Optimal use of spironolactone for treatment of heart failure.

Spironolactone has recently been shown to have a favorable impact on the prognosis and functional status of patients with left ventricular systolic dysfunction and severe symptoms who are receiving standard therapy. However, participants in clinical studies of spironolactone represent a selected group. Clinicians managing a less selected group must be mindful of selection criteria and appropriate methods to monitor patients who are initiated on these medications. In this review, two case studies are described that demonstrate the importance of careful selection of candidates for spironolactone, the need for close laboratory and symptom monitoring, and the need for patients' active participation in reporting changes in their clinical status. (c)2001 CHF, Inc.

Evaluating the cardiovascular tolerance for sex.

The cardiovascular tolerance for sex has largely been equated with physical activity, yet sexual arousal plays a major role. Exercise testing is useful, primarily for evaluating functional capacity, which reflects the extent of physical conditioning and the limitation imposed by symptoms of angina, dyspnea, and fatigue. Exercise testing, which is useful for evaluating functional capacity in sedentary patients, is generally unnecessary in physically active patients. Exercise testing, with or without radionuclide imaging, is of limited value in assessing the risk of future cardiovascular events-a limitation shared by all diagnostic tests, including coronary angiography. The absolute risks of coition-induced myocardial infarction (MI) or death are extremely low-on the order of 2 chances per million per hour in healthy middle-aged individuals or 20 chances per million per hour in "high-risk" patients with ischemic heart disease. This is equivalent to an annual risk of 1. 01% and 1.2%, respectively. Sex is a comparatively weak precipitant of acute coronary events, accounting for only 0.5-1.0% of all such events. The cardiovascular tolerance for sex in an individual can be characterized by the "functional reserve," that is, the extent to which the cardiovascular response to sex-measured by the heart rate, blood pressure, and oxygen consumption-encroaches on the peak response to exercise. Cardiovascular symptoms during sex rarely occur in patients who do not experience similar symptoms during exercise testing at a level equivalent to 6 METS.

Chronic disease management: treating the patient with disease(s) vs treating disease(s) in the patient.

The treatment of chronic disease is often complicated by the coexistence of multiple medical conditions and by the presence of social and psychological impediments. The needs posed by patients with chronic disease are overwhelming the capacity of the American health care system. Alternative disease management systems that rely on specially trained nurse case managers to implement detailed clinical protocols, including drug algorithms, have shown efficacy in managing chronic medical conditions, singly and in combination. By fostering integration of care across subspecialty and medical-social boundaries, such systems enable treatment of the patient with disease(s), not simply treatment of disease(s) in the patient. Working closely with primary care physicians, often by telephone-mediated interaction with patients, nurse case managers may take an expanded role in meeting the challenges posed by chronic disease.

In-hospital smoking cessation programs: who responds, who doesn't?

This study extends the results of a large randomized clinical trial of a multicomponent in-hospital smoking cessation intervention for general hospitalized smokers by examining subgroups of patients who responded to the intervention. The results, obtained using signal detection analysis, produced 6 subgroups of patients with varying degrees of intervention responsiveness. The subgroup most responsive was marked by 100% confidence to quit smoking at baseline. Among patients with less than 100% confidence, confidence interacted with age, depressed mood scores, addiction scores, and alcohol intake to discriminate 5 additional subgroups. Discussion focuses on how this information can be used in clinical decision making to treat subpopulations of smokers and directs attention to possible areas of underlying biopsychosocial processes that may interact to affect successful long-term cessation.

The role of the health care system in primordial prevention.

The health care system has the resources to assume an important role in primordial prevention. The extent to which it does so will be determined largely by the financial and economic forces that are transforming the health care system. There is reason to be optimistic about the effectiveness of a partnership between community-based organizations and medical centers in addressing the challenges of primordial prevention in the 21st century.

The effect of a home-based, case-managed, multifactorial risk-reduction program on reducing psychological distress in patients with cardiovascular disease.

