Interventions to promote patient utilisation of cardiac rehabilitation.

BACKGROUND: International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation. OBJECTIVES: First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations. SEARCH METHODS: Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics. MAIN RESULTS: Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment. AUTHORS' CONCLUSIONS: Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

[Cardiac Rehabilitation 2015]. / Kardiale Rehabilitation 2015.

The goals of cardiac rehabilitation are (re-)conditioning and secondary prevention in patients with heart disease or an elevated cardiovascular risk profile. Rehabilitation is based on motivation through education, on adapted physical activity, instruction of relaxation techniques, psychological support and optimized medication. It is performed preferably in groups either in outpatient or inpatient settings. The Swiss working group on cardiac rehabilitation provides a network of institutions with regular quality auditing. Positive effects of rehabilitation programs on mortality and morbidity have been established by numerous studies. Although a majority of patients after cardiac surgery are being referred to rehabilitation, these services are notoriously underused after catheter procedures.

Promoting patient uptake and adherence in cardiac rehabilitation.

BACKGROUND: Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review. OBJECTIVES: To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation. SEARCH METHODS: We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions. SELECTION CRITERIA: Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome. DATA COLLECTION AND ANALYSIS: At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias. MAIN RESULTS: The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization. AUTHORS' CONCLUSIONS: We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

Tratamiento antiagregante plaquetario personalizado / Personalized Antiplatelet Therapy

Actualmente está bien establecido que la alta reactividad plaquetaria a la adenosina difosfato durante el tratamiento con clopidogrel es un factor independiente predictivo del riesgo de eventos isquémicos en pacientes a los que se ha practicado una intervención coronaria percutánea. Sin embargo, el papel exacto de las pruebas de la función plaquetaria sigue siendo objeto de controversia. Las pruebas de la función plaquetaria para asegurar una inhibición plaquetaria óptima han sido recomendadas por algunos autores para mejorar los resultados en los pacientes tratados con clopidogrel. En ensayos prospectivos y aleatorizados recientes sobre tratamiento antiagregante plaquetario personalizado, no se ha podido demostrar un efecto favorable de las pruebas de la función plaquetaria en cuanto a mejora de los resultados clínicos. En este artículo se analizan los mecanismos de la falta de respuesta a clopidogrel, los ensayos recientes de las pruebas de la función plaquetaria y otros nuevos avances en el campo del tratamiento antiagregante plaquetario personalizado (AU)

It is well established that high on-treatment platelet reactivity to adenosine diphosphate during clopidogrel therapy is an independent risk factor for ischemic event occurrences in a postpercutaneous coronary intervention patients. However, the precise role of platelet function testing remains debated. Platelet function testing to ensure optimal platelet inhibition has been recommended by some authorities to improve outcomes in patients treated with clopidogrel. Recent prospective, randomized trials of personalized antiplatelet therapy have failed to demonstrate a benefit of platelet function testing in improving outcomes. In this review article, we discuss the mechanisms responsible for clopidogrel non reponsiveness, recent trials of platelet function testing, and other new developments in the field of personalized antiplatelet therapy (AU)

Ambulatory cardiac rehabilitation improves pulsatile arterial hemodynamics: a pilot trial.

BACKGROUND: In patients with coronary heart disease, both arterial stiffness and wave reflections are increased and predict unfavorable cardiovascular events. Cardiac rehabilitation has the goal to reduce risk factors and slow the progression of the disease. The aim of this study was to prospectively determine the impact of an ambulatory cardiac rehabilitation program on pulsatile hemodynamics. METHODS: Male patients after coronary interventions, bypass surgery, or acute coronary syndromes underwent exercise and resistance training. Before and after the program, pulsatile hemodynamics was measured. Exercise capacity was assessed with an incremental cycle ergometer protocol. A detailed two-dimensional and Doppler echocardiogram was obtained for systolic and diastolic left ventricular function. RESULTS: A total of 27 men participated in the study. After the intervention (n = 24), carotid-femoral pulse wave velocity decreased significantly from 8.7 (standard deviation (SD): 1.7) to 7.9 (SD: 1.9) m/s (p = 0.019), and augmentation index normalized for a heart rate of 75/min decreased significantly from 20.4 (SD: 8.7) to 17.5 (SD: 8.1; p = 0.017). CONCLUSION: The results suggest that a structured ambulatory rehabilitation program may improve pulsatile hemodynamics in coronary artery disease (CAD) patients.

