Risk prediction in stable angina pectoris.

BACKGROUND: Although stable angina pectoris often carries a favourable prognosis, it remains important to identify patients with an increased risk of cardiovascular (CV) complications. Many new markers of disease activity and prognosis have been described. We evaluated whether common and easily accessible markers in everyday care provide sufficient prognostic information. MATERIALS AND METHODS: The Angina Pectoris Prognosis Study in Stockholm treated 809 patients (248 women) with stable angina pectoris with metoprolol or verapamil double blind during a median follow-up of 3·4 years, with a registry-based extended follow-up after 9·1 years. Clinical and mechanistic variables, including lipids and glucose, renal function, ambulatory and exercise-induced ischaemia, heart rate variability, cardiac and vascular ultrasonography, and psychosocial variables were included in an integrated analysis. Main outcome measures were nonfatal myocardial infarction (MI) and CV death combined. RESULTS: In all, 139 patients (18 women) suffered a main outcome. Independent predictive variables were (odds ratio [95% confidence intervals]), age (1·04 per year [1·00;1·08], P = 0·041), female sex (0·33 [0·16;0·69], P = 0·001), fasting blood glucose (1.29 per mM [1.14; 1.46], P < 0·001), serum creatinine (1·02 per µM [1·00;1·03], P < 0·001) and leucocyte counts (1·21 per 10(6)  cells/L [1·06;1·40], P = 0·008). Smoking habits, lipids and hypertension or a previous MI provided limited additional information. Impaired fasting glucose was as predictive as manifest diabetes and interacted adversely with serum creatinine. Sexual problems were predictive among men. CONCLUSIONS: Easily accessible clinical and demographic variables provide a good risk prediction in stable angina pectoris. Impaired glucose tolerance and an elevated serum creatinine are particularly important.

Evaluation of an educational programme for family members of patients living with heart failure: a randomised controlled trial.

AIMS AND OBJECTIVES: To evaluate the effect of a group-based multi-professional educational programme for family members of patients with chronic heart failure with regard to quality of life, depression and anxiety. The secondary aim was to investigate the impact of social support and sense of coherence on changes in quality of life, anxiety and depression during the period of the study. BACKGROUND: When a person is diagnosed with heart failure, the daily life of the family members is also affected. DESIGN: Randomised controlled trial. METHODS: A total of 128 family members were randomly assigned to participate in a multi-professional educational programme or a control group. Analysis of variance and regression analysis were used. RESULTS: There were no significant differences in anxiety, depression or quality of life between the intervention group and control group. Adequacy of social network was the only independent variable that explained levels of anxiety and depression after 12 months beyond baseline levels of anxiety (p < 0·001, R(2) = 0·35) and depression (p = 0·021, R(2) = 0·37). Younger family members were found to have a higher quality of life (p < 0·01). CONCLUSION: Improved disease-related knowledge may need to be combined with other target variables to induce desired effects on depression, anxiety and quality of life of family members. Antecedents of depression and anxiety, such as sense of control, may need to be specifically targeted. Our results also suggest that intervention aimed at enhancing social support may be beneficial for family members. RELEVANCE TO CLINICAL PRACTICE: Anxiety and depression did not decrease nor did quality of life improve after the intervention. An educational programme for family members with a component specifically targeting anxiety, depression and quality of life warrants testing. Furthermore, it is important that health care providers understand the influence of social support on anxiety, depression and quality of life when interacting with family members.

Long-term effects of an expanded cardiac rehabilitation programme after myocardial infarction or coronary artery bypass surgery: a five-year follow-up of a randomized controlled study.

