A review of current coronary heart disease research

Corona O" Health Care (1997) 1, 47 53 9 1997 Pearson Professional Ltd

RESEARCH NEWS

A review of current coronary heart disease research B. Linden Nurse Advisor, British Heart Foundation

Coronary angioplasty has been used for about 20 years. Certain problems persist such as: the difficulty of treating lesions such as total occlusions; the possible complication of acute closure needing emergency surgery; and re-narrowing of the coronary artery after 3-6 months. New techniques such as atherectomy, laser, and rotational drills have not yet solved these problems. The coronary stent has played a major part in improving long-term outlook - recently the heparin-coated stent has produced lower rates of restenosis and improved event-free survival for albeit a highly selected group of patients with simple coronary disease (Serruys et al 1996).

CORONARY HEART DISEASE AND INFLAMMATION C reactive protein and its relation to cardiovascular risk factors: a population based cross-sectional study. Mendall M, Patel P, Ballam L e t al 1996 British Medical Journal 312: 1061-1065. Studies have suggested a link between increased inflammatory activity (measured by concentrations of C-reactive proteins (CRPs) and the risk of cardiovascular disease. Recently, preliminary work has provided evidence of a link between CRP and longterm risk of coronary heart disease. Mendall et al (1996) studied 303 men, and found that the prevalence of indirect evidence of heart disease, a history of claudication, age, smoking, and other risk factors increased progressively as concentrations of CRP rose. Two other infections Helicobacter pylori and Chlamydia pneumonia - were also linked with raised concentrations of CRR This work offers another potential approach to CHD prevention. Explanations for raised concentrations of CRP are unclear - there is no link with stable angina or prolonged ischaemic episodes. Enhanced production of interleukin 6 occurs, which has intense inflammatory and coagulating properties. While raised levels of CRP persist, the risk of new episodes of unstable angina and myocardial infarction is greatly increased. Questions remain such as: 1) Will this marker be useful in clinical practice? and 2) Does the inflammation trigger risk factors to develop atherosclerosis, or does the atherosclerosis trigger this inflammatory process?

SPEED IS THE ESSENCE WITH MYOCARDIAL INFARCTION Determinants of the delay between symptoms and hospital admission in 5978 patients with acute myocardial infarction. Otteson M M, Kobel L, Jorgenson Set al 1996 European Heart Journal 17: 429-437. A most important aspect of treatment of myocardial infarction is the initiation of prompt therapy. The effect of treatment is inversely related to this timespan. A recent study highlighted the importance of reducing delay by studying 20-25% of all patients in Denmark receiving in-hospital care for myocardial infarction (Otteson et al 1996). The main focus of the research was the delay from pain onset to hospital admission. The results support previous findings that old-age, female gender, history of diabetes and angina are linked with longer delay. It may be that women, elderly people, and diabetics have atypical symptoms. A difference noted between this study and previous studies was that patients with established heart disease had a shorter delay from onset of pain to admission. However, the delay in treating acute myocardial infarction is still considered to be far too long.

HEPARIN-COATED CORONARY STENTS Heparin coated paimaz Schatz stents in human coronary arteries. Serruys P W, Emanuelsson H, van de Griesson W e t al 1996 Circulation 93: 412-422. 47

48

Coronary Health Care

MEALS, EXERCISE AND ANGINA

Angina, exercise and food. Harcombe A A, Shapiro L M 1996 European Heart Journal 17: 335-336. The effect of meals of differing composition on exercise tolerance in patients with angina pectoris Lain FY, Wilson AT, Channer KS 1996 European Heart Journal 17: 394-398. Comparison of cardiovascular response to combined static-dynamic effort, postprandial dynamic effort and dynamic effort alone in patients with chronic ischaemic heart disease. Hung J, McPhillip J, Savin W e t al 1982 Circulation 65:1411-1419. Angina was observed as more easily provoked after eating as long ago as 1772. Exercise capacity has been seen to fall, heart-rate increases and stroke volume can increase by up to 60%. Peripheral vascular resistance falls due to gut dilatation. A recent report discusses the effect of eating meals of differing composition on effort tolerance for patients with stable angina (Lam et al 1996). Exercise treadmill testing and cardiac output measurements were carried out on four occasions after meals of either mainly fat, mainly carbohydrate, a balanced meal, or water alone. Improvement in post-prandial exercise time was seen after the meal of mainly fat compared to the balanced meal. Cardiac output increased significantly only after the balanced meal when compared with water alone. The authors suggest that the higher carbohydrate intake may increase sympathetic activation. Although the meal containing mainly fat improved exercise tolerance, there is no case for encouraging atherosclerosis progression for this reason. Harcombe and Shapiro (1996) suggest that betablockers may attenuate the post-prandial response, but also feel that the complexity of the changes that occur after food demands that further evaluation of the role of beta blockers on post-prandial exercise is needed. Other questions that need to be answered are: should all patients with angina be told to rest for half an hour after a meal? How much food is considered to comprise a meal or a snack? The answers to these questions are not yet certain. A previous study found that patients with a negative exercise test were at a low risk of post-prandial angina and so these patients may be allowed to exercise after eating if they wish (Hung et al 1982). However, Harcombe and Shapiro suggest that a reasonable approach for patient advice may be that all patients with angina should avoid exercise in the immediate period after a meal. Also, if patients find that they suffer from angina after food they may need to be advised to have further investigation because of the increased likelihood of significant coronary disease.

