Fear of exercise and health-related quality of life in patients with an implantable cardioverter defibrillator

Several studies have reported improved survival rates thanks to the use of an implantable cardioverter defibrillator (ICD) in the treatment of patients with life-threatening arrhythmia. However, the effects of the ICD on health-related quality of life (HR-QoL) of these patients are not clear. The aim of this study is to describe HR-QoL and fear of exercise in ICD patients. Eighty-nine ICD patients from the University Hospital in Groningen, the Netherlands, participated in this study. HR-QoL was measured using the Rand-36 and the Quality of Life After Myocardial Infarction Dutch language version questionnaires. Fear of exercise was measured using the Tampa Scale for Kinesiophobia, Dutch version and the Fear Avoidance Beliefs Questionnaire, Dutch version. Association between outcome variables was analysed by linear regression analyses. Study results show that the HR-QoL of patients with ICDs in our study population is significantly worse than that of normal healthy people. Furthermore, fear of exercise is negatively associated with HR-QoL corrected for sex, age and number of years living with an ICD. After implantation of the ICD, patients with a clear fear of exercise should be identified and interventions should be considered in order to increase their HR-QoL

Mitral valve repair and redo repair for mitral regurgitation in a heart transplant recipient

A 37-year-old man with end-stage idiopathic dilated cardiomyopathy underwent an orthotopic heart transplant followed by a reoperation with mitral annuloplasty for severe mitral regurgitation. Shortly thereafter, he developed severe tricuspid regurgitation and severe recurrent mitral regurgitation due to annuloplasty ring dehiscence. The dehisced annuloplasty ring was refixated, followed by tricuspid annuloplasty through a right anterolateral thoracotomy. After four years of follow-up, there are no signs of recurrent mitral or tricupid regurgitation and the patient remains in NYHA class II. Pushing the envelope on conventional surgical procedures in marginal donor hearts (both before and after transplantation) may not only improve the patient’s functional status and reduce the need for retransplantation, but it may ultimately alleviate the chronic shortage of donor hearts

Improving guideline adherence for cardiac rehabilitation in the Netherlands

Background In 2004, the Netherlands Society of Cardiology released the current guideline on cardiac rehabilitation. Given its complexity and the involvement of various healthcare disciplines, it was supplemented with a clinical algorithm, serving to facilitate its implementation in daily practice. Although the algorithm was shown to be effective for improving guideline adherence, several shortcomings and deficiencies were revealed. Based on these findings, the clinical algorithm has now been updated. This article describes the process and the changes that were made. Methods The revision consisted of three phases. First, the reliability of the measurement instruments included in the 2004 Clinical Algorithm was investigated by evaluating between-centre variations of the baseline assessment data. Second, based on the available evidence, a multidisciplinary expert advisory panel selected items needing revision and provided specific recommendations. Third, a guideline development group decided which revisions were finally included, also taking practical considerations into account. Results A total of nine items were revised: three because of new scientific insights and six because of the need for more objective measurement instruments. In all revised items, subjective assessment methods were replaced by more objective assessment tools (e.g. symptom-limited exercise instead of clinical judgement). In addition, four new key items were added: screening for anxiety/depression, stress, cardiovascular risk profile and alcohol consumption. Conclusion Based on previously determined shortcomings, the Clinical Algorithm for Cardiac Rehabilitation was thoroughly revised mainly by incorporating more objective assessment methods and by adding several new key area

