Bakgrund: Dödligheten till följd av hjärtinfarkt minskar i Sverige ändå är det fortsatt en av de främsta dödsorsakerna, och så även i övriga världen. Det finns ett antal viktiga påverkbara riskfaktorer för hjärtinfarkt så som rökning, hypertoni och diabetes. Tidigare genomgången hjärtinfarkt utgör också en stor risk för ett återinsjuknande och vikten av sekundärprevention är vedertagen. Sekundärprevention efter en hjärtinfarkt innebär delvis medicinering men också att reducera riskfaktorer med hjälp av livsstilsförändringar. Syfte: Syftet med litteraturstudien var att sammanställa litteratur kring patienters upplevelser av sekundärprevention efter en hjärtinfarkt. Metod: Uppsatsen utfördes som en litteraturstudie med kvalitativ ansats där urvalet gjordes utifrån strukturerade sökningar i databaserna CINAHL och PubMed. Urvalsprocessen bestod av relevansgranskning samt kvalitetsgranskning utifrån SBU:s kvalitetsgranskningsmall. Tretton studier analyserades med hjälp av innehållsanalys och låg till grund för studiens resultat. Resultat: Resultatet bestod av två kategorier, Att vilja förändra och Stöd med vardera tre subkategorier. Konklusion: Många patienter upplevde inledningsvis ett uppvaknande och en stark motivation att göra livsstilsförändringar, men många upplevde dock svårigheter att bibehålla dessa. Personcentrerad vård och stöd till patienter efter en hjärtinfarkt är viktiga faktorer för att patienten ska lyckas med livsstilsförändringar vilket sjuksköterskan bör tillämpa i mötet med patienten. Även anhöriga bör ges större möjlighet att inkluderas i vården.

Introduction: Every year 17,9 million people dies of myocardial infarction. People with cardiovascular disease have larger risks to be affected again, therefore it’s important with secondary prevention. Things like genetics, age and gender are things that we can´t affect, but some life changes lower the risk for another myocardial infarction. The risk factors that we can affect are example smoking, high blood pressure, hyperlipidemia, diabetes and metabolic syndrome.  Aim: The aim of this study was to chart information to patients about lifestyle changes to reduce the risk of secondary myocardial infarction   Method: A descriptive literature review (Forsberg & Wengström, 2016). The result was based on ten randomized articles. Results: Individualized information about risk factors contributed to an increased understanding and motivation for life changes. The information was adjusted after the level of knowledge and the information was provided from the nurses several times during the hospitalization. Providing the information at an early stage in the hospital as well as follow-up after returning home was an important part for the patients, which contributed to an increased quality of life, motivation and created security. Conclusion: By giving the patients individual support and education the level of knowledge developed. As a result of the patient's strengthened self-confidence and the involvement of relatives, the opportunities to return to a healthy life after a heart attack increased. Person- and family-centered care, participation and personalized information result in reduced risk of recurrent heart attack. Further follow-up was an important part for the patients as they could get answers to questions and concerns that had come up. / Introduktion: Varje år dör cirka 17,9 miljoner människor i hjärtinfarkt. Personer som drabbats av hjärt-och kärlsjukdom har större risk att drabbas igen, därför är förebyggandet extra viktigt efter första insjuknandet. Ärftlighet, ålder och kön är ingenting som individen kan påverka, men det finns livsstilsförändringar som individen kan göra för att minska risken för hjärtinfarkt. De riskfaktorer som finns, som i sin tur kan orsaka en hjärtinfarkt är exempelvis rökning, högt blodtryck, höga blodfetter, diabetes mellitus och det metabola syndromet.   Syfte: Syftet var att kartlägga information om livsstilsförändringar till hjärtinfarktpatienter för att minska risken för återkommande hjärtinfarkt.    Metod: En deskriptiv design användes, med litteraturöversikt som metod (Forsberg & Wengström, 2016). Resultatet baserades på tio randomiserade artiklar.    Resultat: I resultatet framkom det att individanpassad information om riskfaktorer bidrog till en ökad förståelse och motivation för livsstilsförändringar. Informationen anpassades efter kunskapsnivå och gavs av vårdpersonal flertalet gånger under sjukhusvistelsen. Att ge informationen i ett tidigt skede på sjukhuset samt uppföljning efter hemgång var en viktig del för patienterna som bidrog till ökad livskvalité, motivation och skapade trygghet.    Slutsats: Genom att ge patienterna individanpassat stöd och utbildning utvecklades kunskapsnivån. Till följd av stärkt självförtroende hos patienten samt involvering av anhöriga ökade möjligheterna att återgå till ett hälsosamt liv efter hjärtinfarkt. Person-och familjecentrerad vård, delaktighet och individanpassad information resulterar i minskad risk för återkommande hjärtinfarkt. Vidare uppföljning var en viktig del för patienterna då de kunde få svar på frågor och funderingar som hade uppstått.

