Validation of the German HeartQoL: a short health-related quality of life questionnaire for cardiac patients.

PURPOSE: The aim of this study was to evaluate psychometric properties of the core disease-specific 14-item German HeartQoL questionnaire. METHODS: As an extension of the international HeartQol Project, cross-sectional and longitudinal health-related quality of life (HRQL) data were collected from 305 patients with angina (N = 101), myocardial infarction (N = 123), or ischemic heart failure (N = 81) in Austria and Switzerland using German versions of the HeartQoL, the Short Form-36 Health Survey (SF-36), and the Hospital Anxiety and Depression Scale. The underlying factor structure was examined with Mokken Scaling analysis; then convergent, divergent, and discriminative validity, internal consistency reliability, and responsiveness were assessed. RESULTS: The highest HRQL scores were reported by patients with myocardial infarction followed by ischemic heart failure and then angina. The two-factor structure was confirmed with strong physical, emotional, and global scale H coefficients (> .50). Divergent and convergent validity (from r = .04 to .78) were shown for each diagnosis; discriminative validity was verified as well (partially: age, sex, and disease severity; largely: SF-36 health status/transition; totally: anxiety and depression). Internal consistency reliability was excellent (Cronbach's alpha = .91). In terms of responsiveness, physical and global scale scores improved significantly after percutaneous coronary intervention (p < .01) while after cardiac rehabilitation all scale scores improved significantly (p < .001). CONCLUSIONS: The German HeartQoL questionnaire is a valid and reliable HRQL instrument with these data supporting its potential use in clinical practice and research to assess and compare HRQL in German-speaking patients with ischemic heart disease. The shortness of the tool may prove to be helpful particularly in clinical practice.

Kardiologische Rehabilitation in Europa ­ eine kritische Analyse.

Cardiac rehabilitation is an evidence-based treatment to improve prognosis and quality of life in patients after a cardiac event. In general, cardiac rehabilitation programmes are offered in all European countries. Nevertheless a wide dispersion between countries exists in programme structure and design because of different national legislation and funding. The absence of international standards has a negative effect on programme quality and outcome. Most striking imbalance can be observed between patients eligible for cardiac rehabilitation and the real admission rate. Only three European countries report an admission rate of more than 50% of all eligible patients, and less than 25% are women. Thus, rehabilitation programmes in Europe are too heterogeneous. This needs measures for better standardization from "best evidence" to "best practice". The "Quality of Care Continuum" of cardiac rehabilitation could be helpful.

Health related quality of life and mental distress after PCI: restoring a state of equilibrium.

BACKGROUND: Patient self reported measures for Health Related Quality of Life (HRQOL) and mental distress are frequently used to evaluate outcome of therapeutic strategies in cardiac patients.Our study aims to describe changes in HRQOL and mental distress after percutaneous coronary intervention (PCI) focusing on temporal pattern of change and interdependences between both outcome measures. METHOD: 163 PCI patients recruited at 7 cardiovascular care units in Austria answered MacNew Health Related Quality of Life and Hospital Anxiety and Depression Scale (HADS) questionnaires during hospital stay after intervention and at 1, 6, 12 and 24 months. RESULTS: Improvement of MacNew HRQOL was found up to 6 month after PCI. Mental distress declined during the first month of the follow-up period. MacNew HRQOL is negatively correlated to mental distress. The relationship could be well described by a linear regression with MacNew HRQOL as dependent and HADS Total score as independent variable. The explained variance (R2) of the regression equation increases drastically from 45% at the baseline to a level between 67% and 77% in the follow up. CONCLUSION: Our data suggest that the regression equation describing the relation between MacNew HRQOL and HADS-Total score six month after PCI defines a state of equilibrium: In absence of actual symptoms of coronary artery disease (CAD) both measures reflect the general health status and the general attitude underlying the self-assessment of health. At the baseline this equilibrium is imbalanced because the symptoms of CAD have a more pronounced impact on the disease specific MacNew HRQOL measure than on the non-disease specific HADS measure for mental distress. In order to use the MacNew questionnaire as a monitoring and/or prognostic tool it seems promising to refer to the state of equilibrium to define expectancy values for successful treatment.

