Systematic Review and Meta-analyses Investigating Whether Risk Stratification Explains Lower Rates of Coronary Angiography Among Women With Non-ST-Segment Elevation Acute Coronary Syndrome.

BACKGROUND: Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category. OBJECTIVES: The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography. METHODS: PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective. RESULTS: Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations. CONCLUSIONS: Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.

Gender difference in the use of coronary interventions for patients with acute coronary syndrome: Experience from a major metropolitan hospital in Melbourne, Australia.

BACKGROUND: Literature suggests an ongoing gender disparity in the use of coronary angiography and subsequent interventions among patients with acute coronary syndrome (ACS). OBJECTIVES: The study aimed to examine gender differences in the use of coronary interventions amongst patients with acute coronary syndrome (ACS) admitted to a major metropolitan hospital in Melbourne during the period 2009-2012. METHODS: We undertook a retrospective analysis of a hospital database of 2096 ACS patients. ACS included unstable angina (UA), ST-segment-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). RESULTS: The mean age of the patients was 64.3 years and 624 (30%) were women. Half of them were diagnosed as NSTEMI, 23% as STEMI and 25% as UA. Compared to men, women were older at admission, less likely to be diagnosed with STEMI and less likely to smoke. No gender difference was observed for severe co-morbidities or use of coronary angiography. Women diagnosed with STEMI were 39% less likely to receive an angioplasty stent (adjusted odds ratio 0.61, 95% confidence intervals 0.39-0.96) and 66% less likely to receive grafts (adjusted OR 0.34, 95% CIs 0.13-0.93). Women diagnosed with NSTEMI were 44% less likely to receive grafts (adjusted OR 0.56, 95% CIs 0.37-0.83). Younger women aged 35-49 years were less likely to receive an angioplasty stent, and older women >50 years were less likely to receive grafts. CONCLUSIONS: Adherence to guideline based treatment will help to ensure knowledge translation from guideline to practice. Further research investigating symptom presentation, use of non-invasive tests and medical management of ACS by gender may further explain gender difference for coronary interventions.

Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome.

OBJECTIVES: To determine the impact of gender and comorbidity on use of coronary interventions in patients diagnosed with high-risk non-ST-segment acute coronary syndrome (NSTEACS). BACKGROUND: Guidelines recommend the use of coronary angiography for all patients diagnosed with NSTEACS with high-risk features, except in the presence of severe comorbidities. However, little is understood about the relationship between gender, comorbidity, and the use of coronary interventions. METHODS: Retrospective analyses of the Victorian Admitted Episodes Data Set (VAED) including all patients diagnosed with NSTEACS with high-risk features on their first admission for ACS between June 2007 and July 2009. Hierarchical logistic regression models and correspondence analyses were used to understand the relationship between gender, comorbidities, and the use of coronary interventions. RESULTS: Out of 16,771 NSTEACS patients with high-risk features, 6,338 (38%) were female. Females were older than males (aged ≥75: 62% vs 39%, p < 0.001) and more likely to have multiple comorbidities (≥2: 66% vs 59%, p < 0.001). After adjusting for potential confounders, females were more likely to receive no coronary intervention than males with a similar number of comorbid conditions (no comorbidities: OR 1.62, 95% CI 1.28-2.05; 1 comorbidity: OR 1.67, 95% CI 1.44-1.93; 2 comorbidities: OR 1.93, 95% CI 1.66-2.23; ≥3 comorbidities: OR 1.42, 95% CI 1.27-1.60). CONCLUSIONS: Lower rates of coronary intervention in females persisted after adjusting for number of comorbidities which suggests that gender may bias decisions regarding referral for coronary intervention in high-risk NSTEACS independent of other factors.

Is There any Gender Difference for Smoking Persistence or Relapse Following Diagnosis or Hospitalization for Coronary Heart Disease? Evidence From a Systematic Review and Meta-Analysis.

