Patient education in the contemporary management of coronary heart disease

Interactive patient education via an audience response system in cardiac rehabilitation

Objectives:

Patient education and compliance play an important role in the success of rehabilitation in cardiovascular diseases. The aim of this study is to analyze whether interactive learning methods, in this study, the audience response system with a “clicker,” can improve the learning success of patients during and after their rehabilitation process.

Methods:

In a randomized, prospective cohort study, a total of 260 patients were randomized to either an interactive training group using Athens audience response system or to a control group without the use of audience response system during the educational sessions. Patients were taught and tested on four different topics concerning their primary disease: heart failure, arterial hypertension, prevention of cardiovascular diseases, and coronary heart disease. After each session, the patients had to answer questions on the previously taught topics via questionnaires. These questions were asked again at the day of discharge, as well as 3 and 12 months after discharge. Additional information on the patients’ health, plus their mental status, was gathered with the help of further questionnaires (HADS and SF-12).

Results:

A total of 260 patients (201 men and 59 women) were recruited. The patients were on average 61.1 ± 11 years old. A significant short-term effect on the patients’ knowledge about their disease was found immediately after the educational sessions in the intervention group. However, there was no long-term effect in either the intervention or control group. Although there was no statistical significance found in any of the observations, a positive short-term effect on learning capacity as well as positive trends in mental and physical health after discharge could be found in patients after the use of audience response system during their rehabilitation.

Conclusion:

This study provides interesting and new data on the use of an interactive learning method for patients to gain knowledge about their primary disease and eventually improve their physical and mental health status in a long-term perspective. By implementing different and new ways of teaching and interaction during the hospitalization, not only patients, but also medical staff and caregivers could benefit.

Can causal explanations about endothelial pathophysiology benefit patient education? A cluster randomized controlled trial in cardiac rehabilitation

OBJECTIVE

To examine whether explaining causal links among endothelial pathophysiology, cardiac risk factors, symptoms and health behaviors (termed causal information) enhances patients' depth of knowledge about cardiovascular disease self-management and their perceptions of the cardiac rehabilitation and secondary prevention (CRSP) program.

METHODS

Newly referred CRSP patients (N = 94) were cluster randomized to usual care (control; UC) or usual care with causal information (intervention; UC + CI). Depth of knowledge (factual vs. deep) was measured with an adapted cognitive-reasoning task. Patients' cardiovascular knowledge and beliefs about the efficacy of a CRSP program were assessed.

RESULTS

After controlling for education level, patients in UC + CI demonstrated deeper knowledge about cardiovascular management than did those in UC. The UC + CI group showed higher factual knowledge than their counterparts after covarying education, occupation status and BMI. The UC + CI group also rated the CRSP program as more credible than those in UC, after controlling for age. Deep knowledge mediated the relationship between group conditions and perceived credibility of CRSP.

CONCLUSION

Causal information can enhance the depth of patients' understanding of cardiovascular disease management and perceived treatment credibility of the CRSP program.

PRACTICE IMPLICATIONS

Explaining causal links may help improve patient education delivery and enhance patient engagement in CRSP.

Therapeutic effect of irbesartan combined with atorvastatin calcium in the treatment of rats with coronary heart disease

This study aimed to investigate the therapeutic effect of irbesartan combined with atorvastatin calcium in the treatment of rats with coronary heart disease. One hundred sixty Wistar rats were selected to establish coronary heart disease model. Rats with coronary heart disease were randomly divided into 4 groups: Model, irbesartan, atorvastatin calcium and combination groups (irbesartan combined with atorvastatin calcium group). Rats in irbesartan group were treated with 50 mg/(kg.day) irbesartan; rats in atorvastatin calcium group were given atorvastatin calcium at a dose of 10 mg/(kg.day); rats in combination group were subjected to atorvastatin calcium at a dose of 10 mg/(kg.day) and irbesartan at a dose of 50 mg/(kg.day), while rats in model groups were given intragastric administration of normal saline at a dose of 2 ml/day. Serum lipids, including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and TC/HDL-C, were measured by automatic biochemical analyzer. Expression of sPLA2-V in myocardium and aortic trunk of rats was detected by reverse transcription-PCR (RT-PCR) and western blot analysis. After treatment, levels of serum TC, TG, LDL-C, HDL-C and TC/HDL-C in rats of each treatment group were better than those in model group (p<0.05). Expression level of sPLA2-V in myocardium and aortic trunk in model group was significantly higher than that in other groups (p<0.05). Expression level of sPLA2-V in combination group was significantly lower than that in irbesartan and atorvastatin calcium groups (p<0.05). Combination of irbesartan and atorvastatin calcium is superior to irbesartan or atorvastatin calcium alone in the treatment of rats with coronary heart disease. The possible explanation is that the two drugs can reduce the expression of sPLA2-V in myocardium and aortic trunk, which in turn relieved atherosclerosis and achieved better therapeutic effect.

