Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation.

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Attention needed for cognitive problems in patients after out-of-hospital cardiac arrest: an inventory about daily rehabilitation care.

AIM: Recent literature and Dutch guidelines for patients with out-of-hospital cardiac arrest (OHCA) recommend screening for cognitive impairments and referral to cognitive rehabilitation when needed. The aim of this study is to assess the uptake of these recommendations for OHCA patients. METHOD: An internet-based questionnaire was sent to 74 cardiologists and 143 rehabilitation specialists involved in rehabilitation of OHCA patients in the Netherlands. The questionnaire covered: background characteristics, availability and content of cognitive screening and rehabilitation, organisation of care, experienced need for an integrated care pathway including physical and cognitive rehabilitation, barriers and facilitators for an integrated care pathway. RESULTS: Forty-five questionnaires were returned (16 cardiologists and 29 rehabilitation doctors). Thirty-nine percent (n = 17) prescribed cognitive screening. Eighty-nine percent underscores an added value of an integrated care pathway. Barriers for an integrated care pathway included lack of knowledge, logistic obstacles, and poor cooperation between medical specialties. CONCLUSIONS: In the Netherlands, only a minority of cardiologists and rehabilitation specialists routinely prescribe some form of cognitive screening in OHCA patients, although the majority underscores the value of cognitive screening in OHCA patients in an integrated care pathway. The uptake of such a care pathway seems hindered by lack of knowledge and organisational barriers.

Cognitive problems in patients in a cardiac rehabilitation program after an out-of-hospital cardiac arrest.

OBJECTIVE: Estimate prevalence of cognitive problems due to hypoxic brain injury in out-of-hospital cardiac arrest (OHCA) survivors referred for cardiac rehabilitation and association with quality of life as well as autonomy and participation. DESIGN: Prospective cohort study. METHOD/DESIGN: Consecutive OHCA patients. The Mini-Mental State Examination (MMSE), Cognitive Failures Questionnaire (CFQ) and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were administered 4 weeks after the OHCA. Cognitive problems were defined if MMSE <28, CFQ >32 or IQCODE >3.6. The Impact on Participation and Autonomy Questionnaire (IPAQ) (participation/autonomy), the SF-36 Health Survey (SF-36) (quality of life) and the Hospital Anxiety Depression Scale (HADS) (anxiety/depression) were administered. Correlations between cognitive problems and participation/autonomy and quality of life were calculated. RESULTS: 63 of 77 patients were male (82%), median age 59 years (range 15-84). MMSE median 29 (interquartile range 28-30), CFQ mean 20.9 (SD 9.4) and IQCODE mean 3.1 (SD 0.2). Eighteen patients (23%) scored positive for cognitive problems. Significant correlations were found between MMSE and IPAQ: autonomy inside (r = -0.38), family role (r = -0.26), autonomy outside (r = -0.32), social relations (r = -0.38) and social functioning (r = 0.32). MMSE was related to SF-36: social functioning (r = 0.32). The CFQ was related to IPAQ: autonomy outdoors (r = 0.29) and SF-36: bodily pain (r = -0.37), vitality (r = -0.25), mental health (r = -0.35) and role emotional (r = -0.40). The IQCODE was related to IPAQ: autonomy indoors (r = 0.26) and to SF-36: vitality (r = -0.33) and social functioning (r = -0.41). CONCLUSION: Twenty-three percent of the patients referred for cardiac rehabilitation showed cognitive problems. Associations were found between cognitive problems and several aspects of participation/autonomy and perceived quality of life.

High survival rate of 43% in out-of-hospital cardiac arrest patients in an optimised chain of survival.

