The effect of metoprolol and aspirin on cardiovascular risk in bereavement: A randomized controlled trial.

BACKGROUND: Bereavement is associated with an increased risk of cardiovascular disease; however, no reports exist of interventions to reduce risk. In a randomized, double-blind, placebo-controlled trial of 85 recently bereaved participants, we determined whether ß-blocker (metoprolol 25 mg) and aspirin (100 mg) reduce cardiovascular risk markers and anxiety, without adversely affecting bereavement intensity. METHODS: Participants were spouses (n = 73) or parents (n = 12) of deceased from 5 hospitals in Sydney, Australia, 55 females, 30 males, aged 66.1 ±â€¯9.4 years. After assessment within 2 weeks of bereavement, subjects were randomized to 6 weeks of daily treatment or placebo, and the effect evaluated using ANCOVA, adjusted for baseline values (primary analysis). RESULTS: Participants on metoprolol and aspirin had lower levels of home systolic pressure (P = .03), 24-hour average heart rate (P < .001) and anxiety (P = .01) platelet response to arachidonic acid (P < .001) and depression symptoms (P = .046) than placebo with no difference in standard deviation of NN intervals index (SDNNi), von Willebrand Factor antigen, platelet-granulocyte aggregates or bereavement intensity. No significant adverse safety impact was observed. CONCLUSIONS: In early bereavement, low dose metoprolol and aspirin for 6 weeks reduces physiological and psychological surrogate measures of cardiovascular risk. Although further research is needed, results suggest a potential preventive benefit of this approach during heightened cardiovascular risk associated with early bereavement.

A Systematic Review of Risk Factors for Sleep Disruption in Critically Ill Adults.

OBJECTIVES: Numerous risk factors for sleep disruption in critically ill adults have been described. We performed a systematic review of all risk factors associated with sleep disruption in the ICU setting. DATA SOURCES: PubMed, EMBASE, CINAHL, Web of Science, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY SELECTION: English-language studies of any design published between 1990 and April 2018 that evaluated sleep in greater than or equal to 10 critically ill adults (> 18 yr old) and investigated greater than or equal to 1 potential risk factor for sleep disruption during ICU stay. We assessed study quality using Newcastle-Ottawa Scale or Cochrane Risk of Bias tool. DATA EXTRACTION: We abstracted all data independently and in duplicate. Potential ICU sleep disruption risk factors were categorized into three categories based on how data were reported: 1) patient-reported reasons for sleep disruption, 2) patient-reported ratings of potential factors affecting sleep quality, and 3) studies reporting a statistical or temporal association between potential risk factors and disrupted sleep. DATA SYNTHESIS: Of 5,148 citations, we included 62 studies. Pain, discomfort, anxiety/fear, noise, light, and ICU care-related activities are the most common and widely studied patient-reported factors causing sleep disruption. Patients rated noise and light as the most sleep-disruptive factors. Higher number of comorbidities, poor home sleep quality, home sleep aid use, and delirium were factors associated with sleep disruption identified in available studies. CONCLUSIONS: This systematic review summarizes all premorbid, illness-related, and ICU-related factors associated with sleep disruption in the ICU. These findings will inform sleep promotion efforts in the ICU and guide further research in this field.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

OBJECTIVE: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Sleep Quality During and After Cardiothoracic Intensive Care and Psychological Health During Recovery.

BACKGROUND: Intensive care patients experience poor sleep quality. Psychological distress and diminished health-related quality of life (HRQOL) are also common among former intensive care unit (ICU) patients. Coronary artery bypass graft (CABG) surgery is a frequent reason adults require treatment in ICU. The effect of on- versus off-pump surgery on sleep and recovery has not been reported. OBJECTIVE: The aim of this study was to assess sleep quality of CABG patients during and after ICU, psychological well-being, HRQOL during recovery, and whether on- versus off-pump surgery affects sleep and recovery. METHODS: Data were collected in the ICU and hospital ward, and 2 and 6 months after hospital discharge using validated self-report questionnaires. RESULTS: The sample (n = 101) had a mean age of 66.6 ± 11.1 years, was 79% male, and had a median ICU stay of 2 (2-4) days and a mean body mass index of 27.3 ± 4.3; 75% underwent on-pump surgery. Poor sleep was reported by 62% of the patients at 6 months and by 12% of the patients at all time points. Off-pump CABG patients had fewer posttraumatic stress symptoms (P = .02) and better physical HRQOL (P = .01). In multivariate analysis, prehospital insomnia (P = .004), and physical (P < .0005) and mental (P < .0005) HRQOL were independently associated with sleep quality at 6 months. There was no association between on- versus off-pump CABG and sleep quality at 6 months. CONCLUSIONS: Sleep quality of postoperative CABG patients was poor in the ICU and hospital ward and up to 6 months after discharge from the hospital. Poor sleep quality at 6 months was associated with prehospital insomnia, and physical and mental HRQOL at 6 months, but not with on- versus off-pump surgery.

