Implementation of patient education for patients with atrial fibrillation: nationwide cross-sectional survey and one-year follow-up

AIMS

Clinical practice guidelines recommend patient education for patients with atrial fibrillation (AF) as a part of holistic care, however, clinical guidelines lack detailed specification on the content, structure, and delivery of AF education programmes. To examine the implementation of education for patients with AF in Denmark in relation to coverage, organization, and content.

METHODS AND RESULTS

A cross-sectional survey was conducted from February to May 2021. The survey contained questions on the organization, delivery, and content of education for patients with AF from all 29 AF outpatient hospital sites in Denmark. The survey was conducted by email and telephone. One-year follow-up was done in May 2022 by email. Patient education was provided by healthcare professionals in 16 (55%) hospitals. Nurse workforce issues, management, non-prioritization, and lack of guidance for implementation were reasons for the absence of patient education in 13 (45%) hospitals. The structure of patient education differed in relation to group or individual teaching methods and six different education models were used. Content of the AF disease education was generally similar. At 1-year follow-up, another four hospitals reported offering patient education (69% in total).

CONCLUSION

Initially, almost half of the hospitals did not provide patient education, but at 1-year follow-up, 69% of hospitals delivered patient education. Patient education was heterogeneous in relation to delivery, frequency, and duration. Future research should address individualized patient education that may demonstrate superiority in relation to quality of life, less hospital admissions, and increased longevity.

A call for action to include psychosocial management into holistic, integrated care for patients with atrial fibrillation

Contemporary management of atrial fibrillation (AF) has become increasingly complex. Therefore, strong efforts have been made during the past decade to develop models for structured, integrated care for patients with AF. These have also been incorporated in international guidelines for the management of patients with AF. However, implementation of integrated care approaches in daily clinical practice is scarce and far from optimal, and it may require a re-thinking of the structure of the healthcare system. The reasons for the poor implementation are many, from limited time and economic resources to deficits in postgraduate education of healthcare professionals, lack of involvement of patients in how integrated care should be designed, and fragmentation of the healthcare system. Moreover, patients' psychological challenges, which not only impact patients' adherence to treatment but, if untreated, increase their risk of morbidity, mortality, and poor quality of life, are not given sufficient attention. It is time to start a necessary discussion of what integrated care should be, what it should contain, and what is necessary to implement it in daily clinical practice.

Effectiveness of cardiac rehabilitation programs on medication adherence in patients with cardiovascular disease: A systematic review and meta-analysis

Background

Education to improve medication adherence is one of the core components of cardiac rehabilitation (CR) programs. However, the evidence on the effectiveness of CR programs on medication adherence is conflicting. Therefore, we aimed to summarize the effectiveness of CR programs versus standard care on medication adherence in patients with cardiovascular disease.

Methods

A systematic review and meta-analysis was conducted. Seven databases and clinical trial registries were searched for published and unpublished articles from database inception to 09 Feb 2022. Only randomised controlled trials and quasi-experimental studies were included. Two independent reviewers conducted the screening, extraction, and appraisal. The JBI methodology for effectiveness reviews and PRISMA 2020 guidelines were followed. A statistical meta-analysis of included studies was pooled using RevMan version 5.4.1.

Results

In total 33 studies were included with 16,677 participants. CR programs increased medication adherence by 14 % (RR = 1.14; 95 % CI: 1.07 to 1.22; p = 0.0002) with low degree of evidence certainty. CR also lowered the risk of dying by 17 % (RR = 0.83; 95 % CI: 0.69 to 1.00; p = 0.05); primary care and emergency department visit by mean difference of 0.19 (SMD = -0.19; 95 % CI: -0.30 to -0.08; p = 0.0008); and improved quality of life by 0.93 (SMD = 0.93; 95 % CI: 0.38 to 1.49; p = 0.0010). But no significant difference was observed in lipid profiles, except with total cholesterol (SMD = -0.26; 95 % CI: -0.44 to -0.07; p = 0.006) and blood pressure levels.

Conclusions

CR improves medication adherence with a low degree of evidence certainty and non-significant changes in lipid and blood pressure levels. This result requires further investigation.

Patient Journey Mapping: emerging methods for understanding and improving patient experiences of health systems and services

Patient journey mapping is an emerging field of research that uses various methods to map and report evidence relating to patient experiences and interactions with healthcare providers, services and systems. This research often involves the development of visual, narrative, and descriptive maps or tables, which describe patient journeys and transitions into, through and out of health services. This methods corner paper presents an overview of how patient journey mapping has been conducted within the health sector, providing cardiovascular examples. It introduces six key steps for conducting patient journey mapping and describes the opportunities and benefits of using patient journey mapping and future implications of using this approach.

Atrial fibrillation: epidemiology, screening and digital health

Atrial fibrillation (AF) is highly prevalent with a lifetime risk of about 1 in 3-5 individuals after the age of 45 years. Between 2010 and 2019, the global prevalence of AF has risen markedly from 33.5 million to 59 million individuals living with AF. Early detection of AF and implementation of appropriate treatment could reduce the frequency of complications associated with AF. International AF management guidelines recommend opportunistic and systematic screening for AF, but additional data are needed. Digital approaches and pathways have been proposed for early detection and for the transition to early AF management. Mobile health (mHealth) devices provide an opportunity for digital screening and should be part of novel models of care delivery based on integrated AF care pathways. For a broad implementation of mHealth-based, integrated care for patients with chronic diseases as AF, further high quality evidence is necessary. In this review, we present an overview of the present data on epidemiology, screening techniques, and the contribution of digital health solutions to the integrated management of AF. We also provide a systemic review on current data of digital and integrated AF management.

Effectiveness of alternative vs traditional exercises on cardiac rehabilitation program utilization in women with or at high risk of cardiovascular disease: a systematic review protocol

OBJECTIVE

This review will evaluate the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization and other outcomes in women with or at high risk of cardiovascular disease.

