The potential that telemedicine interventions may have in effectively delivering remote specialized cardiovascular care to large numbers of patients with heart diseases has recently come under question. In the first phase of this thesis, a systematic review and meta-analysis was conducted to compare the impact of a basic form of telemedicine that is regular patient follow-up by telephone, with usual care for individuals with coronary artery disease following their discharge. In the second phase of this thesis, a network meta-analysis, using Bayesian methods for multiple treatment comparisons, was conducted to compare the more complex forms of telemedicine for patients with heart failure. In the third and final phase of this thesis, a randomized controlled trial was designed to compare the impact of two forms of telemedicine, identified in the earlier two phases as being the most promising, on clinical outcomes, cardiac risk factors and patient reported outcomes.

This study determined whether a pre-operative cardiac “pre-habilitation” (Prehab) program improves the health of elective coronary artery bypass graft (CABG) surgery patients to a greater extent than standard care (StanC). Seventeen elective CABG patients were randomized to StanC (n= 9) or Prehab (n= 8) at Baseline and were followed at 1-2 weeks pre-operatively (Preop) and Three months post-operatively. Functional walking ability was assessed using the 6-Minute Walk Test (6MWT) and 5-meter Gait Speed Test. Baseline data was not different between groups. Patients in StanC did not improve 6MWT scores; whereas Prehab patients improved 6MWT distance by 35% and 39% at Preop and Three months post-operatively, respectively (p<0.05). Gait speed scores were 25% and 27% lower in Prehab patients at Preop and Three months post-operatively, respectively, as compared to StanC (p<0.05). These data suggest that Prehab is an attractive intervention for enhancing functional walking ability before and after elective CABG surgery.

Bakgrund: I dagens Sverige är hjärt- och kärlsjukdomar en folksjukdom som år 2016 drabbade 26 000 personer. En förbättring gällande mortaliteten har skett sedan sjuksköterskeledda mottagningar öppnade på 1960-talet. Trots denna förbättring är fysisk aktivitet underutnyttjat i samband med rehabilitering, även om det ses som en viktig skyddsfaktor. Vikten med individanpassad vård samt motivation till egenvård av sjukvården är betydande för patientens fysiska aktivitet inom rehabiliteringsprocessen. Syfte: Studiens syfte var att beskriva patienters upplevelser av eller tankar om fysisk aktivitet i samband med rehabilitering efter att ha drabbats av en hjärtinfarkt. Metod: Denna litteraturöversikt har baserats på åtta kvalitativa och två kvantitativa artiklar som hämtats från databaserna CINAHL complete, PubMed samt Web of Science. Artiklarna granskades och analyserades i enlighet med Friberg för att få fram resultatet som sedan sammanställts i olika teman. Resultat: Känslor som rädsla, ångest och oro upplevdes av patienter i samband med fysisk aktivitet efter att ha drabbats av en hjärtinfarkt. Okunskap, bristande motivation och andra fysiska faktorer gjorde att patienter inte deltog i utformade träningsprogram. Sjukvårdens professioner, närstående samt patienters egna tillgångar och sociala nätverk hade en positiv inverkan på deras upplevelser av fysisk aktivitet. Resultatet presenteras i fyra huvudteman; ”Psykiska upplevelser – rädsla, ångest och oro”, ”socialt stöd – anhöriga, familj, deltagare och vårdpersonal”, ”kunskap, förståelse och fysiska faktorer” samt ”musik som strategi till motivering vid fysisk aktivitet”. Diskussion: Dorothea Orems egenvårdsteori, artiklar samt patienters upplevelser har styrt diskussionen. Brist på kunskap och motivation minskar egenvårdskapaciteten och sjukvårdens professioner, anhöriga och egna tillgångar är av betydelse för att motivera och stötta patienten i sin egenvård. / Background: Cardiovascular disease is classified as a public disease in today’s Sweden and affected 26000 people in 2016. The mortality has decreased since nursing wards opened in the 1960s. Despite this improvement, physical activity is underutilized in Sweden associated with rehabilitation, even though it is an important protection factor. Personalized care and motivation is important for the patients’ self-care and their rehabilitation process. Aim: Describe patients' experiences or thoughts about physical activity associated with rehabilitation after suffering from myocardial infarction. Method: This literature review has been based on eight qualitative and two quantitative articles collected from CINAHL complete, PubMed and Web of Science. The articles were reviewed and analyzed in accordance with Friberg to obtain the result that was compiled in different themes. Results: Fear and anxiety were experienced by many patients’ during physical activity after a myocardial infarction. Lack of knowledge and motivation resulted in that patients did not participate in training programs. The healthcare professions, relatives and patient's own assets and social network had a positive impact on the patient's experience of physical activity. The result is presented in four main themes; “Psychic experiences – fear, worries and anxiety”, “social support - relatives, family, participants and healthcare professionals”, “knowledge, understanding and physical factors” and “music as a strategy for motivation in physical activity”. Discussion: Dorothea Orem's self-care theory, articles and patients’ experiences formed the discussion. Lack of knowledge and motivation reduces the self-care capacity. Healthcare professions, relatives and own resources are important for motivating and supporting the patient in his self-care.

