Objective-To evaluate the eVectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting (CABG). Design-Randomised controlled trial. Setting-Community, January 1997 to March 1998. Study groups-98 (75 male) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust. Patients were randomly assigned to usual care (control; n = 49) or a nurse led intervention programme (n = 49). Intervention-A shared care programme consisting of health education and motivational interviews, according to individual need, was carried out monthly. Care was provided in the patients' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic. Outcome measures-Smoking status, obesity, physical activity, anxiety and depression, general health status, and proportion of patients exceeding target values for blood pressure, plasma cholesterol, and alcohol intake. Results-Compared with patients who received usual care, those participating in the nurse led programme were more likely to stop smoking (25% v 2%, p = 0.001) and to reduce obesity (body mass index > 30 kg/m 2 ) (16.3% v 8.1%, p = 0.01). Target systolic blood pressure improved by 19.8% compared with a 10.7% decrease in the control group (p = 0.001) and target diastolic blood pressure improved by 21.5% compared with 10.2% in the control group (p = 0.000). However, there was no significant diVerence between groups in the proportion of patients with cholesterol concentrations exceeding target values. There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in diVerence in mean scores between the groups ranging from 8.1 (p = 0.005) to 36.1 (p < 0.000). Levels of anxiety and depression improved (p < 0.000) and there was improvement in time spent being physically active (p < 0.000). Conclusions-This nurse led shared care intervention was shown to be eVective for improving care for patients on the waiting list for CABG. (Heart 2001;86:317-323) Keywords: coronary artery bypass grafting; coronary heart disease risk; nurse led shared care; risk reduction Coronary artery bypass graft (CABG) surgery has been shown to be a highly eVective intervention for the relief of angina, improving quality of life and for some patients prolonging life. [1][2][3][4] There has been a 10-fold increase in CABG surgery procedures in the UK, from approximately 3000 a year in 1977, either as a single procedure or together with another cardiac procedure, to almost 25 000 operations in 1995.5 In Scotland, rates of CABG are among the highest in the UK, at 448 operations per million of the population in 1995. The national guaranteed maximum waiting time is one year with a mean waiting time on National Health ...

This study investigated in a healthy population (n=220) the association of the Taql B restriction fragment length polymorphism (RFLP) in the cholesteryl ester transfer protein (CETP) gene with plasma high-density lipoprotein (HDL) cholesterol concentration and subfraction distribution. A raised HDL cholesterol level was found in B2B2 homozygotes (B2 cutting site absent) and was associated specifically with a 45% increase in HDL 2 compared with B1B1 homozygotes (B1B1, 77±39 mg/100 mL, mean±SD; B2B2, 112±59 mg/100 mL; / > <0.01). Total plasma, very-low-density lipoprotein, and HDL triglyceride levels did not differ among the genotype groups, nor did plasma apolipoprotein AI levels {B1B1, 1.45+0.35 mg/mL, mean±SD; B2B2, 1.56±0.33 mg/ mL). Thus, the genetic variation appeared to be independent of metabolic factors that are known to regulate HDL levels. Plasma CETP exchange activity was unlikely to be the cause of L ow plasma levels of high-density lipoprotein (HDL) are associated with increased coronary artery disease risk.1 -2 In addition, it has been found that clinical benefit is associated with a rise in HDL concentration in intervention trials. The Helsinki Heart Study 3 showed that a mean increase of 11% in HDL cholesterol levels was associated with a 34% reduction in coronary heart disease even after correction for other risk factors, including low-density lipoprotein (LDL) cholesterol and plasma triglyceride levels.Plasma HDL is composed of two main subfractions, HDL 2 (1.063

The study was sufficiently large to demonstrate higher levels of patient satisfaction and clinical documentation quality with ENP-led than SHO-led care. A larger study involving 769 patients in each arm would be required to detect a 2% difference in missed injury rates. The methods and tools used in this trial could be used in Accident and Emergency departments to measure the quality of ENP-led care.

