Effects of a brief cardiovascular prevention program by a health advisor in primary care; the 'Hartslag Limburg' project, a cluster randomized trial.

OBJECTIVE: To determine in primary care patients at high risk for a cardiovascular event, the effects on biomedical risk factors for and incidence of cardiovascular events, of a brief cardiovascular prevention program executed by a health advisor. DESIGN: cluster randomized controlled trial with 1275 patients (24 general practices) in and around Maastricht, the Netherlands (1999-2004). INTERVENTION: health advisors were to complete computerized cardiovascular risk profiles, provide multi-factorial tailored health education and advice, and communicate with GP's to optimize treatment. OUTCOME: differences in changes in risk factors between baseline and follow up at 6, 18, and 36 months and incidence of cardiovascular events at 36 months. PROCESS: Because of logistic reasons risk profiles were put on paper instead of in the computerized patient files. On average patients attended 2.3 counseling sessions. Interaction with GPs was less productive than expected. OUTCOME: Effect after six months on BMI (-0.20 kg/m(2) (95% CI -0.38 to -0.01, p=0.039), Cohen's d: -0.18), and after 18 months on HDL-cholesterol (+0.05 mmol/l (95% CI +0.01 to +0.09, p=0.014), Cohen's d: 0.14). No other (subgroup) effects were found. CONCLUSION: Given the lack of clinically meaningful effects, implementation of this intervention in its present form is not justified.

Long-term Outcome After Survival of a Cardiac Arrest: A Prospective Longitudinal Cohort Study.

BACKGROUND: A cardiac arrest can lead to hypoxic brain injury, which can affect all levels of functioning. OBJECTIVE: To investigate 1-year outcome and the pattern of recovery after surviving a cardiac arrest. METHODS: This was a multicenter, prospective longitudinal cohort study with 1 year of follow-up (measurements 2 weeks, 3 months, 1 year). On function level, physical/cardiac function (New York Heart Association Classification), cognition (Cognitive Log [Cog-log], Cognitive Failures Questionnaire), emotional functioning (Hospital Anxiety and Depression Scale, Impact of Event Scale), and fatigue (Fatigue Severity Scale) were assessed. In addition, level of activities (Frenchay Activities Index, FAI), participation (Community Integration Questionnaire [CIQ] and return to work), and quality of life (EuroQol 5D, EuroQol Visual Analogue Scale, SF-36, Quality of Life after Brain Injury) were measured. RESULTS: In this cohort, 141 cardiac arrest survivors were included. At 1 year, 14 (13%) survivors scored below cutoff on the Cog-log. Both anxiety and depression were present in 16 (15%) survivors, 29 (28%) experienced posttraumatic stress symptoms and 55 (52%), severe fatigue. Scores on the FAI and the CIQ were, on average, respectively 96% and 92% of the prearrest scores. Of those previously working, 41 (72%) had returned to work. Most recovery of cognitive function and quality of life occurred within the first 3 months, with further improvement on some domains of quality of life up to 12 months. CONCLUSIONS: Overall, long-term outcome in terms of activities, participation, and quality of life after cardiac arrest is reassuring. Nevertheless, fatigue is common; problems with cognition and emotions occur; and return to work can be at risk.

Implementation of an innovative health service a "real-world" diffusion study.

BACKGROUND: Although reporting on the healthcare-setting level of continuance or discontinuance of an intervention once a trial is completed has been recommended, such "real-world" diffusion studies are rare. The present example was made possible by funding to explore opportunities for post-trial implementation of an innovative health counseling intervention for cardiovascular prevention in The Netherlands. METHODS: Between 2001 and 2004, in a longitudinal case study, we compared two healthcare settings: a cardiology outpatient clinic and general practices. Rogers' diffusion of innovations theory served as the theoretical background. Information was extracted from minutes of meetings and informal conversations with health counselors, and checked by the project manager. Additional data were collected from physicians with a short questionnaire. RESULTS: Implementation of the health counseling intervention was successful in the cardiology outpatient clinic, but was unsuccessful in the general practices. Success was related to a centralized diffusion system, stronger "change agent" efforts, avoidance of post-trial interruption of service delivery, easily achievable "reinventions," and positive physician perceptions of the service (i.e., not complex and compatible with current practice routines). Support came from changes in the organization of care that created opportunities for, instead of competition with, the innovative service. However, coincidental events may also have played a part. CONCLUSIONS: Our findings confirm the importance of most theoretically predicted individual and organizational diffusion variables. This implies that the implementation of innovative healthcare services requires attention at both levels.

Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: A randomised controlled trial.

