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Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: A randomised controlled trial
Abstract
To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting (CABG).
Randomised controlled trial.
Community, January 1997 to March 1998. STUDY GROUPS: 98 (75 male) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust. Patients were randomly assigned to usual care (control; n = 49) or a nurse led intervention programme (n = 49).
A shared care programme consisting of health education and motivational interviews, according to individual need, was carried out monthly. Care was provided in the patients' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic.
Smoking status, obesity, physical activity, anxiety and depression, general health status, and proportion of patients exceeding target values for blood pressure, plasma cholesterol, and alcohol intake.
Compared with patients who received usual care, those participating in the nurse led programme were more likely to stop smoking (25% v 2%, p = 0.001) and to reduce obesity (body mass index > 30 kg/m(2)) (16.3% v 8.1%, p = 0.01). Target systolic blood pressure improved by 19.8% compared with a 10.7% decrease in the control group (p = 0.001) and target diastolic blood pressure improved by 21.5% compared with 10.2% in the control group (p = 0.000). However, there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values. There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 (p = 0.005) to 36.1 (p < 0.000). Levels of anxiety and depression improved (p < 0.000) and there was improvement in time spent being physically active (p < 0.000).
This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG.
... These interventions focused on three areas of health care including interventions to improve continence (McGhee et al., 1997;Williams et al, 2000;Shaw et al, 2000), improve pain control (Mackintosh and Bowles, 1997), and promote lifestyle changes for the primary prevention (Wood et al, 1994) and secondary prevention (Wonderling et al, 1996;McHugh et al, 1998;Campbell et al, 1998) of coronary heart disease. ...
... Physical functioning was measured using Barthel index in two studies (Griffiths et al., 2000;Steiner et al, 2001). In four studies, health status was measured using the SF-36 scale (McHugh et al, 1998;Campbell et al, 1998;Venning et al, 2000;Reynolds et al, 2000). One study used scales and biological blood measurements relevant to the chronic arthritis setting being evaluated (Hill et al, 1994). ...
... Seven randomised controlled studies measured patient satisfaction with patient self-administered surveys (Hill et al, 1994;McHugh et al, 1998;Sakr et al, 1999;Kinnersley et al, 2000;Venning et al, 2000;Shum et al, 2000;Reynolds et al, 2000). Ail o f these studies used previously validated satisfaction questionnaires with the exception o f Reynolds et al (2000) and McHugh et al (1998) who devised their own without performing any reliability and validity testing. ...
The development of advanced practice roles for nurses working in the speciality of genitourinary medicine (GUM) is part of a wider process of change in nursing and the National Health Service. Despite the paucity of evidence of their effectiveness, there has been a steady growth of nurse-led GUM clinics over the past decade. This thesis explores the impact of nurse-led GUM clinics for women in a central London GUM service. A process and outcome evaluation was conducted to demonstrate the effectiveness, acceptability and cost of nurse-led GUM clinics. 880 women were randomised to nurse-led or doctor-led clinics of whom 224 had their clinical records audited. A further (non-randomised) sample of 282 women completed a satisfaction survey, 20 completed an exit interview and 18 had their consultation observed. Staff completed 586 waiting time surveys. Staff interviews and focus group discussions identified the issues associated with the nurse-led clinic intervention. A cost analysis determined the average, incremental and marginal costs of nurse-led clinics. The median documentation audit scores for specialist nurses (n=103) and senior house officers (SHOs) (n=121) were 92% and 85% respectively (p<0.0001). Specialist nurses performed equally to the SHOs with regard to requesting the correct diagnostic tests, preliminary diagnosis and treatment. The median satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups respectively (p=0.05). There was no significant difference in the consultation times. Following the introduction of nurse-led clinics, the average cost per patient rose from £8.80 to £8.88 with a marginal cost of £9.43 per patient. The study concluded that trained, experienced specialist nurses supported within the multidisciplinary team were at least as effective in the assessment and management of female patients as SHOs. The model of nurse-led care was acceptable to patients and a cost-effective addition to existing services.
... The main components of planned discharge training and counselling intervention are to help them develop self-care behaviour to deal more comfortably with the problems caused by the disease and, the number of problems they may encounter (Naylor & Mc Cauley 1999, Arthur et al. 2000, McHugh et al. 2001. ...
... Providing training, counselling and support services to patients who have undergone CABG surgery and their close relatives helps individuals develop self-care behaviour and ensures continuity of care at home while away from the hospital environment. Thus, potential problems and rehospitalizations can be significantly averted (Capuano et al. 1997, Lukkarinen & Hentinen 1997, Naylor & McCauley 1999, Arthur et al. 2000, Driscoll 2000, Johnson 2000, McHugh 2001). ...
... Studies by Naylor (1999), Naylor and McCauley (1999) and McHugh et al. (2001) established that discharge training provided by nurses to patients who were hospitalized with cardiac problems and a care programme that involves monitoring at home reduce the length of hospitalization and prevent re-hospitalization. Similarly, we found that, for patients who received discharge training and counselling, there were fewer cases presenting to the hospital between discharge and the first follow-up in the intervention group, as opposed to the control group. ...
2 0 0 8) Journal of Clinical Nursing 17, 412-420 Discharge training and counselling increase self-care ability and reduce post-discharge problems in CABG patients Aims and objectives. The aim of this study was to determine how discharge training and counselling provided to patients, who had undergone coronary artery bypass graft (CABG) surgery, had effects on patients' self-care ability and on the problems encountered after discharge. The objectives were to help patients develop self-care behaviour to deal more comfortably with the problems caused by the disease and, hopefully, to reduce the number of problems they may encounter. Background. CABG surgery patients needing to manage various aspects of their self-care at home often find these tasks very difficult to carry out effectively. Discharge training and counselling services help patients undergoing CABG to develop self-care behaviours. Design. The study was prospective and quasi-experimental. Methods. The intervention and control groups consisted of 57 patients who were given discharge training and counselling by a researcher and 52 patients who were given routines by a nurse, respectively. The intervention group began receiving discharge training and counselling on the day of hospitalization. These were provided according to their individual knowledge needs and patients were given a booklet developed for training purposes. Data were collected by researcher using the Personal Information Form, the Self-Care Agency Scale. Results. It was found that the intervention group had a higher mean self-care score than the control group and experienced fewer problems following discharge compared with patients in the control group. Conclusion. The discharge training and counselling services given to patients in the intervention group had a positive impact on the self-care ability of these patients and on alleviating the problems they encountered. Relevance to clinical practice. As discharge training and counselling services had a positive impact on the self-care and alleviation of the problems that patients encounter after being discharged, we recommend application of these services and the usage of the training booklet for CABG patients.
... From 8,688 studies identified, nine were eligible (Figure 1): five randomized controlled trials (Tønnesen et al., 1999;McHugh et al., 2001;Tønnesen, 2002;Kummel et al., 2008;Weinrieb et al., 2011) two non-randomized controlled trials ( Shourie et al., 2006;Hansen et al., 2012) one pre-to post-intervention study (Ashton et al., 2013) and one mixed design study (Wyman et al., 2014) (which compared some outcomes between a control group [CG] and an intervention group [IG] and some within the IG only). Two studies targeted the use of alcohol and other recreational substances ( Ashton et al., 2013;Wyman et al., 2014), the rest alcohol use only. ...
... Two studies targeted the use of alcohol and other recreational substances ( Ashton et al., 2013;Wyman et al., 2014), the rest alcohol use only. Three studies aimed to modify other behaviors in conjunction with alcohol use e.g., exercise and smoking (McHugh et al., 2001;Kummel et al., 2008;Hansen et al., 2012). Five studies aimed to assess whether intervention could alter perioperative health outcomes (Tønnesen et al., 1999;Tønnesen, 2002;Shourie et al., 2006;Hansen et al., 2012;Wyman et al., 2014). ...
... Five studies delivered multi-session interventions (Tønnesen et al., 1999;McHugh et al., 2001;Tønnesen, 2002;Kummel et al., 2008) (the rest one session only) and three ( Kummel et al., 2008;Ashton et al., 2013;Wyman et al., 2014) involved group (as opposed to one-on-one) interventions. In three studies (McHugh et al., 2001;Kummel et al., 2008;Hansen et al., 2012) the intervention was delivered by nurses, in four ( Tønnesen et al., 1999;Tønnesen, 2002;Shourie et al., 2006;Weinrieb et al., 2011) by a member of the research group, one (Wyman et al., 2014) with multiple interventionists (psychologist, social worker or nurse), and one (Ashton et al., 2013) a psychologist. ...
Background: Preoperative alcohol and other recreational substance use (ORSU) may catalyze perioperative complications. Accordingly, interventions aiming to reduce preoperative substance use are warranted.
Methods: Studies investigating interventions to reduce alcohol and/or ORSU in elective surgery patients were identified from: Cochrane Library; MEDLINE; PSYCINFO; EMBASE; and CINAHL. In both narrative summaries of results and random effects meta-analyses, effects of interventions on perioperative alcohol/ORSU, complications, mortality and length of stay were assessed.
Primary Results: Nine studies (n = 903) were included. Seven used behavioral interventions only, two provided disulfiram in addition. Pooled analyses found small effects on alcohol use (d: 0.34; 0.05–0.64), though two trials using disulfiram (0.71; 0.36–1.07) were superior to two using behavioral interventions (0.45; −0.49–1.39). No significant pooled effects were found for perioperative complications, length of hospital stay or mortality in studies solely targeting alcohol/ORSU. Too few interventions targeting ORSU (n = 1) were located to form conclusions regarding their efficacy. Studies were generally at high risk-of-bias and heterogeneous.
Conclusions: Preoperative interventions were beneficial in reducing substance use in some instances, but more high-quality studies targeting alcohol/ORSU specifically are needed. The literature to date does not suggest that such interventions can reduce postoperative morbidity, length of hospital stay or mortality. Limitations in the literature are outlined and recommendations for future studies are suggested.
... Hypertension is largely diagnosed and managed in primary care, and general or family practice settings have been the usual locations for studies of nurse led interventions [15,. Trials have examined nurse led care in a variety of other settings, with evidence from individual randomised controlled trials for lower outcome blood pressures following delivery at home [48][49][50][51][52][53], in community • Team member or team leader • Measurement of blood pressure-avoiding white coat effect • Educator in non-pharmacological treatment • Translator for the physician with a holistic and psychosocial approach • Promoting lifestyle changes • Promoting medication adherence • Titrating blood pressure treatment to target • Monitoring and maintaining blood pressure treatment centres [48,[54][55][56], faith groups [57], community walking groups [58], and in secondary care clinics for hypertension [59], diabetes [60][61][62][63], cardiology [64,65], stroke [66], or general medicine [67,68]. Greater achievement of study blood pressure targets has also been demonstrated in workplace based interventions [14,69,70]. ...
... Physicians recognise the importance of addressing medication non-adherence but less often actually do so [90]. Many interventions include an element of education and lifestyle advice [56,60,64,67,71,74], or medication adherence support [48]. These elements coupled with regular review are key components of effective longterm care, to which the nurse-patient relationship is central [91]. ...
