10:30 AM-11:30 AM

Thursday, October 17, 2013

Concurrent Scientific

Oral Presentations

Oral #1EVALUATING EXERCISE CAPACITY SUSTAINABILITY IN HOME VERSUS CENTER-BASED CARDIAC REHABILITATION

A. Ramadi,¹ R.G. Haennel,¹ M. Haykowsky,¹ S.G. Aggarwal,² J.A. Stone,² E. Hitt,² L.D. Austford,² R. Arena,³ B. Martin²

¹University of Alberta, Edmonton, Canada, ²Cardiac Wellness Institute of Calgary, Calgary, Canada, ³University of Illinois Chicago, Chicago, IL, USA

BACKGROUND AND AIMS: While it is known that participation in center or home based cardiac rehabilitation (CR) can improve exercise capacity, the sustainability of this improvement following CR is challenging. The purpose of this study was to compare the immediate and one-year effectiveness of home versus center based CR on exercise capacity and self-reported exercise habits. METHODS: This was a retrospective study of patients enrolled in a large multidisciplinary CR program. A sample of 7,142 patients who completed center based (n=5,647, 60+/-10 yrs, 76% male) or home based CR (n=1495, 57+/-11, 69% male) were included. Participants underwent treadmill exercise testing at baseline, after 12 weeks of CR and again 12 months following CR completion (12 month followup: n=4,310; center based: 3,520, home based: 790). Each exercise test continued until the participant experienced volitional fatigue or symptoms of exertional intolerance. Exercise capacity was then estimated using regression equations. At the three assessment points, a subsample of 5,833 participants (center-based: 4,506; home-based: 1,327) reported weekly time spent in their target heart rate during exercise sessions. Changes in exercise capacity and self-reported exercise time were analyzed using paired t-tests. Changes in exercise capacity and exercise time were compared between programs using un-paired t-tests. The level of significance was set at P <.05. RESULTS: Twelve weeks of center based CR resulted in a larger improvement in exercise capacity compared to the home based intervention (0.9 vs. 0.7 METs, P <.0001). From post-CR to the 12 month followup, the center based CR group demonstrated a significant decline in exercise capacity ([DELTA]=-0.1+/-1.5 METs, P <.0001), while exercise capacity remained unchanged in home based CR participants (P =.065). However, the decline in exercise capacity in the centre based group did not appear to be clinically significant ([DELTA]<1 mL[middle dot]kg^-1[middle dot]min^-1). Following CR, self-reported weekly exercise time increased significantly in both groups (P <.0001) in a similar fashion (P =.452). Both groups showed a comparable drop in exercise time between CR completion and the 12 month followup (P <.0001, center vs. home [DELTA]: P =.803). CONCLUSION: The results of this study imply that both programs were effective in maintaining achieved gains in exercise capacity 12 months following CR. Furthermore, despite the decline in self-reported exercise time at 12 months post-CR, both groups still met the exercise volume recommended by the American Heart Association.

Oral #2ASSOCIATION OF BLOOD PRESSURE AND PHYSICAL ACTIVITY ON CARDIOVASCULAR AND ALL-CAUSE MORTALITY: THE SCOTTISH HEALTH SURVEY

Amanda M. Rossi

Concordia University

BACKGROUND AND AIMS: Physical activity has been shown to be beneficial for the prevention and management of hypertension. In the general population, physical activity has been shown to decrease mortality. The purpose of this study was to examine the combined effects of physical activity and systolic and diastolic blood pressure on fatal and non-fatal cardiovascular events as well as all-cause mortality using a contemporary population based study. METHODS: We used the Scottish Health Survey to examine data from 8747 participants (age: 53.5 years, 57% women) recruited in 1995, 1998, and 2003. Physical activity was assessed via questionnaire. Repeated blood pressure measurements were taken in a seated position. Followup was censored to December 2007. Hospitalization and cardiovascular disease history was acquired through patient-based database. Cause of death was classified according to the International Classification of Diseases, 9^th Revision. Cox proportional hazards models were used to calculated risk of incident cardiovascular disease (fatal and non-fatal events combined) and all-cause mortality. RESULTS: Results indicated that there was a significant trend for systolic (P =.002) and diastolic (P =.009) blood pressure showing that risk of cardiovascular events increased with increasing blood pressure. For example, inactive participants with a systolic blood pressure >=160 mmHg had a higher risk of cardiovascular events (Hazard Ratio=1.45 (95% CI:1.04,2.02)) compared to the reference group (active, blood pressure <120 mmHg). Similarly, a significant trend was observed for physical activity, whereby the active group had consistently lower risk of all-cause mortality in comparison to inactive individuals across all systolic and diastolic blood pressure groups (P <.001). Additional analyses showed that the highest risk of cardiovascular (Hazard Ratio: 2.82 (1.72, 3.02)) and all-cause (Hazard Ratio: 1.73 (1.26, 2.38) mortality was attributed to inactive, hypertensive individuals (P <.001). CONCLUSION: These results extend previous findings for all-cause mortality and show that risk for both fatal and nonfatal cardiovascular events is increased with a combination of both inactivity and higher blood pressure.

Oral #3TITRATION OF NICOTINE REPLACEMENT THERAPY IN SMOKERS: THE MEDIATION EFFECT OF NICOTINE WITHDRAWAL

A. Armstrong,[superscript digit one] R. Reid,[superscript digit one] D.A. Aitken,[superscript digit one] K.A. Mullen,[superscript digit one] H. Tulloch,[superscript digit one] A. Mark,[superscript digit one] V. Testa,[superscript digit one] M. Martin,[superscript digit one] A.L. Pipe[superscript digit one] [superscript digit one]University of Ottawa Heart Institute, Ottawa, Canada

BACKGROUND AND AIMS: Smoking cessation is a life-saving intervention for individuals with vascular disease. Nicotine replacement therapy (NRT) has been shown to double a smoker's chances of quitting, however, there is evidence that the standard dose (21 mg) of transdermal NRT patch is insufficient to alleviate withdrawal symptoms. The objective of the current analysis was to determine if the relationship between nicotine titration and continuous abstinence (CA) at the end of treatment is mediated by nicotine withdrawal. METHODS: Smokers (>10 cigarettes/day) were recruited using media advertisements. Participants were randomly assigned to either the usual care (UC-NRT) group that received 10 weeks of standard dose transdermal NRT, or the experimental (EXP-NRT +) group that received 10 weeks of titrated transdermal NRT and NRT inhaler. All participants received five smoking cessation counseling sessions at weeks 1, 3, 5, 8, and 10 posttarget quit date. Nicotine withdrawal scores were collected at each time point using the Minnesota Nicotine Withdrawal Scale. The primary outcome was validated CA, expired carbon monoxide (CO), at the end of treatment (10 weeks). RESULTS: Two hundred and sixty-two participants were included in the analysis (mean age=48 years+/-11.4). A logistic regression indicated that participants in the EXP-NRT + group had significantly higher quit rates (42.7%) compared to those in the UC-NRT group (29.8%), [chi]² (1, N=262)=4.8, P=.029. Participants in the EXP-NRT + group had significantly lower mean nicotine withdrawal scores over the 10 week treatment period (8.5) versus those in the UC-NRT group (10.7), F (1, 262)=8.2, P=.005. Using the Baron and Kenny mediation procedure, treatment group and nicotine withdrawal were entered into the logistic regression model as predictor variables of 10 week CA, [chi]² (2, N=262)=27.9, P =<.001. The effect of treatment group on CA, when controlling for nicotine withdrawal, was nonsignificant. CONCLUSION: Nicotine titration increased quit rates at the end of treatment compared to those receiving standard dose NRT. Nicotine withdrawal mediated the relationship between nicotine titration and CA at end of treatment. Titration works by reducing withdrawal symptoms, thereby improving abstinence rates.

