Psychosocial Predictors of Self-Efficacy Related to Self-Reported Adherence in Older Chronic Patients Dealing with Hypertension: A European Study.

PURPOSE: Non-adherence to clinical prescriptions is widely recognized as the most common cause of uncontrolled hypertension, contributing to develop acute and chronic cardiovascular diseases. Specifically, patients' unintentional non-adherence is related to psychosocial factors as beliefs about medications, perceived physician's communication effectiveness and medication-specific social support. The aim of this study was to observe the impact of these factors on self-efficacy in relation to pharmacological and non-pharmacological self-reported adherence among older chronic patients with hypertension. PATIENTS AND METHODS: This research had a cross-sectional, observational and multicentre study design. Italian inpatients under rehabilitation, and Polish inpatients/outpatients were recruited. Following a cognitive screening, socio-demographic and clinical characteristics were obtained. Data on clinical and behavioral adherence (i.e., pharmacological adherence, adherence to refill medicines, intentional non-adherence) and psychosocial factors related to treatment adherence (i.e., beliefs about medicines, physician's communication skills, medication-specific social support, psychological antecedents and self-efficacy) were collected with self-report questionnaires. RESULTS: A total of 458 patients were recruited. Fischer's LSD post hoc test revealed significant differences between Italian and Polish samples in all measures (p<0.001). Multiple linear regression analysis showed low self-reported intentional non-adherence (ß = -.02, p=0.031), high self-reported adherence to refill medications (ß=-.05, p=0.017), high levels of perceived physician's communication effectiveness (ß=0.11, p<0.001), positive beliefs about medications (ß=0.13, p<0.001), and high perceived medication-specific social support (ß=0.05, p<0.001) to predict significantly high patients' self-efficacy in relation to pharmacological and non-pharmacological self-reported adherence. CONCLUSION: The observed psychosocial and behavioral factors revealed to positively impact on self-efficacy in relation to treatment adherence among older chronic patients dealing with hypertension. In a prevention framework, future studies and clinical practice may consider these factors in order to improve assessment and intervention on adherence in this population.

The reduction of central sleep apnoea severity in the left lateral position is not due to an improvement in cardiac haemodynamics in patients with chronic heart failure.

OBJECTIVE: The severity of central sleep apnoea (CSA), a common comorbidity in patients with chronic heart failure (CHF) and reduced ejection fraction, markedly decreases from the supine to the lateral sleeping position, with no difference between the left and right positions. The mechanisms responsible for this beneficial effect have not yet been elucidated. METHODS: We tested the hypothesis that CSA attenuation in the left lateral position is due, at least in part, to an improvement in cardiac haemodynamics. Sixteen CHF patients (male, aged 60 ± 7 years, New York Heart Association class 2.6 ± 0.5, left ventricular ejection fraction [LVEF] 30% ± 5%) with moderate-to-severe CSA underwent two consecutive tissue Doppler echocardiography examinations in random order, one in the left lateral position (90°) and the other in the supine position (0°). The following parameters were obtained: left ventricular end-diastolic volume (LVEDV) and LVEF, left atrial volume (LAV) and right atrial volume (RAV), mitral regurgitation (MR), cardiac output (CO), transmitral protodiastolic (E) wave deceleration time (DT), E/e' ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular-atrial gradient (RVAG). RESULTS: The LAV, MR, E/e', RAV, and RVAG significantly increased, whereas the LVEF and TAPSE significantly decreased in the left lateral position. All changes, however, were of negligible clinical significance. No significant changes were observed in CO, DT, and LVEDV. CONCLUSIONS: This study shows that the reduction of CSA severity from the supine to the left lateral position in patients with CHF is not due to an improvement in cardiac haemodynamics. Other, noncardiac factors are likely to represent the main cause.

The 6-minute walking test and all-cause mortality in patients undergoing a post-cardiac surgery rehabilitation program.