BACKGROUND: This study examined the effects of a nurse-case-managed, multifactorial, risk-reduction program on psychological distress among patients after myocardial infarction (MI). METHODS: Five hundred eighty-five men and women aged 70 years or younger, who were hospitalized for acute MI in one of five San Francisco Bay Area hospitals, were randomized to receive a nurse-managed, home-based, multifactorial risk-reduction program (n = 293) or usual care (n = 292). The program, which began in the hospital, included a brief screen for five areas of psychological distress with further evaluation if indicated, monitoring during the follow-up phone calls, and referral for mental health treatment if needed. Patients were assessed with single-item scales at baseline, and at 6 and 12 months. Separate analyses were performed for patients with moderate-to-severe levels on the psychological distress domains and for those with low levels. RESULTS: There was a significant reduction in the psychological distress variables for all patient groups between baseline and 12 months. The program had a significant effect on reducing anxiety in the patient group with low levels of anxiety and reducing anger in the patient group with frequent episodes of anger but, overall, the treatment and control groups showed equal levels of improvement. CONCLUSION: Among patients post-MI without complications, psychological distress decreases significantly during the 12 months after MI.

Smoking cessation in hospitalized patients. Results of a randomized trial.

BACKGROUND: Few research studies have evaluated the effectiveness of smoking interventions in hospitalized patients. This randomized controlled trial compared the efficacy of 2 smoking cessation programs in patients hospitalized in 4 community hospitals in a large health maintenance organization within the San Francisco Bay Area in California. METHODS: Patients were randomly assigned to usual care (n = 990), nurse-mediated, behaviorally oriented inpatient counseling focused on relapse prevention with 1 postdischarge telephone contact (minimal intervention, n = 473), or the same inpatient counseling with 4 postdischarge telephone contacts (intensive intervention, n = 561). The main outcome measure, smoking cessation rate, was corroborated by plasma cotinine determination or family confirmation, 1 year after enrollment. RESULTS: At 1 year smoking cessation rates were 27%, 22%, and 20% for intensive intervention, minimal intervention, and usual care groups, respectively (P = .009 for intensive vs usual care). Subgroup analyses by diagnosis revealed that the odds of cessation among patients with cardiovascular disease or other internal medical conditions were greater among those receiving the intensive intervention than among their counterparts receiving usual care (odds ratios, 1.6 and 2.0, respectively). CONCLUSIONS: A multicomponent smoking cessation program consisting of physician advice; in-hospital, nurse-mediated counseling; and multiple postdischarge telephone contacts was effective in increasing smoking cessation rates among hospitalized smokers. Hospital-wide smoking cessation programs could substantially increase the effectiveness of hospital smoking bans.

Development and evaluation of a computer-based system for dietary management of hyperlipidemia.

OBJECTIVE: To describe the development of a computer-based system for dietary management of hyperlipidemia and to evaluate its efficacy for lowering plasma cholesterol level. DESIGN: Using a stepwise approach, we developed and tested a three-part self-management system in five consecutive clinical studies. Each study assessed plasma cholesterol levels before and after dietary intervention using the system. These studies enabled progressive refinement of (a) a food frequency questionnaire used to assess food intake in the preceding month; (b) computer-generated progress reports, based on questionnaire responses, offering dietary change subgoals and strategies for change; and (c) a dietary workbook providing detailed information on how to achieve goals. SUBJECTS/SETTING: Persons with hyperlipidemia (n=814) were enrolled from worksite and clinical settings in the San Francisco Bay area of California. The attrition rate after randomization was 5%. INTERVENTION: Elements of the dietary intervention evolved in response to the results of five clinical studies. In each study, patients underwent a form of baseline assessment of dietary intake followed by counseling/instruction by various means. Follow-up dietary assessments were provided at specific intervals to facilitate subjects' progress toward their dietary goals. A dietary workbook provided the detailed instruction required to implement the recommendations contained in the periodic progress reports. STATISTICAL ANALYSES PERFORMED: Changes in plasma cholesterol level were measured by paired and unpaired t tests. The relationship between the reported reduction in dietary fat and cholesterol level assessed by food frequency questionnaires and the directly measured change in plasma cholesterol level was measured by multiple linear regression. RESULTS: The three major elements of the final computerized system (food frequency questionnaires, computer-generated progress reports, and dietary workbook) were developed and refined in the course of the five clinical studies. Reductions in total plasma cholesterol level of 5.0% to 6.5% achieved by participants in all five studies were consistent with self-reported reductions in intake of dietary saturated fat and cholesterol. Therefore, the computerized self-management system appears to be an effective tool for reducing plasma cholesterol levels. APPLICATIONS/CONCLUSIONS: A computer-based system for dietary self-management of hyperlipidemia, implemented by mail, was effective in short-term studies. This self-management system can potentially provide health-promoting services to large numbers of people at low cost.