Oral #4IDENTIFYING PATIENTS AT LOW-RISK FOR ACTIVITY RELATED EVENTS: THE R.A.R.E. SCORE.

Stephen Andrew LaHaye,^1,2 Shawn Paul Lacombe,¹ David Ball,¹ Diana Hopkins-Rosseel^1,2

¹Queen's University, Kingston, ON; Hospital Cardiac Rehabilitation Centre, Kingston, ON

BACKGROUND: Individuals with cardiac disease are known to be at an increased risk of major adverse cardiac events (AEs) during exercise training, yet these events are extremely rare (estimated 16 cardiac arrests¹ and 3-4 myocardial infarctions per-million-patient-hours of exercise. AEs requiring a medical response are much more frequent, occurring in as many as 28% of cardiac rehabilitation (CR) participants. Risk stratification criteria (RSC) to date have demonstrated that they are poor at predicting AEs in "High-risk" individuals (low positive predictive value). We developed the 'Risk of Activity Related Events (RARE) Score' to more accurately identify individuals who are at low-risk of experiencing an AE during exercise. The RARE Score is quantitative, utilizing a simple point-based scoring system to estimate a patient's risk based upon the following variables: resting heart rate, resting blood pressure, functional capacity, ejection fraction, ischemic burden and presence of arrhythmias. PURPOSE: To prospectively assess whether the Risk of Activity Related Events (RARE) Score accurately identifies patients who are at low-risk of experiencing an AE while exercise training at CR. METHODS: Individuals screened for entry into CR were classified as high-risk (RARE Score>=4) or low-risk (RARE Score<4) using the RARE Score. Patients were followed until program completion or withdrawal, and AEs were documented. RESULTS: 656 individuals were eligible for analysis (high-risk: n=260; low-risk: n=396). Eleven events (1 major, 10 minor) were recorded during the study, and the overall event rate was low (1 event per 1,321 patient hours of exercise training). Individuals triaged as high-risk had significantly more events than the low-risk cohort (high-risk: n=8 versus low-risk: n=3, P =.024), and were four times more likely to experience an AE [Odds Ratio: 4.2 (95% CI 1.0-20.0)]. Over 99% of low-risk patients were event free [Negative Predictive Value: 99.2% (CI 98.3-99.8)] while participating in exercise at CR. CONCLUSION: The RARE Score accurately identifies patients who are at low-risk of experiencing AEs during exercise training at CR. The identification of low-risk patients allows for the possibility of reduced on site supervision and monitoring, or the provision of alternative models of CR, including community or home based CR programs.

Oral #5IS TYPE D PERSONALITY A STABLE TRAIT? NOT IF YOU PARTICIPATE IN CARDIAC REHABILITATION!

Heather Tulloch,¹ V. Tasse,^1,2 P. Greenman,² F. Zachariades¹

¹University of Ottawa Heart Institute, Ottawa, Canada, ²Universite de Quebec en Outaouais, Gatineau, Canada

BACKGROUND AND AIMS: Type D (distressed) personality, characterized by the joint tendency to experience negative emotions and withhold these emotions from others, has been linked to poor cardiovascular outcomes, including death. Personality traits are said to be stable, and are not expected to change without intensive intervention. Cardiac Rehabilitation (CR) improves risk-factor outcomes, but little is known about the effect of CR on Type D personality. The purpose of this pilot study was to investigate the prevalence of Type D personality in a sample of patients enrolled in CR, and to determine if the patients' scores on Negative Affect (NA) and Social Inhibition (SI) change over the 3-month CR program. METHOD: At baseline and 3-months (ie, end-of-intervention), CR patients (N=200) completed the DS14, a validated 14-item tool used to assess NA, SI and Type D personality. One-sample t-tests were used to assess if statistically significant changes in NA and SI scores existed in patients identified as having Type D personality. RESULTS: One in 4 patients met the criteria for Type D personality at baseline, while 40% and 46% surpassed the cut off for negative affect and social inhibition, respectively. Of the 50 patients classified as having Type D Personality, scores reduced significantly over time. Mean NA=16.0+/-4.8 at baseline and 12.2+/-5.8 at 3 months (P =< .001). Mean SI=15.1+/-4.0 at baseline and 13.6+/-5.5 at 3 months (P =<.001). CONCLUSIONS: Patients with distressed personalities gain additional benefit from CR. This finding is important due the previously established link with Type D personality and poor cardiovascular prognoses. Our results challenge claims that Type D personality is a stable trait, and suggest it is amenable to change. Future research should investigate whether specific distress management programs in CR would further reduce distress levels and subsequent cardiovascular outcomes.

Oral #6MEASURING POSTURAL BALANCE IN PATIENTS WITH CARDIOVASCULAR DISEASE

L. Martelli,¹ D.K. Saraswat,¹ N. Giacomantonio,² S.A. Grandy^1,2

¹Dalhousie University, Halifax, Canada, ²Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Canada

BACKGROUND AND AIMS: Research has shown that patients with cardiovascular disease (CVD) have decreased levels of postural balance. Thus, levels of balance should be assessed prior to designing cardiac rehabilitation (CR) exercise programs. However, typical methods used to assess functional balance (eg, Berg balance scale) may not be sensitive enough to detect changes in postural balance due to the wide range of functional ability in these individuals. Thus, a more discrete tool is required to assess balance in this population. The Community Balance and Mobility Scale (CBMS) may be the most suitable assessment technique as it is able to detect subtle changes in postural balance. However, it has not been previously used with CR patients. The purpose of this study was to assess the psychometric properties of the CBMS as well as characterize postural balance in patients participating in CR programs. METHODS: Twenty-four participants were recruited from local CR programs. Study participants performed the CBMS as well as and computerized dynamic posturography measures performed on the Neurocom Pro Balance Master. Since the CBMS is usually administered by a trained physiotherapist (PT), the inter-rater reliability of PT and non-PT scores was examined in a subset of this group (n = 8). Floor and ceiling effects were assessed to determine the suitability of the CBMS for a cardiac population. Dynamic posturography assessments also were analyzed to further characterize the balance of patients participating in CR programs. RESULTS: The results showed that PT and non-PT CBMS assessment scores were strongly correlated (r = 0.95) and showed minimal bias (mean difference = 0.625). The differences in the scores between PT and non-PT fell within the calculated 95% limits of agreement (maximum difference =+/- 7). No floor or ceiling effects were observed for the CBMS (64 +/- 14, minimum = 21, maximum = 85). Dynamic posturography assessments showed that CR patients had the slowest movement velocity, lowest directional control, and least limits of stability in the anterior and posterior directions. These impaired balance capabilities in the anterior and posterior directions may contribute to the overall decreased levels of balance in CVD patients. CONCLUSIONS: The findings of this study demonstrate that the CBMS is a suitable field assessment technique that can be reliably administered by non-PTs to assess postural balance in individuals with CVD. Thus, the CBMS represents a novel assessment technique that can be used to assess and monitor postural balance in patients participating in CR programs.