Clopidogrel pre-treatment is associated with reduced in-hospital mortality in primary percutaneous coronary intervention for acute ST-elevation myocardial infarction.

AIMS Pre-treatment with clopidogrel results in a reduction of ischaemic events in non-ST-elevation acute coronary syndromes. Data on upstream clopidogrel in the setting of primary percutaneous coronary intervention (PCI) are limited. The aim of this study was to investigate whether clopidogrel loading before arrival at the PCI centre may result in an improved outcome of primary PCI for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS In a multicentre registry of acute PCI, 5955 patients undergoing primary PCI in Austria between January 2005 and December 2009 were prospectively enrolled. The patients consisted of two groups, a clopidogrel pre-treatment group (n = 1635 patients) receiving clopidogrel before arrival at the PCI centre and a peri-interventional clopidogrel group (n = 4320 patients) receiving clopidogrel at a later stage. Multiple logistic regression analysis including major confounding factors stratified by the participating centres was applied to investigate the effect of pre-treatment with clopidogrel on the in-hospital mortality. Additionally, two subgroups, with or without the use of GP IIb/IIIa antagonist therapy in the catheterization laboratory, were analysed. On univariate analysis, clopidogrel pre-treatment was associated with a reduced in-hospital mortality (3.4 vs. 6.1%, P< 0.01) after primary PCI. On multivariate analysis, clopidogrel pre-treatment remained an independent predictor of in-hospital mortality [odds ratio (OR) = 0.60, 95% confidence interval (CI) 0.35-0.99; P =0.048], especially in patients receiving additional GP IIb/IIIa antagonist therapy in the catheterization laboratory (OR = 0.40, 95% CI 0.19-0.83; P =0.01). CONCLUSION Clopidogrel pre-treatment before arrival at the PCI centre is associated with reduced mortality in a real world setting of primary PCI. These results strongly support the recommendation of clopidogrel treatment 'as soon as possible' in patients with STEMI undergoing pimary PCI.

Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.

Cardiac patients after an acute event and/or with chronic heart disease deserve special attention to restore their quality of life and to maintain or improve functional capacity. They require counselling to avoid recurrence through a combination of adherence to a medication plan and adoption of a healthy lifestyle. These secondary prevention targets are included in the overall goal of cardiac rehabilitation (CR). Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. The CR approach is delivered in tandem with a flexible follow-up strategy and easy access to a specialized team. To promote implementation of cardiac prevention and rehabilitation, the CR Section of the EACPR (European Association of Cardiovascular Prevention and Rehabilitation) has recently completed a Position Paper, entitled 'Secondary prevention through cardiac rehabilitation: A condition-oriented approach'. Components of multidisciplinary CR for seven clinical presentations have been addressed. Components include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. Cardiac rehabilitation services are by definition multi-factorial and comprehensive, with physical activity counselling and exercise training as central components in all rehabilitation and preventive interventions. Many of the risk factor improvements occurring in CR can be mediated through exercise training programmes. This call-for-action paper presents the key components of a CR programme: physical activity counselling and exercise training. It summarizes current evidence-based best practice for the wide range of patient presentations of interest to the general cardiology community.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1.

BACKGROUND: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. METHODS: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. RESULTS: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. CONCLUSIONS: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2.

BACKGROUND: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. METHODS: Generation of evidence and search of literature have been described in part 1. RESULTS: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for "distress management" and "lifestyle changes". PE is able to increase patients' knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients' groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. CONCLUSIONS: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation.

