THROB DONATION
THROB has donated £3,000 towards the cost of setting up another facility in our area for resuscitation using Automated External Defibrillators (AED's) and oxygen therapy. This potentially life saving piece of equipment has been installed at the Windsor Leisure Centre. The training was carried out by 4Life First Aid Ltd (in partnership with the Royal Borough of Windsor & Maidenhead) and follows guidance laid down by the the Department of Health.
Seven out of ten cardiac arrests occur outside of hospital and currently in the UK only 2-3% of these people survive. When someone suffers a cardiac arrest, their chances of survival drop by up to 10% for every minute that passes, so a speedy response is crucial. Performing CPR can double a person's chances of survival, and having a defibrillator close to hand can further increase their chances by more than a third. Around 270,000 people suffer a heart attack in the UK each year, about a third of whom die before reaching hospital due to cardiac arrest. A cardiac arrest most often ocurs as a result of a heart attack, when the heart is starved of oxygen. Cardiac arrests cause the heart either to quiver - known as fibrillation - or stop beating altogether. The defibrillator works by delivering a controlled electric shock through the chest wall to the heart. The defibrillator restores a normal heartbeat after a cardiac arrest. The AED is a small, safe and lightweight piece of equipment which monitors the heart's activity and gives instructions to the user. Built-in, fail-safe computer software analyses cardiac rhythm and ensures the shock is only delivered to a person who needs the treatment.
From April 2000 to November 2002, the Department of Health (England) placed 681 automated external defibrillators (AEDs) in 110 public places for use by volunteer lay first responders. An audit has been undertaken of the first 250 deployments, of which 182 were for confirmed cardiac arrest. Of these, 177 were witnessed whilst five occurred in situations that were remote or initially inaccessible to the responders. The response interval between collapse and the initiation of CPR or AED placement was estimated to be 3-5 minutes in most cases.
Ventricular fibrillation or rapid ventricular tachycardia (one case) was the first recorded rhythm in 146 cases (82%). In all, 44 of the 177 witnessed cases are known to have survived to hospital discharge (25%). It doesn't seem a lot but 25% is a massive increase in survival rates for cardiac arrests in public places.
Kevin Johnson
ASPIRIN FOR THE OVER - 50s
The Daily Telegraph carried an interesting piece a few weeks ago which urged everyone over the age of fifty to take a mini-aspirin a day to reduce the risk of heart disease and strokes. While heart attacks and strokes could be reduced by about a third, a low dose aspirin a day may also help to protect against cancer and Alzheimer's Disease. These claims were made at a recent London conference by Prof. Elwood of Cardiff University who pioneered research on aspirin and cardiovascular disease over 30 years ago. A colleague of Prof. Elwood, Dr. Bayer, also from Cardiff University, said that 80% of North American specialists thought that aspirin should be given to patients with dementia and cardiovascular problems while other evidence suggested a protective effect of aspirin against Alzheimer's Disease. Prof. Elwood also said that a study had shown that only just over half the patients who had suffered strokes or heart attacks and who should have been taking aspirin to prevent further attacks were actually doing so.
The subject is contentious as the use of aspirin also raises the risk of bleeding. Stomach bleeding can be a serious problem, possibly needing blood transfusions and in extreme cases can be fatal.
David Read
REHAB FOR THE DISABLED
The Chairman of Ascot Round Table, Luke McMath, identified THROB as the local charity he would like to support to mark his year of office - understandable when one learns that his father died recently from coronary heart disease. Tim Grove, who is involved with both Phase III and Phase IV at Maidenhead, has recently been seeking funding to buy an arm ergometry machine for use by disabled patients. This exercise machine is similar to a bike except it sits on a table and the patient pedals the crank with their hands. The Phase III team have been unable to offer rehabilitation services to wheelchair bound patients and to patients with severe orthopaedic limitations of the lower extremities. THROB has acted as middleman and used the £750 generously donated by Ascot Round Table to acquire this machine which will carry a plaque of acknowledgement. Thus thanks to Ascot Round Table it is now possible to cater for disabled patients for both Phases III and IV in their rehabilitation following cardiac heart disease.
