Between mind and heart: Sex-based cognitive bias in cardiovascular disease treatment

Given that both men and women experience cardiovascular disease (CVD), a common misconception is that they have similar risk factors and clinical presentation, receive comparable treatment, and have equivalent clinical outcomes; in reality differences are observed between men and women for each of these endpoints. Moreover, these differences occur as a function of both gender and sex. A review of the literature reveals widespread bias in the selection of research subjects based on these factors, in addition to implicit patient and provider biases that impede the access of women to recommended primary and secondary CVD management. In this perspective, we identify strategies to eliminate such biases and improve women's access to CVD treatments to ensure their care is consistent with current guidelines.

Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study

Background

Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women.

Methods

Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2.

Results

Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety.

Conclusions

Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.

Effects of comprehensive cardiac rehabilitation on functional capacity and cardiovascular risk factors in Brazilians assisted by public health care: protocol for a randomized controlled trial

Background

Cardiovascular Disease (CVD) is the leading burden of disease worldwide. Moreover, CVD-related death rates are considered an epidemic in low- and middle-income countries (LMICs). Research shows that cardiac rehabilitation (CR) participation reduces death and improves disability and quality of life. Given the growing epidemic of CVD in LMICs and the insufficient evidence about CR programs in these countries, a Randomized Control Trial (RCT) in Latin America is warranted.

Objective

To investigate the effects of comprehensive CR on functional capacity and cardiovascular risk factors.

Method

The design is a single-blinded RCT with three parallel arms: comprehensive CR (exercise + education) versus exercise-based CR versus wait-list control (no CR). The primary outcome will be measured by the Incremental Shuttle Walk Test. Secondary outcomes are risk factors (blood pressure, dyslipidemia, dysglycemia, body mass index and waist circumference); tertiary outcomes are heart health behaviors (exercise, medication adherence, diet, and smoking), knowledge, and depressive symptoms. The CR program is six months in duration. Participants randomized to exercise-based CR will receive 24 weeks of exercise classes. The comprehensive CR group will also receive 24 educational sessions, including a workbook. Every outcome will be assessed at baseline and 6-months later, and mortality will be ascertained at six months and one year.

Conclusion

This will be the first RCT to establish the effects of CR in Latin America. If positive, results will be used to promote broader implementation of comprehensive CR and patient access in the region and to inform a larger-scale trial powered for mortality.

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

BACKGROUND

Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation.

METHODS AND RESULTS

Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees, using the Huber-White-sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98-0.99), having a partner (OR 1.31, 95% CI 1.17-1.48), not being employed (OR 0.86, 95% CI 0.77-0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77-0.92), greater anxiety (OR 1.02, 95% CI 1.003-1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42-0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09-2.47).

CONCLUSIONS

CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized.

Advocacy for outpatient cardiac rehabilitation globally

BACKGROUND

Cardiovascular diseases (CVD) are the leading cause of death globally. Cardiac rehabilitation (CR) is an evidence-based intervention recommended for patients with CVD, to prevent recurrent events and to improve quality of life. However, despite the proven benefits, only a small percentage of those would benefit from CR actually receive it worldwide. This paper by the International Council of Cardiovascular Prevention and Rehabilitation forwards the groundwork for successful CR advocacy to achieve broader reimbursement, and hence implementation.

METHODS

First, the results of the International Council's survey on national CR reimbursement policies by government and insurance companies are summarized. Second, a multi-faceted approach to CR advocacy is forwarded. Finally, as per the advocacy recommendations, the economic impact of CVD and the corresponding benefits of CR and its cost-effectiveness are summarized. This provides the case for CR reimbursement advocacy.

RESULTS

Thirty-one responses were received, from 25 different countries: 18 (58.1 %) were from high-income countries, 10 (32.4 %) from upper middle-income, and 3 (9.9 %) from lower middle-income countries. When asked who reimburses at least some portion of CR services in their country, 19 (61.3 %) reported the government, 17 (54.8 %) reported patients pay out-of-pocket, 16 (51.6 %) reported insurance companies, 12 (38.7 %) reported that it is shared between the patient and another source, and 7 (22.6 %) reported another source.

