Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study.

BACKGROUND: Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women. METHODS: Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2. RESULTS: Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety. CONCLUSIONS: Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.

Reliability of vascular access site bruise measurement.

BACKGROUND AND PURPOSE: Vascular access site (VAS) bruising is common following invasive cardiac procedures. The extent of VAS bruising is underreported because of the lack of reliable measurement methods. This study examined the reliability of linear measurement and planimetry to measure VAS bruise size. METHODS: There were 40 participants with VAS bruising after invasive cardiac procedures who completed VAS bruise measurement. Participants, a principal investigator, and a research assistant completed measurements independently. Inter-rater reliability was determined using intraclass correlation coefficient (ICC), 2-way random effects model. RESULTS: The ICC for linear measurement and planimetry was high (.929 and .914 respectively). Both methods were reliable measures of VAS bruise size. CONCLUSIONS: Linear measurement or planimetry can be used with confidence to measure VAS bruising in clinical and research contexts.

Impact of self-management interventions on stable angina symptoms and health-related quality of life: a meta-analysis.

BACKGROUND: Chronic stable angina (CSA) has a major negative impact on health-related quality of life (HRQL) including poor general health status, psychological distress, and inability to self-manage. METHODS: We used meta-analysis to assess the effectiveness of self-management interventions for improving stable angina symptoms, HRQL and psychological well-being. Nine trials, involving 1,282 participants in total, were included. We used standard inverse-variance random-effects meta-analysis to combine the trials. Heterogeneity between trials was evaluated using chi-square tests for the tau-squared statistic and quantified using the I2 statistic. RESULTS: There was significant improvement in the frequency of angina symptoms (Seattle Angina Questionnaire [SAQ], symptom diary) across trials, standardized mean difference (SMD): 0.30 (95% Confidence interval [CI] 0.14, 0.47), as well as reduction in the use of sublingual (SL) nitrates, SMD: -0.49 (95% CI -0.77, -0.20). Significant improvements for physical limitation (SAQ), SMD: 0.38 (95% CI 0.20, 0.55) and depression scores (Hospital Anxiety and Depression Scale), SMD: -1.38 (95% CI -2.46, -0.30) were also found. The impact of SM on anxiety was uncertain due to statistical heterogeneity across trials for this outcome, I2 = 98%. SM did not improve other HRQL dimensions including angina stability, disease perception, and treatment satisfaction. CONCLUSIONS: SM interventions significantly improve angina frequency and physical limitation; they also decrease the use of SL nitrates and improve depression in some cases. Further work is needed to make definitive conclusions about the impact of SM on cardiac-specific anxiety.

Patients' decision making to accept or decline an implantable cardioverter defibrillator for primary prevention of sudden cardiac death.

BACKGROUND: Patients are offered implantable defibrillators (ICDs) for the prevention of sudden cardiac death (SCD). However, patients' decision-making process (DMP) of whether or not to accept an ICD has not been explored. We asked patients about their decision making when offered an ICD. DESIGN/SETTING: A grounded theory methodology was employed. Patients were recruited from three ICD centres. Those who received an ICD underwent interviews the first month after implant. Declining patients had interviews at their convenience. In-depth analysis of transcripts was completed. Identified themes were placed along process pathways in a DMP model and tested. FINDINGS: Forty-four patients consented to participate (25% women). Thirty-four accepted an ICD and 10 (23%) declined. Ages ranged from 26 to 87 (mean = 65; SD = 12.5). Participants were retired (65%), had ischaemic heart disease (64%) and some post-secondary education (52%). The DMP was triggered when patient's risk for SCD was communicated. The physician's recommendation and a new awareness SCD risk were motivators to accept the ICD. Patient's decision-making approaches fell along a continuum, from active and engaged to passive and indifferent. Patient's approaches were influenced most by the following: (i) trust; (ii) social influences and (iii) health state. CONCLUSIONS: Health-care providers need to recognize the DMP pathways in which ICD candidacy and SCD risk are understood. The factors that influence a patient's decision warrant discussion pre-implant. It is imperative that patients comprehend the meaning of ICD candidacy to make an informed decision. Participants did not recall alternatives to receiving ICD therapy.

