Exercise-based cardiac rehabilitation in patients with heart failure: a meta-analysis of randomised controlled trials between 1999 and 2013.

BACKGROUND: Guidelines recommend exercise-based cardiac rehabilitation (EBCR) for patients with heart failure (HF). However, established research has not investigated the longer-term outcomes including mortality and hospitalisation in light of the contemporary management of HF. METHODS: This was a systematic review including a meta-analysis of EBCR on all-cause mortality, hospital admission, and standardised exercise capacity using four separate exercise tests in patients with heart failure over a minimum follow-up of six months from January 1999-January 2013. Electronic searches were performed in the databases: Medline, CENTRAL, EMBASE, CINAHL, and PsycINFO constrained to randomised controlled trials (RCTs). RESULTS: A total of 46 separate RCTs qualified for the meta-analysis, which employed conventional methods for binary and continuous data. The relative risk (RR) ratio for hospital admission (12 studies) was significantly reduced (RR ratio 0.65; 95% confidence interval (CI) 0.50-0.84; p = 0.001), but mortality (21 studies) was not (RR ratio 0.88; 95% CI 0.77-1.02; p = 0.08). The standardised exercise capacity (26 studies) showed a standardised mean difference (SMD) in favour of the exercise group as compared with the controls (SMD 0.98, 95% CI 0.59-1.37; p < 0.001). Women and elderly people were less frequently enrolled in the RCTs independent of the outcomes. Heterogeneity was moderate to high in the analysis of hospital admission and the standardised exercise capacity demonstrated through skewedness in their funnel plots. CONCLUSIONS: EBCR in patients with HF is associated with significant improvements in exercise capacity and hospital admission over a minimum of six months follow-up, but not in all-cause mortality.

The effect of referral for cardiac rehabilitation on survival following acute myocardial infarction: a comparison survival in two cohorts collected in 1995 and 2003.

BACKGROUND: International guidelines recommend referral for cardiac rehabilitation (CR) after acute myocardial infarction (AMI). However, the impact on long-term survival after CR referral has not been adjusted by time-variance. We compared the effects of CR referral after hospitalization for AMI in two consecutive decades. METHODS AND RESULTS: A total of 2196 and 2055 patients were recruited in the prospective observational studies of the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) -1 and 2 in 1995 and 2003, (1995: median age 72 years, 39% women, 74% referred vs 2003: median age 71 years, 36% women, 64% referred) and followed up through September 2010. Survival functions showed CR referral to be an independent predictor for survival in 2003, but not in 1995 (hazard ratio (HR), 0.90; 95% confidence interval [CI]; 0.70 to 1.17, p = 0.44 in 1995 vs HR, 0.80; 95% CI, 0.66 to 0.96, p = 0.02 in 2003) when patients entered the model at three months after discharge and had a common exit at 90 months. Significant positive and negative predictors for CR referral were beta-blocker prescription (+), reperfusion (+) and age (-) in 1995, and reperfusion (+), revascularization (+), heart failure (HF) (+), antiplatelets (+), angiotensin-converting-enzyme inhibitor (ACE-I) (+), statins (+), diabetes (-), and the modified Global Registry of Acute Cardiac Events (GRACE) risk score (-) in 2003. CONCLUSIONS: CR referral was associated with improved survival in 2003, but not in 1995 in patients admitted with acute MI.

The role of a new arrhythmia specialist nurse in providing support to patients and caregivers.

In 2005, the English Department of Health developed a National Service Framework for the identification and treatment of Arrhythmia. A new specialist role was recommended, the Arrhythmia Care Co-ordinator (ACC), to guide patients through their illness and coordinate their care. In 2006, to implement this policy, the British Heart Foundation (BHF) sponsored 32 new nursing ACC staff posts across England and Wales. The BHF also sponsored an evaluation to investigate the impact of ACC support on patients and caregivers, with 30 patients (18 men, 22 women) and 10 caregivers being drawn from a purposive sample across seven arrhythmia treatment centres. Two main key themes emerged to describe the patients' experience of the new service: personalized coordinated care and learning to live with their condition.