OBJECTIVE: To investigate the long-term effect of expanded cardiac rehabilitation on a composite end-point, consisting of cardiovascular death, myocardial infarction or readmission for cardiovascular disease, in patients with coronary artery disease. DESIGN: Single-centre prospective randomized controlled trial. SETTING: University hospital. SUBJECTS: Two hundred and twenty-four patients with acute myocardial infarction or undergoing coronary artery by-pass grafting. INTERVENTION: Patients were randomized to expanded cardiac rehabilitation (a one-year stress management programme, increased physical training, staying at a 'patient hotel' for five days after the event, and cooking sessions), or to standard cardiac rehabilitation. MAIN MEASURES: Data on cardiovascular death, myocardial infarction, readmission for cardiovascular disease and days at hospital for cardiovascular reasons were obtained from national registries of the Swedish National Board of Health and Welfare. RESULTS: The primary end-point occurred in 121 patients altogether (54%). The number of cardiovascular events were reduced in the expanded rehabilitation group compared with the standard cardiac rehabilitation (53 patients (47.7%) versus 68 patients (60.2%); hazard ratio 0.69; P =0.049). This was mainly because of a reduction of myocardial infarctions in the expanded rehabilitation group. During the five years 12 patients (10.8%) versus 23 patients (20.3%); hazard ratio 0.47; P =0.047 had a myocardial infarction. Days at hospital for cardiovascular reasons were significantly reduced in patients who received expanded cardiac rehabilitation (median 6 days) compared with standard cardiac rehabilitation (median 10 days; P =0.02). CONCLUSION: Expanded cardiac rehabilitation after acute myocardial infarction or coronary artery bypass grafting reduces cardiovascular morbidity and days at hospital for cardiovascular reasons.

A group-based multi-professional education programme for family members of patients with chronic heart failure: effects on knowledge and patients' health care utilization.

OBJECTIVE: The aim was to investigate if family members of patients with chronic heart failure (CHF) increased knowledge about CHF through a group-based multi-professional educational programme and whether there was an effect on patients' health care utilization. METHODS: Family members (n=128) were randomly assigned to intervention-group (IG) who received CHF education programme or control-group (CG) who received information according to hospital routines. Programme effects were evaluated with CHF knowledge questionnaire, patient readmissions and number of days hospitalised during 18 months. RESULTS: Knowledge about CHF increased in both groups, significantly higher in IG at second assessment (IG 16±1.9 vs. CG 14.9±2.1, p=0.006), and knowledge maintained at third assessment. In IG 17 patients were re-admitted at least once and 28 patients in CG due to CHF (p=0.085). There were no differences in frequency of readmissions or number of days hospitalised. CONCLUSION: A group-based multi-professional education programme increased family members' knowledge about CHF. Despite this, effect on patient's health care utilization could not be seen during follow-up period. PRACTICAL IMPLICATIONS: We suggest that CHF education programmes for family members should be provided at clinics, with information preferably repeated 2-3 times during a period of six months to maintain knowledge level.

Perceived loneliness and social support in patients with chronic heart failure.

UNLABELLED: Self-reported conditions have become increasingly important in patient care, and perceived loneliness and social relationships in patients with chronic heart failure (CHF) are not sufficiently investigated. AIM: The aim was to investigate perceived loneliness and social support in patients with CHF. Further, to investigate whether loneliness and social support might be associated with gender, age, healthcare utilization and mortality. METHODS: One hundred and forty nine patients with CHF, hospitalised at least once during a 4-month period in 2006, completed a self-reported questionnaire including measurements about loneliness and social support. Healthcare utilization was assessed prospectively by frequency of readmissions and number of days hospitalised during 1 year. RESULTS: Loneliness was reported by 29 (20%) participants. They were more often women (p<0.001) and younger (p=0.024). Patients who perceived loneliness had fewer social contacts (p=0.033), reported lower occurrence of emotional contacts (p=0.004), were less satisfied with social contacts and close relationships (p<0.001). Those reporting loneliness had more days hospitalised (p=0.044), and more readmissions to hospital (p=0.027), despite not having more severe CHF. CONCLUSION: Loneliness is a health-related risk indicator in that patients with CHF who perceived loneliness have more healthcare utilization than those who do not report loneliness despite not having more severe CHF.

Predictors of life situation among significant others of depressed or aphasic stroke patients.