Oral #7PHYSICAL ACTIVITY ACROSS THE HEART FAILURE CONTINUUM

Yavari,¹ M.J. Haykowsky,¹ A. Ramadi,¹ J.R. Dyck,² M.E. Irwin,² R.G. Haennel¹

¹Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada, Acknowledgment-²Alberta HEART, AI-HS Interdisciplinary Team

BACKGROUND AND AIMS: It is recognized that as patients develop heart failure (HF) their maximal exercise capacity declines. However, the impact of developing HF on daily physical activity remains unknown. The purpose of this study was to evaluate physical activity across the AHA/ACC HF continuum. METHODS: 84 participants (Age: 68 +/- 9 yrs. 55% male.) were recruited from the Alberta HEART Study and categorized into the following groups: Healthy controls (n = 20); at risk patients (n = 15), coronary artery disease patients (n = 8), systolic HF (n = 26), and diastolic HF (n = 15) Participants wore a multi-sensor tri-axial accelerometer (SenseWear(TM) Mini Armband) for four consecutive days (including 2 weekend days). The amount and intensity of physical activity for each minute of each day was recorded and categorized in as sedentary time (<=1.5 METs), time spent in mild (1.6-2.99 METs), moderate (3-4.99 METs) and vigorous (>=5 METs) physical activity. Data were analyzed using ANOVA and ANCOVA to determine differences between groups with matched and unmatched covariates (ie, age and gender) respectively. results After controlling for age and gender, mean+/- SD physical activity energy expenditure (PAEE >1.5 METs) was significantly lower in the systolic HF group (mean 783+/- 379 Kcal/day) versus healthy controls (1,271+/-479 Kcal/day; P = .003). The systolic HF group also took fewer steps each day (2,788+/-1,808 steps/day) than either the at-risk patients (6,601+/-2,878 steps/day) or the healthy controls (6,405+/-3,187 steps/day; P = .000 for both). A similar observation was seen for the diastolic HF group (3,167+/-2088 steps/day; P = 0.003 vs. healthy controls or at-risk patients). Waking sedentary time, (sedentary time minus sleeping time) was greater for both the systolic (772+/-100 min/day; P = .000) and diastolic HF (725+/-69 min/day; P = .02) groups compared to healthy controls (626+/-83 min/day). However, there were no differences in PAEE and steps or waking sedentary time between the 2 HF groups. CONCLUSION: These results show a decline in an objective measure of daily physical activity across the HF continuum from healthy controls through to systolic and diastolic HF patients.

Oral #8IMPROVING CARDIOVASCULAR HEALTH IN FAMILY MEMBERS OF PATIENTS WITH HEART DISEASE: A RANDOMIZED TRIAL

Robert D. Reid,¹ Lisa A. McDonnell,¹ Dana L. Riley,¹ Amy Mark,¹ Lori Mosca,² Louise Beaton,³ Sophia Papadakis,¹ Chris M. Blanchard,⁴ Heidi Mochari-Greenberger,² Patricia O'Farrell,¹ George A. Wells,¹ Monika E. Slovenic D'Angelo,¹ Andrew L. Pipe¹

¹Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, ²Preventive Cardiology, Columbia University Medical Center, New York, New York, USA, ³North Bay Parry Sound District Health Unit, North Bay, Ontario, ⁴Dalhousie University, Department of Medicine, Halifax, Nova Scotia, ⁵Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa

BACKGROUND AND AIMS: We conducted a randomized trial to determine whether a family heart health (FHH) intervention would improve coronary risk factors in family members of patients with coronary heart disease. METHODS: Four hundred twenty-six participants completed a coronary risk factor assessment and were randomized to FHH intervention (n = 211) or usual care (UC) (n = 215). FHH participants received feedback on baseline risk factor levels, goal setting assistance, and ongoing cognitive-behavioural counseling for 12 months. Reports and recommendations were forwarded to their primary care physician. UC participants received brief advice and print materials. Primary outcomes were changes in: total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio; levels of physical activity; and intake of fruits and vegetables. Secondary outcomes were changes in: other lipids; fasting glucose; blood pressure; smoking status; waist circumference; and body mass index. RESULTS: TC/HDL improved during follow-up but there was no difference between groups. FHH participants made greater improvements in physical activity (mean difference 36.7 minutes/week, 95% CI 10.6 to 62.8 minutes/week), and consumption of fruits and vegetables (mean difference 1.2 servings/day, 95% CI 0.6 to 1.8 servings/day). Among smokers, verified abstinence was higher in FHH compared to UC (30.0% vs. 5.3%; P = .04). FHH participants also showed greater improvements in fasting glucose, body mass index, and waist circumference. CONCLUSION: Physical activity levels, fruit and vegetable intake, rates of smoking cessation, fasting glucose levels, and measures of adiposity improved with a family heart health intervention. The intervention is an important adjunct to primary care.

Oral #9EXERCISE PRE-HABILITATION FOR ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY PATIENTS

D. Scott Kehler,^1,2 Jo-Ann Sawatzky,³ Rakesh C. Arora,^1,4 Todd A. Duhamel^1,2

¹Institute of Cardiovascular Sciences, St. Boniface Hospital Research Centre. ²Faculty of Kinesiology and Recreation Management, ³ Faculty of Nursing, University of Manitoba. ⁴Faculty of Medicine, University of Manitoba. Winnipeg, MB, Canada

BACKGROUND AND AIMS: Patients with cardiovascular disease and low levels of physical fitness have an increased risk of mortality, as compared to patients with higher levels of physical fitness. However, the current standard of care is to refer cardiac patients to exercise therapy plus cardiovascular health education classes after cardiac surgery. Therefore, the purpose of this randomized controlled trial was to determine whether a preoperative cardiac "pre-habilitation" (Prehab) program improves the health of elective coronary artery bypass graft (CABG) surgery patients to a greater extent than standard care (StanC). METHODS: Seventeen elective CABG patients were randomized to StanC (n=9) or Prehab (n=8). Data was collected at baseline, 1 week preoperatively (Preop), and 3 months postoperatively. Our primary outcome was a change in walking distance using the 6-minute walking test. Secondary outcome variables included a 5-meter gait speed test and physical activity assessed by accelerometry. RESULTS: Fifteen cardiac patients completed the study (StanC, n=7; Prehab, n=8). Total number of sessions attended was 19+/-7 over 8+/-2.2 weeks preoperatively for the Prehab cohort. No adverse cardiovascular events occurred from Prehab participation. Walking distance at baseline was 337+/-20 meters in StanC and 342 +/-28 meters in Prehab (ns). Walking distance remained unchanged in StanC over time, whereas Prehab increased their distance by +132 and +145 meters at Preop and 3 months postoperatively, as compared to baseline (P <.05). Gait speed at baseline was 5.3+/-0.3 seconds in StanC and 5.5+/-0.6 seconds in Prehab (ns). Although gait speed was unchanged in StanC at each subsequent time point, Prehab improved gait speed by 27% and 33% at Preop and 3 months postoperatively, respectively (P <.05). Complete data from 4 Prehab patients that wore an accelerometer at each time point indicate a 384% increase in moderate to vigorous physical activity from baseline to Preop (37+/-25 minutes per week vs. 216+/-81 minutes per week, P <.05), but returned to baseline levels 3 months postoperatively. Enrollment in cardiac rehabilitation 3 months post-operatively was 43% in StanC and 100% in Prehab (P <.05). CONCLUSION: These data provide evidence of the efficacy of Prehab to improve the health status of patients waiting elective CABG surgery and to enhance cardiac rehabilitation utilization postoperatively.

