The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Caregiver Distress and Coronary Artery Disease: Prevalence, Risk, Outcomes, and Management.

PURPOSE OF REVIEW: Caregivers of patients with coronary artery disease (CAD) are integral to the health care system and contribute substantially to patients' management. The purpose of this review is to provide a narrative synthesis of existing research on caregiving for patients who experienced an acute coronary syndrome (MI/unstable angina) and/or coronary revascularization (PCI/CABG). RECENT FINDINGS: Thirty-one articles are included in this review. Overall, caregiver distress is low to moderate, ranging from 6 to 67% of caregivers, and seems to dissipate over time for most caregivers. Interventions have demonstrated success in reducing the distress of caregivers of patients with CAD. Due to the heterogeneity in study samples, measurements used, and timing of assessments and programming, these results are far from definitive. Although evidence is accumulating, further advancement in caregiving science and clinical care is required to adequately understand and respond to the needs of caregivers throughout the patient's illness trajectory.

Recovering from spontaneous coronary artery dissection: Patient-reported challenges and rehabilitative intervention needs.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome that disproportionally affects younger women. The underlying etiology is incompletely understood, postmorbid psychological distress is high, and treatment plans are predominantly based on clinician experience. There remains uncertainty on how to adequately address the needs of patients with SCAD as part of secondary prevention. METHOD: As a Define and Refine phase of the ORBIT model (Phase 1), this study investigated SCAD patients' challenges and rehabilitative intervention needs using a qualitative research design. Patients with SCAD were purposively recruited to participate in structured interviews that were analyzed using inductive thematic coding techniques. RESULTS: Patients with SCAD (n = 15; 86.7% female; mean age = 47.5 years; data saturation reached with patient sample) expressed challenges in (a) navigating uncertainty associated with the disease; (b) living with anxiety; (c) reconciling pre and post-SCAD identities; (d) accurately identifying symptoms and experiencing a sense of isolation in recovery due to gender and young age; and (e) managing changing family dynamics and family members' stress. Intervention needs included (a) addressing unique demographic and cardiovascular profiles when designing programs for cardiac rehabilitation; (b) providing more psychological and peer support resources to address anxiety and sense of isolation; (c) disseminating information on rapidly evolving SCAD research; and (d) acknowledging and providing support to the family system. CONCLUSIONS: The results signal curricula to be included in tailored SCAD programming and underscore the need for further study and dissemination of optimal secondary preventative care for this patient population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Supporting the Health and Well-being of Caregivers: Co-design in Practice at a Canadian Cardiac Care Center.

BACKGROUND: Caregivers contribute substantially to patients' management of and recovery from cardiovascular disease (CVD). Yet, the distress that many caregivers experience in this role continues to be underresearched and their needs undersupported. PURPOSE: Situated within a patient engagement framework and adapted from experience-based co-design guidelines, the process of developing a comprehensive caregiver support resource with joint contributions from caregivers and healthcare providers representing multiple disciplines is described. A discussion of the challenges encountered during the development of the caregiver support resource and recommendations for future sites embarking on co-design work are noted. CONCLUSION: Developing feasible and relevant approaches, such as informational support instruments, to meet the needs of the growing population of CVD caregivers is essential. CLINICAL IMPLICATIONS: Although co-design processes are often complex, take more time and resources to implement, and involve multiple levels of an organization and community than traditional practices, these efforts may help to improve healthcare quality to stem the burden of CVD.

Review of Nutrition Screening and Assessment Practices for Long-Term Care Residents.

The older adult population in Canada is growing, creating a greater demand for long-term care (LTC) facilities. Seniors living in LTC are more vulnerable to malnutrition, making it important to implement nutrition screening tools on a routine basis. The purpose of this study was to explore the practices of Registered Dietitians (RDs) related to nutritional screening, nutritional assessment, and follow-ups conducted within LTC facilities. This study also explored possible barriers hindering the application of these practices. Nine RDs from two health regions in Southern Saskatchewan completed a phone interview to address nutrition care practices/policies and barriers in LTC facilities. Results showed a considerable amount of variability in nutrition care practices for screening and assessment with lack of time identified as the greatest barrier. These findings highlight the importance of having consistent policies and a sufficient amount of RDs available in LTC facilities to provide the expected level of nutrition care for residents.

Psychosocial Burdens of Pulmonary Arterial Hypertension: A Discussion Paper.

