Risk Of Recurrent Cardiac Events Research Articles

Associations Between Psychological Factors and Adherence to Health Behaviors After Percutaneous Coronary Intervention: The Role of Cardiac Rehabilitation.

Cardiac rehabilitation (CR) participation after percutaneous coronary intervention (PCI) for coronary heart disease lowers the disease burden and risk of recurrent cardiac events. Examining psychological factors may improve post-PCI health behavior adherence. To determine whether psychological factors are associated with post-PCI health behavior adherence, and the role of CR participation. Data from 1,682 patients (22.1% female, Mage = 64.0, SDage = 10.5 years) from the THORESCI cohort were included. Adjusted mixed models were used to examine associations between psychological factors and the 1-year course of health behaviors, using interactions to test for moderation by CR participation. Psychological factors were associated with the trajectories of adherence to medical advice, exercise, and diet. The strongest association found was between optimism and the trajectory of dietary adherence (B: = -0.09, p = .026). Patients with high optimism levels had a worse trajectory of dietary adherence compared to patients with low to middle optimism levels. Participation in CR buffered the associations of high anxiety, pessimism, and low to middle resilience, but strengthened the associations of high stress in the past year with the probability of smoking. Psychological factors are associated with post-PCI health behavior adherence, but the pattern of associations is complex. Patients with high levels of anxiety, pessimism, and low to middle resilience levels may disproportionately benefit from CR. Cardiac rehabilitation programs could consider this to improve post-PCI health behavior adherence. NCT02621216.

Activity counseling early postelective percutaneous coronary intervention (ACE-PCI): Mixed-methods pilot randomized controlled trial.

Physical activity(PA) levels of people with coronary heart disease are low in the first 30 days after percutaneous coronary intervention (PCI), increasing the risk of recurrent cardiac events. Following PCI, PA counseling delivered by a physiotherapist before discharge may increase the PA levels of patients. Preliminary work is required to determine the effects of the counseling session compared to usual care. To investigate the feasibility and potential efficacy of a brief physiotherapist-led PA counseling session immediately after an elective PCI compared to usual care for improved PA early post-PCI. Using concealed allocation and blinded assessments, eligible participants (n = 30) were randomized to a physiotherapist-led PA counseling session (30 min) or usual care (nurse-led PA advice < 5 min). The primary outcome was daily minutes of moderate-to-vigorous PA (accelerometry; 3 weeks). Secondary outcomes included cardiac rehabilitation intention, anxiety and depression levels (Hospital Anxiety and Depression Scale), and quality-of-life (MacNew questionnaire). Recruitment, retention, and attrition were assessed for feasibility. Semistructured interviews were conducted with 13 participants to determine intervention acceptability, and barriers and enablers to PA. Between and within-group comparisons were not significant in intention-to-treat analyses. All feasibility criteria were met except for retention and attrition of participants. At 3 weeks, only 25% of participants were planning to attend cardiac rehabilitation, with no between-group differences. Increased PA at 3 weeks was associated with participants that were younger, without other chronic disease,s and more active immediately following discharge. Interviews revealed personal, environmental, and program-based themes for barriers and enablers to PA. A physiotherapist-led PA counseling session may not improve PA levels early post-elective PCI compared to very brief PA advice delivered by nurses. A larger multicentre randomized controlled trial is feasible with minor modifications to participant follow-up. Further research is required.

Abstract 18392: Sedentary Behavior and Risk of 1-Year Cardiac Events and Mortality After Suspected Acute Coronary Syndrome

