Changes in Dietary Behavior among Coronary and Hypertensive Patients: A Longitudinal Investigation Using the Health Action Process Approach

BACKGROUND

Cardiovascular diseases (CVDs) are a major cause of worldwide morbidity and mortality. Nutrition plays an important role in the primary, secondary, and tertiary prevention of CVDs. The present longitudinal study used the Health Action Process Approach (HAPA) to investigate changes in dietary behavior in coronary patients (CPs) affected by acute coronary syndrome and hypertensive patients (HPs) affected by essential arterial hypertension.

METHODS

CPs (N = 250) and HPs (N = 246) completed a questionnaire during three measurement points (baseline, 6-month follow-up, and 12-month follow-up). Statistical analyses included a repeated measures ANOVA and a multi-sample structural equation model.

RESULTS

HPs showed no changes in dietary behavior, whereas CPs improved their nutrition at 6 months and then maintained the healthier diet. The multi-sample analysis indicated equivalence of the HAPA model for both patient populations.

CONCLUSIONS

These findings provide further evidence for the generalisability of the HAPA model, shedding light on dietary behavior among CVD patients and particularly on hypertensive patients which has received little attention. Moreover, the equivalence of the model suggests that the process of change is almost identical for individuals who are at high risk for a coronary event (i.e. HPs) and individuals who have already had the event (i.e. CPs).

Cardiac rehabilitation and mid-term follow-up after transcatheter aortic valve implantation

BACKGROUND

Evaluation of patient outcomes following transcatheter aortic valve implantation (TAVI) has usually been based on survival and clinical improvement. Studies on quality of life are limited, and data from comprehensive assessments after the procedure are lacking.

METHODS

Sixty patients referred for cardiac rehabilitation after TAVI underwent in-hospital and after-discharge multidimensional assessments to evaluate clinical, functional, and nutritional statuses, degree of autonomy, cognitive impairment, depression and quality of life.

RESULTS

On admission to rehabilitation, approximately half of the patients had severe functional impairment and dependence for basic activities of daily living. During their hospital stay, one-third of the patients suffered significant clinical complications and two had to be transferred to the implantation center. Despite this, the overall outcome was very good. All of the remaining patients were clinically stable at discharge and functional status, autonomy and quality of life were improved in most. During a mean follow-up of 540 days (range: 192-738 days), five patients died from noncardiac causes, three were hospitalized for cardiac events, and nine for non cardiac reasons. Functional status and autonomy remained satisfactory in the majority of patients and most continued to live independently.

CONCLUSIONS

Patients referred for rehabilitation after TAVI are often very frail, with a high grade of functional impairment, dependence on others and high risk of clinical complications. During a rehabilitation programme, based on a multidimensional assessment and intervention, most patients showed significant improvement in functional status, quality of life, and autonomy, which remained stable in the majority of subjects during mid-term follow-up.

Regression of cardiac valvulopathy related to ergot-derived dopamine agonists

AIMS

In a previous echocardiographic prevalence study we reported a significant increase in the frequency of heart valve regurgitation in patients with Parkinson's disease taking the ergot-derived dopamine agonists pergolide and cabergoline versus controls. We followed-up our original cohort of patients to ascertain whether valvulopathy regressed after discontinuation of treatment and/or its incidence increased over time.

METHODS

Prospective follow-up of 101 patients treated with ergot-derived dopamine agonists included in the prevalence study: 53 given pergolide and 48 cabergoline (64% male; 66.4 ± 8.7 years of age, 11.5 ± 5.9 years of disease, 21.8 ± 5.9 months of follow-up); 55 stopped treatment while 46 continued. The main outcomes measures, were: echocardiographic quantification of regurgitant valve disease, abnormal leaflet, or cusp thickening and measurement of mitral valve tenting area.

RESULTS

Valve abnormalities regressed in about one third of patients with significant multivalvular and in about half of the patients with monovalvular regurgitation who withdrew; no progression was observed in remaining patients. Patients continuing ergot-derived dopamine agonists showed progression of cardiac valvulopathy: seven new cases with three to four regurgitation grade of any valve occurred during follow-up; this regarded also patients who had been on pergolide for many years.

CONCLUSION

Owing to the persistence of risk of heart valve damage over time and the lack of its mid-term reversibility in many patients, we believe that pergolide and cabergoline should be prescribed only when therapeutic alternatives with a better risk/benefit ratio are unavailable and the patient has access to echocardiography.