Pulmonary arterial hypertension is an uncommon and devastating chronic illness with no known cure. Little is known about the disease, and even less about the psychosocial burdens. While it is important to create awareness about the physical aspects of the disease, it is equally important to create awareness about the psychosocial burdens patients and their families face. We reviewed the literature to better understand these psychosocial burdens, which include impact from physical limitations, emotional strains, financial burdens, social isolation, lack of intimacy in relationships, and an overall lack of information. The findings can be used to assist health care providers to understand the psychosocial challenges that are being experienced by patients and families in order to better provide supportive care. The creation of a standardized tool to assess the psychosocial burdens at each clinic visit can benefit health care providers by addressing challenges faced and facilitate subsequent referral to appropriate specialists.

Effectiveness of performance coaching for enhancing rates of smoking cessation treatment delivery by primary care providers: Study protocol for a cluster randomized controlled trial.

UNLABELLED: Smoking cessation is one of the most powerful preventive interventions available to primary care providers. Rates of tobacco treatment delivery in primary care settings, however, remain sub-optimal. This paper reports on rationale, design, and protocol for a matched-paired, cluster-randomized controlled trial to compare the incremental effectiveness of performance coaching on physician delivery of smoking cessation assistance when delivered as part of a practice-level intervention for smoking cessation (the Ottawa Model for Smoking Cessation; OMSC). Outcome measures included frequency of provider smoking cessation treatment delivery, patient quit attempts, and 7-day point prevalence abstinence measured at 6 months, and changes in provider attitudes and beliefs related to smoking cessation treatment delivery. Primary care clinics were randomly assigned, using a matched paired design, to one of two treatment conditions: OMSC Group or OMSC+Performance Coaching Group. All practices were supported with implementing the OMSC. Half of the practices also received a 1.5 hour, skills-based, coaching session to address barriers encountered in the delivery of smoking cessation treatments and individualized performance feedback reports. All providers, and a cross sectional sample of patients from their practices, were surveyed before and after the implementation of the intervention. Multi-level modeling was used to compare intervention groups. If shown to be effective, the study will lead to an improved understanding of how to best assist clinicians to enhance the delivery of smoking cessation practice and will provide evidence to guide the design of smoking cessation interventions in primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01603524.

E-health physical activity interventions and moderate-to-vigorous intensity physical activity levels among working-age women: a systematic review protocol.

BACKGROUND: The rapid pace of modern life requires working-age women to juggle occupational, family, and social demands. Despite the large numbers of working-age women in developed countries and the proven benefits of regular moderate-to-vigorous intensity aerobic physical activity (MVPA) in chronic disease prevention, few women meet current physical activity (PA) recommendations of 150 min of MVPA per week. It is important that appropriate and effective behavioral interventions targeting PA are identified and developed to improve the MVPA levels of working-age women. As women worldwide embrace modern technologies, e-health innovations may provide opportune and convenient methods of implementing programs and strategies to target PA in an effort to improve MVPA levels and cardiometabolic health. Previous reviews on this topic have been limited; none have focused on working-age women from developed countries who exhibit inappropriately low PA levels. It remains unknown as to which e-health interventions are most effective at increasing MVPA levels in this population. The purpose of this systematic review is to examine the effectiveness of e-health interventions in raising MVPA levels among working-age women in developed countries and to examine the effectiveness of these interventions in improving the health of women. METHODS: Eight electronic databases will be searched to identify all prospective cohort and experimental studies examining the impact of e-health interventions for increasing MVPA levels among working-age women (mean age 18-65 years) in developed countries. Gray literature including theses, dissertations, and government reports will also be examined. Study quality will be assessed using a modified Downs and Black checklist, and risk of bias will be assessed within and across all included studies using the Cochrane's risk of bias tool and Grades of Recommendation, Assessment, Development and Evaluation approach. A quantitative synthesis in the form of meta-analyses for measures of MVPA and health outcomes will be conducted where possible. DISCUSSION: This review will determine the effectiveness of e-health interventions in raising MVPA levels in working-age women in developed countries. It will form a contemporary, rigorously developed, and reliable research base for policy makers and stakeholders; and inform and influence the development and implementation of effective e-health interventions designed to increase MVPA levels and improve health outcomes in this population. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014009534.

Post-Traumatic Stress Disorder among Cardiac Patients: Prevalence, Risk Factors, and Considerations for Assessment and Treatment.