Increasing awareness of the importance of cardiovascular prevention is not yet matched by the resources and actions within health care systems. Recent publication of the European Commission's European Heart Health Charter in 2008 prompts a review of the role of cardiac rehabilitation (CR) to cardiovascular health outcomes. Secondary prevention through exercise-based CR is the intervention with the best scientific evidence to contribute to decrease morbidity and mortality in coronary artery disease, in particular after myocardial infarction but also incorporating cardiac interventions and chronic stable heart failure. The present position paper aims to provide the practical recommendations on the core components and goals of CR intervention in different cardiovascular conditions, to assist in the design and development of the programmes, and to support healthcare providers, insurers, policy makers and consumers in the recognition of the comprehensive nature of CR. Those charged with responsibility for secondary prevention of cardiovascular disease, whether at European, national or individual centre level, need to consider where and how structured programmes of CR can be delivered to all patients eligible. Thus a novel, disease-oriented document has been generated, where all components of CR for cardiovascular conditions have been revised, presenting both well-established and controversial aspects. A general table applicable to all cardiovascular conditions and specific tables for each clinical disease have been created and commented.

Cardiac rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey.

BACKGROUND: Cardiac rehabilitation (CR) programmes support patients to achieve professionally recommended cardiovascular prevention targets and thus good clinical status and improved quality of life and prognosis. Information on CR service delivery in Europe is sketchy. DESIGN: Postal survey of national CR-related organizations in European countries. METHODS: The European Cardiac Rehabilitation Inventory Survey assessed topics including national guidelines, legislation and funding mechanisms, phases of CR provided and characteristic of included patients. RESULTS: Responses were available for 28 of 39 (72%) countries; 61% had national CR associations; 57% national professional guidelines. Most countries (86%) had phase I (acute inhospital) CR, but with differing service availability. Only 29% reported provision to more than 80% patients. Phase II was also available, but 15 countries reported provision levels below 30%. Almost half (46%) had national legislation regarding phase II CR; three-quarters had government funding. Phase III was less supported: although available in most countries, 11 could not provide estimates of numbers participating. Thirteen reported that all costs were met by patients. CONCLUSION: Fewer than half of eligible cardiovascular patients benefit from CR in most European countries. Deficits include absent or inadequate legislation, funding, professional guidelines and information systems in many countries. Priorities for improvement include promoting national laws and guidelines specific for CR and increasing both CR programme participation rates and CR infrastructure. The European Association of Cardiovascular Prevention and Rehabilitation can have an important coordinating role in sharing expertise among national CR-related agencies. Ultimately, such cooperation can accelerate CR delivery to the benefit of cardiac patients across Europe.

Efficacy of extended, comprehensive outpatient cardiac rehabilitation on cardiovascular risk factors: A nationwide registry.

AIM: Cardiac rehabilitation (CR) is a key component of the treatment of cardiac diseases. The Austrian outpatient CR model is unique, as it provides patients with an extended professionally supervised, multidisciplinary program of 4-6 weeks of phase II (OUT-II) and 6-12 months of phase III (OUT-III) CR. The aim of this analysis was to assess the efficacy of the Austrian outpatient CR model using a nationwide registry. METHODS: Data of all consecutive patients (N = 7560) who completed OUT-II and/or OUT-III between 1 January 2005 and 31 December 2015 were entered prospectively into a registry. OUT-III patients were analyzed separately according to whether the preceding phase II was performed as outpatient (OUT-II/OUT-III, N = 2403) or in-patient (IN-II/OUT-III, N = 2789). All patients underwent assessment of anthropometry, resting blood pressure, lipid profile, fasting blood glucose, exercise capacity, quality of life, anxiety and depression. RESULTS: During OUT-II, patients significantly improved their metabolic risk factor profile and increased exercise capacity by 14.3%. OUT-II/OUT-III patients achieved an additional increase in exercise capacity by 10%, further improvement in high-density lipoprotein (HDL) and stabilization of the remaining risk factors. IN-II/OUT-III patients increased their maximal exercise capacity by 18.4% and there was improvement in blood pressure, HDL, low-density lipoprotein and glucose levels. CONCLUSION: Extended, professionally supervised, multidisciplinary outpatient CR in a large nationwide registry of consecutive patients consistently improved maximal exercise capacity and relevant modifiable cardiovascular risk factors beyond effects seen after IN- or OUT-II alone.

In-Hospital Outcome Comparing Bivalirudin to Heparin in Real-World Primary Percutaneous Coronary Intervention.

