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- Borg, Sabina, 1982-
(author)
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Exercise-Based Cardiac Rehabilitation in Patients with Coronary Artery Disease : Attendance, Adherence and the Added Value of a Behavioural Medicine Intervention
- 2021
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Doctoral thesis (other academic/artistic)abstract
- Background: Coronary artery disease (CAD) is the leading global cause of death. After an index event related to CAD, exercise-based cardiac rehabilitation (exCR) is strongly recommended as part of the secondary prevention. Despite the well-established beneficial effects of exCR in patients with CAD, attendance at and adherence to the programme are low, and remain a matter of major concern. One strategy that may increase adherence and rehabilitation outcomes in patients with CAD is to add a behavioural medicine intervention to routine exCR care. The added value of such interventions needs to be further explored. Although several factors associated with non-attendance at exCR appear to be similar between different countries, patterns of attendance may differ due to differences in contextual aspects. The factors that affect attendance at exCR in a Swedish context remain to be explored.Overall aim: To investigate barriers for exCR attendance and to evaluate the added value of a behavioural medicine intervention in physiotherapy on exercise adherence and rehabilitation outcomes in patients with CAD.Methods: The three papers in this thesis are based on two studies of patients with CAD, one registrybased cohort study of 31,297 patients included from the SWEDEHEART registry (Paper I), and one randomised controlled trial of 170 patients included at a Swedish university hospital (Papers II and III). In the first paper, several individual and structural variables were compared for attenders and nonattenders, using multivariable analysis in a logistic regression model. In Papers II and III, patients were randomised 1:1 either to a behavioural medicine intervention in physiotherapy in addition to routine exCR care or to routine exCR care alone for four months. The behaviour change techniques used in the behavioural medicine intervention – specific goal-setting, re-evaluation of the goals, and selfmonitoring and feedback – were based on control theory. Outcome assessment took place at baseline, four and 12 months, and included physical fitness, psychological outcomes and health-related quality of life. Exercise adherence was evaluated at the end of the four-month intervention. An intention-to-treat and a per-protocol analysis were performed.Results: Individual and structural factors associated with non-attendance at exCR in a Swedish context were identified as having a distance greater than 16 km to the hospital, belonging to a county hospital, having a higher burden of comorbidities, being male, and being retired. Exercise adherence was higher for patients who received the behavioural medicine intervention in physiotherapy together with routine exCR (31%) than it was for those who received routine exCR care alone (19%). Rehabilitation outcomes did not differ significantly between the two groups, either between baseline and four months or between four and 12 months. Both groups improved significantly in all measures of physical fitness, and in several measures of health-related quality of life and anxiety at the four-month follow-up. Sufficient enablement remained for patients in both groups at the 12-months follow-up.Conclusions: Distance to the hospital was the strongest predictor for non-attendance at exCR in a Swedish context. The individual factors associated with non-attendance at exCR identified in this thesis confirm previous results, with the exception that female gender was associated with a higher attendance at exCR. The results of this thesis confirm what others have pointed out: it is challenging to achieve behavioural change in patients with the aim to improve rehabilitation outcomes. Even though adherence was higher when a behavioural medicine intervention was added, it was low in both groups. The current behavioural medicine intervention in physiotherapy did not give any improvements over routine exCR care alone in physical fitness, psychological outcomes or health-related quality of life. As such, there is still room for further development and evaluation of behavioural medicine interventions within the context of exCR. A greater tailoring of these interventions to individual needs in a broader population of patients with CAD is suggested.