CONCLUSIONS

Many patients pay out-of-pocket for CR. CR reimbursement around the world is inconsistent and insufficient. Advocacy campaigns forwarding the CR cause, supported by the relevant literature, enlisting sources of support in a unified manner with an organized plan, are needed, and must be pursued persistently.

Ecologically optimizing exercise maintenance in men and women post-cardiac rehabilitation: Protocol for a randomized controlled trial of efficacy with economics (ECO-PCR)

BACKGROUND

Exercise-based cardiac rehabilitation (CR) participation results in increased cardio-metabolic fitness, which is associated with reduced mortality. However, many graduates fail to maintain exercise post-program. ECO-PCR investigates the efficacy and cost-effectiveness of a social ecologically-based intervention to increase long-term exercise maintenance following the completion of CR.

METHODS/DESIGN

A three-site, 2-group, parallel randomized controlled trial is underway. 412 male and 192 female (N=604) supervised CR participants are being recruited just before CR graduation. Participants are randomized (1:1 concealed allocation) to intervention or usual care. A 50-week exercise facilitator intervention has been designed to assist CR graduates in the transition from structured, supervised exercise to self-managed home- or community-based (e.g., Heart Wise Exercise programs) exercise. The intervention consists of 8 telephone contacts over the 50week period: 3 individual and 5 group. Assessments occur at CR graduation, and 26, 52 and 78weeks post-randomization. The primary outcome is change in minutes of accelerometer-measured moderate to vigorous-intensity physical activity (MVPA) from CR graduation to 52weeks post-randomization. Secondary measures include exercise capacity, quality of life, and cardiovascular risk factors. Analyses will be undertaken based on intention-to-treat. For the primary outcome, an analysis of variance will be computed to test the change in minutes of MVPA in each group between CR graduation and 52week follow-up (2 [arm]×2 [time]). Secondary objectives will be assessed using mixed-model repeated measures analyses to compare differences between groups over time. Mean costs and quality-adjusted life years for each arm will be estimated.

Ensuring Cardiac Rehabilitation Access for the Majority of Those in Need: A Call to Action for Canada

Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups-such as women, ethnocultural minorities, and those of low socioeconomic status-are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.

Cardiac rehabilitation delivery model for low-resource settings

Objective

Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries.

Methods

A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not.

Results

Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings.

Conclusions

Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed.

Sex Differences in Cardiac Rehabilitation Adherence: A Meta-analysis

BACKGROUND

Cardiac rehabilitation (CR) participation is associated with significantly lower mortality, and this benefit has been established as dose-dependent. Because it has been suggested that women are adherent to CR programs less than men, the objective of this study was to review CR adherence among women and men, and to determine whether a sex difference exists.

METHODS

MedLine, CINAHL, EMBASE, PsycINFO, and the Cochrane databases were systematically searched. Titles and abstracts were screened, and selected full-text articles were independently considered on the basis of predefined inclusion/exclusion criteria. Data from included articles were extracted by 2 authors independently and assessed for quality. The meta-analysis was undertaken with predefined subgroup analyses.

RESULTS

The search identified 5148 articles, of which 149 were fully examined for inclusion consideration. Fourteen studies reporting data on 8176 participants (2234 [27.3%] women) were included. Overall, CR adherence ranged from 36.7% to 84.6% of sessions, with a mean of 66.5 ± 18.2% (median, 72.5%). Men and women enrolled in CR adhered to 68.6% and 64.2% of prescribed sessions, respectively (mean difference = -3.6; 95% confidence interval, -6.9 to -0.3). The sex difference persisted in studies of high quality, that were undertaken in Canada, published since 2010, and where programs were longer than 12 weeks' duration and offered fewer than 3 sessions per week.

CONCLUSIONS

To our knowledge, this is the first meta-analysis to systematically report CR adherence rates, and results suggest that patients adhere to more than two-thirds of prescribed sessions. CR adherence is significantly lower among women than men. Identified strategies to promote adherence need to be tested among women.