BACKGROUND: The 6-minute walking test (6mWT) is used to prescribe physical activity in cardiac surgery patients. The clinical value of a pre-discharge 6mWT and its association with outcome is not well defined. DESIGN AND METHODS: We retrospectively analyzed data from 313 patients (age 66 ± 11 years, 23% females, left ventricular ejection fraction (LVEF) 52 ± 11%, Hb 10.5 ± 1.3 g/dl, serum albumin 3.9 ± 0.4 mg/dl) who were admitted to our rehabilitation institute following cardiac surgery. A 6mWT was performed at entry and at discharge and expressed as % of theoretical predicted values calculated on the basis of individual age, height, weight and sex. The endpoint was represented by all-cause mortality. The predictive value of 6mWT was tested in univariate and multivariate analysis. RESULTS: A pre-discharge 6mWT was completed by 284 out of 313 patients. Two patients died in hospital. During a median of 23 months, mortality was 9% (26/284) and 44% (12/27) (p < 0.0001) in patients who did or did not perform the pre-discharge 6mWT. The distance covered at the pre-discharge 6mWT as a continuous variable of % predicted values was a significant predictor of subsequent mortality (Hazard Ratio (HR) 0.97 (95% CI 0.96-0.99), p = 0.0019). After adjustment for all preselected covariates, the pre-discharge 6mWT (HR 0.97 (95% CI 0.95-0.99), p = 0.0038) and LVEF (HR 0.93 (95% CI 0.90-0.96), p < 0.0001) remained significantly associated with the outcome. CONCLUSIONS: In recent cardiac surgery patients, the pre-discharge 6mWT is not only a valid measurement of the impact of cardiac rehabilitation but also provides outcome information offering the possibility to identify patients who may need more intensive follow-up.

Assessment of the peripheral ventilatory response to CO2 in heart failure patients: reliability of the single-breath test.

The assessment of chemoreflex sensitivity in heart failure patients is gaining increasing interest since recent studies demonstrated that augmented chemosensitivity is an independent predictor of mortality and represents an important pathogenic factor in the development of Cheyne-Stokes respiration. The single-breath CO2 test is a well-established method to quantify peripheral hypercapnic chemoreflex sensitivity. As the original criteria for the computation of the chemoreflex sensitivity in healthy subjects need to be modified in heart failure patients to take into account impaired cardiac function, the effects of such modifications on measurement reliability deserve investigation. Hence, we devised this study to assess the reliability of the single-breath CO2 test in heart failure patients. In 27 clinically stable, mild-to-moderate heart failure patients (age (mean±SD): 64±10 years, left ventricular ejection fraction: 34±7%, NYHA class: 2.7±0.4), the test was administered on two consecutive days in the same conditions. Reliability was assessed by the standard error of measurement (SEM) and by the intraclass correlation coefficient (ICC). The mean value of the chemoreflex sensitivity on the two days was: 0.25 ± 0.12 and 0.24 ± 0.12 l min(-1) mmHg(-1) (p = 0.45), respectively. The SEM was 0.05 l min(-1) mmHg(-1), indicating large intra-subject variability. Consequently, in order to be 95% confident that a real change has occurred between two measurements taken on the same individual (test-retest), the observed difference must be higher than ±0.15 l min(-1) mmHg(-1), which is about 60% of the mean value across our population. The ICC was 0.71, indicating thatintra-subject variability, although high, is a limited (29%) portion of inter-subject variability. Intra-subject variability should be carefully taken into account when using the single-breath CO2 test in assessing changes in individual patients. The observed ICC indicates that this test may provide useful information for diagnostic/classification purposes.

[Presentation of the Psycho-Cardiological schedule and convergence levels analyses among the psycho-cardiological screening and the psychological assessment]. / Presentazione della Scheda Psico-Cardiologica (SPC) e analisi dei livelli di convergenza tra screening psico-cardiologico e valutazione psicologica.

UNLABELLED: In Cardiovascular Rehabilitation the increasing inpatients complexity suggests the necessity to develop screening methods which allow to identify those patients that require a psychological intervention. MATERIAL AND METHODS: A Psycho-Cardiological Schedule (PCS) was developed with the aim of detecting the critical situation indicators or the presence of psychological, social and cognitive problems. The PCS, compiled by a nurse or cardiologist in collaboration with a psychologist, allows to assess the need for a deeper psychological examination, clinical and/or with tests. Aim of the present study is to identify the convergence levels among the observational and anamnestic data of the PCS collected by a nurse and the clinical and/or test data of the psychological deeper assessment. RESULTS: Among the 87 patients recruited in January-February 2010, 28 (aged 53.5 +/- 12.6, M = 20, F = 8) fulfilled the criteria for a deeper psychological examination: age < or = 50, manifestation of psychological/behavioural problems, neuropsychological disorders, low adherence to prescriptions, inadequate disease knowledge/representation. From data comparisons emerged convergence levels with 100% concordance as to smoke habits and problems in social-family support. High convergence levels also resulted as to emotional and/or behavioural problems (92.8%) and inadequate adherence to prescriptions (89.3%). Lower levels of concordance (82.1%) emerged when considering disease knowledge/representation, issues specifically linked to cognition and subjective illness experience, not directly detectable from behaviour. CONCLUSIONS: our data confirm the synergic efficacy of the two evaluations: the Psycho-Cardiological Schedule reliably identifies the problematic macro-categories, mainly if they are characterized by behavioural indicators, which facilitate the detection. The psychological approach appears more suitable for better specifing macro-categories characteristics and for detecting critical aspects not overt but not less important, providing therefore advice for a therapeutic psychological management.