David Read
MAINLY FOR WOMEN
Exercise treadmill testing is not a very accurate method of detecting clogged coronary arteries in women according to new research, even when a specially designed exercise protocol is used. Previous reports have shown that treadmill testing is not as accurate in women as in men. To address this, a modified exercise protocol was developed to take into account women's lower muscle mass than men and their difficulty with some of the strenuous ramp components of testing — but it hasn't been clear if these changes actually solved the problem.
The new findings, which are reported in the American Heart Journal, are based on an analysis of data from 96 women who had suspected coronary disease and were referred for testing. Twenty-nine women had significant narrowing seen in at least one coronary artery on heart x-ray films (angiography), Dr. Jannet F. Lewis, from George Washington University Medical Center in Washington, DC, and colleagues found. However, only nine of these women had an abnormal exercise treadmill test. On the other hand, of the 67 women with little or no coronary artery blockage, only 35 had a normal exercise treadmill test.
Even with a modified exercise protocol, exercise treadmill tests appear to be of limited diagnostic value for detection of coronary artery narrowing in women with
chest pain, is the conclusion of the investigators.
Lesley Richards
HIGH BLOOD PRESSURE
I came across this interesting item and thought it might benefit some THROB members. It is a breathing exercise (originating from the University of Florida) which is said to lower your blood pressure. It doesn't need any equipment , just fifteen minutes of your time....daily I presume.
Lay flat on your back and
- inhale for six seconds
- hold for three seconds
- exhale for twelve seconds
- hold for three seconds
Repeat until 15 minutes total time has elapsed. If you have one of those home DIY Blood pressure machines you will be able to see if it has worked, otherwise you just have to believe it!
Val Cleaver
RECIPE.......
...........for the cake what Terry brought to the Friday morning class so we could celebrate his birthday and we all thought it was smashing. Official title: The Irish Fruit Cake
Ingredients:
4oz. soft margarine (Flora or Olivio)
4oz. dark Muscavado sugar
8oz. mixed fruit to suit yourself, e.g. raisins, sultanas, glace cherries, chopped dates, etc.
1 tablespoonful cane mollasses or black treacle
1/2 pint cold fruit tea e.g. blackcurrent or wild blackberry and nettle(steep tea bag in hot water for about 10 minutes and then cool)
7oz. wholemeal self-raising flour
2oz. ordinary self-raising flour
1 level teaspoon bicarbonate of soda
1/2 level teaspoon mixed spice
1/2 level teaspoon ground cinnamon
Pinch of salt
Turn on oven to 350F, gas mark 4. Grease and line a deep 7 inch round cake tin. Put margarine in a pan with the tea, sugar, fruit and molasses/treacle. Stir over a gentle heat until the margarine has melted and the sugar has dissolved. Simmer for 5 minutes. Remove from the heat and allow to cool for 30-40 minutes Sift the two flours, bicarb, salt and spices into a large mixing bowl. Make a well in the centre and carefully pour in the cooled fruit mixture. Mix until well blended. If you feel that the mixture is too runny just add a little more flour - it needs to gently fall off the spoon into the cake tin. When all the mixture is in the tin smooth the top and sprinkle with demerara sugar. Bake in the oven for approximately 80 minutes or until cooked through. Allow to cool in the tin for approximately 30 minutes and then turn out carefully on to a wire rack to finish cooling. If stored in an air-tight tin the cake will keep for up to two weeks. Will also freeze well.
Mrs. Kent
STATINS
Most members of THROB will be taking statins and it may be of interest to understand the clinical background to the reasons behind this.
In 2002 the Heart Protection Study was reported, which included over 20,000 people where it was shown that reducing cholesterol with simvastin reduced the risks of heart disease by about one quarter, regardless of age, sex or cholesterol level.
The ASCOT (Anglo Scandanavian Cardiac Outcomes Trial) trial used 10,000 people with high blood pressure who were given 10mg atorvastin or dummy tablets. In a trial over three years those taking atorvastin had a reduction in risk of heart attack, stroke or by-pass surgery of about one-third.