Cardiac rehabilitation referral and enrolment across an academic health sciences centre with eReferral and peer navigation: a randomised controlled pilot trial

OBJECTIVES

To describe (1) cardiac rehabilitation (CR) referral across cardiac units in a tertiary centre with eReferral; (2) characteristics associated with CR referral and enrolment and (3) the effects of peer navigation (PN) on referral and enrolment. This pilot was a 2 parallel-arm, randomised, single-blind trial with allocation concealment.

SETTING

3 cardiac units (ie, interventional, general cardiology, and cardiac surgery) in 1 of 2 hospitals of a tertiary centre.

PARTICIPANTS

CR-eligible adult cardiac inpatients were randomised to PN or usual care. 94 (54.7%) patients consented, of which 46 (48.9%) were randomised to PN. Outcomes were ascertained in 76 (80.9%) participants.

INTERVENTION

The PN (1) visited participant at the bedside, (2) mailed a card to participant's home reminding about CR and (3) called participant 2 weeks postdischarge to discuss CR barriers.

OUTCOME MEASURES

The primary outcome of enrolment was defined as participant attendance at a scheduled CR intake appointment (yes/no). The secondary outcome was referral. Blinded outcome assessment was conducted 12 weeks postdischarge, via CR chart extraction.

RESULTS

Those who received care on the cardiac surgery unit (77.9%) were more likely to be referred than those treated on the general cardiology (61.1%) or interventional unit (33.3%; p=0.04). Patients who had cardiac surgery, hypertension and hyperlipidaemia were significantly more likely, and those with congenital heart disease, cancer and a previous cardiac diagnosis were less likely to be referred. Participants referred to a site closer to home (76.2% of those referred) were more likely to enrol than those not (23.7%, p<0.05). PN had no effect on referral (77.6%, p=0.45) or enrolment (46.0%, p=0.24).

CONCLUSIONS

There is wide variability in CR referral, even within academic centres, and despite eReferral. Referral was quite high, and thus, PN did not improve CR utilisation. Results support triaging patients to the CR programme closest to their home.

TRIAL REGISTRATION NUMBER

NCT02204449; Results.

Evaluating the Heart Wise Exercise™ program: a model for safe community exercise programming

Background

Greater availability of community exercise facilities is recommended to promote physical activity in the large number of people with chronic disease. The Heart Wise Exercise (HWE) program encourages existing community-based exercise facilities to build capacity to serve such patients, by working with interested facilities to ensure they meet safety criteria, and educating exercise leaders.

Methods

Using a piloted checklist, 45 HWE programs were audited for the six HWE criteria (outlined below) in the greater Ottawa and Toronto areas of Ontario, Canada. A survey was also administered to a convenience sample of HWE program participants (N = 127).

Results

Criteria 1: 71 % of leaders encouraged daily aerobic exercise; participants reported engaging in 194 min/week of aerobic exercise. Criteria 2: 100 % of programs incorporated a warm-up and cool-down, and 84 % encouraged self-monitoring during class. Criteria 3: 98 % of programs offered options for participants to exercise at their appropriate intensity. Criteria 4: HWE participants reported having chronic conditions including arthritis (41 %), osteoporosis (26 %) diabetes (8 %), heart disease (6 %) and chronic obstructive pulmonary disease (6 %). Criteria 5: 93 % of instructors offered health screening for participants. Criteria 6: 100 % of sites had automated external defibrillators, and 90 % of the instructors were aware of the documented emergency plan. The exercise leaders reported being ‘knowledgeable/comfortable/confident’ in providing exercise guidance to, and having clients with chronic health conditions; directing clients to other services; offering exercise intensity options; helping clients listen to their bodies; and, encouraging clients to provide information regarding their health. The participants reported being, on average, ‘somewhat happy’ to ‘very happy’ with HWE locations; program dates and times; leaders’ knowledge of disease and exercise; exercise intensity; cost; and, social aspect.

