Objective: Health literacy is increasingly recognised as a potentially important patient characteristic related to patient education efforts. We evaluated whether health literacy would predict gains in knowledge after completion of patient education in cardiac rehabilitation. Method: This was a re-post observational analysis study design based on Summa Health System’s Phase-II cardiac rehabilitation programme in Akron, Ohio, USA. The Medical Term Recognition Test, the Short Test of Functional Health Literacy in Adults, and the Newest Vital Sign were administered to 191 patients enrolled in cardiac rehabilitation between May 2010–April 2011. The Cardiac Knowledge Assessment Tool is routinely administered at the beginning and prior to discharge from cardiac rehabilitation. Consent was obtained in order to access patients’ cardiac rehabilitation medical chart for information such as age and education level. Results: Participants were 72% men with a mean of 66.4 years of age, and with an average level of education of 13.7 years. Health literacy was strongly related to cardiac knowledge at both the beginning and end of cardiac rehabilitation (r=0.46, p<0.001; r=0.41, p<0.001). Controlling for cardiac knowledge at the beginning of cardiac rehabilitation, health literacy predicted gains in cardiac knowledge at the end of cardiac rehabilitation (p<0.01). Conclusion: Health literacy can be used to predict gains in knowledge from patient education programming in cardiac rehabilitation. Health literacy screening may help to identify those who may struggle with patient-education portions of cardiac rehabilitation or who may need additional education to reach a desired knowledge level.

Purpose: This article describes the systematic construction and psychometric analysis of a knowledge assessment instrument for phase II cardiac rehabilitation (CR) patients measuring risk modification disease management knowledge and behavioral outcomes derived from national standards relevant to secondary prevention and management of cardiovascular disease. Methods: First, using adult curriculum based on disease-specific learning outcomes and competencies, a systematic test item development process was completed by clinical staff. Second, a panel of educational and clinical experts used an iterative process to identify test content domain and arrive at consensus in selecting items meeting criteria. Third, the resulting 31-question instrument, the Cardiac Knowledge Assessment Tool (CKAT), was piloted in CR patients to ensure use of application. Validity and reliability analyses were performed on 3638 adults before test administrations with additional focused analyses on 1999 individuals completing both pretreatment and posttreatment administrations within 6 months. Results: Evidence of CKAT content validity was substantiated, with 85% agreement among content experts. Evidence of construct validity was demonstrated via factor analysis identifying key underlying factors. Estimates of internal consistency, for example, Cronbach's α = .852 and Spearman-Brown split-half reliability = 0.817 on pretesting, support test reliability. Item analysis, using point biserial correlation, measured relationships between performance on single items and total score (P < .01). Analyses using item difficulty and item discrimination indices further verified item stability and validity of the CKAT. Conclusions: A knowledge instrument specifically designed for an adult CR population was systematically developed and tested in a large representative patient population, satisfying psychometric parameters, including validity and reliability.

Background: Cognitive impairment in persons with heart failure is common. Theories of cognitive reserve suggest that premorbid factors, such as intellectual ability, may provide a buffer against cognitive impairment due to neuropathological insult. No study has examined the influence of cognitive reserve on cognitive functioning in older adults with heart failure. Aim: This study examined whether cognitive reserve moderates the relationship between heart failure severity and cognitive function. Methods: A total of 157 persons with heart failure (69.26 ± 9.26 years; 39% female) completed neuropsychological testing and a brief fitness assessment. Cognitive reserve was operationalized using estimated premorbid intellect on the American National Adult Reading Test (AMNART). Results: A moderation analysis was performed using hierarchical regression models for each cognitive domain. An interaction term between the AMNART and 2-Minute Step Test was created and entered into the final block of the model, with demographic, psychosocial, and heart failure severity entered in the previous blocks. The interaction term was significant for attention, t(155) = –2.54, p = .012, executive function, t(155) = –3.30, p = .001, and language, t(155) = –2.83, p = .005, domains. Conclusion: The current findings suggest that cognitive reserve moderates the association between heart failure severity and cognitive function in multiple cognitive domains. Further work is needed to clarify the mechanisms by which cognitive reserve attenuates cognitive impairment in this population.