Background: Patients hospitalized with acute coronary syndrome (ACS) remain at high risk for recurrent cardiac events in the first year after discharge, necessitating a need to identify modifiable targets to improve outcomes. While moderate-vigorous physical activity (MVPA) is a hallmark of secondary prevention in this population, sedentary behavior (SB) has emerged as a potentially unique aspect of the physical activity profile that may also have prognostic relevance. Yet little is known regarding whether SB confers risk independent from MVPA and what types of activity should be substituted for SB to impart health benefit among ACS patients in the first year after discharge. Aim: Examine the association between SB and risk of 1-year cardiac events and mortality among patients evaluated for ACS. Methods: Patients (n=609, 52% male, 62 ± 13 y) evaluated in the emergency room for ACS were fitted with a GENEActiv wrist accelerometer in-hospital and wore the device for 30 days post discharge to measure SB, light intensity physical activity (LIPA), MVPA, and sleep. Major adverse cardiovascular events 1-year post discharge were defined as the composite of unstable angina, myocardial infarction, or death. Results: Over follow up, 50 patients (8%) had a major adverse cardiovascular event. SB was associated with an increased risk of 1-year major adverse cardiovascular events after adjusting for demographic and disease severity indicators (HR per 1 h/d increase: 1.33, 95% CI: 1.12, 1.58). The association remained significant after adjusting for MVPA (HR per 1 h/d increase: 1.30, 95% CI: 1.06, 1.59). In isotemporal substitution analyses there were beneficial associations for replacing SB with sleep (per 30 min HR: 0.89, 95% CI: 0.81, 0.97), LIPA (per 30 min HR: 0.51, 95% CI: 0.34, 0.76), and MVPA (per 30 min HR: 0.32, 95% CI: 0.12, 0.85) on 1-year major adverse cardiovascular event risk. Conclusion: SB was associated with increased risk of 1-year cardiac events and mortality among patients evaluated for ACS, independent of MVPA. Replacing SB with sleep, LIPA, or MVPA was associated with lower risk. These findings suggest reducing SB may improve outcomes in ACS survivors and support the public health message that ACS patients should sit less and move or sleep more to mitigate risk.

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review.

Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

Cardiac rehabilitation program: An exploration of patient experiences and perspectives on program dropout.

BackgroundCardiac rehabilitation programs (CRP) are effective evidence‐based secondary prevention programs that reduce morbidity and mortality in patients with cardiovascular disease (CVD). However, participation remains suboptimal, resulting in under‐treatment and greater risk for recurrent cardiac events. Understanding the reasons behind CRP dropout is urgently needed to inform the development of programs that best meet patient needs and support sustained engagement.AimsThe aim of this study was to identify and understand factors impacting CRP dropout from the patient perspective.MethodsA qualitative study using semi‐structured interviews was undertaken to examine the experience of 23 patients who dropped out of a CRP within a large urban hospital in British Columbia, Canada. Data were coded, analyzed using the constant comparison technique, and organized thematically.ResultsParticipants described multiple challenges when attempting to complete CRP. Analysis of the data led to the identification of three main categories: (1) challenges living with CVD, (2) perceived advantages and disadvantages of CRP, and (3) unmet needs during CRP.Linking evidence to actionIn the practice setting, assessment of readiness to engage in CRP, alongside patient preferences and engagement needs, should be undertaken for maximum CRP uptake and completion. Providing diverse modes of CRP delivery, along with exploring the impact of virtual options as compared to traditional in‐person programs, will further advance the CRP evidence and may help address pervasive access barriers.

A history of smoking does not reduce long-term benefits of cardiac rehabilitation on cardiorespiratory fitness in men and women with cardiovascular disease.

Smoking is an important risk factor for cardiovascular disease and all-cause mortality. Cardiac rehabilitation (CR) is effective for reducing the risk of recurrent cardiac events through improving cardiorespiratory fitness (CRF). Little is known about the influence of smoking on CRF throughout long-term CR. The purpose of this analysis was to compare CRF trajectories among individuals with positive and negative smoking history enrolled in long-term CR. Participants had a positive smoking history if they currently or formerly smoked (Smoke+, n = 55, mean age = 64.9 ± 9.0 years) and had a negative history if they never smoked (Smoke-, n = 34, mean age = 61.4 ± 9.0 years). CRF (peak oxygen uptake) was measured at baseline and annually thereafter for 6 years. The Smoke+ group had lower CRF compared with the Smoke- group over enrollment (β = -3.29 (SE = 1.40), 95% confidence interval (CI) -6.04 to -0.54, p = 0.02), but there was no interaction of smoking history and enrollment (β = 0.35 (SE = 0.21), 95% CI: -0.06 to 0.77, p = 0.10). Moreover, trajectories were not influenced by pack-years (β = 0.01 (SE = 0.01), 95% CI: -0.01 to 0.04, p = 0.23) or time smoke-free (β = -0.002 (SE = 0.01), 95% CI: -0.02 to 0.02, p = 0.80). Although the trajectories of CRF do not appear to be affected by smoking behaviour, individuals without a history of smoking maintained higher CRF throughout enrollment. Novelty: The benefits of long-term exercise-based cardiac rehabilitation on cardiorespiratory fitness are similar between those who have smoked and those who have never smoked. Neither the number of pack-years nor the length of time spent smoke-free influence cardiorespiratory fitness trajectories following long-term cardiac rehabilitation.

