11:00 AM-12:00 PM

Saturday, October 23, 2010

Concurrent Scientific

Oral Presentations

Oral #1

RELIABLE CHANGE INDICES TO ASSESS PROGRESS OF INDIVIDUAL CARDIAC REHABILITATION PATIENTS. I. PSYCHOMETRICS: ANXIETY, DEPRESSION & QUALITY OF LIFE

Megan E. O'Connell¹, Peter L. Prior^2,3, Karen L. Unsworth² & Neville G. Suskin^2,3

¹Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan; ²Cardiac Rehabilitation & Secondary Prevention Program, London Health Sciences Centre, London, Ontario; ³University of Western Ontario; London, Ontario

Background and Aims: We propose an innovative application of Reliable Change Indices (RCIs), a statistical method from Psychology, to measure true clinical change of individuals in cardiac rehabilitation (CR). Established research methods can determine whether group means differ or change significantly, for example in randomized trials; yet reveal little about individuals. It remains crucial to determine whether any individual patient has changed meaningfully. RCIs can account for non-treatment variance in change scores, including measurement error and test exposure; and may therefore improve reliability and predictive accuracy. Following Chelune, RCI = [(x₂-x₁) - (M₂-M₁)]/[SD₁[square root]2(1 - r₁₂)]: x₁ and x₂ are an individual's test scores, M₁ and M₂ are the test means, pre- and post-treatment respectively; r₁₂ is test-retest reliability or stability. RCIs are standard scores, can be used in statistical analyses, or as criteria of individual change. For example, RCI >= 1.64 is required to show (p < 0.05, 1-tailed) that an individual has improved. Our objectives were to develop stability estimates for the Hospital Anxiety & Depression Scale anxiety (HADS-A) and depression (HADS-D) subscales, the SF-12 Health Survey physical (PCS) and mental (MCS) composite scores; and to illustrate one potential RCI application.

Methods and Materials: We administered the HADS and SF-12 twice with a 1-week inter-test interval, to each of 103 patients in the middle 2 months of their 6-month CR program. We chose this timeframe to minimize treatment-related change and acute emotional reactions due to referral events or impending CR discharge.

Results: With 80 patients completing (mean age = 64.5y; 29 women), test-retest reliabilities were: HADS-D, r₁₂ = 0.874; HADS-A, r₁₂ = 0.904; PCS, r₁₂ = 0.831; MCS, r₁₂ = 0.781; (all p < 0.001). HADS-A changed significantly, from M₁ = 5.74 (SD₁ = 3.75) to M₂ = 5.01 (SD₂ = 3.69; p < 0.001), consistent with test exposure. HADS-D (M₁ = 3.34, SD₁ = 3.11; M₂ = 3.21, SD₂ = 3.15; p = 0.48,), PCS (M₁ = 44.78, SD₁ = 10.54; M₂ = 44.85, SD₂ = 9.19; p = 0.91), and MCS (M₁ = 51.32, SD₁ = 9.78; M₂ = 52.09, SD₂ = 10.15; p = 0.30) remained similar over time.

Conclusions: All psychometric subscales showed high stabilities, which are therefore good bases for RCIs. For illustration, the HADS-D of an anonymous individual from our program decreased by 3 points, translating into RCI_HADS-D = 1.81; using RCI >= 1.64, this individual's HADS-D improved after accounting for measurement error and test exposure (p < 0.05). In contrast, if the significant (p < 0.0001) overall intake-to-exit HADS-D decrease of 1.03 from the Ontario CR Pilot Project were assigned to an hypothetical individual, then RCI_HADS-D = 0.57; we would be unable to say that this individual's score had decreased reliably. We plan to test predictive accuracy of RCIs against clinically important criteria in future research.

Oral #2

INTEGRATING SELF-DETERMINATION THEORY (SDT) AND SELF-EFFICACY THEORY (SET) INTO A COMPREHENSIVE MODEL TO PREDICT PHYSICAL ACTIVITY IN CARDIAC REHABILITATION PARTICIPANTS

SN Sweet, MS Fortier

University of Ottawa, Ottawa, Ontario

Background and Aims: The benefits of physical activity on cardiovascular disease are well documented. However, cardiac patients' physical activity is still not well understood. In light of this, experts urge that theoretical variables be investigated as determinants of physical activity. SDT and SET are two well supported motivational theory used in physical activity research. Both of these theories have independent contributions, but their combined efforts could result in greater understanding of cardiac patients' physical activity. The objective of this study is to test the aforementioned theories separately and then integrate them into one comprehensive model using Noar & Zimmerman's (2005) approach with a cross-sectional sample of cardiac patients.

Methods and Materials: Cardiac patients (n = 107; mean age: 62.48 +/- 9.68 years) completed a questionnaire package during their initial cardiac rehabilitation session which included the Godin Leisure Time Exercise Questionnaire, scales assessing SDT variables (i.e., autonomy support, psychological needs, self-determined and non-self-determined motivation) and SET constructs (i.e., outcome expectations and self-efficacy). The models were assessed with path analysis and using four goodness of fit indices: chi-square, comparative fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean residual (SRMR).

Results: The SDT model had excellent fit (chi-square = 8.90, p = .45; CFI = 1.00; RMSEA = .00; SRMR = .05) and predicted 5% of the variance in physical activity. For SET, self-efficacy mediated the outcome expectation -physical activity relationship, had excellent fit (chi-square = 0.19, p = .66; CFI = 1.00; RMSEA = .00; SRMR = .02) and predicted 4% of the variance in physical activity. Prior to integrating the models, perceived competence and self-efficacy were combined, as one factor emerged from a factor analysis. The best fitting model (chi-square = 24.07, p = .03; CFI = .94, RMSEA = .90, SRMR = .06) predicted 6% of the variance in physical activity. Specifically, autonomy support predicted all psychological needs which in turn predicted self-determined motivation. Outcome expectation was predicted by autonomy and relatedness and predicted confidence. Confidence, self-determined and non self-determined motivation were slightly related to physical activity (beta = .13, .13 & -.17, respectively).

Conclusions: With adequate fit and a small increase in variance explained, the integrated theoretical model is a more comprehensive model. To our knowledge, this is a first study to fully test and integrate these two theories into one model. This model outlines how two important theories in physical activity can be incorporated together to gain further understanding of physical activity in cardiac rehabilitation participants. Future cardiac rehabilitation could foster concepts from SDT and SET to facilitate physical activity adoption.

Oral #3

USING A HEART-RATE WALKING SPEED INDEX TO REPORT TRUER PHYSIOLOGICAL CHANGES WHEN USING WALKING PERFORMANCE TESTS IN CARDIAC REHABILITATION

JP Buckley, M Reardon, G Innes, M Morris

University of Chester, UK

Background and aims: Walking tests (ISWT; Singh et al., 1992) are commonly used to assess/screen patients and provide outcome measures in cardiac rehabilitation (CR). Distance walked can be misleading as an outcome measure because improvements can be influenced by familiarization/practice and motivation. We have thus employed a simple index ratio between heart rate and walking speed (HRWSI) to determine how much of walking performance following CR is more truly related to a physiological change.

Methods and materials: 26 Male and 7 female patients (MI, CABG or PCI) (mean age 57.3 years) attended an 8-week CR program. All were assessed 3 times using via am ISWT: T1 = practice test; T2 = one week after T1, and T3 = after 8 weeks CR. The HRWSI was calculated by dividing heart rate by walking speed attained in the last full one-minute of ISWT and multiplied by 10 to describe heart-beats per 10m walked.

Results: Walking distance for T1, T2 and T3 with corresponding heart rates and HRWSI are summarized in table 1.

Table. No title available.

With no exercise training, after one week, participants increased walking distance by 17%. There was a corresponding 12% reduction in the HRWSI from 3.2 to 2.8. After 8-weeks CR there was a 42% improvement in walking distance from T1. At best the true physiological change, based on the HRSWI, would be 14% (T2 - T3). The remaining 28%; explained by familiarization/walking economy and/or motivation.

Conclusions: The use of a HRWSI provides for a truer outcome of aerobic fitness, compared with just reporting distance walked; even when a practice test is performed. The HRSWI provides clarity on changes due either to physiological, psychological or motor learning mechanisms. A simple nomogram table to quickly calculate HRSWI has been produced. The HRWSI can also be used to help patients understand CR benefits; in this case the average patient decreased his/her HRWSI by 0.4 for each 10 m walked; thus they can be informed for 100m or every mile walked they now save 4 and 64 heart-beats, respectively.

Oral #4

DEGREE AND CORRELATES OF HEART FAILURE CLINIC USE

Shannon Gravely-Witte¹; Lori Van Langen²; Donna E. Stewart^2,3; Sonia Anand⁴, PhD; Bob Reid⁵; Gilbert Wu⁶; Sherry L. Grace^1-3,6 on behalf of the CRCARE Study Investigators

¹York University, Toronto; ² Women's Health Program, University Health Network, Toronto; ³ The University of Toronto, Toronto; ⁴McMaster University, Hamilton; ⁵University of Ottawa Heart Institute, Ottawa; ⁶York Central Hospital, Richmond Hill

Background and Aims: Heart failure (HF) has become a major burden worldwide as it is associated with high prevalence, incidence and mortality rates, frequent hospital readmissions and high health care costs. HF clinics have been shown to reduce readmission rates by 25%-30%, and have favourable effects on quality of life, survival and cost of care. The objectives of this study were to: (1) describe the rates of HF clinic referral and attendance, and (2) examine the factors related to HF clinic use based on the Andersen's Behavioral Model of Healthcare Utilization.

