Intervening on fear after acute cardiac events: Rationale and design of the INFORM randomized clinical trial

Protocol for the development and validation of a clinical measurement tool for fear of disease progression and recurrence in cardiac patients

Introduction

One in two cardiac patients fear having another heart event or their heart condition getting worse. Research in other chronic illnesses demonstrates that screening for fear of progression and recurrence is vital for adequately addressing such concerns in clinical care. The current project aims to develop and validate a measure for fear of progression and recurrence in cardiac patients.

Methods

The Fear of Cardiac Recurrence and Progression Scale (FCRP) will be developed through a multistep process. An initial item pool will be generated through a review of the literature and existing measures and consultation with and feedback from key informants. The item pool will be tested in a sample of over 250 adults who have ever had an acute coronary event, undergone cardiac surgery, or a chronic cardiac condition. Exploratory factor analysis will be used to identify the underlying factors, and Rasch analysis will be used to reduce the number of items. A short form version of the FCRP will be developed for use as a brief screening tool, informed by clinical relevance and Rasch psychometric indices.

Discussion

While many cardiac patients experience fears related to the progression or recurrence of their illness, there remains the need for a validated tool with which these concerns can be identified and measured. It is expected that the design and validation of the FCRP will aid identification of cardiac patients suffering from clinically significant levels of fear of progression and recurrence and facilitate the design of tailored psychological interventions to target these fears.

Physical Activity After Heart Surgery: Associations With Psychosocial and Sleep Factors

BACKGROUND

Heart surgery is an effective intervention for managing heart disease, the leading cause of death globally. After surgery, physical activity is key to improving patients' quality of life and decreasing mortality, but patients are frequently physically inactive after heart surgery.

OBJECTIVE

This cross-sectional pilot study aimed to examine how psychosocial and sleep factors influenced physical activity in patients after heart surgery. The mediating role of sleep factors between psychosocial factors and physical activity was also examined.

METHODS

Thirty-three patients who had undergone heart surgery were recruited. Psychosocial and sleep factors and physical activity were measured using an online survey and a wrist-worn ActiGraph for 7 days and nights.

RESULTS

The participants had heart surgery an average of about 7 years previously. They exceeded the recommended 150 minutes per week of moderate-intensity physical activity for Americans; however, 64% of them showed poor sleep quality (Pittsburgh Sleep Quality Index >5). Higher anxiety and depressive symptoms, lower self-efficacy, and greater sleep disturbances were associated with lower physical activity. Moreover, self-efficacy, sleep duration, sleep disturbance, sleep efficiency, and wake after sleep onset were predictors for physical activity. No mediating role of sleep factors was observed between psychosocial factors and physical activity.

CONCLUSIONS

Psychosocial and sleep factors should be considered when developing and implementing physical activity strategies for patients after heart surgery. Researchers should examine the relationships among the study variables with larger samples of postsurgical cardiac patients during different periods after heart surgery.

Home-based cognitive bias modification training for reducing maladaptive fear in patients with suspected acute coronary syndrome: a pilot randomized clinical trial

BACKGROUND

Patients evaluated in an emergency department for suspected acute coronary syndromes (ACS; e.g., myocardial infarction) often experience a lingering fear of recurrence, which may adversely affect their mental health and adherence to recommended health behaviors. Cognitive bias modification training (CBMT) is an acceptable, easy-to-use intervention that reduces fear of recurrence in cancer patients, and reduces fear and anxiety in other populations, providing an alternative to psychotherapy or counseling-based approaches. Feasibility testing is needed to assess whether a cardiac-related version of CBMT is acceptable to patients with elevated threat perceptions related to their suspected ACS.

METHODS

We developed a tablet-based CBMT intervention tailored to reduce cardiac-related fear of recurrence. In this double-blinded feasibility trial, patients with elevated threat perceptions related to a recent suspected ACS were randomized either to a 4-week, 8-session, tablet-delivered intervention (CBMT) group or to a sham attention control group. Feasibility outcomes included the proportion of eligible patients who enrolled, drop-out rate, intervention compliance rate, acceptability/pleasantness and usability ratings, and task engagement (i.e., accuracy, response time).

RESULTS

Of 49 eligible patients with suspected ACS and elevated threat perceptions recruited from NewYork-Presbyterian Hospital, over half (53.1%) enrolled after receiving a description of study procedures. Of the 26 randomized patients (mean age 59.15 years, 50% women), 2 patients (7.7%) dropped out. Additionally, 4 (15.4%) enrolled patients were not able to complete the tablet tasks, either due to difficulties with the technology or an inability to process the visually presented linguistic information at a sufficient speed. Still, among patients who returned the tablets (19 returned/20 received; 95%), most completed all assigned tablet tasks (intervention or control; 10/19; 52.6%), reporting that the tablets were easy to use and that the tasks were pleasant to complete.

CONCLUSION

Current findings suggest that cardiac-related CBMT is a promising and generally acceptable intervention for suspected ACS patients with cardiac-related threat perceptions which are akin to fear of recurrence. Nevertheless, challenges related to tablet usage indicate that the intervention user-experience should be further refined to optimize usability.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov on 2/25/2019; NCT03853213. Registered with the Open Science Framework on 11/20/2017; https://osf.io/k7g8c/ .