Valvular heart disease and the use of dopamine agonists for Parkinson's disease

BACKGROUND

Ergot-derived dopamine receptor agonists, often used in the treatment of Parkinson's disease, have been associated with an increased risk of valvular heart disease.

METHODS

We performed an echocardiographic prevalence study in 155 patients taking dopamine agonists for Parkinson's disease (pergolide, 64 patients; cabergoline, 49; and non-ergot-derived dopamine agonists, 42) and 90 control subjects. Valve regurgitation was assessed according to American Society of Echocardiography recommendations. The mitral-valve tenting area was also measured and used as a quantitative index for leaflet stiffening and apical displacement of leaflet coaptation.

RESULTS

Clinically important regurgitation (moderate to severe, grade 3 to 4) in any valve was found with significantly greater frequency in patients taking pergolide (23.4%) or cabergoline (28.6%) but not in patients taking non-ergot-derived dopamine agonists (0%), as compared with control subjects (5.6%). The relative risk for moderate or severe valve regurgitation in the pergolide group was 6.3 for mitral regurgitation (P=0.008), 4.2 for aortic regurgitation (P=0.01), and 5.6 for tricuspid regurgitation (P=0.16); corresponding relative risks in the cabergoline group were 4.6 (P=0.09), 7.3 (P<0.001), and 5.5 (P=0.12). The mean mitral tenting area was significantly greater in ergot-treated patients and showed a linear relationship with the severity of mitral regurgitation. Patients treated with ergot derivatives who had grade 3 to 4 regurgitation of any valve had received a significantly higher mean cumulative dose of pergolide or cabergoline than had patients with lower grades.

CONCLUSIONS

The frequency of clinically important valve regurgitation was significantly increased in patients taking pergolide or cabergoline, but not in patients taking non-ergot-derived dopamine agonists, as compared with control subjects. These findings should be considered in evaluating the risk-benefit ratio of treatment with ergot derivatives.

[Work capacity and re-entry into the workforce for the cardiac patient]

BACKGROUND

Treatment and rehabilitation of patients with heart disease is focused on survival, work resumption, achievement of a state of subjective well-being and compliance with behavioural changes in order to prevent progression of the atherosclerotic process.

OBJECTIVES

To propose a specific job fitness evaluation method for workers with heart disease, based on analysis of occupational factors influencing the cardiovascular system and the definition of a clinical and functional profile of the patient, with special regard to aspects influencing vocational attitude.

METHODS

A literature review was performed.

RESULTS AND CONCLUSION

Although resumption of work is not the sole objective in the rehabilitation process, it remains an important goal not only for economic reasons, but also because it is beneficial for most patients' psychological well-being. However, it must be admitted that specific job fitness evaluation is rarely performed during rehabilitation programmes of cardiac patients and this can cause problems at the time of return to work. Doubts and uncertainties are also due to the lack of standardized evaluation methods and to the clinical peculiarity of these patients, mainly due to the risk of sudden disability. The job fitness evaluation method used in this study allows physicians to perform assessments based on objective data, so improving patients' confidence in their work capacity. To achieve a satisfactory application of the method, close cooperation between the cardiologist and the occupational physician is necessary.

Exercise training in mild hypertension: effects on blood pressure, left ventricular mass and coagulation factor VII and fibrinogen

The aim of this study was to assess the effects of aerobic exercise on resting and 24-hour blood pressure (BP), left ventricular mass (LVM), plasma fibrinogen and factor VII (FVII). For this purpose 14 sedentary subjects with untreated diastolic BP between 90 and 104 mm Hg completed a 12-week supervised exercise program. At the end of this period, 8 subjects resumed a sedentary life-style and were reexamined 2 months later (detraining). Baseline, posttraining and postdetraining examinations included resting BP assessment, ambulatory BP monitoring, cardiopulmonary stress test, echocardiography and measurements of plasma fibrinogen and FVII. Exercise-mediated increase in aerobic fitness (VO2 max + 24%) was associated with a significant reduction in resting systolic and diastolic BP (p < 0.01), mean systolic and diastolic 24-hour BP (p < 0.001) and LVM index. As for the coagulation parameters only the concentration of fibrinogen significantly decreased (p < 0.01) whereas FVII remained unchanged. The 8 subjects that resumed a sedentary life-style were reexamined 2 months later: their resting BP, 24-hour BP and fibrinogen concentration returned to baseline values; only the effect on LVM was conserved. Our study underlines the usefulness and safety of regular physical exercise in mild hypertension. Most of the patients (11 of 14) had their BP normalized and a significant reduction in LVM and fibrinogen concentration was observed, leading to an overall improvement in coronary risk profile.