There is increasing awareness of the impact of post-traumatic stress disorder (PTSD) on physical health, particularly cardiovascular disease. We review the literature on the role of trauma in the development of cardiovascular risk factors and disease, aftermath of a cardiac event, and risk for recurrence in cardiac patients. We explore possible mechanisms to explain these relationships, as well as appropriate assessment and treatment strategies for this population. Our main conclusion is that screening and referral for appropriate treatments are important given the high prevalence rates of PTSD in cardiac populations and the associated impact on morbidity and mortality.

Flexible and extended dosing of nicotine replacement therapy or varenicline in comparison to fixed dose nicotine replacement therapy for smoking cessation: rationale, methods and participant characteristics of the FLEX trial.

Quitting smoking is the single most effective strategy to reduce morbidity and premature mortality in smokers. Research has demonstrated the effectiveness of pharmacotherapy in smoking cessation, but few studies have directly compared varenicline and monotherapy nicotine replacement therapy (NRT) and none have examined varenicline and combinations of NRT products. The majority of smoking cessation trials involve carefully circumscribed populations, making their results less generalizable to those with severe medical conditions or psychiatric comorbidities. This paper reports on the rationale, methodology and participant characteristics of a randomized controlled trial designed to: (1) determine which pharmacotherapy - NRT, long term combinations of NRT, or varenicline - is most effective in achieving abstinence; (2) investigate the incidence of neuropsychiatric symptoms among participants over the course of their quit attempt; and (3) assess whether there is a significant difference in the incidence of neuropsychiatric symptoms in those receiving differing pharmacotherapies, and between those with and without psychiatric illnesses. The primary outcome was carbon monoxide confirmed abstinence from weeks 5-52 following a target quit date. Secondary outcomes included neuropsychiatric (i.e., depression, suicidal ideation, anxiety, anger) and withdrawal symptoms. Smokers (N=737) were randomly assigned to one of three treatment conditions, and were scheduled to attend 8 follow-up appointments over 12 months. All participants received 6-15 minute practical counseling sessions with nurse counselors experienced in treating tobacco dependence. We expect that the results will lead to an enhanced understanding of the efficacy of these pharmacotherapies, including those with a history of psychiatric illness.

Predicting short and long-term exercise intentions and behaviour in patients with coronary artery disease: A test of protection motivation theory.

The purpose of this study was to examine the utility of protection motivation theory (PMT) in the prediction of exercise intentions and behaviour in the year following hospitalisation for coronary artery disease (CAD). Patients with documented CAD (n = 787), recruited at hospital discharge, completed questionnaires measuring PMT's threat (i.e. perceived severity and vulnerability) and coping (i.e. self-efficacy, response efficacy) appraisal constructs at baseline, 2 and 6 months, and exercise behaviour at baseline, 6 and 12 months post-hospitalisation. Structural equation modelling showed that the PMT model of exercise at 6 months had a good fit with the empirical data. Self-efficacy, response efficacy, and perceived severity predicted exercise intentions, which, in turn predicted exercise behaviour. Overall, the PMT variables accounted for a moderate amount of variance in exercise intentions (23%) and behaviour (20%). In contrast, the PMT model was not reliable for predicting exercise behaviour at 12 months post-hospitalisation. The data provided support for PMT applied to short-term, but not long-term, exercise behaviour among patients with CAD. Health education should concentrate on providing positive coping messages to enhance patients' confidence regarding exercise and their belief that exercise provides health benefits, as well as realistic information about disease severity.

Physical activity counseling in primary care: who has and who should be counseling?

OBJECTIVE: To examine the physical activity (PA) counseling literature in primary care in order to identify which intervention provider has been used to date and their relative effectiveness for increasing PA. METHOD: MEDLINE and PsycINFO databases were searched for PA intervention studies in primary care settings. RESULTS: Of the 19 studies, 37% were conducted solely by physicians, 37% by allied health professionals, while 26% were combined-provider interventions. There was a decline in the number of physician-only interventions and a shift towards interventions offered by allied health professionals as adjuncts or alone. Interventions across all provider categories generated some improvements in physical activity behavior, however, it appears that allied health professionals as adjuncts or alone produced the best results in the long-term (>6 months). There was substantial variation in the location and counseling approach employed by allied health professionals. CONCLUSION: We argue for an interdisciplinary model in which physicians recommend PA and provide referrals to allied health professionals such as physical activity counselors. PRACTICE IMPLICATIONS: With physical activity counselors' specialized training and greater time available to the patient, they may provide more intensive and effective counseling required for behavior change and maintenance.