Exercise-based cardiac rehabilitation for adults with stable angina

BACKGROUND

A previous Cochrane review has shown that exercise-based cardiac rehabilitation (CR) can benefit myocardial infarction and post-revascularisation patients. However, the impact on stable angina remains unclear and guidance is inconsistent. Whilst recommended in the guidelines of American College of Cardiology/American Heart Association and the European Society of Cardiology, in the UK the National Institute for Health and Care Excellence (NICE) states that there is "no evidence to suggest that CR is clinically or cost-effective for managing stable angina".

OBJECTIVES

To assess the effects of exercise-based CR compared to usual care for adults with stable angina.

SEARCH METHODS

We updated searches from the previous Cochrane review 'Exercise-based cardiac rehabilitation for patients with coronary heart disease' by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, DARE, CINAHL and Web of Science on 2 October 2017. We searched two trials registers, and performed reference checking and forward-citation searching of all primary studies and review articles, to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a follow-up period of at least six months, which compared structured exercise-based CR with usual care for people with stable angina.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data according to the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors also independently assessed the quality of the evidence using GRADE principles and we presented this information in a 'Summary of findings' table.

MAIN RESULTS

Seven studies (581 participants) met our inclusion criteria. Trials had an intervention length of 6 weeks to 12 months and follow-up length of 6 to 12 months. The comparison group in all trials was usual care (without any form of structured exercise training or advice) or a no-exercise comparator. The mean age of participants within the trials ranged from 50 to 66 years, the majority of participants being male (range: 74% to 100%). In terms of risk of bias, the majority of studies were unclear about their generation of the randomisation sequence and concealment processes. One study was at high risk of detection bias as it did not blind its participants or outcome assessors, and two studies had a high risk of attrition bias due to the numbers of participants lost to follow-up. Two trials were at high risk of outcome reporting bias. Given the high risk of bias, small number of trials and participants, and concerns about applicability, we downgraded our assessments of the quality of the evidence using the GRADE tool.Due to the very low-quality of the evidence base, we are uncertain about the effect of exercise-based CR on all-cause mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.18 to 5.67; 195 participants; 3 studies; very low-quality evidence), acute myocardial infarction (RR 0.33, 95% CI 0.07 to 1.63; 254 participants; 3 studies; very low-quality evidence) and cardiovascular-related hospital admissions (RR 0.14, 95% CI 0.02 to 1.1; 101 participants; 1 study; very low-quality evidence). We found low-quality evidence that exercise-based CR may result in a small improvement in exercise capacity compared to control (standardised mean difference (SMD) 0.45, 95% CI 0.20 to 0.70; 267 participants; 5 studies, low-quality evidence). We were unable to draw conclusions about the impact of exercise-based CR on quality of life (angina frequency and emotional health-related quality-of-life score) and CR-related adverse events (e.g. skeletomuscular injury, cardiac arrhythmia), due to the very low quality of evidence. No data were reported on return to work.

AUTHORS' CONCLUSIONS

Due to the small number of trials and their small size, potential risk of bias and concerns about imprecision and lack of applicability, we are uncertain of the effects of exercise-based CR compared to control on mortality, morbidity, cardiovascular hospital admissions, adverse events, return to work and health-related quality of life in people with stable angina. Low-quality evidence indicates that exercise-based CR may result in a small increase in exercise capacity compared to usual care. High-quality, well-reported randomised trials are needed to assess the benefits and harms of exercise-based CR for adults with stable angina. Such trials need to collect patient-relevant outcomes, including clinical events and health-related quality of life. They should also assess cost-effectiveness, and recruit participants that are reflective of the real-world population of people with angina.

