Feasibility of Implementing a Palliative Care Intervention for People with Heart Failure: Learnings from a Pilot Randomized Clinical Trial

Background: People with heart failure (HF) have high morbidity and mortality and may benefit from palliative care (PC). Objective: To pilot a randomized, clinical trial of a PC intervention for people with HF. Design: Participants were randomized to usual care (UC) or intervention (UC plus specialty PC) between January 2012 and December 2013. The initial PC consultation was conducted in-hospital, with six additional contacts from the PC team over six months. Setting/Subjects: The study was undertaken in a large, urban, academic medical center with patients (n = 30) with New York Heart Association HF Class II-IV. Measurements: Patients completed a survey at baseline, three and six months, assessing pain, dyspnea, depression, and quality of life (QoL). Results: Although there were significant improvements in mean scores from baseline to six months for pain (4.3 vs. 2.4, p = 0.05), dyspnea (3.9 vs. 2.2, p = 0.03), and QoL (59.2 vs. 42.7, p = 0.001), there were no differences between study groups over time. On average, participants in the intervention group received 5 out of 6 contacts and were satisfied with the intervention. Conclusions: The intervention was well accepted by patients, safe, and feasible. Our findings suggest that PC interventions for people with HF should match the PC needs of the patient. Given the trajectory of HF, studies may need to recruit outpatients and follow patients for a longer period to fully evaluate the impact of PC interventions. Clinical trials Identifier: NCT01461681.

Let Us Talk About It: Heart Failure Patients' Preferences Toward Discussions about Prognosis, Advance Care Planning, and Spiritual Support

OBJECTIVE

The objective of this study is to describe preferences of patients with heart failure (HF) for having advance care planning (ACP) discussions with clinicians and to identify characteristics associated with those preferences.

BACKGROUND

National guidelines call for having ACP discussions with patients with serious illnesses such as HF. Many patients with HF do not discuss ACP with their physician despite wanting to have them.

METHODS

We conducted a cross-sectional cohort study between July 2007 and November 2009 within HF clinics affiliated with a large, urban, academic medical center. Patients with New York Heart Association HF classes II and III were surveyed about whether they had or would like to have discussions with their clinician about what to expect in the future regarding their HF, prognosis, ACP, and their surrogate choice.

RESULTS

Patients (n = 104) were on average 53 years old (standard deviation = 14.3; range: 21-84) and had Class II (57%) or Class III (43%) HF. Most patients had discussed what to expect in the future regarding HF (76.5%, 78/102), prognosis (68.0%, 68/100), surrogate choice (90.3%, 93/103), and ACP (46.5%, 47/101). Most of those who did not have these discussions would have liked to discuss expectations regarding their HF (87.5%, 21/24), prognosis (80.6%, 25/31), and ACP (59.6%, 31/52). Men were more likely than women to report having had discussions about their HF (83.6% vs. 62.9%; p = 0.02), prognosis (78.5% vs. 48.6%; p = 0.002), and ACP (56.1% vs. 28.6%; p = 0.01). On average younger patients were more likely to report having discussed what to expect regarding their HF (50 years vs. 59 years; p = 0.007), and to be asked about their spirituality (43 years vs. 56 years; p = 0.0001).

DISCUSSION

Conforming to national guidelines, most patients with HF have discussed ACP with clinicians and most of those who have not, want to. Findings should embolden clinicians to routinely discuss ACP.

Etiology of Pain and Its Association with Quality of Life among Patients with Heart Failure

OBJECTIVE

Describe the etiology of pain among HF patients and examine the relationship between pain and QoL.

BACKGROUND

Little is known about the etiology of pain in patients with heart failure (HF) and the impact it has on quality of life (QoL).

METHODS

A prospective cohort study of outpatients with NYHA Class II or III HF were surveyed at baseline and at three-month follow-up. The study was conducted in Heart Failure clinics affiliated with a large, urban, academic medical center.