Methods and Materials: This study represents a secondary analysis of a larger prospective cohort study on access to cardiac rehabilitation. At baseline, participants comprised of 476 HF inpatients (age 67.83 +/- 11.99, 146 [30.7%] female; 173 [36.3%] left ventricle ejection fraction <40%, 72% response rate) recruited from 11 hospitals across Ontario. Patients completed a survey in-hospital that assessed predisposing, enabling and need factors affecting secondary prevention service utilization. Clinical and demographic data were extracted from hospital charts. A diagnosis of HF was based upon three criteria: (1) HF was indicated in the inpatient hospital chart, (2) patient self-report on the baseline survey and/or (3) a New York Heart Association Class of III or IV. At 1-year post-recruitment, 273 patients (77% retention) completed a follow-up survey that assessed referral to and use of HF clinics and other secondary prevention services (cardiac rehabilitation, outpatient diabetes education, stroke rehabilitation, smoking cessation programs, occupational/physical therapy and/or a consultation with a dietitian).

Results: Of the 273 participants, 41 (15.0%) were referred and 38 (13.9%) attended a HF clinic at one of 16 sites. In an adjusted logistic regression analysis, factors significantly related to program use were: referral to other outpatient disease management programs (OR = 6.56, p = .01), seeing a heart specialist more frequently (OR = 4.76, p = .04), higher education (OR = 3.66, p = .04), and lower perceived stress (OR = 1.08, p = .03). There was a trend towards the absence of exertional dyspnea increasing the likelihood of clinic attendance (p = .09).

Conclusions: Only one-seventh of HF patients were referred and attended a HF clinic. The results of this study suggest that the few patients who are accessing HF clinics are repeated users of healthcare services, potentially due to their greater health literacy. Given the benefits of HF clinics, more research regarding how we can coordinate outpatient disease management program care and optimize utilization is needed.

Oral #5

RISK ASSESSMENT IN ACS PATIENTS WITH EARLY DISCHARGE AND ACCESS TO REHABILITATION (RADAR) PILOT PROJECT

Tracy Downie, Lisa Sorenson, Sherry Pysyk, William Dafoe, Rodrigo Quezada, Lea Carlyle, Bill Daub, Blair J O'Neill

Mazankowski Alberta Heart Institute and the Northern Alberta Cardiac Rehabilitation Program, Edmonton, Alberta

Background and Aims: Increased hospital length of stay (LOS) impacts patient through-put during the acute care journey and increases health care costs. The LOS for cardiology patients (pts) with Acute Coronary Syndrome (ACS) varies from 3-7 days. Patient participation in CR is a cost effective intervention that results in a reduction in cardiac mortality, and may reduce costs to the health care system. The goal of the RADAR pilot was to ensure early facilitated access to CR while simultaneously reducing LOS for low and moderate risk ACS pts.

Methods and Materials: Cardiology and CCU nurses performed the GRACE (Global Registry of Acute Coronary Events) risk score on 223 admitted ACS pts (75% men). The GRACE risk score is a well validated calculated risk assessment tool that identifies ACS pts as meeting low, moderate or high risk criteria for in-hospital death. ACS pts were sub classified as STEMI, NSTEMI and Unstable Angina. Pts scored as low and moderate risk were targeted for discharge on the 3^rd day after admission. Reasons for failure to discharge pts on the target date were recorded. On the discharge day, 79 patients were given an automatic CR referral appointment with a CR nurse or an exercise tolerance test (if appropriate) at the participating CR program for < 10 days. Reasons for exclusion were a high GRACE risk score, need for cardiac surgery or refusal or inability to attend the participating CR program.

Results: The mean number of days to attend CR and the mean LOS was compared before and after RADAR was implemented.

Conclusions: There was a significant decrease in the wait time to attend CR as well as reduced LOS in the RADAR participant group. These results suggest that identifying low and moderate risk ACS pts, as well as an automatic referral to CR decreases the wait time to attend CR. Using the GRACE risk score to identify low and moderate risk ACS patients contributes to reduced LOS by increasing physician awareness of risk stratification and facilitation of meeting discharge target dates. System efficiency can be improved by including CR as an extension of acute care, thereby enhancing the continuum of patient care and the overall patient journey.

Oral #6

IMPLEMENTATION OF AUTOMATIC REFERRAL TO CARDIAC REHABILITATION: PREDICTORS OF PARTICIPATION

AE Mark, SE Tiller, L Leger-Caldwell, P O'Farrell, AL Pipe

University of Ottawa Heart Institute, Ottawa, ON

Background and Aims: Cardiovascular disease (CVD) remains the leading cause of death in Canada. Cardiac rehabilitation (CR) is an essential component of secondary prevention of morbidity and mortality. Despite the known benefits of CR, it is a highly underutilized resource. As well, biases have been noted within the referral process whereby younger and male patients were more likely to receive a referral to CR. At the University of Ottawa Heart Institute (UOHI) measures have been taken to remove such biases through the implementation of automatic referral processes. The current study examined CR referral rates, and the predictors of CR referral and attendance at CR intake session.

Methods and Materials: In 2008 an automatic referral to CR program was implemented at UOHI. Nurses systematically visited all patients admitted to UOHI for each patient. Attendance at CR intake sessions was recorded. Chi square analysis was used to compare CR participation between sex, diagnosis, and location in UOHI. Logistic regression was used to predict accepting CR referral and attendance at CR intake session.

Results: A total of 5666 patients were approached by the automatic referral nurses in 2008 and 2009. The rate of CR referral increased from 25% in 2003/04 (pre-automatic referral) to 72% in 2008/09 (post implementation). The proportion of males being referred. 47% was slightly higher than females, 42% (P < 0.01). Attendance at CR intake was 83% for males and 75% for females. Younger patients were more likely to be referred. Acceptance of a CR referral differed by diagnosis/treatment: 70% aortic valve repair/replacement (AVR), 64% multiple procedure (e.g., AVR + coronary artery bypass graft: CABG), 63% CABG, 40% percutaneous coronary intervention (PCI), 34% angina and 25% coronary heart failure. Compared to CABG patients, AVR patients were 1.45 (1.05-2.00) times more likely to be referred to CR whereas PCI, angina, arrhythmia, catheterization, coronary heart failure, myocardial infarction, and other diagnoses were 0.37 (0.32-0.43), 0.31 (0.18-0.52), 0.13 (0.05-0.34), 0.14 (0.08-0.24), 0.22(0.14-0.33), 0.51 (0.32-0.53, and 0.45(0.34-0.60) less likely, respectively. Only MI (1.702, 1.048-2.764) and PCI (1.691, 1.318-2.168) patients were more likely to attend CR intake compared to CABG patients.

Conclusion: Automatic referral dramatically increase the proportion of patients receiving referral to CR however it still differs between sexes. The likelihood of accepting a CR referral and attending CR intake differs based on diagnosis.

Oral #7

IMPROVEMENT IN EXERCISE PERFORMANCE THROUGH CARDIAC REHABILITATION (CR): COMPARISON OF EXCLUSIVELY CENTRE-BASED CR WITH A CENTRE-TO HOME-BASED TRANSITION CR

Candi J. Flynn¹, Karen Unsworth², Heather Arthur³, Kathy N. Speechley¹, Neville Suskin^1,2

¹University of Western Ontario, London, Ontario;²London Health Sciences Centre Cardiac Rehabilitation and Secondary Prevention Program, London, Ontario; ³McMaster University, Hamilton, Ontario

Background and Aims: Previous studies have reported that patients who participate in home-based cardiac rehabilitation (CR) programs achieve at least similar improvements in exercise performance (EP) compared to those participating in centre-based CR. These results have been obtained from controlled trials where patients were randomized to either centre- or home-based exercise. In our own CR program we have observed that a sizable minority of patients begin centre-based CR and then, following engagement with the CR staff, make a joint decision to transition to a home-based program. It is unknown whether these "transition" patients achieve similar outcomes to those who continue in the centre-based program. The aim of this investigation was to explore whether transition patients achieve similar changes in EP compared to centre-based patients.

Methods and Materials: Beginning in 2008, transition patients were systematically identified in the electronic patient management system of our CR program. Data were extracted on 316 patients who had completed the standard six-month CR program between January 2008 and April 2010. Patients received a personalized exercise prescription of at least twice per week aerobic exercise sessions. Patients who completed the on-site supervised program (n = 250, 57 women) were considered 'centre-based' and those who transitioned to a home-based program (n = 66, 19 women) after attending two or more centre-based exercise sessions were considered 'transition' patients. The change in peak EP between intake and exit stress tests was examined. Peak EP was determined using standardized equations based on the peak treadmill grade and speed. A paired t-test was conducted to determine the mean level of improvement reached overall, and a t-test determined which group experienced greater improvements in EP. Results were considered significant at the 5% critical alpha level (p < 0.05).

Results: Overall, patients' EP increased significantly by 1.92 +/- 1.83 METs during CR (p < 0.0001). Those who completed the centre-based program increased their EP by a mean of 1.95 +/- 1.83 METs. This improvement was not significantly different than the mean increase experienced by transition patients of 1.79 +/- 1.87 METs (p = 0.5317). The results did not change significantly following adjustment for the potential confounders of age, sex and distance traveled to the CR centre.

Conclusions: Centre-based and transition CR programming both resulted in significant improvements in EP for participants and the average amount of improvement did not differ significantly between the two groups. Although confirmatory study is needed, these preliminary data may have important implications for decisions regarding future resource allocation.

Oral #8

THE IMPACT OF PHYSICAL ACTIVITY ON MAJOR ADVERSE CARDIOVASCULAR EVENTS (MACE)

Rossi A^1,2,3, Lavoie KL^2,3,4,5, Arsenault A^3,4, Bacon SL^1,2,3,5

¹Department of Exercise Science (SIP), Concordia University, Montreal, Quebec; ²Montreal Behavioural Medicine Centre, Montreal, Quebec; ³Research Centre, Montreal Heart Institute, Montreal, Quebec; ⁴ Department of Psychology, Universite du Quebec a Montreal, Montreal, Quebec; ⁵Research Centre, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec.