WAITING FOR REVASCULARIZATION AND IMPLICATIONS

Distress correlates with the degree of chest pain: a description of patients awaiting revascularisation. Bengston A, Herlitz J Karlsson T et al 1996 Heart 75: 257-260. Uncertainty is an important symptom in patients awaiting revascularisation procedures. Crisp AH 1996 Heart 75: 221. Some experimental and physical associations of imminent myocardial infarction in males. A prospective epidemiological study. Crisp AH, Queenan M, D'Souza M et al 1985 Fifteenth European Conference on Psychosomatic Research. Safety in numbers: waiting and weighting for coronary surgery. Lira R, Caplin JL, Dymond DS et al 1995 European Heart Journal 16: 1764-1766. The number of patients with coronary heart disease who are awaiting angiography, angioplasty, or coronary bypass surgery has increased over the last 20 years. Uncertainty, anxiety and depression linked with the waiting period are understandable emotions experienced by many patients. Few studies have assessed the association between the symptoms of pain during this waiting period with other factors which affect patients' well-being. A Swedish study recently reported that the majority of patients found fear and uncertainty about the future to be more distressing than the symptoms of chest pain (Bengstom et al 1996). The study involved 904 patients who were sent a questionnaire to evaluate their symptoms. The response rate was 92%: 522 patients awaited angiography, 57 awaited angioplasty, and 325 were waiting for coronary artery bypass surgery. The study showed that patients waiting for revascularization are anxious and depressed and that these measures of well-being are linked with the severity of pain and dyspnoea. The most disturbing symptom uncertainty concerned their chances of survival, speed of treatment, and the future for their families, more than the length of their waiting period. Crisp (1996) suggests that such distress could precipitate further cardiac events. His research indicated that, when emotional distress was included with other major risk factors, the prediction of infarction increased from 50% to 83% (Crisp et al 1985). Waiting for revascularization is an unresolved problem in the UK. A common argument is that there is a chronic shortfall in resources accounting for the long waiting lists. A way to avoid adverse cardiac events is to shorten waiting lists. The evidence from major trials is that the safety time for patients with left main-stem and triple vessel disease is 3 and 12 months respectively but only if swift surgery is available if necessary. Canada, in contrast, regards cardiac surgery as being 'delayed' if performed more than six weeks after angiography. Lim et al (1996) propose that coronary angiography could be restricted to

Research News 49 patients who may benefit from invasive intervention. Safe rational priorities for coronary artery bypass graft may avoid unacceptable delay for patients.

WOMEN ARE DRINKING MORE Living in Britain. General Household Survey. London: HMSO, 1994: A323. Results from the 1994 General Household Survey published by the Office of Population Censuses and Surveys has reported that women are drinking more than ever before, with 13% of women drinking more than 14 units per week. This shows an increase from 11% of women drinking above sensible limits in 1992 and 9% in 1984. Although the 'sensible' limits have recently been revised, the safety margin remains largely unchanged. The General Household Survey is based on a random sample of private households, and women in professional households were twice as likely to exceed the recommended levels of drinking as those in semi-skilled jobs. The same contrast was noted between women who worked full time compared to part time.

THE ROLE OF THE PRIMARY NURSE Practitioners' perceptions of primary nursing. Furlong S 1996 Professional Nurse 11(5): 309 311. Primary nursing aims to enhance the quality of care delivered to patients and emphasizes an understanding of the individual roles of staff, with full responsibility for the nursing care of patients from admission to discharge. Recently a study at the Glenfield Nursing Development Unit examined primary nurses' perception of their roles (Furlong 1996). The 19-bed cardiology unit had 7 primary nurses, 16 associate nurses, and 6 healthcare assistants who completed a questionnaire. Primary nurses were seen as autonomous team leaders who should justify their actions to the team. Associate nurses were continuity nurses with a variable degree of responsibility. Healthcare assistants saw their role as supporting, but were seen by other nurses as support workers and housekeepers. This disagreement in roles is currently being debated within the unit.

