Cardiac Rehabilitation Team Research Articles

Role of Pharmacist in Cardiac Rehabilitation Team

Role of Pharmacist in Cardiac Rehabilitation Team

Abstract P263: Understanding Facilitators Of Cardiac Rehabilitation Completion In Women: A Grounded Theory Approach

Research demonstrates that cardiac rehabilitation (CR) programs improve cardiac outcomes and decrease mortality. However, less than 20% of referred women attend CR programs. Of those studies we found, most researchers studied men or barriers to participation. Little is known about factors that motivate or facilitate women to participate in CR. The purpose of this study is to address that gap. A grounded theory (GT) design was used to develop a theoretical understanding of the decision-making process employed by women who attended 25 or more CR sessions. We sought to identify factors that facilitated CR participation. Grounded theory is theory generating, not theory testing; no research questions or hypotheses are appropriate. Digitally recorded interview data from 12 women and 2 men (contrary cases) from a single Phase II CR program at a large healthcare system was reviewed by the research team. Data collection and analysis occurred simultaneously (constant comparative method) and open, axial and selective coding was used to develop the theoretical framework. Data analysis revealed three requisite conditions (catalysts, expectations, reinforcers) for participation in CR by women. Initially, participation was predicated by a cardiac event (catalyst) and CR recommendation. Then women participated because they believed CR would be effective (expectations). Finally, friendliness, reassurance, and validation from the CR team plus feeling better (reinforcers) were the factors that kept them coming back week after week. Unlike previous studies, factors such as transportation and financial resources did not impact the decision to participate in CR. These factors were perceived by the women interviewed to be nice but not necessarily critical to their decision to participate in CR. It was interesting to note that of all reinforcing factors, the relationship between the participant and the CR staff was the most important factor that facilitated continued participation. Previous research and interventions have been directed toward removing barriers to participation. This is the first study to explore factors that facilitate rather than impede participation and to identify requisite factors specific to women. Findings from this study provide a theoretical foundation for understanding ways to improve CR participation by women.

4033A way forward for cardiac rehabilitation - Nurse clinics with active holistic patient management

Abstract Background Early cardiac rehabilitation (CR) nurse follow up clinics 2- 3 weeks post hospital discharge have been instituted at our Hospital for all patients with established coronary artery disease to improve patient engagement and adherence. In the last 2 years these clinics have increased in attendance rates and patient complexity. These now have medical supervision, allowing for active management of patients. Patients are seen multiple times to maximize evidence based treatments by the same nurse. Risk factors are addressed in these clinics and patients are invited into cardiac rehabilitation education classes and individualized prescribed exercise programmes. Purpose To assess rates of adherence and intervention in CR nurse clinics. Methods The CR team at our Hospital has prospectively recorded rates of adherence and interventions at Nurse Specialist clinics over a 12 month period. Results 718 (94%) patients attended CR nurse clinics following discharge. Of these 413 (57%) patients had an intervention in clinic: up titration was 38% for RAAS/beta blocker, 11% for statin and 18% for antianginal and BP medication. A further 21% were referred for further investigations or treatments including admission to hospital. 48% (Standard deviation 11%) attended a cardiac rehabilitation programme in addition to these 1 hour clinics. Interventions in clinic Conclusion Nurse Specialist clinics with medical supervision that are scheduled early post discharge provide a safety net for patients who are discharged following short hospital stays. They also lead to increased prescription of secondary prevention medication and ensure patients have appropriate investigations and referrals. These clinics have resulted in change in practice with routine doctor follow up clinics now cancelled. Long term follow-up for patients is now rationalized and has freed up doctor clinics for more complex patients. Early and intensive engagement with patients is also associated with higher uptake of cardiac rehabilitation programs. Acknowledgement/Funding None

Mental consequences and behavioral health 18 month after outpatient cardiac rehabilitation in three separated profiles at baseline