Readability and content of patient education material related to implantable cardioverter defibrillators.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) are increasingly offered to patients for primary prevention of sudden cardiac death. Candidates for ICD receive ICD-related patient education material when they make decisions to consent or decline a primary prevention ICD. Printed patient education material directed at ICD candidates has not been the focus of direct appraisal. OBJECTIVE: We evaluated the readability and content of ICD-related print education materials made available to patients who were enrolled in a study involving patient decision making for ICD from 3 ICD sites in southern Ontario, Canada. METHODS: All ICD print materials referred to during interviews and/or that were available in ICD site waiting rooms were collected for analysis. Readability testing was conducted using the "simple measurement of gobbledygook" and Fry methods. The material was evaluated according to selected plain-language criteria, thematic content analysis, and rhetoric analysis. RESULTS: Twenty-one print materials were identified and analyzed. Documents were authored by device manufacturers, tertiary care hospitals, and cardiac support organizations. Although many documents adhered to plain-language recommendations, text-reading levels were higher than recommended. Twelve major content themes were identified. Content focused heavily on the positive aspects of living with the device to the exclusion of other possible information that could be relevant to the decisions that patients made. CONCLUSIONS: Print-based patient education materials for ICD candidates are geared to a highly literate population. The focus on positive information to the exclusion of potentially negative aspects of the ICD, or alternatives to accepting 1, could influence and/or confuse patients about the purpose and implications of this medical device. Development of print materials is indicated that includes information about possible problems and that would be relevant for the multicultural and debilitated population who may require ICDs. The findings are highly relevant for nurses who care for primary prevention ICD candidates.

Patients' perspectives on end-of-life issues and implantable cardioverter defibrillators.

Increasing numbers of cardiovascular patients are receiving implantable cardioverter defibrillators (ICDs) for primary prevention of sudden cardiac death (SCD). This report examines patients' perspectives on related end-of-life issues. Using a grounded theory approach, audiotaped, semi-structured interviews were undertaken with 30 participants from two ICD referral centres in southwestern Ontario (24 who accepted an ICD and 6 who declined). Interview transcripts, verification with interviewees, researcher memos, published literature, and participant demographics were analyzed using NVivo7. Most participants were male, had comorbidities and an ejection fraction of less than 30 percent, and ranged in age from 26 to 87. Consensus was reached by three research team members on three main themes: quality versus quantity of life, preferred mode of death, and the technical realities of the ICD. The ICD was considered in relation to both quantity and quality of life. Most participants focused on the prevention of SCD, not the implications of the ICD for death by any other cause. Participants advocated for incorporating the ICD into advance care planning. Our findings have implications for the development of advance care plans and education of health professionals.

Prevalence of bruising at the vascular access site one week after elective cardiac catheterisation or percutaneous coronary intervention.

AIM: To identify the prevalence and predictors of VAS bruising in the 5-7 days following cardiac catheterisation or percutaneous coronary intervention. BACKGROUND: Complication(s) of cardiac catheterisation and/or percutaneous coronary intervention (PCI) occur commonly at the vascular access site (VAS). While major complications, such as retroperitoneal bleeding, are evident before hospital discharge, the prevalence of VAS bruising in the early post-discharge period is undocumented. DESIGN: Prospective observational study. METHOD: Data were collected on 172 patients following cardiac catheterisation and/or PCI through (1) chart review, (2) pre-discharge assessment and (3) telephone follow up 5-7 days post-discharge. RESULTS: At the time of telephone follow up bruising was reported in 68.6% of all patients (n = 118), with 47% of those patients (n = 56) reporting bruises larger than 7.5 cm (3 inches). Incidence of bruising varied by access site; 73% of patients (n = 86) who had femoral access, 83% (n = 5) with femoral access plus closure device and 60% (n = 17) of patients with radial access reported bruising 5-7 days post-discharge. Bivariate analysis revealed a significant association between female sex and post discharge bruising (χ(2) 10.490, p = 0.001), with a likelihood ratio of 11.20. Abciximab use during the procedure was associated with post discharge bruising (Fisher's exact test, p = 0.045). Logistic regression analysis revealed female sex as a significant predictor of bruising after discharge (p = 0.001). CONCLUSION: This study suggests that the majority of patients will experience significant bruising at the VAS following discharge and that women may be more at risk. RELEVANCE TO CLINICAL PRACTICE: The high prevalence of post-discharge bruising after cardiac catheterisation and/or PCI has important implications for nursing education and preparation of patients prior to hospital discharge.