The CARDS (Collaborative Atorvastin Diabetes Study) Trial assessed atorvastin in just under 3,000 patients with diabetes and showed a clear reduction of about one third in the chances of developing heart problems or of having a stroke.
ALHIT-LLT (Antihypertensive and Lipid-Lowering to Prevent Heart Attack-Lipid Lowering Trial) was carried out in America on over 10,000 volunteers with high blood pressure who were given either 40mg of pravastatin or maintained on their usual regime with doctors who may or may not have prescribed statins. In this there was only a small reduction in heart attacks, strokes or by-pass by patients in the pravastin group which was a disappointing result but felt to be because many in the 'control group' were taking statins.
PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) also assessed 40mg pravastatin against a placebo in 6,000 relatively elderly (aged 70-82) over 3 years and showed a 20% reduction in the risk of heart related death or heart attack.
All the evidence shows, not only a marvellous facility to name trials with a good abbreviation, but that the taking of a statin by anyone at risk of heart problems will give a significantly reduced chance of a cardiac event.
As this is what we are all trying to avoid, then the moral must be "Keep on taking the tablets!"
Roger Mills
REPORT ON THE CORONARY PREVENTION GROUP CARDIAC REHABILTIATION SYMPOSIUM HELD ON 3RD FEBRUARY 2005.
The purpose of the symposium was to present a report on the findings of a survey on the current provision of Cardiac Rehabilitation that had been carried out by the Coronary Prevention Group (CPG). Information was gathered from 28 different centres- one for each Strategic Health Authority in England. This equated to about 11% of the CR centres in England.
The report highlighted many areas of good practice especially on an individual basis, despite a formable lack of resources. However, lamentable shortcomings were also discovered and clearly we are not yet meeting the standards required by the National Service Framework for Coronary Heart Disease (NSF for CHD).
Copies of the report were issued to all symposium participants and can be obtained from the CPG: 2 Taviton Street, London WC1H 0BT
STRUCTURE OF THE SYMPOSIUM
The day was split into 5 sections relating to areas covered by the survey. There were many speakers who were each allocated about 10 minutes – this rapid turnover kept the audience interested and helped to provoke lively debate.
The audience were all supplied with "Who Wants To Be a Millionaire?" type interactive keypads in order to respond instantly from time to time on questions raised. The responses were recorded and in most cases corresponded well with the findings of the CPG survey thereby further confirming the accuracy of the CPG sample.
The five sections covered during the day were
THE PLACE OF CARDIAC REHABILITATION WITHIN THE STRUCTURE OF CARDIAC SERVICES.
Some survey findings:-
40% of Directors of Public Health were unable to supply figures for how many eligible patients received CR in their area; This questions the auditing standards for CHD which affects management and planning decision.
Only 1 in 4 services had a fully integrated "care pathway" through all the Phases of CR making it difficult to track the progress of patients and provide statistics needed to verify standards.
36% of CR coordinators were unable to name the lead physician for CHD in their local Trusts.
71% of CR coordinators were unable to name the Director of Public Health for their area.
In general CHD lead physicians did not have "a finger on the pulse of CR" and were unable to provide data on their rehab service.
Communication is a major failing and NSF indicators (targets) are not being met for smoking cessation and other lifestyle changes.
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These findings highlight the need for improved networking and communication across primary and secondary care boundaries.
Without good outcome data CR teams are not in a position to argue for increased funding from commissioning groups.
CR teams need to work with PCTs to find a solution to collecting long-term data and to link in with CHD registers in GP Practices.
THE FUNDING OF CARDIAC REHABILITATION
Key findings from the survey:-
Only half of the CR programmes held their own budget limiting their ability to make planning decisions.
Only 1 in 5 services meets national standards for staffing levels. Chronic understaffing affects quality of care and staff retention.
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Mean costs across the nation worked out around £88.00 per person per annum for CR. This is comparable to other surveys carried out e.g. Evans et al (2002) and Griebsh Brown et al 2004 (British Journal of Cardiology)
In Cornwall a randomised controlled trial of CR known as CHARMS compared at home CR versus CR based in hospital. This showed a home programme costing £170 per person and hospital –based programme costing £200 per person.