... There is marked variation in the frequency of face to face reviews of patients between trials, with greater reductions of systolic blood pressure for interventions that involve at least monthly contact until blood pressure reaches target (systolic reduction −7.2 mmHg (−10.5 to −3.9); 19 studies, 3760 participants) [29,37,46,47,54,55,58,59,61,64,68,72,74,77,80,81,83,84] By taking account of the interaction between the presence or absence of, and the frequency of, face to face to face interventions and the ability to change prescriptions, it is possible to demonstrate a hierarchy of effectiveness for nurse led interventions to lower blood pressure (Fig. 18.1; p < 0.001 for subgroup differences). Interventions without face to face contact, themselves ineffective on pooled analysis, are enhanced by the ability to alter medications. ...
Hypertension is predominantly detected and managed in primary or community care settings. Nurses are key members of the multidisciplinary primary care team and are commonly involved in measuring or managing blood pressure. Nurses undertake a range of tasks in hypertension care and many randomised controlled trials of different nurse led interventions have been conducted, providing evidence from different populations. There is good evidence to support better blood pressure outcomes when nurses deliver care face to face, but not remotely. Other important components of these complex interventions appear to be the inclusion of a structured care algorithm, ability to prescribe or alter medications, and maintaining contact at least monthly until blood pressure is controlled to target. There is limited reporting of the costs of interventions and evidence for cost-effectiveness of nurse led care compared to usual care is lacking. There is no clear evidence from longer term follow-up of the effect of nurse led interventions on cardiovascular outcomes. The design of programmes for nurse led care in hypertension should take account of the existing evidence and areas of uncertainty. Nurses generally work within teams and future studies of team approaches to hypertension, either including or led by nurses, are needed. Any future studies of nurse led care should include a robust cost-effectiveness analysis.
... This review comprises 2640 patients with CHD who were diagnosed with myocardial infarction or received revascularization. Four formats of nurse-led patient-centered care on secondary cardiac prevention were identified, which included case management (DeBusk et al., 1994;Hanssen et al., 2007Hanssen et al., , 2009Miller et al., 1988Miller et al., , 1989Miller et al., , 1990Mittag et al., 2006;Park et al., 2017;Vahedian-Azimi et al., 2016), booster session (Yates et al., 2005), transitional care (Zhao, 2004), and motivational interviewing (Cao et al., 2012;Kasteleyn et al., 2016;McHugh et al., 2001;Patja et al., 2012). Most included studies were underpinned from a conceptual framework, except for two articles that did not provide details of the framework (Cao et al., 2012;Zhao, 2004). ...
... Most included studies were underpinned from a conceptual framework, except for two articles that did not provide details of the framework (Cao et al., 2012;Zhao, 2004). The interventions were commonly provided at in-patient phase (Cao et al., 2012;DeBusk et al., 1994;Hanssen et al., 2007Hanssen et al., , 2009Miller et al., 1988Miller et al., , 1989Miller et al., , 1990Park et al., 2017;Vahedian-Azimi et al., 2016;Zhao, 2004) and combined with phone and face-to-face sessions (Cao et al., 2012;DeBusk et al., 1994;McHugh et al., 2001;Park et al., 2017;Vahedian-Azimi et al., 2016;Yates et al., 2005;Zhao, 2004). ...
... Regarding the control groups, the comparators of interest were usual care (Cao et al., 2012;DeBusk et al., 1994;Hanssen et al., 2007Hanssen et al., , 2009McHugh et al., 2001;Park et al., 2017;Vahedian-Azimi et al., 2016;Yates et al., 2005;Zhao, 2004), attention placebo (Kasteleyn et al., 2016;Mittag et al., 2006), or intervention featured with no discussion among health professionals on medical regime (Miller et al., 1988(Miller et al., , 1989(Miller et al., , 1990. One included study did not provide details of the usual care (Patja et al., 2012). ...
Background
Despite establishment of advocacies centered on using patient-centered care to improve disease-related behavioral changes and health outcomes, studies have seldom discussed incorporation of patient-centered care concept in the design of secondary cardiac prevention.
Objectives
This review aimed to identify, appraise, and examine existing evidence on the effectiveness of nurse-led patient-centered care for secondary cardiac prevention in patients with coronary heart disease.
Design
A systematic review of randomized controlled trials focusing on nurse-led patient-centered care for secondary cardiac prevention was conducted. Primary outcomes were behavioral risks (e.g. smoking, physical activity), secondary outcomes were clinically relevant physiological parameters (e.g. body weight, blood pressure, blood glucose, blood lipoproteins), health-related quality of life, mortality, and self efficacy.
Data sources
Twenty-three English and seven Chinese electronic databases were searched to identify the trials.
Review methods
The studies’ eligibility and methodological quality were assessed by two reviewers independently according to the Joanna Briggs Institute guidelines. Statistical heterogeneities of the included studies were assessed by Higgins I2 and quantitative pooling was performed when studies showed sufficient comparability.
Results
15 articles on 12 randomized controlled trials were included in this review. Methodological quality of the included studies was fair. Based on the Joanna Briggs Institute critical appraisal tool for experimental studies, the included studies had met a mean of six criteria out the ten in this appraisal tool. The meta-analyses of the included studies revealed that nurse-led patient-centered care had significantly improved patients' smoking habits, adherence toward physical activity advices, and total cholesterol level with medical regime optimization, in short- to medium-term. The intervention was also favorable in improving the patients' health-related quality of life in several domains of SF-36. Furthermore, from single-study results, the intervention was favorable in improving the patients' weight management and alcohol consumption. However, it did not show significant effects on improving the patient's dietary habits, certain cardiac physiological parameters, mortality and self-efficacy. Currently, no addition long-term benefit of the intervention on secondary cardiac prevention was identified.
Conclusion
This review has systematically analyzed the effects of nurseledpatient-centered care on patients' behavioral risks, cardiacphysiological parameters, mortality, health-related quality of life and self-efficacy. Given limited quantity of existing evidence regarding certain outcomes and long-term follow-up period; cross-trial heterogeneity of the interventions, measurement methods and statistical results; high or unclear risk of bias in some quality dimensions, the effectiveness of the intervention on secondary cardiac prevention remains inconclusive and subject to additional trials and evidences.
... The study design and participant information for all four studies are presented in Table 1. All four studies [50][51][52][53] used a pre-/post-test experimental controlled design, but only two randomised participants to study condition [50,51]. TAU control groups were used for comparison in all studies. ...
... The study design and participant information for all four studies are presented in Table 1. All four studies [50][51][52][53] used a pre-/post-test experimental controlled design, but only two randomised participants to study condition [50,51]. TAU control groups were used for comparison in all studies. ...
... McHugh and colleagues [51] invited all patients on a coronary bypass surgery waitlist to participate in their study over the 15 month study period. Of the 147 invited, 125 (85%) agreed to participate and 98 (78%) completed baseline and final follow ups. ...
... No studies that compared different methods for identifying and recruiting smokers for preoperative smoking cessation were identified. There were 18 randomised controlled trials (RCTs) [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] and 14 nonrandomised studies (NRS) [28][29][30][31][32][33][34][35][36][37][38][39][40][41]. The included studies were conducted in the USA (n = 10), Australia (n = 5), UK (n = 6), Denmark (n = 6), Canada (n = 4), and Sweden (n = 1). ...
... Eligible smokers were usually identified and recruited by dedicated research personnel. Smokers were identified from elective surgery waiting lists (or medical records) in six studies [11,14,16,17,39,40]. There was only one study in which the identification of smokers for preoperative smoking cessation was started at the point of referral in primary care [38]. ...
... Smokers were recruited at least 4 weeks before surgery in four of the six waiting list-based studies (67 %) and in only three of the 18 preoperative clinic-based studies (17 %) ( Table 1). In one study of patients awaiting coronary surgery, smokers were identified and recruited from elective surgery waiting lists many months (mean 8 months, standard deviation (SD) 2.7) before surgery [14]. In a recent study [40], smoking cessation materials (leaflets and quitline referral forms) were posted to all patients (smokers and non-smokers) at the time of waiting list placement (>4 weeks before surgery). ...
Background
Smoking cessation before surgery reduces postoperative complications, and the benefit is positively associated with the duration of being abstinent before a surgical procedure. A key issue in providing preoperative smoking cessation support is to identify people who smoke as early as possible before elective surgery. This review aims to summarise methods used to identify and recruit smokers awaiting elective surgery.
Methods
We searched MEDLINE, EMBASE, CINAHL, and PsycINFO, and references of relevant reviews (up to May 2014) to identify prospective studies that evaluated preoperative smoking cessation programmes. One reviewer extracted and a second reviewer checked data from the included studies. Data extracted from included studies were presented in tables and narratively described.
Results
We included 32 relevant studies, including 18 randomised controlled trials (RCTs) and 14 non-randomised studies (NRS). Smokers were recruited at preoperative clinics (n = 18), from surgery waiting lists (n = 6), or by general practitioners (n = 1), and the recruitment methods were not explicitly described in seven studies. Time points of preoperative recruitment of smokers was unclear in four studies, less than 4 weeks before surgery in 17 studies, and at least 4 weeks before surgery in only 11 studies. The recruitment rate tended to be lower in RCTs (median 58.2 %, range 9.1 to 90.9 %) than that in NRS (median 99.1 %, range 12.3 to 100 %) and lower in preoperative clinic-based RCTs (median 54.4 %, range 9.1 to 82.4 %) than that in waiting list-based RCTs (median 70.1 %, range 36.8 to 85.0 %). Smokers were recruited at least 4 weeks before surgery in four of the six waiting list-based studies and in only three of the 18 preoperative clinic-based studies.
Conclusions
Published studies often inadequately described the methods for recruiting smokers into preoperative smoking cessation programmes. Although smoking cessation at any time is beneficial, many programmes recruited smokers at times very close to scheduled surgery so that the benefit of preoperative smoking cessation may have not been fully effected. Optimal delivery of preoperative smoking cessation remains challenging, and further research is required to develop effective preoperative cessation programmes for smokers awaiting elective operations.
Electronic supplementary material
The online version of this article (doi:10.1186/s13643-015-0152-x) contains supplementary material, which is available to authorized users.
... The study design and participant information for all four studies are presented in Table 1. All four studies [50][51][52][53] used a pre-/post-test experimental controlled design, but only two randomised participants to study condition [50,51]. TAU control groups were used for comparison in all studies. ...
... The study design and participant information for all four studies are presented in Table 1. All four studies [50][51][52][53] used a pre-/post-test experimental controlled design, but only two randomised participants to study condition [50,51]. TAU control groups were used for comparison in all studies. ...
... McHugh and colleagues [51] invited all patients on a coronary bypass surgery waitlist to participate in their study over the 15 month study period. Of the 147 invited, 125 (85%) agreed to participate and 98 (78%) completed baseline and final follow ups. ...
Preoperative alcohol use is associated with an increase in postoperative morbidity and mortality. Short-term abstinence prior to elective surgery has been shown to reduce postoperative risks. Therefore, behavioural intervention (BI) targeting risky drinking may have significant utility in preventing surgical complications.
The literature was systematically reviewed to identify the scope and outcomes of BIs aiming to reduce alcohol use in risky drinkers before they underwent surgery. Five databases were searched using PRISMA criteria. Of 1243 studies identified, four met pre-established inclusion criteria: (i) implementation of a BI prior to an elective surgery; (ii) the BI-targeted alcohol use among risky drinkers; and (iii) printed in English.
Two studies indicated significant reductions in alcohol use at follow ups, and one study demonstrated reductions in postoperative risks. These findings are encouraging, but in light of methodological limitations, the efficacy of preoperative BIs for risky drinking could not be determined.