Association of Midlife Status With Response to a Positive Psychology Intervention in Patients With Acute Coronary Syndrome.

Physical activity is strongly associated with lower risk of recurrent cardiac events in patients who experience an acute coronary syndrome (ACS), yet most patients do not meet recommended levels of physical activity. Psychological well-being is associated with higher levels of physical activity, but midlife adults experience a multitude of stressors that can reduce well-being. The aim of this study was to compare midlife (age 45-64) and older (age 65+) participants in a positive psychology intervention to increase physical activity and psychological well-being after an ACS. This was a secondary analysis across 3 phases of a telephone-delivered positive psychology intervention development project. Participants were hospitalized for an ACS and had low pre-ACS health behavior adherence. They received 8-12 weekly intervention sessions. Psychological outcomes, self-reported adherence, and physical activity were measured before and after treatment. Mixed regression models were used to compare session completion rates and change in outcome measures between midlife and older participants. Across 164 participants, midlife participants showed larger improvements in depression, positive affect, and physical activity, but not anxiety or optimism, than older participants; session completion rates did not significantly differ. Midlife patients post-ACS may be particularly responsive to a telephone-delivered positive psychology intervention. Clinically, the post-ACS period may be uniquely motivating for midlife patients to improve their physical and psychological health. Future work could customize positive psychology for unique midlife stressors.

Cohesion and adherence in exercise groups of patients with chronic heart diseases – a prospective study

Objective: In cardiac rehabilitation, long-term adherence to exercise prescription is an important prerequisite to reduce mortality and the risk of recurrent cardiac events. Cohesion seems to be an important predictor of adherence when exercise is conducted in prevention settings, but in clinical settings, this relationship is currently unknown. To address this gap, the goal of this study was to determine the relationship between group cohesion and adherence in cardiac rehabilitation programs considering the duration of membership as a moderator.Design: The study was conducted with 474 participants (21.7% women), in three rehabilitation centres in North Rhine Westphalia, Germany, assessing cohesion, adherence and group membership in outpatient cardiac exercise groups.Main Outcome Measures: Cohesion was assessed using the KIT-FG and adherence was operationalized as the total number of sessions attended over a 7-week period.Results: Moderated hierarchical stepwise regression analyses revealed that perceptions of the social dimension of group cohesion significantly predicted adherence behaviour only for members with a rather long duration of membership.Conclusion: Our findings suggest that cohesion might have a differential effect on an individual’s decision to regularly participate in exercise, depending on the duration of membership in the group.

Impact of Multivessel Coronary Artery Disease on Long Term Prognosis in Patients with ST-segment Elevation Myocardial Infarction

Abstract Background: A significant proportion of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVD), and they are at high risk for recurrent cardiac events. The aim of the present study was to analyze the impact of MVD on long-term cardiovascular mortality in STEMI patients treated with primary percutaneous coronary intervention (pPCI). Method: This study included 3,115 consecutive STEMI patients hospitalized in the Coronary Care Unit of the Clinical Centre of Serbia, between November 2005 and January 2012. Patients were divided in two groups: MVD and no MVD. MVD disease was defined as stenosis greater than 50% by visual assessment in more than one major coronary artery. Primary PCI was limited to the infarct-related artery (IRA). Cardiovascular mortality was defined as any death from cardiovascular reason (myocardial reinfarction, low-output heart failure, and sudden death). Patients presenting with cardiogenic shock were excluded. Patients were followed-up for 6 years after enrollment. Results: Among 3,115 analyzed patients, 1,352 (43.4%) patients had no MVD and 1,763 (56.6%) had MVD; among patients with MVD, 926 (52.6%) had two-vessel disease and 837 (47.4%) had three-vessel disease. Compared with patients with single-vessel disease, patients with MVD were older, had longer pain duration, and presented more often with heart failure; they were more likely to have previous coronary artery disease, diabetes, hypertension, and chronic kidney disease; post-procedural flow TIMI &lt;3 was more frequently observed in patients with MVD than in patients with no MVD (5.9% vs. 3.1%, p &lt;0.001). Patients with MVD had lower left ventricular ejection fraction than patients with single-vessel disease: 45% (interquartile range [IQR] 40¬–55%) vs. 50% (IQR 43–55%), p &lt;0.001. Revascularization of non-IRA lesions was performed at index hospitalization in 1,075 (61%) patients, and in 602 (34.1%) patients revascularization was performed in the first few months after pPCI (median 1.5 months, IQR 1–2.5 months); coronary artery bypass grafting was performed in 291 (18.4%) patients and PCI (with stent implantation) in 1,368 (81.6%) patients. Six-year cardiovascular mortality was significantly higher in patients with MVD than in patients with single-vessel disease (10.4% vs. 4.6%, p &lt;0.001). In multivariate Cox regression analysis, MVD remained an independent predictor for 6-year cardiovascular mortality (HR 1.55, 95% CI 1.11–2.06, p = 0.041). Conclusion: In STEMI patients treated with pPCI, the presence of MVD remained an independent predictor for higher long-term cardiovascular mortality despite early revascularization of the remaining stenosis in non-IRA.