RESULTS

Of 104 patients that completed a baseline survey, 73 (70%) completed a follow-up survey. At baseline, 48% of patients reported having pain the previous week. Patients on prescription pain medication (n = 16) had more severe pain (Mean = 4.5 vs. 2.6; p = 0.001). Physician documented pain etiologies included: musculoskeletal (50%, n = 16), cardiac (22%, n = 7), and headache/neurological (22%, n = 7). Linear regression revealed that significant contributions to QoL included HF Class (p = 0.0001), dyspnea (p = 0.0001), and depression (p = 0.01). Pain was not independently associated with QoL (p = 0.17), but moderately correlated with depression (r = 0.49). Although 15% (n = 11) of patients reported a clinically meaningful improvement in pain scores, it was not associated with improvements in QoL (χ² = 1.6, p = 0.2).

DISCUSSION

Pain is prevalent and persistent, due largely to non-cardiac causes. Although pain did not predict QOL, it was associated with depression, which did adversely affect QoL. Clinicians should screen for and treat both symptoms.

Evidence-Based Heart Failure Medications and Cognition

BACKGROUND

The etiology of cognitive impairment in heart failure (HF) is controversial and likely multifactorial. Physicians may hesitate to prescribe evidence-based HF medication because of concerns related to potential negative changes in cognition among a population that is already frequently impaired. We conducted a study to determine if prescription of evidence-based HF medications (specifically, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blocking agents, diuretics, and aldosterone inhibitors) was associated with cognition in a large HF sample.

METHODS

A total of 612 patients completed baseline data collection for the Rural Education to Improve Outcomes in Heart Failure clinical trial, including information about medications. Global cognition was evaluated using the Mini-Cog.

RESULTS

The sample mean (SD) age was 66 (13) years, 58% were men, and 89% were white. Global cognitive impairment was identified in 206 (34%) of the 612 patients. Prescription of evidence-based HF medications was not related to global cognitive impairment in this sample. This relationship was maintained even after adjusting for potential confounders (eg, age, education, and comorbid burden).

CONCLUSION

Prescription of evidence-based HF medications is not related to low scores on a measure of global cognitive function in rural patients with HF.

Development and feasibility testing of an education program to improve knowledge and self-care among Aboriginal and Torres Strait Islander patients with heart failure

INTRODUCTION

There is a 70% higher age-adjusted incidence of heart failure (HF) among Aboriginal and Torres Strait Islander people, three times more hospitalisations and twice as many deaths as among non-Aboriginal people. There is a need to develop holistic yet individualised approaches in accord with the values of Aboriginal community health care to support patient education and self-care. The aim of this study was to re-design an existing HF educational resource (Fluid Watchers-Pacific Rim) to be culturally safe for Aboriginal and Torres Strait Islander peoples, working in collaboration with the local community, and to conduct feasibility testing.

METHODS

This study was conducted in two phases and utilised a mixed-methods approach (qualitative and quantitative). Phase 1 used action research methods to develop a culturally safe electronic resource to be provided to Aboriginal HF patients via a tablet computer. An HF expert panel adapted the existing resource to ensure it was evidence-based and contained appropriate language and images that reflects Aboriginal culture. A stakeholder group (which included Aboriginal workers and HF patients, as well as researchers and clinicians) then reviewed the resources, and changes were made accordingly. In Phase 2, the new resource was tested on a sample of Aboriginal HF patients to assess feasibility and acceptability. Patient knowledge, satisfaction and self-care behaviours were measured using a before and after design with validated questionnaires. As this was a pilot test to determine feasibility, no statistical comparisons were made.

