Health-related quality of life predicts unplanned rehospitalization following coronary revascularization.

BACKGROUND: Health-related quality of life (HRQL) is an increasingly well-recognized measure of health outcome in cardiology. We examined HRQL as a predictor of unplanned rehospitalization for cardiac reasons in patients after coronary revascularization over a period of 3 years. PATIENTS AND METHODS: Out of 791 patients enrolled in the study, 743 completed the MacNew HRQL questionnaire after coronary revascularization. MacNew HRQL scores were used as predictors of unplanned rehospitalization. RESULTS: Within the 3-year follow-up period, 125 patients (16.8 %) were rehospitalized. After adjustment for age, gender, and myocardial infarction as the initiating event, there were significant differences in unplanned rehospitalization rates between patients with low or moderate vs. high MacNew HRQL global scores (HR: 1.8, 95 % CI: 1.2-2.7) and both physical (HR: 2.2, 95 % CI: 1.4-3.5) and social (HR: 1.8, 95 % CI: 1.2-2.7) subscale scores. CONCLUSION: Poor HRQL assessed after coronary revascularization appears to be a powerful predictor of rehospitalization over a 3-year period.

The dimensional structure of the MacNew Health Related Quality of Life questionnaire: A Mokken Scale Analysis.

OBJECTIVE: The MacNew Health related Quality of Life Questionnaire is a widely used instrument for the assessment of health related quality of life in cardiac patients. The study addresses for the first time the dimensional structure of the MacNew with Mokken Scale Analysis (MSA). METHODS: Separate exploratory MSA of the MacNew was conducted in a large Spanish (n=1012) and a medium sized Austrian sample (n=262) of patients with Coronary Artery Disease (CAD) after Percutaneous Coronary Intervention (PCI). The results of both samples were summarized in a synthesis model. Confirmatory MSA and Confirmatory Factor Analysis (CFA) were used to evaluate the model. RESULTS: The synthesis model comprises 21 items forming a unidimensional sum scale of moderate strength. On the level of subdomains we define two strong unidimensional subscales (restriction: 6 items, and emotional: 10 items) and two smaller item sets (symptoms: 2 items and social: 3 items). 5 items were excluded due to low scalability in both samples. CONCLUSION: Our results generally support the use of the MacNew Global score, with the limitation, that five items may be questionable with regard to scalability. On the level of unidimensional subscales MSA suggests to differentiate between a six-item restriction scale and a ten-item emotional scale. The study demonstrates that Mokken Scale Analysis complements the results of factor analysis and can contribute to a more comprehensive understanding of the dimensional structure of Health-related Quality of Life questionnaires.

[Development and importance of outpatient cardiac rehabilitation in German-speaking countries]. / Entwicklung und Stellenwert der ambulanten kardiologischen Rehabilitation im deutschsprachigen Raum.

Cardiac rehabilitation is a coordinated treatment approach. The interdisciplinary team aims to provide the best possible physical and psychological outcomes for patients with cardiac diseases. Patients should be enable to independently resume work and and social life. Furthermore cardiac rehabilitation wants to limit or reverse the progress of cardiac disease through sustained health-related life habits. Cardiac rehabilitation significantly contributes to long-term success based on comprehensive care of cardiac patients. Outpatient cardiac rehabilitation has shown to be effective after myocardial infarction, coronary artery bypass grafting and chronic heart failure. However randomized controlled trials were performed only in Anglo-American countries. In these trials effects were observed mainly for exercise-based cardiac rehabilitation programs. Because the results have been derived from different program settings they cannot simply be translated to German-speaking countries. However, several cohort studies predominantly performed in Germany also revealed effects of inpatient and outpatient cardiac rehabilitation programs for German-speaking countries. The most recent results demonstrated a significant reduction of recurrent events in patients after inpatient cardiac rehabilitation. Following the current evidence concerning the effect of inpatient and outpatient cardiac rehabilitation programs particularly after myocardial infarction international guidelines provide Class I (USA) and IIa (Europe) recommendation for this treatment intervention.In contrast to Anglo-American countries cardiac rehabilitation in Austria, Germany and Switzerland was established at its beginning exclusively for inpatient programs. In addition more and more outpatient programs were introduced in the last decades. Nevertheless inpatient cardiac rehabilitation is still the most common program in German-speaking countries.Future challenges of cardiac rehabilitation should not address the competition between inpatient and outpatient programs but provide answers to the question "which patient needs which program?" Future cardiac rehabilitation will offer patient-tailored programs. In German-speaking countries inpatient cardiac rehabilitation has long been well established whereas treatment potential of outpatient programs have increased. Outpatient cardiac rehabilitation is more flexible, close to home and it can be done part-time. Furhtermore, outpatient cardiac rehabilitation programs can take on important tasks in long-term cardiac care and thus provide relief to inpatient programs. The initiation of such programs is a challenge and can add to better future development of comprehensive cardiac rehabilitation.