År 2018 drabbades cirka 24 800 personer i Sverige av hjärtinfarkt, och cirka 5800 av dem avled. Sekundärprevention kan minska risken för återinsjuknande i hjärtinfarkt. Medicinsk sekundärprevention innebär att med hjälp av läkemedel reducera riskfaktorer såsom högt LDL-kolesterol eller hypertoni. Inom sekundärpreventionen har sjuksköterskor en viktig roll i att utbilda och handleda patienter och närstående på ett personcentrerat sätt. Syftet var att undersöka patienters upplevelser av information om läkemedel som ordinerats efter hjärtinfarkt, såväl gällande informationens innehåll som hur den förmedlats. Studiens ansats var induktiv kvalitativ med en deskriptiv design, och baserades på sju intervjuer utifrån en semistrukturerad intervjuguide. Informanterna hade drabbats av hjärtinfarkt och ordinerats sekundärpreventiva läkemedel. Informanterna hade varit på återbesök hos sjuksköterska på sekundärpreventiv öppenvårdsmottagning (kranskärlsmottagning). Intervjuerna analyserades enligt en kvalitativ innehållsanalys på manifest nivå. I resultatet framträdde meningsenheter som sorterades in i tre kategorier; Information under vårdförloppet, Individanpassad information och Struktur vid informationsgivning. Flertalet informanter upplevde bristande läkemedelsinformation under tiden i slutenvården, vilket ledde till osäkerhet kring behandlingen tills återbesök skett. Informanter som erhållit information upplevde en känsla av trygghet och att känna sig införstådda med behandlingen. Majoriteten önskade läkemedelsinformation, som skulle vara tydlig, individanpassad, och påbörjas i slutenvården. Önskemål uttrycktes om att informationen skulle inkludera skälen till vald behandling, effekter och bieffekter, samt förmedlas såväl skriftligt som muntligt och repeteras vid återbesök. Studien visar att personer som drabbats av hjärtinfarkt önskar, men ofta upplever att de saknar, information och dialog kring sekundärpreventiv läkemedelsbehandling. Informationen bör förmedlas och utföras på ett personcentrerat sätt samt vara samstämmig och tydlig, och vid behov fördjupas vid återbesök. / In 2018, circa 24 800 individuals in Sweden suffered a myocardial infarction, circa 5800 fatally so. Secondary prevention can reduce the risk of recurring myocardial infarction. Medical secondary prevention entails reducing risk factors like high LDL-cholesterol or hypertension by means of medication. In secondary prevention, nurses play an important part in educating and counselling patients and relations in a patient-centered manner. The aim was to examine patients' experiences of information about medication prescribed after myocardial infarction, both regarding information content and how it had been conveyed. The study approach was inductive qualitative with a descriptive design and based on seven interviews following a semi-structured interview guide. All informants had suffered myocardial infarction and had been prescribed secondary preventive medication. All informants had met with nurses at hospital-based outpatient clinics (Coronary Artery Clinic). The interviews were analyzed according to a qualitative content analysis on a manifest level. In the results, meaning units appeared and were sorted into three categories; Information during course of medical care, Personalized information and Structure during information. Most informants experienced deficiencies in medication information during inpatient care, generating uncertainty surrounding treatment until revisits had occurred. Informants who had received information experienced a sense of security and understanding of the drug treatment. Most informants wanted information about their drugs, and that the information should be clear, personalized, and start during inpatient care. Requests were expressed that information should include reasons for selected treatment, effects and side effects, be conveyed both in writing and orally, and repeated during revisits. The study shows that people who have suffered myocardial infarction want, but often lack, information and dialogue concerning secondary prevention medication. The information should be conveyed and carried out in a patient-centered manner and be consistent and clear. The information should be repeated and, if needed, deepened during revisits.