AIM: The aim of this study was to examine predictors of the life situation of the significant other of depressed or aphasic stroke patients. BACKGROUND: Depression and aphasia are common consequences of stroke, and both may put pressure on the significant other who have to deal not only with a possible physical handicap but also with communication and/or serious psychiatric difficulties. DESIGN: Descriptive, cross-sectional study. METHODS: The participants were significant others of 71 depressed and 77 aphasic stroke patients. Depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorder, and degree of aphasia was diagnosed with the Amsterdam Nijmegen Everyday Language Test. Assessments of the life situation, state of depression and aggression, personality change and need of assistance were made through questionnaires issued to the significant others. RESULTS: Perceived need of assistance was the only common predictor of life situation of the significant other in both groups (p < 0.001). With respect to the aphasic patients, perceived personality change (p < 0.001) and living with the patient (p = 0.004) were factors that had a negative effect on the life situation of the significant other. CONCLUSIONS: This study highlights that the perception of the patient's need of assistance is an important factor in predicting the life situation among spouses of depressed as well as aphasic stroke patients. A comparison of the two groups to explain the life situation of the significant others revealed greater explanatory power for the aphasic group. RELEVANCE TO CLINICAL PRACTICE: Assessments of the spouses' perception as well as of the patients' factual situation may identify those significant others at risk. With this new approach, necessary steps may be taken to alleviate pressure on the significant other.

The impact of gender regarding psychological well-being and general life situation among spouses of stroke patients during the first year after the patients' stroke event: a longitudinal study.

BACKGROUND: The informal caregivers perceive lack of choice to take on the role of caregiving, receiving little or no preparation for the caregiving role at home. The typical informal caregiver is female, either a spouse or adult child of the care recipient, and seldom shares the responsibilities of caregiving with other family members. The spouses worry about the ill relative, but also about what consequences the disease might have for their own life. The worries seem to vary with gender and disease. There are, to our knowledge, few previous longitudinal studies that have focused on gender differences among spouses of stroke patients. OBJECTIVES: To explore gender differences among spouses in perceived psychological well-being and general life situation, during the first year after the patients' stroke event. DESIGN: Longitudinal study with three assessments regarding psychological well-being and general life situation during 1 year. SETTINGS: The study took place at a stroke ward, Stockholm, Sweden. PARTICIPANTS: Consecutively 80 female and 20 male spouses of stroke patients admitted to a stroke unit participated. METHODS: Data were analysed using analyses of variance. RESULTS: Female spouses have a negative impact on psychological well-being, while male spouses have a lower occurrence of emotional contacts in their social network. Consistently, the female spouses reported lower quality of life and well-being than the male spouses. CONCLUSIONS: This study generates the hypotheses that there are gender differences among spousal caregivers of stroke patients; female spouses are more negatively affected in their life situation due to the patients' stroke event than the male spouses. It is important to take the individual differences under consideration when designing a nursing intervention, to meet the different needs and demands of male and female caregivers. The interventions should focus on individual support, so that the caregivers can adapt to their new role and be comfortable and effective as informal caregivers.

Predictors of psychological health in spouses of persons affected by stroke.

AIM: To identify predictors of psychological health and examine if these predictors change over time in spouses of stroke patients during the first year after stroke. A second aim was to identify gender differences in psychological health among the spouses. BACKGROUND: The impact of burden in long-term caregivers may result in psychological consequences for the spouse. The rehabilitation process for the patient can be negatively affected by a stressed caregiver and result in long-term hospitalization. To identify spouses at risk for physical and psychological distress is, therefore, essential to support those in need. DESIGN: Longitudinal, comparative study. METHODS: One hundred spouses of stroke patients were assessed at baseline, as well as after six and 12 months, regarding psychological health, well-being, own illness, need of assistance from general practitioner and/or district nurse, social network and knowledge about stroke. Stepwise multiple regression analyses were conducted for baseline, six- and 12-month assessments, respectively, with psychological health as the dependent variable. RESULTS: General well-being and presence of illness in spouse were the most prominent predictors of psychological health, throughout the first year. CONCLUSIONS: Enhancing psychological health and preventing medical problems in the caregiver are essential considerations to enable patients with stroke-related disabilities to continue to live at home. RELEVANCE TO CLINICAL PRACTICE: Evaluating the situation for spouses of stroke patients is an important component when planning for the future care of the patient.

Effects of expanded cardiac rehabilitation on psychosocial status in coronary artery disease with focus on type D characteristics.