LONG-TERM TREATMENT IN ITU Post intensive care interviews: implications for future practice: Sawden V, Woods I, Proctor M e t al 1995 Intensive and Critical Care Nursing 11(6): 329-332. A recent study has provided insight into the care given to patients admitted to intensive care units and their families, who were interviewed in their own homes 6 months after discharge (Sawden et

al 1995) Fifty-seven patients admitted to an ITU were interviewed using a profile of mood questionnaire and interviews. They recalled physical discomfort, psychological distress, and upset circadian rhythms, with frightening nightmares that some could recall months later. Long-term physical scarring occurred after certain invasive procedures were carried out. Although early post-discharge support for patients was considered adequate, long-term support appeared lacking. Family members also experienced difficulties in adapting to the changed roles within the home. A third of those questioned had not mentioned these problems to their general practitioners, although these could have been resolved by health education advice or a support group. These results have triggered changes within the study area to improve the ITU that carried out the study.

THROMBOLYSIS AND DELAY Pre-hospital thrombolysis with either alteplase or streptokinase. Grijseels EW, Bonton MJ, Lenderink T et al 1995 European Heart Journal 16: 1833-1838. Despite the confirmed effectiveness of thrombolysis following myocardial infarction, the benefits are reduced if there is a delay in starting treatment after the onset of symptoms. There have been many initiatives developed to ensure that rapid treatment is carried out. Grijseels et al (1995) have assessed the practicality and long-term outcome of prehospital thrombolysis for 330 patients from 1988 to 1993 in the Netherlands. The general practitioner or the nurse used a standardized questionnaire to exclude those with contraindications. Computerized ECG was recorded by the ambulance nurses and, if there was extensive ST segment elevation, either alteplase or streptokinase was given. By 1993, 529 patients had received pre-hospital thrombolysis. There was found to be a low rate of complications, low hospital mortality and a 92% survival at 5 years. The 5-year survival for a matched group who received alteplase was 84%. The authors conclude that pre-hospital administration of thrombolytic therapy is safe, saves time and improves long-term survival. ASIAN WOMEN AND PSYCHOLOGICAL DISTRESS Culture, relativism, and the expression of mental distress: South Asian women in Britain. Fenton S, Sadiq-Sangster A 1996 Sociology of Health and Illness 18(1): 66-85. Cultural differences exist in the expression of certain symptoms even though there are common cultural elements in ideas about illness. These views are supported by two studies of South Asian women from the Punjab (Fenton & Sadiq-Sangster 1996).

50

Coronary Health Care

The study aimed to seek their views on health, illness and everyday life, while the second study focused particularly on psychological distress. Few of the women could speak English and none had been born in the UK. The women were mostly unaware of the term 'depression', although their symptoms of loss of appetite, tearfulness, and suicidal thoughts suggested that they were depressed. The term 'thinking in my heart' was often used and linked with distressing experiences such as bereavement.

Artery Risk Development in Young Adults (CARDIA) study is carrying out ongoing investigations of lifestyle and follow-up in a random sample of young adults ranging from 18 to 30 years at baseline (Liu et al 1996). Diastolic blood-pressure over four separate examinations was found to be positively associated with age, body mass index, alcohol intake, and negatively associated with physical activity, cigarette use, intake of potassium, and protein. After adjusting for obesity and other lifestyle factors, differences between blacks and whites were substantially reduced.

Renews TRIGGERING SUDDEN DEATH T R E N D S IN C O R O N A R Y H E A R T D I S E A S E Recent trends in coronary heart disease. Mortality, morbidity, medical care, and risk factors. McGovern