INTRODUCTION: Persistent smoking in patients diagnosed with coronary heart disease (CHD) has a significant effect on morbidity and mortality. Although there has been considerable debate around gender differences in smoking cessation, conclusive evidence on how gender impacts rates of smoking cessation and/or relapse following CHD diagnosis is lacking. AIMS AND METHODS: Our aim was to test the hypothesis that female smokers with CHD were more likely to persist in smoking or relapse post-diagnosis or hospitalization than male smokers. We searched PubMed and Web of Science databases for studies published in the last 10 years. Meta-analyses were conducted using a random effects model. RESULTS: Sixteen studies met the inclusion criteria. The aggregated sample size was 36 591, 20 617 (56%) were smokers of which 2564 (12%) were female. Meta-analyses of eight studies where smoking prevalence could be measured, showed that females were less likely to be smokers at baseline than males (OR = 0.30, 95% CI = 0.13 to 0.70). Overall, one in two (47%) smokers persisted in smoking/relapsed following a diagnosis or hospitalization for CHD; but there was no gender difference in the rate of persistent smoking/relapse (OR = 1.07, 95% CI = 0.95 to 1.21). CONCLUSIONS: Female smokers with CHD were relatively uncommon in the included study populations. However, the rate of persistent smoking/relapse was high in both female and male smokers following a diagnosis or hospitalization for CHD. Therefore similar, sustained smoking cessation efforts are warranted for both genders. IMPLICATIONS: There was no gender difference for persistent smoking/relapse following a diagnosis or hospitalization for CHD, but the rate was high in both female and male smokers. Therefore, similar, sustained smoking cessation efforts are warranted for both genders.

Exploring Aboriginal patients' experiences of cardiac care at a major metropolitan hospital in Melbourne.

Objectives The aim of the present study was to explore Aboriginal patients' lived experiences of cardiac care at a major metropolitan hospital in Melbourne. Methods The study was a qualitative study involving in-depth interviews with a purposive sample of 10 Aboriginal patients who had been treated in the cardiology unit at the study hospital during 2012-13. A phenomenological approach was used to analyse the data. Results Eight themes emerged from the data, each concerning various aspects of participants' experiences: 'dislike of hospitals', 'system failures', 'engagement with hospital staff', 'experiences of racism', 'health literacy and information needs', 'self-identifying as Aboriginal', 'family involvement in care' and 'going home and difficulties adapting'. Most participants had positive experiences of the cardiac care, but hospitalisation was often challenging because of a sense of dislocation and disorientation. The stress of hospitalisation was greatly mediated by positive engagements with staff, but at times exacerbated by system failures or negative experiences. Conclusion Cardiac crises are stressful and hospital stays were particularly disorienting for Aboriginal people dislocated from their home land and community. What is known about the topic? Aboriginal people have higher mortality rates due to cardiovascular diseases compared with other Australians. Along with different factors contributing to the life expectancy gap, Aboriginal people also face significant barriers in the use of the healthcare system. What does this paper add? Aboriginal patients' lived experience of cardiac care at a major metropolitan hospital in Melbourne is explored in this paper. Different issues were revealed during their interaction with the hospital staff and the hospital system in conjunction with their cultural aspect of patient care. What are the implications for practitioners? Positive interactions with staff, ongoing support from family and community, culturally appropriate cardiac rehabilitation programs can improve the cardiac care experiences of Aboriginal patients.

Gender difference in treatment and mortality of patients with ST-segment elevation myocardial infarction admitted to Victorian public hospitals: a retrospective database study.

BACKGROUND: Death from acute coronary syndrome (ACS) is avoidable with early reperfusion therapy, however, evidence suggests inequity in women's ACS treatment within a number of international healthcare systems, when compared to men's. Research indicates mortality rates are higher in some age groups of women when compared to men for the sub-group of ACS known as ST-segment elevation myocardial infarction (STEMI). OBJECTIVE: To determine whether patient sex was associated with patterns of reperfusion treatment variation or increased inhospital mortality in patients with STEMI. METHODS: We undertook retrospective analyses on a government database for patients admitted to Victorian public hospitals with STEMI. Patients were categorised into two age groups: 18-64 and 65-84 years (inclusive), to determine whether patient sex and these age groups influenced treatment from 2005 to 2008 and mortality from 2005 to 2010. RESULTS: Both younger and older women received less frequent angioplasty with stent and more often received no reperfusion treatment than men in corresponding younger and older age groups (p=0.006 and p<0.001, respectively). Overall, women in both age groups were more likely to die inhospital than men from equivalent age groups with STEMI (p<0.001, both groups). CONCLUSIONS: Proportionately, both younger and older women received less interventional reperfusion therapy for STEMI than their male cohorts, and died more often during admission than men. Further research needs to be undertaken to verify the findings and causes, and guide future research to ensure application of evidence to treatment in patients with STEMI.