Don’t stop at statins: complementary PCSK9 use in patients at high risk for recurrent cardiac events

Don’t stop at statins: complementary PCSK9 use in patients at high risk for recurrent cardiac events

Antithrombin levels are associated with the risk of first and recurrent arterial thromboembolism at a young age

Background and aimsIt is as yet unknown whether antithrombin levels are associated with arterial thromboembolism (ATE) at a young age. To investigate the association between antithrombin levels and premature and recurrent ATE, we performed a case-control study and a subsequent nested cohort study of premature coronary heart disease (CHD) patients. MethodsIn the case-control study, we included 571 patients who had a recent premature ATE, including CHD and ischemic stroke (IS), and 461 healthy controls. The association between antithrombin levels (dichotomized: ≤median vs. >median) and ATE was investigated. Subsequently we studied the association between antithrombin levels and recurrent cardiac events, ATE or death in a nested cohort of 323 CHD patients. ResultsLow antithrombin levels (≤median, 1.04 IU/mL) are associated with an increased risk of ATE (OR 1.46; 95% CI:1.09–1.96), after adjustment for classical cardiovascular risk factors. This was observed in the subgroups of CHD patients (1.43; 1.01–2.02) and IS patients (1.48; 1.01–2.19). CHD patients with low antithrombin levels had a higher risk of recurrent cardiac events (HR 2.16, 95% CI:1.07–4.38). Especially in women with low antithrombin levels, the risk of recurrent cardiac events was high (HR 5.97, 95% CI 1.31–27.13) as was the risk of recurrent ATE or death (HR 4.22, 95% CI 1.19–15.00). ConclusionsIndividuals with relatively low antithrombin levels have an increased risk for ATE at a younger age. CHD patients with low antithrombin levels, especially women, have a higher risk of recurrent cardiac events.

Risk of cardiac events in Long QT syndrome patients when taking antiseizure medications

Many antiseizure medications (ASMs) affect ion channel function. We investigated whether ASMs alter the risk of cardiac events in patients with corrected QT (QTc) prolongation. The study included people from the Rochester-based Long QT syndrome (LQTS) Registry with baseline QTc prolongation and history of ASM therapy (n=296). Using multivariate Anderson-Gill models, we assessed the risk of recurrent cardiac events associated with ASM therapy. We stratified by LQTS genotype and predominant mechanism of ASM action (Na+ channel blocker and gamma-aminobutyric acid modifier.) There was an increased risk of cardiac events when participants with QTc prolongation were taking vs off ASMs (HR 1.65, 95% confidence interval [CI] 1.36-2.00, P<0.001). There was an increased risk of cardiac events when LQTS2 (HR 1.49, 95% CI 1.03-2.15, P=0.036) but not LQTS1 participants were taking ASMs (interaction, P=0.016). Na+ channel blocker ASMs were associated with an increased risk of cardiac events in participants with QTc prolongation, specifically LQTS2, but decreased risk in LQTS1. The increased risk when taking all ASMs and Na+ channel blocker ASMs was attenuated by concurrent beta-adrenergic blocker therapy (interaction, P<0.001). Gamma-aminobutyric acid modifier ASMs were associated with an increased risk of events in patients not concurrently treated with beta-adrenergic blockers. Female participants were at an increased risk of cardiac events while taking all ASMs and each class of ASMs. Despite no change in overall QTc duration, pharmacogenomic analyses set the stage for future prospective clinical and mechanistic studies to validate that ASMs with predominantly Na+ channel blocking actions are deleterious in LQTS2, but protective in LQTS1.