In a survey of a healthy population (n = 197), LDL cholesterol, plasma triglycerides and VLDL triglycerides were found to be substantially increased and plasma HDL cholesterol decreased in smokers. The lipid-associated atherogenic risk in smokers as assessed by the LDL/HDL ratio was significantly higher [2.89 (SD 1.18, n = 63)] than in non-smokers [2.38 (SD 0.98, n = 86) P < 0.01]. The lower HDL level found in smokers was explained by a lower HDL-2 subfraction as determined by analytical ultracentrifugation. HDL 2b, 2a and 3a, measured by gradient gel electrophoresis, were all lower in the smokers but this was only significant for HDL 2a. Smoking had no effect on Lp(a) levels. HDL cholesterol and HDL-2 were strongly negatively correlated whereas LDL cholesterol and LDL/HDL ratio were strongly positively correlated with the plasma triglyceride concentration. There was a small but significant reduction in plasma CETP activity [non-smokers 49% t/microliter (SD 17, n = 90), smokers 43% t/microliter (SD 17, n = 66) P < 0.05] but CETP activity was not correlated with any measure of HDL in this population. Smoking was found to be an important independent contributor to the variation in plasma triglyceride, HDL, HDL-2 and LDL/HDL ratio. After correcting for sex, age, BMI, alcohol consumption, oral contraceptive use and plasma triglycerides smoking was still found to be significantly associated with HDL and the LDL/HDL ratio. Upon adjustment for covariant factors the mean differences between smokers and non-smokers for HDL cholesterol, HDL-2 and LDL/HDL were 0.15 mM, 16 mg dl-1 and 0.39 respectively. There appeared to be important sex differences in the influence of smoking on plasma lipoproteins. In women the main impact of smoking was on triglyceride levels and they in turn affected LDL and HDL. In contrast, in men, smoking had little impact on triglycerides and affected HDL more directly. We conclude that smoking cigarettes has an important effect on plasma lipoprotein metabolism through multiple mechanisms.

This prospective descriptive study has analysed 214 patient interviews before and 1 year after coronary artery bypass grafting (CABG). The preoperative interview explored issues related to the impact of coronary artery disease upon health and expectations of benefit from the patients' perspective. The postoperative interview examined patients' accounts of the experience of operation and its impact on their health. A thematic analysis of the interview data was undertaken. The main factors relating to health status preoperatively were described in terms of 'dependency' on others and medication, and 'impending doom' of some major life threatening event. Benefits to health postoperatively were viewed in terms of 'removal of a death sentence' and 'freedom of choice'. Expectations of benefit from operation were varied and included 'freedom and independence', 'hope, chance and uncertainty' and 'addition of years to life and life to years'. Undergoing the operation was described by themes of the 'enormity of the experience' and 'the importance of lay support'. These findings provide a greater understanding of the 'lived experience' of both coronary artery disease and undergoing coronary artery bypass grafting. Unrealistic expectations of the benefits of CABG highlights the need for improvement in the way patients are informed about risks and benefits of interventions. In addition, the views and insights suggest that CABG operation is regarded as a significant major life event; thus more information, advice and counselling might help support patients before, during and after surgery.

