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.

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.

ECG gating of thallium-201 myocardial images: effect on detection of ischemic heart disease.

Using the angiographic findings as the standard, we have examined the sensitivity and specificity of ECG-gated static thallium-201 myocardial images in 54 patients undergoing selective coronary arteriography. Gated and nongated images, each in anterior, 45 degrees LAO, and 65 degrees LAO projections, were processed by interpolative background subtraction. They were then analyzed separately by four independent observers who were unaware of patient identity, the results of coronary arteriography, and which studies were gated or nongated. No significant differences were observed between the gated and nongated images regarding sensitivity or specificity, the detection rate for reversible myocardial ischemia, the accuracy of prediction of arteriographic extent of disease, or the degree of inter- or intraobserver variability. We conclude that ECG-gated acquisition of T1-201 images does not produce any significant advantages, at least when interpolative background subtraction is used.

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.

Reproducibility of exercise-induced ventricular arrhythmia after myocardial infarction.

To evaluate the reproducibility of exercise-induced ventricular arrhythmia, 155 men with a mean age of 53 +/- 8 years underwent serial exercise testing 3 to 52 weeks after myocardial infarction. The reproducibility of categorical test responses, that is, the presence or absence of ventricular arrhythmia, was evaluated with the kappa coefficient, which considers negative as well as possible test responses and expresses reproducibility above the chance level. Reproducibility was highest at an intertest interval of 1 to 5 days and was not enhanced by further categorizing premature ventricular complexes as simple or complex based on their frequency or configuration. Continuous response measures such as frequency of premature ventricular complexes yielded higher reproducibility than categorical responses. Continuous response measures appear preferable to categorical responses for evaluating the clinical significance and response to antiarrhythmic therapy of ventricular arrhythmias.

Training effects of long versus short bouts of exercise in healthy subjects.

To evaluate the "threshold" duration of exercise required to produce training effects, 18 healthy men aged 51 +/- 6 years completing 30 minutes of exercise training/day were compared with 18 men aged 52 +/- 6 years completing three 10-minute bouts of exercise/day, each separated by at least 4 hours. Exercise training intensity was moderate (65 to 75% of peak treadmill heart rate). During the 8-week study period VO2 max increased significantly in both groups from 33.3 +/- 3.2 to 37.9 +/- 3.5 ml/kg/min in men performing long exercise bouts and from 32.1 +/- 4.6 to 34.5 +/- 4.5 ml/kg/min in men performing short exercise bouts (p less than 0.05 within and between groups). Adherence to unsupervised exercise training performed at home and at work by men in long and short bouts was high; total duration of training completed was 96 and 93% of the prescribed amount and total number of sessions completed was 92 and 93% of that prescribed, respectively. In both groups exercise heart rate measured by a portable microprocessor was within or above the prescribed range for greater than 85% of the prescribed duration. Thus, multiple short bouts of moderate-intensity exercise training significantly increase peak oxygen uptake. For many individuals short bouts of exercise training may fit better into a busy schedule than a single long bout.

Strategies for increasing early adherence to and long-term maintenance of home-based exercise training in healthy middle-aged men and women.

Two studies were undertaken to compare strategies for the adoption and maintenance of moderate-intensity, home-based exercise training. In the study of adoption, 52 men and women who had served for 6 months as controls for a study of moderate-intensity, home-based exercise training received 30 minutes of baseline instruction. They were then randomized to receive continuing instruction and support through 10 staff-initiated telephone contacts of 5 minutes each every 2 weeks, or to receive no telephone contacts. In subjects receiving telephone contacts, peak oxygen uptake increased significantly after 6 months, whereas no increase was observed in subjects receiving no staff support (p less than 0.05). In the maintenance study, 51 men and women who had significantly increased their peak oxygen uptake by 6 months of moderate-intensity, home-based exercise training were randomized to undergo daily self-monitoring and receive adherence instructions, or undergo weekly self-monitoring only, during a second 6-month period of training. Subjects performing daily self-monitoring reported completing significantly more exercise training sessions during the 6 months of training than subjects performing weekly self-monitoring; functional capacity in both groups remained higher than before training (p less than 0.05). Taken together, these studies suggest that brief baseline instruction followed by continuing telephone contact with staff can be used to help people adopt a moderate-intensity, home-based exercise training program that can be maintained by simple self-monitoring strategies.

