Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network.

BACKGROUND: Heart failure (HF) care takes place in multiple settings, with a variety of providers, and generally involves patients who have multiple comorbidities. This situation is a "perfect storm" of factors that predispose patients to medication errors. METHODS AND RESULTS: The goals of this paper are to outline potential roles for clinical pharmacists in a multidisciplinary HF team, to document outcomes associated with interventions by clinical pharmacists, to recommend minimum training for clinical pharmacists engaged in HF care, and to suggest financial strategies to support clinical pharmacy services within a multidisciplinary team. As patients transition from inpatient to outpatient settings and between multiple caregivers, pharmacists can positively affect medication reconciliation and education, assure consistency in management that results in improvements in patient satisfaction and medication adherence, and reduce medication errors. For mechanical circulatory support and heart transplant teams, the Centers for Medicare and Medicaid Services considers the participation of a transplant pharmacology expert (e.g., clinical pharmacist) to be a requirement for accreditation, given the highly specialized and complex drug regimens used. Although reports of outcomes from pharmacist interventions have been mixed owing to differences in study design, benefits such as increased use of evidence-based therapies, decreases in HF hospitalizations and emergency department visits, and decreases in all-cause readmissions have been demonstrated. Clinical pharmacists participating in HF or heart transplant teams should have completed specialized postdoctoral training in the form of residencies and/or fellowships in cardiovascular and/or transplant pharmacotherapy, and board certification is recommended. Financial mechanisms to support pharmacist participation in the HF teams are variable. CONCLUSIONS: Positive outcomes associated with clinical pharmacist activities support the value of making this resource available to HF teams.

Caregiving for patients with heart failure: impact on patients' families.

BACKGROUND: Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention. OBJECTIVE: To identify factors associated with the impact of caregiving. METHODS: Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records. RESULTS: A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving. CONCLUSIONS: Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.

Delays in presentation with acute coronary syndrome in people with coronary artery disease in Australia and New Zealand.

OBJECTIVES: To report time from the onset of symptoms to hospital presentation in Australian and New Zealand patients with subsequently confirmed acute coronary syndrome, and to identify factors associated with prehospital delay time in these patients. METHODS: Patients with coronary artery disease enrolled in a randomized clinical trial testing an intervention to reduce delay in responding to acute coronary syndrome symptoms had been followed for 24 months. In cases of admission to the ED for possible acute coronary syndrome, medical records were reviewed to determine the diagnosis, prehospital delay time, mode of transport to the hospital and aspirin use before admission. Clinical and demographic data were taken from the trial database. RESULTS: Patients (n= 140) had an average (SD) age of 67.3 (11.5) years; 36% were female. Two-thirds of patients went to hospital by ambulance and 89.3% had a final diagnosis of unstable angina. The median time from onset of symptoms to arrival at the ED was 2 h and 25 min (interquartile range 1:25-4:59); 12.1% arrived ≤ 1 h and 66% within 4 h. Multiple linear regression analysis showed that use of ambulance (Beta = 0.247, P= 0.012) and younger age (Beta = 0.198, P= 0.043) were independent predictors of shorter delay times. CONCLUSION: The time from the onset of symptoms to hospital presentation was too long for maximal benefit from treatment in most patients. Further efforts are needed to reduce treatment-seeking delay in response to symptoms of acute coronary syndrome.

Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the United States and is responsible for 17% of national health expenditures. As the population ages, these costs are expected to increase substantially. METHODS AND RESULTS: To prepare for future cardiovascular care needs, the American Heart Association developed methodology to project future costs of care for hypertension, coronary heart disease, heart failure, stroke, and all other CVD from 2010 to 2030. This methodology avoided double counting of costs for patients with multiple cardiovascular conditions. By 2030, 40.5% of the US population is projected to have some form of CVD. Between 2010 and 2030, real (2008$) total direct medical costs of CVD are projected to triple, from $273 billion to $818 billion. Real indirect costs (due to lost productivity) for all CVD are estimated to increase from $172 billion in 2010 to $276 billion in 2030, an increase of 61%. CONCLUSIONS: These findings indicate CVD prevalence and costs are projected to increase substantially. Effective prevention strategies are needed if we are to limit the growing burden of CVD.

The Doctor of Nursing Practice: a national workforce perspective.

In 2004, the American Association of Colleges of Nursing (AACN) adopted a position statement concerning the future of advanced practice nursing education. A target date of 2015 was articulated as the point by which master's preparation for advanced practice nurses would be replaced by doctoral level education. Seismic shifts in the realities surrounding nursing education and practice have occurred since the proposal to require a Doctor of Nursing Practice (DNP) degree for entry into advanced practice nursing was proposed. Unprecedented economic challenges have resulted in significant budget downturns for all sectors, including higher education. The consequent cutbacks, furloughs, and restructuring in educational operations of all types have placed enormous demands on faculty, staff, and students across the country. In addition, the growing incidence and earlier onset of chronic disease, a rapidly aging population, health care reform agendas, a shortage of primary care practitioners, and projected severe shortages of nursing faculty have raised fundamental questions about the capacity of nursing education to produce the numbers of advanced practice nurses needed. This article addresses the changing realities and growing concerns associated with the future of advanced practice nursing. Recommendations to ensure continuing development of advanced nursing practice that serves the interests and needs of the public now and in the future are presented within the context of a national workforce perspective.