PG, Pankow JS, Shahar E et al 1996 New England Journal of Medicine 334: 884-890. Major risk-factors for coronary heart disease include smoking, high blood-pressure, obesity, cholesterol, inactivity, heredity, diabetes, and many other contributory factors. Numerous studies continue to investigate these factors to determine associations, differences and trends. Mortality trends in coronary heart disease continue to decline in the UK, but the rate of decline is not as fast as in the USA. McGovern et al (1996) discuss the trends in the USA from 1985-90 and identify possible reasons for the decline by examining residents from Minneapolis and St Paul's, Minnesota. Reduced in-hospital mortality, out-of-hospital mortality, and hospitalizations with improved survival for patients recovering from myocardial infarction, were explained by increased use of thrombolysis, heparin, aspirin, and angioplasty, with improved risk-factor profile of the population studied. Smoking has been associated with the progression of coronary heart disease as well as the incidence of sudden death and myocardial infarction. Voors et al (1996) examined the long-term effects of smoking and smoking cessation after coronary artery bypass surgery using the saphenous vein. A total of 415 patients who had surgery between 1976 and 1977 were followed up prospectively for 15 years. Smoking behaviours at 1 and 5 years after surgery appeared to be important factors influencing future risk. Compared to those who stopped smoking at surgery, those who still smoked at one year had more than twice the risk of myocardial infarction and of repeat operation. Even more at risk of reoperation, myocardial infarction, and angina were those who were still smoking at five years. In contrast, no difference in risk was seen between those who gave up smoking at surgery and non-smokers. Black men and women have higher blood-pressure on average than whites, although this pattern is not apparent in childhood or adolescence. The Coronary

Sudden cardiac death triggered by an earthquake. Leor J, Poole W, Kloner RA 1996 New England Journal of Medicine 334: 413-419. Triggering of sudden death - lessons from an earthquake. Muller J, Verrier R 1996 New England Journal of Medicine 334: 460-461. Autonomic nervous system and sudden cardiac death: experimental basis and clinical observations for post-myocardial infarction risk stratification. Schwartz PJ, La Rovere MT, Vanoli E 1992 Circulation Suppl 1:1 77; 1-91. Researchers have recently investigated links between sudden death and the trigger of an earthquake (Leor et al 1996). The intense fright of an earthquake in 1994 appeared to provoke a 5-fold increase in cases of sudden death. Also, there were more myocardial infarctions, and more ventricular arrhythmias in patients with internal cardiac defibrillators. Although Muller and Verrier (1996) argue that these findings may have been due to more coroners' cases, evidence has accumulated linking acute events with mass triggers such as mornings, Mondays, holidays, and winter. Leor et al's suggestion that psychological rather than physical stress may trigger many cases of sudden death, is likely to generate more research. Schwartz et al (1992) are now investigating the benefits of reducing psychological stress in preventing sudden death.

SUDDEN DEATH IN THE YOUNG Sudden death from cardiac causes in children and young adults. Liberthson RR 1996 New England

Journal of Medicine 334(16): 1039-1044. Sudden death in the young is extremely rare. Data from various studies have shown that the rate of sudden death ranges from 1.3 to 8.5 per 100 000 patient years, but the impact on a community can be dramatic. Liberthson (1996) recently reviewed the causes of sudden death among young people. Commonest causes were myocarditis, cardiomyopathy, coronary artery disease, congenital coronary defects, conduction defects, mitral valve prolapse, aortic

Research News 51 dissection and congenital disease. Screening for family history of sudden death and ECG abnormalities may reduce this risk.

TRIGGERING A HEART ATTACK Triggering a heart attack. Petch MC 1996 British Medical Journal 312: 459-460. News headlines of sudden death during an emotional incident or attack have led the press and public to blame most heart attacks on events. However, Petch (1996) asserts that, although physical activity or emotional upset has been reported to be present in 4-18% of cases, naturally occurring heart attacks are extremely common and therefore some are bound to occur after a physical or emotional event.

transplants but fewer than 3000 human organ transplants were performed in 1996. It is believed that eventually these organ shortages will influence public acceptance of xenotransplantation - if it ever becomes a feasible option. Improving the donor system, antirejection techniques and encouraging more people to donate may even double organ donation, but will not solve the increasing demand for transplants (Rigglesford 1996) Since 1964, there have been various xenotransplants performed in the USA. Major organs such as liver, heart, and kidneys have been used for primates, pigs or sheep without success. However, pig heart valves are now routinely used, and brain tissue from fetal pigs has been transplanted to four patients with Parkinson's disease.