Participants' experiences of care during a randomized controlled trial comparing a lay-facilitated angina management programme with usual care: a qualitative study using focus groups.

AIM: This paper is a report of a qualitative study conducted as part of a randomized controlled trial comparing a lay-facilitated angina management programme with usual care. Its aim was to explore participants' beliefs, experiences, and attitudes to the care they had received during the trial, particularly those who had received the angina management intervention. BACKGROUND: Angina affects over 50 million people worldwide. Over half of these people have symptoms that restrict their daily life and would benefit from knowing how to manage their condition. DESIGN: A nested qualitative study within a randomized controlled trial of lay-facilitated angina management. METHOD: We conducted four participant focus groups during 2008; three were with people randomized to the intervention and one with those randomized to control. We recruited a total of 14 participants to the focus groups, 10 intervention, and 4 control. FINDINGS: Although recruitment to the focus groups was relatively low by comparison to conventional standards, each generated lively discussions and a rich data set. Data analysis demonstrated both similarities and differences between control and intervention groups. Similarities included low levels of prior knowledge about angina, whereas differences included a perception among intervention participants that lifestyle changes were more easily facilitated with the help and support of a lay-worker. CONCLUSION: Lay facilitation with the Angina Plan is perceived by the participants to be beneficial in supporting self-management. However, clinical expertise is still required to meet the more complex information and care needs of people with stable angina.

Randomized controlled trial of a lay-facilitated angina management programme.

AIMS: This article reports a randomized controlled trial of lay-facilitated angina management (registered trial acronym: LAMP). BACKGROUND: Previously, a nurse-facilitated angina programme was shown to reduce angina while increasing physical activity, however most people with angina do not receive a cardiac rehabilitation or self-management programme. Lay people are increasingly being trained to facilitate self-management programmes. DESIGN: A randomized controlled trial comparing a lay-facilitated angina management programme with routine care from an angina nurse specialist. METHODS: Participants with new stable angina were randomized to the angina management programme (intervention: 70 participants) or advice from an angina nurse specialist (control: 72 participants). Primary outcome was angina frequency at 6 months; secondary outcomes at 3 and 6 months included: risk factors, physical functioning, anxiety, depression, angina misconceptions and cost utility. Follow-up was complete in March 2009. Analysis was by intention-to-treat; blind to group allocation. RESULTS: There was no important difference in angina frequency at 6 months. Secondary outcomes, assessed by either linear or logistic regression models, demonstrated important differences favouring the intervention group, at 3 months for: Anxiety, angina misconceptions and for exercise report; and at 6 months for: anxiety; depression; and angina misconceptions. The intervention was considered cost-effective. CONCLUSION: The angina management programme produced some superior benefits when compared to advice from a specialist nurse.

Is cardiac rehabilitation still relevant in the new millennium?

Cardiac rehabilitation is an evidence-based intervention which has evolved over time and incorporates physical, psycho-social and educational components with the aim of improving the patients' functioning following a cardiac event. The evidence base for cardiac rehabilitation following acute myocardial infarction has been growing over the past half a century. Individual randomized control trials were small and, therefore, mortality outcomes usually failed to reach significance; however, meta-analyses have proven consistently that participation in cardiac rehabilitation following a myocardial infarction is associated with a significant improvement in mortality. In the era of revascularization and improved drug therapies, observational studies still provide evidence that independent of other treatments, cardiac rehabilitation is a life-saving measure. Although early studies often only studied young males, more contemporary data include patients from all sectors of society and have found that groups such as women, the elderly and those with heart failure appear to have greater mortality benefits compared with the traditional young male cohort. Uptake remains a problem and one challenge for the future is ensuring improved uptake on to good-quality rehabilitation programmes and demonstrating these positive effects.

Complexities of patient choice in cardiac rehabilitation: qualitative findings.