Objective: The problem addressed in the study was to gain a greater understanding of the health bene®ts of coronary artery bypass grafting (CABG). The purpose of the study was to assess general health status, using the short-form (SF)-36 questionnaire, approximately 12 months following CABG, and to document any associations between pre-operative health status, level of social support, coronary artery disease (CAD) risk factors, CAD symptom severity and post-operative health status. Methods: The study was prospective and observational in design and included assessments at two time points, namely pre-operatively in a hospital outpatient department (1995±1996) and postoperatively at home (1996±1997). Two hundred and fourteen patients awaiting elective CABG were recruited a month before the expected date of operation. Pre-operative assessment included: (1), severity of symptoms; (2), CAD risk factors; (3), SF-36 questionnaire; and (4), social activities questionnaire. Post-operative assessment measured health status using the SF-36 instrument (mean, 16.4 months). Correlation and multiple linear regression analyses were used to identify factors associated with improved health status following CABG. Results: Two hundred and fourteen patients were assessed pre-operatively and underwent CABG. There was a 4.8% 30-day mortality rate, and 183 patients were followed for a mean of 16.4 months after CABG. SF-36 scores following CABG were improved across all of the eight domains (P , 0:001). A higher social network score and higher pre-operative health status were associated with improved health status. Patients with lower health levels (SF-36 scores) prior to CABG were less likely to gain improvement in health (SF-36 scores) following CABG. Lower SF-36 scores following operation were in¯uenced by the presence of diabetes mellitus, cigarette smoking, younger age, a high socio-economic deprivation category and higher alcohol intake. Many patients had uncorrected CAD risk factors at pre-operative assessment. Conclusions: The SF-36 instrument was shown to be a useful and sensitive tool to assess differences and changes in the general health status of patients before and following CABG. High levels of social support were associated with improved health status post-operatively. Lower preoperative general health status, the presence of diabetes mellitus and cigarette smoking were associated with poorer post-operative general health status. q

The barriers to recruitment are largely surmountable, but these will necessitate the use of resource intensive and more personalized approaches than are commonly employed for the White European origin population. Our proposed model to enhance recruitment is likely to have transferability beyond the field of asthma.

Seven moderately hypercholesterolemic subjects were studied before and after 10 weeks of simvastatin therapy (20 mg/day). Therapy reduced low density lipoprotein (LDL) cholesterol by 39% (p<0.001), whereas high density lipoprotein and very low density lipoprotein (VLDL) cholesterol were unchanged. Apolipoprotein (apo) B-containing lipoproteins were divided into VLDL, (S, 60-400), VLDL 2 (S r 20-60), intermediate density lipoprotein , and LDL (S r 0-12), and metabolic changes were sought in dual-tracer VLDL] and VLDL 2 turnover studies. VLDL, apoB pool size was unaltered by therapy, as were its rates of synthesis, catabolism, and delipidation to VLDL 2 . Similarly, the VLDL 2 apoB pool size was unchanged, but its metabolic fate was altered. The IDL pool size fell significantly (27%, p< 0.01) due entirely to an increased fractional catabolism of the lipoprotein. In our subjects, the circulating mass of LDL apoB decreased (49%, p< 0.01) primarily due to a reduction in its synthesis. Before therapy, 30% of the apoB entering the delipidation cascade in these hyperlipidemic subjects was converted to LDL. On therapy the input remained the same, but direct catabolism from VLDL 2 and IDL was increased (p<0.05), and as a result only 16% eventually appeared in LDL. These kinetic changes were associated with a fall in particle cholesteryl ester content throughout the delipidation cascade. We also observed a link between LDL kinetics and its subfraction distribution. Simvastatin influences the metabolism of LDL, IDL, and VLDL 2 but not VLDL,. {Arteriosclerosis and Thrombosis 1993;13:170-189) KEY and more recently from the Helsinki Heart Study 3 has confirmed the importance of lipid lowering as a means of preventing coronary heart disease (CHD). Since the completion of these studies, more powerful lipid-regulating agents have become available; the most potent of these in terms of low density lipoprotein cholesterol (LDL-C) lowering are the 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors or "statins." This is an important class of lipid-lowering drugs whose remarkable efficacy has been documented in studies of several different groups of patients. 4 " 10 The precise mechanism of action of these compounds, however, has not been fully elucidated. At first it was thought that they affected only LDL via activation of hepatic apolipoprotein (apo) B/E receptors. However, further experience has suggested that they have substantial effects on very low density In general, all statins have weak but significant plasma triglyceride-lowering properties; in type III hyperlipoproteinemic subjects it has been shown that statins can, uniquely among lipid-lowering drugs, correct the compositional abnormality seen in VLDL. 9 Investigations of the kinetic changes underlying the LDL reduction on statin therapy have revealed an unsuspected heterogeneity of response. Many subjects, particularly those with familial hypercholesterolemia (FH), exhibit an increase in apoLDL clearance while on the drug, 13 whereas in others decreas...