Made available in DSpace on 2016-12-06T17:06:59Z (GMT). No. of bitstreams: 1 Alexandra Amin Lineburger.pdf: 1015080 bytes, checksum: 1d7fd8b623689b7bd6fd0e3efda64391 (MD5) Previous issue date: 2014-05-30 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Heart failure (HF) is a disease with systemic involvement, because in addition to cardiac involvement it causes cardiorenal, hemodynamic and neurohormonal dysfunctions contributing to aggravate the catabolism and exercise intolerance and impacting on quality of life. In this context, the high prevalence of hypotestosteronemia is associated with increased cardiovascular events and mortality in men with HF. Regular physical exercise, especially high intensity, and testosterone supplementation are therapeutic options in the management of the disease due to the reduction of risk factors such as dyslipidemia and low-grade inflammation. The aim of this study was to analyze the effects of high intensity exercise and testosterone supplementation therapy (TST) on lipid and inflammatory profile of men with HF. The study is characterized as a randomized controlled trial, with 17 men participants of cardiopulmonary rehabilitation program, HF functional class II and III (NYHA) with ejection fraction <45% and testosterone levels <400ng/dl, with 8 patients undergoing high intensity exercise (EAI) and 9 patients who received hormonal supplementation with testosterone undecanoate (Nebido 1000mg) and performed high-intensity exercise (EAIT group). The physical exercise protocol was carried out for 12 weeks and testosterone supplementation was applied in the first and sixth week. Lipid profile (LDL-c, HDL-c, triglycerides and total cholesterol) and plasma levels of inflammatory mediators (TNF-&#945; and CRP) were analyzed before and after the intervention. The results showed significant increase of 26.7% from the level of HDL-C (p = 0.04) in the EAI group. In comparing the two groups, there were statistically significant differences for the variations in the levels of triglycerides (p = 0.03). Both the EAI group as EAIT decreased plasma levels of TNF-&#945;, respectively 47.4% (p = 0.02) and 43.7% (p = 0.04) with no statistically significant difference between groups. Based on these results it is suggested that high intensity exercise positively influence lipid and inflammatory profile without additional effects associated with supplementation of testosterone therapy. / A insuficiência cardíaca (IC) é uma doença de acometimento sistêmico, pois além do comprometimento cardíaco causa disfunções cardiorrenais, hemodinâmicas e neurohormonais que contribuem para agravar o catabolismo e a intolerância ao exercício impactando na qualidade de vida. Neste contexto, a alta prevalência de hipotestosteronemia está associada ao aumento de eventos cardiovasculares e mortalidade em homens com IC. A prática regular de exercícios físicos, especialmente o de alta intensidade, e a suplementação de testosterona são opções terapêuticas no manejo da doença, devido à redução de fatores de risco como a dislipidemia e a inflamação de baixo grau. O objetivo do presente estudo foi analisar os efeitos do exercício de alta intensidade e terapia de suplementação de testosterona (TST) no perfil lipídico e inflamatório de homens com IC. O estudo é caracterizado como ensaio clínico controlado randomizado, com 17 homens participantes de um programa de reabilitação cardiopulmonar, portadores de IC classe funcional II e III (NYHA), com frequência de ejeção < 45 % e níveis de testosterona < 400 ng/dl, sendo 8 pacientes submetidos a exercício de alta intensidade (EAI) e 9 pacientes que receberam suplementação hormonal com undecanoato de testosterona (Nebido 1000 mg) e realizaram exercício de alta intensidade (grupo EAIT). O protocolo de exercícios físicos foi realizado por 12 semanas e a suplementação de testosterona foi aplicada na primeira e na sexta semana. Foi analisado o perfil lipídico (LDL-c, HDL-c, triglicerídeos e colesterol total) e os níveis plasmáticos de mediadores inflamatórios (TNF-&#945; e PCR) antes e após a intervenção. Os resultados mostraram aumento significativo de 26,7% do nível de HDL-c (p=0,04) no grupo EAI. Na comparação entre os dois grupos, houve diferença estatística para as variações dos níveis de triglicerídeos (p = 0,03). Tanto o grupo EAI quanto o EAIT apresentaram redução nos níveis plasmáticos de TNF- &#945;, respectivamente de 47,7% (p=0,02) e 43,7% (p=0,04) sem diferença estatística entre os grupos. Com base nestes resultados sugere-se que o exercício físico de alta intensidade influenciou positivamente o perfil lipídico e inflamatório, sem efeitos adicionais quando associado à terapia de suplementação de testosterona.