Assessment of an established dialysis nurse practitioner model of care using mixed methods research.

AIMS AND OBJECTIVES: To assess a dialysis nurse practitioner (NP) model of care by examining satisfaction, quality of life (QOL) and clinical outcomes of haemodialysis patients and explore experiences of dialysis nurses. DESIGN: Mixed methods. METHODS: Database analyses of dialysis indices amongst a sample (n = 45) of haemodialysis patients; a survey (n = 27) examining patient experience, satisfaction and QOL; and in-depth interviews with a sample (n = 10) of nurses. RESULTS: Nurses commended the NP role, with five themes emerging: "managing and co-ordinating", "streamlining and alleviating", "developing capability", "supporting innovation and quality" and "connecting rurally". Patients' average age was 66 years and 71% were male. Patients' satisfaction with the care they received was rated 3.5/4 or higher across seven parameters and the average QOL score was 7.9/10. CONCLUSION: The NP model of care is effective in enhancing patient care within a collaborative framework. The challenge is to sustain, and enhance the model, through mentorship programs for potential candidates.

The process and utility of classification and regression tree methodology in nursing research.

AIM: This paper presents a discussion of classification and regression tree analysis and its utility in nursing research. BACKGROUND: Classification and regression tree analysis is an exploratory research method used to illustrate associations between variables not suited to traditional regression analysis. Complex interactions are demonstrated between covariates and variables of interest in inverted tree diagrams. DESIGN: Discussion paper. DATA SOURCES: English language literature was sourced from eBooks, Medline Complete and CINAHL Plus databases, Google and Google Scholar, hard copy research texts and retrieved reference lists for terms including classification and regression tree* and derivatives and recursive partitioning from 1984-2013. DISCUSSION: Classification and regression tree analysis is an important method used to identify previously unknown patterns amongst data. Whilst there are several reasons to embrace this method as a means of exploratory quantitative research, issues regarding quality of data as well as the usefulness and validity of the findings should be considered. IMPLICATIONS FOR NURSING RESEARCH: Classification and regression tree analysis is a valuable tool to guide nurses to reduce gaps in the application of evidence to practice. With the ever-expanding availability of data, it is important that nurses understand the utility and limitations of the research method. CONCLUSION: Classification and regression tree analysis is an easily interpreted method for modelling interactions between health-related variables that would otherwise remain obscured. Knowledge is presented graphically, providing insightful understanding of complex and hierarchical relationships in an accessible and useful way to nursing and other health professions.

A review of sedation scales for the cardiac catheterization laboratory.

PURPOSE: Sedation scales have the potential to facilitate effective procedural sedation and analgesia in the cardiac catheterization laboratory (CCL). For this potential to become realized, a scale that is suitable for use in the CCL either needs to be identified or developed. DESIGN: A structured review strategy was applied. METHODS: To identify sedation scales, a review of Medline and CINHAL was conducted. FINDINGS: One sedation scale for the CCL, the North American Society for Pacing and Electrophysiology Sedation Scale, and 15 intensive care unit (ICU) scales met the inclusion and exclusion criteria. Analysis of the scale's item structures and psychometric properties was then performed. CONCLUSION: None of these scales were deemed suitable for use in the CCL. As such, further research is required to develop a new scale. The new scale should consist of more than one item to make it more effective for tracking the patient's response to medications. Specific tests required to conduct a rigorous evaluation of the new scale's psychometric properties are outlined in this article.

Implementing a working together model for Aboriginal patients with acute coronary syndrome: an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse working together to improve hospital care.