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| 2. |
- Ek, Amanda, 1981-
(author)
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Physical activity among patients with cardiovascular disease : a predictor of hospital care utilisation and mortality in clinical work
- 2020
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Doctoral thesis (other academic/artistic)abstract
- Guidelines highlight the importance of physical activity (PA) in secondary prevention of cardiovascular disease (CVD) within the healthcare sector. Previous studies have mainly focused on the effects of PA at moderate-vigorous intensity performed within exercise-based cardiac rehabilitation (CR). However, only a minority of patients with CVD participate in exercise-based CR, and it is not known to what extent the guidelines for PA are implemented in clinical work. This leads to a knowledge gap in PA levels among patients with CVD, and the potential association of PA with hospital care utilisation and all-cause mortality. The overall aim of this thesis was to investigate PA and its importance for patients with CVD, and to what extent it is promoted during clinical work. The associations between self-rated PA level, changes in self-rated PA level, and sedentary time (SED) with hospital care utilisation and all-cause mortality were explored in three cohort studies (Studies I-III). Data were collected via questionnaires, medical records and national registers. Study I explored everyday PA, physical exercise and SED among patients with CVD (n=1148) prior to admittance to a cardiac ward at two of the hospitals in Stockholm. Studies II and III explored PA (of at least moderate intensity) post hospitalisation, and included 30 644 and 22 227 patients with myocardial infarction (MI), respectively, from the national SWEDHEART registry. Finally, in Study IV, healthcare professionals’ (n=251) stated importance and clinical work to promote healthy lifestyle habits (alcohol consumption, eating habits, physical activity, and smoking) were explored in a cross-sectional study. All healthcare professionals working on cardiac departments in two hospitals in Stockholm were included.The main findings were:• PA level (everyday PA, physical exercise, total PA level) and SED pre and post hospitalisation for cardiac events were found to be significant predictors of hospital care duration, readmission and mortality. The effects of high PA level and low SED did not differ between CVD diagnosis, sex, age, or comorbid states such as individuals with and without diabetes mellitus type II, kidney dysfunction, hypertension or dyslipidaemia.• There were no differences between individuals reporting a moderate or high level of PA or a medium or low level of SED, illustrating that “a little activity is better than nothing” and that the greatest health benefits would be achieved by increasing PA among the most inactive patients with CVD.• Changes in PA level during the first year post MI are important. Increased PA lowered the risk of mortality, and decreased PA increased the risk of mortality in patients post MI.• Healthcare professionals considered it important to promote lifestyle habits among patients within the healthcare sector in general, as well as in their own clinical work. However, there was a difference between stated importance and clinical practice as only a minority of healthcare professionals asked or provided counselling on healthy lifestyle habits. Our results indicated a relationship between promoting patients’ lifestyle habits in clinical work, and if they perceived clear organisational routines and objectives.In conclusion, the results of this thesis have a clinical impact. Firstly, asking patients on a cardiac department about their PA level and SED may identify individuals in need of behavioural changes. By identifying and supporting individuals who need to increase their PA level, clinicians may potentially decrease the utilisation of inpatient care and also lower the risk of all-cause mortality among individuals with a CVD diagnosis. Secondly, this information is of great predictive value, and PA can be seen as an additional marker of disease severity.
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| 4. |
- Kristiansen, Oscar, et al.
(author)
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Effect of atorvastatin on muscle symptoms in coronary heart disease patients with self-perceived statin muscle side-effects : a randomized, double-blinded crossover trial
- 2021
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In: European Heart Journal - Cardiovascular Pharmacotherapy. - : Oxford University Press. - 2055-6837 .- 2055-6845. ; 7:6, s. 507-516
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Journal article (peer-reviewed)abstract
- AIMS: To estimate the effect of atorvastatin on muscle symptom intensity in coronary heart disease (CHD) patients with self-perceived statin-associated muscle symptoms (SAMS) and to determine the relationship to blood levels of atorvastatin and/or metabolites.METHODS AND RESULTS: A randomized multi-center trial consecutively identified 982 patients with previous or ongoing atorvastatin treatment after a CHD event. Of these, 97 (9.9%) reported SAMS and 77 were randomized to 7-weeks double-blinded treatment with atorvastatin 40 mg/day and placebo in a crossover design. The primary outcome was the individual mean difference in muscle symptom intensity between the treatment periods, measured by visual-analogue scale (VAS) scores. Atorvastatin did not affect the intensity of muscle symptoms among 71 patients who completed the trial. Mean VAS difference [statin-placebo] was 0.31 (95% CI -0.24-0.86). The proportion with more muscle symptoms during placebo than atorvastatin was 17% (n = 12), 55% (n = 39) had the same muscle symptom intensity during both treatment periods whereas 28% (n = 20) had more symptoms during atorvastatin than placebo (confirmed SAMS). There were no differences in clinical or pharmacogenetic characteristics between these groups. The levels of atorvastatin and/or metabolites did not correlate to muscle symptom intensity among patients with confirmed SAMS (Spearmans rho ≤0.40, for all variables).CONCLUSION: Re-challenge with high-intensity atorvastatin did not affect the intensity of muscle symptoms in CHD patients with self-perceived SAMS during previous atorvastatin therapy. There was no relationship between muscle symptoms and the systemic exposure to atorvastatin and/or its metabolites. The findings encourage an informed discussion to elucidate other causes of muscle complaints and continued statin use.
