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Background Patients with heart failure (HF) are at heightened risk for acute exacerbation requiring hospitalization. Although timely reporting of symptoms can expedite outpatient treatment and avoid the need for hospitalization, few patients recognize and respond to symptoms until acutely ill. Objective The purpose of this study was to explore patients' perceptions of symptoms and self-care behaviors for symptom relief, leading up to a HF hospitalization. Methods To examine prehospitalization symptom scenarios, semistructured interviews were conducted with 60 patients hospitalized for acute decompensated HF. Results Thirty-seven patients (61.7%) said that they had a sense that "something just wasn't quite right" before their symptoms began but were unable to specify further. Signs and symptoms most often recognized by the patients were related to dyspnea (85%), fatigue (53.3%), and edema (41.7%). Few patients interpreted their symptoms as being related to worsening HF and most often attributed symptoms to changes in diet (18.3%) and medications (13.3%). Twenty-six patients (43.3%) used self-care strategies to relieve symptoms before hospital admission. More than 40% of the patients had symptoms at least 2 weeks before hospitalization. Conclusions Despite the wide dissemination of HF evidence-based guidelines, important components of symptom self-management remain suboptimal. Because most of HF self-management occurs in the postdischarge environment, research is needed that identifies how patients interpret symptoms of HF in the specific contexts in which patients self-manage their HF. These findings suggest the need for interventions that will help patients expeditiously recognize, accurately interpret, and use appropriate and safe self-care strategies for symptoms.

Background— This trial tested the effects of multidisciplinary group clinic appointments on the primary outcome of time to first heart failure (HF) rehospitalization or death. Methods and Results— HF patients (n=198) were randomly assigned to standard care or standard care plus multidisciplinary group clinics. The group intervention consisted of 4 weekly clinic appointments and 1 booster clinic at month 6, where multidisciplinary professionals engaged patients in HF self-management skills. Data were collected prospectively for 12 months beginning after completion of the first 4 group clinic appointments (2 months post randomization). The intervention was associated with greater adherence to recommended vasodilators ( P =0.04). The primary outcome (first HF-related hospitalization or death) was experienced by 22 (24%) in the intervention group and 30 (28%) in standard care. The total HF-related hospitalizations, including repeat hospitalizations after the first time, were 28 in the intervention group and 45 among those receiving standard care. The effects of treatment on rehospitalization varied significantly over time. From 2 to 7 months post randomization, there was a significantly longer hospitalization-free time in the intervention group (Cox proportional hazard ratio=0.45 (95% confidence interval, 0.21–0.98; P =0.04). No significant difference between groups was found from month 8 to 12 (hazard ratio=1.7; 95% confidence interval, 0.7–4.1). Conclusions— Multidisciplinary group clinic appointments were associated with greater adherence to selected HF medications and longer hospitalization-free survival during the time that the intervention was underway. Larger studies will be needed to confirm the benefits seen in this trial and identify methods to sustain these benefits. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00439842.

Coronary artery bypass graft (CABG) surgery has been used for the treatment of coronary artery disease (CAD) for approximately 50 years, and has been performed on millions of people globally. However, little is known about the impact of diet and exercise on long-term outcomes of patients who have undergone CABG surgery. Although clinical practice guidelines on the management of this patient population have been available for approximately 2 decades, evidence regarding secondary prevention behavioral interventions, lifestyle modifications and self-management to slow the progressive decline of CAD, reduce cardiac hospitalizations, and prevent reoperation remains virtually absent from the literature. Diet and exercise are modifiable factors that affect secondary CAD risk. This article reviews the relevant current literature on long-term diet and exercise outcomes in patients who underwent CABG. The limited available literature shows the positive impacts of exercise on psychosocial well-being and physical fitness. Current evidence indicates diet and exercise interventions are effective in the short-term, but effects fade over time. Potential age and sex differences were found across the reviewed studies; however, further research is needed with more rigorous designs to replicate and confirm findings, and to define optimal management regimens and cost-effective prevention strategies.

Aims: The aim of this project was to describe patient perceptions of seeking lay advice in symptom evaluation prior to hospitalization for acute decompensated heart failure. Methods: Semi-structured interviews were conducted with 90 patients hospitalized for acute decompensated heart failure. Frequencies and Chi-square tests were used to characterize patient perceptions of lay consultations for symptom evaluation before hospitalization. Results: Seventy-five (83.3%) patients consulted persons in their social networks about symptoms before hospitalization. Forty-six (52.3%) patients received symptom attributions from their lay consultants, and most often lay consultants identified cardiac causes for patients’ symptoms (n=35, 76.1%). Sixty-six (76.7%) patients received advice about what to do for symptoms; most often that advice was to seek medical care (n=55, 83.3%). Lay consultants who identified causes for patients’ symptoms more often gave advice on what to do about symptoms than those consultants who did not provide symptom attributions (95.7% vs. 75.0%, p Conclusions: Heart failure self-management is complex, and this study is a first step toward understanding how patients, with contributions from their lay consultants evaluate and manage their symptoms beyond the walls of acute care hospital environments. Findings have implications for designing community-based self-care interventions and effectively reducing re-hospitalizations.