Mechanisms for decreased exercise capacity after bed rest in normal middle-aged men.

The mechanisms responsible for the decrease in exercise capacity after bed rest were assessed in 12 apparently healthy men aged 50 +/- 4 years who underwent equilibrium gated blood pool scintigraphy during supine and upright multistage bicycle ergometry before and after 10 days of bed rest. After bed rest, echocardiographically measured supine resting left ventricular end-diastolic volume decreased by 16% (p less than 0.05). Peak oxygen uptake during supine effort after bed rest was diminished by 6% (p = not significant [NS]), whereas peak oxygen uptake during upright effort declined by 15% (p less than 0.05). After bed rest, increases in heart rate were also greater during exercise in the upright than in the supine position (p less than 0.05). Values of left ventricular ejection fraction increased normally during both supine and upright effort after bed rest and were higher than corresponding values before bed rest (p less than 0.05). After bed rest, increased left ventricular ejection fraction and heart rate largely compensated for the reduced cardiac volume during supine effort, but these mechanisms were insufficient to maintain oxygen transport capacity at levels during upright effort before bed rest. These results indicate that orthostatically induced cardiac underfilling, not physical deconditioning or left ventricular dysfunction, is the major cause of reduced effort tolerance after 10 days of bed rest in normal middle-aged men.

Effects of early postmyocardial infarction exercise testing on self-perception and subsequent physical activity.

The effects of exercise testing 3 weeks after clinically uncomplicated myocardial infarction (MI) on subsequent physical activity were evaluated in 40 consecutive men with a mean age of 52 +/- 9 years. Patients' confidence in their ability to perform various physical activities was evaluated with self-efficacy scales which patients completed before and after a symptom-limited treadmill exercise test. Increases in confidence (self-efficacy) for activities similar to treadmill exercise (walking, stair climbing, and running) were greatest after treadmill exercise, whereas increases for dissimilar activities (sexual intercourse and lifting) were greatest after test results were explained by a physician and nurse. The intensity and duration of subsequent physical activity at home were more highly correlated with self-efficacy after treadmill exercise than with peak treadmill heart rate. Of the 8 patients whose treadmill tests were limited by angina pectoris, 7 had self-efficacy scores which remained low after treadmill testing or which decreased from initially high values after treadmill testing. These patients had lower peak heart rates and work loads than patients whose self-efficacy increased or remained high after treadmill testing. After MI, patients' perception of their capacity for physical activity and their actual patterns of subsequent physical activity are influenced by early treadmill testing in a manner which is congruent with these patients' treadmill performance.

Stepwise risk stratification soon after acute myocardial infarction.

A stepwise rise stratification procedure sequentially combining historical and clinical characteristics and treadmill exercise test results was applied to 702 consecutive men aged less than or equal to 70 years who were alive 21 days after acute myocardial infarction (MI). Historical characteristics alone (prior MI and prior angina or recurrence of pain in the coronary care unit) identified 10% of patients with the highest rate of reinfarction and death within 6 months (18%). Clinical contraindications to exercise testing identified another 40% of patients with an intermediate rate of cardiac events (6.4%). In the 50% of patients who underwent treadmill testing 3 weeks after MI, the rate of cardiac events within 6 months was 4.4%: 3.9% in patients with a negative test and 9.7% in patients with a positive test (ischemic ST-segment depression greater than or equal to 0.2 mV and a peak heart rate less than or equal to 135 beats/min). Patients with negative treadmill tests, who comprised 46% of patients less than or equal to 70 years and 53% of patients less than or equal to 60 years, had a cardiac death rate of less than 2% in the 6 months after MI. The stepwise classification procedure correctly classified 72% of patients with hard medical events within 6 months. Thus, most patients who experience subsequent cardiac events are correctly classified on the basis of historical and clinical risk characteristics. In patients without these risk characteristics, early treadmill testing is useful for further discriminating high-risk from very low risk patients.

