Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study.

BACKGROUND: Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women. METHODS: Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2. RESULTS: Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety. CONCLUSIONS: Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.

Women's Health Behaviours and Psychosocial Well-Being by Cardiac Rehabilitation Program Model: A Randomized Controlled Trial.

BACKGROUND: Cardiac rehabilitation (CR) is associated with significantly lower mortality and improved psychosocial well-being. However, women are less likely to participate than men. This trial tested whether participation in women-only CR results in better health behaviours and psychosocial outcomes than do other models. METHODS: Cardiac Rehabilitation for her Heart Event Recovery (CR4HER) was a single-blind randomized trial with 3 parallel arms. Low-risk cardiac patients were recruited from 6 sites in Ontario. Consenting participants completed surveys assessing health behaviours (physical activity, diet, medication adherence, smoking) and psychosocial well-being (social support, quality of life, depressive symptoms) and wore pedometers for 7 days. After intake assessment, eligible participants were randomized to mixed-sex, women-only, or home-based CR. Participants were mailed follow-up surveys and pedometers 6 months later. RESULTS: One hundred sixty-nine patients were randomized, and 116 (68.6%) were retained. Self-reported physical activity increased among women in mixed-sex and women-only CR groups (per protocol and as treated, P < 0.05). Diet improved among women in women-only CR groups (as treated, P < 0.05). Quality of life improved among women in mixed-sex (per protocol and as treated, P < 0.05) and women-only CR groups (per protocol, P < 0.05; as treated, P < 0.01). After testing, women in the mixed-sex CR group had higher anxiety symptoms than did those in the women-only group (per protocol, P = 0.017), and those in the mixed-sex CR group had higher depressive symptoms than did those in the women-only group (as treated, P = 0.001). Analyses adjusted for confounding variables revealed no significant differences in any outcome by model. Post hoc equivalency tests were computed on a per-protocol basis, and all outcomes were equivalent by model. CONCLUSIONS: Behavioural and psychosocial outcomes were largely equivalent regardless of model; however, women-only programs may confer an advantage for anxiety and depressive symptoms.

Six-year follow-up of a randomised controlled trial examining hospital versus home-based exercise training after coronary artery bypass graft surgery.

OBJECTIVE: To compare the long-term effectiveness of hospital versus telephone-monitored home-based exercise training during cardiac rehabilitation (CR) on exercise capacity and habitual physical activity. DESIGN: Six-year follow-up of patients who participated in a randomised controlled trial of hospital versus monitored home-based exercise training during CR after coronary artery bypass graft surgery. SETTING: Outpatient CR centre in Central-South Ontario, Canada. PARTICIPANTS: 196 Patients who participated in the original randomised controlled trial and who attended an evaluation 1 year after CR. INTERVENTIONS: 6 months of home or hospital-based exercise training during CR. MAIN OUTCOME MEASURES: Peak oxygen uptake (peak Vo2), Physical Activity Scale in the Elderly (PASE) to assess habitual activity, semi-structured interviews to assess vital status, demographic and descriptive information. RESULTS: Of the 196 eligible patients, 144 (75.5%; 74 Hospital, 70 Home) were available for participation. Patients were predominantly male (n = 120; 83.3%) aged 70 ± 9.5 years. Clinical and sociodemographic outcomes were similar in both groups. While exercise performance declined over time, there were significant between-group differences in peak Vo2) (1506 ± 418 ml/min vs 1393 ± 341 ml/min; p = 0.017) and PASE scores (166.7 ± 90.2 vs 139.7 ± 66.5; p = 0.001) at 6-year follow-up in favour of the home group. CONCLUSIONS: Home and hospital-based exercise training maintained exercise capacity above pre-CR levels 6 years after CR. Exercise training initiated in the home environment in low-risk patients undergoing coronary artery bypass graft surgery conferred greater long-term benefit on Vo2 and persistent physical activity compared with traditional hospital-based CR.

Effect of aerobic vs combined aerobic-strength training on 1-year, post-cardiac rehabilitation outcomes in women after a cardiac event.