Lifestyle Modification in Secondary Prevention: Beyond Pharmacotherapy.

Despite significant advances in medical technology and pharmacology, cardiovascular disease (CVD) remains a major contributor to health care expenses and the leading cause of death in the United States. Patients with established CVD and their health care providers are challenged with achieving cardiovascular risk reduction to decrease the likelihood of recurrent cardiovascular events. This "secondary prevention" can be achieved, in part, through adherence to prescribed pharmacotherapies that favorably modify major coronary risk factors (ie, hypertension, hypercholesterolemia, diabetes, and obesity). However, lifestyle modification can also be helpful in this regard, providing independent and additive benefits to the associated reductions in cardiovascular morbidity and mortality. Accordingly, physicians and other health care providers should routinely counsel their coronary patients to engage in structured exercise and increased lifestyle physical activity, consume a heart-healthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial stressors that may elevate cardiovascular risk. These lifestyle interventions, either as an adjunct to medication therapy or independently in those patients where medications may be poorly tolerated, cost prohibitive, or ineffective, can significantly decrease cardiovascular mortality and the risk of recurrent cardiac events.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

Decades have passed since studies comparing coronary artery bypass grafting (CABG) with medical therapy for multivessel coronary disease indicated a survival advantage of surgery in the subset of patients with significant left ventricular impairment.1–3 These investigations changed the prevailing clinical impression such that severe left ventricular (LV) dysfunction might be an indication for revascularization as opposed to a relative contraindication. Although the studies might currently be deemed obsolete by many measures, they continue to inform societal guidelines with regard to CABG and LV dysfunction.4,5 Recently, the long-term outcomes after the Surgical Treatment for Ischemic Heart Failure (STICH) trial have reinforced the potential benefits of surgical revascularization in patients with congestive heart failure and an ejection fraction of <35%.6 Over the intervening period, numerous trials have compared percutaneous coronary intervention (PCI) with CABG in patients with stable angina and multivessel disease. Aside from diabetes mellitus, the trials by and large have demonstrated equivalence in the end points of death and myocardial infarction. So can one extrapolate equivalence for PCI with CABG in patients with LV dysfunction? The short answer is no. There is scant direct evidence from randomized trials comparing the 2 methods of revascularization because patients with congestive heart failure or severe LV dysfunction have typically been underrepresented or excluded.7–9 Article, see p 2132 Acknowledging the lack of a large randomized evidence base, there are theoretical reasons why PCI might perform less well than CABG in patients with LV dysfunction. PCI, by its nature, addresses short segments of severe stenosis. However surgery will also address the intervening disease that might progress to become culprit lesions in the future.10 This disadvantage of PCI is likely to be particularly important in patients with limited LV reserve who over the longer term …

Depression and anxiety as predictors of recurrent cardiac events 12 months after percutaneous coronary interventions.

Anxiety and depression are associated with recurrent cardiac events after percutaneous coronary interventions (PCIs). However, few investigators have evaluated the impact of depression and anxiety on recurrent cardiac events in Korea. The aim of this study was to examine the relationship among depression, anxiety, and recurrent cardiac events in Korean patients with coronary artery disease (CAD) after PCI. A prospective longitudinal study was undertaken with a sample of 133 CAD patients with PCI. Data were collected between August 2009 and September 2010, and patients were followed after discharge through 2011 with self-report questionnaires on anxiety and depression using the Hospital Anxiety and Depression Scale and with patient medical records on sociodemographic and clinical characteristics. Recurrent cardiac events were collected for 12 months after discharge and were assessed by patient interviews and medical records. There were 18 recurrent cardiac events (13.5%) among the 133 participants. After adjustment for sociodemographic and clinical characteristics, a hierarchical Cox proportional hazards regression model found that a moderate or severe level of anxiety (hazard ratio, 6.21; 95% confidence interval, 1.64-23.54) and a moderate or severe level of depression (hazard ratio, 4.32; 95% confidence interval, 1.35-13.88) were independent predictors of recurrent cardiac events. Patients with CAD who have a high level of anxiety and depression are at increased risk for recurrent cardiac events after PCI. Screening should be focused on patients who experience anxious and depressive feelings in addition to traditional risk factors. Furthermore, psychoeducational support interventions to reduce anxiety and depression after PCI may improve health outcomes.