Changes in rest and exercise myocardial perfusion and left ventricular function 3 to 26 weeks after clinically uncomplicated acute myocardial infarction: effects of exercise training.

The effects of exercise training on exercise myocardial perfusion and left ventricular (LV) function in the first 6 months after clinically uncomplicated acute myocardial infarction (AMI) were assessed in 53 consecutive men aged 55 +/- 9 years. Symptom-limited treadmill exercise with thallium myocardial perfusion scintigraphy and symptom-limited upright bicycle ergometry with equilibrium gated radionuclide ventriculography were performed 3, 11 and 26 weeks after AMI by 23 men randomized to training and 30 randomized to no training. Peak cycle capacity increased in both groups between 3 and 26 weeks (p less than 0.01), but reached higher levels in trained than in untrained patients (803 +/- 149 vs 648 +/- 182 kg-m/min, p less than 0.01). Reversible thallium perfusion defects were significantly more frequent at 3 than at 26 weeks: 59% and 36% of patients, respectively (p less than 0.05), without significant inter-group differences. Values of LV ejection fraction at rest, submaximal and peak exercise did not change significantly in either group. The increase in functional capacity, i.e., peak treadmill or bicycle workload, that occurred 3 to 26 weeks after infarction was significantly correlated with the increase in peak exercise heart rate (p less than 0.001), but not with changes in myocardial perfusion or LV function determined by radionuclide techniques. Changes in myocardial perfusion or LV function do not appear to account for the improvement in peak functional capacity that occurs within the first 6 months after clinically uncomplicated AMI.

Exercise testing to enhance wives' confidence in their husbands' cardiac capability soon after clinically uncomplicated acute myocardial infarction.

The effects of wives' involvement in their husbands' performance of treadmill exercise testing 3 weeks after clinically uncomplicated acute myocardial infarction was compared in 10 wives who did not observe the test, 10 who observed the test, and 10 who observed and participated in the test themselves. In a counseling session after the treadmill test, couples were fully informed about the patient's capacity to perform various physical activities. Wives' final ratings of confidence (perceived efficacy) in their husbands' physical and cardiac capability were significantly (p less than 0.05) higher in those who also performed the test than in the other 2 groups. Only wives who walked on the treadmill increased their ratings of their husbands' physical and cardiac efficacy to a level equivalent to those of their husbands. Spouses' and patients' perceptions of patients' cardiac capability after treadmill testing and counseling at 3 weeks were significantly correlated with peak treadmill heart rate and workload at 11 and 26 weeks. Efficacy ratings at 3 weeks were slightly better than peak 3-week treadmill heart rate and workload as predictors of treadmill performance at 11 and 26 weeks. Participation in treadmill testing early after acute myocardial infarction is an effective means for reassuring spouses about the capacity of their partners to resume their customary physical activities with safety.

Assessment of prescribed increases in physical activity: application of a new method for microprocessor analysis of heart rate.

A portable solid-state recorder-display system was used to measure and analyze heart rate during the waking hours of 3 consecutive days in free-living sedentary normal middle-aged men who were randomized to undergo 3 regimens of physical activity during a 12-week period: low-intensity exercise training at home (n = 21), high-intensity exercise training at home (n = 23) and customary activity (n = 20). This was done to determine whether the system could detect changes in heart rate and, indirectly, in physical activity within the 3 groups. In both training groups the percentage of total recorded time spent within the prescribed high or low heart rate range recorded at 6 or 12 weeks increased significantly (p less than 0.05), whereas control subjects showed no increase above baseline values. Peak oxygen consumption increased by 8% and 17% in men undergoing low- and high-intensity training, whereas in control subjects it did not change. This solid-state system reliably measures prescribed increases in heart rate and provides an indirect measure of physical activity in normal sedentary men undergoing exercise training at home.

