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BACKGROUND: Benefits of cardiac rehabilitation (CR) programme components on attaining risk factor targets post-myocardial infarction (MI) and their predictive strength relative to patient characteristics remain unclear. We aimed to identify organizational and patient-level predictors of risk factor target attainment at one-year post-MI. METHODS: In this observational study data on CR organization at 78 Swedish CR centres was collected and merged with patient-level registry data (n = 7549). Orthogonal partial least squares discriminant analysis identified predictors (Variables of Importance for the Projection (VIP) values >0.8) of attaining low-density lipoprotein-cholesterol (LDL-C)

Background The benefits of specific cardiac rehabilitation (CR) programme components on patient outcomes after myocardial infarction (MI) remain unclear, as does their relative predictive strength compared to patient-level predictors. Purpose To identify CR organizational and patient-level predictors for reaching risk factor targets at one-year post-MI. Methods This was an observational survey- and registry-based study. Data on CR organization at all 78 CR centres in Sweden was collected in 2016 and merged with individual patient data from nationwide registries (n=7549, median age 64 years, 24% females). Cross-validation resampled orthogonal partial least squares discriminant analysis identified predictors for reaching treatment targets for low-density lipoprotein-cholesterol (LDL-C0.8 and 95% confidence intervals (CI) excluding zero, were considered meaningful. Results Of the 71 analysed organizational variables, 36 were identified as meaningful predictors for reaching LDL-C and 35 for BP targets (Figure 1). The strongest predictors (VIP [95% CI]) for LDL-C and BP were: offering psychosocial management at initial CR assessment 2.09 [1.70–2.49]; 2.34 [1.90–2.78], having a CR team psychologist 1.59 [1.28–1.91]; 2.00 [1.46–2.55], having extended CR centre opening hours 2.17 [1.95–2.40]; 1.51 [1.03–2.00], staff reporting satisfaction with CR centre facilities 1.55 [1.07–2.04]; 1.96 [1.64–2.28], having a medical director 1.71 [1.45–1.97]; 1.47 [1.07–1.87], nurses using protocols for antihypertensive and/or lipid lowering medication adjustment 1.58 [1.35–1.81]; 1.56 [1.03–2.08], having operational team meetings 1.36 [1.08–1.64]; 1.34 [0.99–1.70], and using audit data for quality improvement 1.00 [0.79–1.20]; 1.27 [0.99–1.56]. Offering pre-exercise-based CR (exCR) assessment and different modes of exCR were predictors for reaching both targets. The strongest patient-level predictor of reaching LDL-C target was low baseline LDL-C 3.90 [3.25–4.56], and for BP it was having no history of hypertension 2.93 [2.74–3.12]. Second, participation in exCR was the strongest predictor for both outcomes 1.60 [0.83–2.37]; 1.50 [1.15–1.86]. For smoking abstinence, 5 organizational variables were identified as meaningful predictors, the strongest being prescription of varenicline by the centre physicians 1.98 [0.13–3.84] (Figure 2). The strongest patient-level predictors were exCR participation 2.51 [2.24–2.79] and socioeconomic status variables e.g., income 1.67 [1.28–2.06], living with partner 1.47 [0.84–2.09] and education 0.80 [0.48–1.12]. Conclusion The study identified multiple CR organizational and patient-level predictors for reaching key risk factor targets one-year post-MI. The results might contribute to defining the optimal composition of comprehensive CR programmes. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) The Swedish Research Council for Health, Working Life and Welfare (FORTE)2) The Swedish Heart and Lung Foundation (Hjärt Lung Fonden)

Background For smokers who suffer a myocardial infarction (MI), smoking cessation is the most effective measure to reduce recurrent event risk. Still, evidence-based treatment methods for aiding smoking cessation post-MI are underused. Purpose To compare the odds of smoking cessation at two-months post-MI before and after implementing a set of pre-specified routines for optimization of evidence-based treatment methods for smoking cessation, with start during admission. Methods Structured routines for early smoking cessation counselling and treatment optimization were implemented at six cardiac rehabilitation (CR) centres in Sweden. The routines included CR nurses providing current smokers hospitalized for acute MI with short consultation, written material, and optimal dosage of nicotine replacement therapy during admission, increasing early prescription of varenicline for eligible patients, and contacting the patients by telephone 3–5 days after discharge, after which usual care CR follow-up commenced. Centres were also encouraged to strive for continuity in nurse-patient care. Patient data was retrieved from the SWEDEHEART registry and medical records. Using logistic regression, we compared the odds for smoking cessation at two-months post-MI for currently smoking patients admitted with MI (a) before (n=188, median age 60 years, 23% females) and (b) after (n=195, median age 60 years, 29% females) routine implementation. Secondary outcomes included adherence to implemented routines and the association of each routine with smoking cessation odds at two-months. Results In total, 159 (85%) and 179 (92%) of enrolled patients attended the two-month CR follow-up, before and after implementation of the new routines. After implementation, a significantly larger proportion of patients (65% vs 54%) were abstinent from smoking at two-months (crude OR 1.60 [1.04–2.48], p=0.034) (Figure 1). Including only those counselled during admission (n=89), 74% (vs 54%) were abstinent at two-months (crude OR 2.50 [1.42–4.41], p=0.002). After the new routine implementation patients were counselled more frequently during admission (50% vs 6%, p Conclusion Our results support that readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with possible beneficial effects on smoking cessation for the high-risk group of smoking MI patients. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Swedish Heart and Lung AssociationPfizer AB

