2011 Poster Presentation Winners

More than 30 poster presentations were submitted for the Preventive Cardiovascular Nurses Association's 17th Annual Poster Session at the Annual Symposium in Lake Buena Vista, Florida, March 10-12. There were 2 categories for poster presentations, including Data-Based Research for presentation of original research findings and Innovation in Patient Care for presentation of creative projects/programs in patient care. Listed in the following are the top 3 winners.

Category: Data-Based Research

First Place Winner: Integrative Cardiac Health Project Risk Score Improves Cardiovascular Risk Assessment in Women With Subclinical Atherosclerosis

Elaine Walizer, MSN, Mariam Kashani, CRNP, Arn Eliasson, MD, Marina, Vernalis, DO, Henry M. Jackson Foundation, Rockville, Maryland.

Background: The Framingham Risk Score (FRS) substantially underestimates lifetime risk of cardiovascular disease (CVD), especially in women, when only a 10-year risk model is used. The Integrative Cardiac Health Project (ICHP) Risk Score, which incorporates family history and novel risk factors such as body mass index, waist circumference, diastolic blood pressure, low-density lipoprotein cholesterol, triglycerides, and high-sensitivity C-reactive protein, has been previously validated with carotid intima-medial thickness (CIMT), a surrogate marker for atherosclerosis, in middle-aged men where an increase in ICHP Risk Score was associated with increasing CIMT 0.3%.

Objective: To test the hypothesis that the ICHP Risk Score may improve CVD risk identification in women, we compared risk prediction using FRS and ICHP Risk Score in women with abnormal CIMT.

Methods: A total of 113 nondiabetic female military health care beneficiaries underwent clinical and serologic risk factor screening in a study clinic. All had at least 2 CVD risk factors and subclinical atherosclerosis by CIMT (>75th percentile by age/sex). The FRS and ICHP Risk Score were calculated and compared.

Results: Of these middle-aged (mean age = 54 years; range, 26-81 years), predominately black (50%) women, 4% smoked, 47% were hypertensive, and 81% were dyslipidemic, including 27% with low high-density lipoprotein level, 33% with low-density lipoprotein level greater than 130 mg/dL, and 18% with triglyceride levels of 150 mg/dL or greater. Family history of CVD was positive in 65% and 50% had high-sensitivity C-reactive protein level 0.3 mg/dL or higher. Participants were obese (mean body mass index, 32 kg/m²; mean waist circumference, 100 cm). All participants were identified as low risk by FRS. When the ICHP Risk Score was applied, 60% shifted from low to medium risk classification for CVD (P < .0001).

Conclusions: The ICHP Risk Score dramatically improves CVD risk classification in this cohort of women with diagnosed subclinical atherosclerosis.

Implications: These findings emphasize the need for improved CVD risk identification in women. Family history and other novel risk factors add predictive value to current risk models and identify potential therapeutic targets.

2nd Place Winner: The Relationship Between Self-reported Stress Level and Physiologic Measures of Stress in the Hospitalized Cardiac Patient

Robin F. Johns, PhD, RN, Mary Ellen Quinn, PhD, RN, Georgia Health Sciences University, Athens.

Background: Stress is a common finding in patients hospitalized with coronary artery disease (CAD) and is known to have deleterious effects on patient outcomes. Health care providers frequently rely on subjective reporting of feelings of stress provided by the patient. However, little evidence exists to support the use of self-reported stress level (SRSL) as a predictor of stress-induced physiologic changes in CAD patients.

Objective: One objective of this randomized clinical trial was to examine the relationship between SRSL and physiologic measures of stress to include capillary blood glucose (CBG), heart rate (HR), blood pressure (BP), and rate-pressure product (RPP) in patients hospitalized with CAD.

Methods: Using an experimental design, the effects of a brief relaxation response intervention were tested on physiologic markers of stress to include CBG, HR, BP, RPP, and SRSL. Participants in the experimental group were taught to elicit the relaxation response, whereas participants in the control group were instructed to rest quietly during the study period. Pretest and posttest measures of CBG, HR, BP, RPP, and SRSL were obtained for all participants (N = 48; 75% male; mean [SD] age, 64.6 [10.4] years).

Results: Multivariate and follow-up univariate analyses of covariance demonstrated significant differences between the experimental and control groups (P = .002) in relation to CBG (P = .008), HR (P = .024), and RPP (P = .044). However, there was no significant difference in SRSL (P = .109). Further examination of bivariate correlations demonstrated no correlation between SRSL and physiologic measures of CBG (r = 0.139, P = .346), HR (r = 0.177, P = .229), SBP (r = 0.045, P = .762), and RPP (r = 0.076, P = .609).

Summary: The lack of correlation between SRSL and physiologic measures of stress in patients hospitalized with CAD brings into question the usefulness of reliance on patient self-report in assessing stress level. These findings suggest the need for the development of tools that better assess stress levels in CAD patients.

3rd Place Winner: Unrecognized Cardiovascular Disease Risk Factors in Women

Carolyn Strimike, RN, MSN, APN, Margaret Latrella, RN, MSN, APN, Robert T. Faillace, MD, ScM, FACC, FACP, St. Joseph's Regional Medical Center, Paterson, New Jersey.

Background: The majority of women who experience heart disease have preexisting modifiable risk factors. Identifying and treating these risk factors can potentially reduce the incidence of heart disease in women.

Objectives: The aim of this study was to evaluate modifiable cardiovascular disease (CVD) risk factors in women.

Methods: A total of 1533 women were evaluated for the presence of modifiable CVD risk factors during a comprehensive screening. The women were categorized either by the absence or presence of a primary care physician (PCP), ethnicity, and menopausal status.

Results: The majority of the women in the sample were white (53%) and perimenopausal/postmenopausal (70%, P > .01); 80% (n = 1230, P > .01) had a PCP. Sixty-eight percent (n = 1040) of the total sample evaluated had dyslipidemia; 32% (n = 484) had not been previously diagnosed. Of the women not previously diagnosed with dyslipidemia, 25% (n = 121) did not have a PCP and 75% (n = 363) did have a PCP (P = .001). Forty percent of the total sample had HTN; 7% had not been previously diagnosed. Of the women not previously diagnosed with HTN, 22% (n = 25) did not have a PCP and 78% (n = 88) did have a PCP (P = ns). Twenty-six percent (n = 392) of the total sample were newly diagnosed with metabolic syndrome; 16% (n = 62) of these women did not have a PCP and 84% (n = 330) did have a PCP (P = ns). In women without a PCP, 208 previously unrecognized CVD risk factors were diagnosed; and in women with a PCP, 781 (P = .01).

Conclusion: Common modifiable CVD risk factors are not being routinely identified in women, including those with PCPs. Health care providers need to systematically evaluate for these risk factors, educate, and empower women to take control and reduce their risk for CVD.

Category: Innovation in Patient Care

First Place Winner: A New Registered Nurse/Community Health Worker Health Care Delivery Model Proves to be Cost-Effective in Self-management of Chronic Disease

Linda Heine, BSN, RN, Raymond Neff, ScD, Robin Parks, BSN, RN, Spectrum Health, Healthier Communities and Meijer Heart Center, Grand Rapids, Michigan.

Purpose: The aim of this study was to develop a cost-effective methodology for client management of chronic disease.

Design: Elements of our integrated home-based delivery strategy were based on best practices and innovative thinking: (1) care implementation as assured by the registered nurse (RN), (2) medication reconciliation by RN and adherence followed by RN/community health worker (CHW) team, (3) symptom recognition and early reporting through education and mentoring, (4) connecting the client to community and health resources by the CHW, (5) identification of barriers by the RN/CHW team, and (6) mentored goal setting by the client.

Evaluation and Outcomes: Two populations of low-income and minorities within a structured program of chronic disease management were used to test the model: a mixed group of patients with type I or type II diabetes and all classification types (New York) of heart failure. Individual clients were enrolled into the program and baseline data were collected. The program interventions consisted of monthly home visits with more frequent contact during the initial months. Patients with heart failure were seen within 24 to 72 hours of hospital discharge. Patients with diabetes were referred by multiple community resources/agencies. Cost effectiveness was measured by the change in both emergency department (ED) and inpatient usage patterns. Two follow-up analyses showed a decrease in ED and inpatient utilization. For the cohort with diabetes, ED utilization rate went from 17.0% to 14.2% and resulted in 25.7 (18.6%) fewer ED visits: the inpatient utilization rate for this cohort went from 5.6% to 3.0% and resulted in 23.7 (67.8%) fewer inpatient visits. For the cohort with heart failure, the ED utilization rate decreased from 33.3% to 15.3% and resulted in 42.0 fewer ED visits (a drop of 113.6%); inpatient utilization for this cohort went from 25.8% to 8.6%, a reduction of 210.9%.

Implication for Practice: This experience demonstrates the cost effectiveness of the innovative RN/CHW model.