RESULTS

Phase 1: Throughout the process of resource development, two main themes emerged from the stakeholder consultation. These were the importance of identity, meaning that it was important to ensure that the resource accurately reflected the local community, with the appropriate clothing, skin tone and voice. The resource was adapted to reflect this, and members of the local community voiced the recordings for the resource. The other theme was comprehension; images were important and all text was converted to the first person and used plain language. Phase 2: Five Aboriginal participants, mean age 61.6±10.0 years, with NYHA Class III and IV heart failure were enrolled. Participants reported a high level of satisfaction with the resource (83.0%). HF knowledge (percentage of correct responses) increased from 48.0±6.7% to 58.0±9.7%, a 20.8% increase, and results of the self-care index indicated that the biggest change was in patient confidence for self-care, with a 95% increase in confidence score (46.7±16.0 to 91.1±11.5). Changes in management and maintenance scores varied between patients.

CONCLUSIONS

By working in collaboration with HF experts, Aboriginal researchers and patients, a culturally safe HF resource has been developed for Aboriginal and Torres Strait Islander patients. Engaging Aboriginal researchers, capacity-building, and being responsive to local systems and structures enabled this pilot study to be successfully completed with the Aboriginal community and positive participant feedback demonstrated that the methodology used in this study was appropriate and acceptable; participants were able to engage with willingness and confidence.

Psychological symptoms of family members of high-risk intensive care unit patients

BACKGROUND

Family members of patients in intensive care are at increased risk for psychological symptoms.

OBJECTIVES

To compare levels of posttraumatic stress disorder, anxiety, and depression during and 3 months after the intensive care experience in family members of patients at high risk for dying and to determine if differences were related to the patient's final disposition.

METHODS

Longitudinal descriptive study of 41 family members in 3 tertiary care intensive care units.

RESULTS

By repeated-measures analysis of variance, family members' levels of posttraumatic stress disorder were significantly lower (P = .01) at 3 months after (mean score, 1.27; SD, 0.86) than during (mean, 1.61; SD, 0.81) the experience. Mean anxiety and depression scores were significantly lower (P < .001) after (anxiety: 7.35; SD, 3.91; depression: 5.63; SD, 4.58) than during (anxiety: 11.5; SD, 4.88; depression: 9.51; SD, 4.31) the experience. Scores for posttraumatic stress disorder, anxiety, and depression did not differ significantly between family members of patients who died and family members of patients who survived. Yet, all 13 family members of deceased patients and 42% of the total sample of 41 had traumatic stress scores of 1.5 or greater. Among the total sample, 44% had significant anxiety, and 27% were depressed.

CONCLUSION

Family members' symptoms of posttraumatic stress disorder, anxiety, and depression significantly decreased 3 months after the intensive care experience and did not differ according to the patients' final disposition. However, many family members still had significant risk for posttraumatic stress disorder and borderline anxiety and depression at 3 months.

A randomized controlled trial to reduce delay in older adults seeking help for symptoms of acute myocardial infarction

Older adults with symptoms of acute myocardial infarction (AMI) have longer pre-treatment delay times than their younger counterparts. A 2-group, randomized controlled sample consisted of 115 adults, 65 years of age or older with a self-reported history of coronary artery disease. A pre-test was given to all participants followed by a structured education and counseling intervention to those in the experimental group. Data were re-collected at 3 months. There was a statistically significant increase in knowledge, beliefs, and perceived control without an increase in anxiety in the intervention group. There was no significant difference in attitudes. Older adults at risk for AMI should be targeted for individualized education and counseling in clinics, physician offices, and community centers.

A simplified education program improves knowledge, self-care behavior, and disease severity in heart failure patients in rural settings

BACKGROUND

Self-monitoring by heart failure (HF) patients of worsening symptoms caused by fluid overload is a cornerstone of HF care. Disease management has improved outcomes in HF; however, these resource-intensive programs are limited to urban centers and are generally unavailable in rural or limited health care access areas. This pilot study sought to determine whether a simplified education program focused on a single component of disease management (symptom recognition and management of fluid weight) could improve knowledge, patient-reported self-care behavior, and HF severity in a rural setting.