Future efforts to screen and implement BIs addressing alcohol use in preoperative patients should carefully define risky drinking, allow ample time for recruitment prior to surgery, implement empirically supported interventions, examine the impact of relevant covariates, and consider the statistical power needed to detect change in postoperative complications.
Given the strong link between preoperative alcohol use and postoperative risks, additional research on preoperative BIs is critically needed. Existing research suggests several promising directions for research that may enhance future intervention efforts with this high-risk population. [Fernandez AC, Claborn KR, Borsari B. A systematic review of behavioural interventions to reduce preoperative alcohol use. Drug Alcohol Rev 2015].
© 2015 Australasian Professional Society on Alcohol and other Drugs.
... Ten studies met all the inclusion criteria (Table l). [22][23][24][25][26][27][28][29][30][31] Their methodological quality in terms of the Jadad criteria 32 of randomization, blinding and reports of losses to follow-up was generally good. However, the nature of a health promotion intervention meant patients could not be blind as to whether or not they received it, and it was often difficult for the outcome assessors to remain blind. ...
... 23 Most studies found that nurse-led management and cardiovascular health promotion without change in prescribing had little or no effect on blood pressure. [22][23][24][25][26][27][28][29][30][31] In the only trial to show an important difference, 30 patients with blood pressure outside the guidelines were referred to their GP for drug treatment. However, this was a small trial (n = 98), and was of poorer methodological quality with unblinded outcome assessment by the cardiac liaison nurse who conducted the intervention. ...
... 23 Most studies found that nurse-led management and cardiovascular health promotion without change in prescribing had little or no effect on blood pressure. [22][23][24][25][26][27][28][29][30][31] In the only trial to show an important difference, 30 patients with blood pressure outside the guidelines were referred to their GP for drug treatment. However, this was a small trial (n = 98), and was of poorer methodological quality with unblinded outcome assessment by the cardiac liaison nurse who conducted the intervention. ...
... Consequently, a total of six randomised controlled trials were included in the review. Three studies were carried out in the UK (McHugh et al. 2001, Shuldham et al. 2002, Goodman et al. 2008), two in Canada (Arthur et al. 2000, Watt-Watson et al. 2004) and one in Norway (Sørlie et al. 2007). As the individual trials differed considerably in interventions and outcome measures, it was decided not to pool results but synthesise them descriptively. ...
... However, the use of a strict intention-to-treat analysis was impossible in cases of missing data such as loss to follow-up, any withdrawals or noncompliers. Four trials did not use strict 'intention-to-treat' analysis and did not further explain how missing data and/or deviation from protocol were dealt with, although they provided information about the characteristics and reasons for withdrawals (Arthur et al. 2000, McHugh et al. 2001, Watt-Watson et al. 2004, Goodman et al. 2008. Exclusion of any withdrawn participants who have sustained severe side effects to the intervention will affect the results of a trial (Touloumi et al. 2001, Unnebrink & Windeler 2001, Abraha & Montedori 2010. ...
... The exception is Watt-Watson et al. (2004), who focused mainly on the importance of pain relief for recovery and pain relief methods. In three trials, the preoperative education intervention emphasised the provision of individualised information whereby patients were encouraged to express their questions and worries (Arthur et al. 2000, McHugh et al. 2001, Sørlie et al. 2007). ...
Aims and objectivesTo update evidence of the effectiveness of preoperative education among cardiac surgery patients.Background
Patients awaiting cardiac surgery may experience high levels of anxiety and depression, which can adversely affect their existing disease and surgery and result in prolonged recovery. There is evidence that preoperative education interventions can lead to improved patient experiences and positive postoperative outcomes among a mix of general surgical patients. However, a previous review suggested limited evidence to support the positive impact of preoperative education on patients' recovery from cardiac surgery.DesignComprehensive review of the literature.Methods
The Cochrane Central Register of Controlled Trials from the Cochrane Library, MEDLINE, CINAHL, PsycINFO, EMBASE and Web of Science were searched for English-language articles published between 2000–2011. Original articles were included reporting randomised controlled trials of cardiac preoperative education interventions.ResultsSix trials were identified and have produced conflicting findings. Some trials have demonstrated the effects of preoperative education on improving physical and psychosocial recovery of cardiac patients, while others found no evidence that patients' anxiety is reduced or of any effect on pain or hospital stay.Conclusion
Evidence of the effectiveness of preoperative education interventions among cardiac surgery patients remains inconclusive. Further research is needed to evaluate cardiac preoperative education interventions for sustained effect and in non-Western countries.Relevance to clinical practiceA nurse-coordinated multidisciplinary preoperative education approach may offer a way forward to provide a more effective and efficient service. Staff training in developing and delivering such interventions is a priority.
... Methodological reasons for excluding eight articles were unclear randomization in seven studies, no blinding (none of the three: patient, caregiver and researcher) in seven studies, five studies were underpowered and in one study there was no description of the outcomes. Finally, nine of the included studies (DeRiso et al., 1996;Furze et al., 2009;Gamberini et al., 2009;Hulzebos et al., 2006;Segers et al., 2008;Shuldham et al., 2002;Tepaske et al., 2001Tepaske et al., , 2007Watt-Watson et al., 2004) were of high quality (quality level A2) and the remaining fourteen studies were of fair quality (quality level B) (Arthur et al., 2000;Bay et al., 2008;Brasher et al., 2003;Calò et al., 2005;Garbossa et al., 2009;Goodman et al., 2008;Kshettry et al., 2006;Ku et al., 2002;Leserman et al., 1989;Mahler and Kulik, 1998;Marathias et al., 2006;McHugh et al., 2001;Stiller et al., 1994;Yá nez-Brage et al., 2009). Appendix E2 represents an overview of the methodological aspects of the 23 included studies. ...
... Additionally, these studies found an increase in postoperative physical activity . In fair quality studies (quality level B), interventions were identified that achieved a reduction in the occurrence of the following: depression (Goodman et al., 2008; Kshettry et al., 2006;Ku et al., 2002;Leserman et al., 1989); atrial fibrillation (Calò et al., 2005); postoperative pulmonary complications (Yá nez-Brage et al., 2009); length of hospital stay (Arthur et al., 2000;Goodman et al., 2008;Ku et al., 2002;Mahler and Kulik, 1998); length of intensive care unit stay (Arthur et al., 2000;Mahler and Kulik, 1998); high blood pressure (Brasher et al., 2003;Goodman et al., 2008;Kshettry et al., 2006;McHugh et al., 2001), high cholesterol and, high BMI McHugh et al., 2001); anger, fatigue, confusion and reduced vigor (Leserman et al., 1989); anxiety (Garbossa et al., 2009;Goodman et al., 2008;Ku et al., 2002;McHugh et al., 2001); high heart rate and pain Leserman et al., 1989); tension ; and cigarette smoking . Furthermore, these studies examined interventions that increased physical activity and quality of live (Arthur et al., 2000;Goodman et al., 2008;McHugh et al., 2001). ...
... Additionally, these studies found an increase in postoperative physical activity . In fair quality studies (quality level B), interventions were identified that achieved a reduction in the occurrence of the following: depression (Goodman et al., 2008; Kshettry et al., 2006;Ku et al., 2002;Leserman et al., 1989); atrial fibrillation (Calò et al., 2005); postoperative pulmonary complications (Yá nez-Brage et al., 2009); length of hospital stay (Arthur et al., 2000;Goodman et al., 2008;Ku et al., 2002;Mahler and Kulik, 1998); length of intensive care unit stay (Arthur et al., 2000;Mahler and Kulik, 1998); high blood pressure (Brasher et al., 2003;Goodman et al., 2008;Kshettry et al., 2006;McHugh et al., 2001), high cholesterol and, high BMI McHugh et al., 2001); anger, fatigue, confusion and reduced vigor (Leserman et al., 1989); anxiety (Garbossa et al., 2009;Goodman et al., 2008;Ku et al., 2002;McHugh et al., 2001); high heart rate and pain Leserman et al., 1989); tension ; and cigarette smoking . Furthermore, these studies examined interventions that increased physical activity and quality of live (Arthur et al., 2000;Goodman et al., 2008;McHugh et al., 2001). ...
... 39 Dietary advice by a nurse-driven health educational program for patients on the waiting list for CS may be effective by improving physical status and reducing obesity. 69 A retrospective pilot study showed an improvement in hospital LOS with a low glycemic diet, which is a diet with carbohydrate that causes a lower and slower rise in blood glucose (BG) and insulin levels owing to their slower digestion, absorption, and metabolization. 67 Educational strategies that increase patients' involvement in their own care are needed, and the modification of eating patterns may play a role within the prehabilitation program. ...
... Therapeutic strategies Objectives and/or goals Increase physical activity (involve nurses and physiotherapist) 57À61, 63,69 Promote physical activity after evaluating physical reserve and the potential tolerance of it (i.e. clinical walking programs, home physical therapy) ...
The perioperative nutritional status of patients undergoing cardiac surgery influences outcomes; therefore nutritional support is essential for these patients. Owing to the lack of solid evidence, no protocols have been established for the nutritional management of this specific population, and most of the recommendations are based on other critically ill populations. In this review of the main studies performed in this population, the importance of preoperative evaluation of nutritional status, the management of nutritional support immediately after cardiac surgery, the influence of nutrition on outcomes, and the importance of nutrition after hospital discharge are discussed. In addition, the possible influence of glycemic control and pharmaconutrition in the outcomes of these patients are described briefly.
... The report by López et al. (16) focused on caregivers in which the majority of care was provided to persons living with dementia (80%).They found a 38% decrease in mean anxiety score in the Hospital Anxiety and Depression Scale (HADS) (154) for traditional format skills training (60 min weekly over a period of 8 weeks) involving cognitive behavioral approaches, assertiveness training, self-esteem building exercises, and problem-solving skills training. The other studies using the HADS found a 10-20% decrease in anxiety scores after intervention (17,18). The Williams (19) study of 71 women with breast cancer found no effect for a 20-min audiotape to teach skills for decreasing sleep, anxiety, and fatigue problems encountered during chemotherapy. ...
... Dropout rates of less than 20% were reported for all but two studies. Seven studies [five RCTs (17,(35)(36)(37)(38)(39) (38,40) found significant improvements in the mental health composite SF-36 measure (including vitality, mental health, and role limitation emotional). Significant improvements were demonstrated in two studies using emotional health subscales of quality of life-specific measures for older adults with heart failure (13, 22-25, 31, 35-38). ...
Purpose
Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults’ emotional health.
Methods
A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions – physical activity, social support, and skills training – given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness).
Results
In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention–outcome pairings yielded insufficient evidence.
Conclusion
Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area.
... It has already been shown that when such support is provided for patients awaiting CABG surgery, it is highly beneficial for their well-being and QoL. 21 In a randomized study described by McHugh et al 21 a cardiac nurse held a series of educational meetings for patients awaiting CABG surgery. This training was held in the patient's home or at the family doctor's office. ...
... The severity of depression can be reduced by providing psychotherapy before CABG surgery. 21 The research available shows that episodes of depression in patients suffering from CHD undergoing cardiac treatment increases the risk of morbidity and mortality. 12,13 Rates of major depressive disorder of around 15% have been reported in patients post myocardial infarction or CABG. ...
Surgical revascularization of the coronary arteries leads to changes in quality of life (QoL) for patients with coronary heart disease. The aim of this work was to monitor QoL, considering cognitive function, depression, and activities of daily living in elderly patients after coronary artery bypass grafting (CABG).