Patient education in the management of coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the single most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people live with CHD and may need support to manage their symptoms and improve prognosis. Cardiac rehabilitation is a complex multifaceted intervention which aims to improve the health outcomes of people with CHD. Cardiac rehabilitation consists of three core modalities: education, exercise training and psychological support. This is an update of a Cochrane systematic review previously published in 2011, which aims to investigate the specific impact of the educational component of cardiac rehabilitation.

OBJECTIVES

1. To assess the effects of patient education delivered as part of cardiac rehabilitation, compared with usual care on mortality, morbidity, health-related quality of life (HRQoL) and healthcare costs in patients with CHD.2. To explore the potential study level predictors of the effects of patient education in patients with CHD (e.g. individual versus group intervention, timing with respect to index cardiac event).

SEARCH METHODS

We updated searches from the previous Cochrane review, by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 6, 2016), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) in June 2016. Three trials registries, previous systematic reviews and reference lists of included studies were also searched. No language restrictions were applied.

SELECTION CRITERIA

1. Randomised controlled trials (RCTs) where the primary interventional intent was education delivered as part of cardiac rehabilitation.2. Studies with a minimum of six-months follow-up and published in 1990 or later.3. Adults with a diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on the above inclusion criteria. One author extracted study characteristics from the included trials and assessed their risk of bias; a second review author checked data. Two independent reviewers extracted outcome data onto a standardised collection form. For dichotomous variables, risk ratios and 95% confidence intervals (CI) were derived for each outcome. Heterogeneity amongst included studies was explored qualitatively and quantitatively. Where appropriate and possible, results from included studies were combined for each outcome to give an overall estimate of treatment effect. Given the degree of clinical heterogeneity seen in participant selection, interventions and comparators across studies, we decided it was appropriate to pool studies using random-effects modelling. We planned to undertake subgroup analysis and stratified meta-analysis, sensitivity analysis and meta-regression to examine potential treatment effect modifiers. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of the evidence and the GRADE profiler (GRADEpro GDT) to create summary of findings tables.

MAIN RESULTS

This updated review included a total of 22 trials which randomised 76,864 people with CHD to an education intervention or a 'no education' comparator. Nine new trials (8215 people) were included for this update. We judged most included studies as low risk of bias across most domains. Educational 'dose' ranged from one 40 minute face-to-face session plus a 15 minute follow-up call, to a four-week residential stay with 11 months of follow-up sessions. Control groups received usual medical care, typically consisting of referral to an outpatient cardiologist, primary care physician, or both.We found evidence of no difference in effect of education-based interventions on total mortality (13 studies, 10,075 participants; 189/5187 (3.6%) versus 222/4888 (4.6%); random effects risk ratio (RR) 0.80, 95% CI 0.60 to 1.05; moderate quality evidence). Individual causes of mortality were reported rarely, and we were unable to report separate results for cardiovascular mortality or non-cardiovascular mortality. There was evidence of no difference in effect of education-based interventions on fatal and/or non fatal myocardial infarction (MI) (2 studies, 209 participants; 7/107 (6.5%) versus 12/102 (11.8%); random effects RR 0.63, 95% CI 0.26 to 1.48; very low quality of evidence). However, there was some evidence of a reduction with education in fatal and/or non-fatal cardiovascular events (2 studies, 310 studies; 21/152 (13.8%) versus 61/158 (38.6%); random effects RR 0.36, 95% CI 0.23 to 0.56; low quality evidence). There was evidence of no difference in effect of education on the rate of total revascularisations (3 studies, 456 participants; 5/228 (2.2%) versus 8/228 (3.5%); random effects RR 0.58, 95% CI 0.19 to 1.71; very low quality evidence) or hospitalisations (5 studies, 14,849 participants; 656/10048 (6.5%) versus 381/4801 (7.9%); random effects RR 0.93, 95% CI 0.71 to 1.21; very low quality evidence). There was evidence of no difference between groups for all cause withdrawal (17 studies, 10,972 participants; 525/5632 (9.3%) versus 493/5340 (9.2%); random effects RR 1.04, 95% CI 0.88 to 1.22; low quality evidence). Although some health-related quality of life (HRQoL) domain scores were higher with education, there was no consistent evidence of superiority across all domains.

