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Preventive Cardiovascular Nurses Association 21st Annual Symposium Winning Abstracts

Lea Ann Matura, PhD; Mariam Kashani DNP, CRNP; Karen Patalano, MBA, RD, LDN, CDE, NHA; Emily J. Jones, PhD, RNC-OB; Janie Baranyay, RN, MSN, APN; Deborah S. Petty, DNP, APRN, ACNS-BC; Kevin Goodwin, BSN, RN; Denise Taylor, MS, RD; Arn Eliasson, MD; Renata Engler, MD; Todd Villines, MD; Marina Vernalis, DO; AJ Martin, RD; Melanie M. Mott, MS, RD; Andrea D. Coviello, MD, MSE, FACE; Brian Salle, RN-C, CCRN, CSC, RCEP, M.Ed.; John Hanlon, RN, BSN, CCRN; Richard D. Hulse, PA-C; Alex Rodriguez, MD; Susan Levine-Beutel, RN; Carol R. Russell, MS, CPHQ, CFLE; Amanda Malecky, BSN, RN; Janet Cipkala-Gaffin, DrPH, PMHCNS-BC; Jonathon Ledyard, MS, RCEP; Mohammad Alrawashdeh, BSN, MSN; Elisabeth Bradley, MS, APN; Marianne Carter, MS, RD; Margot L. Savoy, MD, MPH, CPE; Edward M. Goldenberg, MD; C. E. Ventetuolo, MD, MS; H. I. Palevsky, MD; D. J. Lederer, MD; E. M. Horn, MD; S. C. Mathai, MD, MHS; D. Pinder, BS; C. Archer-Chicko, MS; E. Bagiella, PhD; K. E. Roberts, MD; R. P. Tracy, PhD; P. M. Hassoun, MD; R. E. Girgis, MD; S. M. Kawut, MD.


Each year, the Preventive Cardiovascular Nurses Association (PCNA) invites healthcare professionals involved in original data-based research or innovative quality improvement projects related to cardiovascular risk reduction and disease management to submit an abstract to be presented at PCNA's Annual Symposium. Abstracts are judged and the top oral and posters presentations at the Annual Symposium are selected for publication in the Journal of Cardiovascular Nursing. The winners are presented below.


Category: Data-Based Research

Oral Presenter: Cardiovascular Risk Factor are Underdiagnosed in Woman With a History of Gestational Diabetes

Emily J. Jones, PhD, RNC-OB1; Melanie M. Mott, MS, RD2,3; Andrea D. Coviello, MD, MSE, FACE2,3, 1University of Massachusetts Boston; 2Boston University; 3Boston Medical Center, Boston, MA.


Background: History of gestational diabetes mellitus (hGDM) is associated with increased risk of type 2 diabetes (T2D) and hypertension (HTN), major risk factors (RFs) for cardiovascular disease (CVD) that may be unrecognized in younger women.


Objective: To examine diagnosis of obesity, prediabetes (preDM), T2D, and HTN in premenopausal women with and without hGDM by provider-assigned diagnoses compared with objective criteria.


Methods: The prevalence of obesity, preDM, T2D, and HTN by provider diagnosis was compared with the prevalence of additional cases by objective measures in 198 premenopausal women with hGDM (by International Classification of Diseases, Ninth Revision code) and 17 239 non-GDM women seen as outpatients at an urban medical center. Obesity was defined as body mass index of 30 kg/m2 or greater, preDM as HbA1c 5.7% to 6.4%, T2D as HbA1c 6.5% or greater, and HTN as BP 140/90 mm Hg or greater. Analyses were stratified by race-ethnicity. Group comparisons were by [chi]2/Fisher exact and t test; [alpha] = .05.


Results: Age (mean) was 34 (SD, 6) (hGDM) versus 33 (SD, 9) years (non-GDM) (P = .09). Women with hGDM women were underdiagnosed with obesity (31% vs 21%), preDM (2% vs 0.6%), T2D (2% vs 1%), and HTN (by 8% vs 5%) more than non-GDM women.


Conclusions: Women with hGDM are under-diagnosed with CVD RFs including obesity, preDM, T2D, and HTN. GDM is an underused opportunity to risk stratify women for CVD and target lifestyle interventions to reduce cardiometabolic risk and promote health across the life course.


