institutions with all coronary artery bypass grafting patients compared in a consecutive manner before the origin of the fast-track protocol and subsequent to its beginning. There were 280 patients in the fast-track and 282 in the non-fast-track group. The two groups were not significantly different except inexplicably there was a lower ejection fraction in the fast-track group and a longer cross-clamp time. Postoperatively, the mean time to extubation decreased from 22.1 to 15.4 hours, and peak weight gain decreased from 2.8 to 1.6 kg from the non-fast-track to the fast-track group (p < 0.01). This was accompanied by significant (p < 0.001) decreases in intensive care unit duration from 2.4 to 1.9 days and in postoperative length of stay from 8.3 to 6.8 days from the non-fast-track to the fast-track group. There was no increase in morbidity or mortality associated with the fast-track protocol either early or late. Thirty-day hospital readmission was not significantly different between the two groups. Fast-track methodology is effective, and we routinely employ this approach for all patients undergoing cardiopulmonary bypass.

Impact of cardiac rehabilitation on depression and its associated mortality

PURPOSE

Depression following major cardiac events is associated with higher mortality, but little is known about whether this can be reduced through treatment including cardiac rehabilitation and exercise training. We evaluated the impact of cardiac rehabilitation on depression and its associated mortality in coronary patients.

PATIENTS AND METHODS

We evaluated 522 consecutive coronary patients (381 men, 141 women; aged 64+/-10 years) enrolled in cardiac rehabilitation from January 2000 to July 2005 and a control group of 179 patients not completing rehabilitation. Depressive symptoms were assessed by questionnaire at baseline and following rehabilitation, and mortality was evaluated after a mean follow-up of 1296+/-551 days.

RESULTS

Prevalence of depressive symptoms decreased 63% following rehabilitation, from 17% to 6% (P <.0001). Depressed patients following rehabilitation had an over 4-fold higher mortality than nondepressed patients (22% vs 5%, P=.0004). Depressed patients who completed rehabilitation had a 73% lower mortality (8% vs 30%; P=.0005) compared with control depressed subjects who did not complete rehabilitation. Reductions in depressive symptoms and its associated mortality were related to improvements in fitness; however, similar reductions were noted in those with either modest or marked increases in exercise capacity.

CONCLUSION

In patients following major coronary events, cardiac rehabilitation is associated with both reductions in depressive symptoms and the excess mortality associated with it. Moreover, only mild improvements in levels of fitness appear to be needed to produce these benefits on depressive symptoms and its associated mortality.

National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns

PURPOSE

Cardiac rehabilitation (CR) programs have been shown to promote numerous health benefits among patients with active coronary heart disease (CHD), but little is known about the percentage of eligible CHD patients who enroll in CR.

METHODS

A survey was performed of 500 randomly chosen CR programs in operation in the United States during 1990. Patient characteristics and enrollment data were combined with data from the 1990 National Hospital Discharge Survey to estimate the percentage of eligible patients who participated in early outpatient (Phase II) CR programs after myocardial infarction (MI), after coronary angioplasty (PTCA), or after coronary artery bypass surgery (CABS).

RESULTS

Completed surveys were returned by 163 programs (32.6%) with information on 1,322 women and 1,418 men who enrolled in their programs in 1990. Women were older, more likely to be single, and had more traditional CHD risk factors than men. Only a minority of MI, PTCA, and CABS survivors enrolled in CR programs (10.8%, 10.3% and 23.4%, respectively). Enrollment was particularly low for post-MI and post-CABS women as compared with men: 6.9% versus 13.3% (P < .001), and 20.2% versus 24.6% (P < .001), respectively. Enrollment was generally lowest for nonwhites, those over age 65, and those living in the southern United States.

CONCLUSIONS

Cardiac rehabilitation programs are used by a minority of eligible patients, particularly among women, nonwhites, and the elderly. To meet newly released national guidelines that recommend CR services for most patients recovering from MI, PTCA, or CABS, and to still contain costs, new methods need to be explored that can expand the delivery of CR services in clinical settings.