AUTHORS' CONCLUSIONS

We found no reduction in total mortality, in people who received education delivered as part of cardiac rehabilitation, compared to people in control groups (moderate quality evidence). There were no improvements in fatal or non fatal MI, total revascularisations or hospitalisations, with education. There was some evidence of a reduction in fatal and/or non-fatal cardiovascular events with education, but this was based on only two studies. There was also some evidence to suggest that education-based interventions may improve HRQoL. Our findings are supportive of current national and international clinical guidelines that cardiac rehabilitation for people with CHD should be comprehensive and include educational interventions together with exercise and psychological therapy. Further definitive research into education interventions for people with CHD is needed.

Exercise-based cardiac rehabilitation in heart transplant recipients

BACKGROUND

Heart transplantation is considered to be the gold standard treatment for selected patients with end-stage heart disease when medical therapy has been unable to halt progression of the underlying pathology. Evidence suggests that aerobic exercise training may be effective in reversing the pathophysiological consequences associated with cardiac denervation and prevent immunosuppression-induced adverse effects in heart transplant recipients.

OBJECTIVES

To determine the effectiveness and safety of exercise-based rehabilitation on the mortality, hospital admissions, adverse events, exercise capacity, health-related quality of life, return to work and costs for people after heart transplantation.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO) and Web of Science Core Collection (Thomson Reuters) to June 2016. We also searched two clinical trials registers and handsearched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of parallel group, cross-over or cluster design, which compared exercise-based interventions with (i) no exercise control (ii) a different dose of exercise training (e.g. low- versus high-intensity exercise training); or (iii) an active intervention (i.e. education, psychological intervention). The study population comprised adults aged 18 years or over who had received a heart transplant.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on pre-specified inclusion criteria. Disagreements were resolved by consensus or by involving a third person. Two review authors extracted outcome data from the included trials and assessed their risk of bias. One review author extracted study characteristics from included studies and a second author checked them against the trial report for accuracy.

MAIN RESULTS

We included 10 RCTs that involved a total of 300 participants whose mean age was 54.4 years. Women accounted for fewer than 25% of all study participants. Nine trials which randomised 284 participants to receive exercise-based rehabilitation (151 participants) or no exercise (133 participants) were included in the main analysis. One cross-over RCT compared high-intensity interval training with continued moderate-intensity training in 16 participants. We reported findings for all trials at their longest follow-up (median 12 weeks).Exercise-based cardiac rehabilitation increased exercise capacity (VO2peak) compared with no exercise control (MD 2.49 mL/kg/min, 95% CI 1.63 to 3.36; N = 284; studies = 9; moderate quality evidence). There was evidence from one trial that high-intensity interval exercise training was more effective in improving exercise capacity than continuous moderate-intensity exercise (MD 2.30 mL/kg/min, 95% CI 0.59 to 4.01; N = 16; 1 study). Four studies reported health-related quality of life (HRQoL) measured using SF-36, Profile of Quality of Life in the Chronically Ill (PLC) and the World Health Organization Quality Of Life (WHOQoL) - BREF. Due to the variation in HRQoL outcomes and methods of reporting we were unable to meta-analyse results across studies, but there was no evidence of a difference between exercise-based cardiac rehabilitation and control in 18 of 21 HRQoL domains reported, or between high and moderate intensity exercise in any of the 10 HRQoL domains reported. One adverse event was reported by one study.Exercise-based cardiac rehabilitation improves exercise capacity, but exercise was found to have no impact on health-related quality of life in the short-term (median 12 weeks follow-up), in heart transplant recipients whose health is stable.There was no evidence of statistical heterogeneity across trials for exercise capacity and no evidence of small study bias. The overall risk of bias in included studies was judged as low or unclear; more than 50% of included studies were assessed at unclear risk of bias with respect to allocation concealment, blinding of outcome assessors and declaration of conflicts of interest. Evidence quality was assessed as moderate according to GRADE criteria.

AUTHORS' CONCLUSIONS

We found moderate quality evidence suggesting that exercise-based cardiac rehabilitation improves exercise capacity, and that exercise has no impact on health-related quality of life in the short-term (median 12 weeks follow-up), in heart transplant recipients. Cardiac rehabilitation appears to be safe in this population, but long-term follow-up data are incomplete and further good quality and adequately-powered trials are needed to demonstrate the longer-term benefits of exercise on safety and impact on both clinical and patient-related outcomes, such as health-related quality of life, and healthcare costs.