ObjectivesThe study aims to perform a cluster analysis on the mental health of patients at the cardiac rehabilitation (CR) baseline as well as attendance in sessions and to compare the mental health and healthy behaviors of the samples in an 18-month follow-up. MethodsIn the first phase of this longitudinal study, 148 CR patients in western Iran participated from January to April 2016. After completing the standard questionnaires, the participants attended 7–26 exercise sessions on average. Then, the cluster analysis was performed based on anxiety, depression, and the number of attended sessions. During the 18-month phone follow-up, 113 participants answered the other standard instruments. The long-term mental and behavioral consequences were compared among the derived clusters using ANOVA and Tukey post-hoc test. ResultsThe average age of participants (69.9% male) was 59.3 ± 9.1. The analysis suggested three clusters: (i) patients with medium distress and weak participation, (ii) patients with mild distress and average participation, and (iii) patients with medium distress and good participation. While there was no significant difference among the clusters with regards to healthy behaviors and mortality rate, the difference was significant with regards to psychological distress, somatic symptoms, duration and quality of sleep, and general quality of life (P < 0.05). ConclusionInitial distress and weak participation of outpatients in CR has more severe long-term somatic and psychological consequences. Screening of increased psychological distress and identification of candidates for failure to adhere to CR at the baseline are considered among the most important responsibilities of the CR team.

Establishment of cardiac rehabilitation program in Yazd-Iran: An experience of a developing country

BackgroundCardiovascular diseases are the most common causes of mortality in the world including Iran and are one of the main causes of disability. Cardiac Rehabilitation (CR) is a multidisciplinary program that helps CVD patients recover faster after a heart attack and avoid any subsequent incident. This report determined the current state of CR in Yazd, Iran. Characteristics of the programHospital-based Afshar CR program in Yazd, Iran, is the only CR facility in Yazd province, which is located in the centre of Iran. Currently, the Afshar CR program has four phases including inpatient, sub-acute, outpatient and maintenance. The CR team includes cardiologists and heart surgeons as physicians, and physical medicine rehabilitation specialist, outpatient and inpatient resident medical officers, psychiatrists, nutritionists, psychologists, physiotherapists and social workers. DiscussionGiven the facilities and training programs mentioned above, the rate of patient referral to the center by the inpatient CR team during the short life of CR in this center was 60%, the patient participation rate was 6.9% and the enrollment rate was 55%. In addition, over the past three years, 57% of registered patients completed the program. ConclusionThe Afshar CR is trying to get closer to the world standard setting. But it seems that it is necessary to develop the standard of CR in Iran based on the culture and socio-economic status of Iranian community.

Management of pharmacotherapy-related problems in acute coronary syndrome: Role of clinical pharmacist in cardiac rehabilitation unit.

Acute coronary syndrome (ACS) is one of the leading causes of mortality worldwide and negatively impacts healthcare costs, productivity and quality of life. Polymorbidity and polypharmacy predispose ACS patients to medication discrepancies between cardiologist-prescribed medication and drug use by the patient, drug-related problems (DRPs) and inadequate drug adherence. This study aimed to evaluate the impact of clinical pharmacist-provided services on the outcome of ACS patients. This was a prospective, randomized, controlled study on ACS patients participating in a cardiac rehabilitation programme. Forty ACS patients were randomly assigned to either control group, who received standard medical care, or intervention group, who received standard medical care plus clinical pharmacist-provided services. Services included DRP management, clinical assessment and enforcing the patient education and adherence. For both groups, the following were assessed at baseline and after 3months: DRPs, adherence (assessed by 8-item Morisky Adherence Questionnaire), patient's knowledge (assessed by Coronary Artery Disease Questionnaire), 36-Short Form Health Survey (SF-36), heart rate, systolic and diastolic blood pressure, low-density lipoprotein (LDL), total cholesterol (TC) and fasting blood glucose (FBG). After 3months, there was a significant difference between the intervention and control groups in the per cent change of DRPs (median: -100 vs 5.882, P=0.0001), patient's adherence score (median: 39.13 vs -14.58, P=0.0001), knowledge score (median: 30.28 vs -5.196, P=0.0001), SF-36 scores, heart rate (mean: -10.04 vs 6.791, P=0.0001), diastolic blood pressure (mean: -17.87 vs 10.45, P=0.0001), systolic blood pressure (mean: -16.22 vs 4.751, P=0.0001), LDL (median: -25.73 vs -0.2538, P=0.0071), TC (median: -14.62 vs 4.123, P=0.0005) and FBG (median: -11.42 vs 5.422, P=0.0098). Clinical pharmacists can play an important role as part of a cardiac rehabilitation team through patient education and interventions to minimize DRPs.