Comparison of the short form (SF)-12 health status instrument with the SF-36 in patients with coronary heart disease

OBJECTIVE

To investigate whether a shorter health status instrument, the short form (SF)-12, is comparable with its longer version, the SF-36, for measuring health related quality of life of patients with coronary heart disease.

DESIGN

Prospective cohort study with follow up at six and 12 months.

SETTING

18 cardiac rehabilitation centres in Germany.

PATIENTS

Patients were enrolled at admission to the rehabilitation centres after myocardial infarction, coronary artery bypass grafting, and percutaneous transluminal coronary angioplasty.

ANALYSES

Correlation coefficients were calculated between SF-12 and SF-36 physical component summary (PCS-12/-36) and mental component summary (MCS-12/-36) scores and the respective change scores. Responsiveness to change was determined with the standardised response mean.

MAIN RESULTS

2441 patients were enrolled (78% men, mean (SD) age 60 (10) years; 22% women, 65 (10) years). Baseline PCS-12 and PCS-36 scores were highly correlated (r = 0.96, p < 0.001), as were baseline MCS-12 and MCS-36 scores (r = 0.96, p < 0.001). Similarly, change scores between baseline and 12 months were highly correlated (PCS-12/-36: r = 0.94, p < 0.001; MCS-12/-36: r = 0.95, p < 0.001). There was no difference in standardised response means between the SF-12 and SF-36 scales.

CONCLUSIONS

The SF-12 summary measures replicate well the SF-36 summary measures and show similar responsiveness to change. The SF-12 appears to be an efficient alternative to the SF-36 for the assessment of health related quality of life of patients with coronary heart disease.

Gender differences in recovery after coronary artery bypass surgery

OBJECTIVES

This study was designed to examine whether female gender is associated with poorer recovery after coronary artery bypass graft (CABG) surgery.

BACKGROUND

The risks and benefits associated with CABG surgery in women are not as well established as they are in men, and there are concerns that women may have worse outcomes. The recovery period after CABG (the first four to eight weeks after the surgery) is a vulnerable time, with higher risks of complications and hospital readmission. There is little information on patients' experiences during this phase, particularly among women.

METHODS

We prospectively followed 1,113 patients (804 men and 309 women) who underwent first CABG consecutively between February 1999 and February 2001. Patients were interviewed at baseline and between six and eight weeks after surgery. Clinical data were abstracted from medical records.

RESULTS

Compared with men, women were older and more often had unstable angina and congestive heart failure, lower physical function (PF), and more depressive symptoms in the month before surgery. At six to eight weeks after CABG surgery, after adjustment for baseline characteristics, the rate of hospital readmission was 20.5% in women and 11.0% in men (p = 0.005), and the mean number of physical symptoms and side effects was 2.5 in women and 2 in men (p = 0.0009). Whereas, on average, PF remained unchanged in men (an increase in score of 0.3 points, 95% confidence interval [CI], -1.1 to 1.8) and depressive symptoms improved (a decrease of 0.2 depressive symptoms, 95% CI, -0.4 to -0.04), women showed, on average, a 13-point decline in physical function (95% CI, -15.8 to -10.4) and an increase of 0.5 in depressive symptoms (95% CI, 0.1 to 0.9).

CONCLUSIONS

After CABG surgery, women have a more difficult recovery compared with men, which is not explained by illness severity, presurgery health status, or other patient characteristics.

Importance of complete revascularization in performance of the coronary bypass operation

Cardiac Data Bank records of 1,238 patients with triple-vessel disease (greater than or equal to 50% diameter reduction) who had undergone coronary bypass surgery were reviewed and divided into 2 groups depending on whether complete (n = 773) or incomplete (n = 465) revascularization had been accomplished. Patients with complete revascularization had a higher incidence of a normal preoperative electrocardiogram than did patients with incomplete revascularization (23 versus 14%, respectively, p less than 0.0001). The ejection fraction for both completely and incompletely revascularized patients was good (m = 0.60 and 0.57, respectively). The mean number of grafts per patient for the 2 groups was 3.8 and 2.6 (p less than 0.0001). There was no significant difference between the 2 groups with regard to postoperative inotropic requirements (8 and 7%), ventricular arrhythmias (1.8 and less than 1%), necessity for intraaortic balloon pumping (1.6 and 1.5%, hospital mortality (1.2 and 2.8%), or myocardial infarction (4.3 and 4.8%). Survival at 5 years was significantly greater (p less than 0.001) in patients with complete (88.5%) than in those with incomplete revascularization (83.5%). Reemployment occurred more often in patients with complete (52%) than in those with incomplete revascularization (40%) (p less than 0.001), and more patients were free of angina after complete (70%) than after incomplete revascularization (58%) (p less than 0.0005). Long-term survival appeared to be mediated primarily through improved revascularization rather than through differences in left ventricular function.