Background: Being physically active has been shown to be protective of developing chronic diseases, including cardiovascular disease. Currently, Canadian guidelines recommend 30 minutes of physical activity on most days of the week for the maintenance of health. The purpose of these analyses were to compare physical activity habits and incidence of major adverse cardiovascular events (MACE) in people without a history of cardiovascular disease, over a 2 year follow up period.

Methods & Materials: A total of 492 participants undergoing a standard nuclear medicine exercise stress test were recruited at the Montreal Heart Institute. Participants underwent an interview and filled out questionnaires concerning their medical history, physical activity, and socioeconomic and psychological parameters. All participants were followed for 2 years through mailed questionnaires. Resting blood pressure and heart rate were also measured. Of this cohort, we considered the 291 participants (56% women; age (SD) = 61 (9) years) who were free of any cardiovascular disease at baseline for these analyses.

Results: Throughout the 2-year follow-up period, 25 participants had a MACE. Leisure time physical activity (LTPA) was shown to be, albeit not significantly, predictive of MACE (odds ratio (95%CI) = 0.94 (0.88-1.001). This represents a 6% decrease in risk of MACE for every increase in exercise intensity of 1 metabolic equivalents (METs). Including age and sex as covariates in this analysis did not change the results. Additionally, decrease in risk of approximately 70% was seen in participants who accomplished the recommended levels of physical activity (odds ratio (95%CI) = 0.32 (0.09-1.001). Again, no difference was noted when age and sex were considered. At baseline, participants who did not later have MACE were significantly more active than those who did have a cardiovascular event (average 8.86 +/- 0.87 vs. 3.11 +/- 2.69 MET-hrs/wk, respectively, p < 0.05); however, this comparison was no longer significant at the 2-year point (7.01 +/- 0.75 vs. 3.76 +/- 2.44, respectively, p < 0.05). When incorporating covariates or controlling for baseline physical activity levels, these results were unchanged.

Conclusion: These findings support those observed in previous studies, suggesting that physical activity is of great benefit for an individual's health. Of note, it would appear from our sample that the benefits of physical activity can even been seen in elderly individuals.

Oral #9

EFFECTS OF NORDIC POLE WALKING ON FUNCTIONAL STATUS IN PATIENTS WITH MODERATE TO SEVERE HEART FAILURE: A RANDOMIZED CONTROLLED TRIAL

ML Keast, M Slovinec, D'Angelo, B Reid, C Nelson

University of Ottawa Heart Institute, Minto Prevention and Rehabilitation Centre, Toronto, Ontario

Background and Aims: Patients with heart failure are a growing population within cardiac rehabilitation programs. Usual care for these patients consists of low to moderate intensity aerobic exercise, typically walking, and upper body strength training exercise. Here we report results from the Nordic Walking Study examining the effects of 12 weeks of walking with Nordic poles versus usual care on functional status, VO₂ peak, physical activity, body weight, waist circumference, anxiety and depressive symptoms in patients with moderate to severe heart failure.

Methods and Materials: Between 2008 and 2009, we conducted a randomized controlled trial at the University of Ottawa Heart Institute where 54 patients (44 men, 10 women; mean age = 62.4 +/- 11.4 years) with moderate to severe heart failure (mean ejection fraction = 26.9 +/- 5.0%) were randomly assigned to usual care (n = 28) or Nordic pole walking (n = 26) for 12 weeks. Our primary outcome was functional status assessed by distance traveled in the 6-minute walk test at 12 weeks.

Results: The follow-up assessment rate for our primary end point of functional status was 76%. Analysis of covariance indicated Nordic pole walking improved functional status (623 +/- 130 vs. 548 +/- 150 meters traveled in 6 minutes; P = .026) and waist circumference (95.4 +/- 15.1 vs. 99.5 +/- 9 cm; P = .051) at 12 weeks compared to usual care. There were no significant differences between groups after 12 weeks for VO₂ peak (24.4 +/- 7.7 vs. 22.2 +/- 7.2 ml/kg/min²; P = .167), physical activity (264 +/-103 vs. 284 +/- 104 minutes per week; P = .567), body weight (81.4 +/- 18.7 vs. 83.6 +/- 12 kg; P = .525), anxiety (5.1 +/- 3.1 vs. 4.4 +/- 3.4; P = .493) or depressive symptoms (3.3 = 2.5 vs. 3.2 +/- 2.9; P = .918).

Conclusions: Improvement in functional status was 14% greater in patients with moderate to severe heart failure assigned to Nordic pole walking versus usual cardiac rehabilitation care. These results need to be replicated in other studies; however, this is a promising exercise modality for this patient population.

Scientific Poster Presentations

Saturday, October 23, 2010

CACR Showcase Posters available for viewing:

9:30 AM-4:30 PM

Authors present: 9:30 AM-10:00 AM

Sunday, October 24, 2010

CACR Showcase Posters available for viewing:

9:30 AM-1:00 PM

Authors present: 10:00 AM-10:30 AM

Scientific Posters

Poster #1

PATIENTS KNOWLEDGE ABOUT CORONARY HEART DISEASE: COMPARISON BETWEEN CARDIAC REHABILITATION PROGRAMS IN BRAZIL AND CANADA

GLM Ghisi¹, P Oh³, S Thomas², M Benetti¹

¹Santa Catarina State University, Florianopolis, Santa Catarina, Brazil; ²Toronto Rehabilitation Institute, Toronto, Ontario; ³University of Toronto, Toronto, Ontario

Background: Socioeconomic status is consistently among the most fundamental determinants of health status and knowledge about health and disease. Much of this relationship can be attributed to the combined effects of disparities in health-related behaviours, environmental conditions, social structures, and the contact and delivery of health care. Because these factors change in developed and developing countries and because they are modifiable, it is important to find ways to reach people with different lifestyles. The purpose of this study was to compare knowledge of coronary patients in cardiac rehabilitation programs in Brazil and Canada, using the CADE-Q (Coronary Artery Disease Educational Questionnaire).

Methods: The sample consisted of 300 coronary patients participating in a cardiac rehabilitation program in Brazil, mean age 63.72 +/- 10 years (min. = 36, max. = 86), 227 men and 300 coronary patients participating in a cardiac rehabilitation program in Canada, mean age 64.02 +/- 9.87 years (min = 40; max. = 88), 236 men. All patients were characterized in terms of age, gender, risk factors, comorbidities or associated diseases, duration in cardiac rehabilitation, surgical procedures and socioeconomic status (occupation, family income and educational level) by a questionnaire to characterize the individuals. Knowledge was assessed using the CADE-Q, validated in both languages and analyzed by means of: general knowledge (total scores, max = 57), knowledge of questions (alternatives marked), specific knowledge (scores of each area of knowledge) and knowledge of groups (population characteristics). Both study instruments were applied in the presence of the researcher and with the consent of patients. The data were processed through descriptive statistics, Post-hoc and Student t-test.

Results: Canadians have a statistically better knowledge than the Brazilians. These significant differences occurred in the general knowledge (43.49 +/- 9.4vs39.34 +/- 9.1; p < 0.001), in the number of complete knowledge alternatives marked (13.47 +/- 3.45vs11.86 +/- 3.43; p = 0.03), in the specific knowledge of three areas of the questionnaire (Area 2, 3 and 4; p < 0.001) and in 13 of 19 questions of the CADE-Q. About knowledge of groups, patients that are Canadian, young (under 65 years old), male, with associated comorbidities, who had any cardiac surgery, with occupations in the health area or superior level, with university or postgraduate educational level, with a family income of over C$50.000 per year or more than 15 Brazilian minimum salaries per month appear to have a significantly knowledge about coronary artery disease.

Conclusion: There is a difference in knowledge of coronary patients in cardiac rehabilitation programs in Brazil and Canada and this difference is related to factors such as socioeconomic status

Poster #2

THE ENGLISH VALIDATION OF THE CORONARY ARTERY DISEASE EDUCATION QUESTIONNAIRE: CADE-Q

GLM Ghisi¹, R McMaster², P Oh³, S Thomas², M Benetti¹

¹Santa Catarina State University, Florianopolis, Santa Catarina; Brazil; ²Toronto Rehabilitation Institute, Toronto, Ontario; ³University of Toronto, Toronto, Ontario

Background: Knowledge of health and disease has been reported as a component related to successful management of chronic health conditions. Studies have shown that the simple act of "giving information" to patients can influence them to make healthier choices, to avoid adverse outcomes and even to cause regression of the disease. The Coronary Artery Disease Education Questionnaire (CADE-Q) is a validated specific tool used to assess the knowledge of coronary patients in cardiac rehabilitation on aspects related to coronary artery disease (CAD). The purpose of this study was to translate, cross-culturally adapt and validate the CADE-Q to English.

Methods: Two initial independent translations were carried out in Brazilian Portuguese (original language) to Canadian English, performed by qualified translators. After their back translation, both versions were reviewed by a committee of Canadian experts. A final version was generated and tested in a pilot study. For the validation of analytical procedures, the tool was applied to 200 coronary patients that participated in cardiac rehabilitation programs: 150 male, and the mean age was 63.58 years old (standard deviation=10.40; range:40-88). The internal consistency was verified by Cronbach's Alpha Coefficient, the reproducibility by test-retest, through the intraclass correlation coefficient (ICC) and the construct validity was verified through exploratory factorial analysis. To verify the results of the use of CADE-Q regarding some characteristics, such as gender, associated comorbidities, occupation, educational level and income, the scores were analyzed in relation to these variables.