Scientific Poster Presentations

Saturday, October 17, 2013

CACR Showcase

Posters available for viewing:

10:00 AM-3:30 PM

Friday, October 18, 2013

CACR Showcase

Posters available for viewing:

9:00 AM-4:30 PM

Scientific Posters

Poster #1SEDENTARY, LIGHT, AND MODERATE TO VIGOROUS PHYSICAL ACTIVITY DURING CARDIAC REHABILITATION: PRELIMINARY RESULTS FROM THE ENVIRONMENTAL CORRELATES OF CARDIAC REHABILITATION (ENCORE) STUDY

C.M. Blanchard, D. Rainham, N. Giacomantonio, Dalhousie University, Halifax, Nova Scotia, Canada

BACKGROUND: Despite the well known benefits of physical activity (PA) for heart disease patients, little is known about the activity levels of cardiac rehabilitation (CR) patients from an intensity perspective utilizing an objective measure (i.e., accelerometer). Therefore, the present paper examined how much sedentary, light, and moderate to vigorous physical activity (MVPA) CR patients engaged in early in their program. PROCEDURE: Once ethical approval was received from each of the 3 participating sites, patients were approached during their first PA session of the 3^rd week of their CR. If interested, they were consented and completed a baseline survey, after which they wore an acceleromter + GPS unit for 7 days. The same procedure was implemented at the end of CR, however, as this is an ongoing trial, not enough patients have reached this phase yet to present data. RESULTS: To date, 164 patients have agreed to participate and wear both devices. The sample was primarily <65 yrs (55.3%), male (74.8%), married/common-law (79.6%), white (95.3%), >grade 12 (78.6%), not employed (66.0%), obese (43.4%), and had at least 1 comorbidity (60.6%). The number of "bouts" (i.e., at least 10 minutes with a 2 minute tolerance) was calculated for each intensity, after which the total time in bouts >=10 minutes and bouts <10 minutes was calculated. Results showed that patients averaged 80.24 bouts of sedentary activity per week (total time in >=10 minute bouts=2048.82 minutes), 2.64 bouts of light activity (total time in >=10 minute bouts=35.82 minutes), and 4.35 bouts of MVPA (total time in >=10 minute bouts=91.61) with only 24% of patients meeting the CACR PA recommendation (ie, >=150 minutes of MVPA per week). Finally, for bouts <10 minutes, patients averaged 2402.09 minutes per week of sedentary activity, 720.15 minutes in light activity, and 140.95 minutes of MVPA. CONCLUSION: Over 80% of CR patients' time early in their program is spent in sedentary activity with only 4% in MVPA. These results highlight the need for behavior modification aimed at increasing PA levels in CR patients.

Poster #2STRATEGIES TO INCREASE CARDIAC REHABILITATION ENROLLMENT: A NARRATIVE REVIEW

S.L. Grace,^1,4 C. Andraos,¹ R. Britto,² N. Suskin³

¹York University, Toronto, Canada, ²Federal University of Minas Gerais, Belo Horizonte, Brazil, ³London Health Sciences Centre and Western University, ⁴University Health Network

BACKGROUND AND AIMS: Although cardiac rehabilitation (CR) is effective in improving patient prognosis, CR is underutilized. The last Cochrane review (Davies, 2010) identified three successful interventions to increase patient uptake. The objective of this study was to review the literature on strategies to increase CR enrollment since the Cochrane analysis. METHODS: Inclusion criteria for this narrative review were based on those used in Davies et al., except non-randomized studies were included. A limited literature search on PubMed, Scopus, ProQuest, CINAHL and Embase for publications between June 2008-March 2013 was undertaken. The primary outcome was patient enrollment. RESULTS: Eleven studies were included, of which 3 were randomized controlled trials. Mazzini (2008) assessed the impact of the "Get-with-the-Guidelines" clinical pathway, and reported a trend towards greater enrollment (33%) with null findings (P =.08). Grace (2013) reported that pre-approval for automatic referral was related to significantly greater enrolment compared to wards without preapproval (65.2% vs. 39.8%; OR=2.91, 95% CI=2.20-8.85). Mueller (2009) reported a significant increase in enrolment using computerized referrals (47-53%; OR=1.49, 95% CI=1.11-1.99). Johnson (2010) automatically referred all eligible patients and reported that referrals by CR nurses significantly increased enrollment (OR=3.40, 95% CI=1.74-6.64). Five studies (Grossman, 2010; Grace, 2012; Cossette, 2012; Parker, 2011; Pack, 2013) assessed the effect of early patient education or contact on enrollment. Grossman reported that outpatient early patient contact was related to significantly greater enrollment (0%-88.2%, P <0.001). Cossette reported that combined inpatient and outpatient education significantly increased enrollment compared to usual care (45% vs. 24%, p = 0.001). Grace (84.1% vs. 52.9%; OR = 4.85, 95% CI = 2.96-7.95) and Pack (77% vs. 59%; RR=1.56, 95% CI=1.03-2.37) reported significantly greater enrollment where early outpatient education was offered. Parker reported that an early access clinic increased enrolment from 37.1%-96.3% (P <.0001). Several studies applied multiple strategies. Tiller (2013) showed that enrollment increased from 15.5% (usual referral), to 26.7% (automatic referral), to 32.6% (addition of CR inpatient discussion at bedside). Grace (2011) reported that a combined automatic and liaison referral resulted in the greatest rates of enrollment compared to usual referral (74.0% vs. 29.1%; OR=4.45, 95% CI=1.98-10.00), however each approach alone was also related to greater enrolment (60.7% and 50.9% respectively). Higgins (2008) implemented a combination of interventions, and demonstrated 72% enrollment. CONCLUSION: CR discussions at the bedside, systematized referrals (including preapproval), and early outpatient contact significantly increased patient enrollment in CR, to upwards of 80%.