This study included 65 patients (29 women and 36 men) aged 61-74 years with stable coronary heart disease who underwent CABG. The control group included 29 women and 36 men aged 61-74 years who were not suffering from coronary heart disease. The questionnaires used in the study canvassed QoL (Nottingham Health Profile), cognitive function, depression, and basic and instrumental activities of daily living. The research was conducted before surgery and repeated 6 and 12 months after surgery.
QoL was comparable between women and men and was lower than in the control group (P<0.05). After CABG, the values for particular domains of QoL improved more in men than in women. There was a reduction in the severity of depression 6 months after surgery in men and 12 months after surgery in women.
Elderly patients with coronary heart disease have decreased QoL, which normalizes in men and improves in women after CABG.
... Way et al. (2001) ...
... The Tasks of Care Coordination Renders et al. (2001) ...
... The importance of QoL assessment in CR and recovery programs is well recognized [39]. Significant improvements in QoL as measured by the SF-36 have been demonstrated in other studies of angina patients awaiting cardiac surgery, however the intervention [40] was delivered over a longer time period and involved face-to face contact with the patient which may have affected results. Both groups in the current trial showed improved scores on some domains of the SF36 as had been reported in other groups with Acute Coronary Syndrome [41]. ...
... This trial, however, demonstrated a comparative reduction over 6 months in BMI for the AP group, both as a continuous and categorical variable. This supports findings of a previous trial which demonstrated improvement in BMI following an intervention delivered on average for a 9-month period for angina patients on the waiting list for by pass surgery [40]. The reduction in BMI in the current trial may have been enhanced by the increase in self-reported activity in the AP participants. ...
... The importance of QoL assessment in CR and recovery programs is well recognized [39]. Significant improvements in QoL as measured by the SF-36 have been demonstrated in other studies of angina patients awaiting cardiac surgery, however the intervention [40] was delivered over a longer time period and involved face-to face contact with the patient which may have affected results. Both groups in the current trial showed improved scores on some domains of the SF36 as had been reported in other groups with Acute Coronary Syndrome [41]. ...
... This trial, however, demonstrated a comparative reduction over 6 months in BMI for the AP group, both as a continuous and categorical variable. This supports findings of a previous trial which demonstrated improvement in BMI following an intervention delivered on average for a 9-month period for angina patients on the waiting list for by pass surgery [40]. The reduction in BMI in the current trial may have been enhanced by the increase in self-reported activity in the AP participants. ...
... Nurse-facilitated interventions were successfully shown to have reduced angina attacks, a number of physical disabilities and have reduced depression among the patients with CAD. In a trial conducted in Glasgow community practice clinics and in patients' homes compared to the usual care for patients who were awaiting open heart surgery, there was a significantly higher rate of patients who stopped smoking with a rate reduction of 25% in the nurse-led group as compared to only 2% in the control group [12]. Cholesterol levels as well as high blood pressure were also significantly reduced in the nurse intervention group showing a favorable outcome. ...
Coronary artery disease (CAD) is one among the major causes of mortality in patients all around the globe. It has been reported by the World Health Organization (WHO) that approximately 80% of cardiovascular diseases could be prevented through lifestyle modifications. Management of CAD involves the prevention and control of cardiovascular risk factors, invasive and non-invasive treatments including coronary revascularizations, adherence to proper medications and regular outpatient follow-ups. Nurse-led clinics were intended to mainly provide supportive, educational, preventive measures and psychological support to the patients, which were completely different from therapeutic clinics. Our review focuses on the involvement and implication of nurses in the primary and secondary prevention and management of cardiovascular diseases. Nurses have a vital role in Interventional cardiology. They also have major roles during the management of cardiac complications including congestive heart failure, atrial fibrillation and heart transplantation. Today, the implementation of a nurse-led tele-consultation strategy is also gaining positive views. Therefore, a nurse-led intervention for the management of patients with cardiovascular diseases should be implemented in clinical practice. Based on advances in therapy, more research should be carried out to further investigate the effect of nurse-led clinics during the long-term treatment and management of patients with cardiovascular diseases.
... These studies utilized similar interventionist and available exposure time to MI [17][18][19][20]24]. MI in addition to psychological treatments for anxiety, successfully reduces anxiety symptoms in populations that suffer from generalized anxiety and post-traumatic stress disorder in cardiac patients [35][36][37][38]. MI may not have been successful in these interventions because MI focuses on increasing the motivation for change and in regard to anxiety and depression motivation might not be the issue [39], but can be used to promote adherence to other treatment options [40]. ...
... 50 Whether weight loss before cardiac Nurse-led community-based programs involving educational and motivational interviews appear to confer benefits in reducing risk factors preoperatively. 11 In Class III obese patients awaiting bariatric surgery, a very-low-calorie ketogenic diet (VLCKD) (comprising <20-30 g carbohydrates per day) for 3 weeks before surgery demonstrated benefit in terms of reduced drain output and improved postoperative hemoglobin levels compared with a lowcalorie diet alone. 53 The utility of a VLCKD in obese cardiac surgery ...
Background
Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery.
Aim
This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients.
Methods
The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed.
Conclusions
Data presented identified the benefits of preoperative respiratory muscle training, off‐pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.
... 22 All studies had mixed-gender groups except three trials being males-only. 22,42,43 The studies originated from Canada (n = 5), 25,[44][45][46][47] China (n = 3), 41,48,49 United Kingdom (n = 3), 24,50,51 United States (n = 3), 22,42,43 Iran (n = 2), 19,52 and had one study each from Austria, 53 Brazil, 21 Germany, 54 Hong Kong, 23 Norway, 20 and Turkey. 55 Most RCTs had participants undergoing exclusive CABG surgery (n = 14), receiving face-to-face education (n = 16) with routine care as control group (n = 21). ...
Background:
Cardiac surgeries pose as an emotional experience for patients. Preoperative education is known to positively alter people's perceptions, emotions, and mitigate surgical distress. However, this intervention's effectiveness in improving perioperative outcomes among patients undergoing cardiac surgery lacked rigorous statistical synthesis and remains inconclusive.
Aims:
The aim was to synthesize the effectiveness of preoperative education on improving perioperative outcomes [anxiety, depression, knowledge, pain intensity, pain interference with daily activities, postoperative complications, length of hospitalization, length of intensive care unit (ICU) stay, satisfaction with the intervention and care, and health-related quality of life] among patients undergoing cardiac surgery.
Methods:
This systematic review and meta-analysis conducted a comprehensive search of nine electronic databases (PubMed, EMBASE, Scopus, MEDLINE, CINAHL, Cochrane CENTRAL, Web of Science, PsycINFO, and ERIC) and grey literature for randomized controlled trials examining the preoperative educational interventional effects on patients undergoing cardiac surgery from inception to 31 December 2020. The studies' quality was evaluated using Cochrane Risk-of-Bias Tool 1 (RoB1). Meta-analyses via RevMan 5.4 software synthesized interventional effects.
Results:
Twenty-two trials involving 3167 participants were included. Preoperative education had large significant effects on reducing post-intervention preoperative anxiety (P = 0.02), length of ICU stay (P = 0.02), and improving knowledge (P < 0.00001), but small significant effect sizes on lowering postoperative anxiety (P < 0.0001), depression (P = 0.03), and enhancing satisfaction (P = 0.04).
Conclusions:
This review indicates the feasibility of preoperative education in clinical use to enhance health outcomes of patients undergoing cardiac surgery. Future studies need to explore knowledge outcomes in-depth and more innovative technologies in preoperative education delivery.
... -The nurse led the shared care intervention that proved effective in improving relevant variables. 18 17 -The participants cited 5 sources of anxiety: chest pain, uncertainty, fear of the operation, physical disability and dissatisfaction with the care offered to them. 19 ...
Objetivo: descrever, com base na literatura, as contribuições das práticas educativas para o controle da ansiedade de pacientes em pré-operatório de cirurgia cardíaca. Método: trata-se de uma revisão integrativa realizada no período de novembro a dezembro de 2017 nas Bases de Dados PUBMED, BDENF – BIREME, SCIELO E MEDLINE, com a inclusão de 24 artigos que compuseram esse estudo. Resultados: Sobre o diagnóstico ansiedade, os artigos analisados mostraram maior presença no sexo feminino, em diferentes faixas etárias, mas mais prevalente em idades mais avançadas. Educação em saúde tem apresentado excelente resultados na diminuição da ansiedade, que uma vez realizada pelo enfermeiro, potencializa o cuidado. Conclusão: Processos educativos realizados no pré-operatório de cirurgia cardíaca, auxiliam para uma boa recuperação, pois com o envolvimento do paciente no processo, o tornará tranquilo e confortável.
... Las principales intervenciones que se encontraron fue la asesoría y la entrevista motivacional [8,11,12]; la asesoría acompañada de la consejería presenta buenos resultados en la disminución del nivel de depresión; así mismo, la entrevista motivacional como única intervención no demuestra buenos resultados, pero en compañía de la asesoría presenta óptimos resultados en la disminución de los niveles de depresión. La entrevista motivacional no se ha implementado en personas con diabetes y depresión; por lo que su uso ha sido para la actividad física, la dieta, malos hábitos alimenticios y el consumo de tabaco [17]; ha sido efectiva para disminuir los síntomas de ansiedad y depresión en personas que están en espera de cirugía cardiaca, aun así, fue acompañada con educación para la salud [18]. ...
Introducción: La Diabetes Tipo 2 (DT2), es considerada como la enfermedad crónica de mayor prevalencia; la depresión es una complicación atribuida a factores psicosociales, enfermeria tiene el papel de intervenir en ello y para ello es importante saber ¿Cuál es el efecto que producen las intervenciones de enfermería en salud mental en el nivel de depresión en personas con diabetes? Material y métodos: Revisión sistemática, de intervenciones de enfermeria para la depresión en personas con diabetes, se identificaron 8 artículos en diferentes bases de datos de enero del 2001 a mayo del 2019. Resultados: Las principales intervenciones que se encontraron fue la asesoría y la entrevista motivacional, teniendo efecto positivo en el nivel de depresión, la intervención psicosocial es igualmente efectiva. Las intervenciones encontradas tienen algunos elementos en común, 1. enfermería debía indagar como se sentía; 2. escuchar al paciente y 3. Guiar al paciente con la intervención. Conclusiones: Las intervenciones de enfermeria en salud mental disminuyen el nivel de depresión y los síntomas depresivos en personas con diabetes, además de tener impacto de forma positiva en la calidad de vida, la ansiedad, el control glucémico, la autoeficacia, el afrontamiento y el estrés.
... and there is evidence that support programs can mitigate this vulnerability 46 . Despite this, there are currently no formalized preoperative interventions in place to promote healthy lifestyle behaviors in the healthcare system. ...
... The health of patients not assigned to the treatment intervention deteriorated as assessed by outcome measures. 275 One RCT provided audio-taped information on strategies to deal with expected physical sensations and their management following CABG. This tape was listened to in the ward on the fourth or fifth postoperative day and was taken home by the patient. ...
... The health of patients not assigned to the treatment intervention deteriorated as assessed by outcome measures. 290 one RCT provided audio-taped information on strategies to deal with expected physical sensations and their management following CABG. This tape was listened to in the ward on the fourth or fifth postoperative day and was taken home by the patient. ...