SAMMANFATTNING: Kranskärlssjukdom är en av de vanligaste orsakerna till död globalt. Kunskap idag påvisar att det finns ett antal modifierbara riskfaktorer där sjuksköterskan tillsammans med det multiprofessionella teamet har en nyckelroll i det sekundärpreventiva arbetet. De senaste årens forskning har påvisat att det akuta insjuknandet kan påverkas av inre eller yttre faktorer. Som ett exempel har studier visat att risken att insjukna i en hjärtinfarkt under julhelgen är kraftigt ökad. Syftet med studien var att studera förekomsten av potentiella triggers till hjärtinfarkt under julhelgen som kan ha betydelse för sekundärpreventiv vård. Studien genomfördes med en kvantitativ metod i form av en tvärsnittsstudie. En egenkonstruerad enkät användes för att identifiera förekomsten av aktuella triggers. Respondenterna fick själva uppskatta förekomsten av dessa dygnet innan hjärtinfarkten jämfört med vid ett normaltillstånd. I tillägg efterfrågades orsak till eventuell stress som fritextssvar. Enkäten skickades ut via post till en kohort av 135 deltagare från hela landet. Urvalet var konsekutivt. Alla som insjuknat i hjärtinfarkt med symtomdebut under föregående julhelg och som registrerats i det nationella kvalitetsregistret Riks-HIA och var levande vid tid för datauttag inkluderades. Svarsfrekvensen var 66 procent. Studiens resultat påvisar förekomst av en rad negativa faktorer som sömnlöshet, ökat matintag, lägre grad av fysisk aktivitet samt ökad stress. En liten del uppgav stress som var direkt knuten till julhelgen exempelvis i form av upplevt påtvingat umgänge samt allmänt julstök med matlagning och städning. Slutsatsen är att studien har ökat kunskapen kring i vilken utsträckning patienter har upplevt potentiella triggers dygnet före sitt insjuknande. Framträdande var den psykosociala ohälsan hos den undersökta populationen. Kunskapen om att vissa faktorer kan agera som akuta triggers bör införlivas i den sekundärpreventiva vården. Ett personcentrerat förhållningssätt med personens berättelse i centrum är av stor betydelse för att nå bestående livsstilsförändringar och utarbeta strategier för att undvika nya händelser. / ABSTRACT: Coronary heart disease is one of the most common causes of death worldwide. Knowledge of today demonstrates that there are a number of modifiable risk factors where the nurse together with the multi-professional team has a key role in the secondary preventive work. In recent years, research has shown that the disease can be acutely affected by internal or external factors. For example, the risk of having a heart attack during Christmas holiday is significantly increased. The purpose of the study was to study the occurrence of potential triggers for heart attack during Christmas holiday that may be of importance for secondary preventive care. The study was conducted using a quantitative method as a cross-sectional study. A self-designed survey was used to identify the presence of triggers. The respondents themselves were able to estimate the presence of these the day before the heart attack compared with a normal condition. In addition, the reason for any stress was requested as a free text reply. The questionnaire was sent by post to a cohort of 135 participants from all over the country. The selection was consecutive. All patients with myocardial infarction with a symptom onset during the previous Christmas weekend registered in the national quality register Riks-HIA and was alive at the time of data collection, were included.The response rate was 66 percent. The results of the study show the presence of a number of negative factors such as insomnia, increased food intake, lower degree of physical activity and increased stress. A small number stated stress that was directly linked to the Christmas weekend in the form of experienced forced socialization or caused by general Christmas disturbances such as cooking and cleaning.In our conclusion, the study has increased the knowledge about into what extent patients experience potential triggers the day before their illness. Prominent was the psychosocial ill health of the population studied. The knowledge that certain factors can act as acute triggers should be incorporated into secondary preventive care. A person-centered approach with the person's story at the center, is of great importance for achieving lasting lifestyle changes and developing strategies to avoid new events.

