Background To improve the quality of exercise-based cardiac rehabilitation (CR) in patients with coronary heart disease (CHD) the CR guideline from the Dutch Royal Society for Physiotherapists (KNGF) has been updated. This guideline can be considered an addition to the 2011 Dutch Multidisciplinary CR guideline, as it includes several novel topics. Methods A systematic literature search was performed to formulate conclusions on the efficacy of exercise-based interventions during all CR phases in patients with CHD. Evidence was graded (1–4) according the Dutch evidence-based guideline development (EBRO) criteria. In case of insufficient scientific evidence, recommendations were based on expert opinion. This guideline comprised a structured approach including assessment, treatment and evaluation. Results Recommendations for exercise-based CR were formulated covering the following topics: preoperative physiotherapy, mobilisation during the clinical phase, aerobic exercise, strength training, and relaxation therapy during the outpatient rehabilitation phase, and adoption and monitoring of a physically active lifestyle after outpatient rehabilitation. Conclusions There is strong evidence for the effectiveness of exercise-based CR during all phases of CR. The implementation of this guideline in clinical practice needs further evaluation as well as the maintenance of an active lifestyle after supervised rehabilitation. LinkedIn: https://www.linkedin.com/in/tinusjongert/
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Aim To provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL]. Methods A questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment. Results All 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients’ functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres ‘often to always’ do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are ‘sometimes to regularly’ available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed ‘sometimes to regularly’ in heart team meetings (n = 10). Conclusions Dutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.
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Abstract People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.
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ObjectiveDepressive and anxiety symptoms are associated with Ischemic Heart Disease (IHD). Exercise interventions might improve both depressive and anxiety symptoms, but an overview of the evidence is lacking. Therefore, we systematically reviewed the existing literature on the effectiveness of exercise therapy to reduce depression and anxiety symptoms specifically in patients with IHD.MethodsMEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials were searched until January 2016. The effectiveness of exercise was assessed within two groups: a) patients selected for study with severe depression or anxiety; and b) studies that did not exclusively targeted patients with increased levels of depression or anxiety. Secondary outcomes were mortality, cardiac events, re-hospitalizations and cardiovascular risk factors.ResultsWe included fourteen studies. Clinical and methodological heterogeneity precluded meta-analysis. Three studies specifically included patients with high levels of depression or anxiety and eleven studies selected patients with unclear levels of depression or anxiety. Some RCTs showed that exercise was effective in lowering severe depressive symptoms (short and long term follow-up), but for the group with unclear depressive symptoms the results were non-conclusive. In the group with elevated anxiety symptoms, exercise had a positive effect on the short term follow-up. In the group with unclear anxiety symptoms the results were inconsistent (short and long term follow-up). No differences were found regarding the secondary outcomes.ConclusionsThere is a general paucity of data on the effect of exercise, precluding firm conclusions about the effectiveness of exercise for depressive and anxiety symptoms in IHD patients.
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Abstract Frailty syndrome (FS) is an independent predictor of mortality in cardiovascular disease and is found in 15-74% of patients with heart failure (HF). The syndrome has a complex, multidimensional aetiology and contributes to adverse outcomes. Proper FS diagnosis and treatment determine prognosis and support the evaluation of treatment outcomes. Routine FS assessment for HF patients should be included in daily clinical practice as an important prognostic factor within a holistic process of diagnosis and treatment. Multidisciplinary team members, particularly nurses, play an important role in FS assessment in hospital and primary care settings, and in the home care environment. Raising awareness of concurrent FS in patients with HF patients and promoting targeted interventions may contribute to a decreased risk of adverse events, and a better prognosis and quality of life.
