Indigenizing Cardiac Rehabilitation: The Role for Cultural Adaptation.

Cardiac rehabilitation (CR) is an integral component of cardiovascular care, which reduces morbidity and mortality, and improves quality of life. Largely as a result of Canada's colonial history, Indigenous communities face higher rates of cardiovascular morbidity and mortality. Indigenous Peoples in Canada have a unique cultural, historical, and geographic context that limits access to high-quality cardiovascular care, including CR, which has traditionally been delivered in an urban, hospital-based setting. Culturally adapted, holistic exercise and diet programs and CR programs have been successful in Canada, Australia, and New Zealand, demonstrating acceptability to the community, safety, and improvements in cardiovascular risk factors. Key components of a successful culturally adapted CR program include program leadership and development by Indigenous community members and key partners, cultural sensitivity training for health care providers and financial and geographic accessibility. Encouragement of traditional practices, including healthy traditional dietary practices, and recognizing land-based activities as exercise have also proved important in the successful delivery of CR in Indigenous communities. This review summarizes the current evidence for culturally adapted CR programming for Indigenous patients, including strategies to engage communities in education on cardiovascular risk-factor optimization and to promote guideline-based exercise and diet through an Indigenous lens.

The AED Project: Multiorganization Collaboration to Streamline Automatic External Defibrillator Data in Out-of-Hospital Cardiac Arrests.

BACKGROUND: In patients with out-of-hospital cardiac arrest (OHCA), automated external defibrillator (AED) devices contain valuable data about the patient's initial rhythm. The retrieval process was previously without protocol, despite its critical role in the patient journey. METHODS: Through a Plan-Do-Study-Act model, the cardiology department at Royal Jubilee Hospital (Victoria, British Columbia, Canada) collaborated with provincial emergency health services (British Columbia Emergency Health Services) to cocreate a request process for data from AEDs used by first responders. British Columbia Fire Departments, which are under municipal oversight, required an alternate strategy. Educational presentations allowed for feedback and spread. Patients surviving OHCA and transfer to the regional cardiac centre were consecutively enrolled from November 2018 to April 2020. We evaluated the timeliness of AED information retrieval, and tracked the process to admission. A retrospective chart review informed specifics after admission. A survey to the Coronary Intensive Care Unit staff was used to assess clinical utility. RESULTS: Seventy-one consecutive patients were enrolled during the study period. Seven rhythm strips arrived with the patient, thus not affected by the initiative. From the remaining 64 cases, 80% (n = 51/64) were received within 48 hours, and 88% (n = 45/51) were received within 24 hours with a median of 1 hour. Eighteen Coronary Intensive Care Unit staff completed the survey; 81% reported AED data as "very useful" to clinical decision-making (n = 13/16). The AED rhythm strips provided insight into OHCA etiology (100%; n = 11/11), supported evidence for diagnoses (100%; n = 11/11), and reduced unnecessary testing (64%; n = 7/11). CONCLUSIONS: Implementing an organized protocol allowed for timely access to AED data, which was directly integrated into clinical decision-making and positively affected hospital stay.

CONTEXTE: Lorsqu'un patient subit un arrêt cardiaque extrahospitalier (ACEH), le défibrillateur externe automatisé (DEA) utilisé par les premiers intervenants contient des données précieuses sur son rythme cardiaque initial. Malgré l'importance de ces données pour le parcours du patient, leur récupération n'était auparavant soumise à aucun protocole. MÉTHODOLOGIE: Dans le cadre d'une initiative fondée sur le modèle Planifier, Développer, Contrôler, Ajuster, le service de cardiologie de l'hôpital Royal Jubilee (Victoria, Colombie-Britannique, Canada) a travaillé en collaboration avec les services médicaux d'urgence de la province (British Columbia Emergency Health Services) afin de créer un processus de demande des données enregistrées dans les DEA utilisés par les premiers intervenants. Pour les services des incendies de la Colombie-Britannique, qui relèvent des administrations municipales, il a fallu adopter une autre stratégie. Des séances de sensibilisation ont permis de recueillir une rétroaction et de diffuser l'information. Nous avons retenu pour notre étude les cas des patients consécutifs qui ont survécu à un ACEH et ont été transférés à un centre de cardiologie régional entre novembre 2018 et avril 2020. Nous avons évalué le caractère opportun de la récupération des données des DEA et fait le suivi du processus jusqu'à l'admission du patient à l'hôpital. L'examen rétrospectif des dossiers a permis d'obtenir les données recueillies après l'admission. Un sondage a été mené auprès du personnel de l'unité de soins intensifs de cardiologie pour évaluer l'utilité clinique de l'initiative. RÉSULTATS: Au total, 71 patients consécutifs ont été recrutés durant la période de l'étude. Sept patients sont arrivés à l'hôpital avec le tracé de l'enregistrement de leur rythme cardiaque, et n'ont donc pas été touchés par l'initiative. Sur les 64 autres cas, 80 % (n = 51/64) des tracés ont été obtenus dans les 48 heures, et 88 % (n = 45/51), dans les 24 heures, l'intervalle médian étant de 1 heure. En tout, 18 membres du personnel de l'unité de soins intensifs de cardiologie ont répondu au sondage; 81 % d'entre eux ont dit que les données des DEA étaient « très utiles ¼ à la prise de décisions cliniques (n = 13/16). Les tracés du rythme cardiaque produits par les DEA ont permis de mieux comprendre l'étiologie des ACEH (100 %; n = 11/11), fourni des données facilitant le diagnostic (100 %; n = 11/11) et réduit l'exécution de tests non nécessaires (64 %; n = 7/11). CONCLUSIONS: La mise en œuvre d'un protocole structuré a permis d'accéder en temps opportun aux données des DEA, qui ont été directement prises en compte dans la prise de décisions cliniques et ont eu un effet positif sur l'hospitalisation.