Randomized controlled trials have shown conflicting results regarding the outcome of bivalirudin in primary percutaneous coronary intervention (PPCI). The aim of this study was to evaluate the in-hospital outcomes of patients receiving heparin or bivalirudin in a real-world setting of PPCI: 7,023 consecutive patients enrolled in the Austrian Acute PCI Registry were included between January 2010 and December 2014. Patients were classified according to the peri-interventional anticoagulation regimen receiving heparin (n = 6430) or bivalirudin (n = 593) with or without GpIIb/IIIa inhibitors (GPIs). In-hospital mortality (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.57 to 2.25, p = 0.72), major adverse cardiovascular events (OR 1.18, 95% CI 0.65 to 2.14, p = 0.59), net adverse clinical events (OR 1.01, 95% CI 0.57 to 1.77, p = 0.99), and TIMI non-coronary artery bypass graft-related major bleeding (OR 0.41, 95% CI 0.09 to 1.86, p = 0.25) were not significantly different between the groups. However, we detected potential effect modifications of anticoagulants on mortality by GPIs (OR 0.12, 95% CI 0.01 to 1.07, p = 0.06) and access site (OR 0.25, 95% CI 0.06 to 1.03, p = 0.06) favoring bivalirudin in femoral access. In conclusion, this large real-world cohort of PPCI, heparin-based anticoagulation showed similar results of short-term mortality compared with bivalirudin. We observed a potential effect modification by additional GPI use and access favoring bivalirudin over heparin in femoral, but not radial, access.

Exercise-based cardiac rehabilitation in twelve European countries results of the European cardiac rehabilitation registry.

AIM: Results from EuroCaReD study should serve as a benchmark to improve guideline adherence and treatment quality of cardiac rehabilitation (CR) in Europe. METHODS AND RESULTS: Data from 2.054 CR patients in 12 European countries were derived from 69 centres. 76% were male. Indication for CR differed between countries being predominantly ACS in Switzerland (79%), Portugal (62%) and Germany (61%), elective PCI in Greece (37%), Austria (36%) and Spain (32%), and CABG in Croatia and Russia (36%). A minority of patients presented with chronic heart failure (4%). At CR start, most patients already were under medication according to current guidelines for the treatment of CV risk factors. A wide range of CR programme designs was found (duration 3 to 24weeks; total number of sessions 30 to 196). Patient programme adherence after admission was high (85%). With reservations that eCRF follow-up data exchange remained incomplete, patient CV risk profiles experienced only small improvements. CR success as defined by an increase of exercise capacity >25W was significantly higher in young patients and those who were employed. Results differed by countries. After CR only 9% of patients were admitted to a structured post-CR programme. CONCLUSIONS: Clinical characteristics of CR patients, indications and programmes in Europe are different. Guideline adherence is poor. Thus, patient selection and CR programme designs should become more evidence-based. Routine eCRF documentation of CR results throughout European countries was not sufficient in its first application because of incomplete data exchange. Therefore better adherence of CR centres to minimal routine clinical standards is requested.

Clinical predictors of health-related quality of life after pacemaker implantation.

BACKGROUND: Health-related quality of life (HRQL) is increasingly accepted as an outcome measure when considering the effectiveness of therapeutic interventions. Little is known about the HRQL of patients with different clinical circumstances before and after pacemaker implantation (PMI). The purpose of this study was to investigate the influence of clinical symptoms and ECG diagnoses as predictors of improved HRQL in patients referred for PMI. METHODS: Sixty eight patients with different indications for PMI completed the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) and the Short Form-36 Health Survey (SF-36) before and one, three and six months after PMI. Symptoms, ECG indications and pacing mode were collected using the European Pacemaker Patient Identification Card codes. RESULTS: Within the first month after PMI overall Mac-New but not SF-36 scores improved significantly and was maintained during the entire 6 month follow up period. Improvement in HRQL as measured with the MacNew was rather related to baseline symptoms and ECG diagnosis than to the pacing mode. CONCLUSION: The important finding of this study is that improved HRQL seen after PMI appears to be largely driven by baseline symptoms and the ECG diagnoses rather than the pacing mode of the device.