Results: Eleven of 19 questions of CADE-Q were culturally adapted in the English version. The pilot study was performed in 50 alumni of the rehabilitation and filling time observed was 11 +/- 5 minutes. For the validation of analytical procedures, the Cronbach's alpha was 0.809, the ICC was 0.846 and factor analysis revealed six factors, four of them directly related to the CADE-Q's four areas of knowledge. The analysis of the population characteristics related to total scores presented significant correlation to income and education level, which demonstrates the relationship between socioeconomic level and the knowledge of the patient.

Conclusion: The English version of the CADE-Q presents adequate validity and reliability for its use. Studies of patients knowledge can be quite useful in the creation of strategies to stimulate patient adherence to cardiac rehabilitation programs and can also interfere in the success of this intervention^. Additionally, the association between CAD and knowledge can collaborate to optimize treatment, with a change in beliefs, bad habits and risk factors.

Poster #3

WHAT DO NON-REHAB CARDIAC SCIENCES HEALTH PROFESSIONALS PERCEIVE OF AND KNOW ABOUT CARDIAC REHAB?

LJ Avery, JW Tam, AH Menkis, N Shaikh, RA Manji

Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba

Background and Aims: Patient participation in a cardiac rehabilitation (CR) program is standard of care as it leads to a decrease in morbidity, mortality and is cost-effective. Despite documented benefits, participation rates remain sub-optimal and this may be partially related to a lack of encouragement to patients from health professionals to join a CR program. It would be important to know what health professionals perceive about CR programs to see if they may need to be better educated or motivated so they in turn can encourage patients. The aims of this study were to determine cardiac sciences staffs' perception of CR and knowledge base of what CR offers.

Methods and Materials: A published survey was distributed to all staff (including nurses, physicians, clinical assistants (CA) and allied health) that are employed at a tertiary care site where cardiac sciences has been consolidated. The survey was modified to include a ranking of staffs' perceived importance of various components and services offered at the local CR program.

Results: An unexpected finding in this study was the very dismal response rate (86/201 = 42.3%) despite incentives to complete the survey. Response rates varied among disciplines and clinical areas, with the highest among allied health care professionals (66-100%) and lowest among staff in the cardiac intensive care unit (CICU) at 10%. Respondents were primarily female, between 36-45 years of age with a mean of 13.15 years of clinical experience. Out of the various services offered by CR, the perceived importance of classes related to stress management was the only variable that was statistically different between health care professional categories (p = 0.001 between physicians/CA and nurses and p = 0.034 between physicians/CA and allied health professionals). Overall, at a local level, staff was knowledgeable about the local referral process and location of the CR sites in Winnipeg.

Conclusions: The low response rates, especially the closer staff is to acute care such as the (CICU) may reflect staffs' perceptions of the lack of relevance of the topic to a busy acute care cardiac intensive care unit. Ongoing efforts need to be undertaken to educate health professionals so that they may encourage patients to join a CR program. This research also provides a foundation for initiatives to further support and refine the acute care CR referral process.

Poster #4

SCREENING FOR OBSTRUCTIVE SLEEP APNEA IN PATIENTS IN PHASE II CARDIAC REHABILITATION. A PRELIMINARY STUDY

Ph Blanc¹, L Mourot², S Chopra¹, Ph Benaich¹, C Freyssin¹, S Maunier¹, A Boussuges³

¹Centre de Reeducation Cardiaque Sainte Clotilde, Sainte Clotilde, Ile de la Reunion;² EA 3920 et IFR133, Universite de Franche Comte, Besancon, France; ³EA 3280, Universite de la Mediterranee et IMNSSA, Marseille, France

Background and Aims: Obstructive sleep apnea (OSA) syndrome is a risk factor for mortality, cardiovascular events, hypertension and diabetes. OSA is very frequent and under-diagnosed in cardiac patient. Thus, a practical screening tool for cardiac rehabilitation (CR) patients is required. In this preliminary study, we prospectively detected patients at high risk of having OSA using both Berlin Sleep Questionnaire (BSQ) and Epworth Sleepiness Scale (ESS).

Methods and Materials: 171 consecutive patients entering a cardiac rehabilitation programme were screened. The BSQ and the ESS was administered simultaneously at the beginning of the programme. CR admissions were due to: coronary artery by-pass grafting (30%), coronary angioplasty/stent (39%), angor pectoris or myocardial infarction (6%), aortic/mitral valve replacement (7%), dilated cardiomyopathy (5%), other (13%).

Results: High risk for OSA was found in 66 patients (39%). 50 patients were detected at high risk of having OSA with the only BSQ, 9 patients with the only ESS and 7 patients with both questionnaires. Characteristics of the high risk patients versus low risk patients were : Age (years) 58.6 vs 56.8, sex female (n) 20 vs 23, heart failure (n) 5 vs 12, current and previous smoking (n) 30 vs 43, hypertension (n) 46 vs 35, diabetes (n) 30 vs 33, body mass index (kg/m2) 29.2 vs 26, glucose (mg/dL) 115 vs 106, LDL cholesterol (mg/dL) 82 vs 83, HDl cholesterol (mg/dL) 43 vs 44, triglycerides (mg/dL) 136 vs 141.

Conclusions: In this preliminary study, screening using Berlin questionnaire and Epworth Scale identify a high prevalence of patients at high risk of having sleep apnea. Screening must be encouraged in cardiac rehabilitation programme. Further investigations are nevertheless required to improve the strategy of screening with procedures that could be complex (overnight oximetry, apnea link, polygraphy).

Poster #5

EFFECT OF THE WII SPORT BOXING VIDEO GAME ON HEART RATE IN CARDIAC PATIENT

Ph Blanc¹, C Freyssin¹, F Riviere¹, L Mourot², S Chopra¹, Ph Benaich¹, S Maunier¹, A Boussuges³

¹Centre de Reeducation Cardiaque Sainte Clotilde, Sainte Clotilde, Ile de la Reunion; ²EA 3920 et IFR133, Universite de Franche Comte, Besancon, France; ³EA 3280, Universite de la Mediterranee et IMNSSA, Marseille, France

Background and Aims: Physical exercise is an important part of the rehabilitation program in cardiac patients. The new generations of active video games allow performing various recreational sport activities at home. However, the cardiac impact of virtual sport activities has been poorly investigated. The purpose of this prospective study was to analyze the heart rate (HR) response of cardiac patients while playing a commercially available gaming system: Wii sports boxing game software.

Methods and Materials: 27 voluntary patients (5 women, 22 men, mean age 50.6 + -13.3 years old) were included in the study after completion of a 6 week cardiac rehabilitation (CR) program. Causes of admission in CR were: percutaneous transluminal angioplasty (33%), coronary artery bypass grafting (19%), valve replacement (15%), dilated cardiomyopathy (11%), other (22%). Patients performed an exercise testing (ET) with gas exchanges measurement at the end of the CR program and before playing video game. The exercise testing allowed the determination of the ventilatory threshold HR and the maximum HR. Participants played competitive boxing matches for 15 minutes, as recommended by Nintendo, with a five minute warm up. HR was recorded using a polar system (S610i) whilst playing Wii sports boxing and compared to ET measures. All participants had not previously used Wii and consented to the study.

Results: During virtual sport activity, mean HR was 106+/-25 bpm and maximum heart rate was 190 bpm. Throughout the HR recordings, 49 + -35 % of the game (8.24 min + -6.22) was performed with a HR above the ventilatory threshold HR (107.0 +/-17.6 bpm). Finally, HR was higher than the ET maximum HR during 9% + -16% of the game (1.52 min + -3.22).

Conclusions: In this preliminary study, the main part of the Wii sports boxing game lead to an HR above the anaerobic threshold, implying an important demand on anaerobic metabolism. Consequently, caution should be recommended to cardiac patients before playing virtual sport activities on video game.

Poster #6

THE IMPORTANCE OF PHYSICAL ACTIVITY MEASUREMENT IN CARDIAC REHABILITATION

CM Blanchard, S Parks, K Lightfoot, N Giacomantonio

Dalhousie University, Halifax, Nova Scotia

Background and rationale: Research examining physical activity (PA) patterns in patients attending cardiac rehabilitation (CR) have relied mostly on self-reported data. Given that pedometers have become cheaper and better validated in recent years, it is important to delineate how much the choice of PA measure may influence the outcomes of a PA trial. Therefore, the present study determined whether self-reported PA and pedometer-based PA had (a) similar percentages of patients meeting PA guidelines, and (b) similar demographic / clinical correlates during CR.

Procedure: Patients completed a demographic / clinical survey during the 3^rd week of CR and a self-reported PA survey during the 2^nd last week of their program, after which they were fitted with a pedometer (Yamax DIGI-WALKER). They were asked to wear the pedometer from the time they woke up until the time they went to bed for 7 days and were given a PA log to record their daily steps. They returned the pedometer, PA log, and survey the following week.

Results: The average age was 61.68 (SD = 9.6), they went to school for approximately 13.25 years (SD = 3.29), their BMI was 29.50 (SD = 5.86), and the majority were male (73%), married (77%), white (96%), and employed (37%). The percentage of patients meeting the PA guideline was 83.1% for self-report (i.e., >= 150 minutes of PA per week) and 67.1% for the pedometer (i.e., >= 6500 steps per day). Logistic regressions showed that patients were more likely to meet the guideline (i.e., >= 150 minutes per week) if they were married vs. other (odds ratio = 2.8) and were in the summer / fall vs. winter / spring (odds ratio = 2.12) seasons for the self-report data. For the pedometer data, results showed that younger (odds ratio = .95), more educated (odds ratio = 1.12), married vs. other (odds ratio = 2.42), summer / fall vs. winter / spring (odds ratio = 2.06), and lower BMI (odds ratio = .92) patients were more likely to meet the PA guideline (i.e., >= 6500 steps per day).