Conclusions

HWE programs are safe and appropriate for persons with varying chronic health conditions, and participants are satisfied with and will likely continue attending their HWE classes. Future efforts should be directed at increasing awareness of HWE programs among referring healthcare professionals and participants at risk of chronic conditions. The HWE training program should emphasize that HWE leaders regularly encourage self-monitoring and daily aerobic exercise, which is well-known to reduce the burden of many chronic diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2866-7) contains supplementary material, which is available to authorized users.

The mental health status of ethnocultural minorities in Ontario and their mental health care

BACKGROUND

Mental disorders are a leading cause of disability and early mortality. The objective of this study was to describe and compare psychosocial indicators and mental health service use among ethnoculturally-diverse Ontarians.

METHODS

This is a cross-sectional analysis of the Ontario Health Study pilot investigation. Residents were mailed an invitation to one of 3 assessment centres (urban, rural and northern sites) from March 2009 to July 2010. Participants had an interview with a nurse and completed a questionnaire on a touchscreen kiosk. The questionnaire included sociodemographic items, and scales assessing symptoms of depressive symptoms (CES-D) and anxiety (GAD-7), social support (Lubben Social Network Scale), stressful life events, and mental health service use.

RESULTS

Eight thousand two hundred thirty-five residents participated, among whom 6652 (82.4 %) self-reported their ethnocultural background as White, 225 (2.8 %) as South Asian, 222 (2.8 %) East Asian, 214 (2.7 %) Southeast Asian, 197 (2.4 %) Black, and 28 (0.3 %) as Aboriginal. Based on their sociodemographic characteristics, participants from these ethnocultural minority groups were matched to White participants. Black participants reported significantly greater stressful life events than White participants (p = .04), particularly death (p < .05), divorce (p = .002) and financial difficulties (p < .001). East Asian participants reported significantly less social support than their White counterparts (p < .001), and this was not confounded by measurement variance. Mental health service use was significantly lower in all ethnocultural minorities except Aboriginals, when compared to White participants (p = .001).

CONCLUSIONS

There is a high burden of psychosocial distress in several preponderant ethnocultural minorities in Ontario; many of whom are not accessing available mental health services.

A bifactor model of the Beck Depression Inventory and its association with medical prognosis after myocardial infarction

OBJECTIVES

Evidence suggests that depression is associated with adverse outcomes in patients with myocardial infarction (MI). Some of the symptoms of depression may also be symptoms of somatic illness and these may confound the association between depression and prognosis. We investigated whether depression following MI is associated with medical prognosis independent of these somatic symptoms.

METHOD

The database of an individual patient data meta-analysis was used. Endpoints were all-cause mortality and cardiovascular events. Nine studies were included. Bifactor factor analysis included 13,100 participants and 7,595 participants were included in survival models. Dimensions were generated from the Beck Depression Inventory using factor analyses. The prognostic association was assessed using mixed-effects Cox regression analysis.

RESULTS

A bifactor model, consisting of a general factor and 2 general depression-free subgroup factors (a somatic/affective and a cognitive/affective), provided the best fit. There was a significant association between the general depression factor and all-cause mortality (hazard ratio [HR] = 1.25; 95% confidence interval [CI] [1.17, 1.34], p < .001) and cardiovascular events (HR = 1.18; 95% CI [1.13, 1.23], p < .001). After adjustment for demographics, measures of cardiac disease severity, and health-related variables, the association between the general depression factor and all-cause mortality (HR = 1.14; 95% CI [1.04, 1.25], p = .003) and cardiovascular events (HR = 1.16; 95% CI [1.10, 1.23], p = .014) attenuated. Additionally, the general depression-free somatic/affective factor was significantly associated with the endpoints, while the general depression-free cognitive/affective was not.

CONCLUSIONS

A general depression factor is associated with adverse medical prognosis following MI independent of somatic/affective symptoms that may be partly attributable to somatic illness. (PsycINFO Database Record

Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial

OBJECTIVE

To compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR).

PATIENTS AND METHODS

Cardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained.

RESULTS

Of the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05).

