Distribution of Mobile Health Applications amongst Patients with Symptomatic Peripheral Arterial Disease in Germany: A Cross-Sectional Survey Study

Awareness of smoking cessation amongst German vascular surgeons

Background: Smoking represents the well-known enemy of vascular well-being. Numerous previous studies emphasised the important role of smoking on the development and progression of atherosclerotic cardiovascular disease. The current study aimed to identify hurdles and barriers for an insufficient implementation of secondary prevention in the treatment of lower extremity peripheral arterial disease (PAD). Methods: All members of the German Society for Vascular Surgery and Vascular Medicine (DGG) with valid email addresses were invited to participate in an electronic survey on smoking. Results are descriptively presented. Results: Amongst 2716 invited participants, 327 (12%) submitted complete responses, thereof 33% women and 80% between 30 and 59 years old (87% board certified specialists). 83% were employed by hospitals (56% teaching hospital, 14% university, 13% non-academic) and 16% by outpatient facilities. 6% are active smokers (63% never) while a mean of five medical education activities on smoking cessation were completed during the past five years of practice. Only 27% of the institutions offered smoking cessation programs and 28% of the respondents were aware of local programs while a mean of 46% of their patients were deemed eligible for participation. 63% of the respondents deemed outpatient physicians primarily responsible for smoking cessation, followed by medical insurance (26%). Conclusions: The current nationwide survey of one scientific medical society involved in the care of patients with vascular disease revealed that smoking cessation, although being commonly accepted as important pillar of comprehensive holistic care, is not sufficiently implemented in everyday clinical practice.

Exercise Training for Patients With Peripheral Arterial Occlusive Disease

BACKGROUND

One-third of all persons with peripheral arterial occlusive disease (PAOD) suffer from intermittent claudication. Exercise training under appropriate supervision is recommended in the pertinent guidelines, but physicians order it too rarely, and so-called vascular exercise groups are not available everywhere. This situation needs improvement in view of the impor - tance of walking ability and cardiorespiratory fitness for patients' quality of life and long-term disease outcome.

METHODS

We review the scientific evidence on exercise training and on ways to lower barriers to the ordering of exercise training and to patient participation, on the basis of pertinent articles retrieved by a search of PubMed and in specialized sports science journals.

RESULTS

10 meta-analyses, 12 randomized controlled trials (RCTs), and 7 cohort studies were considered for this review. Largescale cohort studies have shown that exercise is associated with a lower risk of death (relative risk 0.65-0.78 after 12 months of exercise training, compared to an inactive lifestyle). Exercise training also improves the maximal walking distance by a mean of 136 m (training at home) or 180-310 m (supervised training). An additional improvement by a mean of 282 m can be expected from a combination of exercise training and endovascular revascularization. Further behavior-modifying interventions, such as goal-setting, planning, and feedback, increase both the maximum walking distance and the weekly duration of exercise.

CONCLUSION

Exercise improves walking ability and lowers mortality. To attract patients with intermittent claudication to exercise training, a broad assortment of analog, digital and telemetric tools and a dense network of vascular exercise groups should be made available, along with regular contact between physicians and patients.

Benefits of Integrating Technology into Home Exercise Therapy in Patients with Lower Extremity Peripheral Artery Disease

(1) Background: Telerehabilitation is an approach that uses digital technology to provide remote medical recovery services. It can be an option for cardiovascular recovery at home in patients with peripheral arterial disease (PAD) of the lower limbs. (2) Methods: We performed literature research through two databases: PubMed and Embase. We included randomized controlled trials and cohort studies that evaluated the effectiveness of a technology-assisted home exercise intervention compared with conventional rehabilitation or the usual care in patients with PAD. We analyzed population, intervention, and outcome data. (3) Results: We identified 2468 studies. After rigorous screening, we included 25 articles in the review. The following results were evaluated: dissemination and acceptance of digital technologies among these people, functional capacity, exercise intensity, patient motivation, sex-specific response differences in mortality and clinical outcomes, quality of life assessment, and changes in values of inflammatory biomarkers. All of these were correlated with the type of intervention and the dose of the exercise. (4) Conclusions: Home-based exercise therapy supervised with the help of specific devices could be successfully implemented in the therapeutic management of the PAD population. Health specialists should take into account the clinical-paraclinical profile and the emotional status of the patients. Such individualized interventions could bring significant benefits for the people with this disease and for the healthcare system, including increasing exercise adherence, engagement, self-care capacity, life expectancy, and quality of life for these patients, as well as reducing their symptoms, cardiovascular complications, and hospitalizations.