OBJECTIVE: To compare the effect and sustainability of 6 months combined aerobic/strength training vs aerobic training alone on quality of life in women after coronary artery by-pass graft surgery or myocardial infarction. DESIGN: Prospective, 2-group, randomized controlled trial. PARTICIPANTS: Ninety-two women who were 8-10 weeks post-coronary artery by-pass graft surgery or myocardial infarction, able to attend supervised exercise, and fluent in English. METHODS: The aerobic training alone group had supervised exercise twice a week for 6 months. The aerobic/strength training group received aerobic training plus upper and lower body resistance exercises. The amount of active exercise time was matched between groups. The primary outcome, quality of life, was measured by the MOS SF-36; secondary outcomes were self-efficacy, strength and exercise capacity. RESULTS: After 6 months of supervised exercise training both groups showed statistically significant improvements in physical quality of life (p = 0.0002), peak VO2 (19% in aerobic/strength training vs 22% in aerobic training alone), strength (p < 0.0001) and self-efficacy for stair climbing (p = 0.0024), lifting (p < 0.0001) and walking (p = 0.0012). However, by 1-year follow-up there was a statistically significant difference in physical quality of life in favor of the aerobic/strength training group (p = 0.05). CONCLUSION: Women with coronary artery disease stand to benefit from both aerobic training alone and aerobic/strength training. However, continued improvement in physical quality of life may be achieved through combined strength and aerobic training.

Predicting cardiac rehabilitation enrollment: the role of automatic physician referral.

BACKGROUND: Despite the established benefits of cardiac rehabilitation, evidence suggests referral to, and subsequent enrollment in, cardiac rehabilitation following a coronary event remains low (10-25%). The aim of this study was to identify predictors of attendance to cardiac rehabilitation intake and subsequent enrollment in rehabilitation after coronary artery bypass graft surgery within the framework of an automatic referral system. DESIGN AND METHODS: We conducted a historic prospective study of patients who underwent coronary artery bypass graft surgery between 1 April 1996 and 31 March 2000 and lived within the geographic referral area of a multi-disciplinary cardiac rehabilitation center in central-south Ontario, Canada. Coronary artery bypass graft surgery patients are automatically referred to cardiac rehabilitation at the time of hospital discharge. Consecutive health records of eligible patients were reviewed for medical history, cardiac risk factor profiles, and evidence of cardiac rehabilitation intake attendance and enrolment. RESULTS: A total of 3536 patients met eligibility criteria. Patients were predominantly male (79.1%), approximately 64 years of age, living with a spouse or a partner, English-speaking, retired and had multiple cardiac risk factors. Of eligible patients, 2121 (60.0%) attended the cardiac rehabilitation intake appointment. Of patients who attended cardiac rehabilitation intake 1463 (69%) enrolled in at least one cardiac rehabilitation service, based on their risk factor profile. Selected cardiac rehabilitation services were exercise training (n=1287; 88%), nutrition counseling (n=571; 39.0%), nursing care (n=546; 37.3%), and psychological intervention (n=223; 15.2%). CONCLUSIONS: An institutionalized, physician-endorsed system of automatic referral to cardiac rehabilitation resulted in higher rates of cardiac rehabilitation intake and enrollment following coronary artery bypass graft surgery than previously reported and should be adopted for all cardiac populations.

Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery.

BACKGROUND: Enrollment in cardiac rehabilitation (CR) after coronary artery bypass graft (CABG) surgery is suboptimal (25%-30%). OBJECTIVES: The purpose of this study was to examine the effect of a nurse-initiated telephone call (NIC) on attendance at a CR intake appointment. METHODS: By using a retrospective cohort design, data were collected on 3536 patients who underwent CABG between April 1996 and March 2000 and were referred to CR. Of these, 2285 patients received standard care (no NIC) and 1251 received the NIC. RESULTS: Patients who received the NIC were significantly more likely to attend their CR intake appointment compared with standard care (78.1% vs. 50.1%; P < .0001). Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a CR intake explaining 56.9% of the total variance (odds ratio =3.429; 95% confidence interval = 2.919-4.028; P < .0001). CONCLUSION: These findings suggest that pre-appointment telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake appointment after CABG.

Differences in sustainability of exercise and health-related quality of life outcomes following home or hospital-based cardiac rehabilitation.