Second Place Winner: Dyslipidemia Care Management: Utilizing Registered Nurses to Coach Patients on Therapeutic Lifestyle Changes and Manage Statins Reduces Low-Density Lipoprotein

Ted Praxel, MD, FACP, MMM, Kori Krueger, MD, Marilyn Follen, RN, MSN, Melissa Mikelson, RN, BSN, Deb Johnson, RN, BSN, Marshfield Clinic, Marshfield, Wisconsin.

Purpose: The aim of this study was to reduce low-density lipoprotein (LDL) levels through education, motivational interviewing, and physician-approved medication protocols. Despite the documented evidence confirming the effectiveness of lipid lowering for prevention and treatment of coronary heart disease, undertreatment of dyslipidemia is common. By coaching patients to implement therapeutic lifestyle changes (TLC) and self-care strategies, patients are activated to play a role in reaching their LDL goal.

Design: The program is delivered through telephone by registered nurses to patients in a large rural service area. Education and medication management are tailored to patient abilities and treatment plan goals. Focus is on education, patient participation in care, and wellness promotion. Registered nurses titrate statin therapy, counsel patients regarding TLC and medication intervention, and closely monitor appropriate laboratory testing according to physician-approved protocols.

Outcomes: From December 1, 2008, to November 30, 2010, a total of 539 patients were enrolled into the program; 342 patients had an LDL goal of less than 70 mg/dL. Of those patients, 195 (57.0%) reached their LDL goal, with a median time to goal being 100 days. A total of 197 patients had an LDL goal of less than 100. Of those patients, 121 (61.4%) reached their LDL goal, with a median time to goal being 70 days.

On the patient satisfaction survey, 40% of patients enrolled in the program responded "strongly agree" and 60% responded "agree" to the question "My cholesterol is better managed as a result of this program."

Implications for Practice: Care delivery in a consistent, evidence-based manner increases provider confidence in the program. System-wide evidence-based guidelines and protocols support individual patient care plans. Standardized medication titration, close telephone follow-up, and patient activation to implement TLC resulted in improved LDL control. In high-risk patients, LDL control can lower cardiovascular event rates, reduce hospital admissions, and increase patient functional status.

Third Place Winner: Individualized, Task-Specific Cardiac Rehabilitation Training That Safely Exceeds Traditional Heart Rate Limits: A Retrospective Pilot Study

Anne Lawrence, RN-BC, Danielle Strauss, BS, RN-BC, Jenny Adams, PhD, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; Dunlei Cheng, PhD, Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, Texas.

Background: Conventional cardiac rehabilitation (CR) exercise training is not intensive enough to adequately prepare patients for a safe return to physically demanding occupations or sports. Such patients require higher intensity, task-specific training that can be safely performed in a supervised phase II CR setting.

Objective: The aim of this study was to compare peak heart rates recorded during task-specific training with calculated maximum heart rates typically allowed during conventional CR (resting heart rate + 30) in a group of cardiac patients with an uncomplicated postevent course.

Methods: We retrospectively reviewed the charts of 14 patients who chose task-specific training instead of conventional CR (treadmill or bicycle and 1- to 5-lb hand weights) at our facility from 2007 to 2010. Two patients had experienced a myocardial infarction, 3 had PCI, 3 had valve surgery, and 6 had coronary artery bypass graft surgery; 12 were taking [beta]-blockers. The individualized, task-specific program simulates athletic or occupational challenges (e.g., a firefighter dragging a 165-lb dummy) at gradually increasing intensities while blood pressure and heart rate are monitored. A predetermined peak heart rate is not used to limit training.

Results: Patients completed a total of 337 sessions of task-specific training. The mean (SD) peak heart rate across all the sessions (139 [18] beats/min) was significantly higher than the calculated maximum heart rate (114 [39] beats/min; P < .001). No adverse symptoms were reported. Two transient episodes of possible ST-segment depression were seen with telemetry in 1 patient, but he finished the program without incident.

Conclusions: As a group, the patients reached a significantly higher peak heart rate during the task-specific training than would have been allowed during conventional CR, and they did so without adverse symptoms. Although these results cannot be generalized, they support our belief that with careful monitoring, patients who desire higher intensity training can safely exceed traditional limits and reach their fitness goals.

2011 PCNA Annual Symposium Oral Abstract Presentations

The Preventive Cardiovascular Nurses Association awarded the first or coauthors of the winning abstract in each category, Data-Based Research and Innovation in Patient Care, the opportunity to present their abstract at the Preventive Cardiovascular Nurses Association Annual Symposium. The winning abstracts are presented in the following.

Exercise Decreases Fluctuations in 24-Hour Weight Variability in Patients With Advanced Heart Failure

Andrea M. Boyd, PhD, RN, MA/MSN, Veteran's Health Administration; Georgia Health Sciences University, Augusta, Georgia.

Background: Heart failure (HF) is a significant health care concern in the United States, costing an estimated $37.2 billion/year. Fluid volume overload is considered the major cause of hospitalization for decompensated HF. Exercise training (ET) has been linked to various physiological benefits and decreases in HF hospitalization rates, but translational research has not been conducted yet linking ET to fluid instability.

Objectives: The purpose of the study was to determine if a prescribed, progressive home-based aerobic exercise program would alter the physiological processes that maintain fluid balance stability in the advanced HF patient after medical optimization (titration of oral medical therapy with or without the infusion of an intravenous inotrope).

Methods/Designs: This study used a retrospective design utilizing an innovative application of visual analysis with data from 56 men/women 21 years or older who had been diagnosed with HF for over 6 months and had been hospitalized for a decompensation in which they had been classified as NYHA III or higher recruited from a southeastern, large tertiary trauma I teaching hospital, which had an HF and transplant program. Fluid status (daily body weight) and measures of actual exercise (exercise intensity, duration, and frequency) were the primary variables measured during the 24 weeks of the study. The ET intervention was a home-based ET protocol prescribed and progressed over 24 weeks.

Results: A hierarchical multiple regression model significantly predicted daily weight fluctuations within an advanced HF population after medical optimization (R² linear = 0.713, F = 3.224, P = .015). The model determined that exercise intensity (BORG), exercise frequency (days exercised/week), and exercise duration (minutes of exercise/session) directly predicted daily weight fluctuations (standard deviations of daily weights during a week time frame) when controlling for baseline weight fluctuations and event causing exit from the study.

Conclusions: The study demonstrated that ET is a successful adjunctive therapy to managing the fluid status instability of advanced HF patients that is a debilitating aspect of HF.

Preventing Winter Holiday Weight Gain Through Weekly Weigh-ins and Healthy Tips at the Worksite

Heather McCormick,MS, RD, LD, CDE, Susan Nemer, RN, MS, Linda Fester, RD, LD, Jennifer Fralic, RD, LD, LifeCare Alliance, Columbus, Ohio.

Purpose: The average winter holiday weight gain is only 1 lb; however, this pound is not typically lost by the next holiday season. These pounds can accumulate over the years, contributing to increased body weight in adults. Excess weight increases the risk for coronary heart disease, high blood pressure, stroke, type 2 diabetes, and other diseases. We designed a weigh-in program at the worksite to help employees prevent winter holiday weight gain.

Design/Implementation: Employees are invited to participate in a 12-week program starting the last week of October and concluding the second week of January. The registered nurse or registered dietitian visits employees at the worksite to obtain weekly weights and provides weekly tip cards that include health and nutrition information. The focus of the program is for employees to prevent gaining weight during the 12 weeks. Employees who maintain or lose weight and participate in 75% of weigh-ins receive a wellness-related prize. We titled the program "Don't Let the Holidays Get You Stuffed!"

Evaluation and Outcomes: The table represents 445 employees from 4 worksites who participated in the holiday program from 2005 to 2010. Sixty-nine percent of the employees maintained or lost weight during the 12 weeks. Average weight loss was 1.05 lb.

TABLE Yearly and Total Percentages of Participants Who Maintained or Lost Weight and Average Pounds Lost at Program Completion

Implications for Practice: This program can be adapted to multiple settings. It requires a short time commitment, provides weekly contact with a health professional, and offers an avenue for health and nutrition education. Clients gain a sense of accountability for their weight management because of the weekly weigh-ins and the 75% participation goal to attain a prize. LifeCare Alliance continues expanding the program to other worksites.

2011 PCNA Symposium Accepted Poster Abstracts

The year, the Preventive Cardiovascular Nurses Association accepted 34 abstracts in the categories of Data-Based Research and Innovation in Patient Care. Accepted abstract authors were invited to submit a poster for presentation at the 2011 Preventive Cardiovascular Nurses Association Annual Symposium, March 10-12, at Lake Buena Vista, Florida. There were 34 posters submitted. A list of the first-, second-, and third-place poster winners can be found in this issue.

Category: Data-Based Research

Mobile Cardiac Outpatient Telemetry Detects High Incidence of Potentially Serious Cardiac Rhythm Disturbances, Most of Which Are Asymptomatic and Occur More Than 24 Hours After Initiation of Monitoring

Daniel S. Goldman, MD, Beth Kallen, BA, Elsa Kerpi, CCT, Joyce Sardo, LPN, The Cardiology Center Delray Beach Florida and Cardionet, Inc, Conshohoken, Pennsylvania.