INTRODUCTION

Exercise-based cardiac rehabilitation programs improve health outcomes in women with or at high risk of cardiovascular disease. However, such programs are underutilized worldwide, particularly among women. Some women perceive traditional gym-based exercise in cardiac rehabilitation programs (eg, typically treadmills, cycle ergometers, traditional resistance training) to be excessively rigorous and unpleasant, resulting in diminished participation and completion. Alternative forms of exercise such as yoga, tai chi, qi gong, or Pilates may be more enjoyable and motivating exercise options for women, enhancing engagement in rehabilitation programs. However, the effectiveness of these alternative exercises in improving program utilization is still inconsistent and needs to be systematically evaluated and synthesized.

INCLUSION CRITERIA

This review will focus on randomized controlled trials of studies measuring the effectiveness of alternative vs traditional forms of exercise on cardiac rehabilitation program utilization as well as clinical, physiological, or patient-reported outcomes in women with or at high risk of cardiovascular disease.

METHODS

The review will follow the JBI methodology for systematic reviews of effectiveness. Databases including MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane CENTRAL, Embase (Ovid), Emcare (Ovid), Scopus, Web of Science, LILACS, and PsycINFO (Ovid) will be searched. Two independent reviewers will screen articles and then extract and synthesize data. Methodological quality will be assessed using JBI's standardized instruments. GRADE will be used to determine the certainty of evidence.

REVIEW REGISTRATION

PROSPERO CRD42022354996.

Description of self-care behaviours in patients with non-valvular atrial fibrillation on oral anticoagulant therapy: A scoping review

AIM

The primary aim of this scoping review was to explore and categorise the medication-related self-care behaviours exhibited by patients with non-valvular atrial fibrillation (NVAF) who are on oral anticoagulant (OAC) therapy.

METHODS AND RESULTS

A scoping review was performed, and the systematic search of the literature yielded an initial 887 records. After deduplication and screening, 61 studies were included in the analysis, ranging from 2003 to 2023. The studies represented a wide geographical distribution and diverse methodologies. The results identified 16 self-care behaviours: a higher focus of the included literature on self-care monitoring (60.65% of studies), followed by self-care management and self-care maintenance (each 16.39%). These behaviours ranged from regular blood testing to consulting healthcare providers and lifestyle changes. The results also highlighted the relationship between treatment satisfaction, self-efficacy, and adherence. Several studies emphasised the critical role of healthcare providers in influencing medication adherence. Furthermore, patient knowledge, quality of life, and psychological factors were identified as key elements affecting self-care behaviours.

CONCLUSION

The review provides a comprehensive landscape of medication-related self-care behaviors among NVAF patients on OAC therapy. It underscores the predominance of self-care monitoring behaviours and the critical roles of healthcare providers, psychological factors, and patient knowledge in influencing these behaviours. The findings also highlight the necessity for an integrated, patient-centred approach to improving self-care and self-management in OAC treatment. Future research should focus on addressing the identified gaps, including the relative lack of studies on lifestyle modification, emotional well-being, and technology-assisted interventions.

REGISTRATION

This review is part of a broader project and is documented at ClinicalTrials.gov (NCT05820854).

Effectiveness of nurse-led interventions versus usual care to manage hypertension and lifestyle behaviour: a systematic review and meta-analysis

AIMS

This review aimed to investigate the effectiveness of nurse-led interventions vs. usual care on hypertension management, lifestyle behaviour, and patients' knowledge of hypertension and associated risk factors.

METHODS

A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), EmCare (Ovid), CINAHL (EBSCO), Cochrane library, and ProQuest (Ovid) were searched from inception to 15 February 2022. Randomized controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI tools. A statistical meta-analysis was conducted using STATA version 17.0.

RESULTS

A total of 37 RCTs and 9731 participants were included. The overall pooled data demonstrated that nurse-led interventions may reduce systolic blood pressure (mean difference -4.66; 95% CI -6.69, -2.64; I2 = 83.32; 31 RCTs; low certainty evidence) and diastolic blood pressure (mean difference -1.91; 95% CI -3.06, -0.76; I2 = 79.35; 29 RCTs; low certainty evidence) compared with usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions had a positive impact on lifestyle behaviour and effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent.

CONCLUSION

This review revealed the beneficial effects of nurse-led interventions in hypertension management compared with usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension.

REGISTRATION

PROSPERO: CRD42021274900.

Understanding for whom, under what conditions, and how an integrated approach to atrial fibrillation service delivery works: a realist review

AIMS

To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work).

METHODS AND RESULTS

A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context-mechanism-outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context-mechanism-outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway.

CONCLUSION

It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF.

Associations of dietary patterns, ultra-processed food and nutrient intake with incident atrial fibrillation

OBJECTIVE

To examine the associations between specific dietary patterns and incident atrial fibrillation (AF).

METHODS

Using data from the UK Biobank, dietary intakes were calculated from 24-hour diet recall questionnaires. Indices representing adherence to dietary patterns (Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) and plant-based diets) were scored, and ultra-processed food consumption was studied as a percentage of total food mass consumed. Incident AF hospitalisations were assessed in Cox regression models.

RESULTS

A total of 121 300 individuals were included, with 4 579 incident AF cases over a median follow-up of 8.8 years. Adherence to Mediterranean-style or DASH diets was associated with a lower incidence of AF in minimally adjusted analyses (HR for highest vs lowest quintile 0.87 (95% CI 0.80-0.96) and HR 0.78 (95% CI 0.71-0.86), respectively). However, associations were no longer significant after accounting for lifestyle factors (HR 0.95 (95% CI 0.87-1.04) and 0.94 (95% CI 0.86-1.04) respectively), with adjustment for body mass index responsible for approximately three-quarters of the effect size attenuation. Plant-based diets were not associated with AF risk in any models. Greatest ultra-processed food consumption was associated with a significant increase in AF risk even in fully adjusted models (HR 1.13 (95% CI 1.02-1.24)), and a 10% increase in absolute intake of ultra-processed food was associated with a 5% increase in AF risk (HR 1.05 (95% CI 1.01-1.08)).