User compliance with documenting on a track and trigger-based observation and response chart: a two-phase multi-site audit study.

AIMS: To examine user compliance and completeness of documentation with a newly designed observation and response chart and whether a rapid response system call was triggered when clinically indicated. BACKGROUND: Timely recognition and responses to patient deterioration in hospital general wards remain a challenge for healthcare systems globally. Evaluating practice initiatives to improve recognition and response are required. DESIGN: Two-phase audit. METHODS: Following introduction of the charts in ten health service sites in Australia, an audit of chart completion was conducted during a short trial for initial usability (Phase 1; 2011). After chart adoption as routine use in practice, retrospective and prospective chart audits were conducted (Phase 2; 2012). FINDINGS: Overall, 818 and 1,058 charts were audited during the two phases respectively. Compliance was mixed but improved with the new chart (4%-14%). Contrary to chart guidelines, numbers rather than dots were written in the graphing section in 60% of cases. Rates of recognition of abnormal vital signs improved slightly with new charts in use, particularly for higher levels of surveillance and clinical review. Based on local calling criteria, an emergency call was initiated in 33% of cases during the retrospective audit and in 41% of cases with the new chart. CONCLUSIONS: User compliance was less than optimal, limiting full function of the chart sections and compliance with local calling criteria. Overcoming apparent behavioural and work culture barriers may improve chart completion, aiding identification of abnormal vital signs and triggering a rapid response system activation when clinical deterioration is detected.

Repeated sleep-quality assessment and use of sleep-promoting interventions in ICU.

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep-promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep-promoting interventions has not been widely reported. An observational study was conducted in a 58-bed adult intensive care unit. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep-promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open-ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep-promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards-Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards-Campbell Sleep Questionnaire was used on repeated occasions, and sleep-promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards-Campbell Sleep Questionnaire for the subjective self-assessment of sleep quality in intensive care unit patients and the implementation of simple-promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.

Sleep assessment by patients and nurses in the intensive care: An exploratory descriptive study.

BACKGROUND: Sleep disruption is common in intensive care unit (ICU) patients, with reports indicating reduced quality and quantity of sleep in many patients. There is growing evidence that sleep in this setting may be improved. AIM: To describe ICU patients' self-report assessment of sleep, examine the relationship between patients' self-reported sleep and their reported sleep by the bedside nurse, and describe the strategies suggested by patients to promote sleep. METHODS: An exploratory descriptive study was undertaken with communicative adult patients consecutively recruited in 2014-2015. Patients reported sleep using the Richards-Campbell Sleep Questionnaire (score range 0-100mm; higher score indicates better sleep quality), with nursing assessment of sleep documented across a five level ordinal variable. Patients were asked daily to describe strategies that helped or hindered their sleep. Ethical approval for the study was gained. Descriptive statistical analysis was performed [median (interquartile range)]; relationships were tested using Spearman's rank correlation and differences assessed using the Kruskal-Wallis test; p<0.05 was considered significant. RESULTS: Participants (n=151) were recruited [age: 60 (46-71) years; ICU length of stay 4 (2-9) days] with 356 self-reports of sleep. Median perceived sleep quality was 46 (26-65) mm. A moderate relationship existed between patients' self-assessment and nurses' assessment of sleep (Spearman's rank correlation coefficient 0.39-0.50; p<0.001). Strategies identified by patients to improve sleep included adequate pain relief and sedative medication, a peaceful and comfortable environment and physical interventions, e.g. clustering care, ear plugs. CONCLUSION: Patients reported on their sleep a median of 2 (1-3) days during their ICU stay, suggesting that routine use of self-report was feasible. These reports revealed low sleep quality. Patients reported multiple facilitators and barriers for sleep, with environmental and patient comfort factors being most common. Interventions that target these factors to improve patient sleep should be implemented.