METHODS

This randomized clinical trial enrolled 36 rural HF patients into an intervention or control group. The intervention group received a simplified education program with a follow-up phone call focusing on symptom management delivered by a non-cardiac-trained nurse. Patient knowledge, self-care behaviors, and HF severity (B-natriuretic peptide [BNP]) were measured at enrollment and at 3 months.

RESULTS

The sample was primarily white men and married with a mean age of 71 years and ejection fraction of 47%. There were no differences between groups in knowledge, self-care behaviors and BNP at baseline; however, knowledge and self-care behavior related to daily weights improved significantly at 3 months in the intervention group (P = .01 and .03, respectively). Although the changes in mean BNP at 3 months were in the hypothesized direction, the difference between the 2 groups was not significant.

CONCLUSIONS

A simplified education program designed for use in resource scarce settings improves knowledge and patient-reported self-care behaviors. These findings are important in providing care to patients with HF in limited access settings but should be studied for longer periods in more heterogeneous populations.

A telephone survey to measure communication, education, self-management, and health status for patients with heart failure: the Improving Chronic Illness Care Evaluation (ICICE)

BACKGROUND

Many aspects of quality of care for heart failure cannot be reliably obtained by chart review.

METHODS AND RESULTS

We created and tested a telephone survey to measure provider-patient communication; satisfaction; patient education, knowledge, and self-management; and health status for the Improving Chronic Illness Care Evaluation. A total of 781 patients participated in the survey; 62% were age 65 or older, 66% had a history of coronary artery disease, and 59% were cared for by a cardiologist. The measures of communication, satisfaction, patient education, knowledge, and self-management performed very well with low rates of missing values and good psychometric properties. The self-efficacy scale had acceptable reliability (Cronbach's alpha 0.69); however, it was weakly correlated with objective measures of knowledge about self-management. The Heart Failure Symptom Scale (HFSS) showed high reliability (Cronbach's alpha 0.88) and good correlation with the SF-12 Physical Health Summary Scale (r=0.63); the HFSS was also moderately correlated with measures of mental health.

CONCLUSIONS

Reliable information about processes of care and health outcomes that cannot be reliably assessed by chart can be obtained by telephone. This tool should be useful for measuring quality of care for large patient populations and determining the effectiveness of quality improvement activities.

Sleep Disturbance Symptoms in Patients With Heart Failure

Sleep disturbances have a major impact on physical functioning, emotional well-being, and quality of life, but are not well described in patients with heart failure (HF). Eighty-four HF patients completed a sleep survey and provided demographic and clinical data. Seventy percent of the patients were male with a mean age of 54 years and a mean left ventricular ejection fraction of 22%. Forty-seven patients (56%) reported trouble sleeping and one-third used sleeping medication. The most frequently reported problems were inability to sleep flat (51%), restless sleep (44%), trouble falling asleep (40%), and awakening early (39%). Using logistic regression, physiological variables were tested as predictors of sleep disturbance. Severity of HF, age, gender, etiology, obesity, smoking, and use of beta-blockers were not predictors of sleep disturbance. HF patients experience significant sleep disturbances, which are not predicted by severity of symptoms or clinical status. Problems with sleep are an important component of a clinical assessment in this vulnerable population.

Quality of life in women with heart failure, normative groups, and patients with other chronic conditions

BACKGROUND

In the United States, 2.5 million women have heart failure, yet little is known about their quality of life. Because most studies included small samples of women, the results are not generalizable.

OBJECTIVE

To compare the quality of life of women with heart failure with that of a normative group and with that of women with other chronic conditions.

METHODS

Descriptive techniques were applied to baseline data collected in the Studies of Left Ventricular Dysfunction trials to characterize quality of life in women with heart failure (n = 691). Global quality of life and the quality-of-life dimensions of physical function, emotional distress, social health, and general health were measured by using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the Beta Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

RESULTS

Compared with the normative group of women, women with heart failure had significantly lower global quality of life; worse vigor, intermediate activities of daily living, social activity, and general health ratings; and higher ratings for anxiety and depression. Fewer than half of the women with heartfailure felt that they were healthy enough to perform normal activities.