Psychometric properties of an established heart disease specific health-related quality of life questionnaire for pacemaker patients.

Little is known about the HRQL of pacemaker patients due to the limited availability of disease-specific instruments. The aim of the Pacemaker Patients Quality of Life (PAPQoL) study was to determine the psychometric properties for the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients before and after pacemaker implantation. Patients with a given indication for pacemaker therapy (N = 68) completed two self-administered HRQL instruments, the SF-36, a well-known and psychometrically sound health survey, and the MacNew, a reliable and valid heart-disease-specific HRQL instrument, before and one, three and six months after pacemaker implantation. We assessed disease severity with the New York Heart Association (NYHA) classification. Test-retest reliability, intra-class correlation, Cronbach's alpha, validity coefficients, sensitivity analyses (effect sizes) and confirmatory factor analysis were carried out. The MacNew demonstrated adequate reliability (Cronbach's alpha and ICCs > 0.80 on all scales), validity (correlations between similar SF-36 and MacNew subscales > 0.80), and responsiveness (all effect sizes > or = 0.67) in pacemaker patients. The MacNew demonstrates adequate psychometric properties for evaluating HRQL in patients before and after pacemaker implantation.

Determinants of health-related quality of life in coronary artery disease patients: a prospective study generating a structural equation model.

The authors used structural equation modeling to test a conceptual model of HRQL in coronary artery disease. The model, which included biomedical factors and individual and environmental characteristics, was tested in a multicenter group of 465 patients at three timepoints (baseline evaluation of chest pain and 1- and 3-month follow-ups). A satisfactory fit was obtained for the model over time. Depression and anxiety symptoms exerted the most significant influence on HRQL. HRQL and the mediating factors were found to be distinct phenomena. The authors concluded that mediating factors, especially depression and anxiety symptoms, should be taken into consideration in clinical routine if HRQL is regarded as a clinical outcome.

Impact of total and central obesity on vascular mortality in patients undergoing coronary angiography.

OBJECTIVE: To prospectively investigate the impact of total and central obesity on vascular mortality in patients undergoing coronary angiography. DESIGN: Prospective cohort study; mean follow-up 2.2 y. SUBJECTS: Men (n=513) and women (n=243) undergoing coronary angiography for the evaluation of coronary artery disease. MEASUREMENTS: Body mass index (BMI) was used as a measure of total obesity; waist-to-hip ratio (WHR) and waist circumference (WCf) as measures of central obesity. The primary study end point was vascular mortality; secondary study end points were total mortality, major coronary events, and cumulative vascular events. RESULTS: For both genders, BMI, WHR, and WCf correlated significantly with fasting plasma glucose, with HOMA insulin resistance, with triglycerides, and inversely with HDL cholesterol (P<0.001 for all correlations). In Cox regression analysis adjusting for age, gender, smoking, and total cholesterol, BMI was not associated with any study end point. In contrast, WHR (standardized adjusted odds ratios (OR) 2.01, 95% CI 1.02-3.93 for men and 2.63, 95% CI 1.38-5.00 for women), and WCf (OR=2.31, 95% CI 1.16-4.60 for men and 8.71, 95% CI 1.78-42.68 for women) proved independently predictive of vascular mortality. Additional adjustment for diabetes and hypertension did not substantially alter these results. Also, the predictive value of WHR and Wcf was retained after adjustment for drug treatment and the presence of significant coronary artery disease at baseline. Further, WHR and WCf were associated with total mortality, major coronary events, and cumulative vascular end points. CONCLUSION: Both total and central obesity are associated with insulin resistance and with an atherogenic lipoprotein profile. However, only central obesity is significantly and independently predictive of the 2-y vascular mortality in coronary patients.