Psychosocial and lifestyle impacts of spontaneous coronary artery dissection: A quantitative study

INTRODUCTION

Recent studies suggest that acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) carries significant psychosocial burden. This survey-based quantitative study builds on our earlier qualitative investigation of the psychosocial impacts of SCAD in Australian SCAD survivors. The study aimed to document the prevalence and predictors of a broad range of psychosocial and lifestyle impacts of SCAD.

METHOD

Australian SCAD survivors currently enrolled in the Victor Chang Cardiac Research Institute genetics study were invited to participate in an online survey to assess the psychosocial impacts of SCAD. Participants completed a questionnaire, developed using findings from our earlier qualitative research, which assessed 48 psychosocial and five lifestyle impacts of SCAD. Participants also provided demographic and medical data and completed validated measures of anxiety and depression.

RESULTS

Of 433 SCAD survivors invited to participate, 310 (72%) completed the questionnaire. The most common psychosocial impacts were 'shock about having a heart attack' (experienced by 87% respondents), 'worry about having another SCAD' (81%), 'concern about triggering another SCAD' (77%), 'uncertainty about exercise and physical activity' (73%) and 'confusion about safe levels of activity and exertion' (73.0%) and 'being overly aware of bodily sensations' (73%). In terms of lifestyle impacts, the SCAD had impacted on work capacity for almost two thirds of participants, while one in ten had sought financial assistance. The key predictors of psychosocial impacts were being under 50, current financial strain, and trade-level education. The key predictors of lifestyle impacts were being over 50, SCAD recurrence, trade-level education, and current financial strain. All psychosocial impacts and some lifestyle impacts were associated with increased risk of anxiety and/or depression.

CONCLUSION AND IMPLICATIONS

This quantitative study extends our previous qualitative investigation by documenting the prevalence of each of 48 psychosocial and five lifestyle impacts identified in our earlier focus group research, and by providing risk factors for greater SCAD impacts. The findings suggest the need for supports to address initial experiences of shock, as well as fears and uncertainties regarding the future, including SCAD recurrence and exercise resumption. Support could be targeted to those with identified risk factors. Strategies to enable SCAD survivors to remain in or return to the paid workforce are also indicated.

Fear of Recurrence of Atrial Fibrillation: Translating a Cancer Fear Model to the Atrial Fibrillation Patient Experience

BACKGROUND

Atrial fibrillation occurs when rapid and disorganized electrical signals cause the atria in the heart to beat irregularly and is associated with an increased risk for stroke. Despite medical advancements, first and second line atrial fibrillation treatments exhibit significant recurrence rates. Because of this, atrial fibrillation patients often experience disease-specific fears that are not routinely assessed and targeted in clinical management. Fear of recurrence models in cancer research and other cardiac-specific fears have paved the way for a patient-centric approach to disease intervention.

PURPOSE

Clinical assessment focused solely on the taxonomy of anxiety disorders may miss key components unique to the atrial fibrillation patient experience. An anxiety disorder diagnosis in the presence of an arrhythmia could be misleading and ultimately fail to address patient needs. Modeled from the cancer literature, providers may benefit from a broader disease specific conceptualization for AF patients that differs from a general DSM-5 diagnosis.

AIMS

The objectives of this paper are: (1) to review the medical aspects of atrial fibrillation, (2) to examine the comparability of fear of recurrence concept from cancer literature to the atrial fibrillation patient, and (3) to suggest considerations of these novel concepts in patient care.

FUTURE DIRECTIONS

Increased understanding of fear of recurrence among atrial fibrillation patients aims to define and assess fear of recurrence components, determine treatment targets, and ultimately improve patient outcomes.

The use of medication adherence guidelines in medication taking behaviour research

Medication nonadherence continues to be a serious issue in a range of long-term medical conditions and has been studied extensively over the past few decades. However, despite the plethora of research studies on medication adherence, poor methodological rigour in many studies has contributed to limited generalisability of the positive findings, limited impact on patients' medication adherence, and inability to compare between studies. This paper focuses on current guidelines designed specifically for research on medication adherence. It discusses key elements to consider during study design, selection of adherence measurements, and reporting on medication adherence research, to ensure a higher quality of research in medication adherence. Overall, there appears to be variations in adherence terminology reported in the literature despite improvements in defining medication taking behaviour and the availability of taxonomies. In addition, limited guidance exists on how best to measure adherence. Recommendations are provided on appropriate adherence measures for the adherence behaviour being investigated, including careful consideration of adherence concepts, validity of adherence instruments, appropriate instrument selection, definition of nonadherence threshold, and how to report medication adherence. Improving adherence research requires greater clarity and standardisation of descriptions of nonadherence behaviour, increased methodological rigour in study designs, better selection of adherence measurements, and comprehensive reporting.

Future directions of the National Institutes of Health Science of Behavior Change Program

Background

The National Institutes of Health Science of Behavior Change Common Fund Program has accelerated the investigation of mechanisms of behavior change applicable to multiple health behaviors and outcomes and facilitated the use of the experimental medicine approach to behavior change research.

Purpose

This commentary provides a brief background of the program, plans for its next phase, and thoughts about how the experimental medicine approach to behavior change research can inform future directions in two areas of science—reproductive health and COVID-19 vaccine uptake.

Conclusions

The incorporation of a mechanisms-based approach into behavior intervention research offers new opportunities for improving health.