A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization.

The effectiveness of heart failure management in clinical practice is limited by physicians' suboptimal utilization of effective medications, patients' poor adherence to dietary sodium limitation and optimal drug therapy, and the lack of systematic monitoring of patients after hospitalization. The present study evaluated the feasibility and safety of MULTIFIT, a physician-supervised, nurse-mediated, home-based system for heart failure management that implements consensus guidelines for pharmacologic and dietary therapy using a nurse manager to enhance dietary and pharmacologic adherence and to monitor clinical status by frequent telephone contact. Fifty-one patients with the clinical diagnosis of heart failure were followed for 138 +/- 44 days. Daily dietary sodium intake fell by 38%, from 3,393 to 2,088 mg (p = 0.0001); average daily medication doses increased significantly (lisinopril: 17 to 23 mg, p <0.001; hydralazine: 140 to 252 mg, p = 0.01). Functional status and exercise capacity improved significantly (p = 0.01). Compared with the 6 months before enrollment and normalized for variable follow-up, the frequency of general medical and cardiology visits declined by 23% and 31%, respectively (both p <0.03); emergency room visits for heart failure and for all causes declined 67% and 53%, respectively (both p <0.001). Hospitalization rates for heart failure and for all causes declined 87% and 74%, respectively (p = 0.001), compared with the year before enrollment. The MULTIFIT system enhanced the effectiveness of pharmacologic and dietary therapy for heart failure in clinical practice, improving clinical outcomes and reducing medical resource utilization.

A nurse-managed smoking cessation program for hospitalized smokers.

OBJECTIVES: This study evaluated a nurse-managed smoking cessation program for smokers hospitalized for a variety of conditions. METHODS: Hospitalized patients who smoked prior to hospitalization and who were motivated to quit (n = 660) were randomized to intervention or usual-care groups and followed for the next year. The intervention included a meeting with the nurse-case manager; the use of a videotape, workbook, relaxation audiotape, and nicotine replacement therapy; and nurse-initiated phone contacts after discharge. RESULTS: The 12-month confirmed cessation rates were 21% and 31% for, respectively, the usual-care and intervention groups (odds ratio = 1.7; 95% confidence interval = 1.1, 2.3). CONCLUSIONS: A nurse-managed smoking cessation intervention can significantly increase cessation rates for hospitalized patients.

MULTIFIT: a new approach to risk factor modification.

The MULTIFIT system provides an infrastructure for the management of coronary risk factors and associated conditions. It is well integrated into standard medical practice, relying on existing personnel, facilities, and equipment. It integrates cognitive, executive, and organizational aspects of medical care delivery. It addresses an important national health goal: how to substitute relatively inexpensive preventive care for expensive palliative care for patients with established vascular disease.

Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute.