QUALITY-OF-LIFE MEASUREMENTS XENOTRANSPLANTATION Submission by the Research for Health Charities Group to the Department of Health Advisory Group on the Ethics of Xenotransplantation. Rigglesford M 1996. Pig transplants win ethical backing. Vines G 1996 New Scientist 9 March: 4. Ethics group paves way for human use of animal organs. Hawkes N 1996 The Times 6 March: 10. Animal to human transplantation: the ethics of xenotransplantation. Nuffield Council on Bioethics 1996. London: Nuffield Foundation. The independent bioethics committee, the Nuffield Council of Bioethics, has produced a report describing the steps which should be taken to minimize the risk to the human population from animal organ donation. The panel of scientists on the Nuffield Council have given cautious ethical approval to xenotransplantation. It states that, before human trials begin, there must be rigorous screening and monitoring for any infectious organisms. One of the main clinical concerns is that there is a remote chance of an animal virus spreading to a susceptible human. It is feared that transplanting organs directly to the human body may produce a new situation with the risk of slowly emerging diseases. To produce clean organs, the animals may need to be raised in sterile isolation. Before human trials begin, Imutran, the Cambridge biotechnology company, will need to demonstrate prolonged survival in animals. The Research for Health Charities Group stress that xenotransplantation is an ethical issue for all members of society, and that general public acceptability will depend on informed debate, and a clear understanding of the controls imposed on scientists. Over 400 heart, heart-lung and lung transplants are performed each year, while there are still 600 people on the waiting list for such transplants. Overall, about 5000 patients are on the waiting list for

Assessment of quafity of life outcomes. Testa MA, Simonson D C 1996 New England Journal of Medicine 344 (13): 835-839. Constitution of the World Health Organization. In: World Health Organization Handbook of Basic Documents, 5th edn. Geneva: Palais de Nations, 1952. Health has been defined as not only the absence of disease but also the presence of physical, mental and social well-being (WHO 1952). There has been a massive increase in the number of studies involving qualityof-life measures that gauge changes in physical, social, and psychological health. These are described in a review article by Testa and Simonson (1996) as both subjective (expressing perceptions and expectations) and objective (defining the degree of health). Measurements can be complex, and each area really needs a separate approach. A simple suggestion of scale of 1-10 on quality of life or overall health can be too vague to be usefully interpreted. The questions to measure quality of life can be asked of the patients and then converted into scale scores. The measures should contain both objective and subjective areas such as symptoms, condition or social concerns. Consistent values of similar values in consistent conditions will improve the power of the measurement. The usual study designs used in health research are large cross-sectional or longitudinal and describe predictors of the quality of life, or the randomized study of clinical intervention reflecting the nature of the illness, or the study of cost-effectiveness. Research into quality of life must show that the treatment or intervention is worth considering further in medical practice. A scale reflecting stress, sleeping habits, or well-being as well as overall quality of life may be able to be interpreted more easily. The benefits from research into quality of life depend on whether it can be easily understood and interpreted by clinicians. It will be fully accepted when

52

Coronary Health Care

it answers questions about, for example, the effectiveness of a programme on complications as well as quality of life, compliance of patients with chronic disease, whether gains in survival for those with limited lifeexpectancy are offset by aggressive treatment, or whether cost-reducing programmes are ineffective because of reduced productivity of the staff. Links between the medical intervention, the physical effects, and quality of life can help the clinician better understand the implications of the illness and of the treatment.

Patients who are involved in decision making about their care have been found to have improved outcome - although it is uncertain whether decision-making or exercise of choice is therapeutic. Expectations reflect outcome?: If patients perceive that they will benefit from a particular test or procedure, they have been found to have fewer problems of disability. Also, patients with more positive expectations from coronary bypass surgery have been reported to have a speedier recovery. These issues point to a need for health professionals to share more information with patients this process appears to have real therapeutic potential.

THE VALUE OF PATIENT INFORMATION TRIGLYCERIDES AND CHOLESTEROL Patients' prerogatives and perceptions of benefit. Kee F 1996 British Medical Journal 312: 958-960. Can a physician warn patients of potential side effects without causing fear of those side effects? Lamb G, Green S, Heron J 1994 Archives of Internal Medicine 154: 2753-2756. Patients need information to satisfy themselves that their care and treatment are appropriate to their condition. They are now more ready to question the knowledge and decision-making of the health professional who should provide enough information to help decision-making and avoid confusion. Sound unbiased information?: Kee (1996) questions whether most doctors have the ability to make rational choices based on new information, and also suggests that patients respond more to faith in their doctor's judgement than to clinical trials. There is a wide variation in practice which responds to research findings - this variation appears to depend on the level of enthusiasm for a particular form of care. Kee argues that many doctors are not objective when looking at medical evidence and tend to produce a biased view of treatment success. GPs appear to respond more to studies which show relative rather than absolute reduction in risk when deciding to prescribe a new drug such as cholesterol-lowering medication. Effective communication?: Doctors have been found to overestimate the amount of information understood by patients, while the less the doctor thinks the patient knows the less information is given. The belief that patients become more anxious with more information has been shown to be unlikely, in a recent randomized controlled trial (Lamb et al 1994) where they responded more to in-depth explanation about the treatment effects than simplification of data. Patient participation and choice?: It is argued that increased patient involvement in research-planning both increases control and focuses more clearly on which questions should be addressed. A recent review of 16 studies indicated that effective communication was significantly related to improved health outcome.