CONCLUSION

With the possible exception of reducing ultra-processed food consumption, these findings suggest that attention to other modifiable risk factors, particularly obesity, may be more important than specific dietary patterns for the primary prevention of AF.

Disease-Related Knowledge and Need for Revision of Care for Patients with Atrial Fibrillation: A Cross Sectional Study

Purpose

To evaluate the disease-related knowledge of outpatients with atrial fibrillation (AF), and the relationship with health literacy and other background variables.

Patients and Methods

In this cross-sectional survey study, conducted in Iceland, patients with AF scheduled for an electrical cardioversion or AF catheter ablation were recruited from a hospital outpatient clinic. They completed the validated Atrial Fibrillation Knowledge Scale (AFKS), a 11-item instrument (with possible score 0-10, 10 being the best knowledge) which evaluates knowledge pertaining to AF in general, AF symptom detection and AF treatment. Health literacy was assessed with the 16 item European Health Literacy Survey Questionnaire (HLS-EU-Q) and patients answered questions about their background. Data was analysed with parametric tests.

Results

In total, 185 participants completed the questionnaire (mean age 63 ±10), 77% were male, 74% with previous electrical cardioversion and 76% were on non-vitamin K antagonist oral anticoagulants (NOAC) medication. The mean score on the AFKS was 6.5 (±1.8). The best knowledge was concerning oral anticoagulation therapy (96% answered correctly) and the least knowledge was regarding responses to AF episodes (17% answered correctly). Patients with sufficient health literacy (52%) had better knowledge of AF (M 6.8 ±1.7 vs M 6.3 ±1.9, p = 0.05). Age, educational level, health literacy and AF pattern explained 22% of the variance in AF knowledge.

Conclusion

Patients with AF have inadequate knowledge of their condition, potentially as a result of insufficient health literacy. AF knowledge may be improved using integrated management where patients are actively involved in the care and health literacy is considered in the provided patient education.

Measurement properties of utility-based health-related quality-of-life measures in cardiac rehabilitation: a systematic review protocol

OBJECTIVE

This review will identify and appraise existing evidence on the measurement properties of utility-based health-related quality-of-life (HRQoL) measures used in cardiac rehabilitation programs. The review will map the measure domains against the International Classification of Functioning, Disability and Health and the International Consortium of Health Outcome Measures domains for cardiovascular disease.

INTRODUCTION

Improving HRQoL is an international key indicator for delivering high-quality and person-centered secondary prevention programs. Many instruments and measures assess HRQoL in individuals undergoing cardiac rehabilitation. Utility-based measures are suitable for calculating quality-adjusted life years, a required outcome metric in cost-utility analysis. Cost-utility analysis requires the use of utility-based HRQoL measures. However, there is no consensus on which utility-based measure is best for populations undergoing cardiac rehabilitation.

INCLUSION CRITERIA

Eligible studies will include patients aged ≥18 years with cardiovascular disease who are undergoing cardiac rehabilitation. Empirical studies that assess quality of life or HRQoL using a utility-based, health-related, patient-reported outcome measure or a measure accompanied by health state utilities will be eligible. Studies must report at least 1 of the following measurement properties: reliability, validity, responsiveness.

METHODS

This review will follow the JBI methodology for systematic reviews of measurement properties. The following databases will be searched from inception to the present: MEDLINE, Emcare, Embase, Scopus, CINAHL, Web of Science Core Collection, Informit, PsyclNFO, REHABDATA, and the Cochrane Library. Studies will be critically appraised using the The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) risk of bias checklist. The review will be reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

REVIEW REGISTRATION

PROSPERO CRD42022349395.

Device-detected atrial fibrillation in a large remote-monitored cohort: implications for anticoagulation and need for new pathways of service delivery

BACKGROUND

Remote monitoring (RM) can facilitate early detection of subclinical and symptomatic atrial fibrillation (AF), providing an opportunity to evaluate the need for stroke prevention therapies. We aimed to characterize the burden of RM AF alerts and its impact on anticoagulation of patients with device-detected AF.

METHODS

Consecutive patients with a cardiac implantable electronic device, at least one AF episode, undergoing RM were included and assigned an estimated minimum CHA2DS2-VASc score based on age and device type. RM was provided via automated software system, providing rapid alert processing by device specialists and systematic, recurrent prompts for anticoagulation.

RESULTS

From 7651 individual, 389,188 AF episodes were identified, 3120 (40.8%) permanent pacemakers, 2260 (29.5%) implantable loop recorders (ILRs), 987 (12.9%) implantable cardioverter defibrillators, 968 (12.7%) cardiac resynchronization therapy (CRT) defibrillators, and 316 (4.1%) CRT pacemakers. ILRs transmitted 48.8% of all AF episodes. At twelve-months, 3404 (44.5%) AF < 6 min, 1367 (17.9%) 6 min-6 h, 1206 (15.8%) 6-24 h, and 1674 (21.9%) ≥ 24 h. A minimum CHA2DS2-VASc score of 2 was assigned to 1704 (63.1%) of the patients with an AF episode of ≥ 6 h, 531 (31.2%) who were not anticoagulated at 12-months, and 1031 (61.6%) patients with an AF episode duration of ≥ 24 h, 290 (28.1%) were not anticoagulated.

CONCLUSIONS

Despite being intensively managed via RM software system incorporating cues for anticoagulation, a substantial proportion of patients with increased stroke risk remained unanticoagulated after a device-detected AF episode of significant duration. These data highlight the need for improved clinical response pathways and an integrated care approach to RM.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry: ACTRN12620001232921.

A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.

Progressions in Cardiac Arrhythmia: Specific Populations and the Need for Precision Medicine

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the general population [...].

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation

AIMS

Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure.

METHODS AND RESULTS

Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma.

CONCLUSION

A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.

Assessment of the general public's knowledge of atrial fibrillation through social media: a cross-sectional study

BACKGROUND

Early detection and timely treatment of atrial fibrillation (AF) remains pivotal to preventing AF-related complications. Public involvement in recognising potential AF symptoms and managing AF is vital for early detection and treatment of AF.