Evaluation of: Bangalore S, Steg PG, Deedwania P et al. β-Blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. JAMA 308(13), 1340–1349 (2012). The number of myocardial infarctions (MIs) in population remains high and this event is a significant predictor of mortality. Information in the literature points to a reduction in mortality, reinfarction and sudden death in first year, especially in patients with high risk, if β-blockers (BBs) are used after MI. In a perspective study, Zuckerman et al. have determined outcome following pharmacotherapy after acute MI in older adults. It is apparent that a number of matters require consideration in evaluation of the effectiveness of BBs. It seems that not all patients benefit equally from treatment with BBs but such an intervention reduces mortality. It is also important to recognize that the beneficial effects of BBs should not be considered in isolation since the biological system is too complex to manipulate with the use of a single class of drugs.

Bakgrund: Hjärtinfarkt är ett sjukdomstillstånd som uppstår vid akut skada i hjärtmuskeln. Orsakerna är kopplade till riskfaktorer som hypertoni, diabetes, ålder, rökning och ogynnsam livsstil. Rehabiliteringsprogram bör omfatta fysisk träning och fokusera på psykosociala samt livsstilsrelaterade faktorer. Livsstilsförändringar, inklusive rökstopp, kostförändringar och ökad fysisk aktivitet, är viktiga för sekundärprevention. Dessutom är uppföljning av rekommendationer från sjukvårdspersonal centralt för att minska risken för återinsjuknande. Dock är det inte alla som följer dessa rekommendationer för sekundärprevention. I detta sammanhang bör sjuksköterskans uppgift framträda som central för att bistå patienten i att uppnå en god hälsa. Syfte: Syftet med litteraturstudien var att sammanställa patienters erfarenheter av sekundärprevention efter en hjärtinfarkt. Metod: Examensarbetet utfördes som litteraturstudie med kvalitativ ansats. Resultatet baserades på vetenskapliga artiklar från databaserna CINAHL och PubMed. De utvalda artiklarna kvalitetsgranskades och analyserades med hjälp av innehållsanalys. Resultat: Resultatet baserades på 15 vetenskapliga artiklar som identifierade tre huvudkategorier: Motivation till sekundärprevention, Vikten av stöd från omgivningen och Oro över ostabilt hjärta. Slutsats: Livsstilsförändringar som att sluta röka och engagera sig i fysisk aktivitet var viktiga sekundärpreventiva åtgärder men svårigheter att sluta röka och rädsla för en ny hjärtinfarkt vid fysisk aktivitet kunde upplevas som hinder. Omgivningens stöd var viktigt men ibland kunde oroliga anhöriga försvåra viljan att vara fysisk aktiv. En nödvändig strategi för sekundärpreventiva omvårdnadsåtgärder efter hjärtinfarkt innefattar motivation, fysisk aktivitet, stöd och hantering av oro och främjande av långsiktig hälsa. / Background: Myocardial infarction, marked by acute damage to the heart muscle, is associated with risk factors like hypertension, diabetes, age, and smoking. Rehabilitation programmes, emphasizing physical training and addressing psychosocial and lifestyle factors, underscore the importance of lifestyle changes such as smoking cessation, dietary modifications and increased physical activity for secondary prevention. Despite these recommendations, not everyone adheres to them. This highlights the pivotal role of nurses in assisting patients towards optimal health. Aim: The purpose of this literature review was to compile patients’ experiences of secondary prevention after a myocardial infarction. Method: The study was conducted as a literature review with a qualitative approach. The result was based on scientific articles from databases CINAHL and PubMed. The selected articles were quality reviewed and analyzed using content analysis. Findings: The findings were based on 15 scientific articles identifying three categories: Motivation for secondary prevention, The importance of support from the environment, and Concerns about an unstable heart. Conclusion: Lifestyle changes such as quitting smoking and engaging in physical activity were important secondary preventive measures, but difficulties in quitting smoking and fear of a new heart attack during physical activity could be perceives as obstacles. A necessary strategy for secondary preventive nursing measures after myocardial infarction includes motivation, physical activity, support and management of anxiety and promotion of long-term health.