Poster #3INSOMNIA SYMPTOMS ARE NOT ASSOCIATED WITH ADHERENCE TO A PHASE-II CARDIAC REHABILITATION PROGRAM

C.R. Rouleau,¹ K.J. Horsley,¹ E. Morse,² T. Hauer,² S. Aggarwal,² R. Arena,^2,3 T.S. Campbell¹

¹Department of Psychology, University of Calgary, Calgary, AB, Canada; ²Cardiac Wellness Institute of Calgary; Calgary, AB, Canada; ³University of Illinois Chicago, Chicago, IL, USA

BACKGROUND: Insomnia symptoms (difficulty falling or staying asleep, early awakenings, and non-restorative sleep) are common in cardiac patients and are associated with mood disturbance, impaired concentration, and fatigue. Due to these adverse consequences, patients with insomnia symptoms may find it difficult to optimally adhere to cardiac rehabilitation (CR) program requirements. AIM: To determine whether greater severity of insomnia symptoms is associated with poor CR adherence, as indicated by lower attendance at supervised exercise sessions and at health education classes. METHODS: Insomnia symptoms were measured using the Insomnia Severity Index (ISI) in 155 cardiac patients upon admission to a 12-week phase II CR program at the Cardiac Wellness Institute of Calgary. Data on attendance, demographics, and disease-related variables were obtained by chart review following program completion. Ideally, the CR program entails patients attending 24 supervised exercise sessions and >=2 health education classes (e.g., nutrition, goal-setting). Separate, two-stage hierarchical regression analyses were conducted with (1) supervised exercise attendance as the dependent variable (DV) and (2) health education attendance as the DV. In the first block, age, gender, risk stratification (based on American College of Sports Medicine guidelines), and depressive symptoms (Hospital Anxiety and Depression Scale depression index) were entered as covariates. In the second block, insomnia symptom severity was entered as the focal independent variable. RESULTS: Forty-seven percent of patients endorsed at least subthreshold insomnia symptoms (ISI >7) within the past 2 weeks, indicating mild to severe sleep difficulties. Patients attended an average of 15.85 (SD = 8.04) supervised exercise sessions and 2.40 (SD = 1.63) health education classes. Without insomnia symptom severity in the regression model, covariates accounted for 12% of variance in supervised exercise attendance [F (4, 127) = 4.40, SE=7.66, p <.01] but did not account for significant variance in health education attendance [F (4, 126) = 0.74, SE = 1.64, P = .568, R2 = .023]. Insomnia symptom severity did not improve prediction of supervised exercise session attendance [[DELTA]F (1, 126)~= 0.50, P =.481, [DELTA]R2 = .003] or health education class attendance [[DELTA]F (1, 125) = 0.41, P = .525, [DELTA] R2 = .003]. CONCLUSIONS: Insomnia symptoms are commonly reported by CR patients and warrant appropriate assessment and treatment, but they do not appear to interfere with CR participation. Future analyses should examine associations between insomnia symptoms and other indices of CR engagement (eg, dropout, self-reported exercise, and changes in functional capacity).

Poster #4CHARACTERIZATION OF BALANCE AND MOBILITY IN INDIVIDUALS STARTING A CARDIOVASCULAR REHABILITATION PROGRAM

D.K. Saraswat,¹ L. Martelli,¹ N. Giacomantonio,² S.A. Grandy^1,2

¹Dalhousie University, Halifax, Canada, ²Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Canada

BACKGROUND AND PURPOSE: Exercise is the primary component of cardiac rehabilitation (CR) programs. Balance, the ability to maintain control of one's center of gravity, is necessary to perform exercise safely. Balance deficits can decrease the effectiveness of CR programs by affecting the types and the intensity of the prescribed exercise. Balance deficits also can increase the risk of falls leading to exercise avoidance. Studies have shown that CR patients have numerous risk factors that can contribute to decreased balance. In fact, in the US, a significant proportion of CR patients are reported to have balance deficits. Thus, the purpose of this study was to determine if balance was impaired in individuals starting a Canadian cardiac rehabilitation program (Halifax, Nova Scotia) as well as examine the relationship between self-reported levels of physical activity (PA) and balance. METHODS: Participants in the CR group were recruited from CR programs (N=14; M_age=66.2 years), prior to beginning their rehabilitation training, while healthy controls were recruited from the local community (N=9; M_age=64.7 years). Participants were excluded if they reported comorbidities known to affect balance. All participants completed physical activity questionnaires prior to completing the Community Balance and Mobility Scale (CBMS). The CBMS uses functional tasks that represent activities of daily living to measure functional balance. The assessment is scored out of 96 points, with higher scores representing greater balance levels. Mean CBMS scores were compared between the two groups using a t-test. Pearson product moment correlations were used to examine the association between self-reported levels of PA and CBMS scores. RESULTS: The results showed that CBMS scores were significantly lower in CR participants in comparison to apparently healthy controls (CR CBMS score 57.8+/-18.3; Control CBMS score 77.4+/-6.0; P =.006). In both the CR and control groups self-reported levels of physical were moderately associated with CBMS scores (CR r =0.51; Control r =0.47). There was also a weak correlation between body composition (body mass index) and CBMS scores for all participants (r =-0.35). CONCLUSION: Individuals with cardiovascular disease beginning CR programs have decreased levels of balance and mobility. These altered levels may negatively affect the participant's ability to participate and adhere to the prescribed exercise program, which could limit the effectiveness of the CR program. Thus, levels of balance and mobility should be considered when prescribing exercise for CR participants.

Poster #5HOW PHYSICALLY ACTIVE ARE PATIENTS WITH CORONARY ARTERY DISEASE WHO RECENTLY COMPLETED CARDIAC REHABILITATION?

J.L. Reed, A.E. Mark, A.L. Pipe, R.D. Reid

University of Ottawa Heart Institute, Ottawa, Canada

BACKGROUND: Cardiac rehabilitation programs are successful in ensuring patients initiate regular exercise, but long-term maintenance of exercise behaviour remains a challenge. The purpose of this study was to assess the number of minutes per day cardiac rehabilitation graduates with coronary artery disease (CAD) engage in sedentary, light, moderate and vigorous physical activity. METHODS: Participants wore an Actigraph GT3X accelerometer (Actigraph, Pensacola, Florida) over the right hip for at least 600 minutes per day for 4.9+/-1.8 days. All patients previously attended >=75% of scheduled cardiac rehabilitation sessions. RESULTS: Twenty-seven patients (25 males, 2 females; mean+/- SD=age: 60+/-10 yrs; height: 173.0+/-8.0 cm; weight: 87.3+/-15.9 kg; waist circumference: 101.7+/-13.1 cm; BMI: 29.1+/-4.7 kg/m²; resting blood pressure: 118/72+/-16/8 mm Hg; resting heart rate: 66+/-10 bpm) with diagnosed CAD participated in this study. According to published cut points developed in healthy adults to classify sedentary (0-100 counts/min), light (101-2689 counts/min), moderate (2690-6166 counts/min) and vigorous (>=6167 counts/min) physical activity, participants engaged in 520.9+/-78.6, 195.7+/-41.1, 63.5+/-22.8 and 4.9+/-7.2 minutes per day of sedentary, light, moderate and vigorous physical activity, respectively. Based on cut points developed from a pilot study to classify sedentary (0-100 counts/min), light (101-1699 counts/min), moderate (1700-3699 counts/min) and vigorous (>=3700 counts/min) physical activity in a sample of CAD patients, participants engaged in 520.9+/-78.6, 147.9+/-31.2, 81.4+/-25.2 and 35.1+/-19.0 minutes per day of sedentary, light, moderate and vigorous physical activity, respectively. CONCLUSION: Patients with CAD who recently completed a cardiac rehabilitation program appear to be meeting the American College of Sports Medicine's guidelines for patients with cardiac disease of at least 20-60 minutes of moderate intensity physical activity (40-80% VO_2peak) on most days (4-7) of the week. Specifically, 96% (26/27) of cardiac rehabilitation graduates met physical activity guidelines for moderate intensity physical activity according to published cut points developed in healthy adults, with this value increasing to 100% (27/27) when using population specific cut points. Future studies are needed to assess whether CAD patients continue to meet these guidelines 6 and 12 months following cardiac rehabilitation.