Learning and coping strategies versus standard education in cardiac rehabilitation: a cost-utility analysis alongside a randomised controlled trial

BACKGROUND

Learning and coping education strategies (LC) was implemented to enhance patient attendance in the cardiac rehabilitation programme. This study assessed the cost-utility of LC compared to standard education (standard) as part of a rehabilitation programme for patients with ischemic heart disease and heart failure.

METHODS

The study was conducted alongside a randomised controlled trial with 825 patients who were allocated to LC or standard rehabilitation and followed for 5 months. The LC approach was identical to the standard approach in terms of physical training and education, but with the addition of individual interviews and weekly team evaluations by professionals. A societal cost perspective including the cost of intervention, health care, informal time and productivity loss was applied. Cost was based on a micro-costing approach for the intervention and national administrative registries for other cost categories. Quality adjusted life years (QALY) were based on SF-6D measurements at baseline, after intervention and follow-up using British preference weights. Multiple imputation was used to handle non-response on the SF-6D. Conventional cost effectiveness methodology was employed to estimate the net benefit of the LC and to illustrate cost effectiveness acceptability curves. The statistical analysis was based on means and bootstrapped standard errors.

RESULTS

An additional cost of DKK 6,043 (95% CI -5,697; 17,783) and a QALY gain of 0.005 (95% CI -0.001; 0.012) was estimated for LC. However, better utility scores in both arms were due to higher utility while receiving the intervention than better health after the intervention. The probability that LC would be cost-effective did not exceed 29% for any threshold values of willingness to pay per QALY. The alternative scenario analysis was restricted to a health care perspective and showed that the probability of cost-effectiveness increased to 62% over the threshold values.

DISCUSSION

The LC was unlikely to be cost-effective within 5 months of follow-up from a societal perspective, but longer-term follow-up should be evaluated before a definite conclusion is drawn.

CONCLUSION

Future research should assess the LC strategies' long-term efficacy and cost-utility.

TRIAL REGISTRATION

NCT01668394.

Exercise-based cardiac rehabilitation for coronary heart disease

BACKGROUND

The burden of coronary heart disease (CHD) worldwide is one of great concern to patients and healthcare agencies alike. Exercise-based cardiac rehabilitation aims to restore patients with heart disease to health.

OBJECTIVES

To determine the effectiveness of exercise-based cardiac rehabilitation (exercise training alone or in combination with psychosocial or educational interventions) on mortality, morbidity and health-related quality of life of patients with CHD.

SEARCH STRATEGY

RCTs have been identified by searching CENTRAL, HTA, and DARE (using The Cochrane Library Issue 4, 2009), as well as MEDLINE (1950 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), and Science Citation Index Expanded (1900 to December 2009).

SELECTION CRITERIA

Men and women of all ages who have had myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), or who have angina pectoris or coronary artery disease defined by angiography.

DATA COLLECTION AND ANALYSIS

Studies were selected and data extracted independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

This systematic review has allowed analysis of 47 studies randomising 10,794 patients to exercise-based cardiac rehabilitation or usual care. In medium to longer term (i.e. 12 or more months follow-up) exercise-based cardiac rehabilitation reduced overall and cardiovascular mortality [RR 0.87 (95% CI 0.75, 0.99) and 0.74 (95% CI 0.63, 0.87), respectively], and hospital admissions [RR 0.69 (95% CI 0.51, 0.93)] in the shorter term (< 12 months follow-up) with no evidence of heterogeneity of effect across trials. Cardiac rehabilitation did not reduce the risk of total MI, CABG or PTCA. Given both the heterogeneity in outcome measures and methods of reporting findings, a meta-analysis was not undertaken for health-related quality of life. In seven out of 10 trials reporting health-related quality of life using validated measures was there evidence of a significantly higher level of quality of life with exercise-based cardiac rehabilitation than usual care.

AUTHORS' CONCLUSIONS

Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed. These trials should include validated health-related quality of life outcome measures, need to explicitly report clinical events including hospital admission, and assess costs and cost-effectiveness.