Prognostic significance of peak exercise capacity in patients with coronary artery disease

OBJECTIVES

The aim of this study was to investigate the prognostic significance of peak oxygen uptake in patients with coronary artery disease who had an exercise test that could be sustained to exhaustion without limiting symptoms.

BACKGROUND

Many studies have reported an inverse association between the level of exercise reached during a stress test and mortality or cardiovascular morbidity. These studies have used submaximal or symptom-limited exercise testing in patients with a recent myocardial infarction.

METHODS

Peak oxygen uptake was measured in male patients > or = 4 weeks after myocardial infarction (312 patients) or coronary artery surgery (215 patients) by use of a graded uninterrupted exercise test performed to exhaustion. Apart from peak oxygen uptake, several risk factors for cardiovascular disease, patient and exercise characteristics and drug treatment were considered in the Cox proportional hazards model.

RESULTS

During the total follow-up period of 3,213 patient-years, 53 patients died. Of these 53 patients, 33 died of cardiovascular causes. All-cause and cardiovascular mortality decreased with increasing peak oxygen uptake, even after adjustment for significant covariates. The relative hazard rates of 0.43 and 0.29 indicate that a hypothetic increase in peak oxygen uptake by 1 liter/min could be associated with decreases in all-cause and cardiovascular mortality of 57% and 71%, respectively.

CONCLUSIONS

Exercise capacity is an independent predictor for subsequent all-cause and cardiovascular mortality in patients able to perform an exercise test until exhaustion.

Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and bypass surgery: randomised controlled trial

OBJECTIVE

To evaluate a smoking cessation intervention that can be routinely delivered to smokers admitted with cardiac problems.

DESIGN

Randomised controlled trial of usual care compared with intervention delivered on hospital wards by cardiac rehabilitation nurses.

SETTING

Inpatient wards in 17 hospitals in England.

PARTICIPANTS

540 smokers admitted to hospital after myocardial infarction or for cardiac bypass surgery who expressed interest in stopping smoking.

INTERVENTION

Brief verbal advice and standard booklet (usual care). Intervention lasting 20-30 minutes including carbon monoxide reading, special booklet, quiz, contact with other people giving up, declaration of commitment to give up, sticker in patient's notes (intervention group).

MAIN OUTCOME MEASURES

Continuous abstinence at six weeks and 12 months determined by self report and by biochemical validation at these end points. Feasibility of the intervention and delivery of its components.

RESULTS

After six weeks 151 (59%) and 159 (60%) patients remained abstinent in the control and intervention group, respectively (P=0.84). After 12 months the figures were 102 (41%) and 94 (37%) (P=0.40). Recruitment was slow, and delivery of the intervention was inconsistent, raising concerns about the feasibility of the intervention within routine care. Patients who received the declaration of commitment component were almost twice as likely to remain abstinent than those who did not receive it (P<0.01). Low dependence on tobacco and high motivation to give up were the main independent predictors of positive outcome. Patients who had had bypass surgery were over twice as likely to return to smoking as patients who had had a myocardial infarction.

CONCLUSIONS

Single session interventions delivered within routine care may have insufficient power to influence highly dependent smokers.