Perfil dos pacientes portadores de síndrome coronariana aguda submetidos à intervenção coronariana percutânea / Profile of patients with acute coronary syndrome undergoing percutaneous coronary intervention

Mais de 12 milhões de pessoas têm doença arterial coronariana e maisde 1 milhão apresenta um infarto do miocárdio a cada ano nos EstadosUnidos, resultando em cerca de 466.000 mortes atribuídas à doença arterialcoronariana. No Brasil, o infarto agudo do miocárdio representa a maiorcausa de morte e incapacidade. O atendimento rápido a estes pacientes,bem como a realização de angioplastia transluminal coronariana, podemdiminuir o risco de morbimortalidade destes pacientes. Objetivo: Descrevero perfil dos pacientes portadores de síndrome coronariana aguda submetidosà intervenção coronariana percutânea. Métodos: Trata-se de um estudoseccional, exploratório, descritivo, retrospectivo, com abordagemquantitativa. A amostra foi composta por 39 pacientes, internados naUTI Hemodinâmica de um hospital escola, na cidade de Recife - PE, noperíodo de julho de 2010 a julho de 2011. Foi realizada análise de banco dedados COREHEMO do serviço de cardiologia intervencionista da referidainstituição no período de fevereiro a março de 2012. Resultados: Dos 39pacientes estudados, 56,4% são do sexo masculino, a faixa etária maisacometida foi a de 50-79 anos, com 76,9% dos casos. A hipertensão arterialsistêmica aparece em 97,4% dos casos. A apresentação clínica da doença é,em sua maioria, angina estável, representando 82% da amostra. 87,2% dospacientes fazia uso de antiagregantes plaquetários. Conclusão: A maioriados resultados mostra-se semelhante aos dados nacionais, porém, deve-sedar mais atenção ao correto preenchimento dos formulários dos pacientes,bem como à importância do acompanhamento de exames laboratoriais quesão preconizados por diretrizes vigentes...

More than 12 million people have coronary artery disease and more than1 million has a myocardial infarction each year in the United States,resulting in about 466,000 deaths attributed to coronary artery disease.In Brazil, acute myocardial infarction is the major cause of death anddisability. The quick service to these patients, as well as the performanceof percutaneous transluminal coronary angioplasty may decrease the riskof morbidity and mortality of these patients. Objective: To describe theprofile of patients with acute coronary syndrome undergoing percutaneouscoronary intervention. Methods: This is a cross-sectional study,exploratory, descriptive, retrospective, with a quantitative approach.The sample consisted of 39 patients admitted to the ICU Hemodynamicsof a teaching hospital, in Recife - PE, in the period July 2010 to July2011. Analysis was performed database COREHEMO interventionalcardiology service of that institution in the period February to March2012. Results: Of 39 patients 56.4% were males, the age group mostaffected was between 50-79 years, with 76.9% of cases. Systemic arterialhypertension appears in 97.4% of cases. The clinical presentation ofdisease is mostly stable angina, representing 82% of the sample. 87.2%of patients used antiplatelet. Conclusion: Most of the results were similarto national data, however, more attention should be given to the correctcompletion of patient forms, as well as the importance of monitoringlaboratory tests that are recommended by current guidelines...

Supervised exercise for acute coronary patients in primary care: a randomized clinical trial.