OBJECTIVE

The aim of the study is to assess the general public's knowledge of AF using an online survey, disseminated via social media.

METHODS

A cross-sectional online survey of the general public was conducted between November to December 2021. The survey's URL was shared on National University Heart Centre, Singapore's official Facebook page. Digital marketing strategies were employed to recruit members of the public. The 27-item survey assessed public's knowledge across five domains: basic information about AF, risk factors of AF, detection of AF, prevention of AF, and management of AF.

RESULTS

The survey involved 620 participants. Approximately two-thirds were between the ages 21 to 40 years (64.5%), female (60%) and had at least a degree (64.7%) as their highest level of education. Participants obtained a mean percentage score of 63.3 ± 26.0 for their AF knowledge. One-way ANOVA was done to examine the associations between the participants' characteristics and their knowledge of AF. There were no statistically significant differences in the AF knowledge scores across the various sociodemographic subgroups.

CONCLUSIONS

Members of the public recruited from Facebook and via digital marketing had moderately good knowledge of AF. However, public awareness pertaining to preventing AF has potential for improvement. The utility of social media in reaching the general public was illustrated through this study.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: insights from the Virtual-SAFARI study

BACKGROUND

Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF.

AIM

We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection.

METHODS

Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea-hypopnoea index (AHI) of  ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening.

RESULTS

Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573-0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672-0.805) in the overall population.

CONCLUSION

AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies.

TRIAL REGISTRATION NUMBER

ISOLATION was registered NCT04342312, 13-04-2020.

Instruments Measuring Self-Care and Self-Management of Chronic Conditions by Community-Dwelling Older Adults: A Scoping Review

Given the high prevalence of chronic conditions and multimorbidity in older adults, there is a need to better conceptualize and measure self-care and self-management to promote a person-centered approach. This scoping review aimed to identify and map instruments measuring self-care and self-management of chronic conditions by older adults. We searched six electronic databases, charted data from the studies and tools and reported the results in accordance with the PRISMA-ScR guidelines. A total of 107 articles (103 studies) containing 40 tools were included in the review. There was substantial variation in the tools in terms of their aims and scope, structure, theoretical foundations, how they were developed, and the settings in which they have been used. The quantity of tools demonstrates the importance of assessing self-care and self-management. Consideration of the purpose, scope, and theoretical foundation should guide decisions about tools suitable for use in research and clinical practice.

Cardiac rehabilitation, physical activity, and the effectiveness of activity monitoring devices on cardiovascular patients: An umbrella review of systematic reviews

AIMS

To consolidate the evidence on the effectiveness of activity-monitoring devices and mobile applications on physical activity and health outcomes of patients with cardiovascular disease and attended cardiac rehabilitation (CR) programs.

METHODS

An umbrella review of published randomised controlled trials systematic reviews and meta-analyses was conducted. Nine databases were searched from inception to February 9th, 2022. Search and data extraction followed the JBI methodology for umbrella reviews and PRISMA guidelines. Nine systematic reviews met the inclusion criteria, comparing outcomes of participants of CR programs utilising devices/applications, to patients without access to CR with devices/applications.

RESULTS

A wide range of physical, clinical and behavioural outcomes were reported, with results from 18 712 participants. Meta-analyses reported improvements in physical activity, mins/week (SMD 0.23, [95% CI 0.10, 0.35]) and activity levels (SMD 0.29 [95% CI 0.07, 0.51]), and a reduction in sedentariness (RR 0.54 [95% CI 0.39, 0.75]) in CR participants, compared to usual care. Of clinical outcomes, the risk of re-hospitalization reduced significantly (RR 0.49 [95% CI 0.27, 0.89]) and there was reduction (non-significant) in mortality (RR 0.27 [95% CI 0.05, 1.54]). From the behavioural outcomes, reviews reported improvements in smoking behaviour (RR 0.87 [95% CI 0.67, 1.13]) and total diet quality intake (RR 0.79 [95% CI 0.66, 0.94]) among CR patients.

CONCLUSIONS

The use of devices/applications was associated with increase in activity, healthy behaviours, and reductions in clinical indicators. Although most effects sizes indicate limited clinical benefits, the broad consistency of the narrative suggests devices/applications are effective at improving CR patients' outcomes.

Justification, rationale and methodological approaches to realist reviews

Realist reviews offer a method to understand why an intervention is successful or not. Many factors influence how complex healthcare interventions are delivered and this makes understanding what works difficult. Effectiveness depends on delivery context, and success in one setting does not guarantee the same result in alternate settings. How an intervention works (the underlying mechanisms) in a particular setting for one population group, may not work in the same way for a different group. A realist review provides an iterative theory-driven approach to help understand how and for whom and under what conditions an intervention works.

Integrated care in cardiovascular disease: a statement of the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology

In a rapidly changing health and care landscape, there is acknowledgement that the organisation of care should be integrated with the patient placed at the centre. In reality, care systems are often fragmented, disjointed and focused on the condition rather than the patient. The Science Committee of the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology recognises the need for a statement on integrated care to guide health professionals caring for people with cardiovascular disease. This statement outlines the evidence for integrated cardiovascular care, identifies challenges and offers advice for practice, education and research.

Cardiovascular Nursing and Climate Change: A Call to Action From the CSANZ Cardiovascular Nursing Council

This Call to Action aims to provide key considerations for cardiovascular nursing, related to climate and environmental impacts. Strategies to optimise nursing preparation, immediate response and adaptation to climate emergencies are crucial to ensure those at greatest risk, including First Nations peoples, are protected from potentially avoidable harm. Professionals who manage climate consequences must also understand the impact of their care on the root cause of the problem.

Effectiveness of cardiac rehabilitation programs in improving medication adherence in patients with cardiovascular disease: a systematic review protocol

OBJECTIVE

The objective of this review is to measure the effectiveness of cardiac rehabilitation programs versus standard care on medication adherence in patients with cardiovascular disease.