Poster Presentation

First Place: Inflammation and Symptoms in Pulmonary Arterial Hypertension

Lea Ann Matura, PhD, Harold Palevsky, MD, University of Pennsylvania, Philadelphia; David Lederer, MD, Evelyn Horn, MD, Columbia University, New York, New York; Diane Pinder, BS, Christine Archer-Chicko, MS, University of Pennsylvania, Philadelphia; Emilia Bagiella, PhD, Mount Sanai Hospital, New York, New York; Kari Roberts, MD, Tufts University, Boston, Massachusetts; Russell Tracy, PhD, University of Vermont, Burlington; Reda Girgis, MD, Paul Hassoun, MD, Johns Hopkins University, Baltimore, Maryland; Steven Kawut, MD, University of Pennsylvania, Philadelphia.


Please refer to "Interleukin-6 and Tumor Necrosis Factor-[alpha] Are Associated With Quality of Life-Related Symptoms in Pulmonary Arterial Hypertension" in the March 2015 issue of the Annals of the American Thoracic Society for the full abstract, which has been published previously. Full citation: Matura LA, Ventetuolo CE, Palevsky HI, et al. Interleukin-6 and tumor necrosis factor-[alpha] are associated with quality of life-related symptoms in pulmonary arterial hypertension. Ann Am Thorac Soc. 2015;12(3):370-375.


Second Place: Women Present With Non-Traditional Precursors of CVD

Mariam Kashani CRNP, DNP, Arn Eliasson, MD, Renata Engler, MD, Todd Villines, MD, Marina Vernalis, DO, Integrative Cardiac Health Project, Walter Reed National Military Medical Center, Bethesda, Maryland.


Background: National guidelines for the evaluation of cardiovascular disease (CVD) risk provide clinicians with global recommendations without specifying differences according to sex.


Hypothesis: We hypothesized that important differences are present in the CVD risk profile of men and women, which may point to the need for sex-specific assessment beyond traditional CVD risk scores.


Methods: Subjects presenting to a CVD prevention program underwent comprehensive evaluation for CVD risk including medical history, family history, smoking exposure, perceived stress assessment with the validated Perceived Stress Scale, vital signs, anthropometrics, cardiac-relevant laboratory tests, and calculated Framingham Risk Score. Differences between men and women were assessed using unpaired t tests.


Results: Among 300 women and 208 men (mean age, 57 [SD, 12] years), major differences in presentation were:


There were no significant differences in family history of CVD (P = .99), smoking exposure (P = .08), blood pressure (P = .91 systolic, P = .10 diastolic), BMI (P = .66), or laboratory assessment of glucose metabolism (glucose, 97.6 for men vs 95.1 for women, P = .10; insulin, 12.7 vs 12.2, P = .57; HgA1C, 5.8 vs 5.9, P = .17).

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Conclusions: Men and women present with CVD risk differently. Mean FRS was significantly lower for women despite worse lipid profiles and the presence of nontraditional precursors for CVD risk such as higher rates of depression/anxiety and perceived stress, all of which may manifest overt disease after menopause. In order to target interventions appropriately, screening approaches for CVD risk should aim to capture sex-specific vulnerabilities for CVD.


Third Place: Electronic Medical Record In Private Practice: A Method of Collecting and Reporting Outcomes Data

Karen Patalano MBA, RD, LDN, CDE, NHA, Private Practice, Westford, Massachusetts; AJ Martin, RD.


Clinical Dietitian, Sustainability and Environmental Management Program, Harvard University Extension School, Cambridge, Massachusetts.


Objective: To define the method of use and benefits of an electronic medical record (EMR) to collect, measure, and report statistically significant weight loss outcomes in patients receiving medical nutrition therapy (MNT) by registered dietitians (RDs) in private practice.


Methods: The data on clinical outcomes of nutrition counseling by dietitians in private practice in more than 30 states and Canada were collected and analyzed for weight loss, blood sugar, serum lipid levels, and change in activity levels and restaurant frequency. A Cloud-based EMR was used by RDs in private practice starting on March 1, 2012, and is currently in use. The RD enters information into the database at each patient visit that includes but is not limited to weight, laboratory values, medications, diagnosis, activity frequency and duration, and restaurant and take-out frequency. The deidentified data were collected from March 1, 2012, to December 31, 2013, exported, and analyzed by diagnosis using International Classification of Diseases, Ninth Revision (ICD-9) codes for weight loss, changes in laboratory values, and activity and restaurant frequency levels.


Results: There was a statistically significant (95% confidence interval) decrease in weight in the total sample of 845 patients and in each diagnosis category analyzed by ICD-9 codes for diabetes, hypercholesterolemia, hypertension, obesity, and overweight. There was also a significant increase in activity duration and frequency and a significant decrease in restaurant frequency after MNT.