Background: Evidence-based methods for aiding smoking cessation post-myocardial infarction are effective yet underused in clinical practice. We compared the odds of smoking cessation at 2-months post-myocardial infarction before versus after implementing a set of pre-specified routines optimizing evidence-based treatment methods for smoking cessation, initiated during admission. Methods: Structured routines for early smoking cessation counselling and treatment optimization were implemented at six cardiac rehabilitation centres in Sweden. The routines included cardiac rehabilitation nurses providing current smokers hospitalized for acute myocardial infarction with short consultation, written material, and optimal dosage of nicotine replacement therapy during admission, increasing early prescription of varenicline for eligible patients, and contacting the patients by telephone 3-5 days after discharge, after which usual care follow-up commenced. Centres were also encouraged to strive for continuity in nurse-patient care. Using logistic regression, we compared the odds for smoking cessation at 2-months post-discharge for currently smoking patients admitted (a) before (n=188, median age 60 years, 23% females) and (b) after (n=195, median age 60 years, 29% females) routine implementation. Secondary outcomes included adherence to implemented routines and the association of each routine with smoking cessation odds at 2-months.Results: In total, 159 (85%) and 179 (92%) of enrolled patients attended the 2-month follow-up, before and after implementation of the new routines. After implementation, a significantly larger proportion of patients (65% vs 54%) were abstinent from smoking at 2-months (OR 1.60 [1.04-2.48], p=0.034). Including only those counselled during admission (n=89), 74% (vs 54%) were abstinent at 2-months (OR 2.50 [1.42-4.41], p=0.002). After the new routine implementation patients were counselled more frequently during admission (50% vs 6%, pConclusions: Our results support that readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with possible beneficial effects on smoking cessation for the high-risk group of smoking myocardial infarction patients.

We compared the odds of smoking cessation at 2-months post-myocardial infarction (MI), before and after implementing routines optimizing use of evidence-based smoking cessation methods, with start during admission. The following routines were implemented at six Swedish hospitals: cardiac rehabilitation nurses offering smokers consultation during admission, optimizing nicotine replacement therapy and varenicline prescription, and contacting patients by telephone during the 1st week post-discharge. Using logistic regression, odds for smoking cessation at 2-months before (n smokers/n admitted = 188/601) and after (n = 195/632) routine implementation were compared. Secondary outcomes included adherence to implemented routines and assessing the prognostic value of each routine on smoking cessation. After implementation, a larger proportion of smokers (65% vs. 54%) were abstinent at 2-months (OR 1.60 [1.04–2.48]). Including only those counselled during admission (n = 98), 74% were abstinent (2.50 [1.42–4.41]). After implementation, patients were more often counselled during admission (50% vs. 6%, p p p

Background While patient performance after participating in cardiac rehabilitation programmes after acute myocardial infarction is regularly reported through registry and survey data, information on cardiac rehabilitation programme characteristics is less well described. Aim The aim of this study was to evaluate Swedish cardiac rehabilitation programme characteristics and adherence to European Guidelines on Cardiovascular Disease Prevention. Method Cardiac rehabilitation programme characteristics at all 78 cardiac rehabilitation centres in Sweden in 2016 were surveyed using a web-based questionnaire (100% response rate). The questions were based on core components of cardiac rehabilitation as recommended by European Guidelines. Results There was a wide variation in programme duration (2–14 months). All programmes reported offering an individual post-discharge visit with a nurse, and 90% ( n = 70) did so within three weeks from discharge. Most programmes offered centre-based exercise training ( n = 76, 97%) and group educational sessions ( n = 61, 78%). All programmes reported to the national audit, SWEDEHEART, and 60% ( n = 47) reported that performance was regularly assessed using audit data, to improve quality of care. Ninety-six per cent ( n = 75) had a core team consisting of a cardiologist, a physiotherapist and a nurse and 76% ( n = 59) reported having a medical director. Having other allied healthcare professionals included in the cardiac rehabilitation team varied. Forty per cent ( n = 31) reported having regular team meetings where nurses, physiotherapists and cardiologist could discuss patient cases. Conclusion The overall quality of cardiac rehabilitation programmes provided in Sweden is high. Still, there are several areas of potential improvement. Monitoring programme characteristics as well as patient outcomes might improve programme quality and patient outcomes both at a local and a national level.

Background: Whether personality factors and depressive traits affect patients' utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients' personality factors and depressive symptoms. Methods: We studied 366 myocardial infarction patients admitted to Malmo University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants' health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis. Results: In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions. Conclusion: Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts. (Less)

Smoking is an important cardiovascular risk factor and smoking cessation should be a primary target in secondary prevention after a myocardial infarction (MI). The purpose of this study was to examine whether personality, coping and depression were related to smoking cessation after an MI. MI patients ≤70 years (n = 323, 73 % men, 58.7 ± 8.3 years), participating in the Secondary Prevention and Compliance following Acute Myocardial Infarction study in Malmo, Sweden, between 2002 and 2005, were interviewed by a psychologist to assess coping strategies and completed Beck Depression and NEO Personality Inventories, in close proximity to the acute event. Correlation between smoking status (current, former and never), personality factors, coping and depression was assessed at baseline and 24 months after the MI using logistic regression and in a multivariate analysis, adjusting for age and sex. Of the participating patients, 46 % were current smokers. Two years after the event, 44 % of these were still smoking. At baseline, current smokers scored higher on the depression and neuroticism scales and had lower agreeableness scores. Patients who continued to smoke after 2 years had higher scores on being confrontational (i.e. confrontative coping style) compared to those who had managed to quit. Patients who continued to smoke had significantly lower agreeableness and were more often living alone. Personality, coping strategies and psychosocial circumstances are associated with smoking cessation rates in patients with MI. Considering personality factors and coping strategies to better individualise smoking cessation programs in MI patients might be of importance.

Background Early hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room. Methods Questionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models. Results No correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay. Conclusions We found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.