Type D personality has been shown to increase the risk for cardiovascular events in patients with coronary artery disease (CAD). We investigated the effects of expanded cardiac rehabilitation on type D score and psychosocial characteristics in 224 CAD patients randomised to either expanded cardiac rehabilitation (stress management, increased physical training, stay at a "Patient Hotel" after discharge and cooking sessions), or routine rehabilitation. Follow-up was 1 year. At baseline patients with a high type D score [patients in the upper quartile of type D score (Q4) i.e., type D patients] had a lower sense of coherence (p < 0.001), a lower quality of life (p < 0.001), more depressive symptoms (p < 0.001) and increased anxiety (p < 0.001) as compared to patients with a low type D score (Q1). During follow-up, type D patients (Q4) randomised to intervention had significant decrements in type D-score (p < 0.01), depression and anxiety (p < 0.05) and an increment in quality of life scores (p < 0.001). Quality of life was also improved in control type D patients (Q4; p < 0.01) but no significant changes were seen in type D score, depression or anxiety. Expanded cardiac rehabilitation reduces type D score, anxiety and depressive symptoms, and improves the quality of life in type D patients.

Post-stroke depression - effect on the life situation of the significant other.

The aim of this study was to describe the life situation among 'significant others' to patients with post-stroke depression, and to identify associations between the life situation of the significant others and patient characteristics. Seventy-one dyads consisting of patients with a diagnosed post-stroke depression and their significant others were included. The patients were assessed for depression with the Montgomery-Asberg Depression Rating Scale and diagnosed according to the DSM-IV. The assessments of significant others included their own life situation and proxy assessments of the patients' state of depression, anger, change of personality, and need of assistance. Significant others of male stroke patients reported a more negative impact on their life situation, than did significant others of female stroke patients (p = 0.04). There was a significant association between the patient's level of depression and physical function [activities of daily living (ADL)], with those with less impaired ADL having more major depression than those with more impaired ADL (p = 0.007). This study indicates that major post-stroke depression is more common among patients with limited functional deficits. This highlights the importance of assessment for depression also among seemingly recovered stroke patients in order to treat and support those in need. This study also stresses the importance of identifying different needs of the significant others in order to provide appropriate support in their caregiving role.

Predictors of quality of life among spouses of stroke patients during the first year after the stroke event.

BACKGROUND: Stroke, a disease with severe consequences for patients and their families, often lead to psychosocial stress, and a decline in the quality of life (QoL) among carers. Predicting the QoL is essential in the development of effective nursing support interventions. AIM: The aim of the present study was to identify predicting factors for the general QoL among spouses of stroke patients, and to determine whether these predictors change during the first year after the patient's stroke event. DESIGN: One hundred spouses were followed three times during 1 year regarding QoL, own illness, economic situation, well being, life situation, sense of coherence, social network and the patients' ability in activities of daily living (ADL). Stepwise multiple linear regression analyses were conducted for the baseline, 6- and 12-month assessments respectively, with the present QoL as the dependent variable. RESULTS: Over time during the first year after the patients' stroke event, there were significant differences in the spouses perceived general QoL. Life situation and economic situation were the only predictors of the spouses' QoL, which emerged during the entire year after the patient's stroke event, while well being, education, own illness, social network and ADL ability (patient) emerged at one or two occasions. CONCLUSION: The psychosocial factors -- life situation, well being, social network, education and economy -- are important in predicting QoL among spouses of stroke patients, and these predicting factors change over time. Determining the predictors at an early stage, and continuously over time, will help to focus clinical nursing interventions on the spouses' changing needs.

Spouse's life situation after partner's stroke event: psychometric testing of a questionnaire.

AIM: This paper reports a study to validate and test the reliability of a questionnaire constructed to evaluate the life situation of spouses after their partners have had a stroke. BACKGROUND: Stroke is a disease with great consequences for survivors and their families. Most survivors return home after the hospitalization and rehabilitation due to the stroke event. Relatives, primarily spouses, often feel obligated to care for the survivor at home, providing emotional support or assisting the person in activities of daily living. More specific information is needed about the spouse's life situation after the stroke event in order to develop effective supportive strategies. METHODS: Psychometric testing of the Life Situation Questionnaire was undertaken with 99 spouses of stroke survivors. The 13-item questionnaire consists of four subscales: 'Worries', 'Powerlessness', 'Personal adjustment' and 'Social isolation'. RESULTS: Item analysis showed that each item correlated with its own subscale (r = 0.63-0.78). The instrument had high internal consistency, with Cronbach's alphas of 0.80-0.86 and reasonable high congruent validity when correlated with a Wellbeing instrument, with a correlation of 0.59 (P = 0.001). Exploratory factor analysis confirmed the subscales, accounting for 77% of the variance. CONCLUSION: The Life Situation Questionnaire is a valid and reliable instrument, and could serve as an assessment tool after a stroke event to identify family caregivers who have problems in their life situations and need support from healthcare services.