BACKGROUND: Home-based cardiac rehabilitation (CR) has been demonstrated to be as effective as institution-based CR in post-coronary artery bypass graft surgery (CABG) patients in terms of short-term physical and psychosocial outcomes. The sustainability of these effects is less well studied. The aim of this study was to examine the sustainability of observed changes in physical, quality of life (HRQL), and social support (SS) outcomes in patients 12 months after discharge from a randomized controlled trial (RCT) of 6 months of monitored home-based versus supervised hospital-based CR. DESIGN: Two-hundred and twenty-two (n=222) patients were followed-up 12 months after discharge from a RCT of 6 months of monitored 'Home' versus supervised 'Hospital' CR after CABG. METHODS: At discharge from the 6-month RCT, participants who consented to the 12-month follow-up study, were given individualized guidelines for ongoing exercise, and were not contacted for 1 year. The primary outcome was peak oxygen uptake (VO2). Secondary outcomes were: HRQL, SS and habitual physical activity. RESULTS: One hundred and ninety-eight patients (89.2%), 102 'Hospital' and 96 'Home', returned for follow-up 12-months after discharge from CR. Both groups had similar medical and socio-demographic characteristics. Peak VO2 declined in 'Hospital' but was sustained in 'Home' patients 12 months after discharge from CR (P=0.002). Physical HRQL was higher in the 'Home' group at the 12-month follow-up (P<0.01). Mental HRQL showed general, minor deterioration over time in both groups (P=0.019). Twelve months after discharge from CR, physical and mental HRQL remained higher than at entry to CR in both groups. 'Home' patients had higher habitual physical activity scores compared to 'Hospital' patients. CONCLUSIONS: This follow-up study suggests that low-risk patients whose CR is initiated in the home environment may be more likely to sustain positive physical and psychosocial changes over time than patients whose program is initially institution-based.

Social support and its relationship to morbidity and mortality after acute myocardial infarction: systematic overview.

Among the commonly understood socioeconomic determinants of health, social change, disorganization, and poverty have been associated with an increased risk of morbidity and mortality. One of the postulated mechanisms through which these determinants have been linked to health and illness is their relationship to social support. The health determinant, social isolation or lack of a social support network (SSN), and its effects on premature mortality after acute myocardial infarction mandate further scrutiny by the cardiovascular community for several reasons. First, as a predictor of 1-year mortality, low SSN is equivalent to many of the classic risk factors, such as elevated cholesterol level, tobacco use, and hypertension. Second, treatment of acute myocardial infarction is costly. Because low social support is associated with an increased 1-year mortality, neglecting the role of the SSN may diminish the possible gains accrued during acute-phase treatment. Therefore, lack of an SSN should be considered a risk factor for subsequent morbidity and mortality after a myocardial infarction. Finally, cardiac rehabilitation programs and other extant prevention strategies can be better used to reduce mortality after myocardial infarction. This article systematically reviews recent evidence related to SSNs to provide an update on the role of social support in cardiovascular disease-related outcomes.

Metabolic profile and exercise capacity outcomes: their relationship to overweight and obesity in a Canadian cardiac rehabilitation setting.

PURPOSE: Obesity remains a significant health problem for cardiac rehabilitation patients. The purpose of this study was to examine the relation of overweight and obesity to cardiovascular risk factors in patients, and to compare the change in cardiovascular risk factor profiles in patients with coronary artery disease undergoing cardiac rehabilitation at a tertiary care hospital center in Ontario, Canada. METHODS: Retrospective analysis of cross-sectional data for 3542 patients, ages 63 +/- 11 years, stratified by body mass index (BMI), was performed. RESULTS: The findings showed that 81% of the patients had a BMI exceeding 25 kg/m(2), and that 35% of the patients were obese (BMI > or =30 kg/m(2)). After adjustment for age, sex, smoking, hypertension, diabetes, and peak power output, BMI was a significant independent predictor of a higher total cholesterol level, higher fasting blood glucose and triglyceride levels, and lower levels of high-density lipoprotein cholesterol. The Adult Treatment Panel III criteria were used to examine the prevalence of the metabolic syndrome for each BMI group. At baseline, 77% of the obese males in classes 2 and 3 had three or more risk factors for the metabolic syndrome, as compared with 68% of the obese females in classes 2 and 3. After 24 weeks of intervention, the outcome data for 1353 patients showed that despite no change in body weight, all the BMI groups demonstrated significant improvements in metabolic profiles and peak exercise capacity. CONCLUSIONS: Cardiac rehabilitation results in significant improvement in the cardiovascular risk profile at all levels of BMI, independently of weight loss. Future studies should examine whether targeting weight loss in cardiac rehabilitation further improves outcomes and the overall cardiovascular risk profile.