Background and aims: Cognitive impairment is common in persons with heart failure (HF), and measures like the 6-minute walk test (6MWT) are known to correspond to level of impairment. The 2-minute step test (2MST) has been suggested as a more practical alternative to the 6MWT, though no study has examined whether it is associated with cognitive impairment in persons with HF. This study examined whether the 2MST is associated with cognitive function in older adults with HF. Methods: Older adults with HF (n=145; 68.97±9.31 yrs) completed the 2MST and a neuropsychological test battery that assessed function in multiple cognitive domains. Results: Consistent with past work, HF patients exhibited high rates of cognitive impairment. Hierarchical regression analyses adjusting for demographic and medical characteristics found that the 2MST accounted for unique variance in global cognitive function (ΔR2=0.09, p<0.001), executive function (ΔR2=0.03, p<0.05), and language (ΔR2=0.10, p<0.001). A trend emerged for attention (ΔR2=0.02, p=0.09). Follow-up tests indicated that better 2MST performance was significantly correlated with better global cognitive function, attention, executive, and language test performance. Conclusion: The current results indicate that the 2MST is associated with cognitive function in older adults with HF. Further work is needed to clarify underlying mechanisms for this association and the value of implementing the 2MST during routine visits.

OBJECTIVE:Reduced physical activity is common in persons with heart failure (HF). However, studies of correlates and modifiers of physical activity in this population rarely employ objective measures. Motivational and mood related factors that may exacerbate inactivity in HF patients are also rarely investigated. In this study, we examined the relationship between physical activity as assessed by accelerometry, and depression in older adults with HF.METHODS:At baseline, older adults with HF (N = 96; 69.81 ± 8.79) wore an accelerometer for seven days, and completed a brief fitness assessment, neuropsychological testing, and psychosocial measures including the Beck Depression Inventory-II (BDI-II). Medical and demographic history was obtained through record review and self-report.RESULTS:Accelerometer measures showed that HF patients averaged 587 minutes of sedentary time and just 0.31 minutes of vigorous activity per day. Lower daily step count was associated with poorer quality of life and reduced cognitive function. A multiple linear regression adjusting for important demographic and medical variables found that greater number of depressive symptoms on the BDI-II independently predicted lower physical activity levels.CONCLUSION:Consistent with past work, the current study found that low physical activity is common in older adults with HF. Depression is an independent predictor of physical activity in older adults with HF and reduced physical activity is associated with numerous adverse psychosocial outcomes. Future studies need to determine whether treatment of depression can boost physical activity and thus improve health outcomes in this population.

Background: Heart failure (HF) is a disabling disease that often affects instrumental activities of daily living (instrumental ADLs). Despite high rates of disability in this population, little is known about the effects of cognitive impairment on instrumental ADLs in this population. Objective: The current study examined whether cognitive functioning predicts instrumental ADL performance in persons with HF. Methods: Persons with HF (N = 122; 68.49 [SD, 9.43] years; 35.2% female) completed neuropsychological testing, fitness assessment, and self-reported instrumental and basic ADL function as part of a larger protocol. Neuropsychological tests included the Mini-Mental State Examination and Trail Making Tests A and B. The 2-minute step test estimated fitness. Instrumental and basic ADL function was based on self-report on the Lawton-Brody Activities of Daily Living Scale. Hierarchical regression analyses were used to determine the independent contribution of cognitive function to ADLs in HF. Results: Heart failure patients reported high rates of impairments in instrumental ADLs, but indicated requiring little or no assistance with basic ADLs. Cognitive function showed incremental predictive validity for driving (R2 change = .07, P = .03) and medication management (R2 change = .14, P < .001). In each case, poorer neuropsychological test performance was associated with poorer instrumental ADL function. Conclusion: In persons with HF, cognitive performance is an independent predictor of independence in driving and medication management. Strategies to maintain or improve cognitive functioning in HF may help patients remain functionally independent in their daily living.

BACKGROUND:Completion of a cardiac rehabilitation (CR) program post 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 demographic and clinical variables associated with non-completion of CR and to identify factors that led 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 and the control group. Having a normal ECG during a pre-program stress test and having higher levels of pre-program stress were significant for the attrition group. The most common reason for dropping out was physical health problems. Other influential factors included patients' perception that the exercise component of the program was too difficult and personal perceptions and reactions to the program.IMPLICATIONS:Patients entering CR who present in better physical risk categories with higher home or occupational stress levels may be at risk for dropping out. CR staff should monitor patients early for personal reactions to the program along with their response to physical exercise in order to address issues that promote program attrition.