Best medical treatment in patients with PAD

Background: Guidelines recommend comprehensive lifestyle change in patients with peripheral arterial disease (PAD) to prevent cardiovascular events and death. When compared with other populations, patients with PAD are less likely to receive best medical therapies (BMT). The aim of this pilot study was to integrate all aspects of BMT in an intervention program and to determine the feasibility of such an approach by highlighting strengths and obstacles of a multi-aspect intervention. Patients and methods: Patients consecutively hospitalized due to symptomatic PAD between 01 December 2021 and 28 February 2022 were included and followed for ten weeks. We randomized into a lifestyle intervention (education on BMT, a list of regional contact data for supervised exercise, weekly counselling by phone for ten times) vs. standard of care (one contact to talk about BMT). Vascular Quality of Life Questionnaire - 6 (VascuQoL-6) was used to collect patient reported outcomes. Results: Of 50 eligible patients 40 agreed to participate (32.5% female, 72.5 years in mean). During follow-up nine patients dropped out (4 in intervention group vs. 5). As for risk factor modification one patient was able to reach a normal weight body-mass-index (BMI) and nine reduced weight. Two patients stopped smoking, three reduced their consumption. The reported adherence to medication was a hundred percent. No patient attended supervised exercise therapy but eight trained at a home-based setting according to guidelines. The mean score of VascuQoL-6 at follow-up was higher in the intervention group compared to the control group (17.4 vs. 13.8 points) at last contact with both groups increasing from baseline. Conclusions: This pilot study followed 40 patients for up to 10 weeks after inpatient treatment while we randomized a multi-aspect lifestyle intervention versus standard of care. Thereby, the current study illustrated the numerous obstacles and provided pragmatic solutions for the planning of studies on BMT in this target population.

How German vascular surgeons and angiologists judge walking exercise for patients with PAD

Background: To determine the physician's perspective and perception on walking exercise as well as barriers in guideline-directed best medical treatment of patients with lower extremity peripheral arterial disease (PAD). Patients and methods: All members of the German Society for Vascular Surgery and Vascular Medicine and of the German Society for Angiology - Society for Vascular Medicine with valid email address were invited to participate in an electronic survey on walking exercise for treatment of intermittent claudication that was developed by the authors. Results: Amongst 3910 invited participants, 743 (19%) provided valid responses (33% females, 84% vascular surgery, 15% angiology). Thereof, 65% were employed by non-university hospitals, 16% by university institutions, and 18% by outpatient facilities. A mean of 14 minutes were spent per patient to counsel and educate, while only 53% responded they had enough time in everyday clinical practice. While 98% were aware of the beneficial impact of structured exercise training (SET) on pain free walking distance and 90% advise their patients to adhere to SET, only 44% provided useful guidance to patients to find local SET programmes and merely 42% knew how to prescribe SET as service that can be reimbursed by medical insurances. Approximately 35% knew a local SET programme and appropriate contact person. Health-related quality of life was assessed in a structured way by only 11%. Forty-seven percent responded that medical insurances should be responsible to implement and maintain SET programmes, while only 4% held hospital physicians responsible to achieve this task. Conclusions: This nationwide survey study amongst vascular specialists illustrates the current insufficient utilisation of SET as an evidence-based therapeutic cornerstone in patients with lower extremity PAD in Germany. The study also identified several barriers and flaws from the physician's perspectives which should be addressed collectively by all health care providers aiming to increase the SET use and eventually its' impact on patients with PAD.

A prospective survey study on the education and awareness about walking exercise amongst inpatients with symptomatic peripheral arterial disease in Germany

Background: To determine the adherence to supervised exercise training and underlying reasons for non-adherence amongst patients with inpatient treatment of symptomatic lower extremity peripheral arterial disease (PAD). Patients: This was a prospective questionnaire-based survey study of all consecutively treated inpatients with treatment for either intermittent claudication or chronic limb-threatening ischaemia (CLTI) surveyed at sixteen participating centres in Germany. Results: A total of 235 patients (median age 70 years) were included, thereof 29.4% females and 34.6% with CLTI. The median time from first PAD diagnosis was 4 years (IQR: 1-8). Only 11.4% have previously participated in any walking exercise programme before the index treatment, thereby 10.0% in the IC subgroup and 12.0% with CLTI. Amongst all patients, 35.6% responded they were appropriately informed about the necessity and benefits of walking exercise programmes by their hospital physicians (25.8% by general practitioners), and 65.3% agreed that adherence to supervised exercise may improve their pain-free walking distance. A total of 24.5% responded they had access to necessary information concerning local walking exercise programmes. Amongst 127 free text comments on the reasons for non-adherence to supervised exercise training, 64% of the comments contained lack of information or consent on such measures. Conclusions: Less than 12% of the patients enrolled in the current study have ever participated in a walking exercise programme during their life course. Although all practice guidelines contain corresponding class I recommendations, especially for patients suffering from IC, most patients responded that they were not appropriately informed about the necessity of exercise training along with the fact that 65% agreed that exercise may increase the pain-free walking distance. Taken all together, these results emphasise that we miss an important opportunity in the patient-physician communication. Efforts should be made to improve acceptance and application of structured walking-exercise for patients with PAD.