Fuzzy Linguistic Protoforms to Summarize Heart Rate Streams of Patients with Ischemic Heart Disease

Cardiac rehabilitation is a key program which significantly decreases mortality rates in high‐risk patients with ischemic heart disease. Due to the huge lack of accessibility to such programs at Health Centers, outdoor‐based programs for cardiac rehabilitation have been proposed as an excellent tool to improve accessibility for patients at Health Centers. These outdoor‐based programs make use of wrist‐worn devices for real‐time monitoring of rehabilitation sessions based on clinical guidelines. In this way, a greater number of patients can fortunately gain access to the rehabilitation program. However, this advantage also means that the cardiac rehabilitation team has to monitor a greater number of sessions due to the increase of the number of benefited patients, so the team members spend a lot of time analyzing each patient’s sessions. In this paper, we present a methodology to evaluate heart rate streams of patients with ischemic heart disease using a linguistic approach. This innovative methodology manages relevant linguistic descriptions (protoforms) for the cardiac rehabilitation team to identify sessions with interest indicators by means of linguistic summaries. Therefore, the analysis process is automated in a comprehensible way, offering short linguistic descriptions to the cardiac rehabilitation team, who promptly provide feedback to their patients. In order to show the great efficiency and effectiveness of the proposed methodology, we have used and applied this methodology to real data provided by patients of an outdoor cardiac rehabilitation program run by the Health Council of the Andalusian Health Service (Spain).

Enhanced psychological care in cardiac rehabilitation services for patients with new-onset depression: the CADENCE feasibility study and pilot RCT.

Around 19% of people screened by UK cardiac rehabilitation programmes report having moderate or severe symptoms of depression. These individuals are at an increased risk of cardiac mortality and morbidity, reduced quality of life and increased use of health resources compared with their non-depressed counterparts. Maximising psychological health is a goal of cardiac rehabilitation, but psychological care is patchy. To examine the feasibility and acceptability of embedding enhanced psychological care (EPC) within cardiac rehabilitation, we tested the feasibility of developing/implementing EPC and documented the key uncertainties associated with undertaking a definitive evaluation. A two-stage multimethods study; a feasibility study and a qualitative evaluation, followed by an external pilot cluster randomised controlled trial (RCT) with a nested qualitative study. UK comprehensive cardiac rehabilitation teams. Adults eligible for cardiac rehabilitation following an acute coronary syndrome with new-onset depressive symptoms on initial nurse assessment. Patients who had received treatment for depression in the preceding 6 months were excluded. The EPC intervention comprised nurse-led mental health-care co-ordination and behavioural activation within cardiac rehabilitation. The comparator was usual cardiac rehabilitation care. Measures at baseline, and at the 5- (feasibility and pilot) and 8-month follow-ups (pilot only). Process measures related to cardiac team and patient recruitment, and participant retention. Outcomes included depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Interviews explored participant and nurses' views and experiences. Between September 2014 and May 2015, five nurses from four teams recruited participants into the feasibility study. Of the 203 patients screened, 30 were eligible and nine took part (the target was 20 participants). At interview, participants and nurses gave valuable insights into the EPC intervention design and delivery. Although acceptable, the EPC delivery was challenging for nurses (e.g. the ability to allocate sufficient time within existing workloads) and the intervention was modified accordingly. Between December 2014 and February 2015, 8 out of 20 teams approached agreed to participate in the pilot RCT [five were randomised to the EPC arm and three were randomised to the usual-care (UC) arm]. Of the 614 patients screened, 55 were eligible and 29 took part (the target was 43 participants). At baseline, the trial arms were well matched for sex and ethnicity, although the EPC arm participants were younger, from more deprived areas and had higher depression scores than the UC participants. A total of 27 out of 29 participants were followed up at 5 months. Interviews with 18 participants (12 in the EPC arm and six in the UC arm) and seven nurses who delivered EPC identified that both groups acknowledged the importance of receiving psychological support embedded within routine cardiac rehabilitation. For those experiencing/delivering EPC, the intervention was broadly acceptable, albeit challenging to deliver within existing care. Both the feasibility and the pilot studies encountered significant challenges in recruiting patients, which limited the power of the pilot study analyses. Cardiac rehabilitation nurses can be trained to deliver EPC. Although valued by both patients and nurses, organisational and workload constraints were significant barriers to implementation in participating teams, suggesting that future research may require a modified approach to intervention delivery within current service arrangements. We obtained important data informing definitive research regarding participant recruitment and retention, and optimal methods of data collection. Consideration should be given to the delivery of EPC by dedicated mental health practitioners, working closely with cardiac rehabilitation services. Current Controlled Trials ISRCTN34701576. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 30. See the NIHR Journals Library website for further project information.