Cardiac rehabilitation participation predicts lower rehospitalization costs

The effect of participation in cardiac rehabilitation on medical costs was determined by measuring hospitalization charges for cardiac admissions over a 3-year period in 580 post-coronary event patients (58% after coronary bypass surgery, 42% after myocardial infarction), of whom 230 entered a cardiac rehabilitation program and 350 did not. Baseline left ventricular ejection fraction was similar in entrants and nonentrants (59.9% vs 59.5%). Over the 1 to 46-month follow-up period (mean 21 months), per capita hospitalization charges for participants in cardiac rehabilitation were $739 lower than charges for nonparticipants ($1197 +/- 3911 vs $1936 +/- 5459, p = 0.022). This was due to both a lower incidence of hospitalizations and lower charges per hospitalization. Inasmuch as groups differed with regard to age, sex, diagnostic category, and smoking status, data were adjusted for these baseline differences by means of analysis of covariance. Rehospitalization charges remained significantly higher in nonparticipants (p = 0.015). Because physician charges were not measured, the cost differential between groups is underestimated. Results of this study show an association between participation in comprehensive cardiac rehabilitation and lowered cardiac rehospitalization costs in the years after an acute coronary event.

Prospective study of quality of life before and after coronary artery bypass grafting

OBJECTIVES

Measurement of changes in patients' perceptions of how differing states of health affect their lives and determination of the ability of preoperative variables to predict outcome after coronary artery bypass grafting.

DESIGN

Prospective study with completion of questionnaires before coronary artery bypass grafting and at three months, one year, and five years afterwards.

SETTING

Regional cardiothoracic centre.

PATIENTS

100 Male patients all aged below 60 at the time of operation, who were patients of two cardiothoracic surgeons.

MAIN OUTCOME MEASURES

Patients' assessment of their health state in terms of functional capacity and aspects of distress, according to the Nottingham health profile and outcome of operation in terms of changes in symptoms, working life, and daily activities determined by self completed study questionnaires before operation and at three and six months afterwards.

RESULTS

Intermediate one year results are reported. The differences between the Nottingham health profile scores before operation and at three months afterwards were significantly different (p less than 0.01), indicating an appreciable improvement in general health state, and at one year compared favourably with those from a normal male population. Analysis of responses to the study questionnaire showed that 65 of 89 patients (73%) were working at one year after operation with a further seven (8%) maintaining that they were fit to work but unable to find employment. The proportion of patients complaining of chest pain fell from 90% (88/98) before grafting to 19% (17/89) at one year after coronary artery bypass grafting, when 91% (81/89) patients maintained that their condition was either completely better or definitely improved. The significant positive factors affecting return to work and home activities were working before operation, short wait for operation, absence of breathlessness, and low physical mobility score in the Nottingham health profile (all p less than 0.001).

CONCLUSIONS

Improvements were evident in general health state, symptoms, and activity at three months and one year after coronary artery bypass graft surgery. Interventions likely to influence outcomes included reduction in waiting times for operation; rehabilitation initiatives; and more attention to the quality of information given to patients, their relatives, and the community.

Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery

An inverse association between mortality and exercise capacity has been demonstrated previously in patients with coronary artery disease. Physical training generally increases exercise capacity. Only 1 study investigated the prognostic value of exercise capacity after training, but only in a limited number of patients. No data are available on the relation between mortality and the change in exercise performance with training. Peak oxygen uptake (VO2) was measured before and after a 3-month, predominantly dynamic training period in 417 patients with coronary artery disease. Apart from peak VO2, several patient characteristics, risk factors for cardiovascular disease, and exercise data were considered in a Cox proportional-hazards model. Peak VO2 had increased by 33% after the training period. During the total follow-up of 2,583 patient-years, 37 patients died. The cause of death was cardiovascular in 21. The prognostic value of peak VO2 was higher after training than before training, even after adjustment for age and other significant covariates. Cardiovascular mortality decreased more with greater increases in peak VO2 after training. The relative hazard rate of 0.98 indicates that a 1% greater increase in peak VO2 after training would be associated with a decrease in cardiovascular mortality of 2%. No differences in prognostic value and in training effects were observed between patients with myocardial infarcts and patients after coronary bypass grafting. Peak VO2, evaluated after a physical training program, and its change in response to training are independent predictors for cardiovascular mortality in patients with coronary artery disease.