Conclusion: Medical nutrition therapy by RDs in private practice was effective in achieving statistically significant weight loss in their patients with the diagnosis of diabetes, hypercholesterolemia, hypertension, obesity, and overweight. It would be cost-effective for the Centers for Medicare & Medicaid Services and other insurers to reimburse RDs in private practice for weight loss counseling to decrease the incidence of diabetes, cardiovascular disease, and cancer, especially if RDs are voluntarily completing the PQRS requirements.


Category: Innovations in Patient Care

Oral Presenter: Million Hearts(R) Delaware: A First State Coalition to Prevent Heart Attack and Stroke

Denise S. Taylor, MS, RD, Elisabeth Bradley, MS, APN, Christiana Care Health System, Newark, Delaware; Marianne Carter, MS, RD, Delaware State University, Dover, Delaware; Margot L. Savoy, MD, MPH, FAAFP, CPE, Edward M. Goldenberg, MD, FACC, Christiana Care Health System, Newark, Delaware.


Background: Heart attack and stroke combined are the leading cause of death in Delaware, yet are often preventable by addressing the evidence-based ABCS of cardiovascular disease prevention-aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation.


Purpose: By aligning the efforts and resources of more than 60 statewide partners on the ABCS, Million Hearts(R) Delaware is helping to prevent 1 million heart attacks and strokes nationally by 2017.


Design/Implementation: Our partners include all major Delaware hospitals, government, large employers, and healthcare providers. Our aim is 3-fold-public awareness, blood pressure screening, and provider engagement. For public awareness, we focus on knowing your numbers for blood pressure and waist circumference-2 easily measured risk factors-and tobacco cessation, the single most important behavior for risk reduction. Community outreach includes health fairs and screenings, articles in local newspapers and newsletters, and various forms of social media. We connect at-risk individuals to care and empower them to address the ABCS with their providers. Our tobacco cessation efforts concentrate on the 2 most effective, evidence-based methods for reducing tobacco use-negative advertising and increasing taxes. For provider engagement, we promote best practices of the ABCS through videos, articles, presentations, and educational materials.


Evaluation/Outcomes: We have delivered our key messages to 20 000+ individuals and screened more than 1200 people for hypertension. More than half of our blood pressure screenings are of African Americans, who have a higher prevalence of hypertension, are more likely to have unknown and untreated hypertension, and who have greater rates of complications.


Implications for Practice: Million Hearts(R) Delaware, an award-winning coalition with limited funding, illustrates the power of partnership in a small state. Through this public-private statewide effort, Delaware is a role model state in its initiative to help prevent 1 million heart attacks and strokes nationally by 2017.


Poster Presentation

First Place: Reducing Length of Stay for Cardiothoracic Surgery Patients Via Implementation of a Cardiac Rehab Phase I Program

Janie Baranyay MSN, RN, APN, FPCNA, Brian Salle, MEd, RN-C, CCRN, CSC, RCEP, John Hanlon BSN, RN, CCRN, Richard D. Hulse PA-C, Alex Rodriguez, MD, Susan Levine-Beutel, RN, Carol R. Russell MS, CPHQ, CFLE, Jersey Shore University Medical Center, Neptune, New Jersey.


Background: Early mobilization is known to decrease length of stay and postoperative complications associated with cardiothoracic (CT) surgery while allowing for an assessment of the patient's functional capacity related to discharge disposition.


Purpose: An analysis of the Society of Thoracic Surgery data registry from 2013 indicated, when compared with like-sized programs across the nation, there was a 12% longer length of stay for the CT surgery patient at Jersey Shore University Medical Center. The purpose of the project was to attempt to decrease the length of stay for CT surgery patients via implementation of a cardiac rehabilitation phase I program with a strong emphasis on early ambulation.


Design/Implementation: A multidisciplinary committee was convened to design a safe process for ambulation for CT surgery patients who were deemed medically stable to participate. Implementation was possible by concurrently developing an exercise science internship to assist the clinical staff with early mobilization.


Evaluation/Outcomes: Assessment of length of stay (LOS) data from February 1, 2014, to May 1, 2014, demonstrated a decreased LOS of 1.24 days. Estimated annual cost savings of $355 136.00 are projected based on calculating an average savings of $400.00 per day x 1.24 x 716 cases. The exercise science interns enjoyed a robust experience and interaction with role models that helped shape their future career choices.