Assessing the effectiveness of Enhanced Psychological Care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): a pilot cluster randomised controlled trial

BackgroundAround 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation.MethodsAn external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed.ResultsEight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI − 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI − 1.4 to 10.2; N = 17) at 8 months.DiscussionWhile valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions.Trial registrationISRCTN34701576. Registered on 29 May 2014.Funding details: UK NIHR HTA Programme (project 12/189/09).

Evaluating the Effectiveness of an Online Cardiac Rehabilitation Resource (www.svhhearthealth.com.au) in Improving Knowledge and Confidence for Patients With Newly Diagnosed Cardiac Conditions: A Pre-Experimental Pilot Study

Cardiac rehabilitation (CR) is an important tool for the secondary prevention of cardiac disease. Despite its proven effectiveness, CR remains vastly under-utilised especially amongst the most disadvantaged patients. As an adjunct to CR, the St Vincent's Heart Health website (SVHHH) was created by the St Vincent's Hospital CR team to provide information via simplified medical text, videos and animations. We evaluated the effectiveness of the website in educating patients about their heart condition. Patients with a newly diagnosed cardiac condition were recruited from St Vincent's Hospital inpatient wards and outpatient clinics (n=67, age 63+/-11) and given 30minutes to interact with our online resource. Using a pre-test post-test design we evaluated the success of the website in improving patients' knowledge of their condition using a modified Brief Illness Perception Questionnaire and Patient Activation Questionnaire. After interacting with the website, participants rated a 50% improvement in the control they felt over their heart condition (p<0.01). Understanding of investigations, medications and management improved by 38%, 31% and 38%, respectively (all p<0.01). Subjects' understanding of their heart condition improved by 34% and confidence improved by more than 18% (p<0.01). These improvements were seen irrespective of age and primary place of residence. While older subjects had the lowest confidence using the internet, they demonstrated the greatest self-reported improvement in knowledge. There was no improvement in patients' perceived concern about their illness. The St Vincent's Heart Health website shows real promise as an educational tool for patients, as an adjunct to standard CR and for patients in remote settings. Online health resources will likely become an important adjunct to traditional teaching methods across all medical specialties to improve patient outcomes.

Real-Time Monitoring in Home-Based Cardiac Rehabilitation Using Wrist-Worn Heart Rate Devices.

