Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial.

BACKGROUND: Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD. METHODS: We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications. RESULTS: We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min). INTERPRETATION: A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members. TRIAL REGISTRATION: clinicaltrials.gov, no NCT00552591.

Healthy eating opinion survey for individuals at risk for cardiovascular disease.

OBJECTIVE: To develop and evaluate the validity and reliability of a questionnaire to measure intentions and beliefs about healthy eating in individuals at risk for coronary heart disease. METHOD: The Healthy Eating Opinion Survey was developed using the theory of planned behavior. An open-ended elicitation questionnaire was administered to 21 participants, and a 46-item questionnaire was developed for further testing. Test-retest reliability of each question on the survey was assessed by calculating the correlation coefficients between the responses over a 2- week period in 17 participants. Internal consistency was assessed using Cronbach's alpha, and factor analysis was used to assess the construct validity of the questionnaire in a sample of 388 participants. RESULTS: The responses to the elicitation questions were used to develop behavioral beliefs, normative beliefs, and control beliefs questions for the final questionnaire. Test-retest reliability ranged from 0.22-0.90, with the majority (89%) of correlations being moderate to strong. Internal consistency was good, with Cronbach's alpha ranging from 0.74-0.92. All intentions questions loaded onto a single factor; attitude questions loaded onto two factors; subjective norm questions loaded onto two factors; perceived behavioral control questions loaded onto one factor; behavioral beliefs questions loaded onto one factor; normative beliefs questions loaded onto one factor; and control beliefs questions loaded onto one factor. CONCLUSION: The questionnaire was found to be a reliable, valid questionnaire to assess beliefs and intentions toward eating a healthy diet in individuals at risk for coronary heart disease.

Neighbourhood walkability and physical activity among family members of people with heart disease who participated in a randomized controlled trial of a behavioural risk reduction intervention.

This study adds to the current literature investigating the relationship between individuals' physical activity (PA) and the built environment. Self-reported PA from a prospective behavioural risk reduction intervention was explored in the context of objectively measured Walk Score(®) and neighbourhood walkability in Ottawa, Canada. Participants in the intervention arm had significantly higher odds of meeting PA guidelines at 12-weeks compared to the standard care control group. This was not influenced by Walk Score(®) or walkability. This individual-level intervention was effective in assisting participants to overcome potential structural barriers presented by their neighbourhood to meet PA guidelines at 12-weeks.

Gender differences in satisfaction with life in patients with coronary heart disease: physical activity as a possible mediating factor.

The objective of the present study was to examine if time varying, mediating effect of physical activity plays an important role in the gender-satisfaction with life relationship. Six hundred four male and 197 female patients were included. Principal outcomes of interest were self-report satisfaction with life and physical activity at baseline, 6, 12 and 24 months. The Krull and MacKinnon procedure for hierarchical linear modeling showed that the change in physical activity mediated the gender-satisfaction with life over a 2 year period. Results from the current study suggest that increased physical activity partially explains why males report having increased well-being than females after hospitalization. This suggests that future interventions need to focus on reducing the gender disparity in physical activity to improve differences noted in satisfaction with life. If higher physical activity levels impact satisfaction with life positively, the importance of physical activity for female patients is warranted.

A mixed methods study of continuity of care from cardiac rehabilitation to primary care physicians.

BACKGROUND: Participation in cardiac rehabilitation (CR) programs results in multiple beneficial outcomes, including decreased morbidity and mortality. In Canada, the involvement of the primary care physician post-CR should increase the likelihood of sustaining the benefits achieved by CR and enhance the continuity of care that cardiac patients receive. OBJECTIVES: To identify and describe information that is transferred from CR programs to primary care physicians in discharge summaries, and to assess the usefulness of such information from the perspective of the primary care physician. METHODS: For each of 21 Ontario CR sites to which patients from a larger study were referred, up to four primary care physicians were contacted to request a copy of the CR discharge summary received and their participation in a telephone interview. Discharge data were coded and enumerated. Qualitative data from 17 interviews were transcribed and coded based on grounded analyses. RESULTS: Of the 89 primary care physicians approached, 50 participated (response rate of 61.7%). Twenty-one physicians (42.0%) received the intended discharge summary from the CR site. There was great variability in clinical and service data reported, with 52.0% reporting an exercise prescription for the home or community and 42.0% reporting current medications prescribed. Four themes requiring improvement were generated from the physician interviews: patient behavioural management issues, health system factors, efficiency of data transfer and communication issues. CONCLUSIONS: Major inconsistencies were noted between clinical data communicated versus what was desired. Data relating to attendance rates, behavioural management suggestions and lipid values were among the most notable omissions.

Sex differences in attitudes and experiences concerning smoking and cessation: results from an international survey.