Now Is the Time to Bring a Common but Unpopular Noncommunicable Disease into Focus: Peripheral Arterial Disease Takes Limbs and Lives, but It Must Also Touch Our Hearts!

We have all learned a great deal from the ongoing pandemic that has already taken more than five million lives in less than three years [...]

A cross-sectional survey study on the nutrition patterns of patients with peripheral artery disease

Background: Even though nutrition was demonstrated to have an impact on chronic atherosclerotic disease, there is a paucity of corresponding recommendations for patients with peripheral artery disease (PAD). A Mediterranean Diet based on daily intake of fruits and vegetables with high fibre, vegetable oil, and unsalted nuts including fish several times a week may have protective effects. This cross-sectional survey aimed to determine nutritional patterns amongst inpatients with PAD. Methods: All inpatients with symptomatic PAD who underwent revascularisation at a single centre between 1^st May 2018 and 31^st December 2021 were asked to fill out a questionnaire on nutritional intake. An 8-item frequency rating scale (from never to three times a day) was used for 15 food groups. For 11 of them, an adapted Mediterranean Diet score was calculated using the answers. The descriptive results were stratified by sex and disease stage (intermittent claudication vs. chronic limb-threatening ischaemia). Results: A total of 319 patients (31.7% female, 69.4 years in mean) were included. Thereof, 71.8% reported they did never receive any nutritional information considering their PAD disease. The mean adapted Mediterranean Diet score was 2.7 points (of maximum 11) with most patients not achieving the recommended servings per week for fruits (1.6%), vegetables (1.0%), and unsalted nuts (12.2%). The intake of cereals was sufficient (43.3%). When compared with men, women consumed more fruits and less meat. Conclusions: This survey demonstrated that although healthy nutrition may have a positive impact on patients with PAD, the education and adherence to a Mediterranean Diet was inappropriate. Nutritional patterns should be more focused in future PAD studies to derive specific recommendations and nutritional programmes as well as patient education in clinical practice.

A Systematic Review on Smartphone Use for Activity Monitoring During Exercise Therapy in Intermittent Claudication

OBJECTIVE

Supervised exercise therapy (SET) is recommended as first line in the management of intermittent claudication (IC). Its use is often limited by accessibility, compliance and cost. Home-based exercise therapy (HBET) programs emerged as an alternative solution, but have shown inferior results. Employment of structured monitoring with the use of external wearable activity monitors (WAM) has been shown to improve outcomes. Mobile applications can make use of built-in accelerometers of modern smartphones and become an alternative solution for monitoring patients during HBET, potentially providing wider accessibility. This review aims to assess current use of smartphone technology (i.e., mobile apps) for monitoring or tracking patients' activity in exercise therapy for peripheral arterial disease (PAD).

METHODS

The PubMed database was searched from January 2011 to September 2021. Eligible articles had to include a population of patients with PAD, conduct a mobile-health (m-health) exercise intervention and use smartphone technology for monitoring or tracking patients' activity. Randomized control trials (RCTs), prospective studies, and study protocols were included.

RESULTS

A total of seven articles met the selection criteria. These described six different studies and five different mobile applications. Three were fitness apps (FitBit, Nike+ FuelBand and Garmin Connect) that synchronized with commercially available WAMs to provide users with feedback. Two were PAD-specific apps (TrackPAD and Movn) developed specifically to assess patients' activity during exercise therapy. PAD-specific apps also incorporated coaching and educational elements such as weekly goal setting, claudication reminders, messaging, gamification, training advice and PAD education.

CONCLUSION

Current HBET programs use smartphone applications mainly via commercially available fitness apps that synchronize with WAM devices to register and access data. PAD-specific apps are scarce but show promising features that can be used to monitor, train, coach, and educate patients during HBET programs. Larger studies combining these elements into HBET programs should provide future direction.