Is atherosclerosis in diabetes and impaired fasting glucose driven by elevated LDL cholesterol or by decreased HDL cholesterol?

OBJECTIVE: To evaluate the atherogenicity of lipids in coronary patients with normal fasting glucose (NFG), impaired fasting glucose (IFG), and type 2 diabetes. RESEARCH DESIGN AND METHODS: Serum lipid values, the presence of angiographic coronary artery disease (CAD) at baseline, and the incidence of vascular events over 2.3 years were recorded in 750 consecutive patients undergoing coronary angiography. RESULTS: Triglycerides significantly (P < 0.001) increased and HDL cholesterol (P < 0.001) as well as LDL particle diameter (P < 0.001) significantly decreased from subjects with NFG <5.6 mmol/l (n = 272) over patients with IFG > or =5.6 mmol/l (n = 314) to patients with type 2 diabetes (n = 164). Factor analysis revealed two factors in the lipid profiles of our patients: triglycerides, HDL cholesterol, apolipoprotein A1, and LDL particle diameter loaded high on an HDL-related factor, and total cholesterol, LDL cholesterol, and apolipoprotein B loaded high on an LDL-related factor. In patients with type 2 diabetes, the HDL-related factor (odds ratio 0.648 [95% CI 0.464-0.904]; P = 0.011), but not the LDL-related factor (0.921 [0.677-1.251]; P = 0.597), was associated with significant coronary stenoses > or =50%. Consistently, in the prospective study, the HDL-related factor (0.708 [0.506-0.990]; P = 0.044), but not the LDL-related factor (1.362 [0.985-1.883]; P = 0.061), proved significantly predictive for vascular events in patients with type 2 diabetes. CONCLUSIONS: The low HDL cholesterol/high triglyceride pattern is associated with the degree of hyperglycemia. In coronary patients with type 2 diabetes, this pattern correlates with the prevalence of CAD and significantly predicts the incidence of vascular events.

Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 hours from symptom onset: a randomized controlled trial.

CONTEXT: No specifically designed studies have addressed the role of primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI) presenting more than 12 hours after symptom onset. Current guidelines do not recommend reperfusion treatment in these patients. OBJECTIVE: To assess whether an immediate invasive treatment strategy is associated with a reduction of infarct size in patients with acute STEMI, presenting between 12 and 48 hours after symptom onset, vs a conventional conservative strategy. DESIGN, SETTING, AND PATIENTS: International, multicenter, open-label, randomized controlled trial conducted from May 23, 2001, to December 15, 2004, of 365 patients aged 18 to 80 years without persistent symptoms admitted with the diagnosis of acute STEMI between 12 and 48 hours after symptom onset. INTERVENTIONS: Random assignment to either an invasive strategy (n=182) based predominantly on coronary stenting with abciximab or a conventional conservative treatment strategy (n=183). MAIN OUTCOME MEASURES: The primary end point was final left ventricular infarct size according to single-photon emission computed tomography study with technetium Tc 99m sestamibi performed between 5 and 10 days after randomization in 347 patients (95.1%). Secondary end points included composite of death, recurrent MI, or stroke at 30 days. RESULTS: The final left ventricular infarct size was significantly smaller in patients assigned to the invasive group (median, 8.0%; interquartile range [IQR], 2.0%-15.8%) vs those assigned to the conservative group (median, 13.0%; IQR, 3.0%-27.0%; P<.001). The mean difference in final left ventricular infarct size between the invasive and conservative groups was -6.8% (95% confidence interval [CI], -10.2% to -3.5%). The secondary end points of death, recurrent MI, or stroke at 30 days occurred in 8 patients in the invasive group (4.4%) and 12 patients in the conservative group (6.6%) (relative risk, 0.67; 95% CI, 0.27-1.62; P = .37). CONCLUSION: An invasive strategy based on coronary stenting with adjunctive use of abciximab reduces infarct size in patients with acute STEMI without persistent symptoms presenting 12 to 48 hours after symptom onset.

