ALLiance for sEcondary PREvention after an acute coronary syndrome. The ALLEPRE trial: A multicenter fully nurse-coordinated intensive intervention program

The main objective of cardiovascular disease prevention is to reduce morbidity and mortality by promoting a healthy lifestyle, reducing risk factors, and improving adherence to medications. Secondary prevention after an acute coronary syndrome has proved to be effective in reducing new cardiovascular events, but its limited use in everyday clinical practice suggests that there is considerable room for improvement. The short-term results of evidence-based studies of nurse-coordinated secondary prevention programs have been positive, but there is a lack of long-term outcome data. The Alliance for the Secondary Prevention of Cardiovascular Disease in the Emilia-Romagna region (ALLEPRE) is a multicenter, randomized, controlled trial designed to compare the effects of a structured nurse-coordinated intensive intervention on long-term outcomes and risk profiles after an acute coronary syndrome with those of the standard of care. All of the patients randomized to the intervention group take part in 9 one-to-one sessions with an experienced nurse from the participating centers with the aim at promoting healthy lifestyles, reducing risk factors, and increasing adherence to medication over a mean period of 5 years. The primary clinical end point is the reduction in the risk of the 5-year occurrence of major adverse events (a composite of cardiovascular mortality, nonfatal reinfarction, and nonfatal stroke). The primary surrogate end point is the achievement of prespecified targets relating to classical risk factors, lifestyle modifications, and adherence to pharmacological therapy after 2 years of follow-up. Coronary heart disease is a chronic degenerative disease, and patients who recover from an acute coronary syndrome (ACS) are at high risk of developing recurrent events.1 Although secondary prevention measures have proved to be effective and are strongly recommended by all of the international guidelines,2., 3. the 4 EUROASPIRE surveys4., 5., 6., 7., 8. showed that there was still a high prevalence of conventional risk factors, that secondary prevention measures were inadequately implemented, and that their main goals were often not reached. In addition, there were considerable discrepancy in secondary prevention practices between centers and countries, and a widespread underuse of cardiac prevention and rehabilitation programs despite their demonstrated effectiveness in reducing cardiovascular risk over time.9., 10. Over the last 10 years, nurses have been increasingly involved in successful cardiovascular risk management,11., 12., 13. but although this has improved levels of cardiovascular risk, no clear reduction in hard end points such as major cardiovascular adverse events and mortality has been demonstrated.10 The aim of the ALLEPRE trial is to evaluate the benefit of a homogeneous, structured, secondary prevention intervention program, fully coordinated by nurses from in- and outpatient clinics, in terms of cardiovascular risk profiles and major clinical events in ACS patients living in the large Emilia-Romagna region of Italy.

Bio-clinical and psycho-social nursing practice. An experimental research in an Intensive Coronary Care Unit

BACKGROUND AND AIM

The literature on patients with cardiovascular disease emphasizes the importance of providing a bio-medical and a psycho-social nursing care during the three phases of the nursing process (acceptance, assistance, education). How is his multidimensional nursing approach actually used during nursing practice? The present study aimed to evaluate the effects of a nursing educational training and it was finalized to implement a multidimensional care practice of nurses working in Intensive Coronary Care Unit (I.C.C.U.).

METHOD

The entire nursing staff of the I.C.C.U of Parma Hospital (N = 17) took part in the research and it has been randomized in two subgroups. A group of 9 nurses participated as experimental group. They filled up a semi-structured questionnaire investigating the bio-clinical and psycho-social nursing activities, before (pre-test, time 1) and after (post-test, time 2) a professional training. 8 nurses participated as control group. They filled out the same questionnaire (at the time 1 and 2), but they did not participate at the professional training.

RESULTS

Results indicated how the nursing practice was more related to the bio-clinical (e.g. blood pressure) than to the psycho-social (e.g. mood) activities at the time 1. After the professional training (time 2), only the experimental group changed its professional practice, by integrating the bio-medical with the psycho-social nursing.

CONCLUSIONS

The data showed the importance to promote a multidimensional educational path for nurses that assess the impact of the professional training on the professional practice, in order to improve the quality of care delivered to patients affected by cardiovascular disease.

Using interactive voice response to improve disease management and compliance with acute coronary syndrome best practice guidelines: A randomized controlled trial

BACKGROUND

There is evidence from large clinical trials that compliance with standardized best practice guidelines (BPGs) improves survival of acute coronary syndrome (ACS) patients. However, their application is often suboptimal.

PURPOSE

In this study, the researchers evaluated whether the use of an interactive voice response (IVR) follow-up system improved ACS BPG compliance.

METHOD

This was a single-centre randomized control trial (RCT) of 1,608 patients (IVR=803; usual care=805). The IVR group received five automated calls in 12 months. The primary composite outcome was increased medication compliance and decreased adverse events.

RESULTS

A significant improvement of 60% in the IVR group for the primary composite outcome was found (RR 1.60, 95% CI: 1.29 to 2.00, p <0.001). There was significant improvement in medication compliance (p <0.001) and decrease in unplanned medical visits (p = 0.023). At one year, the majority of patients ( 85%) responded positively to using the system again. Follow-up by IVR produced positive outcomes in ACS patients.

Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention

BACKGROUND AND AIM

Secondary prevention after an acute coronary syndrome (ACS) has proved to be effective in patients with coronary heart disease, and is strongly recommended by the international guidelines. However, there is a lack of widespread secondary preventive programmes in real-world clinical practice, even though it has been shown that these can be successfully conducted by nurses.

METHOD AND RESULTS

We have designed a multicentre randomised trial involving patients with ACS in which nurses will fully coordinate secondary prevention in the intervention arm using a multidimensional nursing form after attending ad hoc teaching sessions.

Therapeutic adherence and health outcomes in acute coronary syndrome (SCA) patient: the role of nursing

BACKGROUND AND AIM

The literature on cardiovascular disease has highlighted that therapeutic adherence is often inadequate. What are the reasons for this poor adherence to medication? The goal has been to measure the different factors related to therapeutic adherence,  differentiating the SCA patients on three levels of self-referred therapeutic adherence and delving the relations between self-reported therapeutic adherence and socio-demographic, clinical, emotive, cognitive and socio-relational variables.

METHOD

A total of 84 Italian patients (66.7% males) with (SCA) took part in the study and completed a semi-structured questionnaire investigating the variables described above.

RESULTS

RESULTS indicate the influence of clinical variables, showing that patients suffer more of dyspnea and angina symptoms than those that state to follow prescriptions. But the emotive aspects seem able to interfere more with the adherence: the subjects scarcely adherent have felt more threatened by their illness, and experimented more symptoms of anxiety and sadness than highly adherent patients. At a cognitive level the adherent patients have chosen coping strategies not centred on emotions, but headed to the solution of the problem. At socio-relational level is confirmed the importance of the social support in favouring the adherence.

CONCLUSIONS

Among the different factors here considered, are those psychological and relational that tend to be associated to level of adherence for prescriptions. The outcomes have shown that the demo-graphical and clinical variables result are not tightly associated to the adherence, confirning instead the importance of psycho-social factors, as already notable in the literature in heart studies. The implications have been discussed.

Content validity of the Toronto Pain Management Inventory-Acute Coronary Syndrome Version

BACKGROUND

Cardiac pain and/or discomfort arising from acute coronary syndromes (ACS) can often be severe and anxiety-provoking. Cardiac pain, a symptom of impaired myocardial perfusion, if left untreated, may lead to further myocardial hypoxia, which can potentiate myocardial damage. Evidence suggests that once ACS patients are stabilized, their pain may not be adequately assessed. Lack of knowledge and problematic beliefs about pain may contribute to this problem. To date, no standardized tools are available to examine nurses' specific knowledge and beliefs about ACS pain that could inform future educational initiatives.

AIM

To examine the content validity of the Toronto Pain Management Inventory-ACS Version (TPMI-ACS), a 24-item tool designed to assess nurses' knowledge and beliefs about ACS pain assessment and management.

METHODS

Eight clinical and scientific experts rated the relevance of each item using a four-point scale. A content validity index was computed for each item (I-CVI), as well as the total scale, expressed as the mean item CVI (S-CVI/AVE). Items with an I-CVI > or = 0.7 were retained, items with an I-CVI ranging from 0.5-0.7 were revised and clarified, and items with an I-CVI < or = 0.5 were discarded.

RESULTS

I-CVIs ranged from 0.5-1.0 and the S-CVI/AVE was 0.90, reflecting high inter-rater agreement across items. The least relevant item was eliminated.

CONCLUSIONS

Preliminary content validity was established on the TPMI-ACS version. All items retained in the TPMI-ACS version met requirements for content validity. Further evaluation of the psychometric properties of the TPMI-ACS is needed to establish criterion and construct validity, as well as reliability indicators.

Acute coronary syndrome

Implementation of the AHA/ACC standards for AMI is crucial for patient management and outcomes. The Centers for Medicare/Medicaid (CMS) has established indicators within the AMI core measure to ensure the evidence-based care is provided during the hospital stay. This core measure includes specific indicators that must be documented in the medical record. Refer to Box 2 for a list of the indicators. A recent announcement by the United States Department of Health and Human Services (HHS) stated the United States is declaring war on heart disease. Current costs for treating heart disease and stroke is estimated to be $1 out of every $6 in health care expenditures. This initiative is called the "Million Hearts Initiative." Ten states will receive $85 million in grants for the purpose of addressing chronic diseases targeting weight reduction, smoking cessation, control of lipids, and prevention of diabetes. Early recognition and early intervention for patients with ACS, followed by management of risk factors with secondary prevention strategies, are key to decreasing ACS-related mortality. Management of the ACS patient does not end with discharge from the hospital, but is continued throughout the patient's lifetime.

Patient-centred assessment of social support, health status and quality of life in patients with acute coronary syndrome

BACKGROUND

Measurement of health status (HS) and social support are becoming increasingly accepted as tools to guide clinical decision-making and patient-centred practice.