BACKGROUND: Survivors of a cardiac arrest frequently have cognitive and emotional problems and their quality of life is at risk. We developed a brief nursing intervention to detect cognitive and emotional problems, provide information and support, promote self-management, and refer them to specialised care if necessary. This study examined its effectiveness. METHODS: Multicentre randomised controlled trial with measurements at two weeks, three months and twelve months after cardiac arrest. 185 adult cardiac arrest survivors and 155 caregivers participated. Primary outcome measures were societal participation and quality of life of the survivors at one year. Secondary outcomes were the patient's cognitive functioning, emotional state, extended daily activities and return to work, and the caregiver's well-being. Data were analysed using 'intention to treat' linear mixed model analyses. RESULTS: After one year, patients in the intervention group had a significantly better quality of life on SF-36 domains Role Emotional (estimated mean differences (EMD)=16.38, p=0.006), Mental Health (EMD=6.87, p=0.003) and General Health (EMD=8.07, p=0.010), but there was no significant difference with regard to societal participation. On the secondary outcome measures, survivors scored significantly better on overall emotional state (HADS total, EMD=-3.25, p=0.002) and anxiety (HADS anxiety, EMD=-1.79, p=0.001) at one year. Furthermore, at three months more people were back at work (50% versus 21%, p=0.006). No significant differences were found for caregiver outcomes. CONCLUSION: The outcomes of cardiac arrest survivors can be improved by an intervention focused on detecting and managing the cognitive and emotional consequences of a cardiac arrest. TRIAL REGISTRATION: Current controlled trials, ISRCTN74835019.

[Cardiac troponin]. / Cardiaal troponine.

Measurement of cardiac troponins (cTnT and cTnI), the only cardiac specific biomarkers available, is the gold standard in diagnosing acute coronary syndrome. Due to the recent introduction of more sensitive methods i.e. the high-sensitivity troponin assays, the diagnostic cut-off concentrations have very recently been established. We describe two male patients who presented at the emergency department with acute chest pain, but in whom clear evidence for a myocardial infarction in the ST segment of the EKG was lacking. Case 1 illustrates that such assays enable the earlier diagnosis of acute myocardial infarction. Case 2 shows that the diagnosis of acute myocardial infarction should be accompanied by a typical rise or fall of troponin concentrations. The latest insights into high-sensitivity cardiac troponin assays are discussed in this article. We focus specifically on sensitivity and specificity, reference values obtained from a healthy control group, and the reference change value required to detect acute myocardial infarction.

Cardiovascular prevention in the Hartslag Limburg project: effects of a high-risk approach on behavioral risk factors in a general practice population.

BACKGROUND: This study describes a general-practice-based high-risk cardiovascular prevention approach in Maastricht, The Netherlands (1999-2003). The intervention consisted of a complete registration of risk factors, optimization of medical treatment and health counseling on high fat consumption, smoking and physical inactivity. METHODS: Behavioral effects were assessed in a trial, randomization by practice and usual care as control. Validated questionnaires were completed by 1300 patients at baseline, 1174 after 4 months (90.3%) and 1046 (80.5%) after 18 months. RESULTS: After 4 months, intention-to-treat analyses revealed a decrease in saturated fat intake of 1.3 points (scale ranging from 7 to 30 points, p=0.000). This was partly sustained after 18 months (-0.5 points, p=0.014). After 18 months, obese intervention patients were more likely to be sufficiently physically active than their control counterparts (OR=1.90, p=0.023). No intervention effects were found for smoking. CONCLUSION: Given the multiple factor and multiple component high-risk approach, the intervention had modest effects on only some of the behavioral risk factors addressed. Process data showed that the registration of risk factors and the optimization of medical treatment were only partly implemented, that the health counseling component could be further improved and that the intervention could benefit from additional health promoting strategies.

Effects of health counseling on behavioural risk factors in a high-risk cardiology outpatient population: a randomized clinical trial.

BACKGROUND: An evaluation study of an individual lifestyle advice intervention to reduce cardiovascular risk behaviours (high fat consumption, smoking, physical inactivity). METHODS: A randomized, controlled trial at the cardiology outpatient clinic of the University Hospital Maastricht. Participants were at high risk of incurring a cardiovascular event. Changes in risk behaviours and behavioural determinants were assessed with self-administered validated questionnaires. RESULTS: Questionnaires were completed by 1270 patients at baseline, 1169 after 4 months (92%), and 1032 after 18 months (81.3%). After 4 months, intention-to-treat analyses revealed a decrease in fat consumption (-5.6%, P = 0.000), a reduction in the percentage of smokers [odds ratio (OR) 0.57, 95% confidence intervals (CI) 0.33-0.97] and a trend towards a maintained physical activity level (OR 1.28, 95% CI 0.97-1.70). No long-term effects were found. CONCLUSION: The lifestyle advice intervention was potentially effective in changing cardiovascular risk behaviours, but should be further improved to be effective in secondary cardiovascular prevention. The main limitations of the study were related to the randomization procedure and the self-selection of patients and cardiologists.