The influence of a "culture of referral" on access to care in rural settings after myocardial infarction.

Access to care is an issue for rural people who require tertiary care following a myocardial infarction (MI). Access to specialized cardiac health services is contingent upon referral to tertiary care in urban centers. Using a critical ethnographic approach, rural women, their nurses and physicians were interviewed to explore how rurality affected women's referral and access to care following a MI. Findings reflect that a previously undocumented culture of referral that was shaped by human factors influenced access to care. The culture of referral reflected an urban-centric approach to the provision of cardiovascular services and a medical hierarchy within the referral system. The findings extend conceptual understandings of access to health care in relation to rural populations.

A prospective, controlled multisite study of psychosocial and behavioral change following women's cardiac rehabilitation participation.

BACKGROUND: Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). Thus, there are few reports of CR outcomes among women, particularly when compared with women who do not participate in CR. The purpose of this study was to prospectively assess psychosocial and behavioral changes, comparing women who participated in CR with those who did not. METHODS: One hundred fifty-seven female cardiac inpatients from three hospitals consented to participate in a prospective study, and 110 (79%) were retained 18 months postdischarge. A mailed survey discerned CR participation 9 months postdischarge. Quality of life (Short-Form Health Survey Physical and Mental Component Summary [SF-12 PCS and MCS]), exercise behavior (Health-Promoting Lifestyle Profile II [HPLPII]), Exercise Benefits and Barriers Scale (EBBS), and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS]) were assessed in hospital and 18 months postdischarge. RESULTS: Fifty-one (45.1%) women self-reported participating in CR at 1 of 18 sites, and site-verified participation was 82.43% +/- 29.97% of prescribed sessions. For CR participants, paired t tests assessing change from hospitalization to 18 months postdischarge revealed significant improvements in physical quality of life (p < 0.001), anxiety (p < 0.05), and exercise behavior (p = 0.01). Women who did not participate in CR experienced significant improvements in physical quality of life (p = 0.02), and depressive symptoms (p = 0.03) but not exercise behavior. CONCLUSIONS: Following a cardiac event, female patients improved their physical quality of life and affect, but only patients who participated in CR increased their exercise behavior. Given the cardiac benefits of exercise and that women are often sedentary and given that this exercise behavior was sustained post-CR, these findings are significant. Randomized controlled trials of women's CR outcomes are needed.

The prevalence and correlates of mind-body therapy practices in patients with acute coronary syndrome.

OBJECTIVES: While the benefits of mind-body therapy (MBT) for cardiac secondary prevention continues to be investigated, the prevalence of such practices by cardiac patients is not well known. The aim of this study was to quantitatively examine the prevalence of MBT practice and its sociodemographic, clinical, psychosocial and behavioral correlates among patients with acute coronary syndrome (ACS). METHODS: Six hundred and sixty-one ACS in-patients (75% response rate) recruited from three hospitals completed a demographic survey, and clinical data were extracted from charts. Four hundred and sixty five patients (81% retention rate; 110 (23.7%) female) responded to an 18-month post-discharge survey that queried about MBT use and its correlates. RESULTS: One hundred and sixty-three (35.1%) ACS patients practised MBT in their lifetime, and 118 (25.4%) were currently practising. MBT users were more often women (OR = 2.98), nonwhite (OR = 2.17), had higher levels of education (OR = 2.22), past smokers (OR = 3.33), reported poorer mental health (OR = 2.15), and engaged in more exercise (OR = 1.65). CONCLUSION: One-third of ACS patients practised some form of MBT. The greater MBT practice among female ACS patients is noteworthy, given their generally lower physical activity and lower receipt of evidence-based treatments including cardiac rehabilitation. In addition, there is some evidence that MBT can promote mental well-being, and thus such practice might reduce risk related to negative affect in cardiac patients.

Fears and beliefs of patients regarding cardiac catheterization.