Yes / Background: Non-adherence to secondary prevention medicines (SPMs) among patients with coronary artery disease (CAD) remains a challenge in clinical practice. This study attempted to identify actual and potential modifiable barriers to adherence that can be addressed in cardiology clinical practice. Methods: This was a cross-sectional, postal survey-based study of the medicines-taking experience of patients with CAD treated at a secondary/tertiary care centre. All participants had been on SPM for ≥3 months. Results: In total, 696 eligible patients were sent the survey and 503 responded (72.3%). The median age was 70 years, and 403 (80.1%) were male; the median number of individual daily doses of all medicines was 6. The rate of non-adherence to at least one SPM was 43.5% (n=219), but 53.3% of reported non-adherence was to only one SPM. Statins contributed to 66.7% and aspirin to 61.7% of overall non-adherence identified by the Single Question (SQ) tool. In 30.8% of non-adherent patients (n=65), this was at least partly intentional. Barriers included forgetfulness (84.9%; n=186), worry that medicines will do more harm than good (33.8%; n=74), feeling hassled about medicines taking (18.7%; n=41), feeling worse when taking medicines (14.2%; n=31) and not being convinced of the benefit of medicines (9.1%; n=20). In a multivariate analysis, modifiable factors associated with overall non-adherence included being prescribed aspirin (OR: 2.22; 95% CI: 1.18 to 4.17), having specific concern about SPM (OR: 1.12; 95% CI: 1.07 to 1.18) and issues with repeat prescriptions (OR: 2.48; 95% CI: 1.26 to 4.90). Different factors were often associated with intentional versus unintentional non-adherence. Conclusions: Using appropriate self-report tools, patients share actual and potential modifiable barriers to adherence that can be addressed in clinical practice. Non-adherence behaviour was selective. Most non-adherence was driven by forgetfulness, concern about the harm caused by SPM and practical barriers. / The study was partially funded by the Leeds Teaching Hospitals Charitable Foundation.

No description available.

The first aim of this study was to develop a research based, integrated, secondary prevention programme, called the Weight Over-concern and Well-being (WOW) programme, for the reduction of Subclinical Eating Disorder (SED) symptoms, associated traits and negative mood states, and the promotion of psychological well-being (PWB) in female students. Consequently the second aim was to determine the effectiveness of the WOW-programme on its own, in comparison with a combined Tomatis Method of sound stimulation (Tomatis, 1990) and WOW-programme, regarding the reduction of SED-symptoms, associated traits and negative mood states; the promotion of PWB; and outcome maintenance. The last aim was to obtain a deeper understanding and "insiders' perspective" of the lived experience of SED, through an interpretative phenomenological inquiry (Smith & Osborn, 2003). The motivation for the current study is a need for research based, integrated, risk-protective, secondary prevention programmes from a social-developmental perspective for female university students (Garner, 2004; Phelps, Sapia, Nathanson & Nelson, 2000; Polivy & Herman, 2002), given their risk status (Edwards & Moldan, 2004; Senekal, Steyn, Mashego & Nel, 2001; Wassenaar, Le Grange, Winship & Lachenicht, 2000). Concurrently in-depth descriptions from an "insiders' perspective" on the lived experience of SED are non-existent and require interpretative phenomenological study (Brocki & Wearden, 2006). Consequently this thesis consists of three articles, namely: (i) Development of a secondary prevention programme for female university students with Subclinical Eating Disorder, (ii) A secondary prevention programme for female students with Subclinical Eating Disorder: a comparative evaluation; and (iii) Lived experiences of Subclinical Eating Disorder: female students' perceptions. The research context comprised Subclinical Eating Disorder, secondary prevention and Positive Psychology. The first article, Development of a secondary prevention programme for female university students with Subclinical Eating Disorder (Kirsten, Du Plessis & Du Toit, 2007a), is qualitative in nature, and narrates a process of participatory action research followed to develop the WOW-programme. This social process of knowledge construction, embedded in Social Constructivist theory (Koch, Selim & Kralik, 2002), gradually revealed best clinical practice, and in retrospect, evolved over four phases. Phase One comprised experiential learning based on personal experiences with SED as undergraduate student and interaction with "participant researchers" as scientist practitioner (Strieker, 2002), resulting in a provisional risk model of intervention. Phase Two, a formal pilot study (Du Plessis, Vermeulen & Kirsten, 2004), afforded an evaluation of ideas generated in Phase One through a three-group pre-post-test design. Outcomes of Phase Two informed Phase Three, an integration of prior learning with Positive Psychology theory and clinical practice, resulting in a risk-protective model of prevention. Theoretical assumptions previously constructed were integrated and operationalised during Phase Four, into the final 9-session WOW-programme. In conclusion the process of knowledge construction was rigorous, despite the small overall sample size (n=28), since data saturation occurred within that sample. Although the multitude of aims involved in each session of the WOW-programme could be seen as unrealistic, in some direct or indirect way, they were addressed by means of relevant interventions due to the integrative approach. Thus future refinement is essential. Finally, despite aforementioned concerns, the WOW-programme proved to be robust on its own in reducing SED-symptoms and associated traits and enhancing PWB, as described in the second article of this thesis. The second article, A secondary prevention programme for female students with Subclinical Eating Disorder: a comparative evaluation (Kirsten, Du Plessis & Du Toit, 2007b), describes the outcomes of the WOW-programme on its own, evaluated comparatively with a combined Tomatis sound stimulation and WOW-programme. In this article the research aims were to determine: (i) whether participation in the combined sound stimulation and WOW-programme (Group 1); and (ii) participation in a WOW-programme only (Group 2), would lead to statistically significant reductions in SED-symptoms, psychological traits associated with eating disorders and negative mood states, and enhancement of PWB; (iii) whether results of Groups 1 and 2 would exceed results of a non-intervention control group (Group 3) practically significantly; and (iv) whether programme outcomes for Groups 1 and 2 would be retained at four-month follow-up evaluation. A mixed method design (Creswell, 2003; Morse, 2003) was used, including a three-group pre-post-test (n=45) and multiple case study (n=30) design. Various questionnaires measuring SED-symptoms, associated traits, negative mood states and PWB were completed. Qualitative data were obtained by means of metaphor drawings, letters to and from the "SED-problem", focus group interviews, the researchers' reflective field notes and individual semi-structured feedback questionnaires (Morse, 2003). Participation in Groups 1 and 2 proved effective, since decreases in SED-symptoms, associated traits, most negative mood states, and increases in PWB differed practically significantly from the results of Group 3. Outcomes for Groups 1 and 2 were maintained at four-month follow-up evaluation. Qualitative findings provided depth, support and trustworthiness to quantitative findings in light of the small sample size, and highlighted the value of using a mixed method design in prevention programming. It was concluded that the WOW-programme on its own, was an effective secondary prevention programme, since it led to reduced SED-symptoms, associated psychological traits and enhanced PWB, with retention of gains at four-months follow-up evaluation. The combined programme involving Tomatis stimulation and WOW-intervention proved to be even more effective, thus the complimentary role of Tomatis stimulation was demonstrated. However, the cost-effectiveness and comparative brevity of the WOW-programme rendered it the programme of choice regarding individuals with SED. Findings showed that conceptually, pathogenic and salutogenic perspectives can be successfully combined into a risk-protective model of secondary prevention. Lastly, the WOW-programme may even prove useful as an enrichment programme for female students in general. The third article, Lived experiences of Subclinical Eating Disorder: female students' perceptions (Kirsten, Du Plessis & Du Toit, 2007c), provides a qualitative, in-depth perspective on the lived experience of SED of 30 