Multiple Risk Factor Counseling to Promote Heart-healthy Lifestyles in the Chest Pain Observation Unit: Pilot Randomized Controlled Trial.

OBJECTIVE: Admission to the chest pain observation unit (CPOU) may be an advantageous time for patients to consider heart-healthy lifestyle changes while undergoing diagnostic evaluation to rule out myocardial ischemia. The aim of this pragmatic trial was to assess the effectiveness of a multiple risk factor intervention in changing CPOU patients' health beliefs and readiness to change health behaviors. A secondary aim was to obtain preliminary estimates of the intervention's effect on diet, physical activity, and smoking. METHODS: We conducted a pilot randomized controlled trial of a moderate-intensity counseling intervention that aimed to build motivation to change and problem-solving skills in 140 adult patients with at least one modifiable cardiovascular risk factor (CRF) who were admitted to the CPOU of an academic emergency department (ED) with symptoms of possible acute coronary syndrome. Study patients were randomly assigned to full counseling (face-to-face cardiovascular risk assessment and personalized counseling on nutrition, physical activity, and smoking cessation in the ED, plus two telephone follow-up sessions) or minimal counseling (brief instruction [<5 minutes] on benefits of modifying cardiovascular risk factors) by a cardiac rehabilitation specialist. We measured Health Belief Model constructs for ischemic heart disease, stage of change, and self-reported CRF-related behaviors (diet, exercise, and smoking) during 6-month follow-up using previously validated measures. We used linear mixed models and logistic regression (with generalized estimating equations) to compare continuous and dichotomous behavioral outcomes across treatment arms, respectively. RESULTS: Approximately 20% more patients in the full counseling arm reported having received counseling on diet and physical activity during CPOU admission, compared to the minimal counseling arm; a similar proportion of patients in both counseling arms reported having received advice or assistance in quitting smoking. There were no significant differences between treatment arms for any cardiovascular health beliefs, readiness to change, or CRF-related behaviors during longitudinal follow-up. In secondary analyses in both treatment arms combined, however, patients showed significant differences between follow-up and baseline measurements: increases in the perceived benefits of improving CRF-related behaviors (27.7 vs. 26.6 on a scale from 7 to 35, p = 0.0001) and increased readiness to change dietary behavior and physical activity during follow-up-intake of saturated fat (83% vs. 49%), readiness to change fruit and vegetable consumption (83% vs 56%), and readiness to perform regular exercise (34% vs. 14%) at 6 months and baseline, respectively (p < 0.0001 for all comparisons in both treatment arms combined). CONCLUSIONS: A multiple risk factor intervention that focused on increasing motivation to change and problem-solving skills did not significantly improve behavioral outcomes, compared to minimal counseling. Patients admitted to the CPOU demonstrated sustained changes in several cardiovascular health beliefs and risk-related behaviors during follow-up; this provides further evidence that the CPOU visit is a "teachable moment" for cardiovascular risk reduction. Future studies should evaluate the effectiveness of ED-initiated counseling interventions to engage patients in changing cardiovascular risk behaviors, in coordination with primary care.

The Value of Detecting Asymptomatic Signs of Myocardial Ischemia in Patients With Coronary Artery Disease in Outpatient Cardiac Rehabilitation.

BACKGROUND: Electrocardiographic (ECG) monitored outpatient cardiac rehabilitation (OP-CR) is routinely performed following a variety of cardiovascular procedures and conditions. OBJECTIVE: The aim of this study is to determine if diagnostic-quality ECG monitoring in patients with coronary artery disease (CAD) during OP-CR is useful in identifying asymptomatic myocardial ischemia, resulting in change(s) in care or medical management. METHODS: A retrospective analysis of ECG monitoring was done on all OP-CR patients diagnosed with CAD (n = 1213) from January 2000 through June 2013. RESULTS: Nearly a quarter of the patients (24%; n = 288) displayed at least 1 mm of asymptomatic ST-segment depression at 80 milliseconds after the J-point during at least 1 session of OP-CR. Of these patients, 57% had medical management change(s) compared with 24% for those who did not show ECG changes suggesting ischemia (P < .0001). In patients with asymptomatic ischemia having medical management change(s), 84% resulted directly from OP-CR staff detection. Fewer patients diagnosed with myocardial infarction and coronary artery bypass graft surgery demonstrated ECG signs of ischemia, whereas more patients diagnosed with stable angina and percutaneous coronary interventions demonstrated ECG signs of ischemia. CONCLUSION: This study demonstrates that most patients with CAD showing asymptomatic ECG signs suggesting ischemia undergo medical management change(s) as a result of the finding. Diagnostic-quality ECG monitoring during OP-CR appears warranted in this population.

Text-messaging program improves outcomes in outpatient cardiovascular rehabilitation.