In 2005-6 I was surgical senior editor of the SIGN Guidelines. This guideline was superseded by guideline 151. The recorded prevalence of angina varies greatly across UK studies. The Scottish Health Survey (2003) reports the prevalence of angina, determined by the Rose Angin questionnaire to be 5.1% and 6.7% in males aged 55-64 and 65-74 respectively. For the same age groups in women the equivalent rates were 4% and 6.8%. This compares with general practitioner (GP) record data in the British Regional Heart Study from across the UK of 9.2% and 16.2% for men in the same age groups. The average GP will see, on average, four new cases of angina each year. Practice team information submitted by Scottish general practices to Information Services Division (ISD) Scotland allows the calculation of an annual prevalence rate for Scotland (the proportion of the population who have consulted their general practice because of a definite diagnosis of angina based on ISD’s standard morbidity grouping). In the year ending March 2005 the annual prevalence rate is given as 8.3 for men and 7.6 for women per 1,000 population. This equates to an estimated number of patients seen in Scotland in that year for angina of 42,600 with 68,200 patient contacts. A diagnosis of angina can have a significant impact on the patient’s level of functioning. In one survey, angina patients scored their general health as twice as poor as those who had had a stroke. In another survey, patients had a low level of factual knowledge about their illness and poor medication adherence. A Tayside study showed that in patients with angina, symptoms are often poorly controlled, there is a high level of anxiety and depression, scope for lifestyle change and an ongoing need for frequent medical contact.
... These all require ongoing nurse intervention over time. However, there are also data to support a single or limited time point intervention of nurse-directed education prior to cardiac surgery [31,32], but no data are available on its effect in patients undergoing catheter ablation for atrial fibrillation. ...
Atrial Fibrillation (AF) is a common condition associated with impaired quality of life (QOL) and recurrent hospitalisation. Catheter ablation for AF is a well-established treatment for symptomatic patients despite medical therapy. We sought to examine the effect of point specific nurse-led education on QOL, AF symptomatology and readmission rate post AF ablation.
Forty-one patients undergoing AF ablation were randomised to Nurse Intervention (NI) versus Control (C), n=22 vs. 19. Both groups were well matched with respect to age, sex and AF subtype. All patients completed SF36 and AF Symptom Checklist, Frequency and Severity Scale questionnaires at baseline and six months post ablation. The NI group underwent nurse education on admission, prior to discharge, and with telephone contact.
Baseline SF-36 and AF Symptom Checklist, Frequency and Severity scores were similar. The NI group showed significant differences compared to Control with respect to higher QOL on the SF-36 score of Physical Functioning and Vitality at six months. There were significant improvements in seven components of the AF Symptom Checklist, Frequency and Severity at six months in the NI group with a trend in a further seven. There was no difference in AF related hospital readmissions at six months between C and NI groups (10.5% vs. 13.6%, p=ns).
Nurse-led education at time of AF ablation is associated with improved QOL and reduced symptom frequency and severity compared to usual care.
... Proučavajući reakcije pacijenata koji čekaju kardiokirurški zahvat, u Kanadi je zabilježena česta pojavnost depresije i anksioznosti koje dovode do povećanja učestalosti i intenzieta boli u prsima, dispneje, ishemije i infarkta miokarda. Nakon podjele bolesnika u dvije skupine: eksperimentalne -u kojoj je bilo 49, te kontrolne s 50 bolesnika, uzeti su podaci o njihovoj dobi, spolu, fizičkoj aktivnosti, tjelesnoj masi, pretilosti, krvnom tlaku, konzumiranju duhanskih proizvoda i općem zdravstvenom stanju te prisutnosti anksioznosti i depresije [12]. Također je pacijentima ponuđen Formanov upitnik kako bi se izjasnili o stupnju općeg zadovoljstva te zadovoljstva uslugama. ...
... Previous studies took advantage of the long waiting time for surgery to deliver longer-term preoperative education, the effectiveness of which remained controversial regarding anxiety. 43,57 Only one study showed that preoperative education increased the postoperative anxiety of patients. 44 Education focused on the individual needs of each patient, in conjunction with the opportunity given to the patients to express concerns, questions and fears, can probably mobilise mechanisms of anxiety reduction, associated with a sense of control that patients acquire through the educational process and the interpersonal relationship with nurses. ...
The effect of preoperative education on anxiety and postoperative outcomes of cardiac surgery patients remains unclear.
The aim of the study was to estimate the effectiveness of a nurse-led preoperative education on anxiety and postoperative outcomes.
A randomised controlled study was designed. All the patients who were admitted for elective cardiac surgery in a general hospital in Athens with knowledge of the Greek language were eligible to take part in the study. Patients in the intervention group received preoperative education by specially trained nurses. The control group received the standard information by the ward personnel. Measurements of anxiety were conducted on admission-A, before surgery-B and before discharge-C by the state-trait anxiety inventory.
The sample consisted of 395 patients (intervention group: 205, control group: 190). The state anxiety on the day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease in state score during the follow-up period was greater in the intervention group (P=0.001). No significant difference was found in the length of stay or readmission. Lower proportions of chest infection were found in the intervention group (10 (5.3) versus 1 (0.5); P=0.004). Multivariate linear regression revealed that education and score in trait anxiety scale on admission are independent predictors of a reduction in state anxiety.
Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients undergoing cardiac surgery, but it was not effective in reducing readmissions or length of stay.
© The European Society of Cardiology 2015.
... Discharge teaching and counselling are one of the important nursing roles. McHugh et al. [20] noted that a program including health teaching and counselling provided by a nurse based on individual requirements reduces the anxiety and depression levels of patients who are awaiting CABG surgery. During the study, it was observed that intervention group patients were very willing to ask questions and learn about the CABG surgery and its intended results. ...
Background: In this study we evaluate the effect of discharge teaching and counselling on anxiety and depression levels of patients undergoing coronary artery bypass graft surgery. Methods: Hundred and nine patients were included in this quasi-experimental survey study and divided into two groups as; the intervention group (n=57) and the control group (n=52). Patients in the intervention group were given planned discharge teaching and counselling by the research nurse beginning from hospitalization while the patients in the control group did not receive planned discharge teaching and counselling other than the routine clinical procedures. The patient data were collected using the "Personal Information Form" and the Hospital Anxiety and Depression Scale. The anxiety and depression levels of the patients in the control and intervention groups were measured on the day of their admission to the hospital, on the day of discharge and one week and one month after discharge using the Hospital Anxiety and Depression Scale. Results: It was found that the mean anxiety and depression scores of the patients in the intervention group were lower than in the control group at the time of discharge and one week and one month after discharge. Conclusion: Discharge training and counselling service given to patients in the intervention group had a positive impact on alleviating the anxiety and depression they had. Therefore, the institutions may be recommended to support multidisciplinary patient training and counselling activities using the methods decribed in this study.
... Fidan et al (2007) report that the cost-effectiveness of cardiac rehabilitation is £1957 per life year gained. The benefits of CR for many other cardiac conditions has also been demonstrated (McHugh et al, 2001;Clarke, 2009;Thompson and Clark, 2009;Rideout et al, 2012) and it is now generally accepted that CR is appropriate after hospital admission for a cardiac diagnosis (e.g. MI, acute coronary syndrome, cardiac surgery or angioplasty, defibrillator implant, cardiac transplantation), and after any step change in a cardiac condition (e.g. ...
Nurses play a key role in leading and delivering cardiac rehabilitation within multidisciplinary teams, and continually face new challenges. However, one aspect of service delivery that remains a particular issue and challenge within many cardiac rehabilitation services is poor patient uptake of phase 3 cardiac rehabilitation programmes. Although there are a variety of factors that may affect uptake, it has been identified that despite efforts lack of equal access for sub groups of patients such as women, those from socio-economically deprived groups, ethnic minority groups and the elderly, remains an issue. This article provides a review of the literature exploring the existing issues affecting attendance within these groups, and offers some recommendations for local changes in service delivery to overcome some of the identified barriers to non- engagement or early drop out from programmes. The aim of the article is to discuss ways in which nurses can strengthen the person-centred approach to identify ways of improving uptake further in these hard-to-reach groups.
... Los autores atribuyen estos resultados al hecho de que los profesionales del grupo control pueden haber tomado los elementos básicos de EM, y los médicos formados en EM utilizaron menos de 2 de cada 3 consultas previstas. El seguimiento de este estudio a 5 años revelará si la EM tiene efectos durante un periodo de tiempo más largo.McHugh et al.41 estudiaron la efectividad de un programa de cuidado compartido dirigido por enfermeras para mejorar los FRCV y el estado de salud en los pacientes en espera de cirugía de revascularización coronaria. En comparación con los pacientes que recibieron la atención habitual, los participantes del programa probado mejoraron en el manejo de los FRCV, la ansiedad y la depresión, así como en la percepción de su estado de salud.En el estudio de Kreman et al.42 se examinan los efectos de una intervención telefónica basada en EM en personas con hiperlipidemia. ...
The motivational interview has been widely used as a clinical method to promote behavioural changes in patients, helping them to resolve their ambivalence to obtain their own motivations. In the present article, a review is made of the main meta-analyses and systematic and narrative reviews on the efficacy of the motivational interview in the primary health care environment.
Copyright © 2012 Elsevier España, S.L. All rights reserved.
... Los autores atribuyen estos resultados al hecho de que los profesionales del grupo control pueden haber tomado los elementos básicos de EM, y los médicos formados en EM utilizaron menos de 2 de cada 3 consultas previstas. El seguimiento de este estudio a 5 años revelará si la EM tiene efectos durante un periodo de tiempo más largo.McHugh et al.41 estudiaron la efectividad de un programa de cuidado compartido dirigido por enfermeras para mejorar los FRCV y el estado de salud en los pacientes en espera de cirugía de revascularización coronaria. En comparación con los pacientes que recibieron la atención habitual, los participantes del programa probado mejoraron en el manejo de los FRCV, la ansiedad y la depresión, así como en la percepción de su estado de salud.En el estudio de Kreman et al.42 se examinan los efectos de una intervención telefónica basada en EM en personas con hiperlipidemia. ...
The motivational interview has been widely used as a clinical method to promote behavioural changes in patients, helping them to resolve their ambivalence to obtain their own motivations. In the present article, a review is made of the main meta-analyses and systematic and narrative reviews on the efficacy of the motivational interview in the primary health care environment.
... These factors undoubtedly contributed to the substantial variability in TUG scores, and most likely attenuated the magnitude of the associations observed. Inter-rater reliability of the TUG has been reported to be excellent in other studies (r ≥ 0.92) [17,[70][71][72][73], although inexperience of the raters was associated with lower inter-rater reliability (r = 0.87) [7]. Our survey team was well trained, which should have minimized the degree of variability introduced due to inter-rater factors. ...
Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.
Background
Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery.
Methods
Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes.
Results
A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08–1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14–1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70–2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06–1.23]).
Conclusions
Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.
This literature review analyzes 418 articles from 2 periods (2000-2010 and 2011-2017) to provide interpretative guidelines for the change in physical (PCS) and mental component summaries (MCS) of well-established patient-reported measures (MOS SF-36 V1, HOS SF-12, VR-36, and VR-12). The magnitude of the intervention effects was calculated using baseline and follow-up data. Results were similar across the 2 periods, although the effects of social and behavioral interventions are less consistent and are smaller for PCS. Both single interventions and multicomponent interventions met the moderate to large effect size criterion for PCS and MCS.
Background:
Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.
Objectives:
To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.
Search methods:
We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.
Selection criteria:
Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.
Data collection and analysis:
Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).
Main results:
Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I2 = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.