white, undergraduate females, purposively sampled. In this interpretative phenomenological, multiple case study (Brocki & Wearden, 2006), Groups 1 and 2 of the aforementioned primary study in the second article were used, since they fitted the criteria of "good informants" and were able to answer the research question (Morse, 2003). Further sampling was deemed unnecessary since data saturation occurred within their written and verbal responses and no negative cases were found. Rich individual qualitative data, further clarified through focus groups, emerged from graphic colour representations of lived SED, explanatory written records and "correspondence" with and from their "SED problem" (Gilligan, 2000; Loock, Myburgh, & Poggenpoel, 2003; White & Epston, 1990). Four main categories, characterised by serious intra-, interpersonal, existential and body image concerns were subdivided into seven subcategories, namely: Personal Brokenness, Personal Shame, Perceived Personal Inadequacy and Enslavement, Existential Vacuum, Perceived Social Pressure, Perceived Social Isolation and Body-image Dysfunction. Results were indicative of underestimation of SED-severity, its comprehensive detrimental impact on participants' PWB and high risk for escalation into full-blown eating disorders. It was concluded that the lived experiences of SED depicted the severity of SED-symptoms; descriptions resonated well with most of their pre-programme mean scores; and their risk status and need for contextually and developmentally relevant secondary prevention programmes were highlighted by the findings. / Thesis (Ph.D. (Psychology))--North-West University, Potchefstroom Campus, 2008.

Introdução: apesar das recomendações de todas as diretrizes sobre a doença arterial coronária e das evidências científicas de que o tratamento medicamentoso otimizado acrescido de intervenção sobre os fatores de risco e a melhoria do estilo de vida reduzem eventos cardiovasculares fatais não-fatais, essa terapêutica de prevenção secundária continua a ser subutilizada na prática clínica. Objetivos: Primário: demonstrar que a utilização de um programa de otimização da prática clínica em pacientes com doença arterial coronária estável aumenta a prescrição de medicamentos comprovadamente eficazes na prevenção secundária desta doença. Secundários: a) documentar a prática clínica vigente em termos de terapia medicamentosa e de medidas para a mudança do estilo de vida b) identificar as ferramentas utilizadas na estratégia para a otimização da prática clínica quanto à eficácia e aderência à medicação prescrita. Métodos: trata-se de um estudo de corte transversal para documentar a prática clínica vigente, seguido de componente longitudinal em que a utilização das ferramentas para a otimização da prática clínica foi avaliada por meio de novo corte transversal, com nova coleta de dados. Foram identificados retrospectivamente através dos prontuários, 710 pacientes consecutivos portadores de doença arterial coronária (Fase 1). Após a aplicação das ferramentas, foram incluídos 705 pacientes consecutivos atendidos no serviço com a coleta dos mesmos dados, para a análise comparativa. Além disso, foram selecionados do primeiro grupo, de forma aleatória, 318 prontuários de seis a doze meses após a primeira avaliação, para a coleta dos mesmos dados, que foram comparados com as informações iniciais destes mesmos pacientes. (Fase 3). Resultados: comparação entre Fase 1 e Fase 2: as características demográficas eram comparáveis entre os dois grupos. Quanto aos fatores de risco, houve melhora com diferença significativa para o tabagismo (p=0,019), dislipidemia (p<0,001) hipertensão arterial e atividade física regular (p<0,001). Quanto aos exames laboratoriais, não houve diferença estatisticamente significativa entre as duas populações. Comparando a prescrição dos fármacos recomendados, houve diferença significativa para IECA (67,2% versus 56,8%, p<0,001); ARA II (25,4% versus 32,9%, p=0,002) e betabloqueador (88,7% versus 91,9%, p=0,047). Comparação entre Fase 1 e Fase 3: os dados demográficos foram semelhantes, assim como as características clínicas, com exceção da doença arterial periférica obstrutiva: 31 pacientes (9,7%) e 42 (13,3%), p=0,007. Em relação aos fatores de risco, consideramos apenas os modificáveis tabagismo e atividade física. Para o tabagismo, considerando três categorias (nunca, ex-fumante e atual), não houve diferença significativa entre as duas fases. Para a