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| 5. |
- Kristiansen, Oscar, et al.
(author)
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The relationship between directly measured statin adherence, self-reported adherence measures and cholesterol levels in patients with coronary heart disease
- 2021
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In: Atherosclerosis. - : Elsevier. - 0021-9150 .- 1879-1484. ; 336, s. 23-29
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Journal article (peer-reviewed)abstract
- BACKGROUND AND AIMS: We aimed to determine the relationship between statin adherence measured directly, and by self-report measures and serum cholesterol levels.METHODS: Patients prescribed atorvastatin (N = 373) participated in a cross-sectional study 2-36 months after a coronary event. Self-reported adherence included statin adherence the past week, the 8-item Morisky medication adherence scale (MMAS-8), and the Gehi et al. adherence question. Atorvastatin was measured directly in spot blood plasma by a novel liquid chromatography tandem mass-spectrometry method discriminating adherence (0-1 doses omitted) and reduced adherence (≥2 doses omitted). Participants were unaware of the atorvastatin analyses at study participation.RESULTS: Mean age was 63 (SD 9) years and 8% had reduced atorvastatin adherence according to the direct method. In patients classified with reduced adherence by the direct method, 40% reported reduced statin adherence, 32% reported reduced adherence with the MMAS-8 and 22% with the Gehi question. In those adherent by the direct method, 96% also reported high statin adherence, 95% reported high adherence on the MMAS-8 whereas 94% reported high adherence on the Gehi question. Cohen's kappa agreement score with the direct method was 0.4 for self-reported statin adherence, 0.3 for the Gehi question and 0.2 for the MMAS-8. Adherence determined by the direct method, self-reported statin adherence last week, and the Gehi question was inversely related to LDL-cholesterol levels with a p-value of <0.001, 0.001 and 0.004, respectively.CONCLUSIONS: Plasma-statin measurements reveal reduced adherence with higher sensitivity than self-report measures, relate to cholesterol levels, and may prove to be a useful tool to improve lipid management.
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| 6. |
- Peersen, Kari, et al.
(author)
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Clinical and psychological factors in coronary heart disease patients with statin associated muscle side-effects
- 2021
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In: BMC Cardiovascular Disorders. - : BioMed Central. - 1471-2261 .- 1471-2261. ; 21:1
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Journal article (peer-reviewed)abstract
- BackgroundTo compare clinical and psychological factors among patients with self-perceived statin-associated muscle symptoms (SAMS), confirmed SAMS, and refuted SAMS in coronary heart disease patients (CHD).MethodsData were obtained from a cross-sectional study of 1100 CHD outpatients and a study of 71 CHD outpatients attending a randomized, double-blinded, placebo-controlled, crossover study to test effects of atorvastatin 40 mg/day on muscle symptom intensity. Clinical and psychosocial factors were compared between patients with and without SAMS in the cross-sectional study, and between patients with confirmed SAMS and refuted SAMS in the randomized study.ResultsBilateral, symmetric muscle symptoms in the lower extremities during statin treatment were more prevalent in patients with confirmed SAMS compared to patients with refuted SAMS (75% vs. 41%, p = 0.01) in the randomized study. No significant differences in psychological factors (anxiety, depression, worry, insomnia, type D personality characteristics) were detected between patients with and without self-perceived SAMS in the cross-sectional study, or between patients with confirmed SAMS and refuted SAMS, in the randomized study.ConclusionsPatients with confirmed SAMS more often present with bilateral lower muscle symptoms compared to those with refuted SAMS. Psychological factors were not associated with self-perceived SAMS or confirmed SAMS. A careful pain history and a search for alternative causes of muscle symptoms are likely to promote communication in patients with SAMS, and may reduce the risk for statin discontinuation.