Acute coronary syndrome (ACS) contributes to the disparity in life expectancy between Aboriginal and non-Aboriginal Australians. Improving hospital care for Aboriginal patients has been identified as a means of addressing this disparity. This project developed and implemented a working together model of care, comprising an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse, providing care coordination specifically directed at improving attendance at cardiac rehabilitation services for Aboriginal Australians in a large metropolitan hospital in Melbourne. A quality improvement framework using a retrospective case notes audit evaluated Aboriginal patients' admissions to hospital and identified low attendance rates at cardiac rehabilitation services. A working together model of care coordination by an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse was implemented to improve cardiac rehabilitation attendance in Aboriginal patients admitted with ACS to the cardiac wards of the hospital. A retrospective medical records audit showed that there were 68 Aboriginal patients admitted to the cardiac wards with ACS from 1 July 2008 to 30 June 2011. A referral to cardiac rehabilitation was recorded for 42% of these. During the implementation of the model of care, 13 of 15 patients (86%) received a referral to cardiac rehabilitation and eight of the 13 (62%) attended. Implementation of the working together model demonstrated improved referral to and attendance at cardiac rehabilitation services, thereby, has potential to prevent complications and mortality. WHAT IS KNOWN ABOUT THE TOPIC?: Aboriginal Australians experience disparities in access to recommended care for acute coronary syndrome. This may contribute to the life expectancy gap between Aboriginal and non-Aboriginal Australians. WHAT DOES THIS PAPER ADD?: This paper describes a model of care involving an Aboriginal Hospital Liaisons Officer and a specialist cardiac nurse working together to improve hospital care and attendance at cardiac rehabilitation services for Aboriginal Australians with acute coronary syndrome. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: The working together model of care could be implemented across mainstream health services where Aboriginal people attend for specialist care.

Factors associated with post-intensive care unit adverse events: a clinical validation study.

BACKGROUND: Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events. AIM: This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice. DESIGN: Prospective, clinical validation study. METHOD: Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge. RESULTS: Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities. CONCLUSION: Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients. RELEVANCE TO CLINICAL PRACTICE: Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced.

Complexity of management and health outcomes in a prospective cohort study of 573 heart failure patients in Australia: does more equal less?

AIMS AND OBJECTIVES: To compare the efficacy of chronic heart failure management programmes (CHF-MPs) according to a scoring algorithm used to quantify the level of applied interventions-the Heart Failure Intervention Score (HF-IS). BACKGROUND: The overall efficacy of heart failure programmes has been proven in several meta-analyses. However, the debate continues as to which components are essential in a heart failure programme to improve patient outcomes. DESIGN: Prospective cohort study of patients participating in heart failure programmes. METHOD: Forty-eight of 62 (77%) programmes in Australia participating in a national register of CHF-MPs were evaluated using the HF-IS: derived from a summed and weighted score of each intervention applied by the CHF-MP (27 interventions overall). The CHF-MPs were prospectively categorised as relatively low (HF-IS < 190 - n = 39 programmes & 407 patients) or high (HF-IS ≥ 190 - n = 9 programmes & 166 patients) in complexity. Six-month morbidity and mortality rates in 573 consecutively recruited patients with systolic dysfunction and in New York Heart Association Class II-IV were prospectively examined. RESULTS: Patients exposed to CHF-MPs with a high HF-IS had a lower rate of unplanned, all-cause hospitalisation (n = 24, 14% vs. n = 102, 25%) compared with CHF-MPs with a low HF-IS within six months. On an adjusted basis, CHF-MPs with a high HF-IS were associated with a reduced risk of unplanned hospitalisation and/or death within six months and remained event-free longer. CONCLUSION: High complexity CHF-MPs applying more evidence-based interventions are associated with a higher event-free survival over six months. RELEVANCE TO CLINICAL PRACTICE: The HF-IS is an easy-to-use evidence-based tool to assist programme coordinators to improve the quality of their heart failure programme which may also improve patient outcomes.

Examining adverse events after intensive care unit discharge: outcomes from a pilot questionnaire.

Adverse events are common in acute clinical settings but little is known about these events occurring after Intensive Care discharge. This study aimed to develop a reliable and valid tool for exploring clinicians' opinions of factors associated with post-Intensive Care adverse events. A convenience sample of Australian Intensive Care Liaison Nurses was invited to complete and appraise a questionnaire using structured guidelines. Content validity and internal consistency were assessed. Twelve Intensive Care Liaison Nurses completed the questionnaire. Cronbach?s alpha coefficient showed high internal consistency for the questionnaire; all 24 items on the questionnaire had coefficients greater than 0.852. The content validity index of the questionnaire overall was 0.76. The post-Intensive Care adverse events questionnaire demonstrated reliability and validity. It is a tool that can be used to explore clinicians? opinions of factors associated with these events. The tool is important as it facilitates further insight into the causes of post-Intensive Care adverse events.

Factors contributing to adverse events after ICU discharge: a survey of liaison nurses.