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A substantial proportion of chronic disease patients do not respond to self-management interventions, which suggests that one size interventions do not fit all, demanding more tailored interventions. To compose more individualized strategies, we aim to increase our understanding of characteristics associated with patient activation for self-management and to evaluate whether these are disease-transcending. A cross-sectional survey study was conducted in primary and secondary care in patients with type-2 Diabetes Mellitus (DM-II), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF) and Chronic Renal Disease (CRD). Using multiple linear regression analysis, we analyzed associations between self-management activation (13-item Patient Activation Measure; PAM-13) and a wide range of socio-demographic, clinical, and psychosocial determinants. Furthermore, we assessed whether the associations between the determinants and the PAM were disease-transcending by testing whether disease was an effect modifier. In addition, we identified determinants associated with low activation for self-management using logistic regression analysis. We included 1154 patients (53% response rate); 422 DM-II patients, 290 COPD patients, 223 HF patients and 219 CRD patients. Mean age was 69.6±10.9. Multiple linear regression analysis revealed 9 explanatory determinants of activation for selfmanagement: age, BMI, educational level, financial distress, physical health status, depression, illness perception, social support and underlying disease, explaining a variance of 16.3%. All associations, except for social support, were disease transcending. This study explored factors associated with varying levels of activation for self-management. These results are a first step in supporting clinicians and researchers to identify subpopulations of chronic disease patients less likely to be engaged in self-management. Increased scientific efforts are needed to explain the greater part of the factors that contribute to the complex nature of patient activation for self-management.
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Chronic diseases represent a significant burden for the society and health systems; addressing this burden is a key goal of the European Union policy. Health and other professionals are expected to deliver behaviour change support to persons with chronic disease. A skill gap in behaviour change support has been identified, and there is room for improvement. Train4Health is a strategic partnership involving seven European Institutions in five countries, which seeks to improve behaviour change support competencies for the self-management of chronic disease. The project envisages a continuum in behaviour change support education, in which an interprofessional competency framework, relevant for those currently practising, guides the development of a learning outcomes-based curriculum and an educational package for future professionals (today’s undergraduate students).
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Abstract: Background: Little is known about frailty among patients hospitalized with heart failure (HF). To date, the limited information on frailty in HF is based on a unidimensional view of frailty, in which only physical aspects are considered when determining frailty. The aims of this study were to study different dimensions of frailty (physical, psychological and social) in patients with HF and the effect of different dimensions of frailty on the incidence of heart failure. Methods: The study used a cross-sectional design and included 965 patients hospitalized for heart failure and 164 healthy controls. HF was defined according to the ESC guidelines. The Tilburg Frailty Indicator (TFI) was used to assess frailty. Probit regression analyses and chi-square statistics were used to examine associations between the occurrence of heart failure and TFI domains of frailty. Results: Patients diagnosed with frailty were 15.3% more likely to develop HF compared to those not diagnosed with frailty (p < 0.001). An increase in physical, psychological and social frailty corresponded to an increased risk of HF of 2.9% (p < 0.001), 4.4% (p < 0.001) and 6.6% (p < 0.001), respectively. Conclusions: We found evidence of the association between different dimensions of frailty and incidence of HF.
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This open access book is a valuable resource for students in health and other professions and practicing professionals interested in supporting effective change in self-management behaviors in chronic disease, such as medication taking, physical activity and healthy eating. Developed under the auspices of the Train4Health project, funded by the Erasmus+ program of the European Union, the book contains six chapters written by international contributors from different disciplines. This chapter sets the stage for the remaining book, by introducing the Train4Health project and by explaining how the learning outcomes presented in subsequent chapters have been derived and linked with content of the book. Firstly, the Train4Health interprofessional competency framework to support behaviour change in persons self-managing chronic disease is briefly presented. This European competency framework was the starting point for developing the learning outcomes-based curriculum, which is succinctly addressed in the subsequent section. Finally, practical considerations about the Train4Health curriculum are discussed, including opportunities and challenges for interprofessional education.
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The author reflects on the need for a comprehensive assessment of the structure and quality of the family or social network given that relationships are affected after the diagnosis of a cardiovascular disease. He points out that families may experience changing needs for support during the disease trajectory and emotional support may be necessary to cope with changing roles. He advocates for a family-oriented approach for patients with heart failure and their families.
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