Effects of conventional physiotherapy, continuous positive airway pressure and non-invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting

BACKGROUND

Coronary artery bypass graft (CABG) surgery with the use of mammary arteries is associated with severe alteration of lung function parameters. The purpose of the present study was to compare the effect on lung function tests of conventional physiotherapy using incentive spirometry (IS) with non-invasive ventilation on continuous positive airway pressure (CPAP) and with non-invasive ventilation on bilevel positive airway pressure (BiPAP or NIV-2P), METHODS: Ninety-six patients were randomly assigned to 1 of 3 groups: NIV-2P (1 h/3 h), CPAP (1 h/3 h) and IS (20/2 h). Pulmonary function tests and arterial blood gases analyses were obtained before surgery. On the 1st and 2nd postoperative days, these parameters were collected together with cardiac output and calculation of venous admixture.

RESULTS

For the 3 groups a severe restrictive pulmonary defect was observed during the 1st postoperative day. On the 2nd postoperative day, in opposition to IS, intensive use of CPAP and NIV-2P reduced significantly the venous admixture (P<0.001) and improved VC, FEV1 and PaO2 (P<0.01).

CONCLUSION

We conclude that preventive use of NIV can be considered as an effective means to decrease the negative effect of coronary surgery on pulmonary function.

Utilisation of outpatient cardiac rehabilitation in Queensland

OBJECTIVES

To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs.

DESIGN AND SETTING

Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs.

PARTICIPANTS

Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private).

MAIN OUTCOME MEASURES

Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance.

RESULTS

15 186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality.

CONCLUSION

There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Promoting patient uptake and adherence in cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review.

OBJECTIVES

To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation.

SEARCH METHODS

We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions.

SELECTION CRITERIA

Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome.

DATA COLLECTION AND ANALYSIS

At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias.

MAIN RESULTS

The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization.

AUTHORS' CONCLUSIONS

We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

A comparison of four quality of life instruments in cardiac patients: SF-36, QLI, QLMI, and SEIQoL

BACKGROUND

With the increasing use of quality of life measures in evaluations of cardiac interventions, criteria are needed for selecting appropriate quality of life measures. An important criterion is the sensitivity of a measure for detecting clinically important changes.

OBJECTIVES

To compare the sensitivity of four measures when used in a group of cardiac patients undergoing the same intervention.

METHODS

The short form 36 (SF-36), the quality of life index-cardiac version (QLI), the quality of life after myocardial infarction questionnaire (QLMI), and the schedule for the evaluation of individual quality of life (SEIQoL) were used to evaluate quality of life in a group of 22 patients after myocardial infarction or coronary artery bypass graft (CABG), at the beginning of rehabilitation and six weeks later. Analysable data were obtained from 16 patients.

RESULTS

A significant improvement over time was only observed for the SF-36 subscale, vitality (p < 0.05). Five of the eight SF-36 subscales and one of the four QLMI subscales showed modest sensitivity (index: > 0.2 and < 0.5), while all other subscales showed poor sensitivity (index: < 0.2). Using SEIQoL, family was most often nominated as an area of importance to quality of life (n = 13), followed by health (n = 10), leisure/hobbies (n = 8), marriage (n = 8), and work (n = 6).

CONCLUSIONS

All four QOL measures used in this study were found to lack sensitivity to change. Further research is needed using other cardiac populations and interventions in order to verify these findings, with a view to developing more sensitive quality of life scales.

Predictors of women's exercise maintenance after cardiac rehabilitation

PURPOSE

Less than 50% of persons who participate in cardiac rehabilitation (CR) programs maintain an exercise regimen for as long as 6 months after completion. This study was conducted to identify factors that predict women's exercise following completion of a CR program.

METHODS

In this prospective, descriptive study, a convenience sample of 60 women were recruited at completion of a phase II CR program. Exercise was measured using a heart rate wristwatch monitor over 3 months. Predictor variables collected at the time of the subjects' enrollment were age, body mass index, cardiac functional status, comorbidity, muscle or joint pain, motivation, mood state, social support, self-efficacy, perceived benefits or barriers, and prior exercise.