Poster #6USING SEISMOCARDIOGRAPHY TO ASSESS SYSTOLIC TIMING INTERVALS PRE AND POST EXERCISE TRAINING IN HEART FAILURE: A PILOT STUDY

J. Silbernagel, M. Ludlow, M. Balbar, A. Dinh, D. MacQuarrie, S-B. Ko, J. Neary

University of Regina, Dr. Paul Schwann Applied Health and Research Centre (DPSAHRC)

INTRODUCTION: Seismocardiography (SCG) is a noninvasive technique that uses an accelerometer to analyze the mechanical events of a cardiac cycle. Three systolic timing intervals have been used to determine the mechanical efficiency of the heart; PreEjection Period (PEP), Left Ventricular Ejection Time (LVET), and PEP/LVET ratio. Individuals with heart failure (HF) go through a remodeling process that reduces the mechanical efficiency of the heart. The purpose of the study was to determine if exercise will produce an improvement in cardiac mechanics for individuals with HF. METHODS: Data from 4 participants who attended a cardiac rehabilitation program volunteered to participate. SCG tracings were obtained at the beginning, at 6 and 12 weeks of the rehabilitation program. The SCG was recorded in the supine position after a 10 minute rest. The accelerometer was placed 2cm above the xyphoid process along with a standard 2-lead electrocardiogram. Thirty beats of each SCG tracing were annotated. Four points were analyzed; the onset of the Q wave, R wave peak, aortic valve open (AVO) and aortic valve closure (AVC). The R to R interval was used to determine heart rate (HR), Q wave onset to AVC was used to determine electromechanical systole and AVO to AVC was used to determine the LVET. The PEP was determined by subtracting the electromechanical systole from the LVET. All SCG periods were normalized for HR. A repeated measures ANOVA with a Bonferroni correction was used to test for significance. RESULTS: All participants were male (n=4) with dilated cardiomyopathy (49.3 +/- 5.7years, 175.5+/-4.8cm, 100.7+/-36.2kgs, body mass index 32.8+/-10.3, Ejection fraction 24.5 +/- 8.2%). Exercise adherence was 76.4%. All participants were taking [DELTA]-blockers and ACE inhibitors. Three of the 4 were using diuretics and one was using digitalis. There were no medication changes throughout the study. The results of the exercise training produced no significant change in LVET but resulted in significant changes to the PEP (F=(2,178)=27.525,<.001) and PEP/LVET ratio (F=(2,178)=17.50,<.001). CONCLUSIONS: Systolic timing intervals are dependent on physiological aspects of the cardiac cycle such as preload and afterload. An increase in preload has shown to lead to a smaller PEP period and concomitant with an increase in end-diastolic volume. The increase in end-diastolic volume leads to a greater amount of blood ejected from the ventricle during systole and therefore increasing cardiac output (Q). Our study leads to a significant decrease in the PEP and therefore an increase in EDV and Q.

Poster #7SYMPTOMS OF DEPRESSION BUT, NOT ANXIETY, ARE ASSOCIATED WITH ATTENUATED HEART RATE RECOVERY FOLLOWING EXERCISE STRESS TESTING IN CARDIAC REHABILITATION PATIENTS

K.J. Horsley, C.R. Rouleau, T.S. Campbell

Department of Psychology, University of Calgary, Calgary, AB, Canada

BACKGROUND: Depressed mood and anxiety are prevalent among patients with cardiovascular disease (CVD) and are associated with adverse CV outcomes including myocardial infarction and CV mortality. While depressed mood has been associated with autonomic nervous system dysregulation, which represents a potential pathway that may confer increased CV risk, the association between other negative emotions, including anxiety, and autonomic function remains unclear. Heart rate recovery (HRR) following a symptom limited exercise stress test is an indirect measure of cardiac autonomic modulation and lower HRR is prognostic of cardiovascular mortality. Aim: To investigate whether previous reports of associations between depressed mood and autonomic dysregulation, as indexed by low levels of HRR, generalize to symptoms of anxiety. METHODS: Anxious and depressive symptoms were measured using the Hospital Anxiety and Depression Scale in 356 cardiac patients entering a 12-week phase II cardiac rehabilitation program at the Cardiac Wellness Institute of Calgary. HRR was measured at 1 minute following a symptom-limited exercise stress test (using the Bruce Protocol) upon admission. A hierarchical multiple regression analysis was conducted with HRR as the dependent variable. In the first block, age, sex, and beta-blocker use were entered as covariates. Depressive and anxious symptoms were entered in the second block. RESULTS: On average, patients fell within the normal range on both anxious (M = 5.58, SD = 3.72) and depressive (M = 3.94, SD = 3.21) symptoms. Anxious symptoms were positively associated with depressive

Poster #8STEP BY STEP TO ACHIEVE A BETTER CONTROL OF MODIFIABLE RISK FACTORS IN SECONDARY PREVENTION OF CORONARY ARTERY DISEASE

M. Roy, C. Villemure, A. Jutras, J. Houle

Universite du Quebec a Trois-Rivieres, Trois-Rivieres, Canada

The pedometer is a simple, inexpensive and effective tool to measure and improve physical activity after a cardiac event. Nevertheless, limited scientific data is available to determine the relationship between daily steps and modifiable cardiovascular risk factors among patients with coronary artery disease. OBJECTIVE: The aim of this study is to describe the dose of physical activity expressed as daily steps and to verify the relationship with cardiovascular risk factors in a population engaged in a cardiac rehabilitation process. METHOD: This is a descriptive correlational study. The average number of daily steps was measured using a pedometer (Yamax Digiwalker New Lifestyle) over seven consecutive days. The pedometer was worn from morning to night without considering the type of activity, except for aquatic activities. Fasting blood sample and physical examination were used to evaluate waist circumference, body mass index, arterial blood pressure, resting heart rate, lipid profile and glycosylated hemoglobin. Descriptive statistics and regression analyzes were performed. RESULTS: Preliminary results are based on 81 participants with coronary artery disease, more precisely 58 men and 23 women. The average daily step count is 7702 +/- 3653 steps. The cardiovascular risk factors are within the therapeutic target values, except of waist circumference ([male sign] 99.3 +/- 11.9 cm, [female sign] 94 +/- 15.8 cm). This variable is significantly influenced by the daily number of steps ([beta] -0.313, P = .005). No significant association with daily step count was observed among the other risk factors. Most participants were under pharmacotherapy to manage cardiovascular risk factors such as hypertension, diabetes and dyslipidemia. CONCLUSION: The population sample demonstrates adequate control of cardiovascular risk factors except for waist circumference. The results show that walking can effectively contribute to waist circumference reduction among patients with cardiac disease. However, we don't know about nutrition's contribution, therefore, it would be relevant to consider the effect of physical activity, combined with nutritional habits, on improving waist circumference. It is also interesting to note that literature has shown a relation between a high waist circumference and an increased risk of developing several chronic diseases.