OBJECTIVE: Males and females may have different attitudes and experiences concerning smoking and smoking cessation. We examined sex differences in reasons for smoking, motivations for quitting, past quit attempts, and types of cessation support provided by physicians by surveying randomly selected smokers from 16 countries. METHODS: Current cigarette smokers were surveyed by telephone about their attitudes and experiences regarding smoking and smoking cessation. RESULTS: Of the 3760 respondents, 1516 (40.3%) were female. Overall, females reported more reasons for smoking, were more likely to be motivated to quit by life changes, and more likely to use medications or counselling for smoking cessation than males. Although 70% of respondents recalled their physician asking about smoking and advising quitting, only 39% of females and 26% of males recalled being offered assistance for cessation. Females recalled more frequent prescription or recommendation of pharmaceutical cessation aids and more assistance in setting a quit date. CONCLUSION: Males and females have different attitudes and experiences when it comes to smoking and cessation. PRACTICE IMPLICATIONS: Health care providers can significantly influence smoking-cessation success by offering efficacious treatment to patients. Our data will help physicians to optimally tailor smoking-cessation interventions to patients, according to their sex.

Smoking cessation: lessons learned from clinical trial evidence.

PURPOSE OF REVIEW: Cigarette smoking and exposure to secondhand smoke cause coronary heart disease. Cessation dramatically reduces the incidence of primary and secondary cardiac events. The review presents up-to-date information regarding nicotine dependence, recent findings related to its treatment, and recommendations for addressing smoking cessation for the primary and secondary prevention of coronary heart disease. RECENT FINDINGS: Bans on smoking in public places are associated with significant reductions in the incidence of acute myocardial infarction. Counseling and pharmacotherapy (nicotine replacement therapy, bupropion) are proven, effective treatments for nicotine dependence. Clinical trials of two new pharmacotherapies, varenicline and rimonabant, have recently been reported. Varenicline is a safe and efficacious medication for smoking cessation, and has been approved in the US, Canada and Europe. Rimonabant has shown mixed results for smoking cessation and is undergoing further evaluation. SUMMARY: All patients should be screened for tobacco use. Clinicians can effectively treat nicotine dependence in the general population using counseling and first-line pharmacotherapies (nicotine replacement therapy, bupropion, varenicline). These same treatments, with some modification, are appropriate for smokers with coronary heart disease; however, brief interventions without follow-up are not effective in this population. For smokers with coronary heart disease, the best time to intervene may be during hospitalization.

Who will be active? Predicting exercise stage transitions after hospitalization for coronary artery disease.

We describe transitions between exercise stages of change in people with coronary artery disease (CAD) over a 6-month period following a CAD-related hospitalization and evaluate constructs from Protection Motivation Theory, Theory of Planned Behavior, Social Cognitive Theory, the Ecological Model, and participation in cardiac rehabilitation as correlates of stage transition. Seven hundred eighty-two adults hospitalized with CAD were recruited and administered a baseline survey including assessments of theory-based constructs and exercise stage of change. Mailed surveys were used to gather information concerning exercise stage of change and participation in cardiac rehabilitation 6 months later. Progression from pre-action stages between baseline and 6 month follow-up was associated with greater perceived efficacy of exercise to reduce risk of future disease, fewer barriers to exercise, more access to home exercise equipment, and participation in cardiac rehabilitation. Regression from already active stages between baseline and 6 month follow-up was associated with increased perceived susceptibility to a future CAD-related event, fewer intentions to exercise, lower self-efficacy, and more barriers to exercise.

Continuity of cardiac care: cardiac rehabilitation participation and other correlates.

BACKGROUND: Continuity of care refers to the ongoing management of a patient's care over time and across practitioners, and the patient's experience of this care as coherent and consistent with their medical needs and context. Continuity of cardiac care is integral to secondary prevention and improved health outcomes. DESIGN: This study examined patient perceptions of continuity, and how they relate to cardiac rehabilitation participation and other correlates. METHODS: Consecutive acute coronary syndrome patients at 3 hospitals were approached, and 661 consented to complete a survey (504 men, 157 women; 75% response rate). Nine months later, 506 participants completed a survey including the Heart Continuity of Care Questionnaire, open-ended continuity perceptions, and self-reported cardiac rehabilitation participation (yes/no). RESULTS: The mean continuity perceptions were highly positive, and were equivalent to those found in another Canadian province, although open-ended responses revealed discontinuity with regard to outpatient visits and pharmacotherapy prescriptions. In a multivariate model (p=.003), the correlates of greater perceptions of continuity of cardiac care 9 months post-discharge were cardiac rehabilitation participation (p<.05), greater tangible support (p<.05), and less serious perceptions of illness consequences (p<.001) at the time of the acute coronary syndrome, after controlling for demographic and clinical factors. CONCLUSION: Given the benefits of continuity of care, it is important to promote cardiac rehabilitation participation, a significant correlate of continuity, and to solicit various supports throughout the process of cardiac recovery.