Background: Assessment of left ventricular ejection fraction (LVEF) is an important aspect of diagnosing and treating patients with cardiovascular disease. While cardiac MRI is considered the gold standard for assessing LVEF, high cost and patient risk has precluded routine use of MRI in clinical practice. Echocardiography is a common non-invasive, safe, and economic method for assessing LVEF. Traditionally, these measures required making visual determinations, resulting in wide variations in LVEF estimates. Using calculations from global longitudinal peak strain (GLPS) in speckle tracking echocardiography (STE) might reduce variability in estimations of LVEF and enhance treatment decision-making. To examine whether STE GLPS compared to cardiac MRI provides clinically acceptable variation in LVEF estimations, the congruence between GLPS in STE and cardiac MRI was examined. Methods: At a single Midwestern regional referral center, medical records were abstracted for inpatients and outpatients with a first-listed cardiovascular disease diagnosis who were ≥18 years of age and who were evaluated using speckle tracking echocardiogram and magnetic resonance imaging procedures within a 30-day period between January, 2011 and May, 2014. Demographic and relevant clinical variables that might affect echocardiographic and MRI quality and interpretation were extracted from medical records. Overall agreement between LVEF estimates from cardiac MRI and from STE GLPS was assessed using the concordance correlation coefficient, Bland-Altman analysis, and weighted Kappa. The influence of demographic and co-morbidity factors on the agreement was also assessed using multivariable regression analysis. Results: A total of 93 patient medical records (48 males; age 59±18 years) underwent both STE and MRI within a maximum 30-day period. For quantification of LVEF, STE correlated well with MRI (r=0.73; CCC=0.67), but LVEF was significantly underestimated (bias=6.8%), with wide limits of agreement (-17% to 31%). Categorization of LVEF into four classes, ranging from severely impaired to normal, resulted in a weighted kappa of 0.65 (95% CI: 0.53, 0.77). The difference between MRI and STE increased with increasing BMI (b=0.48, P=.01), and this difference was greater for those with hypertension (mean=9.5) than those without hypertension (mean=3.8, P=.02). Discussion and Conclusions: While these two measures indicate moderate to substantial agreement, STE-derived LVEF was underestimated in most patients compared with MRI. The magnitude of STE underestimation was positively associated with both BMI and hypertension. Further research is needed on technological developments in echocardiography, as well as interventions focused on addressing inter-observer agreement variability and treatment decision-making to effectively achieve desired clinical outcomes.

s / Heart & Lung 44 (2015) 547e559 548 instrumentation study. Patients were predominantly male (66%) and Caucasian (74%) with mean age of 50.4 13.7 years. Caregivers were predominantly female (80%) and Caucasian (80%) with mean age of 48.9 12.7 years. In this study, patients and caregivers were asked to complete an 18-item survey designed for understanding their discharge process and home-care management issues prior the hospital discharge. The format of the survey consisted of six open-ended questions, ten dichotomous and two multiple-item responses. Data were analyzed using descriptive statistics and content analysis procedures. Results: Preparations for hospital discharge consisted of providing education/training, performing competency evaluation, and supporting patients/caregivers with LVAD resource materials. The majority of patients (78%) and caregivers (97%) learned LVAD home-care management with “hands-on training.” Return demonstration (patients 76%, caregivers 95%) was the common method of LVAD competency evaluation. Although most patients (61%) and caregivers (90%) felt adequately prepared for hospital discharge and satisfied with the information they received, overall results still yielded three main issues (themes) regarding LVAD home-care management: reality of LVAD care, need for knowledge/ skill review, and lack of home-care RN trained for LVAD. Conclusion: Caregivers appeared to be more engaged than patients during preparations for hospital discharge process. However, they shared the same concerns about LVAD home-care management. Future research is needed to scrutinize the current discharge preparation process and long-term care support. Furthermore, longitudinal simultaneous dyadic research should be implemented to make definitive conclusions about this study’s findings, which may have negative influence on the health status and quality of life among LVAD patients and their caregivers.

Problem. Heart failure (HF) clinical trials often use medical record review data to determine HF related hospital events, such as emergency room visits and readmissions. However, reviewing medical records for each hospital event can be daunting. The purpose of this project was to expedite medical record review processes using an automated method for identifying potential HF related hospital events. Methods. A stepwise procedure was developed for obtaining electronic information of all consented HF clinical trial participants' hospital events. First, an electronic list of all study participants was generated from a study data base and electronically sent to the Medical Records department each month. Next, a list of all emergency room visits and hospitalizations, including admission and discharge dates, discharge disposition, and diagnosis and procedure codes was electronically generated by the Medical Records department. A trained cardiovascular research nurse reviewed the abstracted coding and billing data for each hospital event and identified specific codes potentially related to HF. Last, hospital events identified as meeting specific criteria were included in the medical record review. Results. Using the automated system, a total of 294 hospital events for 125 subjects were obtained from the Medical Records department during the initial 2 years of the clinical trial. Of these, 85 (29%) hospital events were identified as needing to undergo chart review. Thirty-three (39%) of the 85 charts that underwent blinded review were identified as being HF related hospital events. Conclusions. Automating procedures for obtaining hospital event information expedited both the systematic data review and chart review processes. In this study, combined use of automated processes for obtaining hospital event data and nurse review reduced the number of charts requiring blinded review by nearly 60%.

Clinically useful and measurable patient outcomes that are sensitive to nursing interventions are needed to determine the effectiveness of nursing care. Nursing Outcomes Classification (NOC) researchers are evaluating the reliability, validity, and usefulness of the first 190 published outcomes in 10 sites representing the continuum of care. Preliminary analysis of inter-rater reliability and construct or criterion validity of 15 outcomes are described. Results indicate NOC outcomes can be used to accurately document the effectiveness of nursing interventions.