Social inequalities in health have been well documented in the literature. Despite the universal health care system and detailed measures of health surveillance, socioeconomic disparities related to cardiovascular diseases (CVD) remain present and are predicted to increase due to growing socioeconomic inequalities (Pampalon, 2008). Many health policy initiatives, such as the development of cardiac rehabilitation programs, were put in place in order to promote heart healthy lifestyles. These programs are provided as a medical and educational solution to prevent, manage, and lower risks of developing complications due to cardiovascular diseases, yet participation rates are as low as 37% for eligible individuals (Heart and Stroke Foundation of Canada, 2013). By drawing chiefly on Pierre Bourdieu’s sociocultural theory of practices, this qualitative study aims to understand the social variation of lifestyles in the context of cardiac rehabilitation of two groups of men from contrasting socioeconomic conditions. Sixty in-depth interviews were conducted with francophone men (mean age of 56.5) from the Outaouais region (Québec, Canada) who have suffered from a cardiac event requiring hospitalization. A number of studies on cardiovascular health have indicated health and lifestyle disparities among the male population. In order to provide a new perspective, this specific study drew principally on the notion of social capital in order to provide a more complete understanding of the social variation of lifestyles in the context of cardiac rehabilitation, particularly the impact these socioeconomic differences have on the quality of participants’ social capital, and how it shapes lifestyles after a heart intervention The results of this study are presented in an article which compares lifestyles and cardiac rehabilitation practices on the basis of three concepts of social capital, – social cohesion, trust, and social support. Results suggests that socioeconomic conditions influence levels of social cohesion, trust, and the quality of social support provided by social networks in the context of cardiac rehabilitation. Despite the underprivileged participant’s awareness of normative health lifestyles, they also were constrained by socio-cultural barriers, which limited a heart-healthy lifestyle.

Men in economically advanced societies are more at-risk of premature mortality due to heart disease than women, and this risk is inversely proportional to their socioeconomic status (SES). In Canada, many public health reports indicate that cardiovascular disease represent about one third of all causes of death and that men’s mortality rates from these diseases are two times higher than women, making it the main contributor to health inequality. Underprivileged men have been identified as being less receptive to cardiac rehabilitation guidelines, yet research promoting heart healthy behaviours has often neglected the social mechanisms that influence the lifestyle of this population. This study aims to understand the social variation in dispositions and commitments toward body care of men from two contrasting socioeconomic groups who have suffered from a cardiovascular incident requiring hospitalization. It draws primarily on Pierre Bourdieu’s socio-cultural theory of practice and his concept of bodily habitus in order to understand distinctive lifestyle patterns in the context of cardiac rehabilitation. Qualitative data was collected through 60 semi-structured interviews of an average duration of 90 minutes. Participants were Francophone men (average age of 57.3) from the Outaouais region of the Province of Québec, Canada. A thematic content analysis showed strong social variation in terms of lifestyle and identified different dispositions towards body care in the context of heart disease. Results are organized according to three key strategies for human flourishing following a heart incident that are relevant to understand the dispositions to adopt (or not) heath practices in the context of cardiac rehabilitation: (a) achieving a sense of security; (b) preserving autonomy; and (c) maintaining dignity. The comparison between socioeconomic groups highlights the incompatibilities of healthcare services and rehabilitation programs with the priorities of underprivileged men. It also flags the potential ethical and political dimension of healthcare by examining notions of health citizenship. In conclusion, the thesis discusses the socio-political characteristics of cardiac rehabilitation programs, and the usefulness of class-based masculinities as an alternative point of view to understand health implications of lifestyles.

The potential that telemedicine interventions may have in effectively delivering remote specialized cardiovascular care to large numbers of patients with heart diseases has recently come under question. In the first phase of this thesis, a systematic review and meta-analysis was conducted to compare the impact of a basic form of telemedicine that is regular patient follow-up by telephone, with usual care for individuals with coronary artery disease following their discharge. In the second phase of this thesis, a network meta-analysis, using Bayesian methods for multiple treatment comparisons, was conducted to compare the more complex forms of telemedicine for patients with heart failure. In the third and final phase of this thesis, a randomized controlled trial was designed to compare the impact of two forms of telemedicine, identified in the earlier two phases as being the most promising, on clinical outcomes, cardiac risk factors and patient reported outcomes.