Health-related quality of life in patients with coronary artery disease treated for angina: validity and reliability of German translations of two specific questionnaires.

The German versions of two patient-perceived heart disease specific health-related quality of life (HRQL) questionnaires, the Seattle Angina Questionnaire (SAQ) and the MacNew Heart Disease questionnaire, were examined for their psychometric properties in patients with angiographically documented coronary artery disease and angina who were treated either medically or invasively and followed up for 1 year. Both HRQL questionnaires and the modified Canadian Cardiovascular Society (CCS) angina-associated disability scale were completed by 158 patients at baseline and 12 months later when they also completed a generic health status questionnaire, the SF-36. Both specific HRQL questionnaires were acceptable to patients. Three of the four MacNew scales, but none of the SAQ scales, discriminated between patients by baseline CCS disability levels I and IV. Internal consistency ranged from 0.75 to 0.94 for the SAQ and from 0.86 to 0.97 for the MacNew scales. Test-retest reliability over a 4-week period of time ranged from 0.45 to 0.81 for the SAQ scales and 0.61 to 0.68 for the MacNew scales. Over 12 months, HRQL improved (p < 0.001) on three of the five SAQ and on all four of the MacNew scales with the responsiveness statistic ranging from 0.59 to 1.55 for the SAQ and 0.86 to 1.12 for the MacNew. The 12 month scores on all SAQ and MacNew scales were significantly higher in patients who improved than those who deteriorated on the SF-36 reported health transition question. We conclude that the SAQ and the MacNew are both valid, reliable, and responsive in German, that the MacNew discriminates better between angina grades at baseline, that HRQL improves over 12 months with both measures, that the SAQ angina frequency and disease perception scales have the largest effect sizes, and that the 12-month change in HRQL with both instruments was associated with change in SF-36 reported health transition status.

Revascularization of residual viable myocardium improves left ventricular dysfunction in patients after myocardial infarction.

The symptoms and prognosis of patients after myocardial infarction are essentially influenced by left ventricular function. About 50% of infarct related segments contain partly viable myocardium. The aim of this study was to test the hypothesis that regional and global left ventricular function can be improved by revascularization of infarct related segments with residual myocardial viability. In 15 of 30 consecutive patients, residual viable myocardium was found in the affected segment within 2.2 +/- 1.6 months after AMI. Myocardial viability was estimated by exercise-redistribution-reinjection thallium scintigraphy (SPECT imaging). Rest and exercise radionuclide ventriculography was performed to measure regional and global left ventricular ejection fraction before and after revascularization of the infarct related artery. 10 +/- 3 months after revascularization we observed a significant increase in the regional left ventricular ejection fraction at rest (from 32 +/- 16% to 41 +/- 19%; p = 0.03), global left ventricular ejection fraction at rest (from 38 +/- 12% to 46 +/- 11%; p = 0.01), regional LV ejection fraction during exercise (from 34 +/- 16% to 46 +/- 20%; p = 0.01), and global left ventricular ejection fraction during exercise (from 38 +/- 14% to 49 +/- 14%; p = 0.02). The results show that after revascularization of infarct related segments with residual myocardial viability, the regional and global left ventricular ejection fraction may be significantly improved, both at rest and during exercise. Thus infarct related segments should be tested for residual viability. In its presence revascularization is recommended, as the left ventricular function may be markedly improved.

[Significance of supraphysiologic administration of magnesium after myocardial infarct]. / Die Bedeutung einer supraphysiologischen Gabe von Magnesium nach Myokardinfarkt.