A hidden HIV epidemic among women in Vietnam

<p>Abstract</p> <p>Background</p> <p>The HIV epidemic in Vietnam is still concentrated among high risk populations, including IDU and FSW. The response of the government has focused on the recognized high risk populations, mainly young male drug users. This concentration on one high risk population may leave other populations under-protected or unprepared for the risk and the consequences of HIV infection. In particular, attention to women's risks of exposure and needs for care may not receive sufficient attention as long as the perception persists that the epidemic is predominantly among young males. Without more knowledge of the epidemic among women, policy makers and planners cannot ensure that programs will also serve women's needs.</p> <p>Methods</p> <p>More than 300 documents appearing in the period 1990 to 2005 were gathered and reviewed to build an understanding of HIV infection and related risk behaviors among women and of the changes over time that may suggest needed policy changes.</p> <p>Results</p> <p>It appears that the risk of HIV transmission among women in Vietnam has been underestimated; the reported data may represent as little as 16% of the real number. Although modeling predicted that there would be 98,500 cases of HIV-infected women in 2005, only 15,633 were accounted for in reports from the health system. That could mean that in 2005, up to 83,000 women infected with HIV have not been detected by the health care system, for a number of possible reasons. For both detection and prevention, these women can be divided into sub-groups with different risk characteristics. They can be infected by sharing needles and syringes with IDU partners, or by having unsafe sex with clients, husbands or lovers. However, most new infections among women can be traced to sexual relations with young male injecting drug users engaged in extramarital sex. Each of these groups may need different interventions to increase the detection rate and thus ensure that the women receive the care they need.</p> <p>Conclusion</p> <p>Women in Vietnam are increasingly at risk of HIV transmission but that risk is under-reported and under-recognized. The reasons are that women are not getting tested, are not aware of risks, do not protect themselves and are not being protected by men. Based on this information, policy-makers and planners can develop better prevention and care programs that not only address women's needs but also reduce further spread of the infection among the general population.</p

Pharmacological management of arrhythmias in the elderly

The incidence of cardiac arrhythmia increases with advancing age, as does the prevalence of structural heart disease. Serious arrhythmias, such as sustained ventricular tachycardias, are uncommon in elderly patients, but nonsustained ventricular tachycardias and atrial fibrillation are relatively frequent. The first step in the treatment of supraventricular and ventricular arrhythmias is the identification of an underlying (cardiac) disease, which should be treated appropriately. Patients with supraventricular arrhythmias who do not have a severe underlying cardiac disease may be treated with antiarrhythmic drugs to prevent recurrences of the arrhythmia. In selected patients, radiofrequency catheter ablation may nowadays be a first-line therapeutic strategy. In elderly patients with underlying cardiac disease who are experiencing non-life-threatening arrhythmias, antiarrhythmic drugs are generally discouraged because of the risk of proarrhythmic effects or other adverse events. In patients experiencing life-threatening ventricular arrhythmias, beta-blockers may be the first-line therapy. If these drugs are not effective, or cause adverse effects, class III or class IC antiarrhythmic drugs may be used as alternatives. Radiofrequency ablation is only moderately effective for haemodynamically stable ventricular tachycardias occurring post-myocardial infarction, but may be an option in drug-refractory patients

Current treatment recommendations in antiarrhythmic therapy

Over the past decade, various studies have demonstrated that class I antiarrhythmic drugs should be avoided in patients with heart failure, cardiac ischaemia or a previous myocardial infarction. In contrast, class II drugs (P-blockers) reduce morbidity and may even lower mortality in patients suffering from moderate to severe heart failure. In these patients, careful titration of the drug dosage, frequently during hospital admission, may be necessary. If in the setting of heart failure ventricular arrhythmias are symptomatic and/or sustained, patients can be treated effectively, after appropriate treatment of the underlying disease, with the class III drug amiodarone. Unfortunately, this drug does not lower overall mortality, implying that prophylactic institution of amiodarone is not indicated. Pure class III antiarrhythmic drugs like d-sotalol, ibutilide and dofetilide show a high rate of torsade de pointes, Currently, only ibutilide has been approved for clinically monitored intravenous administration. Class IV drugs, the calcium channel blockers, are still very useful for rate control of atrial fibrillation and conversion or prevention of atrioventricular nodal re-entrant tachycardias and circus movement tachycardias using a (concealed) bypass tract. Finally. an implantable cardioverter defibrillator seems to improve overall survival in patients with life-threatening ventricular arrhythmias. This may imply that an increasing number of patients will be candidates for such a device. However. it will be necessary to await publication of data involving these devices from current ongoing studies