Introduction: The ability of standard 24 Holter monitoring and patient-activated event recorders to detect significant CRDs is limited. Mobile Cardiac Outpatient Telemetry (MCOT) (Cardionet Inc, Conshohocken, Pennsylvania) offers full 24-hour surveillance (with continuous technician supervision and immediate physician notification and patient annotation) for the detection of Brady and tachyarrhythmias. CRDs detected can have implications with regard to diagnosis, treatment, need for device therapy, and possible anticoagulation, which, at times, need to be addressed urgently. We hypothesized that MCOT would be effective in uncovering a significant number of CRDs, particularly those that may be asymptomatic or have variable timing and therefore may be missed by other conventional monitors.

Methods: We retrospectively reviewed the demographic data and monitoring results on 56 consecutive patients undergoing MCOT for up to 2 weeks for a variety of indications to document the frequency of significant CRDs, timing of these events after enrollment as well as symptom (Sx) correlation. Significant CRDs included (1) asymptomatic bradycardia less than 40 beats/min or symptomatic bradycardia less than 60 beats/min, (2) pauses of 2.5 seconds or longer, (3) onset of new atrial fibrillation with or without Sx, (4) any SVT with Sx and SVT greater than 150 beats/min without Sx, (5) established atrial fibrillation with rate greater than 130 with or without Sx, and (6) nonsustained ventricular tachycardia 4 beats or more with or without Sx.

Results: The mean age was 74 years, and 30 patients (53.6%) were women. The indication for monitoring included palpitations, n = 22 (39%); syncope/near syncope or dizziness/lightheaded, n = 13 (23%); and paroxysmal atrial fibrillation, n = 9 (16%). Significant CRDs were detected in 36 (64%) patients and included 13 patients (36%) having NSVT, only 1 of whom was symptomatic; 12 patients (33%) with new onset of atrial fibrillation, none of whom had correlated Sx; and 2 patients with asymptomatic pauses of longer than 2.5 seconds. Asymptomatic bradycardia occurred in 2 patients, and 1 patient had symptomatic bradycardia. Significant arrhythmias occurred more than 24 hours after enrollment in more than 90% of the patients.

Conclusions: (1) In this group of MCOT patients, monitoring had a high yield of significant CRDs. (2) Most of these arrhythmias were asymptomatic and occurred more than 24 hours after enrollment and therefore may have gone undocumented using standard Holter monitoring or patient-activated event recorder.

Collaborating Against Disparities: Research From the Campus to Community

Jo Ann Cross, RN, MS, Patricia J. Callahan, RN, Anekwe Onwuanyi, MD, Rigobert Lapu-Bula, MSCR, Adefisayo Oduwole, MD*, Elizabeth Ofili, MD, Morehouse School of Medicine, Atlanta, Georgia; *Grady Health System.

Recruitment of minorities into clinical trials has traditionally been challenging. President Clinton apologized to the African American survivors and family members of the Tuskegee Study, but mistrust still remains high in communities nationwide. Atlanta is approximately 100 miles from the infamous city of Tuskegee, the site of the ill-fated research on syphilis, performed under the auspices of the federal government. The Morehouse School of Medicine's Clinical Research Center (CRC) and the Section of Cardiology, working in collaboration with the Community Advisory Board (CAB), are committed to the transition research from academic medical center to the communities with the objective of promoting participation of minorities and specifically African Americans in trials.

The CRC and Section of Cardiology participate in different forms of clinical research, including population-based, disease-specific health disparities, preventative medicine, and comparative effectiveness research. Among the important goals of community-based clinical research is the elimination of health disparities. The robust enrollment of minorities in clinical studies is 1 of several steps required to achieve this goal.

There is a specialized team in the CRC and a community liaison responsible for recruitment of participants into trials. This recruitment core has developed effective strategies for recruitment of minorities. The clinical trial team, including investigators and study coordinators, is required to have cultural sensitivity training and encourage maximum community participation in their programs. The essence of research and the benefits to the community are properly explained to the community representatives and individual participants. It is often an advantage to have the participation of the clergy and churches as this plays a pivotal role in spiritual, social, and cultural affairs of the community. Research core in collaboration with CAB participates in educational and health fair programs in various settings, which simultaneously provide opportunity for discussion of various research projects. These events typically take place in churches, community centers, salons, and colleges.

Community-based research must engage the community in a partnership role to build trust between researchers and the community; CAB is a critical part of this process. Researchers must be able to explain their proposed research succinctly and address all the concerns of the community. There must be an ongoing dialogue with the community to ensure that there is a channel of communication even if no active trial is going on. This strategy will solidify a healthy and productive relationship between the community and researchers. Another step in building trust is the inclusion of a representative of the community on the institutional review board of the center, which is responsible for reviewing all research protocols to ensure that they are consistent with the guidelines for human subject research.

All of these processes together create new avenues for translation and acceleration of innovations in science to the community.

Correlations Between Body Mass Index, Waist-Hip Ratio, and Waist Circumference to Cardiovascular Risk Factors in Miami Hispanics

Connie Ingram, RN, CCRC, Claudia Correa, ND, LD, Mary Comerford, MSPH*, Maria A. Canossa-Terris, MD, Paul A. Kurlansky, MD, Florida Heart Research Institute, Miami, Florida; *University of Miami School of Medicine, Florida.

Background: Overweight and obesity have been associated with increased risk of cardiovascular disease. Traditionally, body mass index (BMI) has been the most accepted measure. However, recent studies indicate that excess abdominal fat, measured by waist circumference (WC) or waist-to-hip ratio (WHR), may be a better indicator of cardiovascular risk. Hispanics are known to have disproportionately high prevalence of metabolic risk factors (BMI, WC, and lipids), so it is important to begin to characterize the association between these metabolic risk factors and the risk of cardiovascular disease.

Objective: The aims of this study were to assess and compare the correlations of WC, WHR, and BMI to associated cardiovascular risk factors in a sample of Miami Hispanics.

Methods: Between 2009 and 2010, 727 Miami Hispanics (244 men and 483 women) participated in free cardiovascular screenings conducted by Florida Heart Research Institute. Data gathered included measurements of height, weight, waist, hip, blood pressure, fasting glucose, and lipid profile.

Results: Chi-square tests revealed that in women, a BMI of 25 kg/m² or higher was associated with elevated triglyceride levels (>=150 mg/dL; p < .001), hypertension (BP >= 140/90 mm Hg or hypertension medicines; P = .001), and high glucose levels (>=126 mg/dL or diabetes medicines; P < .029). No significant association was seen in men.

In women, WC of 35 in or greater was found to be significantly correlated to high triglyceride levels, hypertension (P < .001), high glucose levels (P = .001), and low high-density lipoprotein (HDL) levels (<=40 mg/dL; P = .004). Among men, WC of 40 in or greater was associated with low HDL (P = .010) and high glucose (P = .036.) levels.

In women, WHR 0.88 or greater was associated with high triglyceride and glucose levels and low HDL levels, for all (P < .001). In men, WHR 0.95 or greater was significantly associated only with high glucose level (P < .001). No studied measure was significantly related to total cholesterol or low-density lipoprotein level.

Conclusion: In this unadjusted, pilot data analysis of Miami Hispanics, WC and WHR appeared to be more correlated with cardiovascular risk factors than BMI is. These results are interesting and suggest that WC and WHR could be important standard anthropometric measures that may help to identify patients at risk of cardiovascular disease who might otherwise not receive healthy lifestyle because of normal BMI. A larger study powered to demonstrate these associations and control for confounders is needed.

Relax a Little! Reducing Stress in Cardiac Rehabilitation Patients

Rebecca Powers, MSN, RN, Suzy T. Fehr, MS, RN, NE-BC, Inova Alexandria Hospital, Alexandria, Virginia; Sari D. Holmes, PhD, Inova Fairfax Hospital, Fairfax, Virginia.

Background: Stress is widely known to exacerbate the development and progression of coronary artery disease. Many patients in cardiac rehabilitation report stress management as one of their goals. Nursing staff adapted a brief version of a progressive muscular relaxation (PMR) technique to assist patients with stress reduction.

Purpose: The purpose of this study was to determine whether patients receiving brief PMR instruction reported lower stress and improved general health after cardiac rehabilitation.

Method: We conducted a 3-year retrospective review of cardiac rehabilitation patients who completed at least 1 session of PMR compared with a control group. Pre- and post-CR Perceived Stress Scale (PSS) and SF-36 General Health scores were compared. Patient characteristics compared included demographics, cardiac risk factors, diagnosis, treatment, and type and resolution of symptoms. Repeated-measures analysis of variance was conducted to assess the effect of PMR on stress.