Symptom experiences of family members of intensive care unit patients at high risk for dying.

OBJECTIVE: To describe the symptom experiences of family members of patients at high risk for dying in the intensive care unit and to assess risk factors associated with higher symptom burden. DESIGN: Prospective, cross-sectional study. SETTING: Three intensive care units at a large academic medical center. PARTICIPANTS: A sample of 74 family members of 74 intensive care unit patients who had a grave prognosis and were judged to be at high risk for dying. Patients at high risk for dying were identified as having Acute Physiology and Chronic Health Evaluation II scores >20, an intensive care unit length of stay >72 hrs, and being mechanically ventilated. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We assessed the degree of symptom burden approximately 4 days after the patient's admission to the intensive care unit in the following domains: traumatic stress, anxiety, and depression. Overall, the prevalence of symptoms was high, with more than half (57%) of family members having moderate to severe levels of traumatic stress, 80% having borderline symptoms of anxiety, and 70% having borderline symptoms of depression. More than 80% of family members had other physical and emotional symptoms, such as fatigue, sadness, and fear, and these were experienced at the moderate to severe levels of distress. Factors independently associated with greater severity of symptoms included younger age, female gender, and non-white race of the family member. The only patient factor significantly associated with symptom severity was younger age. Despite their symptom experience, the majority of the family members were coping at moderate to high levels and functioning at high levels during the intensive care unit experience. CONCLUSIONS: We document a high prevalence of psychological and physical symptoms among family members during an intensive care unit admission. These data complement existing data on long-term symptom burden and highlight the need to improve family centered care in intensive care units.

Smoking among women following heart transplantation: should we be concerned?

The serious detrimental effects of smoking after heart transplantation (HTX) are well established, but data that demonstrate the effects on female HTX recipients are scarce. The purpose of this study was to describe tobacco use, exposure to second hand smoke (ESHS), and health perceptions of female HTX recipients and examine relationships between these variables of interest and demographic and clinical characteristics of women following HTX. Seventy-two women (mean age, 54.3+/-12.7 years; mean time since transplant, 5.5+/-4.5 years) were enrolled from a single HTX center. Demographic and clinical data, tobacco use, ESHS, and health perceptions were obtained through self-report and chart reviews. Tobacco use was verified by measurement of urine cotinine levels. Twenty-four women were nonsmokers before and after HTX. Eighteen (37.5%) of the 48 women who were former smokers before HTX had returned to tobacco abuse. Only 4 of the 18 accurately reported their smoking behaviors. Forty percent of nonsmokers reported ESHS. Tobacco use and ESHS were highest among African American women. Forty percent of the sample perceived their health status as fair-poor; the remaining 60% reported good-excellent health. In a multivariate analysis, current tobacco use (odds ratio [OR], 5.20; confidence interval [CI], 3.83-9.13) and ESHS (OR, 1.82; CI, 1.17-2.82) were independent predictors of lower health perceptions. Although a majority of the female recipients who used tobacco ceased smoking before HTX, a substantial proportion demonstrated recurrent tobacco use after HTX. Our findings suggest the need for aggressive screening and risk factor interventions to promote smoking cessation before and after HTX in this unique population of female HTX recipients.

A review of cardiovascular risk factors in US military personnel.

As the civilian population exhibits increasing trends in major cardiovascular (CV) risk factors in younger age groups, the US military is observing similar trends. These worrisome developments are seen even in young adulthood. Despite the need for a fit, combat-ready force, increases in CV risk are increasingly evident in the military population. This review provides an overview of coronary artery disease in the young and the prevalence of risk factors in the military population. With increases in current military operations in an acutely stressful environment, the role of stress and the manifestation of CV disease are also examined.

Are there gender differences in the reasons why African Americans delay in seeking medical help for symptoms of an acute myocardial infarction?

OBJECTIVES: To identify gender differences in delay time and the reasons why African Americans delay in seeking medical care for symptoms of acute myocardial infarction (AMI). DESIGN: Cross-sectional. SETTING: Five hospitals in the San Francisco and East Bay areas. PATIENTS: Sixty-one African American men and women diagnosed with an AMI. MAIN OUTCOME MEASURES: Prehospital delay time. RESULTS: Median delay time was longer for women compared to men (4.4 hours vs 3.5 hours), although the difference was not significant. Single women delayed longer than single men (P = .03), and women who were alone when symptoms began delayed longer than women with someone (P = .03). Women who received advice to seek help or call 911 upon symptom onset had shorter delays compared to women who were not advised to call 911 (P = .01). Men at home delayed longer than men who experienced their symptoms outside the home (P = .01). Men with emergency room insurance delayed longer than men without emergency room insurance (P = .03), and men who took an ambulance to the hospital had shorter delay times than men who took other means of transportation (P = .04). CONCLUSION: Women compared to men often delay seeking treatment for an AMI, which further increases their risks. Our findings suggest specific characteristics that can serve as a profile to those African Americans most likely to delay seeking treatment for AMI.