BACKGROUND: Outpatient cardiac rehabilitation (OP-CR) is a highly beneficial program but vastly under utilized. METHODS: The efficacy of a text-messaging program was analyzed to determine if implementation could improve number of OP-CR sessions completed. All patients enrolled in OP-CR from July 2011 through December 2012 were invited to join a text-messaging program on their first visit. The program required that the patient possesses a cell phone with texting capabilities. Participants received three to five text-messages per week offering heart-healthy tips and requests for body weight, minutes of exercise, blood pressure, and medication adherence. Patients enrolled (n = 52) in the texting program (Tx) were compared with those who were not (n = 185) (NTx) in several clinical indices and were compared using matched pairs (same subjects), comparison of means and frequencies, chi-square statistics, t-tests, and the Wilcoxon Rank Sum test. RESULTS: Significantly more patients in the Tx group completed the OP-CR program (61.5% versus 50%, p = 0.01). For those completing OP-CR, subjects in the Tx group completed significantly more sessions (31.4) than the NTx group (25.3) (p = 0.01). Additionally, significantly more in the Tx group were younger than those in the Ntx group. CONCLUSIONS: Patients enrolled in OP-CR who participated in a text-messaging program were younger, attended significantly more sessions and were significantly more likely to complete the program.

Circulating levels of ß2-microglobulin and cystatin C are associated with left atrial size: additional link between the kidney and the heart.

OBJECTIVE: More attention is being paid to the relationship between kidney dysfunction and cardiovascular events Characteristic features include renal dysfunction, left ventricular (LV) and left atrial (LA) enlargement. The aim of this study is to evaluate the relationships between circulating levels of ß2-microglobulin (ß2-m) and cystatin C and left atrial size in patients with coronary artery disease. MATERIALS AND METHODS: We recruited 300 patients who presented with chest tightness or chest pain and subsequently underwent coronary angiography. Of these, 202 patients were diagnosed with coronary artery disease (CAD) and 98 patients without CAD (non-CAD). Laboratory measurements included liver, kidney function (urea nitrogen, creatinine, ß2-m and cystatin C), fasting glucose, and lipid analysis. CrCl were calculated according to Cockroft-Gault formula. Echocardiology was used to evaluate the cardiac structure and function. RESULTS: Significant differences of ß2-m and cystatin C exist and no difference of creatinine and CrCl existed between the two groups. LA diameters were positively related to circulating levels of ß2-m in the CAD group (r = 0.452, p < 0.001) and non-CAD group (r = 0.360, p < 0.001), and the similar relationships between LAD and circulating levels of cystatin C in the CAD group (r = 0.302, p < 0.001) and non-CAD group (r = 0.243, p = 0.016). LA diameters were negatively related to CrCl in both groups. After multivariate logistic regression analysis, the data indicated that the independent cardiovascular risk factors of LA enlargement for the patients with CAD were age, BMI, systolic blood pressure, LV mass, LVEDD, E/A, Em/Am, CrCl, and circulating levels of ß2-m (OR = 1.630, 95% CI: 1.115 - 2.384, p = 0.012), cystatin C (OR = 4.504, 95% CI: 1.478 - 13.726, p = 0.008). CONCLUSIONS: A linear correlation exists between circulating levels of ß2-m or cystatin C and LA diameters. Higher circulating levels of ß2-m or cystatin C are independent cardiovascular risk factors of LA enlargement in patients with CAD, and could be a link between the kidney and the heart.

Health beliefs toward cardiovascular risk reduction in patients admitted to chest pain observation units.

OBJECTIVES: Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long-term risk of ischemic heart disease (IHD)-related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a "teachable moment" with regard to modification of CRFs. METHODS: The authors conducted a baseline face-to-face interview and a 3-month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self-reported CRF-related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t-test or signed rank test was used to compare baseline and 3-month measures of health behavior within the analysis sample. RESULTS: Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3-month follow-up compared to baseline. Patients also reported greater readiness to change and improved self-reported behaviors at follow-up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002). CONCLUSIONS: Observed changes in IHD health beliefs and CRF-related behaviors during follow-up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF-related counseling during observation unit evaluation.

Gender disparities in common sense models of illness among myocardial infarction victims.

Symptom attributions were contrasted between male and female myocardial infarction victims (N = 157) who were comparable on age, cardiac risk status, medical history, symptom presentation, and other variables. Women were less likely than men to attribute their prehospital symptoms to cardiac causes. In the context of hearing symptom attributions or advice from support persons, women were less likely than men to report receiving a cardiac attribution or advice to seek medical attention. Results have implications for how victim gender influences the lay interpretation of cardiac symptoms.

How do female and male cardiac patients and their spouses share responsibilities after discharge from the hospital?

This study explored sex differences in household and employment responsibilities among cardiac patients (N = 63; 46 men) and spouses during the 5 months following discharge from the hospital. Results showed that both patients and partners maintained traditional sex-typed activities. As patients or spouses, women tended to assume greater responsibility for domestic tasks such as laundry, cleaning, and cooking than their husbands. Men as patients or spouses tended to assume greater responsibility for household repair and maintenance tasks. Husbands also worked more for pay outside the home than did wives, except in couples where the male patient was high risk. Correlations for male patients indicated that reports of more cardiac symptoms were associated with assuming fewer responsibilities. In contrast, among women, the correlations between symptoms and activities were more complex and suggested that female patients might not be heeding signs of overexertion.