AIM: This paper is a report of a study of the choices patients make when offered home-based or hospital-based cardiac rehabilitation. BACKGROUND: In some countries, patients may be offered a choice of home-based or hospital-based cardiac rehabilitation. While evaluating a home-based programme, Road to Recovery, developed by the British Heart Foundation, we examined patients' experiences of being offered this choice. METHODS: Interviews were conducted with 35 patients and 12 staff members delivering the pilot programme in five rehabilitation services during 2006-2008. FINDINGS: While the staff members interviewed reported that all patients were given a clear choice between a home-based and hospital-based or community-based programme, this choice was less clear-cut in the patient interviews. When choice was offered, the choice of a home-based programme was often based on constraints rather than on being a positive choice. Obstacles patients faced in making the choice included lack of information on which to base a choice; inadequate systems of referral; insufficient appropriately trained staff; restricted choice of times to attend the hospital programmes; the geographical location of services and restrictive socio-economic factors (inflexible working hours, access to transport). CONCLUSION: The possibility of informed choice relies in the first instance on the availability and accessibility of appropriate services. Nurses need awareness and commitment to finding out about and overcoming obstacles that impede patient participation in cardiac rehabilitation. Only in this manner will it be possible to fulfil the calls in national and some international clinical guidelines for 'individualized' or 'menu-based' programmes tailored to specific patient needs.

Misconceived and maladaptive beliefs about heart disease: a comparison between Taiwan and Britain.

AIMS AND OBJECTIVES: To assess and compare misconceived and maladaptive beliefs about coronary heart disease between Taiwanese and British people with heart disease. BACKGROUND: Holding misconceived and maladaptive beliefs about heart disease has deleterious effects on a patient's quality of life. Cultural contexts influence a person's responses to illness, but little information exists about the ways in which cultural values influence a person's attributions and coping behaviours regarding their heart disease. DESIGN: A cross-sectional survey using a descriptive comparative design was carried out in Taiwan and Britain. METHODS: A structured questionnaire was used to elicit misconceived or potentially maladaptive beliefs about heart disease. People with a confirmed diagnosis of coronary heart disease were recruited from a teaching hospital in Taipei (n = 238) and a tertiary cardiothoracic centre in the North of England (n = 204). RESULTS: Taiwanese patients held more misconceived and maladaptive beliefs about heart disease than those in Britain. Both British and Taiwanese patients showed high agreement on 'stress is one of the main causes of heart disease' and 'always avoid stress', but these beliefs were more common in Taiwanese patients (p < 0.001). Misconceptions about avoiding anything that might bring on angina were common in both countries. CONCLUSIONS: While there were some similarities in the cardiac beliefs held by the two groups of patients, Taiwanese patients held significantly more misconceptions. This may be explained by differences between the patients' cultures, including social norms, health care provision and health information from the media. RELEVANCE TO CLINICAL PRACTICE: Interventions should be developed to dispel maladaptive beliefs thereby altering the coping actions of patients. The meaning and purpose of specific behaviours needs to be interpreted within the context of a patient's culture. Awareness of cultural perspectives may help to develop nursing care plans that are more successful as they are more individually applicable to patients.

"Prehabilitation" prior to CABG surgery improves physical functioning and depression.

BACKGROUND: Many patients demonstrate psychological distress and reduced physical activity before coronary artery bypass graft surgery (CABG). Here we evaluated the addition of a brief, cognitive-behavioural intervention (the HeartOp Programme) to routine nurse counselling for people waiting for CABG surgery. METHODS: Randomised controlled trial comparing nurse counselling with the HeartOp programme to routine nurse counselling in 204 patients awaiting first time elective CABG. Primary outcome measures were: anxiety and length of hospital stay; secondary outcome measures were: depression, physical functioning, cardiac misconceptions and cost utility. Measures were collected prior to randomisation and after 8 weeks of their intervention prior to surgery, excepting length of hospital stay which was collected after discharge following surgery. RESULTS: 100 patients were randomised to intervention, 104 to control. At follow-up there were no differences in anxiety or length of hospital stay. There were significant differences in depression (difference=7.79, p=0.008, 95% CI=2.04-13.54), physical functioning (difference=0.82, p=0.001, 95%CI=0.34-1.3) and cardiac misconceptions (difference=2.56, p<0.001, 95%CI=1.64-3.48) in favour of the HeartOp Programme. The only difference to be maintained following surgery was in cardiac misconceptions. The HeartOp Programme was found to have an Incremental Cost Effectiveness Ratio (ICER) of pound 288.83 per Quality-Adjusted Life Year. CONCLUSIONS: Nurse counselling with the HeartOp Programme reduces depression and cardiac misconceptions and improves physical functioning before bypass surgery significantly more than nurse counselling alone and meets the accepted criteria for cost efficacy.