The more patients rehabilitated the more the cost per person drops. Whichever way this is looked at CR is better value for money than almost any other major medical intervention.
CR often finds itself bidding against other cardiology resource needs and CR staff are not trained in commissioning skills or grant applications. To help ease this situation the CPG have designed a Business Case Toolkit to assist in business plans for CR which is almost ready for publication. Details can be found on the British Heart Foundation (BHF) web site under Cardiac Rehab UK. Training for using the toolkit will also be available.
RECORDING INFORMATION
All recording should be based on NSF milestones and goals for CR. All programmes surveyed collected 100% of all he required data with the exception of anxiety and depression scores.
30% of programmes were collecting data on paper as opposed to computer and those using IT did so with differing software and no overall consistency.
Recognising the need to collect good quality data in order to commission better funding, the BHF have spent the last 5 years developing an IT dataset for the collection of CR data. This data when collected will become part of the National Cardiac Care Audit.
The BHF dataset will be freely available to all CR programmes – using the same dataset nationally will provide comparable statistics which will then be automatically posted on a web site for access by all. The dataset has been piloted in 8 centres and is available now from York University who will also supply support for the IT package.
The adoption of the BHF dataset will be optional but it is to be hoped that all CR programmes will see the value of changing their systems to one that will be nationally coordinated. Enquiries regarding the package can be done via www.cardiacrehabilitation.org.uk
THE STAFFING OF CARDIAC REHABILITATION
All programmes have coordinators of which 98% are nurses. Of these 50% are G grade nurses and 25% H grade. 25% were of grades lower than G which is below the recommendation for CR coordinator posts.
Over 50% of programmes felt that they would benefit from having a psychologist's input.
The Scottish Intercollegiate Guidelines Network (SIGN) recommend the average district general hospital CR programme should have as a minimum
1 G grade nurse (or above) whole time equivalent
2 physiotherapists (or equivalent exercise personnel)
1 dietician (0.3 whole time equivalent)
Of the 28 programmes surveyed only 6 met these staffing guidelines.
Virtually all programmes have doctor support but no doctor as part of the team.
Discussions as to who is most appropriate to lead or be part of a CR team can be a divisive factor. It is generally accepted that a multi-disciplinary approach benefits all, both patients and staff. A way to view the staffing of CR in the future is likely to be based on a "competencies" approach. This would mean each post would have a relevant competency base that must be met whether the applicant is a doctor, nurse, physio, dietician or occupational therapist.
PSYCHOLOGICAL MANAGEMENT IN CR
SIGN recommends that CR programmes should screen for anxiety and depression in cardiac patients. However, across the 28 programmes there was no consistency of approach and 71% did not screen for any quality of life outcomes. All centres offered some relaxation but only 30% offered relaxation after exercise sessions.
The European Interheart study (2004) shows that stress increase is a significant factor in patients with CHD yet conventional risk factors still dominate over psycho-social interventions. Psychological profiles e.g. the Type A personality, have remained controversial for several decades but have never entirely disappeared and are now joined by the Type D psychological profile.
There is a known advantage in early detection of patients who have a severe reaction psychologically to having a sudden cardiac event- if identified these patients often require extra intervention over and above the normal support offered to CR patients. Psychologists have in depth knowledge of behavioural interventions and anxiety reducing strategies and access to a psychologist is of enormous benefit to a CR programme.
Various simple tools are available for patient assessment e.g. Hospital Anxiety and Depression Scale ( HAD) or the MacNew Quality of life after Myocardial Infarction Questionnaire.
SOME KEY RECOMMENDATIONS FROM THE CPG SURVEY
Some recommendations to Trusts and Cardiac Networks
Some recommendations to CR practitioners
SUMMARY
The symposium was an imaginative and thought provoking day. The survey results were not surprising to those working in CR and the day helped us to value our contributions and to celebrate the achievements of CR over the past decade. We acknowledge that more work need to be done and that a new approach may be required to lead CR forward into its next phase of achievements. CR needs to learn to plead its case for increased resources more effectively as we have the research base to back up the claims for its cost-effectiveness.
Lesley Richards