Patient’s emotional reactions in cardiac rehabilitation: analysis and perspectives

Subject: Evaluation and treatment of psychological diseases are often included in cardiology rehabilitation programs. The aim of this study was to analyze the emotional reactions in a very consistent sample of cardiac patients, hospitalized for a rehabilitation program. Materials and methods: The sample consisted of 5417 patients, 4563 males and 854 females, with a mean age of 57.36±9.15 (range 18-83). They were admitted in the period between 1995 and 2005 and completed the Cognitive Behavioral Assessment, Hospital form (CBA-H) Results: Significant level of state- anxiety was shown by 27.8% of the subjects, 22.1% reported health-related fears and 10% depressive symptoms. Women show higher scores in all of the three scales, and patients over 65 years scored higher in the depression scale. It is interesting to note that the mean scores in the three scales showed a progressive and significant decrease over the years. Conclusions: These data confirm that an accurate psychological screening can be extremely useful to support the Psychologist working in cardiac rehabilitation as it helps to plan more specifically the interventions, focusing on the objective patients’ educational and psychological needs

Interventional Strategies in early Atherosclerosis

Atherosclerosis remains clinically mute for a long time and frequently manifests itself with an acute cardiovascular event; therefore, the possibility to detect the disease in a subclinical phase and to reduce or reverse its progression is an issue of relevance. Non-invasive diagnostic procedures such as B-mode ultrasonography of carotid intima-media thickness (CIMT), electron beam computed tomography (EBCT) and magnetic resonance angiography (MRA) allow to identify atherosclerotic disease in its early phases, to evaluate the disease progression and monitor the effects of interventions. In recent years, several therapeutic strategies have been adopted over time to slow early atherosclerosis in asymptomatic individuals at intermediate/high cardiovascular risk. Prospective trials employing multifactorial non-pharmacological interventions (diet, exercise, smoking cessation) have demonstrated a favorable effect on progression of atherosclerosis. Hence lifestyle modification may be an effective therapeutic strategy to be adopted as a first step and a highly cost-effective intervention in a preclinical setting involving a large number of individuals. Drugs should be considered as a second step or should be associated to further reduce the risk in individuals at high probability of future events, who require more intensive interventions. Reducing low-density lipoprotein levels, blood pressure and platelet aggregation seems to be the most effective intervention in these subjects, whereas the treatment of emerging coronary risk factors, e.g. oxidative stress, inflammatory activation and infections has not produced the expected protective effect

Analysis of the vital exhaustion construct in a female population during cardiac rehabilitation

Background: Vital Exhaustion (VE) is a psychological construct that has been shown to be predictive for cardiac morbidity and mortality. There are not sufficient data which clarify whether the female population express this construct differentely comparing to males. This study aims to analyze the construct of Vital Exhaustion in a population of women admitted to a cardiac rehabilitation program. Material and Method: The selected sample consisted of 854 women with an average age of 58 years (SD ± 10.2). All patients were at their first hospitalization for a cardiac rehabilitation program. The tool used to analyze the construct of Vital Exhaustion was the B scale of the Cognitive Behavioural Assessment Hospital form (CBA-H). The study also analyzed the answers to the D scale of the CBA-H concerning aspects of lifestyle and behavioral habits. Results: The percentage of women with considerable value of Vital Exhaustion was very high (67.7%). Moreover, the group of women with higher Vital Exhaustion showed more dysfunctional habits (smoking, poor physical activity, incorrect diet) and more referred psychological problems as well as job and/or family distress and insomnia. 207 women (24.2%) of the sample belonged to economically active population; 136 (69%) of these women presented a high value of VE and 61 (31%) a low one. Among the employed women, 24% of the group with high VE value reported to be unsatisfied, while the same condition lowered at 9.6% in the group with low VE value (p=.004); moreover, 41.7% versus 18.5% (p=.000) described their working life as a source of tension. Conclusions: Considering a sample of female cardiac patients, this study shows that the construct of Vital Exhaustion is particularly present. It also appears that the construct of Vital Exhaustion can be interpreted as an indicator of lifestyle problems in women, helping health-professionals in selecting efficient educational and/or psychological interventions

Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction

AbstractObjectives. The aim of this study was to investigate the correlations between Doppler-derlved transmitral flow velocity variables and pulmonary capillary wedge pressure in patients with severe left ventricular systolic dysfunction.Background. Abnormal relaxation and increased chamber stiffness have opposing effects on the left ventricular filling pattern. When both abnormalities are present at the same time, as often occurs in patients with systolic dysfunction, the ability of Doppler recording to assess diastolic function and predict left ventricular fillng pressure may be significantly compromised.Method. Pulmonary capillary wedge pressure and Doppler transmitral flow velocity profile were simultaneously recorded in 140 postinfarction patients with ejection fraction ≤35%.Results. Correlation between the ratio of mitral peak low velocity in early diastole to peak low velocity in late diastole (E/A ratio) and pulmonary capillary wedge pressure was weak (r = 0.65). Although the specificity of E/A ≥ 2 in predicting ≥29 mm Hg in pulmonary capillary wedge pressure was high (99%), its sensitivity was low (43%). Conversely, a very close negative correlation was found between mitral deceleration time of early filling and pulmonary capillary wedge pressure (r = −0.91). Sensitivity and specificity of ≤120 ms in deceleration time in predicting ≥20 mm Hg in pulmonary capillary wedge pressure were 100% and 99%, respectively.Conclusions. Doppler-derived mitral deceleration time of early filling provides a simple and accurate means of estimating pulmonary capillary wedge pressure that is particularly useful in patients with a normal or normalized mitral low velocity pattern

Technetium-99m sestamibi tomographic evaluation of residual ischemia after anterior myocardial infarction

Objectives.This study investigated the value of sestamibi scintigraphy in assessing residual ischemia after anterior myocardial infarction.Background.Serial imaging with sestamibi, the uptake and retention of which correlate with regional myocardial blood flow and viability, has been used to estimate salvaged myocardium and risk area after acute infarction. We recently documented that recovery of perfusion and contraction in the infarcted area may continue well after the subacute phase, suggesting myocardial hibernation. Some underestimation of viability in the setting of hibernating myocardium by sestamibi imaging has been reported.Methods.We studied 58 patients in stable condition after Q wave anterior infarction. Regional perfusion and function were quantitatively assessed by sestamibi tomography and two-dimensional echocardiography at 4 to 6 weeks and at 7 months after infarction. In sestamibi polar maps, abnormal areas with tracer uptake >2.5 SD below our reference values were computed at rest and after symptom-limited exercise. On two-dimensional echocardiography the ejection fraction and extent of rest wall motion abnormalities were assessed by a computerized system. All patients had coronary angiography between the two studies.Results.At 7 months the extent of rest sestamibi defect was significantly reduced in 40 patients (69%, group 1) and unchanged in 18 (31%, group 2). Rest wall motion abnormalities and ventricular ejection fraction significantly improved in group 1 but not in group 2. Underlying coronary disease, patency of the infarct-related vessel and rest sestamibi defect extent at 5 weeks were comparable between the two groups. At 7 months, an increase in the reversible (stress-rest defect) tracer defect was observed in group 1 (p < 0.05) despite a smaller stress-induced hypoperfusion (p < 0.05). Reversible sestamibi defects and stress hypoperfusion were unchanged in group 2. In 38 (95%) of 40 group 1 patients, the area showing reversible sestamibi defects at 7 months matched the area showing fixed hypoperfusion at 5 weeks.Conclusions.The reduction in the rest tracer uptake defect that can occur late after infarction may affect the assessment of ischemic burden by sestamibi imaging early after anterior myocardial infarction

Long-term physical training and left ventricular remodelling after anterior myocardial infraction: Results of the excercise in anterior myocardial infraction (EAMI) trial