This Quick Reference Guide for Clinicians highlights the conclusions and recommendations from Cardiac Rehabilitation, Clinical Practice Guideline No. 17, which was formulated by a panel representing the major health care disciplines involved in cardiac rehabilitation. The conclusions and recommendations were derived from an extensive and critical review of the scientific literature pertaining to cardiac rehabilitation, as well as from the expert opinion of the panel. This guide addresses the role of cardiac rehabilitation and the potential benefits to be derived in the comprehensive care of the 13.5 million patients with heart disease in the United States, as well as the 4.7 million patients with heart failure and the several thousand patients undergoing heart transplantation. This Quick Reference Guide for Clinicians highlights the major effects of multifactorial cardiac rehabilitation services: medical evaluation; prescribed exercise; cardiac risk factor modification; and education, counseling, and behavioral interventions. The outcomes of and recommendations for cardiac rehabilitation services are categorized as to their effects on exercise tolerance, strength training, exercise habits, symptoms, smoking, lipids, body weight, blood pressure, psychological well-being, social adjustment and functioning, return to work, morbidity and safety issues, mortality and safety issues, and pathophysiologic measures. Patients with heart failure and after cardiac transplantation, as well as elderly patients, are specifically addressed. Alternate approaches to the delivery of cardiac rehabilitation services are presented.

A case-management system for coronary risk factor modification after acute myocardial infarction.

OBJECTIVE: To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification. DESIGN: Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction. SETTING: 5 Kaiser Permanente Medical Centers in the San Francisco Bay area. PATIENTS: 585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction. INTERVENTION: In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy. OUTCOME: Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction. RESULTS: In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 +/- 0.69 mmol/L and 3.41 +/- 0.90 mmol/L (107 +/- 30 mg/dL and 132 +/- 30 mg/dL) (P = 0.001), and functional capacities were 9.3 +/- 2.4 METS and 8.4 +/- 2.5 METS (P = 0.001), respectively. CONCLUSION: In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.

Home-based and worksite-based exercise training for patients with coronary artery disease.

In the era of thrombolysis, exercise training for patients with ischemic heart disease should be reserved for enhancement of functional capacity and psychological well-being rather than improvement of prognosis. Low to moderate intensity exercise training enhances functional capacity to the same extent that group-based exercise training does and can be performed safely at home. The physical demands of occupational work have decreased to the point where patients with ischemic heart disease who manifest neither treadmill-induced myocardial ischemia nor left ventricular dysfunction can perform virtually any occupational task.

Cholesterol-related counseling by registered dietitians in northern California.

BACKGROUND: An estimated 40 million Americans have serum cholesterol levels that warrant medically supervised dietary intervention. Although registered dietitians are expected to play an important role in treating these patients, current treatment practices in the community are largely unknown. METHODS: A questionnaire concerning treatment practices was mailed to all 377 registered dietitians listed in the directories of the American Dietetic Association for two large California districts. Number of patients seen and length and content of dietary counseling were ascertained for three types of patients: (a) hypercholesterolemic outpatients without heart disease, (b) hypercholesterolemic outpatients who have heart disease, and (c) inpatients with myocardial infarction. RESULTS: A return rate of 59% (n = 252) was obtained for the questionnaire. A total of 44% of the registered dietitians counseled hypercholesterolemic patients in any of the categories surveyed. About 30% of the respondents counseled hypercholesterolemic outpatients without heart disease. They saw an average of 4.9 such patients a week, spent an average of 53 min in an initial session, and usually did not see the patient again in follow-up. Fewer than 10% of patients had as many as four sessions. About 27% of the respondents saw hypercholesterolemic outpatients with heart disease, averaging 3.5 such contacts per week. The reported practices were similar to those provided to noncardiac outpatients. About 22% of registered dietitians worked with hospitalized myocardial infarction patients. They spent an average of a total of 41 min over 2.5 visits with each patient. CONCLUSION: Currently, outpatient registered dietitian counseling for hypercholesterolemia appears to be limited in both the number of patients reached and the duration of the counseling. Further research into the impact of, barriers to, and efficacy of alternative delivery methods of dietary counseling is needed.