User acceptance of observation and response charts with a track and trigger system: a multisite staff survey.

AIMS AND OBJECTIVES: To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical-surgical patients. BACKGROUND: Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice. DESIGN: Prospective multisite survey of user acceptance of the charts in practice. METHODS: New observation and response charts were trialled in parallel with existing charts for 24 hours across 36 adult acute medical-surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences. RESULTS: Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration. CONCLUSIONS: This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended. RELEVANCE TO CLINICAL PRACTICE: Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice.

The complexities of recruiting bereaved family members into a research study in the critical care environment: a discussion paper.

Research on the effects of stressful events on human health and wellbeing has progressed in recent years. One such stress, bereavement, is considered one of life's greatest stresses, requiring significant readjustment. The Cardiovascular Risk in Bereavement study (CARBER) investigated in detail cardiovascular risk factors during the first weeks following the death of a partner or adult child in the critical care environment. The purpose of this paper is to explore the once held perception that the bereaved population should not be involved in research, using an actual illustrative project. The paper specifically focuses on the challenges regarding acceptability and feasibility of recruitment of recently bereaved individuals from the critical care environment. The question of whether bereaved individuals have capacity to consent to involvement in research immediately after loss is considered. The appropriateness of asking newly bereaved individuals to participate in research immediately after the death of their relative is also discussed. The work of the research team demonstrates that early recruitment of bereaved family members into a research project is feasible and acceptable to participants, especially when a multidisciplinary collaborative approach is employed and a personal mode of recruitment used.

The nature of death, coping response and intensity of bereavement following death in the critical care environment.

INTRODUCTION: Bereavement, defined as the situation of having recently lost a significant other, is recognised as one of life's greatest stressors and may lead to decrements in health status, psychological morbidity and excess risk of mortality. AIM: The aim of this study was firstly to describe the relationships between the nature of death and bereavement intensity following death in the adult critical care environment and secondly to examine the modifying effects of coping responses on intensity of bereavement reaction. METHOD: Prospective evaluation of the impact of the nature of death and coping responses on bereavement intensity. 78 participants completed a nature of death questionnaire within 2 weeks of bereavement and at 3 and 6 months completed the Core Bereavement Items Questionnaire (CBI-17) and Brief COPE Inventory. RESULTS: At 6 months, univariate variables significantly associated with bereavement intensity were: being unprepared for the death (p<0.001), a drawn out death (p<0.001), a violent death (p=0.007) and if the deceased appeared to suffer more than expected (p=0.03). Multivariate analysis revealed being unprepared for the death appears to account for these relationships. Regarding coping, there were significant increases from 3 to 6 months in both acceptance scales (p=0.01) and planning (p=0.02) on The Brief COPE Inventory. Greater use of emotional support (p=0.02), self-blame (0.003) and denial (p<0.001) were multivariate variables associated with higher bereavement intensity at 6 months. CONCLUSION: The results from this evaluation provide insight into the impact of bereavement after death in the critical care environment and inform potential preventative approaches at the time of death to reduce bereavement intensity.

Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study.

INTRODUCTION: Many intensive care patients experience sleep disruption potentially related to noise, light and treatment interventions. The purpose of this study was to characterise, in terms of quantity and quality, the sleep of intensive care patients, taking into account the impact of environmental factors. METHODS: This observational study was conducted in the adult ICU of a tertiary referral hospital in Australia, enrolling 57 patients. Polysomnography (PSG) was performed over a 24-hour period to assess the quantity (total sleep time: hh:mm) and quality (percentage per stage, duration of sleep episode) of patients' sleep while in ICU. Rechtschaffen and Kales criteria were used to categorise sleep. Interrater checks were performed. Sound pressure and illuminance levels and care events were simultaneously recorded. Patients reported on their sleep quality in ICU using the Richards Campbell Sleep Questionnaire and the Sleep in Intensive Care Questionnaire. Data were summarised using frequencies and proportions or measures of central tendency and dispersion as appropriate and Cohen's Kappa statistic was used for interrater reliability of the sleep data analysis. RESULTS: Patients' median total sleep time was 05:00 (IQR: 02:52 to 07:14). The majority of sleep was stage 1 and 2 (medians: 19 and 73%) with scant slow wave and REM sleep. The median duration of sleep without waking was 00:03. Sound levels were high (mean Leq 53.95 dB(A) during the day and 50.20 dB(A) at night) and illuminance levels were appropriate at night (median<2 lux) but low during the day (median: 74.20 lux). There was a median 1.7 care events/h. Patients' mean self-reported sleep quality was poor. Interrater reliability of sleep staging was highest for slow wave sleep and lowest for stage 1 sleep. CONCLUSIONS: The quantity and quality of sleep in intensive care patients are poor and may be related to noise, critical illness itself and treatment events that disturb sleep. The study highlights the challenge of quantifying sleep in the critical care setting and the need for alternative methods of measuring sleep. The results suggest that a sound reduction program is required and other interventions to improve clinical practices to promote sleep in intensive care patients. TRIAL REGISTRATION: Australian New Zealand clinical trial registry (http://www.anzctr.org.au/): ACTRN12610000688088.