Orientador: Luiz Carlos Marques Vanderlei / Resumo: INTRODUÇÃO: A reposição das perdas hídricas decorrentes da atividade física é recomendada em consensos internacionais para indivíduos sadios e atletas de alto rendimento. Entretanto, permanece pouco compreendida a sua influência quando administrada, igualmente, durante e/ou após o exercício, sobre a modulação autonômica cardíaca, frequência cardíaca de recuperação (FCR) e percepções subjetivas de esforço (PSE), desconforto (PSD) e recuperação (PSR) de indivíduos com alteração autonômica conhecida, como os coronariopatas. OBJETIVO: Investigar a influência da ingestão hídrica realizada durante e/ou após uma sessão de reabilitação cardiovascular (RC) de intensidade moderada sobre a modulação autonômica cardíaca, FCR, PSE, PSD e PSR de coronariopatas. MÉTODOS: Foram recrutados 31 adultos acima de 45 anos de idade com coronariopatia isquêmica, participantes de programas de RC, os quais foram submetidos a dois desenhos de estudos, ambos compostos por três etapas (48 horas de intervalo entre elas): I) Teste de esforço máximo; II) Protocolo controle (PC); III) Protocolo experimental (PH). Os PC e PH de ambos os estudos foram compostos por atividades realizadas em RC convencional, com ingestão de água no PH, calculada a partir da variação de massa corporal no PC. A modulação autonômica foi avaliada utilizando índices de variabilidade da frequência cardíaca calculados nos domínios do tempo, frequência e geométricos durante o repouso, exercício e recuperação. Foram avaliados ainda a FCR... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: BACKGROUND: The replacement of water losses due to physical activity is recommended in international consensus for healthy individuals and high performance athletes. However, its influence when administered equally during and / or after exercise on cardiac autonomic modulation, recovery heart rate (HRR) and subjective perceptions of exertion (PSE), discomfort (PSD) and recovery (PSR) of individuals with known autonomic alterations, such as coronary artery disease, remains poorly understood AIM: To investigate the influence of fluid intake during and / or after a moderate intensity cardiovascular rehabilitation (CR) session on coronary heart disease autonomic modulation, HRR, PSE, PSD and PSR. METHODS: We recruited 31 adults over 45 years of age with ischemic coronary artery disease who participated in CR programs, who underwent two study designs, both composed of three steps (48 hours apart): I) maximum effort; II) Control Protocol (PC); III) Experimental Protocol (PH). The PC and PH of both studies were composed by activities performed in conventional CR, with water intake in the PH, calculated from the body mass variation in the PC. Autonomic modulation was evaluated using heart rate variability indices calculated in the time, frequency and geometric domains during rest, exercise and recovery. FCR, PSE, PSD and PSR were also evaluated. RESULTS: Hydration during exercise and recovery promoted significant difference between protocols (RMSSD - p value = 0.024; SD1 - p value = ... (Complete abstract click electronic access below) / Doutor