Effects of low- and high-intensity home-based exercise training on functional capacity in healthy middle-aged men.

The effects of 12 weeks of home-based exercise training on peak oxygen consumption (VO2 max) in healthy sedentary middle-aged men, mean age 49 +/- 6 years, were evaluated. Twenty-one men trained at low intensity, 23 trained at high intensity and 20 were control subjects. Individually prescribed low- and high-intensity training was performed 5 times per week within a range of 42 to 60% and 63 to 81% of baseline VO2 max, corresponding to average heart rates of 102 to 122 and 128 to 148 beats/min, respectively. Caloric expenditure per training session approximated 350 kcal in both groups; adherence was at least 90% in both groups. VO2 max increased 8% in patients who trained at low intensity, 17% in those who trained at high intensity (both p less than 0.001), and not at all in control subjects. Low-intensity exercise training at home significantly augments functional capacity in healthy sedentary middle-aged men.

Effectiveness of self-monitored, home-based, moderate-intensity exercise training in middle-aged men and women.

The effects of 6 months of self-monitored, home-based exercise training on maximal oxygen uptake (VO2 max), body composition and plasma lipid levels of healthy, sedentary, middle-aged persons were evaluated in 60 men, aged 49 +/- 6 years, and 60 women, aged 47 +/- 5 years. Moderate-intensity training was performed 5 times per week in sessions of 47 +/- 7 minutes and 54 +/- 8 minutes for men and women, respectively. The individually prescribed range of heart rate corresponded to 65 to 77% of the peak value during symptom-limited treadmill testing (mean of 72% for men and 69% for women). Caloric expenditure per training session was approximately 345 kcal for men and 235 kcal for women. VO2 max increased 15% in men and 9% in women (both p less than 0.01). The greater increase in VO2 max in men than in women primarily reflected greater adherence to training in men (greater than or equal to 90% vs greater than or equal to 75%). The increase in VO2 max in women who showed very high adherence was comparable to that of men. Body weight decreased, by 1.5 +/- 10 kg, in men (p less than 0.05) but not in women undergoing training. No significant training-induced changes in plasma lipid levels were noted in either men or women. Baseline orientation and follow-up telephone calls required less than 1 hour of staff time per participant. Self-monitored, moderate-intensity, home-based exercise training significantly increases functional capacity in healthy, middle-aged men and women. Such training provides an alternative to group-based exercise training.

Assessment by a microprocessor of adherence to home-based moderate-intensity exercise training in healthy, sedentary middle-aged men and women.

Research in exercise training of healthy persons, which has been conducted almost exclusively in supervised group programs, is relatively expensive for the investigator and inconvenient for the participant. To overcome these obstacles, self-monitored moderate-intensity home-based exercise training was prescribed for 28 middle-aged men and 26 middle-aged women. The median energy expenditure prescribed for each of 5 weekly exercise sessions was 4 cal/kg body weight, or 317 kcal for men and 265 kcal for women, corresponding to a median duration of 45 and 60 minutes, respectively. In the next 24 weeks, peak oxygen uptake increased 13.7% in men who exercised, from 31 +/- 4 to 37 +/- 4 ml/kg/min, and 10% in women who exercised, from 26 +/- 4 to 29 +/- 5 ml/kg/min (p less than 0.001 for both comparisons). The proportion of prescribed caloric expenditure per session, which was documented by a solid-state heart rate recorder, was 108% in men and 90% in women. The duration of training at heart rates above the prescribed range approximated 10 minutes per session for both men and women; the proportion of total caloric expenditure represented by exercise at heart rates exceeding the prescribed limit was 9% for men and 4% for women. The proportion of time spent within the prescribed heart rate range during training sessions was 76% for men and 84% for women. Training-induced musculoskeletal problems were reported by 6 men and no women. No subject sought medical attention and all resumed training within 1 week.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative value of maximal treadmill testing, exercise thallium myocardial perfusion scintigraphy and exercise radionuclide ventriculography for distinguishing high- and low-risk patients soon after acute myocardial infarction.