RESULTS

Of women, 25% did not exercise at all following completion of a CR program and only 48% of the subjects were exercising at 3 months. Different predictors were found of the various dimensions of exercise maintenance. Predictors of exercise frequency were comorbidity and instrumental social support. Instrumental social support was the only predictor of exercise persistence. Comorbidity was the only predictor of exercise intensity. The only predictor of the total amount of exercise was benefits or barriers.

CONCLUSIONS

Interventions aimed at increasing women's exercise should focus on increasing their problem-solving abilities to reduce barriers to exercise and increase social support by family and friends. Because comorbidity was a significant predictor of exercise, women should be encouraged to use exercise techniques that reduce impact on muscles and joints (eg, swimming) or exercising for short periods several times a day.

Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation

BACKGROUND

Rehabilitation is an important part of the treatment of patients with ischemic heart disease. Therefore, many patients undergoing coronary artery bypass surgery (CABS) also participate in cardiac rehabilitation programs. This study was conducted to investigate whether rehabilitation influences quality of life and work status after CABS.

METHODS

Consecutive patients undergoing elective CABS were randomly assigned to a rehabilitation group (R, N = 119) and a hospital-treatment group (H N = 109). All patients received usual medical care. Group R participated in a rehabilitation program based on exercise and counseling. The follow-up time was 5 years. The measured domains of health-related quality of life were heart symptoms, functional class, exercise capacity, use of medication, depression, the patients' perception of health, and overall life situation. The Nottingham Health Profile as a measure of perceived distress was used.

RESULTS

Symptoms, use of medication, exercise capacity, and depression scores did not differ between groups R and H. Five years after the CABS, the patients in group R reported less restriction in physical mobility on the Nottingham Health Profile than patients in group H (P = 0.005), and more patients in group R than in group H perceived their health (P = 0.03) and overall life situation (P = 0.02) as good. The increase in the proportion of subjects working was higher in group R than group H at 3 years after the CABS (P = 0.02), but not at other follow-up times.

CONCLUSION

A cardiac rehabilitation program in conjunction with usual medical care after CABS may induce a perception of improved health. The influence on return to work is limited.

Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.

Functional status outcomes of patients with a coronary artery bypass graft over time

OBJECTIVE

To examine functional status outcomes among patients with a coronary artery bypass graft (CABG) over time (ie, at baseline; 3 months, 6 months, and 12 months after surgery) and the impact of selected patient characteristics (ie, age, sex, comorbidities, and cardiac rehabilitation participation) on functional outcomes.

DESIGN

A prospective, repeated-measures design was used to examine functional status in patients with a CABG over time.

SETTING

A midwestern community hospital and regional cardiac referral center was the setting for enrolling patients with a CABG.

OUTCOME MEASURES

Functional status outcomes were measured by using the Medical Outcomes Study (MOS) Short Form 36 (SF-36) and Modified 7-Day Activity instruments.

METHODS

Baseline data were obtained by patient interview in the hospital setting after CABG surgery. At 3 months, 6 months, and 12 months after surgery, telephone interviews were conducted to administer research instruments.

RESULTS

Baseline scores on 7 of the 8 subscales of the MOS SF-36 were significantly lower than at 3 months, 6 months, or 12 months after surgery. Role-emotional functioning baseline scores were not significantly lower than 3-month scores; however, baseline scores were significantly lower than 6-month and 12-month scores. Three-month subscale scores were also significantly lower than 6-month or 12-month scores except for the subscales measuring social and general health functioning. Functional status as measured by the Modified 7-Day Activity tool did not demonstrate any significant differences between 3-month, 6-month, or 12-month activity levels. There were no significant differences by age group on any of the 8 subscales of the MOS SF-36 instrument. Women and subjects with more than 1 comorbidity had a significantly lower preoperative level of physical functioning. Cardiac rehabilitation participants had lower preoperative scores on role-emotional functioning than subjects who were not in rehabilitation.

CONCLUSION

Findings from this study can assist nurses and other health care workers to gain a perspective of the recovery and rehabilitation trajectory of patients with a CABG. The results of the study provide a basis for determining areas of functional limitations during recovery from CABG surgery. Study results can also be the foundation for evaluating outcomes of patients with a CABG when specific interventions (eg, pain management, psychosocial support, physical strengthening, fatigue management) are implemented during hospitalization, home recovery, and rehabilitation to target optimal psychosocial and physiologic functioning of patients with a CABG.