Abstract MP66: AREST Lifestyle: Adherence Effects of a Comprehensive Reminder System on Exercise Adherence in Post-Myocardial Infarction Patients

Background: The risk of recurrent cardiac events can be reduced by 30-50% through regular, structured exercise; however, there remains a high rate of inactivity in post myocardial infarction (MI) patients. Forgetting to exercise may be a contributor to inactivity. This study assessed the hypothesis that text message reminders may be an effective strategy to reduce forgetfulness and inactivity. Methods: In this one year, single center study, we recruited 50 cardiac rehabilitation patients within 2 weeks of their MI. Participants were randomized to usual care or to receive text message reminders 4 times daily which stated "Please remember to exercise 45 minutes today". The outcomes measured were the frequency and total duration of exercise (assessed by log books) and physical endurance/ aerobic fitness (assessed by exercise stress testing at months 1, 3 and 12). Results: Intervention and control patients had similar baseline characteristics with an average age of 64. In the control group, monthly duration of exercise fell from an average of 683 minutes over 17 days at month 1 to 416 minutes over 11 days at month 12. Patients randomized to text message reminders exercised 772 minutes over 18 days at month 1 and 794 minutes over 18 days in month 12 (p&lt;0.01 for duration of exercise, control versus intervention, month 12). Baseline aerobic fitness and cardiac endurance was similar between control and intervention groups. However, there was a significant improvement in aerobic fitness and cardiac endurance at month 12 with text reminders (7.4 versus 6.1 METS achieved month 12, p&lt;0.01). In all sub-groups analyzed this intervention significantly improved exercise adherence and fitness. Conclusions: In summary, this system improved frequency and duration of exercise, and objective measures of cardiac endurance and aerobic fitness. While this study was not designed to assess clinical outcomes, this text message reminder system represents a simple and scalable method for improving adherence to exercise regimens among post-MI patients.

The Development of a New Cardiac Rehabilitation Needs Assessment Tool (CRNAT) for Individualised Secondary Prevention

Cardiac rehabilitation and secondary prevention are evidence-based strategies to reduce the risk of recurrent cardiac events but are underutilised. New approaches are required to improve uptake. A new cardiac rehabilitation needs assessment tool (CRNAT), for use by cardiology ward nurses, was developed and refined in collaboration with stakeholders through action research. The tool documented patients' risk factors, initiated a discussion about secondary prevention and linked patients to post-discharge follow-up. The initial version of the tool was developed through consultation with cardiac rehabilitation specialist staff (n=3), reviewed by ward nurses (n=4) and general practitioners (GP) (n=8), and piloted in patients (n=8). Review was undertaken at six months post implementation through patient (n=66) and GP (n=10) surveys, with additional patient feedback through focus groups (n=8 patients) and phone interviews (n=14). At 12 months, ward nurses (n=21) were surveyed. The CRNAT was well regarded by patients and GPs and stakeholder feedback resulted in only minor changes to the tool's content. Feedback from ward nurses led to important changes to the process of administering the tool to streamline its use in an inpatient setting. Feedback from end users is important when developing a new clinical tool to ensure it meets their requirements.

A practical guide to early repolarization.

Early repolarization has been associated in the past decade with idiopathic ventricular fibrillation and arrhythmic death. The purpose of this review is to clarify recent changes in the definition of early repolarization and provide a practical approach to patients with this electrocardiographic sign. Recent population studies have associated early repolarization with arrhythmic death. Challenges remain, however, in interpreting the risk of the early repolarization electrocardiographic pattern, as it is a common finding in the general population with a prevalence of 3-13%. Early repolarization characteristics associated with an especially high risk include high-amplitude J-point elevation, horizontal/descending ST segment, and inferior lead location.In view of the association of early repolarization with sudden death, a syndrome termed 'early repolarization syndrome' (ERS) has been accepted as the latest 'channelopathy' in patients with cardiac arrest, pronounced early repolarization pattern, and an otherwise structurally normal heart.The physiological basis of early repolarization is thought to involve an electrical transmural gradient produced by the transient outward current. Recent genetic studies have associated mutations in genes contributing to this current and other ion channels with ERS, although definitive genetic data do not yet exist to confirm pathogenicity. ERS patients are rare and have a high risk of recurrent cardiac events. ICD implantation and possibly quinidine are the recommended treatments in this group. Opposingly, asymptomatic individuals with early repolarization are very common and, as a group, have a good prognosis. Sudden death preventive measures in these asymptomatic patients are limited to rare and unique cases.