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| 7. |
- Peersen, Kari, et al.
(author)
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Medical and Psychosocial Factors Associated With Low Physical Activity and Increasing Exercise Level After a Coronary Event
- 2020
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In: Journal of Cardiopulmanory Rehabilitation and Prevention (JCRP). - : Lippincott Williams & Wilkins. - 1932-7501 .- 1932-751X. ; 40:1, s. 35-40
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Journal article (peer-reviewed)abstract
- Purpose: The reasons why many coronary patients are inactive or have a low level of physical activity (PA) are not completely understood. We identified medical and psychosocial factors associated with PA status and increasing exercise level after a coronary event. Methods: A cross-sectional study investigated the factors associated with PA in 1101 patients hospitalized with myocardial infarction (MI) and/or a revascularization procedure. Data were collected from hospital records, a self-report questionnaire, and a clinical examination. PA was categorized as inactivity, low activity, and adequate activity (>= moderate intensity of 30 min >= 2-3 times/wk), an overall summary PA-index was measured as a continuous variable, and self-reported PA increase since the index event was measured on a 0- to 10-point Likert Scale. Results: In all, 18% reported inactivity, 42% low, and 40% adequate activity at follow-up after median 16 mo. In multiadjusted linear regression analyses, low PA-index was significantly associated with smoking, obesity, unhealthy diet, depression, female, low education, MI as index diagnosis, and >= 1 previous coronary event. Motivation, risk and illness perceptions, and low reported need of help to increase PA were significantly associated with self-reported increasing PA level in adjusted continuous analyses. Conclusions: Daily smoking, obesity, unhealthy diet, and depression were the major potentially modifiable factors associated with insufficient PA, whereas high motivation and risk and illness perceptions were associated with increasing PA level. Further research on the effect of interventions tailored to the reported significant factors of failure is needed to improve PA level in CHD patients.
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| 10. |
- Sverre, E., et al.
(author)
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Challenges in coronary heart disease prevention - experiences from a long-term follow-up study in Norway
- 2021
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In: Scandinavian Cardiovascular Journal. - : Taylor & Francis Group. - 1401-7431 .- 1651-2006. ; 55:2, s. 73-81
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Journal article (peer-reviewed)abstract
- Objective. To determine longitudinal changes in lifestyle behaviour and lipid management in a chronic coronary heart disease (CHD) population. Design. A multi-centre cohort study consecutively included 1127 patients at baseline in 2014-2015, on average 16 months after a CHD event. Data were collected from hospital records, a questionnaire and clinical examination. Seven hundred and seven of 1021 eligible patients participated in a questionnaire-based follow-up in 2019. Data were analysed with univariate statistics. Results. After a mean follow-up of 4.7 years (SD 0.4) from baseline, the percentage of current smokers (15% versus 16%), obesity (23% versus 25%) and clinically significant symptoms of anxiety (21% versus 17%) and depression (13% versus 14%) remained unchanged, whereas the proportion with low physical activity increased from 53% to 58% (p < .001). The proportions with reduced physical activity level were similar in patients over and under 70 years of age. Most patients were still taking statins (94% versus 92%) and more patients used high-intensity statin (49% versus 54%, p < .001) and ezetimibe (5% versus 15%, p < .001) at follow-up. 73% reported >= 1 primary-care consultation(s) for CHD during the last year while 27% reported no such follow-up. There were more smokers among participants not attending primary-care consultations compared to those attending (19% versus 14%, p = .026). No differences were found for other risk factors. Conclusions. We found persistent suboptimal risk factor control in coronary outpatients during long-term follow-up. Closer follow-up and intensified risk management including lifestyle and psychological health are needed to improved secondary prevention and outcome of CHD.
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