[Physical training exercise reduces the plasma levels of fibrinogen in subjects with mild hypertension]

We evaluated the behaviour of plasma fibrinogen in subjects undergoing physical training in a prospective non-controlled open study, carried out in 14 sedentary, mildly hypertensive individuals (mean age 52 +/- 5 years). Subjects underwent 3 months of controlled physical training (3 times a week) tailored to reach, at each session, 80-90% of maximal heart rate based upon a baseline test. Before and after the period of training, resting systolic and diastolic blood pressure, 24-hour systolic and diastolic blood pressure, plasma fibrinogen, body mass index (BMI), maximum oxygen consumption (VO2max), serum cholesterol and triglycerides were evaluated. After training VO2 max increased (24 +/- 5 vs 30 +/- 5 mL/Kg/min, p < 0.01); there were no variations in BMI (24 +/- 2 vs 23 +/- 2 Kg/m2, p = 0.35), cholesterol (220 +/- 30 vs 213 +/- 36 mg/dL, p = 0.41) or triglycerides (117 +/- 51 vs 118 +/- 37 mg/dL, p = 0.58). Resting systolic (148 +/- 10 vs 133 +/- 10 mmHg, p < 0.01) and diastolic blood pressure (97 +/- 5 vs 85 +/- 6 mmHg, p < 0.01) and 24-hour systolic (135 +/- 6 vs 129 +/- 5 mmHg, p < 0.01) and diastolic blood pressure (86 +/- 7 vs 81 +/- 6 mmHg, p < 0.01) decreased; plasma fibrinogen also decreased (324 +/- 60 vs 278 +/- 53 mg/dL, p < 0.01). Eight individuals tested 5 months after cessation of training, showed a return of fibrinogen, blood pressure and VO2 max to baseline values.(ABSTRACT TRUNCATED AT 250 WORDS)

[Health surveillance and prevention in the service industries: the problems and outlook]

The great expansion of the services industry in the developed countries of the world is producing profound changes in the composition of the work force and, consequently, also in the health needs that are traditionally part of occupational medicine. Of all the medical disciplines, occupational medicine is most strongly affected by social and economic changes. In recent years experience has been acquired both at national and international level that can identify the new health needs in practical terms. The aim of this paper is to describe such experience with particular reference to the situation in Italy. The authors describe the shift of prevalent diseases from occupational to work-related diseases, the problems concerning the human, social and economic cost of these diseases, prevention and control strategies, relationships between company health services and the national health service and possible synergic action of the public and private sectors.

[New problems in occupational medicine: findings on the risk of coronary heart disease in the services industry]

The distribution of the major coronary risk factors: total and HDL cholesterol, blood pressure, smoking and body mass index, was studied during the course of a routine screening of 1404 male bank employees in Northern Italy. The recent Italian and international consensus conferences and particularly the results from the Italian areas of the WHO-MONICA Project were taken as reference points. There was a widespread coronary risk in the bank employees who had a 5-10% excess of cholesterol, corresponding to a 10-20% increase in the theoretical risk of coronary heart disease. Compared to the data produced by the Lipid Research Clinics (USA), coronary risk appeared higher for all the surveyed factors in the Italian general population, and particularly in bank employees. Greater stress at home and at work and above all the change from the traditional, poor Mediterranean diet to a richer diet might provide an explanation for these results. A new perspective is thus opened for occupational health due to the new health problems produced by the cultural and technological changes occurring in the country.

Can glycosylated hemoglobin be a job stress parameter?

Glycosylated hemoglobin (HbA1c) levels are evaluated as a possible integrated measure parameter of chronic job stress. HbA1c and fasting blood glucose levels in 100 healthy male printing workers (pressmen) exposed to noise, rotating shifts, and overwork were compared with levels measured in 200 healthy male clerical workers not exposed to those stressors. While blood glucose levels and their variability were found to be approximately the same in both groups, HbA1c levels were found to be 8.64% higher among the pressmen and this difference was significant at p less than .001. These findings support the hypothesis, and further research to confirm the test is suggested.