Cardiac rehabilitation is a key program which significantly reduces the mortality in at-risk patients with ischemic heart disease; however, there is a lack of accessibility to these programs in health centers. To resolve this issue, home-based programs for cardiac rehabilitation have arisen as a potential solution. In this work, we present an approach based on a new generation of wrist-worn devices which have improved the quality of heart rate sensors and applications. Real-time monitoring of rehabilitation sessions based on high-quality clinical guidelines is embedded in a wearable application. For this, a fuzzy temporal linguistic approach models the clinical protocol. An evaluation based on cases is developed by a cardiac rehabilitation team.

Development and refinement of a complex intervention within cardiac rehabilitation services: experiences from the CADENCE feasibility study

BackgroundPatients who experience a cardiac event are at higher risk of developing depression than the general population. Despite this, cardiac rehabilitation (CR) programmes do not provide a systematic approach to psychological care for depression. The CADENCE study aimed to develop and pilot an enhanced psychological care (EPC) intervention consisting of behavioural activation (BA) and mental health care coordination. Following original research commissioning guidance, the intervention was planned to be embedded in routine care and delivered by CR nurses to patients with depression attending CR. This paper describes how qualitative methods were used to develop, embed and refine the intervention.MethodsThis feasibility study involved three CR teams. Observations were made of CR nurses delivering usual care, of EPC training given to nurses, and of supervision sessions provided to the CR nurses. Four nurses were interviewed shortly after their EPC training, and three were interviewed again 6–7 months later having delivered EPC to patients. All nine patients recruited to receive EPC were interviewed. Analyses of the observation notes and interview transcripts focused on how the intervention could be improved in terms of its acceptability and implementation.ResultsVariations were found between the CR teams regarding patient waiting list times, how CR was delivered, what facilities were available and how many CR sessions were offered to patients. EPC was acceptable to both nurses and patients. However, nurses struggled to provide this additional care within their existing workload and resources, and patients’ disrupted progression through the CR programme affected EPC delivery. Limited time and availability of private space meant nurses also delivered EPC by telephone, which was viewed as a pragmatic solution but less preferable than face-to-face. Nurses indicated that patients struggled with some of the written materials. Findings were used to revise the intervention to become a protocol of care coordination which included guided self-help BA.ConclusionsInsights gained through conducting interviews and observations enabled us to identify barriers to the implementation of EPC, and to modify the intervention to facilitate its delivery within existing services whilst remaining acceptable to both nurses and patients. The multiple method, iterative approach used was key to the success of this qualitative study.Trial registrationISRCTN34701576 Registered 29/05/2014.

Interventions at Nurse Specialist Clinics for Cardiac Rehabilitation Patients at Auckland District Health Board: A 3 Month Snapshot

Aim: Early Nurse follow-up clinics 2- 3 weeks post hospital discharge have been instituted at ADHB since 2012. In the last 2 years these clinics have increased in attendance rates, patient complexity and now have medical supervision. Some patients will only have nurse follow-up post discharge. To assess rates of adherence and intervention in CR nurse clinics. Methods: The Cardiac Rehabilitation (CR) team at the Auckland District Health Board have prospectively recorded rates of adherence and interventions at Nurse Specialist clinics over a 6-month period. Results: 161 (89%) patients attended CR nurse clinics. Of these 45 (28%) patients required medication changes with 20 prescribed/up titration in ACE1/beta blocker, 2 antiplatelet agent, 11 statin and other 13 medication. A further 18 (12%) were referred for further investigation and, 15 (9%) to appropriate specialist clinics, for example diabetes/hyperventilation clinics. Conclusion: Nurse Specialist clinics with medical supervision that are scheduled early post discharge provide a safety net for patients who are discharged following short hospital stays. They also lead to increased prescription of secondary prevention medication and ensure patients have appropriate investigations and referrals

Implementing a community-based structured exercise programme for patients with peripheral arterial disease in conjunction with an existing cardiac rehabilitation service results in better outcomes