The fears and beliefs patients hold about invasive medical interventions may affect their perceptions about risk and subsequent decisions to undergo those procedures. Little is known about fears and beliefs in patients undergoing invasive cardiac procedures and their relationship to perceptions of risks. Using a grounded theory approach, 10 men and 10 women referred for their first cardiac catheterization (CATH) from referral centers in Ontario, Canada were interviewed to identify fears and beliefs related to the procedure. Overall, women expressed more fears than men. Fears for both groups arose from: (1) lack of control about (i) physical aspects and (ii) psychosocial aspects of the CATH; (2) an unknown future; and (3) possible medical complications. Beliefs related to health personnel involved in the CATH, the technology used during the CATH and personal coping mechanisms. Men were more inclined to believe in technology, which overrode concerns about the procedure. Participants viewed CATH as a routine and necessary step in determining their future. Patients imputed previously held fears and beliefs and formulated new ones regarding the CATH during the process of anticipating the procedure. They viewed themselves as passive participants and not as actively consenting to the CATH. This paper offers previously undocumented insights from patients regarding CATH and provides the basis for developing future investigations.

Preferences of patients with heart failure for prognosis communication.

BACKGROUND: Communication about prognosis is fundamental to discussions and planning for end-of-life (EOL) care for patients with advanced heart failure (HF). Little is known about the preferences of patients that could guide communication about prognosis. OBJECTIVES: To identify the preferences of patients with advanced HF regarding communication about their prognosis and its implications. METHODS: A qualitative study using a grounded theory methodology, based on one-to-one interviews with 20 patients recruited from Heart Function Clinic at the McMaster University Medical Centre in Hamilton, Ontario. RESULTS: The following four main themes about patient preferences were identified: level of wellness--patients wanted to learn about their prognosis and its implications at a time of optimal cognitive function, and not when their capacity for EOL decision making was diminished; opportunity to be informed--patients preferred physicians to initiate discussions about prognosis at the time of diagnosis; tell the truth--there was a strong preference for physicians to disclose prognostic possibilities, treatments and outcomes associated with HF, including the possibilities of deterioration and death; and maintain hope--there was a need for truth to be balanced with hope. Hope for quality of life, symptom control and control over EOL decisions were important to participants. CONCLUSIONS: The findings suggested that communication about prognosis between patients and physicians may be difficult and deferred. Preferences identified by patients offer guidance to physicians in planning and initiating dialogue about prognosis.

Effect of aerobic vs combined aerobic-strength training on 1-year, post-cardiac rehabilitation outcomes in women after a cardiac event.

OBJECTIVE: To compare the effect and sustainability of 6 months combined aerobic/strength training vs aerobic training alone on quality of life in women after coronary artery by-pass graft surgery or myocardial infarction. DESIGN: Prospective, 2-group, randomized controlled trial. PARTICIPANTS: Ninety-two women who were 8-10 weeks post-coronary artery by-pass graft surgery or myocardial infarction, able to attend supervised exercise, and fluent in English. METHODS: The aerobic training alone group had supervised exercise twice a week for 6 months. The aerobic/strength training group received aerobic training plus upper and lower body resistance exercises. The amount of active exercise time was matched between groups. The primary outcome, quality of life, was measured by the MOS SF-36; secondary outcomes were self-efficacy, strength and exercise capacity. RESULTS: After 6 months of supervised exercise training both groups showed statistically significant improvements in physical quality of life (p = 0.0002), peak VO2 (19% in aerobic/strength training vs 22% in aerobic training alone), strength (p < 0.0001) and self-efficacy for stair climbing (p = 0.0024), lifting (p < 0.0001) and walking (p = 0.0012). However, by 1-year follow-up there was a statistically significant difference in physical quality of life in favor of the aerobic/strength training group (p = 0.05). CONCLUSION: Women with coronary artery disease stand to benefit from both aerobic training alone and aerobic/strength training. However, continued improvement in physical quality of life may be achieved through combined strength and aerobic training.

A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.