Results: The PMR group (n = 116) was similar to the non-PMR group (n = 46) in all characteristics, except that fewer African Americans were in the non-PMR group (5.2% vs 17.4%; P < .03). There was a significant PSS reduction for all patients (F = 11.20, P < .002). After adjusting for sex, the PMR group had greater PSS reduction (F = 6.35, P < .02). The effect of PMR was marginally different by sex for PSS change (F = 2.76, P = .10). All patients had significant improvement in SF-36 General Health (F = 15.84, P < .001), although the PMR group improved similarly to the non-PMR group (F = 0.40, P = .53).

Implications: These analyses suggest benefits from the PMR program, but these benefits may differ by sex. Implications for nursing include adding to evidence-based practice by defining who benefits most from the brief PMR intervention and focusing attention and resources to time effective interventions like brief PMR.

The Effect of Daily Hempseed Consumption on Elevated Triglycerides in Middle-Aged Women

Jessica L. Backe, MSN, RN, CNP*, Colleen M. Renier, BS**, Lisa A. Abrahams, MD, FACC, FSCAI*, Julia F. Pattison-Crisostomo, BSN, RN, CCRC**, *Essentia Heart and Vascular Center, Duluth, Minnesota; **Essentia Institute of Rural Health, Duluth, Minnesota.

Background: High triglyceride (TG) levels have been shown to be an independent risk factor for cardiovascular disease, the leading cause of death in women. Multiple alternative treatments exist for high TG levels, most containing omega-3 and omega-6 fatty acids. Hempseed, a grain used as food and medicine in China, Canada, and many European countries, but rarely in the United States, contains significant amounts of omega-3 and omega-6 and may help treat high TG levels. However, there have been no prior evaluative human studies.

Objectives: The purpose of this study was to evaluate the effect of daily hempseed consumption on the TG levels of middle-aged women. Secondary objectives examined hempseed's effects on other lipid parameters, fasting glucose, body mass index (BMI), and blood pressure.

Methods: A 12-week case series was conducted on a randomly selected sample of women aged 45 to 64 years, whose baseline fasting TG level was 150 to 400 mg/dL (n = 19). Women consumed 42 g (approximately 1/4 cup) of hempseed daily. Total cholesterol, TG, high-density lipoprotein (HDL), low-density lipoprotein, glucose, BMI, and blood pressure were measured before and after the intervention. Intent-to-treat analyses used paired t tests to evaluate preintervention-postintervention differences.

Results: Eighteen women completed the study. Intent-to-treat analyses included all 19 women (mean age, 55.5 years; 94% Caucasian). Mean baseline TG levels, BMI, and HDL levels were 214.7 mg/dL, 33.4 kg/m², and 45.1 mg/dL, respectively. After intervention, there were significant mean decreases in TG levels, BMI, and HDL levels of 48.3 mg/dL (P = .011), 0.6 kg/m² (P = .014), and 2.3 mg/dL (P = .026), respectively. No other significant laboratory changes were found.

Conclusion: In this pilot study, unadjusted analyses demonstrated a significant association between daily hempseed consumption and decreased TG levels in middle-aged women. These preliminary results are noteworthy as a reduction in TG levels has the potential to reduce global cardiovascular disease risk. Larger randomized controlled studies of this relatively unknown but potentially valuable grain are warranted.

Risk Factors for Early Postdischarge Sleep Disturbances After Cardiac Surgery

Robbi Cwynar,MSN, RN, Nancy M. Albert, PhD, RN, FAHA, Xiaobo Liu, MS, Kathryn Piccolo, MSN, RN, Cleveland Clinic, Ohio.

Background: Sleep disturbance is a problem after coronary artery bypass graft surgery (CABG); however, little is known about factors associated with sleep disturbance during early convalescence.

Objective: The purpose of this study was to investigate sleep disturbances in CABG patients during early convalescence.

Method: At 7 days postdischarge, sleep disturbances were assessed using the General Sleep Disturbance Scale; and patient characteristics, using a Society of Thoracic Surgery registry. After assessing associations between the overall sleep disturbance and subscale scores, logistic regression with backward model selection was performed to assess associations between sleep disturbance and risk factors.

Results: In 70 patients, mean (SD) age was 68 (10) years and 20% had postdischarge sleep disturbances. Age, history of myocardial infarction, diabetes, stroke and heart failure, obesity, postoperative atrial fibrillation, ventilator hours, length of stay (hospital and intensive care), and some surgical complications were significantly associated with overall and specific sleep disturbance factors univariably. The table here provides predictors of sleep disturbances from logistic regression analyses. Patients taking pain medicines were less likely to have sleep quality disturbances (P = .008), and antidepressants or sedatives were associated with sleep disturbances requiring sleep promotion aides (P = .04).

Table No caption available

Conclusion: Early after CABG, sleep disturbances were not frequent and most were due to nonmodifiable factors; however, reducing weight and using pain medications can improve sleep.

Factors Affecting Program Completion in Phase II Cardiac Rehabilitation

Carrie J. Scotto, PhD, RN*, Donna Waechter, PhD, Jim Rosneck, RN, MS, FAACVPR, Summa Health System, Akron, Ohio, *The University of Akron, Ohio.

Background: Completion of a cardiac rehabilitation (CR) program after a cardiac disease event promotes successful recovery and subsequent cardiovascular health. Attrition rates for CR programs have been reported as high as 65%. Little is known about the attrition population.

Purpose: The purpose of this study was to describe the demographic and clinical variables associated with noncompletion of CR and to identify factors that lead to attrition.

Methods: A comparative retrospective survey design was used to identify differences in demographic and clinical variables between patients who completed CR and those who did not. Prospectively, CR participants who dropped out received follow-up calls to identify reasons for program cessation.

Results: Demographic variables were not significantly different between the attrition group (n = 61) and the control group (n = 58). Having a normal electrocardiogram result during a preprogram stress test (P < .004) and having higher levels of preprogram stress (P < .029) were significant for the attrition group. The most commonly stated reason for dropping out was physical health problems (n = 19, 31%). However, open-ended questions revealed other influential factors, including patients' perception that the exercise component of the program was too difficult (n = 31, 51%) and personal perceptions and negative reactions to the program (n = 6, 10%).

Conclusions: Patients entering CR who present in better physical risk categories with higher home or occupational stress levels may be at risk for dropping out. Cardiac rehabilitation staff should monitor patients early for personal reactions to the program along with their response to physical exercise to address issues that promote program attrition.

Adherence to Diet and Exercise 2 Months After Completing Phase II Cardiac Rehabilitation

Carrie J. Scotto, PhD, RN*, Donna Waechter, PhD, Jim Rosneck, RN, MS, FAACVPR, Summa Health System, Akron, Ohio; *The University of Akron, Ohio.

Background: Nonadherence to diet and exercise significantly increases morbidity and mortality for patients after a cardiac event. Research indicates poor adherence 6 to 12 months after completing cardiac rehabilitation (CR). Adherence in the immediate post-CR period has not been examined and could provide insight to promote early adherence.

Purpose: The aims of this study were to determine participants' knowledge of discharge diet and exercise prescriptions and to identify if knowledge level or select variables were correlated with adherence behaviors.

Methods: Diet Habit Survey and Duke Activity Survey Index scores were assessed for 174 graduates at entry, discharge, and 2 months after discharge. Structured telephone interviews evaluated 2-month adherence behaviors. Selected variables were examined to determine relationships to adherence.

Results: Repeated-measures analysis of variance showed Diet Habit Survey scores and Duke Activity Survey Index scores significantly higher at discharge without significant drift 2 months after the program. However, 77% did not know discharge dietary recommendations; 67% followed their diet sometimes or never; and 44% knowingly stray from their diet 6 to 10 times per week. Knowledge of recommended diet was positively correlated with consistency of following the diet (r = 0.426, P > .000) and negatively correlated with occasional straying (r = -0.456, P > .000). In addition, 68% did not know discharge exercise recommendations; 39% reported less than 3 exercise sessions per week, lasting less than 30 minutes. Knowledge of recommended exercise was positively correlated with exercise frequency (r = 0.677, P > .000) and duration (r = 0.474, P > .000). Small significant correlations were found among the demographic and clinical variables and adherence.

Conclusion: Although CR participants gain and retain knowledge about necessary dietary changes and improve their exercise activity tolerance during CR, most immediately fail to translate the information into lasting behavior changes after completing the program. Research to identify methods that translate knowledge into behavioral change after CR is warranted.

Clinical Outcomes Following Cardiac Rehabilitation in Diabetic Versus Nondiabetic Patients: A Need for More Comprehensive Diabetic Cardiac Rehabilitation

Hormoz Kianfar, MD, Seema Patel, MD, Harmony Leighton, DO, Bharathi Reddy, MD, John Nicholson, MD, New York Hospital Queens, Flushing, New York.

Background: Diabetes is a major risk factor for cardiac morbidity and mortality. Cardiac rehabilitation (CR) has been shown to be beneficial in both diabetic and nondiabetic patients, with significant improvement in exercise capacity. However, because of increased macrovascular and microvascular disease in patients with diabetes, we hypothesize that diabetic patients will have worse long-term clinical outcomes as compared with those without diabetes after completion of the CR.