Mobile ventricular thrombus arising from the mitral annulus in patients with dense mitral annular calcification.

Mitral annular calcification (MAC) has been considered a risk factor for thrombo-embolic disease. Superimposed thrombus formation on MAC has not been well described as a possible underlying mechanism for this association. We report three patients with mobile left ventricular (LV) thrombus arising from the LV aspect of severe calcified mitral annulus in the setting of normal LV function, mitral valve function, and sinus rhythm.

Efficacy of alternate day versus daily dosing of rosuvastatin.

BACKGROUND: Compared with other statins, rosuvastatin has a relatively long half-life, which may allow for the administration of this medication on an alternate day basis. OBJECTIVE: To compare the efficacy of administering rosuvastatin on a daily basis versus on an alternate day basis for the treatment of dyslipidemia. METHODS: In the present crossover study, 45 patients with documented hypercholesterolemia requiring pharmacotherapy were administered either 20 mg of rosuvastatin on alternate days or 10 mg of rosuvastatin daily for six weeks. After a four-week washout period, patients were then switched to the other regimen for another six weeks. The primary end point was the percentage reduction of low-density lipoprotein cholesterol (LDL-C). RESULTS: LDL-C decreased by 48.5% versus 40.9% with daily and alternate day dosing, respectively. This represented an additional absolute reduction of LDL-C of 7.6% (95% CI 1.8% to 13.4%, P=0.012) with the daily dosing regimen. Both dosing regimens provided similar improvements in high-density lipoprotein cholesterol and triglycerides. CONCLUSIONS: Compared with alternate day dosing, daily dosing of rosuvastatin provides a statistically significant advantage in LDL-C reduction. However, the alternate day regimen may be a viable option for those patients in whom cost is a limitation to compliance.

Detection of symptoms by adolescents and young adults with type 1 diabetes during experimental induction of mild hypoglycemia: role of hormonal and psychological variables.

OBJECTIVE: To identify hormonal, psychological, and demographic predictors of symptom detection and accuracy of blood glucose estimation during mild hypoglycemia in adolescents and young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS: During an insulin-glucose clamp study, 53 adolescents and 19 young adults estimated blood glucose levels and reported symptoms at euglycemia and after 30 min of mild hypoglycemia (3.3 mmol/l). Epinephrine and pancreatic polypeptide were measured, and both change in anxiety level during hypoglycemia and baseline level of anxiety were measured with the Spielberger Anxiety Inventory. Elevated levels of anxiety during euglycemia were used as an indicator of the psychological trait "negative affectivity." Previous studies have suggested that individuals with higher negative affectivity are more internally focused and, therefore, more likely to report somatic and visceral changes. RESULTS: During mild hypoglycemia, 42% of the sample subjects reported an increase in autonomic symptoms; 29% reported an increase in neuroglycopenic symptoms, and 28% estimated blood glucose levels accurately (within 10% of actual). Hormonal excursions did not predict any outcome, but higher anxiety levels during the euglycemic baseline were associated with better detection of hypoglycemic symptoms and more accurate estimation of blood glucose values after controlling for change in anxiety level during hypoglycemia. CONCLUSIONS: Psychological factors such as elevated anxiety levels ("negative affectivity") can influence blood glucose estimation and symptom detection in adolescents and young adults and may explain why some individuals are more adept than others at reducing their risk of severe hypoglycemia after participation in a formal blood glucose awareness training program.