IMPROVING ADHERENCE TO EXERCISE REGIMENS POST-MI THROUGH A NOVEL TEXT MESSAGE REMINDER SYSTEM

Regular and structured exercise after myocardial infarction (MI) has been demonstrated to reduce the risk of recurrent cardiac events by 30-50% but non-adherence to exercise regimens is extremely common. While the causes of inactivity in post-MI patients have yet to be fully described, forgetfulness is believed to be a central contributor. With the proliferation of cell phones, text message reminders may be a cost effective strategy to remind people to exercise. We recruited patients recently discharged after MI who were receiving care at a single cardiac rehabilitation facility. To be included, all individuals had to be within 2 weeks of their MI and be able to read and understand English. Individuals without cell phones and those that unwilling or unable to provide informed consent were excluded. Participants were randomized into usual care or to receive text message reminders four times daily that simply stated "Please remember to exercise 45 minutes today". The co-primary outcomes were the frequency of exercise and the total duration of exercise, assessed through self-reported logs. In additional, physical endurance and aerobic fitness was tested in all participants through exercise treadmill testing at baseline, month 3 and month 12. Fifty patients were randomized. Patients were on average 64 years of age. Intervention and control patients had similar baseline characteristics. In the control group, activity fell over time from an average of 683 minutes of exercise (over an average of 17 days) at month 1 to 416 minutes of exercise (over an average of 11 days) by month 12. By contrast, intervention groups patients exercised 772 minutes (over an average of 18 days in month 1) and 794 minutes of exercise (over 18 days) in month 12 (p<0.0001 for difference between intervention and control at month 12). By month 12, aerobic fitness and cardiac endurance as measured on a cardiac stress test was greater among intervention patients (7.4 METS vs. 6.2 METS, p<0.038). In all sub-groups analyzed, text message reminders significantly improved activity and exercise endurance measures. The frequency of exercise, its duration and objective cardiac endurance and aerobic fitness improved significantly with a simple automated text-message exercise remind system. While the impact of this intervention on health outcomes has not been established, it represents a simple and scalable method for improving adherence to exercise regimens among post-MI patients.

Abstract MP40: Vital Exhaustion as a Predictor of Recurrent Cardiac Events in Patients with Coronary Heart Disease: The Atherosclerosis Risk in Communities (ARIC) Study

Several studies have demonstrated a positive relationship between vital exhaustion and incident coronary heart disease (CHD), but the association of exhaustion with recurrent cardiac events has not been established in large, epidemiologic studies. Vital exhaustion is considered the end-stage of prolonged psychological distress and is characterized by excessive fatigue, increased irritability, and a sense of demoralization. We assessed the hypothesis that vital exhaustion predicts recurrent cardiac events (myocardial infarction and CHD-related mortality) among middle-aged men and women with documented CHD. Participants were 589 black or white men and women (mean age = 59.8; range = 47 - 69 years) with a history of CHD at the 1990-1992 clinical examination of the ARIC Study. Vital exhaustion was measured at the same ARIC examination using the 21-item Maastricht Questionnaire, and scores were categorized into quartiles. Recurrent cardiac events were monitored in short term (0-5 years), mid- term (6-13 years), and long-term (14-19 years) follow-up. Cox proportional hazards regression models were adjusted for age, sex, race-center, educational level, body mass index, plasma LDL-and HDL-cholesterol levels, hypertension status, and pack-years of cigarette smoking. During short term follow-up, the risk for recurrent cardiac events among participants in the highest quartile of vital exhaustion was twice that of participants in the remainder of the sample (HR = 2.08; 95% C.I: 1.24 to 3.48). The risk was less strong but remained statistically significant in mid-term (HR = 1.77; 95% C.I: 1.26 to 2.48) and long-term (HR = 1.54; 95% C.I: 1.12 to 2.11) follow-up. In conclusion, vital exhaustion is positively associated with short-term and long-term risks for recurrent cardiac events among middle-aged men and women with established coronary heart disease, independent of the traditional biomedical risk factors.