Return to work after myocardial infarction/coronary artery bypass grafting: patients' and physicians' initial viewpoints and outcome 12 months later

Nonmedical factors play an important role in determining whether patients resume their work after myocardial infarction or CABG. The main questions dealt with in this study are: What is the respective basis of physicians' and patients' judgements as far as vocational disabilities are concerned, and what are the decisive factors that facilitate a prediction as to who will return to work and who will not? 132 male patients participating in a cardiac rehabilitation program served as subjects. The age group was limited to patients between 40 and 59 yr of age. The work situation 12 months following rehabilitation is known for 119 subjects; 74 had resumed their occupations. Results of regression analyses show that patients' and physicians' views on disabilities and re-employment are based on different factors. The physicians derive their estimates mainly from medical variables (cardiac status and comorbidity), whereas the patients' views are based on the overall health status, their former job status, job satisfaction, and negative incentives for the return to work. Three variables were found that allow a prediction to be made as to re-employment in 85% of all cases: (1) age, (2) patients' feelings about the extent to which they are disabled by their cardiac problem, and (3) the physicians' views on the extent to which the patient is vocationally disabled by his overall medical situation. Medical variables (e.g. cardiac status) had little relevance to re-employment. The results are discussed with regard to the consequences for cardiac rehabilitation.

HeartCare: an Internet-based information and support system for patient home recovery after coronary artery bypass graft (CABG) surgery

HeartCare is an Internet-based information and support service for patients recovering at home from coronary artery bypass graft (CABG) surgery. The system is designed to meet the nursing challenges in health information to support needs of CABG patients. HeartCare (a) provides information and support, tailored to patients' individual and changing recovery needs during CABG recovery, (b) makes recovery information more accessible for timely use by patients, and (c) extends the scope of nursing services to CABG patients from hospital through home. An ongoing randomized controlled study is underway to evaluate the clinical outcomes of patients' use of the HeartCare system and to examine its acceptance as a usable resource for postCABG patients who have limited previous computer experience.

The importance of self-efficacy expectations in elderly patients recovering from coronary artery bypass surgery

OBJECTIVE

To describe and test a model of recovery in the elderly after coronary artery bypass surgery derived from Self-Care and Self-Efficacy Theory.

DESIGN

Prospective, longitudinal, repeated measures.

SETTING

Two large urban teaching hospitals on the East Coast.

PATIENTS

One hundred thirty-three adults over the age of 65 years who had coronary artery bypass surgery on hospital admission. There were 32 women and 101 men with an age range of 65 to 87 years (M = 71.8 years +/- 4.8 years) in whom 77.5% were in a New York Heart Association class of 3 or 4, indicating significant functional limitations.

OUTCOME MEASURES

Self-care agency, self-efficacy expectations, and the performance of self-care/recovery behaviors at discharge, 6, and 12 weeks after coronary artery bypass surgery.

INSTRUMENTS

The exercise of self-care agency was measured with the Exercise of Self-Care Agency Scale, self-efficacy expectation, and the performance of self-care/recovery behavior by the Jenkins Self-Efficacy Expectation Scales and Activity Checklists. Data were collected at discharge, 6 weeks, and 12 weeks after surgery for the specific behaviors of walking, climbing stairs, resuming general activities, and the performance of roles.

RESULTS

Repeated measures analysis of variance revealed significant changes in self-care agency, the self-efficacy expectations for all behaviors, and the performance of the behaviors for walking, resuming general activities, and performance of roles over the recovery period (p < 0.01).

CONCLUSIONS

In support of the model, self-efficacy expectations mediated between self-care agency and all self-care/recovery behaviors at selected times. Comparison of the performance of self-care/recovery behaviors with other samples from the literature found recovery in the elderly to be protracted. Nurses can be pivotal in providing the elderly with accurate projections of recovery and an environment to support the initial mastery of self-care/recovery behaviors to promote optimal health in this vulnerable population.