Structured exercise has been shown to improve intermittent claudication symptoms in patients with peripheral arterial disease, and the National Institute for Health and Care Excellence recommend it as a first-line treatment. A community-based podiatry-led lower limb arterial assessment service implemented a structured exercise programme for claudicants by liaising with a cardiac rehabilitation team to incorporate claudicants into an existing exercise programme for cardiac patients, thus using the skills, manpower and facilities already in place. Key findings of an audit of the first 12 months were: (1) higher than average uptake by claudicants compared with other supervised exercise programmes; (2) 72% reported an improvement in claudication symptoms; (3) 24% reported no deterioration in walking distance; (4) only 17% of patients were referred on for a surgical opinion on completion of the programme: prior to the community-based exercise programme all claudicants were seen in secondary care for assessment before being offered hospital-based structured exercise; (5) high level of patient satisfaction. Patients were supported to address modifiable cardiovascular risk factors such as smoking cessation, weight management, increasing physical activity and commencing best medical therapy. The audit indicates a high level of patient satisfaction, improvement in claudication symptoms and prevention of unnecessary surgical referrals. Patients were empowered to take ownership of their cardiovascular health. This has implications for financial savings and better use of resources and may contribute to a long-term reduction in cardiovascular-related morbidity and mortality, although further research into long-term outcomes should be considered.

A review of issues concerning implementation of cardiac rehabilitation programs

Cardiac rehabilitation (CR) is a tertiary preventative intervention for patients who have experienced adverse cardiac events such as a myocardial infarction (MI). Interdisciplinary CR teams focus on reducing multiple risk factors by addressing diet, exercise, and behavior change. CR programs have proven to be comparable in cost to other interventions for cardiac diseases, however the appropriate delivery of these programs faces multiple issues. One major barrier to effective delivery of CR programs is the lack of referral by the health care teams who assess cardiac patients. Other barriers are funding, team structure, and patient access to these programs. This article examines the issues facing CR delivery and possible ways to address them. Given the evidence for its efficacy and cost effectiveness, physicians should work to ensure proper CR referral and improved program delivery.

What is needed to implement a web-based audit and feedback intervention with outreach visits to improve care quality: A concept mapping study among cardiac rehabilitation teams

IntroductionEvidence on successful quality improvement (QI) in health care requires quantitative information from randomized clinical trials (RCTs) on the effectiveness of QI interventions, but also qualitative information from professionals to understand factors influencing QI implementation. ObjectiveUsing a structured qualitative approach, concept mapping, this study determines factors identified by cardiac rehabilitation (CR) teams on what is needed to successfully implement a web-based audit and feedback (A&F) intervention with outreach visits to improve the quality of CR care. MethodsParticipants included 49 CR professionals from 18 Dutch CR centres who had worked with the A&F system during a RCT. In three focus group sessions participants formulated statements on factors needed to implement QI successfully. Subsequently, participants rated all statements for importance and feasibility and grouped them thematically. Multi dimensional scaling was used to produce a final concept map. ResultsForty-two unique statements were formulated and grouped into five thematic clusters in the concept map. The cluster with the highest importance was QI team commitment, followed by organisational readiness, presence of an adequate A&F system, access to an external quality assessor, and future use and functionalities of the A&F system. ConclusionConcept mapping appeared efficient and useful to understand contextual factors influencing QI implementation as perceived by healthcare teams. While presence of a web-based A&F system and external quality assessor were seen as instrumental for gaining insight into performance and formulating QI actions, QI team commitment and organisational readiness were perceived as essential to actually implement and carry out these actions. These two sociotechnical factors should be taken into account when implementing and evaluating the success of QI implementations in future research.

In Your Own Words: What do Patients Priortise for Lifestyle Change Following Outpatient Cardiac Rehabilitation?