atividade física, a proporção de pacientes sem informação para esta variável era elevada, 83,9% na primeira fase e 72,8% na terceira fase, dificultando a análise estatística. Quanto às medidas de exame físico, houve redução significativa do peso, p=0,044, pressão arterial sistólica e diastólica, p<0,001. Os exames laboratoriais não mostraram diferenças significativas entre as duas fases. Em relação à prescrição de medicamentos recomendados, houve diferença para IECA (64,8% versus 61,6%, p=0,011) e ARA II (27,0% versus 31,3%, p=0,035). Conclusão: com base nos resultados obtidos, o presente estudo permite concluir: não houve mudança significativa na utilização de medicamentos comprovadamente eficazes na prevenção secundária da DAC entre o período pré- e pós-intervenção; houve melhora significativa em relação ao tabagismo e atividade física na Fase 2; melhora substancial nos níveis de pressão arterial, tanto sistólica como diastólica na comparação tanto entre a Fase 1 e 2 como entre a Fase 1 e 3; a inclusão de enfermeiro treinado para gerenciar o processo é fundamental para a eficácia do programa; programas abrangentes de melhoria de qualidade assistencial em hospitais terciários e acadêmicos, provavelmente devem ser continuados por período de seguimento superior a um ano. / Background: despite guidelines recommendations on coronary artery disease treatment and scientific evidence confirming that optimal medical therapy added to risk factors and lifestyle management, reduce both fatal and non-fatal cardiovascular events, these secondary prevention strategies have been underutilized in clinical practice. Objectives: Primary: to demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients would increase the evidence-proved treatment prescription in secondary prevention. Secondaries: a) to describe the ongoing clinical practice on medical therapy and lifestyle change counseling b) to identify tools to be utilized in the strategy to improve clinical practice, assessing efficacy and adherence to prescribed treatment. Methods: cross-sectional study to describe the ongoing clinical practice, followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional crosssectional data collection. 710 consecutive coronary artery disease patients were included after chart review following eligibility criteria (Phase 1). After tools implementation, within 6-month period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3). Results: Phase 1 to Phase 2 comparison: demography was comparable. Concerning to risk factors, there were improvement on smoking (p=0,019), dyslipidemia (p<0,001), hypertension and physical activity (p<0,001). There were no statistical significant differences on laboratory results. By comparing the proven pharmacological treatment prescription, there was significant difference on ACEI (67,2% versus 56,8%, p<0,001); ARB II (25,4% versus 32,9%, p=0,002) and beta-blocker (88,7% versus 91,9%, p=0,047). Phase 1 to Phase 3 comparison: demography was comparable, as well as clinical characteristics, except peripheral artery disease: 31 patients (9,7%) and 42 (13,3%), p=0,007. Regarding risk factors, smoking and physical activity were considered. There was no significant difference on smoking rates taking into account three categories (never, ex-smoker and smoker). The proportion of patients without available data for physical activity was high, 83,9% (Phase 1) and 72,8% (Phase 3), making the data analysis not appropriated. Anthropometric measurement showed significant on weight reduction, p=0,044, both systolic and diastolic blood pressure, p<0,001. Laboratory results did not show significant differences. There was statistical significant difference on ACEI (64,8% versus 61,6%, p=0,011) and ARB II (27,0% versus 31,3%, p=0,035). Conclusion: based upon study results the following might be concluded: there was no significant change on the evidence-based pharmacological treatment utilization on secondary prevention coronary artery disease patients between pre and post-intervention Phases; there was significant improvement concerning smoking and physical activity in Phase 2; substantial improvement on blood pressure levels, both systolic and diastolic in both comparisons (Phase 1 to 2 and Phase 1 to 3); the inclusion of a case-manager for the process management is crucial for program efficacy; comprehensive programs for clinical practice improvement in tertiary academic hospitals should be pursued for longer follow-up period.