Poster #9EVALUATING THE FEASIBILITY OF LINKING HOSPITAL- INITIATED SMOKING CESSATION PROGRAMS TO COMMUNITY CESSATION SERVICES PROVIDERS THROUGH THE USE OF CENTRALIZED DATABASE

Melissa Laroche, Kerri-Anne Mullen, Debbie Aitken, Anne-Marie Larue, Jocelyne Legault, Donna Pittman, Robert D. Reid

University of Ottawa Heart Institute, Ottawa, Canada

BACKGROUND AND AIMS: There is a need for effective integration between organizations offering cessation services. A pilot study was completed to assess the feasibility of an innovative, technology-based solution to facilitate cessation services from hospital to community. Smokers who receive an intervention in hospital, or outpatient clinic with such programs as the Ottawa Model for Smoking Cessation (OMSC) could benefit from greater access and a more seamless referral to post-hospital smoking cessation services such as the Centre for Addiction and Mental Health's program, Smoking Treatment for Ontario Patients (STOP) and the Canadian Cancer Society's Smokers' Helpline (SHL). METHODS: Smoking status was ascertained for all smokers admitted to hospital. Participants included inpatient smokers admitted to two Ontario hospitals who were referred to an in-hospital smoking cessation intervention (the OMSC), who were ready to quit smoking, and who agreed to participate in both post hospitalization telephone followup (by UOHI or the SHL) and the STOP program (offering 5 boxes of nicotine patch and one box of nicotine inhaler cost-free). Patients' smoking cessation consultation data were gathered using an iPad application at the bedside and were automatically stored in a 'cloud' server. Data was transferred through a Secure File Transfer Program (SFTP). Daily, this data was transferred from the cloud server to the OMSC automated telephone follow-up database and to the STOP program in order for telephone follow-up to commence and NRT orders to be processed and sent to patients' homes. RESULTS: Overall, 344 inpatient smokers were provided the OMSC intervention during hospitalization and 165 (48.0%) were eligible to participate in the CLOUD feasibility study. Of those eligible, 93 agreed to participate. NRT fulfillment was slightly below 100%. The quit rate measured 1 month after hospital discharge was 34.8%. Conclusion: This project demonstrated the feasibility of using a centralized cloud-based server to create a more integrated smoking cessation system to link smoker-patients to services in Ontario. Having 1 point of registration appeared to reduce the burden for smokers seeking and accessing services, removed duplicate efforts by service providers, and sent a strong message that there is a system at work in Ontario. Importantly, were able to demonstrate that three existing smoking cessation programs can effectively and efficiently collaborate with one another in order to improve cessation treatment access for Ontarians.

Poster #10NON-RN SMOKING CESSATION COUNSELLOR PROTOCOL

Mustafa Coja, Jo-Anne Gagnier, Tamara Brown, Sophia Papadakis, Debbie Aitken,

University of Ottawa Heart Institute, Ottawa, Canada

BACKGROUND: Followup of patients for 2-6 months is 1 of the 5 elements of the Ottawa Model for Smoking Cessation (OMSC). Followup support has been shown to increase long-term abstinence rates among quitters. The University of Ottawa Heart Institute (UOHI) supports Family Health Teams in Ontario who are involved as partners in the OMSC with delivering this follow-up. Family Health Teams are able to refer their patients to enroll in the Smoker's Telephone Followup Support Program. This program involves five automated phone calls in which patients at risk of relapse or requiring more support are triaged to a Registered Nurse (RN) Counsellor who will provide additional counselling and support. AIMS: The aim of this pilot was to examine the feasibility of involving trained non-RN staff in delivering telephone followup support to patients referred to the Smoker's Telephone Follow-up Support Program who are using Nicotine Replacement Therapy. METHODS: Protocols were developed to outline the duties of the non-RN protocol as well as to clearly identify situations in which the non-RN counselors will refer patients to a RN counselor, primary care physician or urgent care. Each non-RN counselor received training which included review of a developed non-RN protocol as well as on-site shadowing of trained RN counselors. Feasibility of this protocol was measured by recording all referrals made to an RN by non-RN counselors, and all followup outcomes of the non-RN calls. RESULTS: Counselors were able to easily assess patient needs and direct accordingly through the protocol's scripted dialogue and flow charts. Followup call volumes are controlled more easily with the availability of additional trained staff members. The cost of shift coverage is lower with a non-RN counselor. Reasons for referral of patients to a RN counselor included a rating of >=7 for the scale of side-effects, as well as for patients wanting more information on pill-based medication (Varenicline/Bupropion). CONCLUSIONS: The development of the non-RN protocol has allowed the opportunity to explore other possibilities of ongoing support for smokers trying to quit outside of the UOHI. The UOHI is presently working with the Ontario Smoker's Helpline to coordinate a system of telephone support followup using their trained non-RN staff. The non-RN protocol will be used as a guide to determine when a patient should be referred back to the UOHI's Smoking Cessation RN Counselor for support.

Poster #11IS SOCIAL INTEGRATION RELATED TO EXERCISE ADHERENCE IN SEDENTARY INDIVIDUALS WITH SLIGHTLY ELEVATED BLOOD PRESSURE?

Sandra Pelaez,^1,2 Paul J. Mills,³ Kathy Wilson,³ Julie Sadja,³ Kim L. Lavoie,^2,4,5 Simon L. Bacon^2,5,6

¹McGill University, Montreal; ²Montreal Behavioural Medical Centre; ³University of California, San Diego; ⁴Universite de Quebec a Montreal; ⁵Hopital Sacre Coeur de Montreal; ⁶Concordia University, Montreal

BACKGROUNDand objective: Although the benefits of adherence to healthy life habits (eg, regular exercise), for the prevention of cardiovascular disease (CVD) are widely known, it has been well documented that CVD patients fail to adhere to these medical recommendations. Previous research identified a relationship between social integration (SI) and adherence to healthy habits. The objective of this study was to investigate the role of SI on predicting exercise adherence in sedentary participants with slightly elevated blood pressure. METHOD: 55 participants (28 women (51%), Mean [SD] age = 46.8 [8.9]; Mean [SD] SBP/DBP = 141 [11]/85 [9] mmHg) were recruited and randomly assigned to 2 different intervention groups: (a) exercise (16 women and 11 men) and (b) exercise and diet (16 women and 12 men). Both groups completed the same semisupervised exercise intervention including aerobic and weight training components. Prior to randomization, patients completed Sarson's social support questionnaire (SSQ) and the family component of the Social Network Index (f-SNI) scale. RESULTS: The SSQ was positively associated with the number of days of weight training (Beta [SE] = 0.50 [0.24], P = .044) such that for every point increase on the scale participants exercise for an extra half day across the intervention. The SSQ was not associated with total (Beta [SE]=0.51 [0.39], P=197) or aerobic (Beta [SE] = 0.43 [0.39], P =.280) exercise days. There were no main effects of f-SNI on total, aerobic, or weight exercise. However, there was a trend of an interaction between f-SNI and intervention group for total aerobic exercise minutes (Beta [SE] =-130.9 [77.5], P=.098). Tentative post-hoc analyses suggest that only for those in the exercise group, a larger family network was associated with more aerobic exercise (Beta [SE] =29.1 [42.0]), whereas for the exercise and diet group, a larger family network was associated with lower levels of aerobic exercise (Beta [SE] =-93.2 [71.5]). All analyses were adjusted for age and gender. Discussion: The patterns of association between SI and exercise varied depending on the indicators considered for each measure. This suggests that the underlying dynamic between these two variables in sedentary individuals is complex and requires further exploration. These findings seem to indicate that in order to attain better results, interventions aiming at promoting adoption, maintenance, commitment, and adherence to exercise in sedentary individuals should probably target not only the individuals, but also people with whom the individuals establish social ties.