Predictors of oral feeding difficulty in cardiac surgical infants.

PURPOSE: The purpose of this study was to identify factors contributing to postoperative feeding difficulties in neonates following cardiac surgery. METHODS: A retrospective cohort study used chart audit of 101 consecutive infants who underwent cardiac surgery. Ten variables were analyzed as possible predictors of postoperative feeding difficulties including: diagnosis, demographics, details of surgery, and postoperative course. RESULTS: At hospital discharge, 72 (71.3%) infants were orally feeding and 29 (28.7%) were not. Overall mean hospital length of stay was 17.73 (+ 16.40 days). Multivariate logistic regression analysis revealed vocal chord injury (odds ratio 11.80), length of postoperative intubation (odds ratio 1.10 per day), and weight at surgery (odds ratio 0.34) as independent predictors of failure to feed orally at discharge from hospital. CONCLUSION: Risk factors for feeding difficulties in the postcardiac surgery infant are vocal chord injury, prolonged intubation, and low weight at surgery. Early identification of neonates at risk for feeding difficulties may lead to development of strategies to reduce morbidity, improve patient care, and provide better resource utilization.

Effect of coronary artery bypass graft surgery on older women's health-related quality of life.

OBJECTIVE: The purpose of this study was to determine if health-related quality of life (HRQL) improves after coronary artery bypass graft (CABG) surgery in older women. DESIGN: The study design was longitudinal observational. SETTING: The study took place in a tertiary-care teaching hospital in Hamilton, Ontario, Canada. PATIENTS: Study participants included 34 women 61 years or older who had elective or urgent CABG surgery for the first time. OUTSOME MEASURES: The 2 measures of HRQL were the Medical Outcomes Study Short Form-36 and the Feeling Thermometer (FT). The Short Form-36 is composed of 8 subscales that are summarized into the Physical and the Mental Composite Scores. The FT is a utility measure that rates patients' preferences for different health states. RESULTS: HRQL of older women was improved after CABG surgery: 7.79 points in the physical composite scores (P = .001), 7.26 in the mental composite scores (P = .008), and 29.77 points in the FT scores (P < .001). Age was a predictor of HRQL, with older women demonstrating poorer physical and better mental HRQL 3 months after the operation. CONCLUSIONS: HRQL of older women is improved significantly as early as 3 months after CABG surgery.

A controlled trial of hospital versus home-based exercise in cardiac patients.

BACKGROUND: Large numbers of patients who stand to benefit from the exercise training component of cardiac rehabilitation are not being served due to access issues. Home-based exercise training may be a potentially useful alternative to training in institutional environments. PURPOSE: The purpose of this study was to examine the benefit of 6 months of hospital-based exercise training versus 6 months of monitored, home-based exercise training with respect to physical, quality of life, and social support outcomes in patients after coronary artery bypass graft (CABG) surgery. METHODS: Randomized controlled trial of "direct-to-home" (Home; = 120) versus "direct-to-hospital" (Hosp; = 122) exercise training, 35-49 d post CABG surgery. The primary outcome was peak exercise capacity, measured by peak oxygen consumption (VO(2)) on a symptom-limited cycle ergometer exercise test. Secondary outcomes were health-related quality of life (measured by the SF-36) and social support (measured by the ISEL). Measurements were taken at baseline and after 3 and 6 months of exercise training. RESULTS: The study groups had similar demographic and health profiles at baseline. Peak VO(2) improved significantly in both groups after 6 months of exercise training; 36% in the Hosp group (1,222.1 +/- 269.0 mL x min(-1) to 1,497.2 +/- 594.3 mL x min(-1); < 0.0001) and 31% in the Home group (1,260.3 +/- 306.5 mL x min(-1) to 1,433.4 +/- 589.7 mL x min(-1); < 0.05). The Home group reported greater total social support than the Hosp group at 3 (36.2 +/- 4.5 vs 34.0 +/- 6.7; < 0.0001) and 6 months (36.0 +/- 4.9 vs 34.6 +/- 6.4; = 0.05). The Home group demonstrated a greater improvement in health-related quality of life (physical) by 6 months in comparison to the Hosp patients (51.2 +/- 6.4 vs 48.6 +/- 7.1; = 0.004). CONCLUSION: This study suggests that low-risk CABG surgery patients may be served as well or better with a monitored, home-based exercise program than with an institution-based program.