Magnesium is an essential element for the regulation of energy dependent metabolism and transmembranous electrolyte flow. Despite the present controversial interest, magnesium has some beneficial effects on several manifestations of coronary artery disease and myocardial infarction. In supraphysiologic serum levels magnesium causes dilatation of epicardial coronary arteries and modulates better diastolic relaxation of the left ventricle. It protects the ischaemic myocardium against calcium overload, preserves the intracellular ATP and brakes the acidosis caused by anaerobic metabolism and free radicals with subsequent cell necrosis. Spontaneous depolarization of the myocardial cell decreases after magnesium administration. Supraventricular and ventricular arrhythmias become less frequent under supraphysiologic magnesium serum levels. Also magnesium inhibits platelet aggregation. The conflicting results of randomized trials examining the efficacy of magnesium supplementation have failed to establish conclusively whether magnesium is generally useful in coronary artery disease and after myocardial infarction. Although findings of experimental studies showed beneficial effects of supraphysiologic administration of magnesium before or in the early phase of ischaemia and reperfusion during acute myocardial infarction. By the way supraphysiologic magnesium application is safe, cheap and has no side effects in common dosage.

[Hormone replacement in postmenopausal women with coronary heart disease. Results and clinical consequences from recent studies]. / Hormonsubstitution bei postmenopausalen Frauen mit koronarer Herzkrankheit. Ergebnisse und klinische Konsequenzen aus neueren Studien.

Despite the comparable risk profile, women in reproductive age have less frequently cardiovascular disease than men. Hormone replacement therapy in postmenopausal women is associated with further reduction of coronary artery disease and myocardial infarction. There is good evidence, that estrogens cause these differences. Several well observed biological effects of estrogens seem to be responsible for this benefit. Estrogen replacement therapy reduces cholesterol and LDL-cholesterol levels and has also some antioxidant potential. Furthermore estrogens have effects on vasodilation of the coronary arteries. A benefit on haemostasis through fibrinogen attenuation and platelet inhibition is also described. A main problem of patients compliance during estrogen replacement therapy are postmenopausal bleeding and being afraid of breast cancer. Hormone replacement therapy is indeed not without any risk. The incidence of breast cancer is controversially discussed. Thrombosis and pulmonary infarction are described as further risks. Comparing the risks and benefits of estrogen replacement therapy concerning the reduction of cardiovascular disease, actually the objections are to be dissipated from an epidemiological point of view. Thus if the results of the ongoing large randomized studies prove, that estrogen replacement therapy reduces the risk of coronary artery disease, a challenge in primary- and secondary prevention of cardiovascular disease in women will have to occur.

[Ambulatory rehabilitation after myocardial infarct in Austria]. / Ambulante Rehabilitation nach Herzinfarkt in Osterreich.

Cardiac rehabilitation after myocardial infarction has a positive effect on the patient's quality of life and on the prognosis of the disease as well. The cost-saving effect is of importance from the socioeconomical viewpoint. A measurable benefit of such rehabilitation programs can only be achieved by long-term comprehensive care, however. Therefore a hospital rehabilitation program should be followed by regular participation in a long-term community rehabilitation program. The network of cardiac rehabilitation centres in Austria is highly developed and consequently it is possible for every insured patient to be placed for inpatient follow-up therapy on recovering from myocardial infarction. On the other hand, the long-term community cardiac rehabilitation programs are organized only on a sketchy and small scale. A survey amongst patients after myocardial infarction carried out all over Austria showed that 700 patients are currently being treated in 56 community programs. The sponsorship varies a lot. A majority of these groups is organized and financed by the patients themselves. The medical and physiotherapeutic services are mainly organized by the patients as well. They are only partly trained for their task. The care programs take place on a regular basis and the provided services appear adequate, some groups excepted. Medical follow-up examinations to evaluate progress hardly exist. Therefore, quality control of the work in the community programs is not possible at the moment in Austria. A well-organized community care rehabilitation program covering the whole region exists only in Vorarlberg. This program mainly follows the "Feldkircher Modell". The results of this study indicate the urgent necessity to establish additional community care programs for outpatient cardiac rehabilitation in Austria. Furthermore, a common register of the groups, a common organisational model and sponsorship, as well as quality control based on regular medical examination of the patients are essential requirements. A constant exchange of experience with the inpatient rehabilitation centres is to be recommended as well.