Heart rate and cardiac allograft vasculopathy in heart transplant recipients.

BACKGROUND: Elevated heart rate (HR) has been indicated as risk factor for cardiovascular disease. Experimental data support a role of HR in the progression and severity of atherosclerotic lesions. Sinus tachycardia is common in heart transplant patients due to the lack of autonomic control. This study assessed the role of HR in the development of cardiac allograft vasculopathy (CAV) in heart transplant recipients. METHODS: Data from 244 allograft recipients were analyzed. Known factors affecting CAV and mean HR obtained from 24-hour recordings at 1 year (dichotomized at ≥90 beats/min) were tested in univariate and multivariable Cox analysis. RESULTS: During a median of 96 months, 60 patients (25%) experienced CAV. Surprisingly, HR < 90 but not ≥90 beats/min was significantly associated with an increased CAV development. Univariate analysis showed several predictors were associated with the end point; however, at multivariable analysis, only donor's age, chronic renal failure, and left ventricular end-diastolic wall thickness were significant predictors of CAV, with hazard ratios of 1.02 (95% confidence interval, 1.00-1.04), 1.90 (1.13-3.21), and 1.11 (1.00-1.22), respectively. A highly statistically significant difference in donor's age was found among patients with mean heart rate ≥90 or <90 beats/min (30 ± 13 vs 40 ± 14 years, p < 0.0001). CONCLUSIONS: In the denervated heart, sinus tachycardia is not a risk factor for coronary atherosclerosis. HR in heart transplant recipients reflects "intrinsic heart rate" and is a simple epiphenomenon of the donor's age.

Nocturnal cardiac arrhythmia in patients with obstructive sleep apnea.

BACKGROUND AND PURPOSE: Nocturnal cardiac arrhythmias occur in patients with obstructive sleep apnea (OSA), reportedly as a consequence of the autonomic effects of recurrent apnea with subsequent oxygen desaturation. We have investigated whether different patterns of OSA are associated with specific arrhythmia during sleep. PATIENTS AND METHODS: Electrocardiographic (ECG) data recorded during polysomnography (PSG) were analysed in 257 consecutive OSA patients to determine the prevalence of cardiac rhythm disturbances, and to relate these to breathing pattern (normal, apnea/hypopnea, recovering ventilation, snoring) and oxygen saturation. RESULTS: Arrhythmias were found in 18.5% of patients. Patients with nocturnal bradyarrhythmia (BA) had higher values of ventilatory disturbance (apnea-hypopnea index [AHI] 58.8+/-36.8 vs 37.2+/-30.3, p=0.02), mean desaturation amplitude (8.9+/-4 vs 5.9+/-3.4%, p=0.03), and a lower SaO(2) nadir (69% vs 77%, p=0.003) than those without arrhythmia. The prevalence of BA in patients with AHI>or=30/h was significantly higher than that observed in those with AHI<30/h (7.8% vs 1.5%, respectively; chi(2)=5.61, p=0.01). In contrast, patients with tachyarrhythmia (TA) had no significant differences in AHI, mean desaturation amplitude or SaO(2) nadir than those without arrhythmia. No associations were found between arrhythmia and the presence of comorbidity or concomitant medical therapy, except for an association between tachyarrhythmia and chronic obstructive pulmonary disease (COPD) (odds ratio 2.53; 95% confidence intervals 1.1-5.8, p=0.03). CONCLUSIONS: We conclude that while BA during sleep is associated with OSA severity, concomitant COPD or beta(2)-treatment may play a role in the development of TA during sleep.