Authors' conclusions:
There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.
Background:
The admission and assessment of patients for elective procedures is a task faced by all healthcare organisations that provide elective surgical services. Several different strategies have been used to facilitate the management of these tasks. Nurse-led preadmission clinics or services have been implemented in many health services as one of these management strategies; however their effectiveness has not been established.
Objectives:
The objective of this review was to examine the available research on the effectiveness of nurse-led elective surgery preoperative assessment clinics or services on patient outcomes.
Inclusion criteria:
Types of participants The review considered studies that included adult or paediatric patients who were undergoing any type of elective surgical procedure, either as a day-only case or as an inpatient.Types of interventions The review considered studies that evaluated the effect of attending or receiving the services of a nurse-led elective surgery outpatient preadmission or preoperative assessment clinic.Types of outcomes This review considered studies that included the following outcome measures: length of stay, cancellation of surgery, incidence of non-attendance for scheduled surgery, mortality, morbidity, adverse surgical events, preoperative preparation, recognition and fulfilment of postoperative care needs, patient anxiety and reducing the number of overnight stays for day or ambulatory surgery patients.Types of studies The review considered any randomised controlled trials published after 1999; in the absence of RCTs other research designs, such as non-randomised controlled trials and before and after studies, were considered for inclusion in a narrative summary to enable the identification of current best evidence regarding the effectiveness of nurse-led preoperative assessment services.
Exclusion criteria:
This review excluded studies of preoperative education as this has been the subject of a previous review. We also excluded studies of emergency admissions. Additionally, studies comparing nurse-led with physician-led preadmission assessments were excluded as that has also been the subject of a previous systematic review.
Search strategy:
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilised in each component of this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies.
Methodological quality:
Papers selected for retrieval were assessed by two independent reviewers for congruence to the review's inclusion criteria, using a tool developed for the purpose. Methodological validity was assessed by two reviewers prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
Data collection/extraction:
Data were extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI.
Data synthesis:
Due to the methodological heterogeneity of the included studies, no statistical pooling was possible and all results are presented narratively.
Results:
Of the 19 included articles, there were 10 audits of patient and hospital data, 3 surveys or questionnaires, 3 descriptive studies, 1 action research design, 1 prospective observational study and 1 RCT. Five of ten studies reporting data on cancellations rates found that nurse-led preadmission services reduced the number of day-of-surgery cancellations. Non-attendance for surgery was also reduced, with nine studies reporting decreases in the number of patients failing to attend. Eight studies reporting data on patient or parent satisfaction found high levels of satisfaction with nurse-led preadmission services. Three of four studies investigating the effect of the nurse-led preadmission service on patient anxiety found a reduction in reported anxiety levels. Three studies found that preoperative preparation was enhanced by the use of a nurse-led preadmission service.
Conclusions:
While all included studies reported evidence of effectiveness for nurse-led preadmission services on a wide range of outcomes for elective surgery patients, the lack of experimental trials means that the level of evidence is low, and further research is needed.
Implications for practice:
Nurse-led preadmission services may be an effective strategy for reducing procedural cancellations, failure to attend for procedures, and patient anxiety, however currently the evidence level is low.
Implications for research:
Currently the overall level of evidence regarding nurse-led preadmission services is low and further more rigorous studies are required for all the examined outcomes. There is little evidence regarding the effect of this intervention on length of stay, mortality rates and morbidity, and therefore more research is needed on the effect of nurse-led preadmission services on these important outcomes.
To determine the impact of nurse practitioners' counselling on reducing cardiovascular risk factors in patients participating in routine preventive check-ups.
A new model of 'renewed' family practice was introduced in Slovenia as a pilot project in 2011, in which nurse practitioners are included in a team carrying out preventive activities and managing patients with stable chronic diseases.
A retrospective cohort study.
This study was conducted in 16 family medicine practices (eight renewed and eight regular family practices). In each family practice, a systematic sample was selected of registered patients participating in a cardiovascular preventive check-up. Data on sex, age, blood pressure, cholesterol, blood sugar, smoking, level of physical activity and cardiovascular risk were collected. Patients attending renewed family practices received counselling on risk factors from nurse practitioners (test group), and patients attending regular family practices received counselling from family physicians (control group). Data were collected again at least one and no more than five years after the baseline consultation.
There were 128 patients in the test group and 129 patients in the control group. At the control visit, the patients counselled by nurse practitioners had significantly lower levels of systolic blood pressure and cholesterol and practiced regular physical activity significantly more often than patients counselled by family physicians.
Nurse practitioners can be at least as successful as physicians when counselling patients on cardiovascular risk factors during their preventive check-ups.
This study showed that nurse practitioners have an important role in managing patients at the primary care level.
© 2015 John Wiley & Sons Ltd.
Background:
Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking.
Objectives:
To determine whether or not motivational interviewing (MI) promotes smoking cessation.
Search methods:
We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014.
Selection criteria:
Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation.
Data collection and analysis:
We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.
Main results:
We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.
Authors' conclusions:
Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.
Background:
Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.
Objectives:
To determine the effectiveness of nursing-delivered smoking cessation interventions.
Search methods:
We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.
Selection criteria:
Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.
Data collection and analysis:
Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).
Main results:
Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.
Authors' conclusions:
The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.
This article reviews and assesses the existing research literature on the efficacy of motivational interviewing (MI) to promote lifestyle changes and improve functioning among older adults confronting serious health challenges. A comprehensive literature review was conducted of intervention studies that tested the use of MI to achieve behavioral change among older adults with acute and chronic illnesses. Although limited in number, the studies revealed a significant improvement in physical activity, diet, cholesterol, blood pressure and glycemic control, and increased smoking cessation following MI. MI and its derivatives can be useful in dealing with a range of health issues faced by older adults. Further research to extend findings and address methodological issues is recommended. The integration of MI into social work courses focused on practice with older adults should be considered.
There has been much role expansion in nursing in the last two decades, with advanced nurses now performing minimally invasive surgery such as central venous access device insertion. However, there is a lack of research exploring the perceptions of nurses performing these procedures. This study explored the lived experiences of nurses who perform minimally invasive surgery, namely central venous access device insertion. Three key themes emerged from this analysis:stress associated with the unpredictable nature of the procedure,coping with responsibility and a patient-focused approach. Although the practitioners experience a degree of stress in the role, they also experience job satisfaction and feel that their roles have a positive impact on the patients in their care. The study findings provide information to managers and nurses performing these roles, and suggest how stress and burnout can be prevented.
MEDLINE, Cochrane, EMBASE και CINAHL έως το 2006 χρησιμοποιώντας ως λέξεις-κλειδιά τους όρους ("myocardial ischemia" [MeSH], "coronary disease" [MeSH], "smoking cessation" [MeSH]), "nicotine-bupropion-antidiprease", ("randomized controlled trial" [MeSH] ή "controlled clinical trial" [MeSH]). Εντάχθηκαν οι μελέτες που αφο-ρούσαν στην αξιολόγηση της αποτελεσματικότητας διακοπής του καπνίσματος, με φαρμακευτικά ή μη μέσα σε ασθενείς με στεφανιαία νόσο. Από το σύνολο των 16 μελετών που εισήχθησαν στην ανασκόπηση 4 αφορούσαν σε φαρμακευτική και 12 σε μη φαρμακευτική παρέμβαση. Μολονότι για τα επιθέματα νικοτίνης δεν μπορούν να προκύψουν αξιόλογα συμπεράσματα, φαίνεται ότι η χρήση bupropion είναι αποτελεσματική και ασφαλής. Οι μη φαρμακευτικές παρεμβάσεις περιλαμ-βάνουν συμβουλές, συνοπτικές οδηγίες ή τροποποίηση και άλλων παραγόντων κινδύνου. Φαίνεται ότι η ενδονοσοκομειακή έναρξη οποιασδήποτε παρέμβασης, φαρμακευτικής ή μη, με συγκεκριμένο πρόγραμμα στο οποίο συμμετέχει ιατρός ή νοσηλευτής και η παρακολούθηση όταν συνεχίζεται έως και 6 μήνες μετά στην κοινότητα, έχει σημαντική αποτελεσματικότητα στη διακοπή του καπνίσματος. Λέξεις ευρετηρίου: Διακοπή καπνίσματος, στεφανιαία νόσος
Objective: To determine whether the priority given to patients referred for cardiac surgery is associated with socioeconomic status.Design: Retrospective study with multivariate logistic regression analysis of the association between deprivation and classification of urgency with allowance for age, sex, and type of operation. Multivariate linear regression analysis was used to determine association between deprivation and waiting time within each category of urgency, with allowance for age, sex, and type of operation.Setting: NHS waiting lists in Scotland.Participants: 26 642 patients waiting for cardiac surgery, 1 January 1986 to 31 December 1997.Main outcome measures: Deprivation as measured by Carstairs deprivation category. Time spent on NHS waiting list.Results: Patients who were most deprived tended to be younger and were more likely to be female. Patients in deprivation categories 6 and 7 (most deprived) waited about three weeks longer for surgery than those in category 1 (mean difference 24 days, 95% confidence interval 15 to 32). Deprived patients had an odds ratio of 0.5 (0.46 to 0.61) for having their operations classified as urgent compared with the least deprived, after allowance for age, sex, and type of operation. When urgent and routine cases were considered separately, there was no significant difference in waiting times between the most and least deprived categories.Conclusions: Socioeconomically deprived patients are thought to be more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority.
To determine whether the priority given to patients referred for cardiac surgery is associated with socioeconomic status.
Retrospective study with multivariate logistic regression analysis of the association between deprivation and classification of urgency with allowance for age, sex, and type of operation. Multivariate linear regression analysis was used to determine association between deprivation and waiting time within each category of urgency, with allowance for age, sex, and type of operation.
NHS waiting lists in Scotland.
26 642 patients waiting for cardiac surgery, 1 January 1986 to 31 December 1997.
Deprivation as measured by Carstairs deprivation category. Time spent on NHS waiting list.
Patients who were most deprived tended to be younger and were more likely to be female. Patients in deprivation categories 6 and 7 (most deprived) waited about three weeks longer for surgery than those in category 1 (mean difference 24 days, 95% confidence interval 15 to 32). Deprived patients had an odds ratio of 0.5 (0.46 to 0.61) for having their operations classified as urgent compared with the least deprived, after allowance for age, sex, and type of operation. When urgent and routine cases were considered separately, there was no significant difference in waiting times between the most and least deprived categories.
Socioeconomically deprived patients are thought to be more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority.
To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease.
Randomised controlled trial of clinics over one year with assessment by self completed postal questionnaires and audit of medical records at the start and end of the trial.
Random sample of 19 general practices in northeast Scotland.
1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound.
Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up.
Health status measured by the SF-36 questionnaire, chest pain by the angina type specification, and anxiety and depression by the hospital anxiety and depression scale. Use of health services before and during the study.
There were significant improvements in six of eight health status domains (all functioning scales, pain, and general health) among patients attending the clinic. Role limitations attributed to physical problems improved most (adjusted difference 8.52, 95% confidence interval 4.16 to 12. 9). Fewer patients reported worsening chest pain (odds ratio 0.59, 95% confidence interval 0.37 to 0.94). There were no significant effects on anxiety or depression. Fewer intervention group patients required hospital admissions (0.64, 0.48 to 0.86), but general practitioner consultation rates did not alter.
Within their first year secondary prevention clinics improved patients' health and reduced hospital admissions.