OBJECTIVE: Cardiac rehabilitation remains grossly under-utilized despite its proven benefits. This study prospectively compared verified cardiac rehabilitation enrollment following automatic vs usual referral, postulating that automatic referral would result in significantly greater enrollment for cardiac rehabilitation. DESIGN: Prospective controlled multi-center study. PATIENTS AND METHODS: A consecutive sample of 661 patients with acute coronary syndrome treated at 2 acute care centers (75% response rate) were recruited, one site with automatic referral via a computerized prompt and the other with a usual referral strategy at the physician's discretion. Cardiac rehabilitation referral was discerned in a mailed survey 9 months later (n = 506; 84% retention), and verified with 24 cardiac rehabilitation sites to which participants were referred. RESULTS: A total of 124 (52%) participants enrolled in cardiac rehabilitation following automatic referral, vs 84 (32%) following usual referral (p < 0.001). Automatically referred participants were more likely to be referred from an in- patient unit (p < 0.01), and to be referred in a shorter time period (p < 0.001). Logistic regression analyses revealed that, after controlling for sociodemographic characteristics and case-mix, automatically referred participants were significantly more likely to enroll in cardiac rehabilitation (odds ratio = 2.1; 95% confidence interval 1.4-3.3) than controls. CONCLUSION: Automatic referral resulted in over 50% verified cardiac rehabilitation enrollment; 2 times more than usual referral. It also significantly reduced utilization delays to less than one month.

Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.

BACKGROUND: Patient decision aids (PtDA) support quality decision-making. The aim of this research was to evaluate the feasibility of conducting a randomized controlled trial delivering an implantable cardioverter defibrillator (ICD)-specific PtDA to new ICD candidates and examining preliminary estimates of differences in outcomes. METHODS: Prior to recruitment, ICD candidacy was determined. Consented patients were randomized to (1) usual care or (2) PtDA intervention. Feasibility outcomes included referral and recruitment rates, successful PtDA delivery, and completion of measures. The PtDA intervention was administered prior to specialist consultation and baseline demographics, and measures of decision quality including decisional conflict (DCS), SURE test (Sure of myself, Understand information, Risk-benefit ratio, Encouragement), patient's ICD specific values, ICD knowledge, and health-related quality of life were recorded. Post-consultation, participant's DCS was repeated and decisions to proceed, decline, or defer ICD implantation were collected. Feasibility data was determined using descriptive statistics (continuous and categorical). Preliminary estimates of differences in outcomes were assessed using mean differences. Concordance between values and decision choice was assessed using logistic regression of the intervention group. RESULTS: We identified 135 eligible patients. Eighty-two consented to the trial randomizing patients to usual care (n = 41) or PtDA intervention (n = 41). Feasibility outcome results were (1) referral rate at approximately 20/month, (2) recruitment rate 61%, and (3) successful delivery of PtDA and study management. Pre-consultation, PtDA patients scored lower on the DCS scale (mean, standard deviation [SD] 27.3 (18.4) compared to usual care, 49.4 (18.6); the between-group difference in means [95% confidence interval (CI)] was - 22.1[- 30.23, - 13.97]. A difference remained post-implantation 21.2 (11.7), PtDA intervention 29.9 (13.3), and usual care - 8.7 [- 14.61, - 2.86]. SURE test results supported DCS differences. The PtDA group scored higher on the ICD-related knowledge questions, with 47.50% scoring greater than 3/5 of the knowledge questions correct, compared to 23.09% receiving usual care. The mean [SD] number of correct knowledge responses out of 5 was 3.33(1.19) in the PtDA group and 2.62 (1.16) in usual care pre-implant. Concordance between values and decision choice found a strong association between predicted and actual ICD implant status in the intervention group. CONCLUSION: Our results suggest that a future definitive trial is feasible. The ICD-specific PtDA shows promise with respect to preliminary estimates of differences in outcomes. TRIAL REGISTRATION: NCT01876173.

Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review.