Methods: We performed an observational cohort study of 178 (54 diabetic and 124 nondiabetic) patients who completed a minimum of 24 weeks of CR from January 2008 to December 2009 at our ambulatory CR center. We defined major adverse cardiac events as death, myocardial infarction, stroke, coronary revascularizations and hospitalization for heart failure or chest pain. A telephone questionnaire was used to determine events during a 16-month average follow-up period.

Results: Indications for CR were similar between the 2 groups, with the exception of diabetics undergoing more coronary bypass grafting (50% vs. 39%; P = ns). The mean (SD) age for the nondiabetic and diabetic patients was 69 (11) years and 66 (9) years, respectively. Twenty-eight percent of the patients in the nondiabetic group were women versus 33% in the diabetic group. Baseline exercise capacity was similar in both groups, and standard CR yielded similar improvements in exercise capacity. During the follow-up period after CR, major adverse cardiac events occurred at a significantly higher rate in diabetic patients as compared with nondiabetic patients (48% vs 25%; P < .05). Diabetic patients had higher rates of hospitalizations (20% vs 10%), myocardial infarction (3.7% vs 1.6%), and revascularizations (24% vs 11%) as compared with nondiabetic patients.

Conclusion: Despite similar improvements in exercise capacity with CR, diabetic patients appear to have worse long-term clinical outcomes as compared with patients without diabetes. Our results suggest the need to identify diabetic patients undergoing CR and target them for aggressive risk reduction management. However, these results are based upon a convenience sample that does not take into account other confounding factors that might affect the clinical endpoint, and more studies are needed to evaluate outcomes in diabetics who undergo CR.

Through the Looking Glass; Clinical Observations From a Community-Based Cardiovascular Screening Program

Denise Goldstein, RN,MSN,APN-C,Mary Collins, RN,MSN, APN-C, Andrea Storper, RN,MSN,APN-C, Pat Delaney, RN, The Valley Hospital, Ridgewood, New Jersey.

Background: Despite pharmacologic and technologic advances, heart disease remains the number 1 killer of both men and women. Although outcomes in women using conventional therapy are poorer than those in men, women benefit tremendously from therapeutic lifestyle changes. Prevention is paramount to decrease the incidence of heart disease in women.

Objectives: After screening 947 women in our hospital-based cardiovascular screening program, we sought to describe and analyze the prevalence of risk factors identified in a predominantly affluent, well-educated, Northern New Jersey population of women. The goal of this analysis was to adjust current practice to better screen and educate these women on risk factor modification.

Methods: Free cardiovascular screenings, including comprehensive history and focused physical examinations were provided to 947 women, aged 24 to 90 years, over a 2-year period. Clinical data relevant to risk for cardiovascular disease were collected and recorded on an excel spreadsheet. This information was tabulated and analyzed to identify the prevalence of specific risk factors in this patient population. Adjustments to current practice in the program were recommended based on these findings.

Results: Analysis of the data revealed that in a study group of 947 women, 55% of patients were identified as having increased body mass index, with 28% having waist circumferences greater than 35 in; 37% of patients were found to have hypertension, with 11% of these newly identified. Of the women, 38% had hyperlipidemia, and 10% had low high-density lipoprotein levels. Two percent were found to be current smokers.

Conclusions: In a predominantly affluent, well-educated population of women, findings varied markedly from national norms with respect to overweight/obesity and smoking, with significantly higher levels of the first and lower levels of the latter. The presence of hypertension and hyperlipidemia were consistent with national norms. Motivational interviewing to encourage risk factor modification has been adopted.

Underrecognition and Ethnic Variations of the Metabolic Syndrome Components in Women

Margaret Latrella, RN, MSN, APN-C, Carolyn Strimike, RN, MSN, APN-C, Robert T. Faillace, MD, ScM, FACC, FACP, St. Joseph's Regional Medical Center, Paterson, New Jersey.

Background: The metabolic syndrome (MS) is a group of interrelated risk factors that can predispose women to cardiovascular disease (CVD) and diabetes. Approximately 23% of adult American women have MS. Research has demonstrated that women with MS have a 33% higher risk of dying or developing CVD than men do. Ethnic minorities are at an increased risk for CVD and should be systematically evaluated for modifiable risk factors.

Objectives: The aims of this study were to evaluate women for the presence of MS and to determine if ethnicity influences MS components.

Methodology: In this study, we evaluated 3084 women for the presence of MS risk factors during a visit to the Women's Heart Center at St Joseph's. Each woman was evaluated for MS using the modified NCEP ATP III guidelines. A total of 892 women (29%) were diagnosed with MS: 250 Hispanic, 264 African American, and 348 white.

Results: Criteria for MS occurred in the following percentages of women: fasting blood sugar greater than 100 mg/dL, 64%; waist circumference greater than 35 in, 84%; high-density lipoprotein less than 50 mg/dL, 61%; triglyceride 150 mg/dL or higher, 62%; and blood pressure 130/85 mm Hg or higher, 77%. Hispanic and African American women were more likely to be diagnosed with MS. Interestingly, of the premenopausal women with MS, 44% were Hispanic. Ethnic variations among MS components were identified but were not statistically significant. If waist circumference had not been measured, the diagnosis of MS would have been missed in 46% of these women. Seventy-six percent of the women we evaluated and diagnosed with MS had a primary care physician and less than 10% of these women had been previously informed.

Conclusions: Unfortunately, many women are not being consistently diagnosed with MS during routine physical examinations. Hispanic women may be at higher risk for MS at a younger age. The health care team can prevent CVD and diabetes through early diagnosis and treatment of MS risk factors.

Walking Employees Heart-Healthy Lifestyle Lessons: Nutrition and Exercise Strategies for Success (WELLNESS) Study

Barbara George, EdD, MSN, RN, Kevin Marzo, MD, Wendy Drewes, BSN, RN, Dipti Patel, BSN, RN, MPH, Ingrid Calliste, MD, Winthrop-University Hospital, Mineola, New York.

Background: Despite the recently popular trend in employee wellness programs, the effectiveness of a hospital-based worksite walking program on cardiovascular disease (CVD) risk for its employees is limited.

Objectives: The main purpose of this study was to see the effect a worksite walking program had on CVD risk factors for hospital employees.

Methods: The WELLNESS study was a retrospective, observational study. Health information that was obtained at the onset of a hospital-wide employee walking program and repeated at 1 year was retrospectively reviewed and compared. This included body mass index (BMI), heart rate, blood pressure, and waist circumference.

Results: Baseline characteristics of 28 participants (mean [SD] age, 43.2 [12.8] years; female, 93%) were compared between onset and 12 months from starting the walking program (Table). The mean (SD) BMI at onset was 27.6 (6.4) kg/m² and at 12 months was 26.9 (5.3) kg/m². The mean (SD) BMI drop was 0.7 (2.1) kg/m² (P = .12). There were no significant changes over time with respect to other risk factors (i.e., blood pressure, heart rate, and waist circumference).

TABLE Mean With 95% CI for Baseline and 12 Months Along With Signed Rank

Conclusion: A trend toward improvements in CVD risk was observed in hospital employees participating in a worksite walking program. The lack of significant findings is most likely due to small sample size. A follow-up study that includes serial educational lectures and cooking demonstrations is currently underway to see if these additional strategies will further improve CVD risk factors for hospital employees.

Testosterone Has Links With Insulin Resistance and Other Cardiometabolic Risk Factors

Sanjay Kapur, PhD, Margaret Groves, MPhil, Sonia Kapur, PhD, David Zava, PhD, ZRT Laboratory, Beaverton, Oregon.

The association of metabolic syndrome or insulin resistance with low testosterone in men has led to interest in testosterone therapy to improve risk.

Cardiometabolic risk markers were tested after overnight fasting in dried blood spots (DBSs), and testosterone was assayed simultaneously in either DBS or saliva. After excluding samples with insulin level greater than 15 [mu]IU/mL (to eliminate diabetics) or high-sensitivity C-reactive protein (hs-CRP) level greater then 10 mg/L (indicative of inflammatory disease, not cardiometabolic risk), 228 samples were available for analysis.

Samples were categorized (in tertiles) by testosterone level: low T (<300 ng/dL in DBS or <40 pg/mL in saliva), normal T (300-800 ng/dL DBS or 40-140 pg/mL saliva), and high T (>800 ng/dL DBS or >140 pg/mL saliva). Current testosterone therapy was self-reported in 1 of 20, 15 of 174, and 24 of 34 participants in the low, normal, and high T groups, respectively; mean (SD) age was 54 (9.5), 50 (11), and 49 (13) years, respectively.

Mean insulin was significantly higher in low T than either normal or high T men; hs-CRP was significantly higher in low T than in high T men; high-density lipoprotein cholesterol was significantly lower in high T than in normal T men; and low-density lipoprotein cholesterol was significantly higher in high T than in low T men. Total cholesterol, triglycerides, and hemoglobin A_1c were not significantly different between groups.