BACKGROUND: Functional capacity is a prognostic factor for coronary patients; accordingly, they are recommended to walk. OBJECTIVE: To assess whether an exercise program supervised in primary care increases their functional capacity more than unsupervised walking. METHODS: A randomized clinical trial was carried out at eight primary care centres of the Spanish Health Service and involving 97 incident cases of low-risk acute coronary patients, <80 years old, randomly assigned to either an unsupervised walking program (UW group; n = 51) or a 6-month cycle ergometer exercise program with gradually increasing frequency and workload intensity supervised by primary care nurses (SE group; n = 46). The two groups received the same common components of secondary prevention care. Changes in functional capacity were assessed in terms of peak oxygen consumption (VO2peak) during exercise testing measured at baseline and at 7 months by cardiologists blinded to group assignment. RESULTS: Overall, 76% of participants completed the study, 30 in the SE and 44 in the UW. Both groups increased baseline-adjusted VO2peak: 5.56ml/kg per minute in the SE (95% confidence interval [CI] 3.38-7.74) and 1.64ml/kg per minute in the UW (95% CI -0.15 to 3.45). The multivariate-adjusted difference between groups was 4.30ml/kg per minute (95% CI 1.82-6.79; P = 0.001) when analyzing completers and 2.83ml/kg per minute (95% CI 0.61-5.05; P = 0.01) in the intention-to-treat analysis, including all participants with baseline values carried forward for those lost to follow-up. CONCLUSIONS: A cycle ergometer exercise program supervised by primary care nurses increased the functional capacity of coronary patients more than unsupervised walking with a clinically relevant difference.

Effect of guidance during cardiac catheterization on emotional, cognitive and behavioral outcomes.

AIMS: Percutaneous coronary intervention (PCI) may be perceived as a frightening experience. Some psychological factors are known correlates of recovery and rehabilitation of cardiac patients. Our objective was to investigate the emotional, cognitive and behavioral effects of patient guidance during their cardiac catheterization. METHODS: We performed a randomized trial comparing a patient group that was instructed while watching the monitor screen during their PCI (study group) and another group that was not (controls). Replies to questionnaires measuring emotional, cognitive and behavioral variables known to be associated with cardiac patients' health status, rehabilitation and quality of life were collected 1 day and 1 month after the procedure. RESULTS: The study group included 57 patients and the control group included 51 patients. Most patients (∼87%) were men at the mean age of 60. They were well matched for reasons for referral to PCI. The study group reported less pain, a more positive affect, greater self-efficacy and stronger intentions to change health-related behaviors than the control group. At 1 month following the procedure, the study group evaluated their general health as significantly better, and reported a less negative affect, less cardiac anxiety, greater functional self-efficacy and more positive outcome expectancies regarding diet, and quitting smoking than the controls. CONCLUSION: A simple adjustment in the standard PCI protocol can become a highly beneficial psychological intervention for enhancing patient outcomes.

Programa cubano de rehabilitación cardíaca. Resultados / Cuban program for cardiac rehabilitation. Results

Introducción: Las enfermedades cardiovasculares constituyen la primera causa de muerte en Cuba desde hace más de 40 años, con una elevada prevalencia y una muy negativa repercusión socioeconómica. Un programa de rehabilitación cardíaca integral se ha desarrollado a nivel de la comunidad en todo el país desde 1989. Objetivos: El propósito principal de este estudio ha sido evaluar el comportamiento y los resultados de dicho programa durante un período de 3 años. Métodos: Fueron incluidos todos los pacientes con infarto miocárdico, angina inestable o después de angioplastia y cirugía coronaria o valvular, dados de alta en los 23 hospitales de la Red Nacional de Cardiología. El programa de rehabilitación cardíaca abarcó sus 3 fases habituales que incluyeron modificación de los factores de riesgo y medidas para cambios en el estilo de vida, así como ejercicios físicos con una intensidad necesaria para alcanzar el pulso de entrenamiento determinado en pruebas ergométricas previas. La fase de convalecencia tuvo una duración de 8 semanas y la de mantenimiento duró por lo menos hasta el primer año de evolución. La prueba de la chi al cuadrado fue empleada para la comparación de los datos cualitativos. Resultados: Fueron incluidos en el estudio 40.738 pacientes, de los cuales se le realizó la fase hospitalaria de la rehabilitación al 79,1%. En el último año evaluado, fueron incorporados a su fase de convalecencia el 62,5%, con un incremento de un 13,5% con relación al año interior; se incorporaron el 58,5% de los pacientes infartados, un 34,4% de aquellos con angina o después de la angioplastia coronaria y el 94,5% de los pacientes después de la cirugía coronaria o valvular. La mayoría de los pacientes rehabilitados en el último año (56,4%) pertenecían a la región occidental del país, donde también se hizo mayor cantidad de pruebas ergométricas (58,3%), así como consultas especializadas de rehabilitación e intervenciones psicológicas. Conclusiones: Aunque debe aun mejorarse la aplicación del programa de rehabilitación cardíaca en Cuba, particularmente en algunas zonas del interior del país, nuestros resultados están a la altura de muchos países con un adecuado desarrollo socioeconómico (AU)