El Programa de Prevención y Rehabilitación Cardiaca Integral: CARDIOMOVE ; es una empresa de salud con fines de lucro que busca rentabilidad económica y social, cuyo objetivo es mejorar clínicamente al paciente; tanto del punto de vista cardiológico, como psicológico a quienes han sufrido de una cardiopatía isquémica como ; infarto o ataque al corazón, sometidos a una intervención coronaria percutáneo , cirugía de revascularización, angina crónica estable, implantación de dispositivo, trasplante cardiaco, insuficiencia cardíaca, intervención sobre válvulas cardiacas, enfermedad arterial periférica, y pacientes sin ninguna cardiopatía pero con factor de riesgo cardiovascular (hipertensión, diabetes mellitus , obesidad y dislipidemias) El Programa de Prevención y Rehabilitación cardíaca Integral: CARDIOMOVE; está compuesto por pilares fundamentales como el control de los factores de riesgo, la mejoría de la capacidad física, optimización del tratamiento médico, la educación de hábitos de vida saludable, y el soporte psicológico y nutricional. Nuestro servicio va dirigido para el público mayor de 18 años con cardiopatía o sin ella, pero con factor cardiovascular pertenecientes al nivel socioeconómico B y C de Lima Metropolitana con posibilidad de pago de bolsillo. El Programa de Prevención y Rehabilitación Cardíaca Integral: CARDIOMOVE: tiene su sede central localizada en el distrito de Jesús María, debido a que es un lugar de fácil acceso geográfico desde los distintos distritos de Lima. La idea de negocio, nace ante la prevalencia de enfermedades cardiovasculares, el aumento de factores de riesgo y pobre fomentación de estilos de vida saludable, ausencia de programas de rehabilitación prevención cardiovascular, ausencia de programa de rehabilitación cardiaca como estrategia de prevención secundaria demostrada, la desinformación sobre los grandes beneficios de la rehabilitación cardiaca ; la escasa derivación de pacientes a dichos programas casi inexistentes y el crecimiento de las enfermedades no transmisibles. Nuestra propuesta de valor es mejorar la calidad de vida; reincorporándolo laboral y socialmente; evitando el deterioro psicológico, fortaleciendo la capacidad física; brindando una experiencia única y segura; mediante una atención multidisciplinaria y personalizada a las personas que requieran un programa de prevención y rehabilitación cardiaca Integral. Todo esto es posible con un equipo humano profesional de salud y administrativo, cuyos valores principales son: Hospitalidad, Respeto, Responsabilidad, Calidad y Espiritualidad. Respecto a la evaluación económica financiera; se ha estimado una inversión de S/427,369 nuevos soles, el cual se financia 30% por capital y 70% por deuda. Con un precio promedio de venta por paquete completo del programa de prevención y rehabilitación cardíaca integral de S/. 1440 nuevos soles, un costo mensual de S/ 480 nuevos soles y un costo variable unitario promedio de S/. 40 nuevos soles. Con un tiempo de retorno de la inversión del segundo semestre del 1 año. Obteniendo un valor actual neto económico de la empresa de aproximadamente S/1,067.984nuevos soles. Respecto a la Tasa Interna de Retorno de la empresa corresponde de 30.83 %. Después de lo expuesto según los datos de rentabilidad financiera y estudios de sensibilidad, se concluye que se trata de una inversión de moderado riesgo con una gran posibilidad de crecimiento en el tiempo aunado a un gran impacto de salud de las personas. / The Comprehensive Cardiac Prevention and Rehabilitation Program: CARDIOMOVE; is a for-profit health company that seeks economic and social profitability, whose objective is to improve the patient clinically; both from a cardiological and psychological point of view to those who have suffered from ischemic heart disease such as; infarction or heart attack, undergoing percutaneous coronary intervention, bypass surgery, chronic stable angina, device implantation, heart transplantation, heart failure, intervention on heart valves, peripheral arterial disease, and patients without any heart disease but with a risk factor cardiovascular (hypertension, diabetes mellitus, obesity and dyslipidemias) The Comprehensive Cardiac Prevention and Rehabilitation Program: CARDIOMOVE; It is made up of fundamental pillars such as control of risk factors, improvement of physical capacity, optimization of medical treatment, education of healthy lifestyle habits, and psychological and nutritional support. Our service is aimed at the public over 18 years of age with or without heart disease, but with cardiovascular factors belonging to socioeconomic status B and C of Metropolitan Lima with the possibility of paying out of pocket. The Comprehensive Cardiac Prevention and Rehabilitation Program: CARDIOMOVE: has its headquarters located in the Jesús María district, due to the fact that it is a place with easy geographic access from the different districts of Lima. The business idea was born due to the prevalence of cardiovascular diseases, the increase in risk factors and poor promotion of healthy lifestyles, absence of cardiovascular prevention rehabilitation programs, absence of a cardiac rehabilitation program as a proven secondary prevention strategy, misinformation about the great benefits of cardiac rehabilitation; the scarce referral of patients to these programs almost non-existent and the growth of non-communicable diseases Our value proposition is to improve the quality of life; reincorporating him to work and socially; avoiding psychological deterioration, strengthening physical capacity; providing a unique and safe experience; through multidisciplinary and personalized care for people who require a comprehensive cardiac prevention and rehabilitation program. All this is possible with a professional health and administrative human team, whose main values ​​are: Hospitality, Respect, Responsibility, Quality and Spirituality. Regarding the financial economic evaluation; An investment of S / 427,369 nuevos soles has been estimated, which is financed 30% by capital and 70% by debt. With an average sale price for a complete package of the comprehensive cardiac prevention and rehabilitation program of S /. 1,440 nuevos soles, a monthly cost of S / 480 nuevos soles and an average unit variable cost of S /. 40 new soles. With a return on investment of 1 years. Obtaining a net present economic value of the company of approximately S / 1,067.984 new soles. Regarding the Internal Rate of Return of the company it corresponds to 30.83%. After the above, according to the financial profitability data and sensitivity studies, it is concluded that it is a low risk investment with a great possibility of growth over time coupled with a great impact on people's health. / Trabajo de investigación

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