The impact of a nurse-led support and education programme for spouses of stroke patients: a randomized controlled trial.

AIMS AND OBJECTIVES: The aim of the present study was to determine the impact of a nurse-led support and education programme for improving the spouses' perceived general quality of life, life situation, general well-being and health state. BACKGROUND: Stroke is a disease with great consequences for the patients and their families. The spouses often feel obligated to care for the patient, providing psychological and physical support and having to cope with the patient's physical and cognitive impairments. This might lead to increased problems, as family members struggle to adapt to their new roles and responsibilities. DESIGN AND METHODS: Longitudinal, randomized controlled trial. One hundred spouses were randomly assigned to intervention or control groups, 50 in each group. The intervention group participated in a support and education programme, six times during six months, led by stroke specialist nurses. Both groups were followed for 12 months. RESULTS: No significant differences were found, between intervention and control groups, over time. In the sub analyses, we found that the group attending 5-6 times had a significant decrease in negative well-being and increased quality of life over time, while the group attending fewer times had a significant decrease in positive well-being and health state, similar to the control group, which also had a significant decrease in negative and general well-being. CONCLUSIONS: A support and education programme might have a positive effect on spouses' well-being, on condition that they attend at least five times. RELEVANCE TO CLINICAL PRACTICE: To facilitate the spouses' role as informal caregivers to the stroke patients, further development of the support and education programme used in the present study is needed, including empowerment approach and implementation of coping strategies.

A nurse-based management program in heart failure patients affects females and persons with cognitive dysfunction most.

It is important that congestive heart failure (CHF) patients know how to monitor and manage disease-associated signs and symptoms. CHF patients were randomised to follow-up at a nurse-based outpatient clinic (intervention group (IG); n = 103), or to follow-up in primary healthcare (control group (CG); n = 105). Patient knowledge of CHF and self-care were assessed by a questionnaire and cognitive function by a Mini Mental State Examination (MMSE) at baseline and at six months. Men knew more about CHF as compared to females at baseline (p < 0.01). However, females in the IG increased their knowledge of self-care between baseline and six months as compared to CG females (p < 0.05). Patients with cognitive dysfunction (MMSE < 24) presented lower scores on knowledge as compared to those with a MMSE of >24 at baseline (p < 0.01). These differences disappeared after the intervention. Thus, females seemed to gain more than men from a nurse-based management program and patients with in-hospital signs of cognitive dysfunction should be encouraged to participate.

Testing of an audit instrument for the nursing discharge note in the patient record.

OBJECTIVES: This study validates and tests the reliability of an audit instrument constructed to evaluate the content of nursing discharge notes. DESIGN: Instrument validation and reliability testing. MAIN OUTCOME MEASURES: Factor analysis identifying structure through data summarization of the instrument, association between scores in test-retest, and interrater reliability between auditors. VALIDITY: Three factors emerged in the factor analysis: 'General information', 'Planning', and 'Assessment', accounting for 76% of the variance regarding the quantitative aspect and 79% of the variance regarding the qualitative aspect, confirming the distinctiveness. Reliability: The Spearman rank-order correlation coefficient calculated per item in the test-retest ranged from 0.72 to 1.0 (p=0.01). The correlation coefficient for the total score was 0.98 (p=0.01). There were no differences in item scores between the test and retest in 93% of the comparisons (n=486). Between the two auditors, the Spearman rank-order correlation coefficient in each item ranged from 0.83 to 1.00 (p=0.01) and weighted kappa values from 0.70 to 1.00 with the exception of one item in both calculations. The correlation coefficient for the auditors' total score was 0.99 (p=0.01). The Student's paired t-test comparing the two auditors' mean values in five different parts of the instrument showed no significant differences in score. CONCLUSION: The Cat-ch-Ing EPI instrument shows a high reliability and validity as an audit instrument to evaluate the content of nursing discharge notes.