Introduction: Cardiovascular diseases have been the leading cause of death in Cuba for over 40 years, with a high prevalence and very negative socio-economic impact. A national communitybased comprehensive cardiac rehabilitation program has been implemented all over the country since 1989. Objectives: The principal aim of this study was to evaluate the behavior and results of this program over a 3-year period. Methods: All patients with acute myocardial infarction, unstable angina pectoris or after coronary angioplasty and aorto-coronary or valvular surgery discharged alive in the 23 hospitals of the National Heart Network were included in this study. The cardiac rehabilitation program covered its three common phases. These included modification of risk factors and measures to change style of life. Physical exercises were also included with an intensity necessary to achieve the training heart rate identified by previous ergometric tests. The convalescence phase lasted eight weeks and the maintenance one continued until at least the first year of evolution. Chi-square test was used for the comparison of qualitative data. Results: In this study, 40,738 patients, 79.1% of who underwent the hospital rehabilitation phase, were included. In the last year, 62.5% were incorporated into the convalescence phase, this representing an increase of 13.5% in relation to the previous year. A total of 58.5% of infarction patients, 34.4% of those with angina or after coronary angioplasty and 94.5% of patients after coronary artery or valvular surgery were incorporated. The majority of patients rehabilitated in the last year (56.4%) belonged to the Western region of the country, an area where a higher number of ergometric tests (58.3%) were performed and which also had specialized rehabilitation consultations and psychological interventions. Conclusions: Although the implementation of the cardiac rehabilitation program in Cuba still remains to be improved, particularly in some regions of the countryside, our results are at the same level of many countries with an appropriate socio-economic development (AU)

Neighbourhood income and cardiac rehabilitation access as determinants of nonattendance and noncompletion.

BACKGROUND: Despite known benefits of exercise-based cardiac rehabilitation (CR), attendance and completion rates remain low. Our objective was to review attendance and completion of CR overall and by level of neighbourhood income in Saskatoon, Canada and then determine the effect of opening a new CR facility in close proximity to low-income neighbourhoods. METHODS: From January 2007 to December 2011, our retrospective cohort included hospital discharge data, CR attendance, and completion rates, stratified according to neighbourhood income, and adjusted for sex and age. RESULTS: Residents from low-income neighbourhoods were more likely (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.60-1.94) to be hospitalized for ischemic heart disease (IHD), percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass graft (CABG) than residents from high-income neighbourhoods. Among those hospitalized for IHD, PTCA, or CABG, 12.7% attended CR. Patients of low-income neighbourhoods were less likely (OR, 1.58; 95% CI, 1.39-1.71) to attend CR than patients of high-income neighbourhoods. Among those who attended, 66.7% quit before program completion. Participants from low-income neighbourhoods were more likely (OR, 1.38; 95% CI, 0.57-3.50) to not complete CR. In total, only 4.2% of patients hospitalized for IHD, PTCA, or CABG started and completed CR. Expanding access to those living in low-income neighbourhoods did not increase attendance (OR, 1.31; 95% CI, 0.79-2.19) or completion rates (OR, 1.25; 95% CI, 0.23-2.41) to a significant level. CONCLUSIONS: High rates of nonattendance and noncompletion of CR were observed. Living in a low-income neighbourhood was associated with lower rates of attendance and completion. Expanding access to CR did not increase attendance or completion among patients of low-income neighbourhoods to a significant level.

Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up.

OBJECTIVE: To investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose-response relationship between the proportion of CR sessions attended and long-term mortality. DESIGN: Retrospective cohort study. SETTING: CR programmes in Victoria, Australia PATIENTS: The sample comprised 544 men and women eligible for CR following myocardial infarction, coronary artery bypass surgery or percutaneous interventions. Participants were tracked 4 months after hospital discharge to ascertain CR attendance status. MAIN OUTCOME MEASURES: All-cause mortality at 14 years ascertained through linkage to the Australian National Death Index. RESULTS: In total, 281 (52%) men and women attended at least one CR session. There were few significant differences between non-attenders and attenders. After adjustment for age, sex, diagnosis, employment, diabetes and family history, the mortality risk for non-attenders was 58% greater than for attenders (HR=1.58, 95% CI 1.16 to 2.15). Participants who attended <25% of sessions had a mortality risk more than twice that of participants attending ≥ 75% of sessions (OR=2.57, 95% CI 1.04 to 6.38). This association was attenuated after adjusting for current smoking (OR=2.06, 95% CI 0.80 to 5.29). CONCLUSIONS: This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose-response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation.

T-wave normalization during follow-up after early and late mechanical recanalization of infarct-related artery with and without stent implantation.

OBJECTIVE: The aim of this study was to evaluate T-wave normalization during the 6-month follow-up in the patients who underwent early or late mechanical recanalization of the infarct-related artery with and without stent implantation. MATERIAL AND METHODS: A total of 248 consecutive patients were divided into the following groups: early angioplasty (≤24 hours) without (n=114) or with stents (n=6) and late angioplasty (>24 hours) without (n=114) or with stents (n=14). The changes in T-wave recovery, QRS score, and echocardiographic left ventricular ejection fraction were compared between the groups. RESULTS: At 3 months, a greater percentage of patients in the group of early angioplasty with stents had again positive T wave than in the group of early angioplasty without stents (75% vs. 35%, P=0.05). After 6 months, all patients in the group of early angioplasty with stents had again positive T wave. A significant increase in left ventricular ejection fraction after 3 months was also observed only in the groups of early angioplasty, especially that with stents (30.0% [SD, 3.5%] vs. 38.4% [SD, 5.2%], P=0.008). However, there was no significant difference in the QRS score in this group comparing the data at discharge and after 3 months (5.4 [SD, 4.3] vs. 5.0 [SD, 1.9], P>0.05). CONCLUSIONS: The group of early angioplasty with stents showed the best recovery of T wave and left ventricular ejection fraction, but the QRS score did not change significantly from discharge to the 3-month follow-up, so the evolution of T wave corresponded to an improvement in ejection fraction at follow-up better than the evolution of QRS score.

Return to work after coronary angioplasty or heart surgery: a 5-year experience with the "CardioWork" protocol.

OBJECTIVE: The "CardioWork" protocol, for work resumption after invasive heart procedures and subsequent cardiac rehabilitation, is presented. METHODS: Over 5 years, 107 consecutive patients of working age were enrolled. Jobs were classified as multiples of basal metabolism according to the entity of physical strain. These data were integrated with instrumental evaluations to provide indications regarding time and modality of work resumption. RESULTS: A total of 89.7% of patients resumed working. Other relevant findings include the correlation of time for work resumption with the kind of treatment and the task energy requirement; the earliness of return to work, even for older people and those performing heavy tasks; and the difficulty of work resumption for those who failed to restart work within 6 months. CONCLUSIONS: This study highlights the importance of a multidisciplinary rehabilitative approach to facilitate work resumption, adapting the work tasks to the changed psychophysical capabilities.