INTRODUCTION

Poor adherence to long-term medications increases the risk of morbidity and mortality, and decreases quality of life in patients with cardiovascular diseases. Several strategies have been trialed to improve medication adherence, one of which is cardiac rehabilitation programs. Although evidence has indicated that such programs increase medication adherence, the extent of their effectiveness and translation into clinical practice is not well documented. Our systematic review will collect and analyze the available evidence for clinical practice implementation.

INCLUSION CRITERIA

The search will aim to locate randomized controlled trials. Where randomized controlled trials are not available, quasi-experimental studies, case-control studies, observational studies, and other study designs will be included. Studies that measure effectiveness of cardiac rehabilitation programs compared with standard care on medication adherence in cardiovascular disease patients will be included.

METHODS

Databases, including MEDLINE (Ovid), Emcare (Ovid), Embase (Ovid), Cochrane CENTRAL, Scopus, CINAHL (EBSCO), and unpublished sources will be searched. Articles in English and non-English-language articles with an English abstract, published from database inception to the present, will be included. Articles will be screened and reviewed by 2 independent reviewers for inclusion. Critical appraisal tools will be applied to the included studies. Data will be extracted using the appropriate extraction tools and synthesized for the objectives of the study.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021284705.

Effectiveness of telehealth versus standard care on health care utilization, health-related quality of life, and well-being in homebound populations: a systematic review protocol

OBJECTIVE

The objective of the review is to determine the effectiveness of telehealth versus in-person care on health care utilization, health-related quality of life, and well-being in homebound populations.

INTRODUCTION

Globally, an increasing number of people are becoming homebound. These individuals experience high levels of social isolation and deterioration of their well-being. Reports from homebound people and recent publications suggest that this cohort may benefit from accessing telehealth solutions from their homes to treat and prevent serious issues affecting their health and well-being. This review will synthesize the evidence on the effectiveness of telehealth compared to standard care (in-person care) on health care utilization, health-related quality of life, and well-being in homebound populations.

INCLUSION CRITERIA

Studies including people living in community settings, whose daily life is physically limited to the boundary of their homes because of their ongoing health, energy, and psychosocial or socio-functional impairments will be considered for inclusion.

METHODS

This review will consider relevant, peer-reviewed primary experimental and quasi-experimental studies, with no limit on language or date. Databases to be searched include MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, LILACS, JBI Evidence Synthesis (hand-searched for further studies), and Web of Science. Two independent reviewers will be involved in study selection and data extraction. Eligible studies will be critically appraised for methodological quality using the relevant JBI critical appraisal checklists, and statistical meta-analysis will be done (where possible). Findings will be presented in narrative form.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021289578.

Effectiveness of activity-monitoring devices in patients with cardiovascular disease participating in cardiac rehabilitation programs: an umbrella review protocol

OBJECTIVE

The objective of the review is to investigate the effect of activity-monitoring devices and mobile applications on physical activity and health outcomes of patients with cardiovascular disease who are participating in cardiac rehabilitation programs.

INTRODUCTION

Supporting patients with cardiovascular conditions to achieve and maintain healthy physical activity levels is the cornerstone of cardiac rehabilitation programs. The effectiveness of activity-monitoring devices and mobile applications (such as physical activity interventions) utilizing consumer-grade monitoring devices and applications to support patients to improve exercise levels during and after program completion has been investigated. Several systematic reviews evaluating the effectiveness of monitoring devices and applications have indicated varying clinical impact, depending on patient characteristics, stage of rehabilitation, and type of intervention.

INCLUSION CRITERIA

This review will consider systematic reviews and/or meta-analyses of randomized controlled trials of patients who participated in cardiac rehabilitation programs that included a physical activity intervention that incorporated activity monitoring using electronic devices and/or mobile applications and reported activity and patient health outcomes.

METHODS

MEDLINE, Embase, Sport Discus, the Cochrane Database of Systematic Reviews, Scopus, CINAHL, the International Network of Agencies for Health Technology Assessment database, Epistemonikos, and Web of Science will be searched from inception to the present. PROSPERO will be searched for unpublished reviews. Articles will be screened by two independent reviewers for inclusion, and methodological quality will be assessed using a JBI critical appraisal tool. Data will be extracted from systematic reviews and a data synthesis of findings will be presented. The certainty will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298877.

Dyspnea in patients with atrial fibrillation: Mechanisms, assessment and an interdisciplinary and integrated care approach

Atrial fibrillation (AF) is the most common sustained heart rhythm disorder and is often associated with symptoms that can significantly impact quality of life and daily functioning. Palpitations are the cardinal symptom of AF and many AF therapies are targeted towards relieving this symptom. However, up to two-third of patients also complain of dyspnea as a predominant self-reported symptom. In clinical practice it is often challenging to ascertain whether dyspnea represents an AF-related symptom or a symptom of concomitant cardiovascular and non-cardiovascular comorbidities, since common AF comorbidities such as heart failure and chronic obstructive pulmonary disease share similar symptoms. In addition, therapeutic approaches specifically targeting dyspnea have not been well validated. Thus, assessing and treating dyspnea can be difficult.

This review describes the latest knowledge on the burden and pathophysiology of dyspnea in AF patients. We discuss the role of heart rhythm control interventions as well as the management of AF risk factors and comorbidities with the goal to achieve maximal relief of dyspnea. Given the different and often complex mechanistic pathways leading to dyspnea, dyspneic AF patients will likely profit from an integrated multidisciplinary approach to tackle all factors and mechanisms involved. Therefore, we propose an interdisciplinary and integrated care pathway for the work-up of dyspnea in AF patients.

Mobile app-based symptom-rhythm correlation assessment in patients with persistent atrial fibrillation

BACKGROUND

The assessment of symptom-rhythm correlation (SRC) in patients with persistent atrial fibrillation (AF) is challenging. Therefore, we performed a novel mobile app-based approach to assess SRC in persistent AF.

METHODS

Consecutive persistent AF patients planned for electrical cardioversion (ECV) used a mobile app to record a 60-s photoplethysmogram (PPG) and report symptoms once daily and in case of symptoms for four weeks prior and three weeks after ECV. Within each patient, SRC was quantified by the SRC-index defined as the sum of symptomatic AF recordings and asymptomatic non-AF recordings divided by the sum of all recordings.