BACKGROUND Adherence to diet and exercise regimens significantly limits morbidity and mortality for cardiac patients. Research at six and 12 months post CR program indicates that healthy behaviours learned in CR are not sustained. However, little is known about the extent of adherence in the immediate program completion period. PURPOSE To determine CR participants' knowledge of their diet and exercise prescription and the degree of adherence two months after completing CR, and to examine demographic and clinical variables to identify relationships to adherence behaviours. METHODS Participants (n = 174) were recruited from Phase II CR over a one-year period. The Diet Habit Survey (DHS) and Duke Activity Status Index (DASI) scores were administered at admission, discharge, and two months post discharge. Structured telephone interviews were conducted to evaluate adherence behaviours. Spearman correlation was used to determine relationships between demographic and clinical variables and adherence behaviours. RESULTS Repeated measures ANOVA showed DHS and DASI scores were significantly higher at discharge (p < 0.001) without significant drift at two months post program (p < 0.09). These scores were in contrast with low self-report of knowledge of dietary and exercise recommendations and adherence to dietary and exercise instructions. Lower knowledge about diet and exercise were correlated with employment (diet, p < 0.001; exercise, p < 0.025). Decreased dietary adherence was correlated with BMI (p < 0.005). Exercise adherence was correlated with gender (p < 0.021) and marital status (p < 0.042). CONCLUSION Although CR participants gain and retain knowledge about necessary dietary changes and improve their exercise activity tolerance during CR, most fail to translate the information into health promoting behaviour changes beginning in the immediate discharge period. Research to identify methods that transform knowledge into lasting behaviour change post CR is needed.

Cognitive impairment is common in persons with cardiovascular disease (CVD). Cardiac rehabilitation (CR) improves many aspects of CVD linked to cognitive impairment. The current study explored whether CR may improve cognitive function. Potential mechanisms for cognitive changes were also examined through exploratory analyses, including changes in cardiovascular fitness and cerebral blood flow. Fifty-one older adults with CVD underwent neuropsychological assessment at baseline and discharge from a 12-week CR program. Cardiovascular fitness (i.e., metabolic equivalents [METs]) was estimated from a symptom-limited volitional stress test. Transcranial doppler quantified mean cerebral blood flow velocity and pulsatility indexes for the middle cerebral artery and anterior cerebral artery (ACA). Repeated measures ANOVA showed improvements in global cognition, attention-executive-psychomotor function, and memory. Exploratory analyses revealed improvement in METs and changes in ACA flow velocity, but only improvement in METs was related to improved verbal recall. CVD patients exhibited improvements in multiple cognitive domains following a 12-week CR program, suggesting that cognitive impairment is modifiable in this population. Although other studies are needed to elucidate underlying mechanisms, exploratory analyses suggest that cognitive improvements may be better explained by physiological processes other than improved cardiovascular fitness and cerebral blood flow.

An exercise-based cardiac rehabilitation program improves cardiovascular fitness and perceived exertion (RPE) in cardiac patients. Afferent sensory feedback from increases in heart rate (HR), blood pressure (BP), workload (METs) and ventilation during volitional peak treadmill exercise test (GXT peak) are known to affect RPE. These responses may differ between depressed (DEP) and non-depressed (NON) cardiac patients. PURPOSE: To determine whether functional capacity (FC) and RPE rating would improve among depressed cardiac patients enrolled in a phase II cardiac rehabilitation (CR) program. METHODS: Participants (DEP-N=10; BDI-13 or above) and (NON-N=8; BDI-6 or below) who took both an entry and exit treadmill exercise stress test and underwent 25 sessions of CR exercise training program were assessed. Depressive symptoms were measured pre- and pos- intervention using the Beck Depression Inventory (BDI) and structured diagnostic interview. Three -way ANOVAs with repeated measures were conducted to compare DEP and NON groups on measures of METS and RPE at 50%, 75%, and 100% exercise intensity levels of GXT peak. RESULTS: After CR exercise training program, there were no significant differences in the responses of DEP and NON groups (p > 0.005). Mean RPE scores (Borg scale) for both DEP and NON groups were significantly lower at the 50% intensity level of the exercise stress test, DEP (M = 11.1, SD = 1.7 to M = 9.0, SD = 2.8, p = 0.002); NON (M = 10.6, SD = 1.4 to M = 8.0, SD = 1.4, p = 0.015). The mean max MET scores significantly improved for both DEP and NON groups, DEP (M = 5.6, SD = 2.2 to M = 9.5, SD = 3.1, p = 0.001); NON (M = 6.2, SD = 1.8 to M = 11.8, SD = 2.1, p < 0.001). CONCLUSIONS: After a CR exercise training program, depressed and non-depressed cardiac patients will increase FC, improve exercise tolerance, and most importantly lower RPE rating at the 50% exercise intensity level of GXT peak. This may motivate and enhance exercise adherence for depressed cardiac patients even after the CR program.