Conclusion: When examining PA during CR, it appears that patients are over-reporting the amount of PA they do when using a self-report PA measure. Furthermore, the relationships between subjective and objective PA measures and demographic / clinical correlates also vary emphasizing the importance of choosing the best measure to identify appropriate target groups warranting a PA intervention.

Poster #7

COMMUNITY SOCIOECONOMIC STATUS, URBAN SPRAWL, AND THE PERCEIVED ENVIRONMENT'S RELATIONSHIP TO PHYSICAL ACTIVITY DURING HOME-BASED CARDIAC REHABILITATION

CM Blanchard¹, D Rainham¹, J McSweeney¹, JC Spence², L McDonnell³, B Reid³, R Rhodes⁴, K McGannon⁵, N Edwards⁶

¹Dalhousie University, Halifax, Nova Scotia; ²University of Alberta, Edmonton, Alberta; ³Ottawa Heart Institute, Ottawa, Ontario; ⁴University of Victoria, Victoria, British Columbia; ⁵University of Iowa, Iowa City, Iowa; ⁶University of Ottawa, Ottawa, Ontario

Background and rationale: Research explaining why patients with heart disease engage in moderate to vigorous physical activity (MVPA) has relied on intrapersonal (e.g., self-efficacy) and interpersonal (e.g., social support from family) correlates and has ignored the potential importance of broader environmental correlates. The present study examined the association between MVPA and urban vs. rural residential status, community socioeconomic status (SES), and the perceived environment in patients attending a home-based cardiac rehabilitation (CR) program.

Procedure: Patients completed a questionnaire assessing demographic and clinical characteristics, MVPA, and the perceived environment (i.e., the availability of home MVPA equipment, access to facilities, and neighborhood characteristics) measured at the beginning and end of a 3-month home-based CR program. Patient addresses were geocoded and linked to the 2006 Canadian census to establish the urban / rural distinction and community SES.

Results: 280 patients were recruited that were primarily male (77%), had greater than a grade 12 education (61.3%), and an average age of 42.8. Multi-level modeling analyses showed that urban and rural patients had similar baseline MVPA and improvements in MVPA by 3 months. However, higher community SES was significantly related to baseline MVPA levels for urban (beta = 1.24, p = .01) and rural (beta = 3.26, p < .001) patients, although it was not related to the change in MVPA. For urban patients, owning an outdoor bike, having access to walking paths and interesting things to look at in their communities was significantly related to increased MVPA. For rural patients, owning an indoor stationary bike and living in a community that had access to many shops and markets, interesting things to look at, and where they saw other people exercising was significantly related to increased MVPA. None of these relationships were moderated by community SES.

Conclusion: Although there does not appear to be an urban advantage in MVPA over rural patients, the perceived environmental correlates of MVPA do vary for urban and rural patients during home-based CR and should be considered in future MVPA behavioral interventions.

Poster #8

THE ROLE OF SOCIAL COGNITIVE VARIABLES DURING HOSPITALIZATION IN PREDICTING FUTURE ATTENDANCE IN CARDIAC REHABILITATION PROGRAMS

Suzanne Ferrier, Chris Blanchard

Dalhousie University, Halifax, Nova Scotia

Background and Aims: Despite the numerous benefits associated with cardiac rehabilitation (CR), uptake to these programs ranges from 15% to 20%. Although various clinical, demographic, and physician referral patterns have been used to explain this, very little research has utilized a theoretical approach to do so. Therefore, the present study used Social Cognitive Theory (SCT) to determine if theoretical differences were apparent in hospital between patients who attend versus those who do not attend CR.

Methods and Materials: Patients were recruited in the hospital and asked to complete a survey that included SCT variables (i.e., barrier and task self-efficacy, outcome expectations, social support, anxiety, depression, and modeling). They were then tracked to determine if they entered CR or not over a 1-year period.

Results: 433 patients, with a mean age of 62 years, were recruited. Of these, 172 (39.7%) went to CR. Significant differences were found such that patients who did not attend CR had more confidence that they could overcome barriers to physical activity (No CR: 60.76; CR: 55.04, p < .05), they had stronger beliefs that they would receive health benefits from engaging in physical activity (No CR: 6.29; CR: 6.08, p < .05), and they were more influenced by seeing others close to them engaging in physical activity (No CR: 5.48, CR: 5.05, p < .01) than the patients who did attend CR. There were no between-group differences in patients' confidence to do physical activity (i.e., task self-efficacy), social support from family and friends, or in patients' anxiety or depression levels.

Conclusions: These findings suggest that theoretical variables (i.e., barrier self-efficacy, outcome expectations, and modeling) measured in hospital may need to be considered in conjunction to other known predictors of CR uptake when designing interventions to increase uptake.

Poster #9

ABORIGINAL PEOPLES WITH CARDIOVASCULAR DISEASE RECEIVE THE GREATEST BENEFITS FROM EXERCISE TRAINING

HJA Foulds, SSD Bredin, DER Warburton

University of British Columbia, Vancouver, British Columbia

Background and Aims: Aboriginal Canadians experience significantly greater CVD-related prevalence and premature mortality rates, and as such are considered a high-risk population. Exercise training is a well-established means of improving health status and reducing risk of mortality in individuals with and without cardiovascular disease (CVD). However, limited information exists regarding the health benefits of exercise training in Aboriginal peoples, particularly individuals with established CVD. This study sought to examine the health benefits of exercise training in Aboriginal Canadian individuals with a history of CVD in comparison to healthy (asymptomatic) Aboriginal and non-Aboriginal Canadian controls.

Methods and Materials: Aboriginal Canadian adult males (n = 6) and females (n = 8) with a history of CVD (age: 53 +/- 13 yrs) completed a 13 week community-based walking program. Additionally, two healthy age, gender, and physical activity-matched control groups: one of Aboriginal descent (n = 14, age: 53 +/- 13 yrs) and of non-Aboriginal descent (n = 14, age: 53 +/- 13 yrs) completed the same community-based physical activity program. Individuals participated in 13 weeks of brisk walking, three times per week in a group within their local community. Health measures evaluated included anthropometry, blood pressure, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, blood glucose, and physical activity frequency.

Results: Aboriginal participants experienced significantly greater increases in physical activity frequency in comparison to their non-Aboriginal counterparts. All groups improved in both systolic and diastolic blood pressure measures, with Aboriginal participants experiencing the greatest improvements. Aboriginal adults with a history of CVD also experienced greater improvements in blood glucose and TC:HDL ratios in comparison to both Aboriginal and non-Aboriginal healthy controls. All three groups experienced similar non-significant improvements in weight, body mass index and waist circumference.

Conclusions: Aboriginal participants demonstrated the greatest improvements in exercise frequency with training. Health benefits were greater in Aboriginal Canadians, and specifically Aboriginal Canadians with a history of CVD in comparison to their healthy counterparts. Within this high-risk population, individuals with a history of CVD appear to particularly benefit from a community-based physical activity intervention.

Poster #10

THE IMPACT OF PRE-MORBID AND POST-MORBID DEPRESSION ONSET ON MORTALITY AND MORBIDITY AMONG CORONARY ARTERY DISEASE PATIENTS: A META-ANALYSIS

Yvonne W Leung, MA¹; David B Flora, PhD²; Shannon Gravely-Witte, MSc¹; Jane Irvine, PhD^1,2, Robert M Carney, PhD³, Sherry L Grace, PhD^1,4

¹Department of Kinesiology and Health Science, York University, Toronto, Canada; ²Department of Psychology, York University, Toronto, Canada; ³Departments of Psychiatry, Washington University School of Medicine, St Louis, Missouri; ⁴University Health Network, Toronto Canada.

Rationale: Depression is common and persistent, with a burden of about 20% among coronary artery disease (CAD) patients. Depression has also been shown to increase cardiac morbidity and mortality in CAD patients. Given this burden, the CACR Guidelines and an AACVPR Position Statement (JCRP, 2005) both endorse identification and referral or treatment of depression in cardiac rehabilitation (CR). Indeed, CR can have ameliorative effects on depression, but paradoxically depression is also one of the major barriers to CR use. Recent evidence suggests that patients with new-onset depression post-CAD diagnosis have worse outcomes than those who had previous or recurrent depression. Understanding which depression timeframes are more prognostic is important in screening and treatment decisions for physicians and CR providers.

Objectives: This meta-analysis investigated timing of depression onset in CAD and CAD-free cohorts to determine what timeframe is associated with greater mortality and morbidity.

Methods: The MEDLINE, EMBASE, and PsycINFO databases were searched systematically to identify articles examining timeframe of depressive episodes or symptoms which specified an endpoint of all-cause mortality, cardiac mortality, re-hospitalization, or major adverse cardiac events (MACEs). A meta-analysis was conducted to estimate effect sizes by timeframe of depressive episodes.

Results: Twenty-two prospective cohort studies were identified. Eight studies investigated pre-morbid depression in CAD-free cohorts in relation to cardiac death. Fourteen studies in CAD-patients examined new-onset depression in comparison to previous or recurrent depression. The pooled effect size (risk ratio) was 0.76 (95% CI 0.48-1.19) for history of depression only, 1.8 (95% CI 1.42-2.29) for pre-morbid depression onset, 2.11 (95% CI 1.66-2.68) for post-morbid or new depression onset, and 1.59 (95% CI 1.08-2.34) for recurrent depression. The results suggest that new-onset depression especially in-hospital may be more predictive of mortality and morbidity than recurrent or pre-morbid depression. However, sensitivity analysis revealed that this finding was subject to the quality of the studies reviewed.