BACKGROUND: A significant number of patients experience an adverse event when discharged from intensive care to a ward. More than half of these events may be preventable with better standards of care. AIM: To explore the opinions of an expert group of clinicians around factors contributing to adverse events in patients discharged from ICU. METHOD: Online survey of Australian ICU Liaison Nurses (n=39) using a validated questionnaire of 25 items. RESULTS: The response rate was 92.8%. Key contributing factors included a lack of experienced ward staff, patient co-morbidities and the clinically challenging nature of many patients. CONCLUSION: Modifying processes of care may decrease the risk or impact of adverse events in this high risk patient population.

Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure.

BACKGROUND: Heart failure (HF) patients who follow the treatment regimen and attend to symptoms before they escalate are assumed to have better health-related quality of life (HRQOL) than those with poor self-care, but there are few data available to support or refute this assumption. OBJECTIVE: The objective of the study was to describe the relationship between HF self-care and HRQOL in older (≥65 years old) adults with moderate to advanced HF. METHODS: Self-care was measured using the 3 scales (maintenance, management, and confidence) of the Self-care of Heart Failure Index. Scores range from 0 to 100, with higher numbers indicating better self-care. Health-related quality of life was measured with the Minnesota Living With Heart Failure Questionnaire, a 2-subscale (physical and emotional) instrument. Lower numbers on the Minnesota Living With Heart Failure Questionnaire indicate better HRQOL. Pearson correlations, independent-samples t-tests, and linear and logistic regression modeling were used in the analysis. RESULTS: In 207 adults (72.9 [SD, 6.3] years), New York Heart Association class III (82%) or IV, significant linear associations were observed between self-care confidence and total (r = -0.211; P = .002), physical (r = -0.189; P = .006), and emotional HRQOL (r = -0.201; P = .004). Patients reporting better (below median) HRQOL had higher confidence scores compared with patients reporting above-median HRQOL scores (58.8 [19.2] vs 52.8 [19.6]; P = .028). Confidence was an independent determinant of total (ßs = -3.191; P = .002), physical (ßs = -2.346; P = .002), and emotional (ßs = -3.182; P = .002) HRQOL controlling for other Self-care of Heart Failure Index scores, age, gender, and New York Heart Association class. Each 1-point increase in confidence was associated with a decrease in the likelihood that patients had worse (above median) HRQOL scores (odds ratio, 0.980 [95% confidence interval, 0.963-0.998]) with the same controls. No significant associations were found between self-care maintenance or management and HRQOL. CONCLUSIONS: The degree of individual confidence in HF self-care is related to HRQOL, but self-reports of specific maintenance and management behaviors are not. Interventions that improve self-care confidence may be particularly important in older adults with moderate to advanced HF.

Clinical outcomes associated with screening and referral for depression in an acute cardiac ward.

AIM: The aim of this paper is to describe the implementation of a depression screening and referral tool in two cardiac wards of a major metropolitan public hospital. The tool consisted of two sections: (1) screening for depression risk (Cardiac Depression Scale-5) and (2) consequential referral actions. BACKGROUND: Prior research has shown that depression in patients with heart disease is associated with significantly impaired quality of life, decreased medication adherence, increased morbidity and increased use of healthcare services. DESIGN: A prospective in-patient study design. METHOD: A consecutive sample of 202 patients admitted to either the cardiac medical (n = 145) or surgical (n = 57) wards of a major Melbourne metropolitan hospital were recruited into the study over an 18-week period. RESULTS: Just over half (54%) of the patients were identified as 'at risk' of depression. Of these, 19% were assessed as moderate risk and 35% high risk. Of those patients, 91% had the risk score documented in their medical history, 90% had engaged in discussions with clinicians regarding their risk score, 85% had their risk score communicated formally to the medical team and 25% were formally referred for appropriate follow-up - significantly more than prior to implementation of the screening and referral tool. CONCLUSIONS: By providing a formalised mechanism for detecting depression, documented screening and referral rates improved for those with comorbid depression and heart disease affording an opportunity for early intervention. These findings support a move towards integrated approaches to screening of depression to become standard practice in the acute cardiac setting. RELEVANCE TO CLINICAL PRACTICE: Such mechanisms also have the potential to initiate the development of new models of care that acknowledge the complexity of comorbid depression and heart disease and provide pathways from speciality to primary care which integrate the physical and psychosocial domains inclusive of screening, referral, systematic monitoring and streamlined behavioural and physical care.

Reason's accident causation model: application to adverse events in acute care.