Twenty-five years of critical care nursing scholarship in Australia.

BACKGROUND: Australian Critical Care has been published since 1988 and has been an important medium for the development of critical care nursing scholarship in Australia over 25 years. PURPOSE: To review scholarship in critical care nursing in Australia since 1988 and record its progress in the context of developments in nursing education and intensive and critical care practice. APPROACH: Australian Critical Care issues since 1988 were reviewed, and abstracts from the Australian and New Zealand Annual Scientific Meeting on Intensive Care published in Australian Critical Care since the 1991 Meeting. Available evidence for the contribution of this body of scholarship to critical care nursing practice and patient care was considered. RESULTS: Original research reports and review articles have steadily increased from 1988 to 2012. The peak years for research publications were 2001, 2005 and 2012, and for reviews 2010 and 2011. Approximately 760 abstracts were presented at the Annual Scientific Meeting from 1991 to 2010; overall 24% were found lead to peer-reviewed publications, with an increase to 30% in recent years. SUMMARY: Over 25 years, the scholarship of critical care nursing in Australia has evolved into an established area of disciplinary knowledge, based firmly in practice. Our discipline has witnessed the opportunity for PhD training, the introduction of professorial positions, a knowledge base built on original research and rigorous reviews, and sustainable dissemination. The challenges are to further strengthen this development, increase publication of research that is done, to demonstrate the influence on practice and to develop sustainable research funding.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome.

BACKGROUND: Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not. OBJECTIVE: To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay. METHODS: This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters. RESULTS: Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952). DISCUSSION: Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?

OBJECTIVES: Symptoms are compared among patients with coronary artery disease (CAD) admitted to the emergency department with or without acute coronary syndrome (ACS). Sex and age are also assessed. METHODS: A secondary analysis from the PROMOTION (Patient Response tO Myocardial Infarction fOllowing a Teaching Intervention Offered by Nurses) trial, an multicenter randomized controlled trial, was conducted. RESULTS: Of 3522 patients with CAD, at 2 years, 565 (16%) presented to the emergency department, 234 (41%) with non-ACS and 331 (59%) with ACS. Shortness of breath (33% vs 25%, P = .028) or dizziness (11% vs 3%, P = .001) were more common in non-ACS. Chest pain (65% vs 77%, P = .002) or arm pain (9% vs 21%, P = .001) were more common in ACS. In men without ACS, dizziness was more common (11% vs 2%; P = .001). Men with ACS were more likely to have chest pain (78% vs 64%; P = .003); both men and women with ACS more often had arm pain (men, 19% vs 10% [P = .019]; women, 26% vs 13% [P = .023]). In multivariate analysis, patients with shortness of breath (odds ratio [OR], 0.617 [confidence interval [CI], 0.410-0.929]; P = .021) or dizziness (OR, .0311 [CI, 0.136-0.708]; P = .005) were more likely to have non-ACS. Patients with prior percutaneous coronary intervention (OR, 1.592 [CI, 1.087-2.332]; P = .017), chest pain (OR, 1.579 [CI, 1.051-2.375]; P = .028), or arm pain (OR, 1.751 [CI, 1.013-3.025]; P <.042) were more likely to have ACS. CONCLUSIONS: In patients with CAD, shortness of breath and dizziness are more common in non-ACS, whereas prior percutaneous coronary intervention and chest or arm pain are important factors to include during ACS triage.