AIMS: Survival to hospital discharge after out-of-hospital cardiac arrest (OHCA) varies widely. This study describes short-term survival after OHCA in a region with an extensive care path and a follow-up of 1 year. METHODS: Consecutive patients ≥16 years admitted to the emergency department between April 2011 and December 2012 were included. In July 2014 a follow-up took place. Socio-demographic data, characteristics of the OHCA and interventions were described and associations with survival were determined. RESULTS: Two hundred forty-two patients were included (73 % male, median age 65 years). In 76 % the cardiac arrest was of cardiac origin and 52 % had a shockable rhythm. In 74 % the cardiac arrest was witnessed, 76 % received bystander cardiopulmonary resuscitation and in 39 % an automatic external defibrillator (AED) was used. Of the 168 hospitalised patients, 144 underwent therapeutic procedures. A total of 105 patients survived until hospital discharge. Younger age, cardiac arrest in public area, witnessed cardiac arrest, cardiac origin with a shockable rhythm, the use of an AED, shorter time until return of spontaneous circulation, Glasgow Coma Scale (GCS) ≥13 during transport and longer length of hospital stay were associated with survival. Of the 105 survivors 72 survived for at least 1 year after cardiac arrest and 6 patients died. CONCLUSION: A survival rate of 43 % after OHCA is achievable. Witnessed cardiac arrest, cardiac cause of arrest, initial cardiac rhythm and GCS ≥13 were associated with higher survival.

Improving guideline adherence for cardiac rehabilitation in the Netherlands.

BACKGROUND: In 2004, the Netherlands Society of Cardiology released the current guideline on cardiac rehabilitation. Given its complexity and the involvement of various healthcare disciplines, it was supplemented with a clinical algorithm, serving to facilitate its implementation in daily practice. Although the algorithm was shown to be effective for improving guideline adherence, several shortcomings and deficiencies were revealed. Based on these findings, the clinical algorithm has now been updated. This article describes the process and the changes that were made. METHODS: The revision consisted of three phases. First, the reliability of the measurement instruments included in the 2004 Clinical Algorithm was investigated by evaluating between-centre variations of the baseline assessment data. Second, based on the available evidence, a multidisciplinary expert advisory panel selected items needing revision and provided specific recommendations. Third, a guideline development group decided which revisions were finally included, also taking practical considerations into account. RESULTS: A total of nine items were revised: three because of new scientific insights and six because of the need for more objective measurement instruments. In all revised items, subjective assessment methods were replaced by more objective assessment tools (e.g. symptom-limited exercise instead of clinical judgement). In addition, four new key items were added: screening for anxiety/depression, stress, cardiovascular risk profile and alcohol consumption. CONCLUSION: Based on previously determined shortcomings, the Clinical Algorithm for Cardiac Rehabilitation was thoroughly revised mainly by incorporating more objective assessment methods and by adding several new key areas.

Standardised pre-hospital care of acute myocardial infarction patients: MISSION! guidelines applied in practice.

Background. To improve acute myocardial infarction (AMI) care in the region 'Hollands-Midden' (the Netherlands), a standardised guideline-based care program was developed (MISSION!). This study aimed to evaluate the outcome of the pre-hospital part of the MISSION! program and to study potential differences in pre-hospital care between four areas of residency.Methods. Time-to-treatment delays, AMI risk profile, cardiac enzymes, hospital stay, in-hospital mortality, and pre-AMI medication was evaluated in consecutive AMI patients (n=863, 61±13years, 75% male) transferred to the Leiden University Medical Center for primary percutaneous coronary intervention (PCI).Results. Median time interval between onset of symptoms and arrival at the catheterisation laboratory was 150 (interquartile range [IQR] 101-280) minutes. The alert of emergency services to arrival at the hospital time was 48 (IQR 40-60) minutes and the door-to-catheterisation laboratory time was 23 (IQR 13-42) minutes. Despite significant regional differences in ambulance transportation times no difference in total time from onset of symptoms to arrival at the catheterisation room was found. Peak troponin T was 3.33 (IQR 1.23-7.04) µg/l, hospital stay was 2 (IQR 2-3) days and in-hospital mortality was 2.3%. Twelve percent had 0 known risk factors, 30% had one risk factor, 45% two to three risk factors and 13% had four or more risk factors. No significant differences were observed for AMI risk profiles and medication pre-AMI. Conclusions. This study shows that a standardised regional AMI treatment protocol achieved optimal and uniformly distributed pre-hospital performance in the region 'Hollands-Midden', resulting in minimal time delays regardless of area of residence. Hospital stay was short and in-hospital mortality low. Of the patients, 88% had ≥1 modifiable risk factor. (Neth Heart J 2010;18:408-15.).