CONCLUSIONS

Women with heart failure have worse quality of life than do normative populations and patients with other chronic diseases such as hypertension, Parkinson disease, and cancer.

Predictors of isotonic exercise in patients with heart failure

PURPOSE

Study aims were to determine the predictors of isotonic resistance exercise performance in patients with advanced heart failure and to compare the preexercise values of patients who experienced a negative physiologic response to resistance exercise with those who had minimal or no response.

METHODS

A correlational design was used. After pharmacologic left ventricular unloading therapy using a pulmonary artery catheter, 34 patients with advanced heart failure performed graduated isotonic weight-lifting exercises. Measurements were made of hemodynamics and rating of perceived exertion after each test.

RESULTS

The following variables, measured at baseline, were significantly correlated with the amount of weight patients were able to lift: rating of perceived exertion (RPE; r = -0.42, P = 0.014); diastolic blood pressure (DBP; r = 0.49, P = 0.03); systolic blood pressure (SBP; r = 0.40, P = 0.017); pulmonary capillary wedge pressure (PCWP; r = 0.39, P = 0.026); and right atrial pressure (RAP; r = 0.35, P = 0.041). Multiple regression analysis, using a stepwise procedure, showed that 47% of the variance in exercise performance was explained by DBP, RPE, and PCWP. There were no significant differences in baseline hemodynamics, ejection fraction, or age between the group of patients who had a negative hemodynamic response at peak exercise and the group of patients who had minimal or no response.

CONCLUSIONS

Resting PCWP, DBP, and RPE can provide important information to help clinicians predict isotonic resistance exercise performance in patients with advanced heart failure. However, those patients who have a negative response to this type of exercise cannot be distinguished at baseline by clinical characteristics or age.

Quality of life in patients with heart failure: do gender differences exist?

OBJECTIVE

The purpose of this study was to evaluate gender differences in quality of life (QOL) in a large sample of age-matched and ejection fraction (EF)-matched patients with heart failure.

DESIGN

Matched comparisons of secondary data were used.

SETTING

The setting consisted of multicenter Studies of Left Ventricular Dysfunction trials.

SAMPLE

The sample included 1382 patients (691 men and 691 women) who were age-matched and EF-matched.

OUTCOME MEASURES

Global QOL and the QOL dimensions of physical function, emotional distress, social health, and general health were measured using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the beta-Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

RESULTS

Women had significantly worse general life satisfaction, physical function, and social and general health scores than men. There were no significant differences found between gender groups for current life situation or emotional distress. After controlling for New York Heart Association classification, women still had significantly worse ratings for intermediate activities of daily living (a sub-dimension of physical functioning) and social activity.

CONCLUSIONS

Despite controlling for age, EF, and New York Heart Association classification, women had worse QOL ratings than did men for intermediate activities of daily living and social activity. Research should focus on identifying why differences exist and developing measures to improve QOL, particularly physical functioning, in women with heart failure.

The hemodynamic effects of isotonic exercise using hand-held weights in patients with heart failure

BACKGROUND

Controversy surrounds the use of resistance exercise in patients with heart failure because of concerns that increases in rate-pressure product and systemic vascular resistance might lead to increased afterload and decreased cardiac output.

METHODS

Following pharmacologic left ventricular unloading therapy using a pulmonary artery catheter, 34 patients with advanced heart failure performed isotonic weightlifting exercise at 50%, 65%, and 80% of the calculated one repetition maximum. Measurements were made of hemodynamics, ST segment, rate-pressure product, serum norepinephrine, rating of perceived exertion, and dysrhythmias following each exercise set.