This study examined the relations among the triggers of ischemia during the activities of daily life, mental stress-induced ischemia in the laboratory and functional severity of ischemia on exercise testing.
Myocardial ischemia is readily induced with exercise testing, but most episodes of ischemia in daily life occur during relatively sedentary activities. Although mental and emotional arousal are known to trigger myocardial ischemia, mental stress testing induces ischemia in only approximately 50% of patients with active coronary disease. It is not known whether such patients are particularly susceptible to nonexertional ischemia during daily activity.
We studied 45 men (mean age +/- SD 58 +/- 9 years) with coronary artery disease by means of 48-h Holter ambulatory electrocardiography for ST segment analysis and quantification of physical and mental activity with a structured diary system. These data were cross-tabulated with new left ventricular dyssynchrony (detected on two-dimensional echocardiography) induced by two mental stressors and by bicycle exercise.
During mental stress testing, 24 patients (53%) (Group I) had a new wall motion abnormality; the other 21 patients (Group II) did not. The average wall motion dyssynchrony score increased from 1.20 +/- 0.29 to 1.34 +/- 0.36 (p = 0.001), but the increase was less than that with exercise stress (1.52 +/- 0.41, p = 0.001). The total duration of ischemia during sedentary activities was greater in Group I (22.9 +/- 24.5 min) than in Group II (3.6 +/- 3.9 min, p = 0.025). Group I had more ischemic events while sedentary (23 of 290 diary entries) than did Group II (8 of 256 diary entries, p = 0.015). The magnitude of dyssynchrony with mental stress and the number of mental stressors capable of triggering ischemia were related to severity of ischemia with exercise.
Patients with ischemia during mental stress testing also have increased ischemia during sedentary activities in daily life. This finding may reflect greater functional severity of coronary artery disease or a propensity toward coronary vasoconstriction while sedentary.
Several important new issues have arisen in the management of patients with hypertension. A working party of the British Hypertension Society has therefore reviewed available intervention studies on anti-hypertensive treatment and made recommendations on blood pressure thresholds for intervention, on non-pharmacological and pharmacological treatments, and on treatment goals. This report also provides guidelines on blood pressure measurement, essential investigations, referrals for specialist advice, follow up, and stopping treatment.
To assess anxiety, depression, and social adjustment in patients awaiting coronary artery bypass surgery.
Patient completed questionnaire study.
Regional cardiothoracic centre.
109 questionnaires were sent to patients on the waiting list of two cardiothoracic surgeons. Sixty eight (62%) were returned and 15 (22%) of the respondents were women. There was no difference in the response rates for men (53/84) 63% and women (15/25) 60%.
Anxiety and depression were assessed by the hospital anxiety and depression (HAD) scale. Social functioning was assessed by several nine point rating scales on which patients indicated how their work, family relationships, social activities, private leisure activities, and home management were impaired. Patients also indicated the severity of their cardiac symptoms on a questionnaire based on the New York Heart Association classification for the assessment of the functional state of patients with heart disease.
On the HAD scale 19 (28%) patients scored in the clinically significant range for anxiety. Time spent on the waiting list was positively and significantly related to anxiety (p = 0.05). Thirty two (47%) patients scored in the clinically significant range for depression. Time spent on the waiting list was positively and significantly related to depression (p = 0.005). Positive and significant relations were found between time spent on the waiting list and impairment of work (p = < 0.0001), family relationships (p = < 0.0001), private leisure activities (p = < 0.0001), and social activities (p = 0.004). No correlation was found between any of the above variables and the indicated level of clinical symptoms.
This study documents previously unreported associations between the time patients wait for coronary artery surgery and levels of anxiety, depression, and social functioning. Conclusions regarding the causes of these symptoms cannot be made from this small population of patients but these results do suggest that these associations should be studied further.
To measure the potential for secondary prevention of coronary disease in the United Kingdom.
Cross sectional survey of a representative sample of coronary patients from a retrospective review of hospital medical records and patient interview and examination.
Stratified random sample of 12 specialist cardiac centres and 12 district general hospitals drawn from 34 specialist cardiac centres and 261 district general hospitals in 12 geographic areas in the United Kingdom.
2583 patients < or = 70 yr; 25 consecutive males and 25 consecutive females identified retrospectively in each of four diagnostic categories: coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute myocardial infarction, and acute myocardial ischaemia without evidence of infarction.
Risk factor recording and management in medical records; the prevalence and control of risk factors at interview six months after the procedure or event.
Recording of coronary risk factors in patient's records was incomplete and this varied by risk factor. Smoking habit and blood pressure were most completely recorded, whereas a history of hyperlipidaemia and blood cholesterol concentrations were least complete. Risk factor records were more likely to be complete in cardiac centres than in district hospitals. At interview 10% to 27% of patients were still smoking cigarettes and 75% remained overweight, females more severely so. Up to a quarter of patients remained hypertensive, males more severely so than females. Over three quarters had a total cholesterol > 5.2 mmol/l. In patients on medication for blood pressure, cholesterol or glucose, risk factor profiles were little better than in those who were not. Only about one patient in three was taking a beta blocker after infarction. Up to a fifth of patients who had had acute myocardial ischaemia were not taking aspirin at follow up.
There is considerable potential to reduce the risk of a further major ischaemic event in patients with established coronary disease. This can be achieved by effective lifestyle intervention, the rigorous management of blood pressure and cholesterol, and the appropriate use of prophylactic drugs.
To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain.
All patients were sent a postal questionnaire for symptom evaluation.
All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904).
88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing.
In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.
To determine the relative risk of myocardial ischemia triggered by specific emotions during daily life.
Relative risk was calculated by the recently developed case-crossover method, in which the frequency of a presumed trigger during nonischemic, or control, hours is compared with the trigger's frequency during ischemic, or case, hours. Outpatients at Duke University Medical Center, Durham, NC, underwent 48 hours of ambulatory electrocardiographic (ECG) monitoring with concurrent self-report measures of activities and emotions. Occurrences of negative emotions in the hour before the onset of myocardial ischemia were compared with their usual frequency based on all hours in which ischemia did not occur.
From a sample of 132 patients with coronary artery disease and recent evidence of exercise-induced ischemia who underwent 48 hours of ambulatory ECG monitoring, 58 patients exhibited ambulatory ischemia and were included in the analysis.
Myocardial ischemia during 48-hour ECG monitoring was defined as horizontal or downsloping ST-segment depression of 1 mm (0.1 mV) or more for 1 minute or longer compared with resting baseline. The ECG data were cross-tabulated with subjects' concurrent diary ratings of 3 negative emotions-tension, sadness, and frustration-and 2 positive emotions-happiness and feeling in contro-on a 5-point scale of intensity.
The unadjusted relative risk of occurrence of myocardial ischemia in the hour following high levels of negative emotions was 3.0 (95% confidence interval [CI], 1.5-5.9; P<.01) for tension, 2.9 (95% CI, 1.0-8.0; P<.05) for sadness, and 2.6 (95% CI, 1.3-5.1; P<.01) for frustration. The corresponding risk ratios adjusted for physical activity and time of day were 2.2 (95% CI, 1.1 -4.5; P<.05) for tension, 2.2 (95% CI, 0.7-6.4; P=.16) for sadness, and 2.2 (95% CI, 1.1-4.3; P<.05) for frustration.
Mental stress during daily life, including reported feelings of tension, frustration, and sadness, can more than double the risk of myocardial ischemia in the subsequent hour. The clinical significance of mental stress-induced ischemia during daily life needs to be further evaluated.
To evaluate whether nurse run clinics in general practice improve secondary prevention in patients with coronary heart disease.
Randomised controlled trial.
A random sample of 19 general practices in northeast Scotland.
1173 patients (685 men and 488 women) under 80 years with working diagnoses of coronary heart disease, but without terminal illness or dementia and not housebound.
Nurse run clinics promoted medical and lifestyle aspects of secondary prevention and offered regular follow up.
Components of secondary prevention assessed at baseline and one year were: aspirin use; blood pressure management; lipid management; physical activity; dietary fat; and smoking status. A cumulative score was generated by counting the number of appropriate components of secondary prevention for each patient.
There were significant improvements in aspirin management (odds ratio 3.22, 95% confidence interval 2.15 to 4.80), blood pressure management (5.32, 3.01 to 9.41), lipid management (3.19, 2.39 to 4.26), physical activity (1.67, 1.23 to 2.26) and diet (1.47, 1.10 to 1.96). There was no effect on smoking cessation (0.78, 0.47 to 1.28). Of six possible components of secondary prevention, the baseline mean was 3.27. The adjusted mean improvement attributable to intervention was 0.55 of a component (0.44 to 0.67). Improvement was found regardless of practice baseline performance.
Nurse run clinics proved practical to implement in general practice and effectively increased secondary prevention in coronary heart disease. Most patients gained at least one effective component of secondary prevention and, for them, future cardiovascular events and mortality could be reduced by up to a third.
To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infarction or angina.
Randomised controlled trial; stratified random allocation of practices to intervention and control groups.
All 67 practices in Southampton and south west Hampshire, England.
597 adult patients (422 with myocardial infarction and 175 with a new diagnosis of angina) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996.
Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up.
Serum total cholesterol concentration, blood pressure, distance walked in 6 minutes, confirmed smoking cessation, and body mass index measured at 1 year follow up.
Of 559 surviving patients at 1 year, 502 (90%) were followed up. There was no significant difference between the intervention and control groups in smoking (cotinine validated quit rate 19% v 20%), lipid concentrations (serum total cholesterol 5.80 v 5.93 mmol/l), blood pressure (diastolic pressure 84 v 85 mm Hg), or fitness (distance walked in 6 minutes 443 v 433 m). Body mass index was slightly lower in the intervention group (27.4 v 28.2; P=0.08).
Although the programme was effective in promoting follow up in general practice, it did not improve health outcome. Simply coordinating and supporting existing NHS care is insufficient. Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus.
To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease.
Cluster randomised controlled trial.
883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity.
Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity.
Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months.
Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation.
Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge.
Objective : To evaluate integrated care for asthma in clinical, social, and economic terms.
Design : Pragmatic randomised trial.
Setting : Hospital outpatient clinics and general practices throughout the north east of Scotland.
Patients : 712 adults attending hospital outpatient clinics with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%.
Main outcome measures : Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; pyschological aspects of health including perceived asthma control; patient satisfaction; and financial costs.
Results : After one year there were no significant overall differences between those patients receiving integrated asthma care and those receiving conventional outpatient care for any clinical or psycho-social outcome. For pulmonary function, forced expiratory volume was 76% of predicted for integrated care patients and 75% for conventional outpatients (95% confidence interval for difference -3.6% to 5.0%). Patients who had experienced integrated care were more likely to select it as their preferred course of future management (75% (251/ 333) v 62% (207/333) (6% to 20%); they saved pounds sterling 39.52 a year. This was largely because patients in conventional outpatient care consulted their general practioner as many times as those in integrated care, who were not also visiting hospital.
Conclusion : Integrated care for moderately severe asthma patients is clinically as effective as conventional outpatient care, cost effective, and an attractive management option for patients, general practioners, and hospital consultants.