The prognostic value of symptom-limited treadmill exercise electrocardiography, exercise thallium myocardial perfusion scintigraphy and rest and exercise radionuclide ventriculography was compared in 117 men, aged 54 +/- 9 years, tested 3 weeks after a clinically uncomplicated acute myocardial infarction (MI). During a mean follow-up period of 11.6 months, 8 men experienced "hard" medical events (cardiac death, nonfatal ventricular fibrillation or recurrent MI) and 14 were hospitalized for unstable angina pectoris, congestive heart failure or coronary bypass surgery (total of 22 combined events). By multivariate analysis (Cox proportional hazards model), peak treadmill work load and the change in left ventricular ejection fraction (EF) during exercise were significant (p less than 0.01) predictors of hard medical events; these 2 risk factors and recurrent ischemic chest pain in the coronary care unit were also significantly predictive (p less than 0.001) for combined events. A peak treadmill work load of 4 METs or less or a decrease in EF of 5% or more below the value at rest during submaximal effort distinguished 22 high-risk patients (20% of the study population) from 89 low-risk patients. The rate of hard medical events within 12 months was 23% (5 of 22 patients), vs 2% (2 of 89 patients) in the high- and low-risk patient subsets, respectively (p less than 0.001). Thus, in patients who underwent evaluation 3 weeks after a clinically uncomplicated MI, exercise radionuclide ventriculography contributed independent prognostic information to that provided by symptom-limited treadmill testing and was superior to exercise thallium scintigraphy for this purpose.

Medically directed at-home rehabilitation soon after clinically uncomplicated acute myocardial infarction: a new model for patient care.

Medically directed at-home rehabilitation was compared with group rehabilitation which began 3 weeks after clinically uncomplicated acute myocardial infarction (AMI) in 127 men, mean age 53 +/- 7 years. Between 3 and 26 weeks after AMI, adherence to individually prescribed exercise was equally high (at least 71%), the increase in functional capacity equally large (1.8 +/- 1.0 METs) and nonfatal reinfarction and dropout rates equally low (both 3% or less) in the 66 men randomized to home training and the 61 men randomized to group training. No training-related complications occurred in either group. The low rate of reinfarction and death (5% and 1%, respectively) in the study as a whole, which included 34 patients with no training and 37 control patients, reflected a stepwise process of clinical evaluation, exercise testing at 3 weeks and frequent telephone surveillance of patients who underwent exercise training. Medically directed at-home rehabilitation has the potential to increase the availability and to decrease the cost of rehabilitating low-risk survivors of AMI.

Cost-benefit analysis of early return to work after uncomplicated acute myocardial infarction.

The economic consequences of an Occupational Work Evaluation designed to identify low risk patients recovering from uncomplicated acute myocardial infarction (AMI) and hasten their return to work was evaluated in a randomized trial. Two hundred one employed, clinically low risk men recovering from AMI were randomized to undergo an intervention (intervention group, 99 patients) consisting of an Occupational Work Evaluation or to receive usual care (usual care group, 102 patients). The time to return to work was reduced from 75 days in usual care patients to 51 days in intervention patients (p less than 0.002). Significant differences were found between groups for medical costs and occupational income during follow-up. Total medical costs per patient were lower in the intervention patients than in the usual care patients in the 6 months after AMI ($2,970 vs $3,472). Occupational income per patient was higher in intervention patients than in the usual care group in the 6 months after AMI ($9,655 vs $7,553). The per capita benefit accounting for medical costs and occupational income was $6,685 for intervention patients and $4,081 for usual care patients. Projected to the greater than 300,000 low risk, employed survivors of AMI annually in this country, the savings generated by the Occupational Work Evaluation could yield an annual economic benefit greater than 800 million dollars.

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.