[Cardiac rehabilitation in Austria. A need to treat analysis]. / Kardiologische Rehabilitation in Osterreich. Eine Bedarfsanalyse.

The aim of this analysis is to survey the general demand and current supply of cardiac rehabilitation in Austria on the basis of best evidence practice and to produce recommendations for a cost-effective structure of the entire cardiac rehabilitation system. Following the standards of indication of the Austrian Society of Cardiology an analysis of demand of cardiac rehabilitation has been carried out and juxtaposed with the current supply of facilities for cardiac rehabilitation. According to hospitalizations in the year 2000, 11,630 patients per annum would require inpatient phase II rehabilitation, 6,270 patients institutional based outpatient phase II rehabilitation and 14,319 patients institutional based phase III rehabilitation. In the year 2000, 14,746 patients received treatment in the 9 Austrian inpatient cardiac rehabilitation centres. This number is compared with an annual demand of 11,630 admissions for phase-II treatment. It follows that an equilibrium can be argued for the supply of and demand for inpatient cardiac rehabilitation in Austria. At present, 10 approved institutions in Austria offer outpatient cardiac rehabilitation services. The maximum number of positions for treatment per institution is currently 200-250. Consequently, maximally 2,000-2,500 patients per annum can be treated. In comparison, there exists a calculated demand for 6,270 patients in institutional based outpatient phase II rehabilitation and 14,319 patients in institutional based phase III rehabilitation. Altogether this amounts to a demand for 20,588 positions for treatment per annum. In Austria, the expenditures for inpatient phase II rehabilitation of a patient given an average duration of stay of 28 days, are [symbol: see text] 4,774.-. Presuming 100% compliance, the institutional based outpatient phase II rehabilitation program costs [symbol: see text] 2,760.- per patient. The costs for institutional based phase III rehabilitation services are [symbol: see text] 2,990.- per patient. This number is accompanied by a potential effective reduction of risks for the patients and a potential effective reduction of costs for the carrier as the number of rehospitalizations and recurrent procedures would decrease significantly. At present, the supply of cardiac rehabilitation in Austria is sufficient for inpatient phase II, but insufficient for the institutional based outpatient phase II and mainly phase III. Thus, a striking asymmetry exists between supply and demand. In view of the enduring effects of institutional based phase III rehabilitation, the individual and social use and finally the expected efficiency in terms of costs, this program should at least be offered without limits to all eligible patients.

Change in health-related quality of life in patients with coronary artery disease predicts 4-year mortality.

AIMS: Self-reported health-related quality of life (HRQL) and changes in HRQL have been shown to predict mortality and/or adverse events in patients with coronary artery disease. MacNew Heart Disease HRQL questionnaire scores were examined as predictors of 4-year all-cause mortality. METHODS: Following referral for angioplasty in 385 patients with coronary artery disease, data were analyzed for differences in all-cause mortality by MacNew Global and subscale baseline and 1- and 3-month change scores (deteriorated ≥0.50; unchanged (-0.49 to +0.49); and improved ≥0.50 points). RESULTS: Mean baseline, 1-month, and 3-month MacNew Global and subscale scores were similar in survivors and non-survivors. Mean 1- and 3-month Global and emotional subscale and mean 1-month social subscale change scores decreased more in non-survivors than survivors. Compared with patients whose Global MacNew HRQL scores improved at one month, 4-year all-cause mortality hazard ratio (HR) was higher in patients whose HRQL deteriorated (HR, 1.70, 95% CI, 1.09, 2.65; p=0.021). Compared with patients whose Global MacNew HRQL improved at three months, 4-year all-cause mortality was higher in both patients whose HRQL had deteriorated (HR, 2.07, 95% CI, 1.29, 3.32; p=0.003) and patients with unchanged HRQL (HR, 2.62, 95% CI, 1.11, 6.17; p=0.028). CONCLUSIONS: A deterioration of ≥0.50 points in MacNew HRQL Global scores at both one and three months is predictive of 4-year all-cause mortality. Serial HRQL information may be useful to identify patients at higher risk for adverse cardiac events and mortality and may have implications for determining follow-up frequency and treatment in individual patients.