Conclusions: Both pre-morbid and post-morbid depression onset is hazardous to CR clients. The findings also suggest that historical depression may have a protective effect on survival. This might indicate a retention bias in cohort studies. Depression in CAD outpatients is related to 2-times greater morbidity and mortality, which underlines the importance of screening and treating clients within CR programs. An AHA Science Advisory (Circulation, 2008) recommends screening using the Patient Health Questionnaire, which is available at no charge and corresponds to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (APA).

Poster #11

THE RELATIONSHIP BETWEEN BODY IMAGE AND PHYSICAL ACTIVITY IN PEOPLE ATTENDING CARDIAC REHABILITATION

Kathryn A. Lightfoot, BA, Chris M. Blanchard, PhD,

Dalhousie University, Halifax, Nova Scotia

Background and Aims: Increased exercise capacity, as achieved through engaging in sufficient physical activity (PA), is one of the strongest predictors of longevity among people living with heart disease. Unfortunately, there appear to be barriers (e.g., low self-efficacy, poor attitudes and intentions with regards to exercise, depressive symptomology, etc.) to engaging in PA in this population. Another important potential barrier that may impede PA in people living with heart disease is body image. While research in non-clinical populations has shown that people with poor body image tend to engage in less PA than those with a healthy body image, there has been a dearth of research on body image and PA in cardiac patients. The purpose of this study is to determine the relationship between body image and PA over time in people attending CR.

Methods: This longitudinal pilot study consisted of a sample of 31 participants (mean age of 63.74 years, 61.3% male, 96.7% Caucasian), recruited at the beginning of a hospital-based CR program (T1), and followed up three months later at the end of CR (T2). Informed consent was obtained, demographic information was collected, and participants completed self-report questionnaires assessing body image (McKinley and Hyde's Objectified Body Consciousness Scale, 1996) and PA (Godin's Leisure Time Exercise Questionnaire, 1985) at both time points. Pearson correlations were calculated using SPSS version 15.0 to determine the relationship between each of the three body image subscales (body surveillance, body shame, and control beliefs) and PA at each time point.

Results: A significant inverse relationship (r = -.37, p = .043) was found between total minutes of moderate intensity PA at T1, and body shame at T2; that is, those with fewer minutes of moderate PA at T1 tended to report higher body shame at T2. Significant inverse relationships were also found between the number of days of vigorous intensity PA and body surveillance at T2 (r = -.40, p = .027), and days of vigorous PA and body shame at T2 (r = -.45, p = .010).

Conclusion: It appears that there is a relationship between body image and PA in hearts patients attending CR, with lower minutes of moderate intensity PA at the beginning of CR predicting higher body shame upon completion. In addition, both high body surveillance and high body shame at the end of CR were associated with fewer days of vigorous PA at this time point.

Poster #12

ADHERENCE TO A CARDIAC REHABILITATION HOME PROGRAM MODEL OF CARE-A COMPARISON TO A TRADITIONAL PROGRAM

K Naidoo¹, DA Alter², PI Oh³, D Brooks⁴

¹University of Toronto; ²Toronto Rehab; ³Toronto Rehab; ⁴University of Toronto, Toronto Ontario

Rationale: Cardiac Rehabilitation (CR) is recommended for patients living with heart disease. The benefits of CR have been well documented showing an improvement in functional capacity and quality of life and lower mortality rates. Despite these benefits, CR continues to be underutilized and adherence to programs is sub-optimal. Eighty percent of eligible patients are not participating in the service and of those who do participate, 40-50% drop out prematurely. Alternative models of care like the Home Program (HP) have been proven to provide similar outcomes to traditional on-site programs (TP) and have been suggested to help combat this adherence problem. Despite the established effectiveness of the HP, its effect on adherence and the factors that affect adherence have been only briefly examined.

Objectives: The primary objective was to compare adherence of patients in a HP and TP model of CR. The secondary objectives were to compare their profiles and outcomes.

Methods: A retrospective review of 200 consecutively enrolled patients who chose either a TP or HP model was undertaken. Profiles and characteristics were based on information collected at the time of their intake assessment. Anthropometric and exercise clinical outcome data were based on initial and 6-month assessments and adherence data by attendance records and overall compliance determined at discharge.

Results: No significant difference was seen between the home and traditional programs for adherence to pre-scheduled contacts (p = 0.21). The same completion rate was seen when compared between programs (p = 0.22). HP patients were younger (p = 0.01), had more males (p = 0.02), lived farther from the centre (p = 0.02), had more workers (p = 0.007) and had a higher peak V0₂ (p = -0.001) than patients in the TP. No differences were seen in the change of outcomes for functional capacity, BP and depression between programs when entry and 6-month assessments were compared. Weight (p < 0.001), waist measurement (p = 0.002) and percent body fat (p = 0.01) improved more in the TP.

Conclusion: Individuals who chose the HP model of care showed a different profile, showed different changes in body composition but had similar results for adherence and completion of CR when compared to the TP. Further research is needed to determine an optimal design for the HP model and to explore the reasons for drop-out from the HP.

Poster #13

IS SOCIAL INTEGRATION ASSOCIATED WITH EXERCISE INVOLVEMENT IN CORONARY HEART DISEASE PATIENTS?

Sandra Pelaez^1,2, Kim L. Lavoie^2,3,4, Andre Arsenault², Simon L. Bacon^1,2,4

¹Department of Exercise Science, Concordia University; ²Montreal Behavioural Medicine Centre, Montreal Heart Institute; ³Department of Psychology, Universite de Quebec a Montreal; ⁴Montreal Behavioural Medicine Centre, Hopital Sacre-Coeur de Montreal

Background and goal: Exercise (EX) is a crucial component of prevention and recovery from Coronary Heart Disease (CHD). However, CHD patients generally fail to initiate or adhere to EX programs. Social integration has been largely associated with EX adherence and reduced CHD. Building on previous evidence indicating a relationship between the presence of spouse and children and exercise involvement, the aim of this study was to investigate the role of available social networks (defined as kind of people the patient lived with) and a marker of social capital (social trust). The final goal was to compare a measure of social relationships that requires no involvement from the patient's side (i.e., the availability of social networks) and a measure of social relationships that requires patient's active involvement (i.e., the creation and development of social trust).

Method: 493 cardiac outpatients (30% women; Mage = 62.10; SD = 9.32) referred for an exercise stress test at a tertiary care cardiac center were recruited. Patients' demographic, social integration (social networks and social trust), and EX involvement (using the 12 month physical activity recall questionnaire) were assessed.

Results: After controlling for age, sex, total exercise metabolic equivalence of task, and any antecedent of cardiovascular disease, the results indicate that neither living with spouse, nor living with children were positively associated (F = 0.74; p = .391 and F = 1.85; p = .173 respectively). Similarly, there was a no significant relationship between patients social trust and exercise involvement (F = 0.01, p = .916). In the same vein, when the three independent variables (living with spouse, living with children, and social trust) were included in the same model, no relationships were found. However, the interaction between social trust and living with children indicated a trend (F = 2.59; p = .108). Specifically, in those people with children high social trust was associated with high EX No other significant relationship or trend between variables were found.

Discussion: Previous studies examining social networks and EX have mostly focused on the role of partners (or spouses). This epidemiological longitudinal study indicates that partners do not appear to play a significant role in the EX habits of the CHD patients we studied. Results indicate a trend between social trust and living with children.

Poster #14

A PILOT STUDY OF THE RELATIONSHIP BETWEEN DOG OWNERSHIP AND PHYSICAL ACTIVITY DURING CARDIAC REHABILITATION

ML Petter, CM Blanchard

Dalhousie University, Halifax, Nova Scotia

Background and Aims: Research has consistently shown that participation in cardiac rehabilitation (CR) programs increases exercise capacity and reduces subsequent mortality for coronary heart disease (CHD) patients. Despite these promising findings, exercise adherence during and following CR programs remains suboptimal. It is therefore imperative that researchers identify determinants of exercise which may be targeted toward developing more effective exercise interventions. One determinant which has been ignored to date is dog ownership. This is an important oversight as research has generally found that dog ownership is associated with increased exercise. The purpose of this study was therefore to examine whether this relationship holds true in CHD patients attending CR.

Methods and Materials: 96 CHD patients (74% males; mean age: 61.81 (SD = 9.01); BMI 29.37 (SD = 6.19)) attending CR programs in the Halifax region participated in the current study. During the 3^rd week of a 12 week CR program, participants were asked to complete a questionnaire which contained a self-report measure of physical activity (The Godin Time-Leisure Exercise Questionnaire), demographic information, and information related to dog ownership. During the last week of their CR program participants completed the same questionnaire and also wore a pedometer for one week's time to provide an objective measure of physical activity.

Results: Of the 96 participants, 21 (22%) reported owning a dog. Dog ownership was not related to baseline age, years of education, gender, BMI, or self-reported physical activity. Furthermore, dog ownership was not associated with self-reported physical activity at the end of CR. However, dog owners took significantly more steps per day (M = 9429.03 (SD = 6754.44)) than non owners (M = 7266.14(SD = 2987.77) (F(1,94) = 4.59, p < .05). Using hierarchical regression analyses, dog ownership was still a significant predictor (accounting for roughly 4% of the total variance) of steps per day after controlling for age, education, gender, BMI, and baseline physical activity.

Conclusions: Dog ownership was not related to self-reported physical activity at baseline or at the end of CR. However, based on objective measures collected through pedometer recordings, dog ownership was found to be a significant predictor of physical activity, even after controlling for other potentially relevant variables. Dog ownership shows promise as a determinant of PA which may be targeted during CR. More research is needed to determine the nature and extent of this relationship.