Although oversupplementing with testosterone to supraphysiological levels may affect lipids adversely, normal or high testosterone levels were associated with favorable insulin and hs-CRP levels. Testosterone supplementation should be monitored to ensure that levels remain in a physiological range for optimum cardiometabolic risk benefits.

Prevalence of Smoking Among Patients With Coronary Artery Disease

Bharathi Reddy, MD, Nancy Rullo, MS, Kiseok Lee, MS, RCEP, Donna Cheslik Candy, RN, MSN, John P. Nicholson, MD, New York Hospital Queens, Fresh Meadows, New York.

Background: Smoking remains the number 1 preventable risk factor of coronary artery disease (CAD) and is associated with a significant increase risk of CAD. Although there is greater emphasis in regard to the risks involved with smoking, it still accounts for a greater than 70% death rate. The estimated national average of adults still smoking is 20.6%, and an average of 23.7% range between the ages of 25 to 44 years, 21.9% between the ages of 45 to 64 years, and 9.5% over the age of 65 years.

Objective: The purpose of this study was to document the prevalence of cigarette smoking in younger and older patients with CAD.

Methods: The study sample was composed of 596 adult patients (mean [SD] age, 65.47 [12.02] years) discharged from New York Hospital Queens, a community-based hospital serving a multidiverse population in Queens, New York, after acute myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass surgery in the year 2009. All patients were referred to phase II cardiac rehabilitation (CR) through liaison referral.

Results: Of the 596 patients referred to the CR program, patients were categorized into 2 groups: patients younger than 65 years (n = 278) and patients 65 years or older (n = 318). Risk factor analysis revealed that 54.2% of patients younger than 65 years were still smoking compared with 38% of patients older than 65 years. This is remarkably higher than the national smoking estimates for both age groups. Among both patient groups, smoking was found to be more prevalent in men (88.7% <65 years, 74.8% >65 years) compared with women (11.3% <65 years, 25.2% >65 years).

Conclusions: The results show significant prevalence of cigarette smoking despite attempts to educate the population regarding tobacco and its association with CAD. The high prevalence of cigarette smoking and associated high consequences of CAD needs to be addressed more vigorously in this population. Aggressive strategies including smoking cessation programs need to become an integral part of the CR program.

Category: Innovation in Patient Care

Developing a Community-Driven Referral Process: Implementation of a Community Cardiovascular Disease Risk Factor Education and Screening Program

Jauna Patterson, MSN, NP-C, Gopal Rao, MD, FACC, Lynne T. Braun, PhD, CNP, FPCNA, FAAN, Atlanta Heart Associates, Georgia; Rush University, Chicago, Illinois.

Background: In 2006, the death rate from cardiovascular disease (CVD) in Georgia was 9% greater than the national average. The George Data Summary estimates that nearly 2.3 million Georgians do not know the modifiable risk factors for CVD.

Purpose: This community education/screening program created a new referral process initiated from CVD risk factor identification before the onset of symptoms.

Methods: Community sponsors were recruited to host risk factor education/screening programs. The Heart Disease Fact Questionnaire was used to evaluate knowledge before and after the education component. Participants underwent the following physical measurements: height, weight, blood pressure, waist circumference, electrocardiogram, glucose, and lipid panel. In addition, participants were asked about nutrition, smoking, and physical activity. Modifiable risk factors were identified, and 1-on-1 counseling was tailored to individuals. Satisfaction of the program was assessed. Participants with abnormal electrocardiogram results or multiple modifiable risk factors were referred to primary care or cardiology for follow-up. Revenue generated by new patients seen by the sponsoring cardiology practice during the first 6 months was calculated and compared with program cost.

Outcomes: Sixty-one participants (mean age, 56.9 years; 26% male, 74% female) completed the education/screening program. The average number of modifiable risk factors identified was 2.1. Posttest knowledge of CVD risk factors increased by 8.5% (P = .001). African Americans showed a significant increase in learning (P = .04). Both participants and staff rated satisfaction as good/great. Ninety-three percent of participants were referred to primary care (36%) or cardiology (64%). Of those referred to primary care, 66% followed up; of those referred to cardiology, 44% followed up. In the first 6 months, the revenue was 30% higher than the cost of the program.

Conclusion: A community-driven education/screening program was effective in increasing knowledge and identification of CVD risk factors, and participants were motivated to seek health care prior to the onset of symptoms.

Education for Emerging Cardiometabolic Risk and Disorders

Jean Berry, PhD, APN, University of Illinois at Chicago, Illinois.

In response to the escalating incidence of cardiometabolic diseases, faculty at the University of Illinois at Chicago College of Nursing created a specialty advanced practice nursing (APN) focus. Worldwide, 1 billion adults are overweight, 300 million of whom are clinically obese. Obesity is one escalating cardiometabolic disease; others include type 2 diabetes, stroke, and heart disease, which account for about 60% of all deaths worldwide. The University of Illinois at Chicago College of Nursing's APN focus builds APN knowledge and expertise in assessing and managing patients at risk for or having cardiometabolic disorders. Using the foundations of the existing APN programs, we developed a new Cardiometabolic Advanced Practice Nursing Certificate program, designed to prepare nurse practitioners for practice across all health care settings. The program includes three 3-semester-hour courses focused on the following topics: (1) Cardiometabolic Risk Factors and Disease Development, (2) Metabolic Disturbances in the Older Adult, and (3) Advanced Diabetes Management. Students are admitted to their program of choice and then choose the option of the Cardiometabolic Advanced Practice Nursing Certificate. In addition to meeting the requirements of their core program, they take the 3 cardiometabolic courses; also, one of their required clinical practice must be in a specialty cardiometabolic setting: a clinic that sees a high proportion of patients with cardiometabolic disorders: endocrine, obesity, lipid, and cardiovascular clinics. In addition, students may participate in activities such as Diabetes Camp, cardiometabolic health screening events, standardized patients, interactive case studies, and community presentations on cardiometabolic risks and disease. This program is online, and didactic coursework will be available throughout the United States and, eventually, beyond. Our goal is for APNs to incorporate early prevention screenings and expert interventions into care for all individuals at high risk for cardiometabolic disorders.

Cardiovascular Disease Prevention Tailored for Women: Shared Medical Appointments

Ann M. Rossi, DNP, ACNP, Amy L. Tucker, MD, Anne C. Hedelt, MSN, FNP, University of Virginia, Charlottesville, Virginia.

Cardiovascular disease (CVD) is clinically unique in women and is often underdiagnosed and undertreated. Fortunately, most CVD in women is preventable. The Club Red Clinic at the University of Virginia uses a novel approach to enhance the care of women at risk for or with CVD. Through shared medical appointments (SMAs), Club Red utilizes a multidisciplinary team as well as evidence-based practice to reduce risk factors for CVD in women. The role of the nurse practitioner is that of a health care provider. Club Red provides a unique opportunity for improving patient access, medical and behavioral management, and health promotion education for women.

This retrospective cohort study was done to test the hypothesis that the intervention of SMA encounters improves the outcomes of blood pressure, body mass index, lipid profile, hemoglobin A_1c (if applicable), and patient satisfaction as compared with the general cardiology standard care group with 1:1 encounters from December 2008 to December 2009. Findings included increased patient satisfaction and increased patient access in the SMA intervention group.

Feasibility of Including Limited Mindfulness Training in an Existing Therapeutic Lifestyle Change Program

Nancy S. Saum, MS, AHN-BC, Elaine Walizer, MSN, Marina Vernalis, DO, Henry M. Jackson Foundation, Rockville, Maryland.

Background/Problem Being Addressed: Because mindfulness (the simple act of paying attention to what is happening in any moment-without judgment or criticism) encourages us to take greater responsibility for our choices, a potential role for mindfulness in improving diet and exercise lifestyle habits and behaviors has been suggested. However, most often, mindfulness training occurs as a referral to a separate, time-intensive program.

Description: This presentation describes the novel integration of brief mindfulness training into an existing therapeutic lifestyle change (TLC) curriculum within a cardiovascular risk reduction program. Abbreviated (10-minute) mindfulness practices (mindful eating, body scan, awareness of breath, mindful movement, walking meditation) were successfully incorporated into 12 weekly 1-hour support groups. Over a 2.5-year period, 142 participants met as 30 cohorts, for a total of 360 support group sessions.

Evaluation: All 142 group members participated in the mindfulness practices. On the postcurriculum evaluations (n = 123), the mean participant rating for "meeting personal objectives and expectations" (weight loss and increased physical activity) was 4.6, on a scale of 1 (low) to 5 (high). Stated benefits of the mindfulness practices included relaxation, self-compassion, body awareness, increased patience, improved sleep, greater health consciousness, and better management of time and stress. Thirty-two percent of the respondents also reported incorporating mindfulness practices into their daily lives during the 12 weeks of the TLC program.

Conclusions: Although some participants were indeed skeptical, all were willing to learn about mindfulness and participate in the practices. Many participants reported benefit from even brief exposure to mindfulness principles and practice. A formative evaluation of the TLC program is underway to explore the extent of the positive impact of mindfulness and its influence on participant success.