Cardiac misconceptions: comparisons among nurses, nursing students and people with heart disease in Taiwan.

AIM: This paper is a report of a study to examine the misconceived and potentially maladaptive beliefs (cardiac misconceptions) about heart disease held by nurses, nursing students and people with heart disease in Taiwan. BACKGROUND: Research suggests that misconceived and maladaptive beliefs about heart disease influence outcomes in people with heart disease, and that eliciting and dispelling incorrect beliefs can reduce disability in this population. However, nurses do not routinely elicit maladaptive beliefs or attempt to dispel them. METHOD: Between October 2005 and March 2006, a survey was conducted using version 1 of the York Cardiac Beliefs Questionnaire to measure cardiac misconceptions in 64 hospital-based nurses (13 of whom were cardiac nurses), 134 nursing students and 238 people with heart disease. RESULTS: Nursing students held fewer cardiac misconceptions than nurses (P = 0.042). There were no statistically significant differences in the numbers of misconceptions between cardiac and general nurses, and no statistically significant associations between level of qualification, years of nursing experience and number of misconceptions. Nurses with higher levels of education were more likely to hold fewer misconceptions (P = 0.24). Patients held statistically significantly more misconceptions about heart problems than nurses (P < 0.001). CONCLUSION: Nurses who are involved in the care for people with heart disease have a responsibility to assess and dispel people's misconceptions about their condition, and therefore continuing professional education is required to develop this clinical expertise. Future research should focus on methods of dispelling cardiac misconceptions in both nursing and patient education.

A randomised trial of a 5 week, manual based, self-management programme for hypertension delivered in a cardiac patient club in Shanghai.

BACKGROUND: In Shanghai there are 1.2 million people with hypertension, many of whom have difficulty in affording medical treatment. Community based, anti-hypertensive clubs have been created to provide health education but education alone is often ineffective. Lifestyle change programmes have shown some potential for reducing blood pressure but in previous trials have required specialist staff and extensive contact. We have previously demonstrated that self-management programmes delivered by health professionals, such as a nurse who has had short training in self-management techniques can change health behaviour and reduce symptoms. This study was designed to evaluate the benefits of a simple, cognitive-behavioural, self-management programme for hypertension based around a hypertension manual and delivered in the setting of a community anti-hypertensive club in Shanghai. METHOD: The method was a pragmatic randomised controlled trial with an intention-to-treat analysis. Adult patients with mild-to-moderate primary hypertension, waiting to join a neighbourhood anti-hypertension club, were randomised to the self-management programme or to an information only control procedure. They attended the group treatment sessions on 4 occasions over 5 weeks for education combined with goal setting for lifestyle change and an introduction to exercise. The main outcome measures were: changes in blood pressure; blood total cholesterol; diet; activity level and health related quality of life 1 month and 4 months after the end of treatment. RESULTS: A total of 140 adults with mild-to-moderate primary hypertension took part. All of the main outcomes showed beneficial changes. Four months after the end of treatment the mean blood pressure differences between groups were systolic 10.15 mm Hg (P < 0.001, 95% CI 7.25-13.05), and diastolic 8.29 mmHg (P < 0.001, 95% CI 6.71-9.88). Patients in the intervention group also had significantly reduced weight, lowered blood total cholesterol, increased physical activity and improved quality of life. CONCLUSION: Patients with mild-to-moderate primary hypertension attending a 5 week, group and manual based, cognitive-behavioural self-management programme, delivered through a voluntary club in Shanghai experienced a significant reduction in blood pressure. TRIAL REGISTRATION: Current Controlled Trials ISRCTN73114566.