Poster #15

RELIABLE CHANGE INDICES TO ASSESS PROGRESS OF INDIVIDUAL CARDIAC REHABILITATION PATIENTS. II. STRESS TESTING: EXERCISE CAPACITY.

PL Prior^1,3, ME O'Connell², NG Suskin^1,3, KL Unsworth¹

¹Cardiac Rehabilitation & Secondary Prevention Program, London Health Sciences Centre, London, Ontario; ²Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan; ³University of Western Ontario; London, Ontario

Background & objectives: This project concerns an innovative application of Reliable Change Indices (RCIs), a statistical method from Psychology, to measure true clinical change of individuals in cardiac rehabilitation (CR). A mean increment of 1 metabolic equivalent (MET) from exercise training has been associated with significantly fewer clinical events in subjects with coronary artery disease; 1 MET might therefore be used as a benchmark of change. Alternatively, 7 METs is sometimes taken as a threshold of functional limitation. Clearly, interpretation of individual change scores may vary considerably depending on change criteria. RCIs may improve reliability and predictive accuracy, as they account for non-treatment variance in change scores, including measurement error and test practice. Following Chelune, RCI = [(x₂-x₁) - (M₂ - M₁)]/[SD₁(2(1-r₁₂)]: x₁ and x₂ are an individual's test scores, M₁ and M₂ are the test means, pre- and post-treatment respectively; r₁₂ is test-retest reliability (stability). RCIs can be used in statistical analyses, or as individual change criteria. For example, RCI >= 1.64 is required to show (p < 0.05, 1-tailed) that an individual has improved. Our objectives were to develop stability estimates for stress test treadmill time (TT) and indirectly determined peak METs, and to illustrate one potential RCI application.

Method: We recruited 42 subjects to take a second stress test 1 week after their usual CR intake stress test (both preceded CR programming), using a modified Bruce protocol with standardized instructions to patients and physicians. We chose this interval to minimize spontaneous recovery or deterioration.

Results: With 32 subjects completing (mean age = 58.8 y; 6 women), test-retest reliability for TT was r₁₂ = 0.955 (p < 0.001); for peak METs r₁₂ = 0.906 (p < 0.001). TT increased significantly (p = 0.001) by 37.4 sec, from M₁ = 13.81 min (SD₁ = 3.26) to M₂ = 14.43 min (SD₂ = 3.04), consistent with practice. Peak METs increased non-significantly (p = 0.062) by 0.48 METs, from M₁ = 9.68 (SD₁ = 3.02) to M₂ = 10.16 METs (SD₂ = 3.28).

Conclusions: TT and peak METs demonstrated very high stabilities, which are therefore good bases for RCIs. To illustrate, an anonymous individual from our CR program gained 3.6 METs from intake to exit. Then RCI_METs = 2.38; using RCI >= 1.64, this individual's exercise capacity improved above and beyond error and test practice (p < 0.05). In contrast, if the significant (p < 0.0001) overall mean increase of 1 MET from the Ontario CR Pilot Project were assigned to an hypothetical individual, RCI_METs = 0.40; we would be unable to say that this person's exercise capacity had increased reliably. We plan to test predictive accuracy of RCIs against clinically important criteria in future research.

Poster #16

WOMEN'S CARDIAC REHABILITATION PROGRAM MODEL PREFERENCES: A PILOT STUDY

Cassandra Racco¹, Shamila Shanmugasegaram¹; Stephanie Brister^2,3; Donna E Stewart^2,3; Paul Oh^4,5; Louise Pilote^6,7; Sherry L. Grace^1,2,3,4

¹York University, Toronto, ON; ²University Health Network, Toronto, ON; ³University of Toronto, Toronto, ON; ⁴Sunnybrook Health Sciences Centre, Toronto, ON; ⁵Toronto Rehabilitation Institute, Toronto, ON; ⁶McGill University Health Center, Montreal, QC; ⁷McGill University, Montreal, QC.

Background: Heart disease is the leading cause of morbidity and mortality in women in Canada. Although cardiac rehabilitation (CR) is effective in improving prognosis for heart patients, women are less likely to adhere to these programs than men. Innovative models of CR care have been developed which may better meet women's needs. Indeed, patient preference is an important factor influencing CR attendance. The objective of this study was to investigate women's preference for hospital-based co-ed, women-only or home-based CR following participation in either hospital-based co-ed or home-based CR, as well as their degree of program participation and satisfaction.

Methods: Within this cross-sectional component of a pilot quasi-experimental study, consenting female cardiac inpatients (age=64.4+/-10.4) recruited from 1 of 2 hospitals were referred to either hospital or home-based CR. 31 participants completed a mailed 9-month post-recruitment survey which assessed CR enrollment, degree of participation, model preferences (co-ed hospital based, women-only hospital-based, or home-based) and satisfaction (5-point Likert scale).

Results: 13 (50%) participants enrolled in the co-ed hospital-based program, 11 (42.3%) did not enroll in any program, and 2 (7.7%) attended the home-based program following referral. Overall, 13 (50%) participants preferred a co-ed hospital-based model, 9 (34.6%) preferred home-based, and 3 (11.5%) preferred a women-only hospital-based CR program. Model preference was significantly related to model attended, with co-ed hospital-based participants preferring the co-ed program model to which they were allocated (60%), and the home-based participants preferring the home-based program model (66.7%, p = .03). Program satisfaction did not significantly differ by program model attended (mean = 3.4 +/- 1.8). Percentage of prescribed exercise sessions attended did not differ between co-ed hospital-based attendees who preferred hospital-based co-ed CR (89% +/- 8.9) versus co-ed attendees who preferred women-only or home-based (58% +/- 53.0; p > .05).

Conclusions: This is the first study to investigate women's preferences for CR program delivery, despite much discussion of the issue in the literature. These preliminary results suggest that women are quite satisfied with the program model they attend, regardless of the model. Replication with a larger sample is warranted, in addition to investigating female patient model preferences before referral.

Poster #17

DEVELOPMENT AND PSYCHOMETRIC EVALUATION OF A THEORY OF PLANNED BEHAVIOUR PHYSICAL ACTIVITY QUESTIONNAIRE FOR INDIVIDUALS AT RISK FOR CORONARY HEART DISEASE

DL Riley, AE Mark, L McDonnell, AL Pipe, RD Reid

University of Ottawa Heart Institute, Ottawa, Ontario

Background and Aims: Physical activity is important for the prevention of coronary heart disease (CHD), a leading cause of death in Canada. Understanding the factors that influence physical activity patterns in individuals at risk for CHD is important. The theory of planned behavior (TPB) may provide insight regarding the underlying beliefs about physical activity. Currently there are few theoretically-based measures of beliefs and intentions regarding engaging in regular physical activity in individuals at risk for CHD. The purpose of this study was to develop an appropriate questionnaire and test its psychometric properties.

Methods and Materials: The current questionnaire was developed for use as part of a randomized control trial of a lifestyle intervention in individuals with a family history of CHD and >=1 additional risk factor. The elicitation questionnaire was administered to a sub-sample of 16 participants, and was comprised of a series of nine open-ended questions related to behavioral, normative, and control beliefs and intentions regarding physical activity. The open-ended responses were coded and analyzed qualitatively. These responses from the open-ended questionnaire were used to develop the response options for the final version of the physical activity questionnaire. A psychometric evaluation of the questionnaire was completed in a separate sample of 10 participants over a two week period. Correlations for each scale (behavioural beliefs, normative beliefs, control beliefs and intentions) were analyzed to assess reliability and Cronbach's alpha was computed to test the internal consistency of the questionnaire.

Results: Qualitative analysis of the open-ended responses led to the development of a questionnaire with 18 items related to behavioural beliefs, 10 items related to normative beliefs, 9 items related to control beliefs and 6 items related to intentions. The correlation coefficients ranged from 0.100-0.909 for behavioural, 0.469-0.913 for normative, 0.108-0.826 for control and 0.179-0.975 for intentions. The internal consistency was good with Cronbach's coefficient alphas of 0.940, 0.903, 0.947 and 0.923 for behavioral belief, normative belief, control belief and intention, respectively.

Conclusions: The physical activity questionnaire based on the TPB was found to be a reliable measure of participants' behavioral, normative and control beliefs and intentions towards engaging in regular physical activity and it is suitable for use in individuals who are at risk of developing CHD.

Poster #18

EXERCISE FOR WOMEN WITH HEART FAILURE: SYSTEMATIC REVIEW

SA Rizza

University of Toronto, Toronto, Ontario

Purpose: Women with heart failure (HF) present a major challenge to the health care system. Women with HF tend to be older in age than their male counterparts and are more likely to be hypertensive, diabetic and have diastolic dysfunction. Studies suggest that women living with HF have a worse quality of life, more dyspnea, worse functional status and more depression but survive longer. The use of exercise as an intervention to improve functional status and symptoms of HF is recommended as a beneficial strategy to improve symptoms for those with HF.

Methods: An electronic search of MEDLINE, CINAHL, Psych Info and The Cochrane Library database was performed. The literature search included selecting online, full text journal articles in English of studies that examined the use of physical exercise and/or cardiac rehabilitation for women with heart failure published within the last ten years (1999-2009). Relevant journals and reference lists of selected articles were reviewed. Studies that excluded those with preserved systolic function, the elderly (over 65 years), and those studies that did not have adequate representation of women were excluded.