Implications for Practice: Abbreviated mindfulness training has the potential to augment the benefits of a TLC program. Further studies are needed to demonstrate its efficacy in health promotion.

Literacy-Based Discharge Instructions

Mary Toma-McConnell, RN, MaryClare Prasnikar, RN, MSN, CCRN, Carolyn McGowan, RN, ADN, Ruth Appel, RN, PCCN, Nicole Marsh, RN, MSN, Tara Oxendine, RN, BSN, Jean Dowdy, RN, REX Healthcare, Raleigh, North Carolina.

Purpose: Health literacy is a known mediator of quality patient care and positive health outcomes. Health information is presented at the 10th grade reading level or higher. Average Americans read at the eighth grade level. In Southern states, the reading level can be fourth to fifth grade. The purpose of the study was to recreate text of our current Acute Coronary Syndrome (ACS) Discharge Instructions to fit lower health literacy levels (fifth grade).

Design: A convenience sample of 25 ACS patients was asked to complete a survey comparing revised discharge instructions to the current version between December 2009 and January 2010. Patients were asked the following:

1. Which discharge instruction sheet (current or revised) is easiest to read and follow?

2. Did the information provided help you understand the lifestyle changes you need to make?

The innovation of the project was to have patients comprehend lifestyle changes through the use of effective literacy-based discharge instructions with key points highlighted.

Outcomes/Impact: The stoplight ACS Discharge Instructions were viewed positively by patients. Feedback included material was simple to read and easy to understand. Patients preferred the stoplight format, and information was kept to 1 page. In addition, patients favored brief bulleted, educational information that is worded in an easy-to-read format.

Implications for Practice: The discharge instructions were presented to the Interdisciplinary Service Line Team for approval. The unit-based council implemented an education plan to move the instructions into practice. Our long-term goal is to evaluate discharge instruction materials to incorporate health literacy plain language (fifth grade reading level) and address key educational points to limit the length of instructions. Quality programs supported the formation of an interdisciplinary health literacy committee to educate nurses and health care professionals about the use of plain language and teach-back methodology in the development of patient education materials.

Kenya Heart and Sole Quick Look Guide for Cardiovascular Disease Patient Evaluation

Joelle Chateauneuf, RN, BSN*, Samuel Kimani, RN, MSc, BScN, Anna K. Karani, PhD, MA, BScN, DAN, RN/M/CHN, Jacob Kariuki, RN, BSN, University of Nairobi, Nairobi, Kenya, Eileen M. Stuart-Shor, PhD, APRN, FAHA, FAAN*, *University of Massachusetts, Boston.

Purpose: The aim of this study was to develop a culturally tailored guide for management of cardiovascular disease (CVD) in Sub-Saharan Africa.

Project Description: Morbidity and mortality due to CVD are on the rise in Sub-Saharan Africa. More innovative, culturally appropriate methods are required to assist in early detection, management, and prevention of CVD. The Kenya Heart and Sole project team, composed of clinicians and students from the United States and Kenya, developed a tool to improve the prevention and management of CVD in Kenya (Kenya Heart and Sole Quick look guide for CVD evaluation). This pocket guide is based on the successful Preventive Cardiovascular Nurses Association Lipid Pocket Guide and is meant to be a quick reference tool for clinicians. The pocket guide contains elements of clinical assessment, a schema for risk stratification, lifestyle change recommendations, effective patient-centered communication, and locally available pharmacologic treatments. The tool was piloted among clients who attended a cardiovascular screening in 5 community health centers in Central province of Kenya. The project design uses rapid cycle change methods for practice improvement (plan/do/study/act).

Evaluation and Outcomes: After implementation of the pilot in June 2010, the US/Kenyan team interviewed key stakeholders for feedback regarding the pilot tool, updated their literature search including international treatment guidelines, and solicited expert opinion. Based on this qualitative assessment, several themes that need revision were identified: (1) Treatment guidelines should reflect World Health Organization guidelines as well as US guidelines; (2) the layout of the tool may need to be slightly revised to be more user friendly; and (3) lifestyle change recommendations need additional cultural tailoring.

Implications for Practice: Global risk assessment is important for both prevention and management of CVD; however, due to resource constraints, costly laboratory tests are not feasible in Kenya. This tool is user friendly and culturally tailored, allowing clinicians at the point of service to quickly assess, risk stratify, and appropriately manage individuals with CVD.

How to Improve Compliance in Cardiovascular Risk Reduction Education for the Phase II Cardiac Rehabilitation Patient

C. Joyce Kratz-Klatt, MS, Kootenai Heart Center, Coeur d'Alene, Idaho.

Purpose: The aim of this study was to improve compliance in the education component to reduce risk for cardiovascular disease. Traditionally, phase II cardiac rehabilitation (CR) risk reduction education is held daily or weekly for an additional 30 to 60 minutes before or after exercise sessions. Attendance in these CR educational classes is recommended but is frequently missed by the patients.

Design: A comprehensive Cardiovascular Risk Reduction workbook was chosen and divided into 12 topics of 3 to 6 pages to be reviewed at each class. Patients were given their own workbook to take notes and complete assigned homework. This workbook could be shared with caregivers or kept in the CR facility but should be available for each class period.

Implementation: After the cool-down period of each monitored exercise session and before taking the final blood pressure, patients are instructed to open their workbook to the assigned page. This provides us a captured audience that assures every CR patient receives information to reduce his/her cardiovascular risk. Using these 5 to 10 minutes of education, we are able to complete the entire workbook in 12 sessions or 1 month. Most patients attend 12 to 36 sessions, allowing them exposure to fully understand this information 1 to 3 times before graduation. Because the patient group and staff leader change each month, the topic is presented with a different emphasis depending on the group participation. Education topics are chosen in the workbook based on the specific speaker (dietitian, pharmacist, or social worker), who provides a 45-minute presentation weekly, in addition to our 5- to 10-minute daily workbook review.

Outcome: Patients' satisfaction scores regarding understanding their health and improvement have exceeded 90% since implementing this model of captured audience at the end of each class period. In addition, we are providing best practice for patient education.

The Impact of Cardiac Rehabilitation on Cardiovascular Risk Reduction and Quality of Life

Sara Sariotti, RN, BSN, CDE, Donna Louie, RN, BSN, CDE, FPCNA, Helen Chaknova, RN, MSN, Mills-Peninsula Health Services, Cardiac Rehabilitation, Burlingame, CA.

Purpose: The aim of this study was to determine the degree of cardiovascular risk reduction and quality of life (QOL) improvement on phase II cardiac rehabilitation (CR) patients at Mills-Peninsula Health Services (MPHS) during 2009.

Background: Cardiac rehabilitation is a medically supervised program designed to optimize cardiac patients' physical, psychological, and social functioning, while stabilizing, slowing, or reversing the progression of atherosclerotic processes, thereby reducing death and disability. As a certified American Association of Cardiovascular and Pulmonary Rehabilitation program, MPHS follows established standards of care and core competencies, which mandate education, counseling, and behavioral interventions to improve the individual's cardiac risk profile. The MPHS CR team includes specialty-trained registered nurses, exercise physiologists, and certified diabetes educators, all of whom partner with the CR patient through a multicomponent intervention including 1:1 orientation and monitoring, exercise assessment, group exercise, social support, and patient education.

Methods: During 2009, 120 patients were referred to phase II CR with diagnoses of coronary artery bypass graft surgery, myocardial infarction, stent, PTCA, valve repair/replacement, stable angina, or heart transplant within a 12-month period. Of those, 97 patients completed the program. Data were collected on entrance and exit from the program. The CR intervention included an initial 1:1 orientation with a registered nurse including assessment of risk factors with subsequent modification plan development, verbal and written educational materials, and an exercise prescription/protocol incorporating personal goals. Then, patients were stratified as high, intermediate, or low risk and prescribed 36, 24, or 12 visits, respectively, using the Sutter Health Risk Matrix. Patients attended supervised monitored classes 3 times weekly. To measure success of the intervention, the SF-36 was administered to evaluate the participant's QOL, the "Rate Your Plate" tool was used to evaluate adherence to a low-fat/high-fiber diet, weight and blood pressure were monitored, and evaluation of metabolic equivalents was completed at the third and final visits. Furthermore, lipids, fasting blood glucose, and hemoglobin A_1c were tracked. Evaluation of progress toward risk factor goals and personal goals was performed on visits 10, 22 and 33. Self-report of symptoms was obtained throughout the program. Further counseling was done as needed based upon progress toward outcomes. Lastly, an exit interview was completed to review progress, establish future goals, and discuss risk modification plans after discharge.