AbstractObjectives. The aim of this multicenter randomized study was to investigate whether long-term physical training would influence left ventricular remodeling after anterior myocardial infarction.Background. Exercise is currently recommended for patients after myocardial infarction; however, the effects of long-term physical training on ventricular size and remodeling still have to be defined.Methods. Patients with no contraindications to exercise were studied 4 to 8 weeks after anterior Q wave myocardial infarction and 6 months later by echocardiography at rest and bicycle ergometric testing. After the initial study, patients were randomly allocated to a 6-month exercise training program (n = 49) or a control group (n = 46). A computerized system was used to derive echocardiographic variables of ventricular size, function and topography.Results. After 6 mongths, a significant (p < 0.01) increase in work capacity (from 4,596 ± 1,246 to 5,508 ± 1,335 kp-m) was observed only in the training group, whereas global ventricular size, regional dilation and shape distortion did not change in either the control or the training group. However, compared with patients with an ejection fraction >40%, patients with an ejection fraction ≤ 40% had more significant (p < 0.001) ventricular enlargement at entry and demonstrated further (p < 0.01) global and regional dilation after 6 months, in both the control and the training, group (end-diastolic volume from 77 ± 14 to 85 ± 17 ml/m2in the control group and from 74 ± 11 to 77 ± 15 ml/m2in the training group; regional dilation from 46 ± 18% to 57 ± 21% in the control group and from 42 ± 18% to 44 ± 26% in the training group). Ventricular size and topography did not change in patients with an ejection fraction >40%.Conclusions. Patients with poor left ventricular function 1 to 2 months after anterior myocardial infarction are prone to further global and regional dilation. Exercise training does not appear to influence this spontaneous deterioration. Thus, postinfarction patients without clinical complications, even those with a large anterior infarction, may benefit from long-term physical training without any additional negative effect on ventricular size and topography

Systemic perfusion at peak incremental exercise in left ventricular assist device recipients: Partitioning pump and native left ventricle relative contribution

AbstractBackgroundIn continuous-flow left ventricular assist device (LVAD) recipients, little is known about the relative pump- and left ventricle-generated blood flow (PBF and LVBF, respectively) contribution to peak systemic perfusion during incremental exercise and about how PBF/LVBF interplay and exercise capacity may be affected by pump speed increase.MethodsTwenty-two LVAD recipients underwent ramp cardiopulmonary exercise tests at fixed and increasing pump speed (+ 1.5% of baseline speed/10 W workload increase), echocardiography and NT-proBNP dosage. Peak systemic perfusion was peak VO2/estimated peak arterio-venous O2 difference, and LVBF was systemic perfusion minus PBF provided by LVAD controller. A change of peak percentage of predicted VO2max (Δpeak%VO2) ≥ 3 in increasing- vs. fixed-speed test was considered significant.ResultsTricuspid annular plane systolic excursion (TAPSE) and NT-proBNP were significantly lower and higher, respectively, in Δpeak%VO2 13 mm as a predictor of Δpeak%VO2 ≥ 3.ConclusionsA significant LVBF contribution to peak systemic perfusion and pump speed increase-induced peak VO2 improvement was detectable only in patients with a more preserved right ventricular systolic function and stable hemodynamic picture. These findings should be taken into consideration when designing LVAD controllers aiming to increase pump speed according to increasing exercise demands

Left ventricular assist device: which emotional impact on the patient?

Background: Advanced heart failure is a challenging disease; the implantable Left Ventricular Assist Device (L-VAD) is becoming a good chance for relieving symptoms and prolong survival in most CHF patients. The emotional impact of L-VAD implantation is thought to be high but, at present, published data are scant about that. Aim of this study was to evaluate the modifications of perceived quality of life (QoL) in a group of patients recently treated with L-VAD implantation, admitted to a residential cardiac rehabilitation program, and to compare the results to those obtained in patients awaiting heart transplantation and recently transplanted. Material and Method: We enrolled 66 patients (pts) with a recent implant of L-VAD, 51 with refractory heart failure awaiting heart transplantation (HT) and 55 recently treated with HT. On day two after admission, all patients underwent a complete psychometric assessment consisting in the compilation of: – Minnesota Living with Heart Failure Questionnaire (MLHFQ) – Beck Anxiety Inventory (BAI) – Beck Depression Inventory-II (BDI - II) Results: L-VAD recipients had significantly higher scores at MLHFQ. Both the total score and the 2 subscales scores (respectively physical and emotional disturbances) were statistically significant when compared with posttransplant patients. Post- transplant pts had the lowest scores regarding anxiety symptoms, while the bearers of device had the highest ones. The same results were obtained for depression scores (BDI - II), both in total score and in the subscales (somatic symptoms and affective symptoms). Conclusions: With an opening scoring, this study showed the development of more relevant psychological troubles in patients treated with L-VAD when compared to those awaiting for heart transplantation and those transplanted