Background Given rapidly accumulating evidence that health literacy is correlated with important health-related measures, assessing patients’ health literacy level is of increasing concern for researchers and practitioners. Practical limitations for use of existing health literacy measures include length of time and practitioner involvement in administration. Objective To develop and validate a brief, self-administered measure of health literacy, the Medical Term Recognition Test (METER). Participants 155 participants were recruited from an outpatient cardiology program at an urban hospital. Measures Patients completed measures of health literacy (METER and REALM), neuropsychological function, psychosocial health, and self-report questionnaires about health behaviors. Indicators of cardiovascular health were also recorded from patients’ medical charts. Key results The measure took 2 min to complete. The internal consistency of the METER was 0.93, and it correlated highly with REALM (r = 0.74). Regarding sensitivity and specificity for identifying individuals below REALM’s cutoff for functional literacy, METER resulted in 75% correct identifications and 8% false positives. METER and REALM were both associated with various health-related measures (including significant correlations with measures of neuropsychological function and cardiovascular health). Conclusions These initial findings show that the METER is a quick and practical measure of health literacy for use in clinical settings.

Background: Sleep problems are common in the normal population and likely to be especially prevalent in persons with cardiovascular disease. Purpose: We examined the prevalence of sleep difficulties and their impact on cognitive function in 77 persons (mean age, 62.8 [SD, 12.5] years; 24% female) presenting for perfusion stress scan at an outpatient cardiology center. Methods: Participants completed the Pittsburgh Sleep Quality Index and Modified Mini-Mental State Examination as part of a larger project. Results: Analyses showed that approximately 94% of participants met the criteria for "poor'' sleep (ie, Pittsburgh Sleep Quality Index global score >= 5). Poorer reported sleep was associated with reduced cognitive function as measured by the Modified Mini-Mental State Examination after adjusting for age, depression, and cardiovascular fitness (ie, estimated metabolic equivalents; R-2 change = 0.08, F = 7.17; P < .001). Conclusion: These findings indicate that sleep problems are common in cardiovascular disease and extend previous research by demonstrating they negatively impact cognitive function. Further work is needed to identify other consequences of poor sleep in this population and optimal treatment.

Cardiac patients with depression have shown altered autonomic nervous system functioning, expressed as reduced heart rate variability. This may be associated with poorer physical fitness and less physical activity among depressed patients. These relationships were explored among patients enrolled in outpatient cardiac rehabilitation. 22 depressed and 22 nondepressed patients, matched for sex and age, were assessed at enrollment. The Beck Depression Inventory and structured interviews were used to measure depression. Patients completed ambulatory monitoring of ECG (i.e., Holter) and physical activity, as well as a treadmill stress test. Depression was associated with several measures of heart rate variability. Activity and fitness were lower among the depressed patients. Although exploratory, accounting for activity and fitness attenuated the relationship between depression and heart rate variability. This suggests that altered fitness and activity may help explain altered autonomic tone that characterizes patients with cardiovascular diseases who are psychologically depressed.

Graduates of a cardiac rehabilitation program reported they did not use self-monitoring skills at home. This unexpected outcome led to an investigation of the reasons for this lack of use. Results of the study informed program revision including the teaching tool and teaching strategies designed to enhance program effectiveness and improve patient outcomes.

American Association of Cardiovascular and Pulmonary Rehabilitation Annual Meeting and Scientific Abstracts: Scientific Poster Presentations, Friday, September 19, Saturday, September 20