PURPOSE

To assess self-reported HS, cardiac-health related quality of life and social support in subjects with a diagnosis of acute coronary syndrome (ACS).

DESIGN

The study used a quantitative descriptive design.

SAMPLE

36 subjects with a diagnosis of ACS were selected from patients admitted to medical units at a teaching hospital in Toronto, Ontario.

METHODS

One-time, semi-structured interviews were conducted using valid and reliable cardiac-specific HS and social support measures.

RESULTS

Analysis indicated that subjects with higher perceived social support and patients with higher income reported greater treatment satisfaction and C-HROL. Subjects with severe angina reported a higher perceived level of social support than those with more moderate physical limitation due to angina.

CONCLUSION

Patients' social environment and HS significantly impact their satisfaction with treatment. Patient-centred measures assist in clinical decision-making, patient-centred care planning and patient involvement in their care.

[Effectiveness of a nurse-led educational intervention for patients admitted for acute coronary syndrome]

OBJECTIVE

To assess the effectiveness of a nurse-led class with phone follow-up, to help patients achieve lifestyle changes after an acute coronary syndrome (ACS).

METHODS

Each patient < or = 75 years, admitted to a intensive cardiac care unit (ICCU) for ACS from September 2003 to December 2004, who attended the education class (case) was matched with two patients paired for age, sex and admission time, admitted for ACS to ICCUs in the other hospitals in the same area (controls). One year later the two groups were blindly interviewed on the phone, using a structured questionnaire about their lifestyles.

RESULTS

One-hundred-nineteen cases and 238 controls were phoned and 84% cases and 61% controls completed the interview. Cases reported a more correct lifestyle: they ate > or = 4 portions/day of fruit or vegetables (55% vs. 36%, p = 0.003) and > or = 2 portions/week of fish (48% vs. 32%, p = 0.010), reported > or = 30 min/day of physical activity (67% vs. 59%, p = 0.262) and stopped smoking (82% vs. 71% of previous smokers, p = 0.264).

CONCLUSION

An educational intervention led by cardiology nurses, with a group meeting and personal phone follow-up, improved lifestyle habits one year after an ACS.

Introduction to electrocardiogram interpretation: part 2

Twelve-lead electrocardiograms (ECGs) record 12 different views of cardiac electrical activity, or leads. They therefore provide more information than bedside monitors, which usually record one or sometimes two leads. Many acutely ill patients have 12-lead ECGs recorded either on admission to hospital, before undergoing operations or when specific cardiac concerns have arisen. Traditionally, ECGs have aided clinical diagnoses and, by learning how to understand and interpret them, nurses will know when they need to summon expert help. This article describes what each of the 12 leads represents, outlines the main indications for recording 12-lead ECGs and identifies likely causes of error in interpreting them.

Student satisfaction with high-fidelity simulation: does it correlate with learning styles?

The purpose of this study was to explore how learning styles correlate with student satisfacation when high-fidelity human simulation is used in a baccalaureate nursing program. Seventy-eight undergraduate students enrolled in an advanced medical-surgical course completed the Student Satisfaction and Self-Confidence in Learning scale after participating in an experiental learning lab activity that included high-fidelity human simulation-enhanced cardiac case scenarios. Data were then correlated with learning styles identified by a nurse entrance test. Analyses of the data revealed positive relationships between the social and solitary learning styles and student satisfaction with simulation.

[Enzymatic biomarkers]

The demand of consultation in the emergency rooms by patients with SICA without elevation of segment ST has modified the methodology in the integration of his diagnose, the seric markers are key point in this process isoenzymes can determine foretell and treatment in addition to new markers based on the inflammatory process of the atherosclerosis that stratifies the cardiovascular risk of the patient. The obtaining of these data obtains by total blood sample in qualitative and quantitative form permit in short time of 10 to 15 minutes, which allows to make agile the therapeutic interventions and to limit the damage the patient.

[Pharmacologic treatment of the ischaemic syndromes]

The term acute coronary syndromes includes a phantom of symptomatic clinical pictures that represent the acute occlusion of the coronary arteries by diverse degrees of plate of cholesterol, clot and spasm. They are divided in acute coronary ischemic syndromes without elevation of the ST (instable angina). And with elevation of the ST (acute infarct to the myocardium). The pharmacologic therapy includes a treatment in common for the syndromes before diagnosing the tipe of syndrome, this called therapy attached treatment includes the administration of oxygen, morphine, aspirin, nitrates, betablock, astatines and laxatives. The treatment for the acute coronary ischemic syndromes without elevation of the ST is with a preservative strategy where plaquetary antithrombotic drugs are used, while in the treatment of the acute coronary ischemic syndromes with elevation of the ST the strategy is of repercussion with the fibrinolytic drugs use like streptokinase anda rt-PA. The participation of infirmary is essential during the evolution and treatment of the individual dividing in four sections its interventions according to the clinical situation and time of intervention.