Poster #12TARGETING PATIENT ENGAGEMENT OF SOUTH ASIANS WITH HEART FAILURE: USING PATIENT JOURNEY MAPPING FOR HEALTH SYSTEMES QUALITY IMPROVEMENT

S.L. Burns, R. Dong, S. Juneja, C. Galte, C. Prentice

Fraser Health Authority, Cardiac Services, New Westminster, BC

BACKGROUND: South Asians (SA) have earlier prevalence of cardiovascular disease and higher mortality than other populations. South Asians may face cultural, language and navigational barriers when seeking health care. The complexity of heart Failure (HF) is substantial, costly and carries significant mortality and morbidity. Burden to patients and families is extensive requiring targeted treatment, education and support for successful management. SA HF management strategies are not well documented. We performed patient journey mapping to better understand the current processes and improvement opportunities for SA people living with HF in the Fraser Health Authority. PURPOSE: To use patient journey mapping (PJM) as a quality improvement tool to understand the complex processes involved for SA people with HF seeking health services. PJM shows service delays, service gaps, bottle necks, complex decision points and opportunities for improvement in a variety of clinical areas. METHOD: Three SA patients (1 male) and 15 different medical disciplines participated in an all-day journey mapping session. Facilitators guided all stakeholders to document steps from symptom onset, diagnosis, and treatment planning to self-management at home, through the patient's perceived experience. Mapping was achieved with documentation on large wall-mounted paper with writing and post-it notes on a time-line spectrum. Verbal accounts were also documented by a recorder. Multiple analysis sessions by health team derived patient concerns, system problems and health service issues. RESULTS: Main themes identified 1) challenges in delay of diagnosis with delays in access to diagnostics and specialist referral, 2) delay of diagnosis from primary care and emergency room settings, 3) significant fear and anxiety by patient with new HF diagnosis and resulting stress on how to manage post discharge, 4)lack of educational support and lack of Ethnic specific patient education resources in primary care and acute care settings and 5) lack of referral to outpatient programs of heart function clinic, diabetes clinic and cardiac rehab programs. CONCLUSION: SA patients with HF have a complex journey from symptom onset to self-management at home. Barriers to care are similar to nonethnic specific populations and acknowledge the need for improved diagnostic tools and support for health care providers in all service areas. Further journey mapping of non-English speaking SA patients needs to be completed for comprehensive quality improvement for this high risk population.

Poster #13CARDIAC CHECK-IN: BRIDGING THE GAP FROM HOSPITAL DISCHARGE TO COMMUNITY

S.L. Burns, R. Brown, E. Mulvaney, C. Hooper, B. Reid-Girard, M. Whittle, N. Walshaw.

Fraser Health Authority, Cardiac Services, New Westminster, British Columbia

BACKGROUND: Acute Coronary Syndrome (ACS) patients enter the health care system, receive rapid intervention and treatment and discharged with a diagnosis of cardiovascular disease. Patients and families may be overwhelmed and lack knowledge and resources to self manage. Referral to cardiac rehabilitation may be absent or delayed. Frequently, patients may not have access to any other health services for up to 6 weeks postdischarge. To target quality improvement in our cardiac program, we implemented a community-based Cardiac Check-In program in December 2011, to create a bridge between acute care and cardiac rehabilitation. METHOD: Cardiac Check-in is an interactive program developed out of Royal Columbian Hospital Cardiac Clinic. This program targets ACS patients immediate posthospital discharge with a 5-week program delivered by an interdisciplinary team. An initial group visit with a nurse practitioner or cardiologist is followed by 4 weekly interactive sessions. Interactive sessions cover immediate post discharge recommendations, CVD pathophysiology, nutrition, medications, physical activity, and psychosocial factors. The importance of dual anti-platelet therapy is highlighted in the initial session. Intensive self-management support is provided through interdisciplinary team members, the participant group and with the Heart Manual. RESULTS: Sessions are delivered in a community center rather than a hospital to focus on wellness rather than illness. Client and family members in Cardiac Check-In engage with both the health team and the Heart Manual, embracing the right health information and preventing further hospital readmissions. Clients are referred into a cardiac rehab program in their community at the initial session. Patient satisfaction session surveys are delivered every session (See Table).

Table. No title available.

Quality of life, medication compliance, health care utilization and psychosocial risk factors are screened at baseline with post session evaluation and final program evaluations. Process outcomes include total number referrals received, total number of patients enrolled and total number of sessions completed. Importantly, the number of patients entering cardiac rehabilitation programs will be captured. CONCLUSION: Patients begin positive lifestyle behavior changes on entry into Cardiac Check-In. Education and confidence increase with self-management support. Targeting post discharge interventions of ACS patients provides opportunity for knowledge exchange, self-management support and client engagement in beginning risk reduction strategies. Long-term evaluation will determine program effectiveness.

Poster #14A QUALITATIVE EVALUATION OF THE OTTAWA MODEL FOR SMOKING CESSATION (OMSC) IN PRIMARY CARE

T. Brown,¹ S. Papadakis,¹ Mechthild Meyer,² Alma Estable²

¹University of Ottawa Heart Institute, Ottawa, Canada, ²Gentium Consulting, Ottawa, Canada

BACKGROUND AND RATIONALE: The University of Ottawa Heart Institute (UOHI) conducted a qualitative evaluation of the Ottawa Model for Smoking Cessation (OMSC) in Primary Care program to assess: 1) the value OMSC has provided to Family Health Teams (FHTs); 2) barriers to and enablers of successful uptake of the model, and; 3) recommendations to improve the OMSC program. METHODS: Gentium Consulting was awarded the contract and completed the evaluation in March 2013 and conducted all interviews and data analysis. A sample of 9 FHTs was divided into high and low performers based on quantitative monitoring data. A total of 27 interviews were conducted with FHT team members using a structured interview guide. Interviews were transcribed and analyzed using Nvivo10 qualitative analysis software. RESULTS: The report identified barriers and enablers of successful uptake of each step of the model (Ask, Advise, Act). Examples of enablers included routine EMR documentation, effective training, and OMSC tools and resources. Examples of barriers included time pressure, competing priorities, inconsistent implementation across providers, and the ability to motivate challenging patients. Suggestions for program improvement were varied, and often specific to each component of the program. More general suggestions included ensuring physician buy-in to the program; minimizing paperwork; providing more detailed explanation of OMSC feedback reports, and; providing opportunities to learn from and coordinate with other organizations providing cessation services. Overall, participants noted only minor suggestions for improvement, and saw great value in having the program in place at their FHT. In terms of value added, participants highlighted newly acquired cessation skills and knowledge; greater accountability for smoking cessation, and; a stronger overall priority placed on cessation which translated into improved access to these services for patients. Summary of the qualitative data identified several factors that facilitate a successful OMSC program, such as: high team functioning, clearly assigned responsibilities, the existence of provider "champions", and a shared understanding of the nature of tobacco addiction. Other factors that facilitated success included a well implemented EMR, strong initial support from the OMSC facilitators, and free NRT in clinics that are simultaneously operating the CAMH STOP program. CONCLUSIONS: The OMSC appears to be a value-added quality improvement program. The evaluation has identified specific enablers and barriers to the successful uptake of the program which can be used to further refine the OMSC program.