Avaliação de possíveis fontes externas de estresse e o seu nível em duas unidades de terapia intensiva em pacientes pós-angioplastia coronariana / Evaluation of two possible external sources of stress and its level in two intensive care units in patients submitted to coronary angioplasty

Várias alterações de ordem psicológica são frequentemente encontradas em pacientes internados em unidades de terapia intensiva (UTI). As características físicas desse ambiente, em pacientes submetidos à angioplastia coronariana que permanecem acordados e orientados em seu pós-operatório, podem interferir na percepção que o paciente tem da UTI, sendo que essa percepção pode gerar estresse. Objetivo: Identificar e comparar os níveis e os fatores causadores de estresse em pacientes coronarianos internados em duas unidades de terapia intensiva com características físicas distintas, em um hospital na cidade de Goiânia, GO. Casuística e Métodos: Vinte e nove indivíduos submetidos à angioplastia por doença coronariana foram divididos em duas unidades de terapia intensiva, doravante denominados grupo I (UTI I: 10 pacientes, idade: 53,6+ ou menos 9,9, oito maculinos), e grupo II (UTI II: 19 pacientes, idade: 66,3 + ou menos 8,0, 11 masculinos). Os dados referentes aos níveis de estresse foram coletados, utilizando a Escala de Estressores em Unidades de Terapia Intensiva (EETI), com um intervalo mínimo de 12 horas após a realização do procedimento. Resultados: Não houve diferença entre as variáveis sexo, idade e escolaridade entre os dois grupos (p>0,05). O grupo I apresentou nível de estresse superior ao grupo II (grupo I: 75,5 + ou menos 8,1 pontos; grupo II: 66,6 + ou menos 12,2 pontos p=0,04). Conclusão: A estrutura física de uma UTI influencia na percepção dos pacientes sobre os fatores desencadeadores de estresse e também nos níveis de estress e observados em pacientes submetidos a procedimento de angioplastia coronariana.

Several psychological disturbances are commonly related to patients admitted in intensive care units (ICU). The physical characteristcs in this environment, in patients submitted to coronary angioplasty that remains oriented and awake in his post-operatory period may interfere in the stress perception when patients are admitted on it, and this perception can lead to stress. Objective: To identify and to compare the stress levels and the factors involved in the stress genesis among coronary patients admitted in two different intensive care units, at a hospital in Goiania city. Methods: Twenty-nine individuals who underwent an angioplasty procedure due to coronary artery disease were divided in two different ICUs, thereby nominated as group I (ICI I: 10 patients, age: 53,6+ ou menos 9.9 years old, eight male) and group II (ICU II: 19 patients, age: 66.3 + or less 8.0 years old, 11 male). Data referred to stress levels were collected using the Intensive Care Environmental Stressor Scale (ICUESS), observing a 12 hour interval between the addmission to the ICU and the collecting data interview. Results: There were no differences in gender, age or educational levels among the two groups(p=0,05). Group I presented higher stress levels when compared to group II (group I: 75.5 + or less 8.1 vs. group II: 66.6 = or less 12.2 points, p=0,04). Conclusion: The physical structure in an ICU may interfere in the stress levels and in the stressing factors perception among patients admitted on it after and angioplasty procedure.

Ambulatory surveillance of patients referred for cardiac rehabilitation following cardiac hospitalization: a feasibility study.

BACKGROUND: Our purpose was to examine the feasibility of implementing an ambulatory surveillance system for monitoring patients referred to cardiac rehabilitation following cardiac hospitalizations. METHODS: This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance at cardiac rehabilitation, waiting times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse. RESULTS: Among the 1208 consecutive patients referred, only 44.7% attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 18.9% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths), with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program, 114 (25.9%) had adverse clinical events while in the queue; 46 of these events required cardiac hospitalization and 8 patients died. CONCLUSIONS: Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs, underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.