Results: Completion of the CR program resulted in positive changes in all areas: diabetes (2.3% overall reduction in hemoglobin A_1c level), prediabetes (65% of patients with fasting blood glucose level >99 mg/dL reached the goal of <100 with lifestyle alone), functional capacity (50% overall increase in metabolic equivalents), exercise adherence (72% achieved home exercise goal, a 12% increase), weight (4% of obese patients reduced body weight by >5%), heart-healthy diet (66% reached goal and 42% of participants improved), blood pressure (86% achieved goal; an 8% improvement), QOL (all categories showed improvement, except general health), symptom reduction (angina, 56%; shortness of breath, 74%; fatigue, 63%). Overall, 74% of the participants achieved 75% to 100% of their personal goals at exit.

Conclusion: All health domains of the patient made moderate to significant improvements, demonstrating the efficacy of CR in cardiac risk reduction and improvement in QOL. Cardiac rehabilitation is a low-cost intervention with a high rate of return on improved overall health and well-being. Incorporating systematic ways to assist patients in making behavioral changes and improving self-efficacy could further improve outcomes.

The Diabetes Detectives: Detecting Unrecognized Diabetes in Patients Admitted to a Heart and Vascular Hospital

Paul St. Laurent, MSN, APRN, ACNP-BC, CCRN, Baylor Heart and Vascular Hospital, Dallas, Texas.

Background: Diabetes is underdiagnosed. About one-third of people with diabetes are unaware they have it, and the average lag between onset and diagnosis is 7 years. A fasting blood glucose (FBG) level of 126 mg/dL or higher and a hemoglobin A_1c level (HbA_1c) of 6.5% or higher are criteria used to diagnose type 2 diabetes. Early identification and treatment are key to preventing diabetes-related complications. Patients had FBG levels 126 mg/dL or higher with no history of diabetes. A process was needed to ensure appropriate treatment and follow-up care.

Implementation: A team was formed to analyze the current process and further understand barriers to identifying patients with unrecognized diabetes. An emerging theme was lack of follow-up for increased FBG levels in nondiabetic patients. Interventions included obtaining FBG levels and, if levels are 126 mg/dL or higher, obtaining HbA_1c level. If the HbA_1c level was 6.5% or higher, the patient was identified as diabetic. Teaching was provided and referral was made for outpatient education. A letter with the FBG and HbA_1c results was given to the patient and mailed to their physician.

Outcome: A pilot was started on May 24 and ended August 6, 2010. Of 339 nondiabetic patients admitted, 15 had FBG levels of 126 mg/dL or higher and HbA_1c levels of 6.5% or higher, meeting criteria for type 2 diabetes. Since then, 24 additional patients have been identified. As a result, a HbA_1c was added to all order sets for patients with a FBG level of 126 mg/dL or higher with no history of diabetes. This resulted in recognition of patients with diabetes who may otherwise have not received appropriate treatment and follow-up care.

Implications for Practice: In 2007, the total costs of undiagnosed diabetes in the United States were $18 billion. For the cost of a fasting glucose and HbA_1c, unrecognized diabetes can be detected; and treatment, initiated. This could have profound effects on patient outcomes.

Motivating Patient Action in Women Through an Activated Hospital and Clinician Network

Kara Briseno, CHES, Spirit Health Group, HeartCaring Program, Virginia Beach, Virginia. Linda Masterson, MBA, Spirit Health Group, HeartCaring Program, Boca Raton, Florida.

Purpose: The complex nature of today's health care environment combined with direct-to-consumer pharmaceutical messaging can create consumer confusion and inaction. Patients can successfully be motivated within a trusted health care environment if evidence-based, consumer-friendly, and sex-sensitive materials are used with positive, action-oriented language. The HeartCaring program's interactive Clinician/Patient Workbook is designed to improve receptivity, utilization, and uptake of consumer cardiovascular disease messaging.

Implementation: The unique HeartCaring Clinician/Patient Workbook prompts examination room dialogue about personal risk and articulates action steps and written goal statements to track patient progress and accountability. Fifty HeartCaring hospitals in 23 states have worked with clinicians for 7 years to:

* Relay personalized risk messages in the examination room through patient discussion using the purse-sized HeartCaring Workbook (90,000 distributed/year through 800 practices).

* Train clinicians how to effectively use guidelines and the clinical algorithm, "Evidence-based Guidelines for the Prevention of Cardiovascular Disease in Women" (Mosca et al).

* Provide accessible screenings and disseminate the multifunctional workbook at health fairs, educational events, and on inpatient floors.

* Share best practices within HeartCaring's learning collaborative of noncompeting hospitals.

* Specialties represented are as follows:

[white circle] Primary care: 42%

[white circle] Obstetrics/gynecology: 20%

[white circle] Cardiology: 14%

[white circle] Other: 24%

Outcomes: Hospitals report effective utilization in various point-of-service patient-teaching opportunities, as documented in individual case studies:

* HeartCaring trained primary care physician-referred women at twice the rate of non-HeartCaring counterparts for cardiovascular testing.

* Sixty-six percent of patients assessed in cardiovascular risk programs were referred for further hospital services or to their primary care physician (over 18 months).

* Nineteen percent of consumers screened by HeartCaring had cardiovascular patient encounters within 12 months.

* Increased referrals for cardiovascular diagnostic testing of women from the emergency department.

* Using workbooks to fulfill stroke and chest pain center certification.

Implications for Practice: Targeted cardiovascular messages from a clinician in the examination room or hospital, coupled with an evidence-based health education tool, have proven successful for women taking action for their cardiovascular disease health.

Carotid Intima-Media Thickness: Refining Cardiovascular Disease Risk Prediction and Evaluating Effects of Lipid Therapies

Amy L. Doneen, MSN, ARNP, Heart Attack & Stroke Prevention Center, Spokane, Washington. Carol M. Mason, ARNP, CLS, FAHA, FNLA, FPCNA, LifeLink Healthcare Institute, Tampa, Florida.

Background: The Preventive Cardiovascular Nurses Association follows national guidelines that determine cardiovascular disease (CVD) risk and treatment by assessing major risk factors (eg, lipids). However, patients at all risk levels may still have atherosclerotic thickening of arteries, as measured by carotid intima-media thickness (CIMT), and may require more aggressive treatment. The CIMT procedure is noninvasive, safe, reproducible, and cost-effective; however, standardization of the procedure may increase its utility to refine CVD risk prediction and evaluate treatment effect.

Objective: The aim of this study was to highlight data from recent clinical trials evaluating lipid-modifying therapy on CIMT.

Methods: A literature review was performed on randomized controlled studies examining the effect of lipid therapy on CIMT. Carotid intima-media thickness was measured by B-mode ultrasound, and changes from baseline in mean CIMT were summarized.

Results: Consistent CIMT readouts were obtained in the listed studies by carefully designed protocols. In the studies evaluated, statin monotherapy significantly inhibited the progression of CIMT/atherosclerosis. Niacin combined with statin or colestipol significantly inhibited the progression or caused regression of CIMT/atherosclerosis (Table).

TABLE Effect of Lipid Therapy on CIMT in Moderate/High CVD Risk Patients

Conclusions: Lipid therapy (niacin and/or statin) can positively affect CIMT. Measuring CIMT can further clarify CVD risk and improve prevention/treatment of atherosclerosis.

The Intersection of the Need for Aggressive Patient-Centered Atherosclerosis Risk Factor Modification, Nurse Scope of Practice, and Preventive Cardiovascular Nurses Association Is the Change Agent That Closes Care Gap Between Medical and Behavioral Care

Patricia Baum, RN, BSN, Lahey Clinic, Burlington, Massachusetts.

Problem: The delivery of life-saving teaching called "Aggressive Risk Factor Management" for persons with coronary artery disease (CAD) frequently becomes a hurried monologue, a lecture. A wholly integrated person who enters the hospital becomes an accidental passive audience, a patient confronted with his/her lifestyle in direct conflict with his/her cardiovascular health and even life itself. In a more therapeutic fashion, this scene should be a patient-centered dialogue. But health care professionals in hospitals oftentimes do not have the time or the empathic compassionate connection to the person.

Evidence-Based Intersection: Evidence-based existential needs from patients are plentiful: "Stress! Are you kidding? His job is killing him!" "I have been praying for a miracle to undue all my bad habits, guess it's too late." The registered nurse (RN) incorporates a philosophy that recognizes an integrated whole person interacting with and being acted upon by internal and external environment and studies and appreciates the interrelationship of bio-psycho-social-spiritual dimensions. The RN scope of practice meets client goals by creating coping mechanisms, reducing stress, and increasing sense of well being. A literature search performed is replete with evidence that nurse-patient interaction reduces morbidity and mortality. The Preventive Cardiovascular Nurses Association is the vehicle to create and distribute worldwide methodology producing RN direct-to-patient independent private-pay consult.

Implications and Implementation: There is no cure for CAD. The RN as witness, teacher, and advocate represents the cure for the care gap between medical and behavioral care when addressing risk factor modification via the vehicle of the Preventive Cardiovascular Nurses Association paving the way for independent RN practice. A template is shared to create National Initiative including collaboration with local government legislators. As the RN workforce ages, this creates RN income and personal and professional fulfillment delivering patient-centered consultation to improve quality and length of life for persons with CAD.