RESULTS

Of 88 patients (33% women, age 68 ± 9 years) included, 78% reported any symptoms during recordings. The overall SRC-index was 0.61 (0.44-0.79). The study population was divided into SRC-index tertiles: low (<0.47), medium (0.47-0.73) and high (≥0.73). Patients within the low (vs high) SRC-index tertile had more often heart failure and diabetes mellitus (both 24.1% vs 6.9%). Extrasystoles occurred in 19% of all symptomatic non-AF PPG recordings. Within each patient, PPG recordings with the highest (vs lowest) tertile of pulse rates conferred an increased risk for symptomatic AF recordings (odds ratio [OR] 1.26, 95% coincidence interval [CI] 1.04-1.52) and symptomatic non-AF recordings (OR 2.93, 95% CI 2.16-3.97). Pulse variability was not associated with reported symptoms.

CONCLUSIONS

In patients with persistent AF, SRC is relatively low. Pulse rate is the main determinant of reported symptoms. Further studies are required to verify whether integrating mobile app-based SRC assessment in current workflows can improve AF management.

Patient motivation and adherence to an on-demand app-based heart rate and rhythm monitoring for atrial fibrillation management: data from the TeleCheck-AF project

AIMS

The aim of this TeleCheck-AF sub-analysis was to evaluate motivation and adherence to on-demand heart rate/rhythm monitoring app in patients with atrial fibrillation (AF).

METHODS AND RESULTS

Patients were instructed to perform 60 s app-based heart rate/rhythm recordings 3 times daily and in case of symptoms for 7 consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥3/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period.Data from 990 consecutive patients with diagnosed AF [median age 64 (57-71) years, 39% female] from 10 centres were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm [90 (53-100%) vs. 100 (64-100%), P < 0.001] compared with others. Older age and absence of diabetes were predictors of both optimal motivation and adherence [odds ratio (OR) 1.02, 95% coincidence interval (95% CI): 1.01-1.04, P < 0.001 and OR: 0.49, 95% CI: 0.28-0.86, P = 0.013, respectively]. Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were older age (OR: 1.02, 95% CI: 1.00-1.04, P = 0.014), female sex (OR: 1.70, 95% CI: 1.29-2.23, P < 0.001), previous AF ablation (OR: 1.35, 95% CI: 1.03-1.07, P = 0.028).

CONCLUSION

In the TeleCheck-AF project, more than one-fourth of patients had optimal motivation and adherence to app-based heart rate/rhythm monitoring. Older age and absence of diabetes were predictors of optimal motivation/adherence.

Patient motivation and adherence to an on-demand app-based heart rate and rhythm monitoring infrastructure for atrial fibrillation management through teleconsultation. TeleCheck-AF project results

Funding Acknowledgements

Type of funding sources: None.

Background

TeleCheck-AF is a mobile health (mHealth) infrastructure developed to provide remote management and comprehensive care to patients with atrial fibrillation (AF) during the Covid disease-19 pandemic lockdown within cardiology centers in Europe. TeleCheck-AF integrates an on-demand photoplethysmography-based heart rate/rhythm monitoring application supported a scheduled teleconsultation.

Purpose

The current sub-study of the TeleCheck-AF project aimed to provide the first real-world dataset on patient adherence and motivation to a standardized mHealth application integrated in remote AF management.

Methods

Patients were instructed to perform 60-second app-based heart rate/rhythm recordings three times daily and in case of symptoms for seven consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥three/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period.

Results

Data from 990 consecutive patients with diagnosed AF (median age 64 [57-71] years, 39% female) from 10 centers that included the highest number of patients (≥25) were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm (90 [53-100%] vs 100 [64-100%], P&lt;0.001) compared to others. Age and diabetes were predictors of both optimal motivation and adherence (odds ratio [OR] 1.02, 95% coincidence interval [95% CI] 1.01-1.04, P&lt;0.001 and OR, 0.49, 95% CI 0.28-0.86, P=0.013, respectively). Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were age (OR 1.02, 95% CI 1.00-1.04, P=0.014), female sex (OR 1.70, 95% CI 1.29-2.23, P&lt;0.001), previous AF ablation (OR 1.35, 95%CI 1.03-1.07, P=0.028).

Conclusion

In the TeleCheck-AF project, older age and diabetes were predictors of optimal patient motivation and adherence to app-based heart rate/rhythm monitoring. Therefore, physicians, nurses and allied health specialists involved in the management and care for patients with AF should not be discouraged to provide a mHealth infrastructure to elderly patients. Patient engagement improves mHealth adherence/motivation, hence, it is crucial to tailor the mHelath intervention to the needs and preferences of the patient.

The impact of a structured polygraphy screening incorporated in a novel remote mobile health pathway on sleep apnoea prevalence in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Untreated obstructive sleep apnoea (OSA) contributes to progression of atrial fibrillation (AF) and reduces the success rate of heart rhythm control strategies. OSA remains one of the most frequently underdiagnosed modifiable risk factors in AF patients due to a lack of standardized screening methods and low awareness.

Purpose

To assess the impact of implementation of a structured remote OSA screening and management pathway on the prevalence of OSA in AF patients scheduled for AF ablation procedures.

Methods

In October 2020, a novel remote OSA screening and management pathway (VIRTUAL-SAFARI) was introduced in two AF outpatient clinics in the Netherlands. Consecutive patients scheduled for AF ablation were offered OSA screening consisting of sending a portable home sleep test to patients’ homes to perform a remote sleep recording for one night, analysis by a sleep physician, discussion of results with the patient, and initiation of treatment (when applicable). The impact of this structural screening strategy was assessed by comparing the prevalence of concomitant OSA (defined as apnoea-hypopnoea index ≥5) for patients scheduled for AF ablation in the year before and after introduction of the OSA management pathway.