Randomised trial of cholesterol in 4444 patients with coronary heart disease: [4s]. Scandinavian Simvastatin Survival Study Group 1994 Lancet 344: 1383-1389. Prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia. Shepherd J, Cobbe S M, Ford Iet al 1995 New England Journal of Medicine 333: 1301-1307. Exercise increases diet induced drops in cholesterol. Fricker J 1996 Lancet 347: 819. Conference update. Focus on triglycerides and new triglyceride therapy. Mason I 1996 British Journal of Cardiology 3: 26. Angiographic assessment of effects of bezafibrate on progression of coronary artery disease in young male postinfarction patients. Ericcson C 1996 Lancet 347: 849-853. Lipid lowering to prevent CHD: where will it all end? Lindsey D 1996 British Journal of Cardiology 3:11-12. Lipid lowering: Findings from recent studies on the treatment of hyperlipidaemia has had dramatic effects upon mortality and morbidity from coronary heart disease (Scandinavian Simvastatin Survival Study Group 1994, Shepherd et al 1995). Although dietary measures remain an important part of the treatment of hyperlipidaemia, the introduction of 'statins' has led to a striking reduction in mortality for those with or without coronary heart disease. Despite the unarguable need for secondary prevention with lipid lowering, Lindsay (1996) poses some questions which still remain: are statins more effective than other lipid lowering drugs? How important are high triglycerides? These issues need clarifying with further studies. Bezafibrate has recently been found to improve the lipid profile, slows atherosclerosis, and reduces coronary events for those recovering from an MI (Ericsson et al 1996). Triglycerides: Speakers at the XIIth International Symposium on Drugs Affecting Lipid Metabolism stressed that triglycerides can be an independent cardiovascular risk factor. Combined data from Europe, the Physicians' Health Study, and the PROCAM study in Germany predicted an increased risk of

Research News 53 coronary heart disease with raised triglyceride levels. Two studies in the USA and Italy have been carried out on the use of Omacor, made up of omega-3 concentrate. Omacor has been found to lower blood triglyceride levels effectively and has been suggested as being useful, along with statins, for lowering elevated cholesterol and triglyceride levels (Mason 1996). Cholesterol lowering, diet and exercise: Cholesterol lowering can be more effective if dieters add regular daily exercise. A study in California evaluated the effect of diet with or without exercise on 370 people with high low-density lipoprotein (LDL) and low high-density lipoprotein cholesterol levels (Fricker J 1996). For both men and women, the drop in LDL cholesterol was twice as effective in the exercising and dieting group as in the dieting only group. This reinforces previous findings that cholesterol lowering is more effective with regular exercise - at least 45 min of brisk walking 3 times a week.

THE PATIENT IN HOSPITAL An alien place. Rosenthal H 1996 Nursing Times 92(12):4849. The need for communication and support of the patient in ITU is of prime importance in recovery. Although recollections of intensive care are often hazy, a recent article provides a patient's vivid account of her experience in ITU after cardiothoracic

surgery and reconfirms the need for care, however technical the setting (Rosenthal 1996). Although unaware of her surroundings on the first post-operative day, there followed many dream-like images of distorted faces, with sounds within the ITU interpreted as part of these dreams. Explanations of procedures by staff did not help correct the interpretation of these noises. She experienced loss of trust in certain staff who did not appear concerned with her care. The total dependence on these staff and the technical equipment was frightening. Communication was helped considerably by direct eye-contact and a system of hand-squeezes to indicate yes or no. People often spoke too fast or did not allow time for a response. Words written on paper were most important for communication. Time lost its day-and-night pattern, and the clock was often concealed by a curtain. Mouth rinses were a small pleasure which was enhanced if the rinse was ice-cold. Discussion among staff about who had previously carried out a procedure understandably created fears and lost confidence. Other inadequacies included insufficient links between specialities, medical and nursing staff; no clear plan on which to measure progress; no envisaged discharge date; no communication about rehabilitation. Rosenthal recommends that patients should be encouraged to revisit the ITU to reshape any distorted perceptions.