RESULTS

Repeated analysis of variance showed significant increases in systolic blood pressure (p = 0.0005), diastolic blood pressure (p = 0.01), rate-pressure product (p = 0.005); serum norepinephrine (p = 0.004), and rating of perceived exertion (p = 0.0005). However, systemic vascular resistance and cardiac output did not change significantly (p>0.05). Pulmonary capillary wedge pressures, the incidence of dysrhythmias, and ST segments did not significantly differ from baseline. No patients experienced angina or dyspnea during the study.

CONCLUSIONS

Isotonic exercise using hand-held weights was well tolerated hemodynamically and clinically, and no patients experienced adverse outcomes during exercise.

Predictors of quality of life in women with heart failure. SOLVD Investigators. Studies of Left Ventricular Dysfunction

BACKGROUND

Two and one half million women have heart failure (HF). Yet little is known about quality of life (QOL) in this population and the factors influencing it. Given the importance of QOL as an outcome of care, we conducted a study to evaluate predictors of QOL in women with HF.

METHODS

Using baseline QOL data collected in the Studies of Left Ventricular Dysfunction (SOLVD) trials, we studied predictors of QOL in 691 women with HF. Univariate, bivariate, and multiple regression analyses were used. Potential predictors included age, education, tobacco use, social isolation, life stresses, comorbidity index, New York Heart Association (NYHA) class, HF symptoms, etiology, and medications. We measured global QOL and QOL dimensions of physical function, emotional distress, and social and general health.

RESULTS

Women were older (61+/-10.5 years), predominantly Caucasian (75%), and their mean ejection fraction was 0.27 (+/-6.51). Variables with the strongest relationship to QOL included dyspnea, NYHA class, and life stresses. As dyspnea, life stresses, and NYHA class increased, QOL decreased. Additionally, smoking behavior and vasodilator use was associated with decreased QOL. Heart failure etiology of ischemic origin was associated with decreased social life satisfaction, and use of digitalis was predictive of increased social life satisfaction. Finally, increasing age was related to an increase in general life satisfaction.

CONCLUSION

Symptom amelioration, which may improve functional ability, has the greatest potential for increasing QOL in women with HF. Programs to increase physical activity in women with HF should be developed and tested. Finally, clinicians may need to optimize HF medications in women.

A longitudinal causal model of cardiac invalidism following myocardial infarction

BACKGROUND

Invalidism has been discussed in the cardiovascular literature for decades. Researchers have studied health perceptions, emotional distress, and dependency in patients after acute myocardial infarction in an attempt to understand the phenomenon. However, no theory of the manner in which these variables interact has been proposed.

OBJECTIVES

Using previous research, a model of invalidism was specified in which individuals' perceptions that their health is poor lead to emotional distress and increased dependency. As health perceptions improve over time, emotional distress and dependency decrease.

METHOD

Survey data were collected from 111 men and women 1 and 4 months after a first myocardial infarction and were tested using structural equation modeling.

RESULTS

The model was rejected using a confirmatory approach (chi2(89) = 141.40; p= .00034). The fit indices, however, suggested an adequate fit of the model to the data (CFI = .96; NNFI = .94).

CONCLUSION

The conclusion is that the model is reasonable and serves as a starting point for a theory-based empirical exploration of the invalidism process.

Needs of recovering cardiac patients and their spouses: compared views

Identifying the needs of patients and spouses following an acute cardiac event is an essential first step in the development of nursing interventions to facilitate couples' psychosocial adaptation. Therefore, the self-perceived needs of 49 couples were compared 5 months following the patients' hospitalization for an acute cardiac event (i.e. myocardial infarction or coronary artery revascularization). Both patients and spouses identified the need for information as being most important compared with all other needs; however, significant discrepancies were found in ratings between patients and spouses. Needs which spouses rated as having a high priority included receiving information about the patient's feelings during the recovery period, having time alone, talking with the patient about concerns, and receiving information about the expected psychological recovery. Patients did not consider these same needs as they related to their spouses particularly important. Rather, they rated the need for information about their condition, the need to have honest explanations, and the need to talk with a health professional about their problems as having the highest priority. Many of the needs that both patients and spouses ranked as being important or very important were unmet in 40-70% of the cases. In this study, both patients and spouses expressed similar needs for information, but the type of information that they wanted differed and, in the majority of cases, these needs were not met by nurses and physicians.