CONCLUSION

Offering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01019135.

Cardiac rehabilitation in Canada and Arab countries: comparing availability and program characteristics

Background

Despite the high burden of cardiovascular diseases in Arab countries, little is known about cardiac rehabilitation (CR) delivery. This study assessed availability, and CR program characteristics in the Arab World, compared to Canada.

Methods

A questionnaire incorporating items from 4 national / regional published CR program surveys was created for this cross-sectional study. The survey was emailed to all Arab CR program contacts that were identified through published studies, conference abstracts, a snowball sampling strategy, and other key informants from the 22 Arab countries. An online survey link was also emailed to all contacts in the Canadian Association of Cardiovascular Prevention and Rehabilitation directory. Descriptive statistics were used to describe all closed-ended items in the survey. All open-ended responses were coded using an interpretive-descriptive approach.

Results

Eight programs were identified in Arab countries, of which 5 (62.5 %) participated; 128 programs were identified in Canada, of which 39 (30.5 %) participated. There was consistency in core components delivered in Arab countries and Canada; however, Arab programs more often delivered women-only classes. Lack of human resources was perceived as the greatest barrier to CR provision in all settings, with space also a barrier in Arab settings, and financial resources in Canada. The median number of patients served per program was 300 for Canada vs. 200 for Arab countries.

Conclusion

Availability of CR programs in Arab countries is incredibly limited, despite the fact that most responses stemmed from high-income countries. Where available, CR programs in Arab countries appear to be delivered in a manner consistent with Canada.

Objectively-measured sedentary time and its association with markers of cardiometabolic health and fitness among cardiac rehabilitation graduates

BACKGROUND

Sedentary time is an independent risk factor for cardiometabolic disease and mortality. It is unknown how much time individuals with coronary artery disease spend being sedentary or how their sedentary time relates to markers of health. The objectives of this study were to: (a) quantify sedentary time in a post-cardiac rehabilitation (CR) population, and (b) assess association with cardiometabolic risk, independent of moderate-to-vigorous physical activity.

DESIGN

Cross-sectional.

METHODS

As part of a larger trial, 263 recent CR graduates (∼10 days post-CR, mean age 63.6 ± 9.3 years, 75% male) wore an ActiGraph GT3X accelerometer during waking hours (≥4 days, ≥10 hours/day) to quantify sedentary time (≤150 counts per minute). Spearman correlations were computed to assess relationships between sedentary time (adjusted for wear time) with markers of cardiometabolic health and fitness. Significant markers were examined using multiple linear regressions.

RESULTS

Participants spent an average of 8 hours/day sedentary (∼14 bouts/day). Sedentary time was negatively correlated with high-density lipoprotein and [Formula: see text]O2peak and positively correlated with triglycerides, body mass index and waist circumference. After adjusting for age, sex, medications and moderate-to-vigorous physical activity, hours/day of sedentary time remained significantly associated with log[Formula: see text]O2peak (β = -0.02, p = 0.001) and body mass index (β = 0.49, p = 0.02).

CONCLUSIONS

Findings suggest that even among a group of post-CR individuals who are already probably more active than patients who have not undergone CR, sedentary time remains high and is associated with poorer cardiorespiratory fitness, suggesting a possible new area of focus among CR programs.

Adult Congenital Heart Disease-Coping And REsilience (ACHD-CARE): Rationale and methodology of a pilot randomized controlled trial

INTRODUCTION

One-third of North American adults with congenital heart disease (CHD) have diagnosable mood or anxiety disorders and most do not receive mental health treatment. There are no published interventions targeting the psychosocial needs of patients with CHD of any age. We describe the development of a group psychosocial intervention aimed at improving the psychosocial functioning, quality of life, and resilience of adults with CHD and the design of a study protocol to determine the feasibility of a potential full-scale randomized controlled trial (RCT).