Complications after acute coronary syndrome are reduced by perceived control of cardiac illness.

AIMS: To investigate the relationship between anxiety, perceived control and rate of in-hospital complications after acute coronary syndrome. BACKGROUND: Anxiety may be associated with higher risk of complications following acute myocardial infarction; perceived control may moderate this relationship. DESIGN: Prospective observational study. METHODS: Patients enrolled in a trial investigating delay in seeking treatment for acute coronary syndrome had anxiety measured at enrolment and 3 months using the Brief Symptom Inventory anxiety subscale. The acute coronary syndrome hospital presentations investigated occurred between 2001-2006. Patients with anxiety scores greater than the population norm at both time points were categorized as persistently anxious. Perceived control was measured at enrolment using the control attitudes scale-revised. Data were collected from the medical record on in-hospital complications in patients presenting with acute coronary syndrome within 2 years of enrolment. Chi-square and t-tests were used for univariate analyses and multiple logistic regression to identify independent predictors of complications. RESULTS: Patients (n = 171) were 64% men with mean age 69 years. Ischaemic or arrhythmic complications occurred in 26 patients (15%) with no difference in complication rates between those persistently anxious and others. Important univariate predictors of in-hospital complications were lower perceived control, diagnosis of acute myocardial infarction, heart failure and higher pulse rate on admission. Low perceived control and diagnosis of acute myocardial infarction were independent predictors of in-hospital complications in the multiple logistic regression. CONCLUSION: Perceived control, but not persistent anxiety, prior to acute coronary syndrome was an important predictor of in-hospital complications after acute coronary syndrome. Interventions to increase cardiac patients' perceived control of their cardiac illness may reduce in-hospital complications after acute coronary syndrome.

Relationship of persistent symptoms of anxiety to morbidity and mortality outcomes in patients with coronary heart disease.

OBJECTIVE: To examine the association of symptoms of persistent anxiety with the development of acute cardiac events in patients with coronary heart disease (CHD) followed for 2 years. The prevalence of symptoms of anxiety is high in patients with CHD, but their effect on cardiac events and mortality has not been well characterized. METHODS: Of 3522 patients with confirmed CHD enrolled, data on symptoms of anxiety were available at two time points in 3048 patients who were then followed up for detection of the composite end point of hospitalization for myocardial infarction, unstable or stable angina, other cardiac causes, or all-cause mortality. A composite anxiety symptoms score composed of baseline and 3-month anxiety data, in which the continuous-level scores were used, was tested using Cox proportional hazards regression model. Groups (persistent anxiety [anxiety at both time points] versus nonanxious [no anxiety at either time point] versus not persistently anxious [anxiety only at one time point]) were also compared. RESULTS: Symptoms of persistent anxiety, whether considered as a continuous- or categorical-level variable, were associated with shorter time to event. Persistent anxiety remained as an independent predictor of the end point after controlling for multiple variables (persistent anxiety as a summary score [hazard ratio = 1.27, 95% confidence interval = 1.067-1.514] and persistent anxiety as a categorical variable [hazard ratio = 1.52, 95% confidence interval = 1.149-2.015]). CONCLUSIONS: By measuring anxiety symptoms at more than one time point and controlling for relevant sociodemographic, comorbidity, risk factor, and psychological covariates, we illustrate that symptoms of persistent anxiety are a strong, independent predictor of cardiac event-free survival.

Health-related quality of life and physical recovery after a critical illness: a multi-centre randomised controlled trial of a home-based physical rehabilitation program.