Adverse events are unintended harm to a patient caused by the health care provided; more than half of all these events have been deemed avoidable. Adverse events are a common problem in acute care and represent a breach in care quality and safety. They are generally not caused by a single mistake or error and although safety barriers exist in health care, patients today are still harmed. Using an accident causation model is a constructive way of identifying the underlying causes of adverse events and to strengthen a study's theoretical underpinnings. Reason's model is recommended as a useful framework for adverse event analysis as it promotes a focus on the conditions or situation in which the clinician was trying to perform, rather than apportioning blame.

Women and cardiovascular disease: at a social disadvantage?

BACKGROUND: Cardiovascular disease is the most common cause of death in Australian women. The genesis and progression of cardiovascular disease is modulated by a complex interplay of genetic, physiological, social and economic circumstances. Increasingly the impact of racial, ethic, social and economic inequalities is identified as predictors of cardiovascular disease outcome. Despite important advances over the last 30 years in reducing age adjusted mortality from cardiovascular disease, it continues to represent a major social and economic burden nationally and internationally. AIM: This paper provides a critical review of the social issues impacting upon women in Australia. It also identifies areas for future interventions with a view to improving outcomes in women with cardiovascular disease. METHOD: The bibliographic databases; CINAHL, MEDLINE, PsycARTICLES, were searched for relevant studies using the search terms 'women', 'cardiovascular disease', and 'socio-economic status'. FINDINGS: While some gains have been made in reducing the risk factor profile and rates of death from cardiovascular disease, it is clear that gender, race and socioeconomic disparities persist. CONCLUSIONS: New approaches are required to improve health differentials for CVD, and reduce the impact of gender, racial, ethic, social and economic factors on health disparities.

Assessing risk post intervention for an acute coronary syndrome: a review of the risk assessment tools and their development.

Considerable variability in survival rate after an acute myocardial infarction exists and accurate risk stratification is of significant importance. The American College of Cardiology and the American Heart Association has recommended early risk stratification using several clinical risk scoring instruments to identify high risk patients. The aim of this paper is to identify secondary cardiovascular risk scoring instruments that could be utilized at the time of intervention for acute coronary syndromes and compare their psychometric properties as they were developed. A search using Medline, Cumulative Index to Nursing and Allied Health Literature and the Psychology and Behavioral Sciences Collection databases identified studies published between January 1990 and January 2010 used to measure risk after intervention for acute coronary syndrome. Four validated secondary risk prediction scoring instruments were identified for comparison. Secondary risk prediction scoring instruments for the acute coronary syndrome patient population are evidence based, valid and reliable. Use of the instruments by cardiac focused clinicians will aid in the determination of treatment strategies, and estimation of short and long term events and mortality.

From novice to expert: confidence and activity status determine heart failure self-care performance.

BACKGROUND: In a previous, small, mixed-methods study, heart failure patients were described as novice, expert, or inconsistent in self-care. In that study, self-care types differed in experience, confidence, attitudes, and skill. OBJECTIVES: The aims of this study were to validate the novice-to-expert self-care typology and to identify determinants of the heart failure self-care types. METHODS: A cross-sectional descriptive study was performed using data from 689 adults with heart failure (61 ± 2.5 years; 36% female, 50% New York Heart Association class III). Two-step likelihood cluster analysis was used to classify patients into groups using all items in the maintenance and management scales of the Self-care of Heart Failure Index. Multinomial regression was used to identify the determinants of each self-care cluster, testing the influence of age, gender, left ventricular ejection fraction, body mass index, depression, anxiety, hostility, perceived control, social support, activity status (Duke Activity Status Index), and self-care confidence. RESULTS: Self-care behaviors clustered best into three types: novice (n = 185, 26.9%), expert (n = 229, 33.2%), and inconsistent (n = 275, 39.9%). The model predicting self-care cluster membership was significant (χ2 = 88.67, p < .001); Duke Activity Status Index score and Self-care of Heart Failure Index confidence score were the only significant individual factors. Higher activity status increased the odds that patients would be inconsistent (odds ratio [OR] = 1.02-1.09) or novice (OR = 1.02-1.10) in self-care. Higher self-care confidence increased the odds of being an expert (OR = 1.05-1.09) or inconsistent (OR = 1.01-1.05) in self-care. DISCUSSION: The three-level typology of heart failure self-care was confirmed. Patients who have fewer limitations to daily activities may not be driven adequately to engage in heart failure self-care and may need extra assistance in developing expertise.