[Prevention of iodine-induced hyperthyroidism after coronary angiography]. / Zur Vorbeugung jodinduzierter Hyperthyreosen nach Koronarangiographie.

Coronary angiography (CA) is followed by an iodine load of 15 to 20 mg for the thyroid and may be the cause of iodine-induced hyperthyroidism. 60 consecutive patients hospitalized for CA without any thyroid history were examined and 56 had thyroid diseases with normal thyroid function. 33 patients still showed a significant decrease of 20 min Technetium uptake (TcU) and an increase of urine iodine excretion because of iodine excess 12 weeks after CA. 3 patients developed latent hyperthyroidism. 27 patients received medication of 1 g natrium-perchlorate and 60 mg methimazole 24 hours before and on the day of CA. These patients showed normal TcU and urine iodine excretion 4 and 12 weeks after CA. 1 out of these 27 patients developed overt hyperthyroidism but had PTCA without premedication 2 weeks after CA. Since Iodine excess leads to iodine-induced hyperthyroidism even in euthyroids a prophylaxis with perchlorate and methimazole is generally recommended in patients with CA.

[Ophthalmological significance of stenosing carotid processes]. / Ophthalmologische Bedeutung stenosierender Karotisprozesse.

In a retrospective study we looked at the incidence of carotid artery stenosis in 191 ophthalmological patients, which underwent duplex sonography. In all these patients the oculist had considered carotid artery stenosis to be a possible reason for the present eye disease or visual disturbance. The incidence of stenosis found in these patients was compared to a group of 186 persons of the same mean age, which underwent routine-sonography without suffering from any symptoms related to carotid artery disease. Patients with amaurosis fugax, with occluded retinal veins and patients with glaucoma associated changes of the retina (in spite of normal eye pressure) suffered more often from carotis stenosis than asymptomatic persons (statistically significant), patients with occluded retinal arteries showed also more often carotid artery stenosis than the asymptomatic collective but without statistical significance. We conclude, that patients presenting with the mentioned symptoms should undergo carotid artery sonography. Furthermore these results could be of importance in evaluation the indication for carotid thrombendarterectomy (stadium II of cerebrovascular insufficiency).

[Characteristics of insulin and glucose regulation in short-term physical exertion and recovery in type I diabetic patients]. / Besonderheiten der Insulin- und Glukoseregulation während kurzdauernder körperlicher Belastung und Erholung bei Typ-I-Diabetikern.

It is a recognized fact that diabetics stand greater risk of developing diseases of the heart and circulation system. Active sport participation, however, can reduce this risk and is therefore of particular importance for diabetics. In order to give the juvenile type diabetics the best possible advice on a 15 minute physical training program, we examined 6 insulin-dependent diabetics and compared their insulin and glucose regulation during physical activity and recovery with that of 6 healthy hobby-sportsmen of the same age. During the phase of recovery a highly significant difference in the blood sugar levels was observed (p less than 0.01). Whereas the blood sugar levels of the healthy group increased quickly in the first 5 minutes immediately following the course of activity, it was seen to decrease during the phase of recovery in 4 diabetics and 2 diabetics showed mostly a very slight increase. The insulin levels of the healthy group remained constant both during activity and recovery. Widely differing, but nevertheless constant values were also shown in the diabetics insulin levels during the course of activity. In the recovery phase however divergent courses were observed. The insulin levels of 4 diabetics increased and of the other 2 they decreased slightly. Juvenile type diabetics therefore show no special characteristics compared to their healthy counterparts during a 15 minute physical activity. In the recovery phase however their blood glucose increase reaction is lacking. This reaction is in fact impeded by the slight increase of the insulin level. Thus, juvenile type diabetics are potentially prone to hypoglycemia immediately following physical activity.(ABSTRACT TRUNCATED AT 250 WORDS)