Results

A total of 733 patients was studied, 308 in the year before (Oct ’19 - Sep ’20) and 425 in the year after (Oct ’20 - Sep ’21) introduction of the VIRTUAL-SAFARI pathway. Median age was 65 [58-71], 64% was male and median body mass index (BMI) was 27 [25-30] kg/m2. Baseline characteristics were comparable for the groups before and after introduction of the pathway (Table 1).

In the cohort before pathway introduction, OSA had been diagnosed in 26 patients (8%, Figure 1) and was treated with positive airway pressure in 10 cases (3%).

In the cohort after pathway introduction, OSA had previously been diagnosed in 53 patients (12%). Eighty-eight percent of patients without previous OSA screening was referred via the remote pathway. Results of the sleep recordings were available for 213 (59%) at the time of this analysis. Previously unknown OSA was diagnosed in 184 patients (86% of available recordings), increasing the prevalence of confirmed OSA to 237 (55%). For 22% of patients, results of sleep recordings are pending. Absence of OSA was confirmed in 9%, and 13% of patients had not been screened (e.g. because of patient preference or logistical reasons). After pathway introduction, 82 patients (19%) were treated or received advice to start treatment with positive airway pressure. Treatment decisions are pending for 9% of the cohort.

Conclusion

After the implementation of structured remote OSA screening in a well characterized cohort of consecutive patients scheduled for AF ablation, the prevalence of diagnosed OSA increased from 8% to 55%. Whether appropriate risk factor management, including treatment of OSA identified by structured screening, will improve AF outcomes needs to be tested in future studies.

Mobile app-based symptom-rhythm correlation assessment in patients with persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with persistent atrial fibrillation (AF) it is difficult to determine the association between patient self-reported symptoms and the underlying heart rhythm (symptom-rhythm correlation [SRC]). No standardized strategy to assess SRC in AF patients is available.

Purpose

We assessed for the first time SRC in persistent AF patients using a mobile health approach of simultaneous photoplethysmography (PPG)-based rhythm monitoring and active interrogation of patient-reported symptoms, which provides a novel approach to systematically assess SRC in persistent AF.

Methods

Consecutive persistent AF patients planned for electrical cardioversion (ECV) used a mobile app to record a 60-second PPG and report symptoms once daily and in case of symptoms for four weeks prior and three weeks after ECV. Within each patient, SRC was quantified by the SRC-index defined as the sum of symptomatic AF recordings and asymptomatic non-AF recordings divided by the sum of all recordings.

Results

Of 88 patients (33% female, age 68±9 years) included, 78% reported any symptoms during recordings. The overall SRC-index was 0.61 (0.44-0.79). The study population was divided into SRC-index tertiles: low (&lt;0.47), medium (0.47-0.73) and high (≥0.73). Patients within the low (vs high) SRC-index tertile had more often heart failure and diabetes mellitus (both 24.1% vs 6.9%). Extrasystoles occurred in 19% of all symptomatic non-AF PPG recordings. Within each patient, PPG recordings with the highest (vs lowest) tertile of pulse rates conferred an increased risk for symptomatic AF recordings (odds ratio [OR] 1.26, 95% coincidence interval [CI] 1.04-1.52) and symptomatic non-AF recordings (OR 2.93, 95% CI 2.16-3.97). Pulse variability was not associated with reported symptoms.

Conclusion

In persistent AF patients, simultaneous mobile app-based symptom and rhythm monitoring revealed a relatively low overall SRC, suggesting that the majority of patients experienced symptoms irrespective of AF. Extrasystoles can explain a minority of symptomatic non-AF PPG recordings. Pulse rate, but not pulse variability, is the main determinant of reported symptoms during AF and non-AF PPG recordings. Further studies are required to test whether mobile app-based SRC assessment can be implemented in current workflows and integrated into a personalized symptom and rhythm control AF management approach.

Identifying Feasible Heart Failure Interventions Suitable for the Jordan Healthcare system: A Delphi Study

Interventions and strategies should align with the context and capacity of the health system. Identifying the most feasible and appropriate heart failure interventions in Jordan will improve heart failure management and clinical outcomes. Therefore, this study aimed to derive consensus from clinicians (using the Delphi method) regarding the most feasible and appropriate heart failure interventions in Jordan. A two-round Delphi study involving seven clinicians and policy makers were conducted. The Delphi results found consensus for the feasibility of the educational materials, follow up phone call, cardiac rehabilitation, group session, and training courses for staff. The components that were not feasible were: multidisciplinary team, individual session, and telemonitoring devices. The present study demonstrates the importance of utilizing interventions tailored to patients' characteristics and aligned with the capacity of healthcare system.

Implementation and prospective evaluation of the Country Heart Attack Prevention model of care to improve attendance and completion of cardiac rehabilitation for patients with cardiovascular diseases living in rural Australia: a study protocol

INTRODUCTION

Despite extensive evidence of its benefits and recommendation by guidelines, cardiac rehabilitation (CR) remains highly underused with only 20%-50% of eligible patients participating. We aim to implement and evaluate the Country Heart Attack Prevention (CHAP) model of care to improve CR attendance and completion for rural and remote participants.

METHODS AND ANALYSIS

CHAP will apply the model for large-scale knowledge translation to develop and implement a model of care to CR in rural Australia. Partnering with patients, clinicians and health service managers, we will codevelop new approaches and refine/expand existing ones to address known barriers to CR attendance. CHAP will codesign a web-based CR programme with patients expanding their choices to CR attendance. To increase referral rates, CHAP will promote endorsement of CR among clinicians and develop an electronic system that automatises referrals of in-hospital eligible patients to CR. A business model that includes reimbursement of CR delivered in primary care by Medicare will enable sustainable access to CR. To promote CR quality improvement, professional development interventions and an accreditation programme of CR services and programmes will be developed. To evaluate 12-month CR attendance/completion (primary outcome), clinical and cost-effectiveness (secondary outcomes) between patients exposed (n=1223) and not exposed (n=3669) to CHAP, we will apply a multidesign approach that encompasses a prospective cohort study, a pre-post study and a comprehensive economic evaluation.