The accelerated doctoral program in nursing: a university-foundation partnership.

A recent increase in nursing faculty vacancies presents an important impediment to solving the nursing shortage. Today, many schools of nursing are unable to accept qualified nursing students because they do not have sufficient faculty to teach them. Retirements projected during the next decade raise the issue to crisis proportions. One foundation, the Gordon and Betty Moore Foundation, has partnered with the School of Nursing at the University of California, San Francisco, to solve this crisis by supporting the development of an accelerated doctoral program for post-master's degree students in which students earn a PhD in 3 years. Students receive a generous stipend that allows them to devote themselves to study, but they must commit to teaching for 3 years in a nursing program on graduation. This partnership is an innovative solution to the current nursing crisis.

Physical activity patterns in heart transplant women.

Maintaining regular, long-term physical activity is critical to achieve favorable effects of heart transplantation. Yet, at present, little is known about the physical activity patterns of transplant recipients, especially women. The study was conducted to (1) describe levels and types of physical activity using actigraphy and self-report, (2) determine the association between physical activity and sociodemographic variables, and (3) assess the relationship between physical activity, quality of life (QOL), and relevant health indicators (hypertension, hyperlipidemia, and obesity) among female heart transplant recipients. Twenty-seven women (average age, 57 +/- 13 years, primarily Caucasian [82%], retired [89%], married [67%], average time since transplant 2.1 +/- 1.3 years) from a single heart transplant facility were asked to report amount and types of physical activity and overall QOL and wear an actigraph for 1 week to measure physical activity level. Physical activity levels by actigraphy averaged 280,320 +/- 52,416 counts for the week (range, 206,784-354,144); self-reported physical activity level on a 0 to 10 scale was 4.3 +/- 0.37 (range, 0-7). The actigraph and self-reported measures were significantly correlated (r = 0.661, P = .000). It was found that women were more likely to engage in household tasks and family activities than occupational activities or sports. Significant differences in physical activity (F = 6.319, P = .006) were observed in participants who reported fair (n = 13), good (n = 9), and very good (n = 5) overall QOL. The only demographic factor associated with physical activity was age; younger women were more active than older women (r = -0.472, P = .013). A negative correlation was found between levels of physical activity and presence of hypertension, hyperlipidemia, and obesity. It was found that a majority of female transplant recipients remains sedentary. Given the association between physical activity and overall QOL and relevant health indicators, measures to enhance physical activity need to be developed and tested; these strategies may be beneficial in improving overall outcomes.

A case for consideration of cultural diversity in heart failure management--Part 1: Rationale for the DISCOVER Study.

Heart failure is a condition increasing in prevalence and responsible for high health care utilization, morbidity and mortality. Randomised controlled trials of nurse-coordinated interventions have determined self-care and the incorporation of the patient and their family in care planning as critical elements of service delivery. Coping with a chronic illness, such as heart failure, forces the individual to adjust to changed physical, social and emotional functioning and to modify their lifestyle accordingly. Clinicians increasingly use models of care that focus care delivery on the community setting. In order to develop strategies to assist patients and their families with self-care it is important that clinicians understand the health-care seeking behaviours of all individuals targeted in the community. Australia is a culturally diverse nation, yet evaluations of models of care have been undertaken largely in individuals from predominately Anglo-Celtic origins. The end result of this approach is failure to understand the full range of diverse perspectives that individuals hold that can have an impact on self-care behaviours. Consideration of cultural diversity should extend beyond language to a broader appreciation of cultural values, health seeking beliefs and engagement of culturally unique communities. The 'Understanding the cultural experiences of individuals with chronic heart failure (CHF) in South East Health (DISCOVER) Study' seeks to uncover information on the health patterns, information needs and the adjustment process for overseas-born individuals with heart failure. Such information will assist clinicians to tailor health care service delivery and ensure the delivery of appropriate, quality care. This manuscript provides the background, rationale and methods for this study.

International comparison of factors associated with delay in presentation for AMI treatment.

BACKGROUND: Prehospital delay in response to acute myocardial infarction (AMI) symptoms is well documented in the US and Europe, but little is known about it in Asian countries where cardiovascular disease is increasing. AIMS: We conducted an observational study of delay times and factors associated with hospital presentation times in 595 patients with AMI from the US, England, Japan and South Korea. METHODS: Patients were interviewed about responses to symptoms within 72 h of hospital admission and the medical records were reviewed. RESULTS: The proportions of patients with delay times of 1 h or less were: US--23%, Korea--18%, England--15% and Japan--8%. In the US and England when others present at symptom onset called an ambulance patients presented two to three times sooner. Independent predictors of presentation within an hour of symptom onset were attribution of symptoms to the heart and not waiting for symptoms to go away. CONCLUSION: Similar education about the need to seek treatment early in response to AMI symptoms may be applicable in Western and Eastern industrialised populations.

Consensus statement: Palliative and supportive care in advanced heart failure.

BACKGROUND: A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure." EVIDENCE: Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews. CONCLUSIONS: The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.