Does overprotection cause cardiac invalidism after acute myocardial infarction?

OBJECTIVE

To determine if overprotection on the part of the patient's family and friends contributes to the development of cardiac invalidism after acute myocardial infarction.

DESIGN

Longitudinal survey.

SETTING

Nine hospitals in the southwestern United States.

SUBJECTS

One hundred eleven patients who had experienced a first acute myocardial infarction. Subjects were predominantly male, older-aged, married, caucasian, and in functional class I. Eighty-one patients characterized themselves as being overprotected (i.e., receiving more social support from family and friends than desired), and 28 reported receiving inadequate support. Only two patients reported receiving as much support as they desired.

OUTCOME MEASURES

Self-esteem, emotional distress, health perceptions, interpersonal dependency, return to work.

RESULTS

Overprotected patients experienced less anxiety, depression, anger, confusion, more vigor, and higher self-esteem than inadequately supported patients 1 month after myocardial infarction (p < 0.05). Inadequately supported patients were more dependent 4 months after the event.

CONCLUSIONS

Overprotection on the part of family and friends may facilitate psychosocial adjustment in the early months after an acute myocardial infarction rather than lead to cardiac invalidism.

Direct and indirect blood pressure in critical care patients

The purpose of this study was to determine the relationship between direct intraarterial blood pressure readings and indirect auscultated blood pressure readings by using different listening pieces and auscultation sites. The two listening pieces used for correlation and comparison were the bell and the diaphragm of the stethoscope. The two sites for auscultation were the antecubital fossa and the upper arm immediately superior to the internal medial condyle and medial to the biceps tendon. Simultaneous direct and indirect blood pressure readings were obtained from 50 critical care patients with indwelling radial arterial lines. The averages for three blood pressure readings obtained from each site and for each listening piece were correlated and compared with the averages of three simultaneous direct blood pressure readings. Statistical testing was done separately for systolic and diastolic readings. Auscultation techniques using both listening pieces and sites were found to be accurate, r greater than .8 for all correlations; p less than .0001 for all comparisons, but auscultation using the diaphragm of the stethoscope over the brachial artery in the upper arm provided the most accurate readings.

Efficacy of medical therapy tailored for severe congestive heart failure in patients transferred for urgent cardiac transplantation

Cardiac transplantation can only be performed in a few patients with severe congestive heart failure (CHF), due to the shortage of donor hearts. The efficacy of current medical therapy tailored for severe CHF, which has not previously been determined for transplant candidates, is of particular importance in patients considered for urgent cardiac transplantation. In this study, 50 consecutive in-patients transferred from other hospitals for urgent transplantation underwent intensive afterload reduction therapy, initially with intravenous and subsequently with oral vasodilators and diuretics tailored to hemodynamic goals. Oral regimens allowed hospital discharge without surgery for 40 of 50 patients. Nineteen of these patients had arrived on inotropic infusions and 32 had received oral vasodilators in the previous month. Cardiac index increased from 1.9 +/- 0.6 to 2.8 +/- 0.7 liters/min/m2, while pulmonary capillary wedge pressure decreased from 30 +/- 8 to 15 +/- 4 mm Hg and systemic vascular resistance decreased from 1,800 +/- 800 to 1,100 +/- 200 dynes-s-cm-5. Despite poor initial hemodynamics, ejection fraction 16 +/- 4%, serum sodium 131 +/- 6 mEq/liter, and apparent failure of previous medical therapy, actuarial survival for 24 discharged patients receiving sustained medical therapy alone was 67% at 1 year, with 67% of survivors employed full- or part-time, and 14 of 16 (88%) discharged transplant candidates survived until transplantation. By decreasing the need for transplantation to be performed urgently, increased emphasis on the design of medical therapy may allow more effective distribution of limited donor hearts.