INTRODUCTION: Significant physical sequelae exist for some survivors of a critical illness. There are, however, few studies that have examined specific interventions to improve their recovery, and none have tested a home-based physical rehabilitation program incorporating trainer visits to participants' homes. This study was designed to test the effect of an individualised eight-week home-based physical rehabilitation program on recovery. METHODS: A multi-centre randomised controlled trial design was used. Adult intensive care patients (length of stay of at least 48 hours and mechanically ventilated for 24 hours or more) were recruited from 12 Australian hospitals between 2005 and 2008. Graded, individualised endurance and strength training intervention was prescribed over eight weeks, with three physical trainer home visits, four follow-up phone calls, and supported by a printed exercise manual. The main outcome measures were blinded assessments of physical function; SF-36 physical function (PF) scale and six-minute walk test (6MWT), and health-related quality of life (SF-36) conducted at 1, 8 and 26 weeks after hospital discharge. RESULTS: Of the 195 participants randomised, 183, 173 and 161 completed the 1, 8 and 26 weeks assessments, respectively. Study groups were similar at Week 1 post-hospital; for the intervention and control groups respectively, mean norm-based PF scores were 27 and 29 and the 6MWT distance was 291 and 324 metres. Both groups experienced significant and clinically important improvements in PF scores and 6MWT distance at 8 weeks, which persisted at 26 weeks. Mixed model analysis showed no significant group effects (P = 0.84) or group by time interactions (P = 0.68) for PF. Similar results were found for 6MWT and the SF-36 summary scores. CONCLUSIONS: This individualised eight-week home-based physical rehabilitation program did not increase the underlying rate of recovery in this sample, with both groups of critically ill survivors improving their physical function over the 26 weeks of follow-up. Further research should explore improving effectiveness of the intervention by increasing exercise intensity and frequency, and identifying individuals who would benefit most from this intervention. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register ACTRN12605000166673.

Impact of prehospital delay in treatment seeking on in-hospital complications after acute myocardial infarction.

BACKGROUND: Rapid arrival to the hospital for treatment of acute myocardial infarction (AMI) improves long-term outcomes. Whether prehospital delay time is associated with short-term, in-hospital complications remains unknown. OBJECTIVE: The purpose of this study was to evaluate the fit of a theoretical model where prehospital delay time was indirectly associated with hospital length of stay through in-hospital complications after AMI considering simultaneously for demographic, clinical, and psychosocial factors using structural equation modeling. METHODS: Acute myocardial infarction patients (N = 536; 66% men; mean age, 62 [SD, 14] years) were enrolled in this prospective study. Demographic and clinical data were obtained by patient interview and medical record review. After patient discharge, complications were abstracted from the medical record. RESULTS: Prehospital delay, admission Killip class, and in-hospital anxiety were the best predictors of in-hospital complications, including recurrent ischemia, reinfarction, sustained ventricular tachycardia or fibrillation, and cardiac death, after AMI (P = .019). The occurrence of in-hospital complications was related to length of stay in the hospital (P < .001). CONCLUSION: Prehospital delay in promptly seeking hospital treatment for AMI symptoms, together with state anxiety and worse heart failure, was associated with the occurrence of more frequent serious complications during the hospital stay. It is essential that research and clinical efforts focus on the complex and dynamic issue of improving prehospital delay in AMI patients.

Haemodynamic changes during early bereavement: potential contribution to increased cardiovascular risk.

BACKGROUND: bereavement is associated with increased cardiovascular risk, particularly in surviving spouses and parents, however the mechanism is not well understood due to limited studies. The purpose of this study was to evaluate haemodynamic changes (blood pressure (BP) and heart rate (HR)), that may contribute to increased cardiac risk in early bereavement. METHODS: we enrolled 80 bereaved individuals and 80 non-bereaved as a reference group. Twenty-four hour ambulatory blood pressure monitoring was performed within two weeks (acute assessment) and at six months following bereavement. RESULTS: compared to the non-bereaved, the acutely bereaved had higher 24-hour systolic BP (mean (SE) 130.3 (1.5) vs 127.5 (1.4)mmHg, p=0.03), higher daytime systolic BP (135.6 (1.5) vs 131.6 (1.4)mmHg, p=0.02) and higher daytime systolic load (median % 39.0 vs 29.3, p=0.02). By six months the BP of the bereaved tended to be lower than acute measures. This difference was significant amongst those not taking BP lowering medications for 24-hour systolic BP (126.5 (2.4) vs 129.7 (2.3)mmHg, p=0.04), daytime systolic BP (129.8 (2.1) vs 133.9 (2.0)mmHg, p=0.01) and daytime diastolic pressure (76.7 (1.0) vs 78.9 (0.9)mmHg, p=0.03). Twenty-four hour heart rate was also higher acutely in the bereaved compared with the reference group (74.0 (1.2) vs 71.7 (0.9) b/min, p=0.02); at six months heart rate in the bereaved had fallen to non-bereaved levels (70.4 (0.09), p=0.02). CONCLUSION: early bereavement is associated with increased systolic blood pressure and heart rate. These haemodynamic changes may contribute to a time-limited increase in cardiovascular risk.