Objective: To assess the needs of patients awaiting coronary bypass surgery. Design: Structured questionnaire Patients: 85 consecutive patients from south-west Scotland, who had coronary bypass surgery at the same cardiothoracic centre in Glasgow, and who had completed our post-bypass exercise programme. A total of 75 (88%) responded. Results: The median waiting time from angiography to surgery was four months. Forty per cent of patients had been told they midht die without surgery and a similar percentage were expecting to live longer as a result of their surgery. A total of 85% claimed their angina was interfering with daily activities in the run-up to their operation, and 62% experienced angina at rest during this time. Some 48% found the wait for surgery either moderately, very, or extremely stressful, and 75% felt that a pre-surgical programme would have been helpful. Conclusions: These results suggest that the needs of pre-surgical patients have been relatively neglected in south-west Scotland. Stress levels are high, as might be expected when patients are told they could die without intervention, and then have to wait some considerable time for their surgery. Demand for pre-surgical advice and support is high, but unlikely to pose too many difficulties for centres with pre-existing rehabilitation programmes.
A home-based exercise programme has been found to be as useful as a hospital-based one in improving cardiovascular fitness after an acute myocardial infarction. To find out whether a comprehensive home-based programme would reduce psychological distress, 176 patients with an acute myocardial infarction were randomly allocated to a self-help rehabilitation programme based on a heart manual or to receive standard care plus a placebo package of information and informal counselling. Psychological adjustment, as assessed by the Hospital Anxiety and Depression Scale, was better in the rehabilitation group at 1 year. They also had significantly less contact with their general practitioners during the following year and significantly fewer were readmitted to hospital in the first 6 months. The improvement was greatest among patients who were clinically anxious or depressed at discharge from hospital. The cost-effectiveness of the home-based programme has yet to be compared with that of a hospital-based programme, but the findings of this study indicate that it might be worth offering such a package to all patients with acute myocardial infarction.
The Coronary Artery Surgery Study (CASS) randomized 780 patients to an initial strategy of coronary surgery or medical therapy. Of medically randomized patients, 6% had surgery within 6 months and a total of 40% had surgery by 10 years. At 10 years, there was no difference in cumulative survival (medical, 79% vs. surgical, 82%; NS) and no difference in percentage free of death and nonfatal myocardial infarction (medical, 69% vs. surgical, 66%; NS). Patients with an ejection fraction of less than 0.50 exhibited a better survival with initial surgery treatment (medical, 61% vs. surgical, 79%; p = 0.01). Conversely, patients with an ejection fraction greater than or equal to 0.50 exhibited a higher proportion free of death and myocardial infarction with initial medical therapy (medical, 75% vs. surgical, 68%; p = 0.04) although long-term survival remained unaffected (medical, 84% vs. surgical, 83%; p = 0.75). There were no significant differences either in survival and freedom from nonfatal myocardial infarction, whether stratified on presence of heart failure, age, hypertension, or number of vessels diseased. Thus, 10-year follow-up results confirm earlier reports from CASS that patients with left ventricular dysfunction exhibit long-term benefit from an initial strategy of surgical treatment. Patients with mild stable angina and normal left ventricular function randomized to initial medical treatment (with an option for later surgery if symptoms progress) have survival equivalent to those patients randomized to initial surgery.
We studied survival rates among 767 men with good left ventricular function who participated in the European Coronary Surgery Study, 10 to 12 years after they were randomly assigned to either early coronary bypass surgery or medical therapy. At the projected five-year follow-up interval, we observed a significantly higher survival rate (+/- 95 percent confidence interval) in the group that was assigned to surgical treatment than in the group assigned to medical treatment (92.4 +/- 2.7 vs. 83.1 +/- 3.9 percent; P = 0.0001). During the subsequent seven years, the percentage of patients who survived decreased more rapidly in the surgically treated than in the medically treated group (70.6 +/- 5.8 vs. 66.7 +/- 5.3 percent at 12 years). Thus, the improvement in the survival rate among patients with stable angina who were treated surgically appears to have been attenuated after five years. However, the gradually diminishing difference between the two survival curves still favored surgical treatment after 12 years (P = 0.04), despite the fact that 136 patients in the medically treated group had coronary bypass surgery and 23 in the "surgically treated" group did not. The benefit of surgical treatment tended to be greater, but not significantly so, as assessed by interaction analysis in the subgroups of patients who were older or who had signs of ischemia or previous infarction on the resting electrocardiogram, a markedly ischemic response to exercise testing, peripheral arterial disease, an absence of hypertension, and proximal obstruction in the left anterior descending artery. The reasons for the loss of a beneficial effect of surgery after five years are unknown and merit further study.
Physical exertion is a well-documented trigger of transient myocardial ischemia in patients with coronary disease. More recently, studies have shown that mental stress may also be a cause of myocardial ischemia. The purpose of this study was to examine the relationship of physical activities and perceived mental states to myocardial ischemia while patients were going about their normal daily activities. Twenty-eight patients with documented coronary artery disease underwent ambulatory monitoring of the electrocardiogram. Physical activity and perceived mental status were recorded by patients in a diary which was then graded according to intensity of the activity. Analyses of the continuous electrocardiographic recordings were done separately from the analysis of the diaries. The time of each episode of ischemia, the duration of each episode in minutes and the number of episodes in each 24-hour period were calculated. A total of 372 episodes of ST-segment depression occurred in 912 hours of monitoring. Ischemic events occurring during usual physical and usual mental activities were most frequent (36%). Twenty-six percent of ischemic episodes occurred during increased physical activity, but usual mental activities. Interestingly, 22% of the ischemic events occurred at high levels of mental stress, but low physical activity. Ten percent of episodes occurred during sleep. Although the majority of events occurred during usual daily activities, when duration of ischemia was normalized for time spent in each category, increasing physical or mental activity was associated with an increasing duration of ischemia per unit (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Risk factors for major ischaemic heart disease (acute myocardial infarction or sudden death) have been investigated in a prospective study of 7735 men aged 40-59 years drawn from general practices in 24 British towns. After a mean follow-up of 4.2 years, there have been 202 cases of major ischaemic heart disease. Univariate estimates of the risk of ischaemic heart disease show that serum total cholesterol, HDL-cholesterol and triglyceride concentrations, systolic and diastolic blood pressures, cigarette smoking, and body mass index are all associated with increased risk of ischaemic heart disease. Evidence of ischaemic heart disease at initial examination is also strongly associated with increased risk of subsequent ischaemic heart disease. All these factors were then considered simultaneously using multiple logistic models. Definite myocardial infarction on electrocardiogram and recall of a doctor diagnosis of ischaemic heart disease remained predictive of subsequent major ischaemic heart disease, after allowance for all other risk factors. Serum total cholesterol, blood pressure, and cigarette smoking each remained as highly significant independent risk factors whereas overweight, above average levels of HDL-cholesterol and serum triglyceride were not predictive of risk after allowance for the above factors. Men with and without pre-existing ischaemic heart disease were examined separately in the same way (using multiple logistic models). The strength of association between the principal risk factors and subsequent major ischaemic heart disease was reduced in the men with pre-existing ischaemic heart disease, only age and serum total cholesterol remaining highly significant. Overall the levels of the major risk factors commonly encountered in British men have a marked effect on the risk of ischaemic heart disease. Modification of these risk factors in the general population constitutes an important national priority.
Patients with angina and coronary disease have many episodes of symptomless transient myocardial ischaemia, most of which cannot be explained by physical exertion. 16 patients with typical stable angina pectoris were examined to test the hypothesis that these episodes can be triggered off by ordinary daily events, such as changes in mental activity. Regional myocardial perfusion and ischaemia were assessed by measurement of the uptake of rubidium-82 with positron tomography after mental arithmetic and physical exercise. With mental arithmetic, 12 (75%) patients had abnormalities of regional perfusion, accompanied in only 6 by ST-segment depression and in 4 of these 6 by angina, leaving 6 patients with perfusion abnormalities but neither pain nor electrocardiographic changes. After exercise, all the patients showed abnormal regional myocardial perfusion in the segments that became ischaemic with mental arithmetic. This was accompanied by ST depression in all and angina in 15. The association between mental activity and myocardial ischaemia may operate frequently during everyday life and may explain many of the transient and symptomless electrocardiographic changes in patients with coronary disease.
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
To describe the characteristics and the severity of symptoms amongst patients on the waiting list for possible coronary revascularization.
All the patients were sent a postal questionnaire for symptom evaluation.
All hospitals in western Sweden.
All patients in western Sweden on the waiting list in September 1990, who had been referred for coronary angiography or revascularization (n = 904) and a sex- and age-matched reference group (n = 809).
More than half of the patients had daily attacks of chest pain, whereas 16% reported less than one attack per week or no pain at all. However, other symptoms such as dyspnoea, tachycardia and nervous reactions were also common and 25% of all patients used sedatives. A long waiting time for a given procedure was not associated with more pain but with more nervous symptoms such as restlessness and insomnia (P < 0.0001) and greater use of sedatives and cigarettes (P < 0.05).
We conclude that a long waiting time for possible coronary revascularization is associated with more nervous symptoms but not with more pain.
Patients with peripheral vascular disease have complex and challenging health needs. This article describes an innovative nurse practitioner role in the provision of care for patients with intermittent claudication in an acute hospital setting. A small-scale evaluative study of patient satisfaction with the nurse consultation revealed high levels of satisfaction with the care received. It is suggested that experienced nurses can make substantial contributions to improving care for patients with chronic disease.
We describe the 2- and 5-year prognoses following coronary artery bypass grafting (CABG) in relation to smoking habits among consecutive patients being operated on in western Sweden during a 3-year period. Among the 2,121 patients, 10.2% admitted smoking at coronary angiography as compared with 7.5% 2 years after CABG (NS). Among smokers, the mortality during the subsequent 2 years was 8.9% as compared with 6.5% for exsmokers and 7.3% for never smokers (NS). During the 5-year follow-up, smokers had a mortality of 18.8% as compared with 13.6% for exsmokers and 12.5% for never smokers (p = 0.03). When correcting for dissimilarities in previous history, smoking was a strongly significant independent (p < 0.0001) predictor of 5-year mortality.
To elicit patients' maximal acceptable waiting times (MAWT) for non-urgent coronary artery bypass grafting (CABG), and to determine if MAWT is related to prior expectations of waiting times, symptom burden, expected relief, or perceived risks of myocardial infarction while waiting.
Seventy-two patients on an elective CABG waiting list chose between two hypothetical but plausible options: a 1-month wait with 2% risk of surgical mortality, and a 6-month wait with 1% risk of surgical mortality. Waiting time in the 6-month option was varied up if respondents chose the 6-month/lower risk option, and down if they chose the 1-month/higher risk option, until the MAWT switch point was reached. Patients also reported their expected waiting time, perceived risks of myocardial infarction while waiting, current function, expected functional improvement and the value of that improvement.
Only 17 (24%) patients chose the 6-month/1% risk option, while 55 (76%) chose the 1-month/2% risk option. The median MAWT was 2 months; scores ranged from 1 to 12 months (with two outliers). Many perceived high cumulative risks of myocardial infarction if waiting for 1 (upper quartile, > or = 1.45%) or 6 (upper quartile, > or = 10%) months. However, MAWT scores were related only to expected waiting time (r = 0.47; P < 0.0001).
Most patients reject waiting 6 months for elective CABG, even if offered along with a halving in surgical mortality (from 2% to 1%). Intolerance for further delay seems to be determined primarily by patients' attachment to their scheduled surgical dates. Many also have severely inflated perceptions of their risk of myocardial infarction in the queue. These results suggest a need for interventions to modify patients' inaccurate risk perceptions, particularly if a scheduled surgical date must be deferred.