Poor survival of patients with idiopathic cardiomyopathy considered too well for transplantation

Although the success of cardiac transplantation has encouraged earlier referral of potential candidates, those with mild symptoms of heart failure are frequently considered "too well" for transplantation. Outcome was investigated for 28 patients with non-ischemic dilated cardiomyopathy and ejection fraction of 25 percent or less who were denied transplantation due to lack of severe symptoms. One-year survival without transplantation was 46 percent. Low stroke volume and history of ventricular arrhythmias were independent predictors of early mortality. High risk, defined as either stroke volume of 40 ml or less or history of ventricular arrhythmia, identified 13 of 14 patients who did not survive one year and only one of 12 one-year survivors (p less than 0.001). Low stroke volume predicted hemodynamic failure (p less than 0.05) whereas arrhythmic history predicted sudden death (p less than 0.001). Clinical status improved in only six patients, all of whom had symptom duration of seven or less months at initial evaluation (p less than 0.001). Thus, patients referred to transplantation for dilated cardiomyopathy with an ejection fraction of 25 percent or less have a poor prognosis even if symptoms are mild. Patients with high hemodynamic risk may require early transplantation, whereas those with high arrhythmia risk may require other aggressive therapy in order to avoid transplantation until symptoms become severe.

Urgent priority transplantation: when should it be done?

The success of heart transplantation has created longer waiting lists of candidates, some of whom require transplantation urgently. Decisions must be made regarding which patients require urgent transplantation and how many donor hearts should be committed to urgent transplantation. To determine whether some patients who are considered refractory to medical therapy may be stabilized for elective transplantation, 40 patients transferred for urgent transplantation underwent intensive vasodilator and diuretic therapy, and outcomes were determined. To examine the impact of urgent transplantation on survival, we then determined the survival for urgent priority candidates in the western region. Discharge of the patients who were receiving oral dosages of vasodilators and diuretics was possible for 32 of 40 patients (80%), with a 6-month actuarial survival of 75% on medical therapy, despite an initial ejection fraction of 0.15 +/- 0.04, a cardiac index of 1.9 +/- 0.6 L/min/m2, and a pulmonary wedge pressure of 30 +/- 8 mm Hg. Of 11 patients discharged to await regular priority transplantation, one died suddenly, one died postoperatively, and the others went home 14 +/- 4 days after transplantation. The eight patients unable to be discharged after transfer had lower initial mean arterial pressures and serum sodium levels. Of 59 urgent priority patients from the five western region programs, 50 patients underwent transplantation after 33 +/- 41 days. Subsequent 1-month survival was 88% and overall survival 80%, compared with 97% and 90% in 137 regular priority patients, with a 4.5 times greater risk of early mortality in the urgent group (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Compliance: an interactionist approach

Compliance is central to health care, but by its very nature it remains problematic to health care providers and health care receivers. In this article an interactional approach, the utilization of role theory, in the study of compliance is proposed. Rationale for the need for such a framework is provided through the presentation and critique of currently used models and theories, such as the medical model, the health belief model, control theory, and learning theory. Assumptions of the proposed framework are presented, and four components are identified when considering compliance enactment from an interactional perspective. These are: self-concept, role enactment, complementary roles, and periodic evaluation of role enactment by self and others. Several theoretical propositions evolve as central to the development of a unified framework for compliance. The propositions can be considered potential hypotheses. This article demonstrates one approach to theory development in nursing.

Using nursing research findings to meet the needs of grieving spouses

This article describes the utilization of nursing research findings in a coronary care setting. A standardized nursing care plan, based on Hampe's eight research-identified needs of grieving spouses, was developed by staff nurses in an intensive care unit. The 13 spouses of acutely ill coronary patients who had received specific nursing interventions reported more of their needs were met by nurses than did 13 spouses on whom base-line data were collected prior to the adoption of systematic nursing interventions.