A brief cognitive-behavioral intervention reduces hospital admissions in refractory angina patients.

Chronic refractory angina is an increasingly prevalent, complex chronic pain condition, which results in frequent hospitalization for chest pain. We have previously shown that a novel outpatient cognitive-behavioral chronic disease management program (CB-CDMP) improves angina status and quality of life in such patients. In the present study of 271 chronic refractory angina patients enrolled in our CB-CDMP, total hospital admissions were reduced from 2.40 admissions per patient per year to 1.78 admissions per patient per year (P<0.001). The rising trend of total hospital bed day occupancy prior to enrollment fell from 15.48 days per patient per year to a stable 10.34 days per patient per year (P<0.001). There were 32 recorded myocardial infarctions prior to enrollment compared to eight in the year following enrollment (14% vs. 2.3%, P<0.001) and overall mortality was lower that comparable groups treated with surgery. This study shows that educating patients and demystifying angina using a brief outpatient CB-CDMP produces an immediate and sustained reduction in hospital admission costs that represents a major potential health care saving. This benefit accrues in addition to the known effects of CB-CDMP on symptoms and quality of life. These data suggest that a CB-CDMP approach to symptom palliation represents a low cost alternative to palliative revascularization.

A simple screening method for determining knowledge of the appropriate levels of activity and risk behaviour in young people with congenital cardiac conditions.

OBJECTIVE: To assess a novel method for assessing risk and providing advice about activity to children and young people with congenital cardiac disease and their parents. DESIGN AND SETTING: Questionnaire survey in outpatient clinics at a tertiary centre dealing with congenital cardiac disease, and 6 peripheral clinics. INTERVENTIONS: Children or their parents completed a brief questionnaire. If this indicated a desire for help, or a serious mismatch between advised and real level of activity, they were telephoned by a physiotherapist. MAIN MEASURES OF OUTCOME: Knowledge about appropriate levels of activity, and identification of the number exercising at an unsafe level, the number seeking help, and the type of help required. RESULTS: 253/258 (98.0%) questionnaires were returned, with 119/253 (47.0%) showing incorrect responses in their belief about their advised level of exercise; 17/253 (6.7%) had potentially dangerous overestimation of exercise. Asked if they wanted advice 93/253 (36.8%) said "yes", 43/253 (17.0%) "maybe", and 117/253 (46.2%) "no". Of those contacted by phone to give advice, 72.7% (56/77) required a single contact and 14.3% (11/77) required an intervention that required more intensive contact lasting from 2 up to 12 weeks. Of the cohort, 3.9% (3/77) were taking part in activities that put them at significant risk. CONCLUSIONS: There is a significant lack of knowledge about appropriate levels of activity, and a desire for further advice, in children and young people with congenital cardiac disease. A few children may be at very significant risk. These needs can be identified, and clinical risk reduced, using a brief self-completed questionnaire combined with telephone follow-up from a suitably knowledgeable physiotherapist.

The rise and fall of cardiac rehabilitation in the United Kingdom since 1998.

BACKGROUND: Provision of cardiac rehabilitation is inadequate in all countries in which it has been measured. This study assesses the provision in the United Kingdom and the changes between 1998 and 2004. METHODS: All UK cardiac rehabilitation programmes were surveyed annually. Figures for each year were up-rated to account for missing data and compared with national data for acute myocardial infarction, coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The total numbers and percentage of eligible patients included were charted for 7 years. RESULTS: For centres giving figures, the total number treated rose from 29,890 in 1998 to 37,129 in 2004. The up-rated figures show that the percentage of eligible patients enrolled rose from 25.0% in 1998 to 31.5% in 1999 and has changed little since, falling from 31.3% in 2002 to 28.5% in 2004. About 25% of myocardial infarction patients, 75% of CABG patients and 20% of PCI patients joined cardiac rehabilitation programmes. CONCLUSIONS: The National Service Framework for Coronary Heart Disease set a target for 85% of myocardial infarct and coronary revascularization patients to be enrolled in rehabilitation programmes. Only one-third of this number is currently being enrolled and the percentage is falling.