BACKGROUND: Despite the documented efficacy of cardiac rehabilitation (CR), a minority of patients with diagnosed coronary artery disease are referred. Although referral is a necessary step in the promotion of CR uptake, little is known about its determinants. PURPOSE: The objective of this paper was to systematically review the available literature on factors predicting referral of patients to CR to appraise both their relative impact and consistency across studies. METHODS: Studies were identified by searching MEDLINE (1966-2003), CINAHL (1982-2003), HealthSTAR (1975-2003), EMBASE (1966-2003), and The Cochrane Library Controlled Trials. Search terms were "myocardial infarction," "acute myocardial infarction," "coronary artery disease," combined with "rehabilitation," "cardiac rehabilitation," "secondary prevention," "exercise training," "referral," and/or "consultation." Forty-five studies were identified and independently assessed by 2 reviewers using predetermined eligibility criteria. RESULTS: Ten published observational studies (1999-2004) including 30,333 coronary artery disease patients were selected. Determinants of referral to CR were grouped as sociodemographic, health status, and health care system factors. Major predictors were English speaking (RR 9.56, 95% CI 2.18-41.93), prior myocardial infarction (RR 2.73, 95% CI 1.69-4.42), being admitted to hospitals providing CR (RR 5.35, 95% CI 4.04-7.10), and having insurance coverage (RR 2.94, 95% CI 1.13-7.66). CONCLUSION: This review highlights disparities in referral to CR and reveals a treatment gap in the secondary prevention of cardiovascular disease. Precise estimates of the impact of all factors on referral are not possible, but some hierarchies and potential priorities for action are evident.

Depression, isolation, social support, and cardiovascular disease in older adults.

Research evidence related specifically to psychosocial issues in older adults with cardiovascular disease remains sparse; however, widespread recognition of the impact of the changing population demographic is spurring new research in this important area. National guidelines for cardiac rehabilitation and secondary prevention in several countries include recommendations related to psychosocial issues; authors are beginning to address the older cardiac patient in their recommendations. The purpose of this article is to highlight some key psychosocial factors that have been independently associated with coronary heart disease but to do so with a focus on the older adult in the secondary prevention setting. The selected psychosocial factors are social support, social isolation, and depression. Although evidence supports a relationship between psychosocial factors and coronary heart disease, the issue addressed in this article is whether such relationships hold true in the older adult and whether rehabilitation and secondary prevention interventions are targeted to address these factors. As much as possible, current recommendations (related to psychosocial issues) from worldwide Clinical Practice Guidelines are highlighted. Finally, any examination of psychosocial factors and coronary heart disease must consider the possibility of sex and/or gender differences. Therefore, a commentary on reported differences between men and women with respect to social support, social isolation, and depression is included.

Integrating self-efficacy and aging theories to promote behavior change and reduce stroke risk.

The increasing incidence of stroke has resulted in the establishment of secondary stroke prevention clinics. Such clinics have successfully reduced wait-to-treatment times for individuals diagnosed with transient ischemic attack or minor stroke. In addition to improving access to consultation, diagnosis, and treatment, healthcare clinics need to implement behavioral risk-reduction programs tailored to older adults to help them better adhere to treatment regimens. The integration of two social-psychological theories--(a) self-efficacy and (b) selection, optimization, and compensation-provide the foundation for an approach that could lead to the development of evidence-based behavioral risk-reduction programs for older adults at high risk of stroke.

Considerations for adolescent integrative health care in Canada.

The increased use of complementary/alternative medicine (CAM) has stimulated practitioners, policy makers, and researchers to examine its integration into mainstream medicine. For adolescents, there is evidence that they are using CAM as an option for health care. However, there is limited information on how adolescent integrative care should be developed in Canada. Practice, practice environments, and education are the three areas identified in which modifications should be made to current adolescent-focused practice in Canada to make it more of an integrative system.

Exercise and the heart failure patient: aerobic vs strength training--is there a need for both?

Heart failure (HF) is characterized by general muscular weakness, muscle atrophy, and exercise intolerance that lead to reductions in functional capacity, ability to perform activities of daily living, and health-related quality of life. Until recently, exercise programs for patients with HF were centered on aerobic exercise training alone. Although many activities of daily living require significant muscle strength, the role of strength training for HF patients, either alone or in combination with aerobic exercise, has not been well studied. There is suggestive evidence that combined strength-aerobic exercise training may offer additional benefits in terms of health-related quality of life and functional capacity. Strength training can be targeted to reduce muscle atrophy to a greater extent than aerobic training. Further research is required to isolate the specific role of strength training regarding improvements in prognosis, HF-related morbidity and hospitalization, and health-related quality of life for patients with HF.