Background: Cardiac rehabilitation (CR) aims to improve and maintain patient wellbeing following a cardiac event by helping them understand their condition and provide advice and support in respect to secondary prevention. Such measures include advice on healthy eating, getting back into physical activity, managing stress, and understanding the importance of cardiac medications. Methods: In 2015 a feedback survey for all CR education classes was created by the CR team. A database with a structured standardised data-entry system was also created to allow for uniform data entry. The question ‘what changes to help your heart health are you going to make?’ was included to gauge what patients prioritse for change following their education program. Results: 100 complete responses were extracted from the database and analysed. Emphasis was placed on the capturing actual and unique responses from patients without modification. 70% of respondents indicated more than one priority. Exercise was the greatest priority with 65 responses, closely followed by diet and healthy eating with a cumulative 59 responses. Other common responses included dealing with stress (6), being smoke-free (5), adhering to medications (5) and losing weight (5). Conclusion: Respondents in our survey deem exercise to be the most important lifestyle change for secondary prevention, closely followed by diet. The findings suggest emphasis be placed on these two lifestyle changes. Comprehensive CR at its foundation should support patients to start or resume optimal cardiovascular exercise. Further investigation into what particular support for exercise and diet lifestyle changes patients need is recommended.

Psychosocial Aspects in Cardiac Rehabilitation: From Theory to Practice. A Position Paper From the Cardiac Rehabilitation Section of The European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with establishedCHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

Experience of Spiritual Care in Cardiac Rehabilitation: An Interpretative Phenomenological Analysis.

The aim of the study was to explore the experience of spiritual care among a cardiac rehabilitation team. Spiritual care is an important dimension of providing comprehensive care, and understanding the views of health professionals is pivotal to making recommendations for caring. This study used an interpretive phenomenological approach. Semi-structured interviews were undertaken with 13 cardiac rehabilitation professionals. Seven persons participated in individual interviews and six in focus group discussions. Data were analyzed using Smith and Osborn's interpretative phenomenological analysis method. Study data were categorized into more than 150 initial themes, 12 clustered and four superordinate themes, included: 'Helping patients to obtain a meaningful sense of being', 'Providing religious/spiritual focused care', 'holistic approach to rehabilitation is needed' and 'spirituality as a neglected aspect of rehabilitation'. Participants described that they did not have sufficient training in providing spiritual care. Nurses' awareness of spiritual care meaning among a cardiac rehabilitation team is helping to respond to rehabilitation care in a holistic approach. Helping patients to get a meaningful sense of being is an important part of assisting in recovery and adjustment following an acute cardiac event. Providing clear guidelines and support for providing spiritual care in cardiac rehabilitation is required.

A five-year follow-up of a patient with fulminant myocarditis who underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program

A 39-year-old man developed fulminant myocarditis and was transferred on mechanical ventilation and a ventricular-assist device to our hospital. On Hospital Day 10, he was weaned from all medical engineering devices, and bedside rehabilitation was initiated. Although a multidisciplinary cardiac rehabilitation team had intervened since Hospital Day 3, he could not be encouraged to begin ambulation because of hypotension and tachycardia. Moreover, he complained of loss of self-confidence and anxiety regarding physical strength, and expansion of activities was difficult. Exercises reflecting his immediate desires and daily activities were used as activity goals, and we developed an individualized exercise program with stepwise increase in load to motivate him to perform rehabilitation. At the time of discharge, his cardiac function recovered to nearly normal levels; however, muscle strength and respiratory function had not recovered. While the intervention was continued at the cardiac rehabilitation outpatient unit, improvement was observed in physical health and mental health-related scale scores. The patient returned to work 4 months after onset of his myocarditis. Moreover, the cardiac rehabilitation team provided support to him for his long-term overseas assignment in the fifth year after myocarditis onset. Long-term comprehensive support by the cardiac rehabilitation team was feasible and useful.<Learning objective: Comprehensive intervention by a cardiac rehabilitation team from the acute phase may be helpful for motivating patients not only to participate in rehabilitation during hospitalization, but also to continue it on an outpatient basis after discharge. Moreover, continuous outpatient intervention can lead to recovery of physical/mental function in patients that is not achievable with only inpatient intervention, and support can be provided to patients for setting new life goals.>