Do illness perceptions predict attendance at cardiac rehabilitation and quality of life following myocardial infarction?

OBJECTIVE: The aim of this study was to examine the extent to which illness perceptions predict attendance at cardiac rehabilitation and quality of life following myocardial infarction (MI). METHODS: The illness perceptions of 194 MI patients were assessed whilst the patients were still in hospital following an MI. The mean age was 63.3 years (S.D. = 10.6), and 142 of the patients were men. Cardiac rehabilitation attendance and quality of life were assessed via a postal questionnaire 6 months later. RESULTS: In contrast to previous work reported in this area, illness perceptions were not significantly associated with attendance at cardiac rehabilitation. Illness perceptions measured within 24 h of an acute MI were predictive of quality of life 6 months later. CONCLUSION: Previous reports may have overestimated the extent to which illness perceptions predict attendance at cardiac rehabilitation. The relationship between illness perceptions and quality of life at 6 months suggests that interventions to alter illness perceptions, especially perceptions of consequences, may be useful in improving health-related quality of life (HRQoL) following an MI.

Does it matter what patients think? The relationship between changes in patients' beliefs about angina and their psychological and functional status.

OBJECTIVE: The aim of this study is to examine the association between changes in misconceived or maladaptive beliefs about angina and patients' functional and psychological status. METHOD: The method used was a prospective follow-up study over 1 year of 133 people with angina. RESULTS: Beliefs about angina were significantly associated with functional and psychological status. People with more misconceived or maladaptive beliefs were more anxious and physically limited than were people with fewer such beliefs, with differences in physical functioning that were clinically significant. Change in angina beliefs over 1 year was the most significant predictor for physical functioning at follow-up, after controlling for the effects of demographic variables and the outcome variable at baseline, whereas change in the frequency of angina did not contribute significantly to this model. CONCLUSION: Misconceived and maladaptive beliefs about angina are associated with reductions in both functional and psychological status. These beliefs are easily and quickly identified using a simple questionnaire and should be corrected.

The information needs of head and neck cancer patients prior to surgery.

OBJECTIVE: To describe the common themes in the experiences and expressed information needs of patients undergoing head and neck surgery. Summary background data : Patients who suffer head and neck cancers and undergo surgery often report considerable psychological distress and impaired social functioning. To optimise survival, the decision about what treatment option to follow is often made quickly, with little support in terms of counselling or the provision of information. There is inadequate previous work exploring the content and delivery of information required by patients at this time. PATIENTS AND METHODS: Participants included patients who had undergone surgery for head or neck cancer (n=29) and their immediate relatives who were present at the initial consultation with the surgeon (n=13). Patients were recruited from out-patient departments in two hospitals in the north of England. All interviews were conducted in participants' homes and were guided by a semistructured interview schedule devised both from literature and a pilot study. RESULTS: Whilst most participants felt well informed about the surgical procedure they were undergoing, many reported feeling unprepared for the long-term lifestyle changes that occurred. Information, support and advice throughout the 3-6 months postoperative period was reported to be inadequate. The majority of participants did not ask any questions and did not perceive there was a choice regarding treatment. Individuals who wanted to take an active role in decision-making reported difficulties accessing information to enable them to do so. CONCLUSION: The findings of this study emphasise the need for individualised information provision defined not exclusively by the surgical procedure.

Development of the York Angina Beliefs Questionnaire.

It is known that people who have suffered a heart attack can hold misconceived or maladaptive beliefs and that these can have a deleterious effect on quality of life and functioning. It has also been noted that clinicians do not routinely elicit these maladaptive beliefs. It is probable that angina sufferers also hold such beliefs. As angina is a great burden in the western world, with over two million people with angina in the UK alone, there may be large numbers of people who suffer from these frightening and unhelpful misconceptions. We believe that there is a need for a simple questionnaire that could assist the delivery of tailored education directed at dispelling common misconceptions. This article details the development and psychometric properties of just such a brief questionnaire, designed for use both in research and in clinical practice.