METHODS/DESIGN

Drawing upon our quantitative and qualitative research, we developed the Adult CHD-Coping And REsilience (ACHD-CARE) intervention and designed a feasibility study that included a 2-parallel arm non-blinded pilot RCT. Eligible participants (CHD, age ≥ 18 years, no planned surgery, symptoms suggestive of a mood and/or anxiety disorder) were randomized to the ACHD-CARE intervention or Usual Care (1:1 allocation ratio). The group intervention was delivered during eight 90-minute weekly sessions. Feasibility will be assessed in the following domains: (i) process (e.g. recruitment and retention), (ii) resources, (iii) management, (iv) scientific outcomes, and (v) intervention acceptability.

DISCUSSION

This study underscores the importance of carefully developing and testing the feasibility of psychosocial interventions in medical populations before moving to full-scale clinical trials. At study conclusion, we will be poised to make one of three determinations for a full-scale RCT: (1) feasible, (2) feasible with modifications, or (3) not feasible. This study will guide the future evaluation and provision of psychosocial treatment for adults with CHD.

Observing temporal trends in cardiac rehabilitation from 1996 to 2010 in Ontario: characteristics of referred patients, programme participation and mortality rates

OBJECTIVES

We sought to describe temporal trends in the sociodemographic and clinical characteristics of participants referred to cardiac rehabilitation (CR), and its effect on programme participation and all-cause mortality over 14 years.

SETTING

A large CR centre in Toronto, Canada.

PARTICIPANTS

Consecutive patients between 1996 and 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

Referrals received were deterministically linked to administrative data, to complement referral form abstraction. Out-of-hospital deaths were identified using vital statistics. Patients were tracked until 2012, and mortality was ascertained. Percentage attendance at prescribed sessions was also assessed.

RESULTS

There were 29,171 referrals received, of which 28,767 (98.6%) were successfully linked, of whom 22,795 (79.2%) attended an intake assessment. The age of the referred population steadily increased, with more females, less affluent and more single patients referred over time (p<0.001). More patients were referred following percutaneous coronary intervention and less following coronary artery bypass graft surgery (p<0.001). The number of comorbidities decreased (p<0.001). Hypertension increased over time (p<0.001), yet the control of cholesterol steadily improved over time. The proportion of smokers decreased over time (p<0.001). Participation in CR significantly declined, and there were no significant changes in mortality. 3-year mortality rates were less than 5%.

CONCLUSIONS

Characteristics of referred patients tended to reflect broader trends in risk factors and cardiovascular disease burden. Physicians appear to be referring more sociodemographically diverse patients to CR; however, programmes may need to better adapt to engage these patients to fully participate. More complex patients should be referred, using explicit criteria-based referral processes.

A Comparison of Accelerometer Cut-Points among Individuals with Coronary Artery Disease

Background

Accurate assessment of physical activity among coronary artery disease patients is important for assessing adherence to interventions. The study compared moderate-to-vigorous physical intensity activity and relationships with cardiometabolic health/fitness indicators using accelerometer cut-points developed for coronary artery disease patients versus those developed in younger and middle-aged adults.

Methods

A total of 231 adults with coronary artery disease wore an Actigraph GT3X accelerometer for ≥4 days (≥10 hours/day). Moderate-to-vigorous intensity physical activity between cut-points was compared using Bland-Altman analyses. Partial spearman correlations assessed relationships between moderate-to-vigorous intensity physical activity from each cut-point with markers of cardiometabolic health and fitness while controlling for age and sex.

Results

Average time spent in bouts of moderate-to-vigorous intensity physical activity using coronary artery disease cut-points was significantly higher than the young (mean difference: 13.0±12.8 minutes/day) or middle-aged (17.0±15.2 minutes/day) cut-points. Young and middle-aged cut-points were more strongly correlated with body mass index, waist circumference and systolic blood pressure, while coronary artery disease cut-points had stronger relationships with triglycerides, high-density and low-density lipoproteins. All were similarly correlated with measures of fitness.

Conclusion

Researchers need to exert caution when deciding on which cut-points to apply to their population. Further work is needed to validate which cut-points provide a true reflection of moderate-to-vigorous intensity physical activity and to examine relationships among patients with varying fitness.