Statement of Conclusions: Implementation of a cardiac rehabilitation phase 1 program while concurrently developing an exercise science internship demonstrates a significant financial savings for the institution while positively impacting both the CT surgery patient's postoperative course as well as the future course for the student interns.


Implications for practice: Institution of an inpatient cardiac rehabilitation phase 1 program leads to improved patient outcomes while demonstrating a solid financial savings via decreased LOS.


Second Place: Preventive Care in Women: A Community-Based Intervention to Decrease the Risk of Cardiovascular Disease

Deborah S. Petty DNP, APRN, ACNS-BC, MidAmerica Nazarene University, Olathe, Kansas.


Background: In women, the leading cause of death is heart disease, and the third leading cause of death is stroke. Data reveal that 83% of women are at risk or at high risk of developing cardiovascular disease (CVD); 13% of women without risk factors do not participate in healthy lifestyle behaviors, and only 4% of women are at optimal risk.


Purpose: A workplace wellness program was provided to decrease women's risk of CVD. The program was designed to increase awareness and knowledge about women and heart disease, provide a 10-year predicted CVD risk percentage, obtain an explicit commitment to close one's intention-behavior gap, and provide resources to develop skills to aggressively lessen CVD risk factors.


Design/Implementation: This quasi-experimental study of female employees used a pretest and posttest design. The 12-week intervention consisted of an educational session, weekly lessons and e-mail communication, and monthly support group sessions. The CVD Risk Prediction Model Using Non-laboratory Predictors guided data collection (age, body mass index, blood pressure, tobaccoism, diabetes mellitus) and was used to measure change in 10-year predicted CVD risk percentages.


Evaluation/Outcomes: Twenty-five (mean age, 49.1 [SD, 8.6]) of 28 women (89.3%) completed the program. Nineteen (76%) were at risk or at high risk for developing CVD. Eight (32%) experienced a statistically significant (P = .003) decrease in CVD risk. Decrease in systolic blood pressure in women not on antihypertensive medication was the CVD predictor that was most impacted (group P = .06; women 50-59 years old, P = .06; women with decreased risk, P = .05). Five (20%) were referred to their primary care provider for follow-up of elevated blood pressure.


Implications for Practice: Cost-effective CVD prevention efforts can be implemented in community settings where people live, work, worship, study, and play to increase awareness, improve health, and avert risk.


Third Place: Screening for Depression and Quality of Life in Cardiac Rehabilitation

Kevin Goodwin, BSN, RN, Amanda Malecky, BSN, RN, Janet Cipkala-Gaffin, DrPH, PMHCNS-BC, Jonathon Ledyard, MS, RCEP, FACC, University of Pittsburgh Medical Center, Pennsylvania, Mohammad Alrawashdeh, MSN, BSN, University of Pittsburgh, Pennsylvania.


Background: Cardiovascular disease and depression are 2 of the nation's most prevalent health problems. Depression is 3 times more common in patients with heart disease compared with the general population and is associated with decreased medication compliance, higher healthcare costs, and interruptions in cardiac rehabilitation participation. It is important therefore to determine the influence depression has on individuals' quality of life (QOL), a measure increasingly acknowledged and advocated in clinical settings.


Purpose: The aim of this project was to describe the pattern of depression and patients' perceived QOL and to determine if a significant association exists between the 2 measures among patients affected by cardiovascular disease in a cardiac rehabilitation setting.


Design/Implementation: The Patient Health Questionnaire (PHQ-9) and Dartmouth Quality of Life Index were administered to 279 cardiopulmonary rehabilitation participants during their initial visit and again at the conclusion of the program. The pattern of both measures was described at both time points, and the association between them was examined using Spearman correlation.


Evaluation/Outcomes: Of the 171 (61.2%) who completed both the PHQ-9 and the QOL measures at the initial visit, 16 patients (9.4%) screened positive for depression, and the majority reported moderate QOL score (mean, 21.7 [SD, 5.3]). For the final visit, 105 completed both measures; only 4 (3.8%) screened positive for depression, and there was improvement in the QOL score (15.5 [SD, 3.7]) compared with the initial score (21 [SD, 5.2]) for the same patients. A significant relationship was found between depression and QOL at both the initial (correlation = 0.514, P < .001) and final visits (correlation = 0.531, P < .001).


Implications for Practice: Understanding the significant association between depression and QOL scores may assist healthcare practitioners in treating this population and subsequently enhancing patients' QOL. Additional studies should be conducted to further determine the clinical relevance of this association.