Results: Eleven studies were selected that examined the impact of exercise for 659 participants with HF. Nine of the studies examined exercise capacity using various methods of measurement. Four of the studies measured quality of life (QoL). Three of the studies measured adherence while two of the studies reported the impact of self efficacy on exercise. Other outcomes reported include anxiety, depression, anger, hostility, fatigue and dyspnea. Where measured, most studies reported an improvement in exercise capacity, QoL, improved symptoms of HF, and improved adherence rates with self efficacy. Variability in the type and length of the exercise programs, the measurements tools used and study designs was evident. Under-representation of women was apparent in five of the studies.

Conclusions: Research on the use of exercise in women with heart failure is limited. Further research of large randomized controlled trials using consistent measurement tools inclusive of women with preserved systolic HF and reduced LVEF would help to inform the health care community of how women with HF experience the impact of exercise. Practitioners collaborating with multi-disciplinary HF, diabetes and hypertension clinics can work to increase accessibility of exercise programs for women with heart failure. Improving accessibility to cardiac rehab programs can also be achieved through education of health care providers on the safety and benefit of exercise for women with HF.

Poster #19

MEASURING BARRIERS TO CARDIAC REHABILITATION USE: CONCEPTUAL OVERLAP AND UNIQUENESS IN THREE SCALES

Shamila Shanmugasegaram¹, Donna E. Stewart^2,3, Paul Oh⁴, Victoria Chan⁵, Sherry L. Grace^1,3,4,6

¹York University, Toronto, Ontario; ²University Health Network, Toronto, Ontario; ³University of Toronto, Toronto, Ontario; ⁴Toronto Rehabilitation Institute, Toronto, Ontario;⁵ York Central Hospital, Richmond Hill, Ontario; ⁶University Health Network, Toronto and Richmond Hill, Ontario.

Background: Cardiac rehabilitation (CR) is a lifesaving yet underused chronic disease management program. This study investigated the nature of barriers to use, by exploring the component structure and criterion validity of the investigator-generated Cardiac Rehabilitation Barriers Scale (CRBS), with the Beliefs About Cardiac Rehabilitation (BACR) and Cardiac Rehabilitation Enrolment Obstacles (CREO) scales.

Method: 135 cardiac outpatients [45 (33.3%) female; age 64.9 +/- 10.5] from 2 hospitals enrolled in a larger study completed a mailed survey including the 3 scales outlined above. Regardless of CR referral or enrollment, participants were asked to rate their level of agreement with the statements on the three scales. The 21 items of the CRBS were rated on a 5-point Likert-type scale that ranges from 1 = strongly disagree to 5 = strongly agree. The 13 items of the BACR Scale were rated on a 5-point Likert-type scale that ranges from 1 = strongly disagree to 5 = strongly agree. The 15-items of the CREO Scale were rated on a 5-point Likert-type scale that ranges from 1 = strongly agree to 5 = strongly disagree. The CRBS consisted of perceived need/health care factors, logistical factors, work/time conflicts, and comorbidities/functional status subscales. The BACR Scale consisted of perceived necessity, concerns about exercise, practical barriers, and perceived suitability subscales. The CREO Scale consisted of patient-related obstacles and health service-related obstacles subscales. CR utilization was assessed through forced-choice response options to questions about the enrollment (yes/no) and percentage of prescribed CR sessions attended.

Results: Maximum likelihood factor analysis with oblique rotation of the subscales in the 3 scales resulted in a 3-factor solution. Overall, the factors explained about 45.3% of the total variance. Factor loadings revealed that the CRBS, BACR scale, and CREO scale assessed both common and unique barriers. With regard to the latter, the CRBS uniquely assessed work/time conflicts, logistical factors, and comorbidities/functional status. With regard to criterion validity, non-enrollees reported significantly greater barriers compared to enrollees on the CRBS (p < .001) and the BACR scale (p < .05), but not on the CREO scale (p > .05). In addition, only the CRBS was negatively and significantly related to degree of CR participation (r = -.50, p < .01).

Conclusions: The results suggest that while each of these scales assesses common barriers to CR utilization, the CRBS uniquely assesses work/time conflicts, logistical factors, and comorbidities/functional status and it may have the best criterion validity. These scales have been developed for research purposes, and replication of this study would be useful to determine their clinical utility for identification and tackling barriers.

Poster #20

DEVELOPMENT OF THE FRENCH VERSION OF THE CARDIAC REHABILITATION BARRIERS SCALE

Shamila Shanmugasegaram ¹, Donna E. Stewart^2,3, Sonia Anand^4,5, Caroline Chessex^2,3, Robert Reid⁶, Paul Oh⁷, Sherry L. Grace^1,2,3,7,8

¹York University, Toronto, Ontario; ²University Health Network; ³University of Toronto, Toronto, Ontario; ⁴Hamilton Health Sciences; ⁵McMaster University, Hamilton, Ontario; ⁶University of Ottawa Heart Institute, Ottawa, Ontario; ⁷Toronto Rehabilitation Institute, Toronto, Ontario; ⁸York Central Hospital, Toronto, Ontario.

Background: Despite the established benefits of cardiac rehabilitation (CR), it is alarmingly underutilized. This is particularly the case in Quebec, where CR services are not covered through provincial health insurance. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess patient, provider, and system-level barriers for both CR enrollees and non-enrollees. The purpose of this study was to develop and pilot the French version of the CRBS.

Method: Cardiac inpatients from 11 hospitals across Ontario, including in Ottawa and Sudbury that have French-speaking populations, were recruited. One year later, 1808 participants [451(24.9%) female; age 65.4 +/- 10.4; 80.5% retention rate] completed a mailed survey that included the CRBS. Regardless of CR referral or enrollment, participants were asked to rate 21 CR barriers on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree, with higher scores indicating greater barriers. An adapted World Health Organization process for translation and adaptation of the psychometrically-validated English version was undertaken, including forward translation, review and cultural adaptation by a bilingual expert panel, back-translation, and pre-testing in the target population.

Results: 1785 participants completed the CRBS in English and 22 in French. Previously-established subscales in the English version of the CRBS remained internally-consistent in the French version: perceived need/health care factors (Cronbach's [alpha] = .78), logistical factors (Cronbach's [alpha] = .95), work/time conflicts (Cronbach's [alpha] = .88), and comorbidities/functional status (Cronbach's [alpha] = .91). Descriptive analysis showed that the most strongly-endorsed barriers reported by patients who completed the CRBS in English were the following: "I already exercise at home or in my community" (2.87 +/- 1.42), "travel" (2.31 +/- 1.30), "distance" (2.30 +/- 1.41), "work responsibilities" (2.22 +/- 1.28), and "severe weather" (2.21 +/- 1.30). In the French version of the CRBS, the most strongly-endorsed barriers were: "distance" (2.88 +/- 2.03), "I don't have the energy" (2.70 +/- 1.70), "I already exercise at home or in my community" (2.67 +/- 1.61), "travel" (2.50 +/- 1.43), and "I find exercise tiring or painful" (2.45 +/- 1.69).

Conclusion: Overall, results provide preliminary support for the French translation of the CRBS. Future research should psychometrically-validate the French version of the CRBS through factor analysis. In addition, the CRBS should be translated and validated in South Asian languages. Given that French is the second official language and South Asians are the most at-risk cardiac population in Canada (yet are least likely to be represented in CR programs), availability of the CRBS in French and South Asian languages should enable future investigation of cultural and health system differences in CR barriers.

Poster #21

THE QUIT SMOKING PROGRAM (QSP) AT THE UNIVERSITY OF OTTAWA HEART INSTITUTE: DESIGN, PATIENT CHARACTERISTICS AND OUTCOMES.

D. A. Aitken, L. Robert, A. Larue, M. Laroche, H. Tulloch, K.A. Mullen, R. D. Reid, A. L. Pipe

University of Ottawa Heart Institute, Ottawa, Ontario

Background: Quitting smoking is the most important step that a smoker can take for cardiovascular health. Best practice guidelines recommend the use of first-line smoking cessation medications, strategic advice and follow-up support. The Quit Smoking Program (QSP) at the University of Ottawa Heart Institute is a nurse-managed program that assists smokers to quit using these recommended interventions. Here we describe the QSP, characteristics of smokers using the program, and smoking cessation outcomes achieved.

Method: All smokers entering the program from December 2006-2009 were included in the analysis. Smokers attended an information session followed by individual appointments with a tobacco treatment nurse specialist at -2, +2, +5, and +10 weeks relative to a target quit date. Questionnaires including demographics, medical and psychiatric history, and smoking-related and motivational variables were completed. All participants received strategic advice tailored to their individual needs and pharmacotherapy as appropriate. The primary outcome measures included 7-day point-prevalence abstinence. Our results are reported on the basis of an "intention to treat" analysis. Patients lost to follow-up were considered smokers.

Results: Participants (N = 876; mean age = 50.7(+/-11.2) years; 47% male) reported smoking on average 23 (+/-13.5) cigarettes per day. Mean age of first cigarette use = 19.4 (+/-7.1) years. Co-morbidities included hypertension/dyslipidemia (49.3%), respiratory (45.1%), cardiovascular (42.1%), depression (40.9%), gastrointestinal (33.8%), endocrine (24.4%), dermatologic (23.5%), anxiety (23.1%), and cancer (14.0%). Smokers attributed a high level of importance to cessation at the baseline session (mean = 9.4; 0-10 scale), however their confidence level was lower (mean = 6.8; 0-10 scale). First line medications used were nicotine replacement therapy (82.5%), bupropion (7.7%); varenicline (7.1%). On average, participants attended 3 out of 4 sessions. The biochemically confirmed quit rate at the end of the QSP is 18%.

Conclusions: The QSP serves primarily smokers with long smoking histories and high levels of nicotine dependence. These participants are frequently already suffering from tobacco-related illnesses and /or psychiatric illness. Despite these challenges, the program has been able to achieve clinically important improvements in cessation outcomes.