ETHICS AND DISSEMINATION

This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (HREC/20/SAC/78) and by the Department for Health and Wellbeing Human Research Ethics Committee (2021/HRE00270), which approved a waiver of informed consent. Findings and dissemination to patients and clinicians will be through a public website, online educational sessions and scientific publications. Deidentified data will be available from the corresponding author on reasonable request.

TRIAL REGISTRATION NUMBER

ACTRN12621000222842.

Predictors of Effective Self-care Interventions Among Jordanians With Heart Failure

Jordan has dramatic increases in the prevalence of risk factors for heart failure. However, there are few studies addressing heart failure self-care in Jordan. Identifying predictors of heart failure self-care among Jordanian patients is crucial in providing comprehensive care including addressing risk factors. The study aimed to identify predictors of self-care behaviors among Jordanians with heart failure. A cross sectional study with a convenience sample of 300 Jordanian patients was performed in an educational hospital in the north of Jordan. Differences in the level of self-care between selected sociodemographic and clinical variables were identified using univariate statistics, and multiple regression was used to adjust estimates for covariates. The predictors of self-care were insomnia (p ≤ .001) and marital status (p = .018). Identifying factors influencing self-care can assist with addressing the causes of insomnia to ensure effective treatment, providing patients with social support, and eventually promoting heart failure self-care.

Self-Reported Mobile Health-Based Risk Factor and CHA2DS2-VASc-Score Assessment in Patients With Atrial Fibrillation: TeleCheck-AF Results

Introduction

The TeleCheck-AF approach is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring through teleconsultation. We evaluated feasibility and accuracy of self-reported mHealth-based AF risk factors and CHA2DS2-VASc-score in atrial fibrillation (AF) patients managed within this approach.

Materials and Methods

Consecutive patients from eight international TeleCheck-AF centers were asked to complete an app-based 10-item questionnaire related to risk factors, associated conditions and CHA2DS2-VASc-score components. Patient's medical history was retrieved from electronic health records (EHR).

Results

Among 994 patients, 954 (96%) patients (38% female, median age 65 years) completed the questionnaire and were included in this analysis. The accuracy of self-reported assessment was highest for pacemaker and anticoagulation treatment and lowest for heart failure and arrhythmias. Patients who knew that AF increases the stroke risk, more often had a 100% or ≥80% correlation between EHR- and app-based results compared to those who did not know (27 vs. 14% or 84 vs. 77%, P = 0.001). Thromboembolic events were more often reported in app (vs. EHR) in all countries, whereas higher self-reported hypertension and anticoagulant treatment were observed in Germany and heart failure in the Netherlands. If the app-based questionnaire alone was used for clinical decision-making on anticoagulation initiation, 26% of patients would have been undertreated and 6.1%—overtreated.

Conclusion

Self-reported mHealth-based assessment of AF risk factors is feasible. It shows high accuracy of pacemaker and anticoagulation treatment, nevertheless, displays limited accuracy for some of the CHA2DS2-VASc-score components. Direct health care professional assessment of risk factors remains indispensable to ensure high quality clinical-decision making.

A VIRTUAL Sleep Apnoea management pathway For the work-up of Atrial fibrillation patients in a digital Remote Infrastructure: VIRTUAL-SAFARI

AIMS

In atrial fibrillation (AF) patients, untreated sleep-disordered breathing (SDB) is associated with lower success rates of rhythm control strategies and as such structured SDB testing is recommended. Herein, we describe the implementation of a virtual SDB management pathway in an AF outpatient clinic and examine the utility and feasibility of this new approach.

METHODS AND RESULTS

Prospectively, consecutive AF patients accepted for AF catheter ablation procedures without previous diagnosis of SDB were digitally referred to a virtual SDB management pathway and instructed to use WatchPAT-ONE (ITAMAR) for one night. Results were automatically transferred to a virtual sleep laboratory, upon which a teleconsultation with a sleep physician was planned. Patient experience was measured using surveys. SDB testing was performed in 119 consecutive patients scheduled for AF catheter ablation procedures. The median time from digital referral to finalization of the sleep study report was 18 [11-24] days. In total, 65 patients (55%) were diagnosed with moderate-to-severe SDB. Patients with SDB were prescribed more cardiovascular drugs and had higher body mass indices (BMI, 29 ± 3.3 vs. 27 ± 4.4kg/m2, P < 0.01). Patients agreed that WatchPAT-ONE was easy to use (91%) and recommended future use of this virtual pathway in AF outpatient clinics (86%). Based on this remote SDB testing, SDB treatment was recommended in the majority of patients.

CONCLUSION

This novel virtual AF management pathway allowed remote SDB testing in AF outpatient clinics with a short time to diagnosis and high patient satisfaction. Structured SDB testing results in a high detection of previously unknown SDB in AF patients scheduled for AF ablation.

Evaluation of the feasibility and accuracy of remote mobile app-based self-reported atrial fibrillation risk factor assessment in patients with atrial fibrillation: TeleCheck-AF results

Background

Previously, we introduced the TeleCheck-AF approach, which is an on-demand mobile health (mHealth) infrastructure incorporating mobile app-based heart rate and rhythm monitoring as well as mobile app-based self-reported atrial fibrillation (AF) risk factor assessment to allow comprehensive remote AF management through teleconsultation. Herein, we evaluated the feasibility and accuracy of remote mobile app-based self-reported AF risk factor assessment in AF patients.

Methods

In our University Medical Center, 545 patients were managed within the TeleCheck-AF project by an on-demand heart rate and rhythm mHealth infrastructure through teleconsultation. Patients were asked to fill in a short mobile app-based 10-item questionnaire related to AF risk factors. A reminder to complete the questionnaire automatically popped-up after the following four heart rate and rhythm recordings. Furthermore, patient's medical history was retrieved from the electronic health records (EHRs).

Results

Out of 545 patients, 542 (99.4%) patients (217 female, age 67 (59–72) years) completed the mobile app-based 10-item questionnaire and were included in this analysis. The number of patients with diabetes mellitus was similar in the EHRs and mobile app-based questionnaire (both 11.3%, p=1.000). There was no significant difference in the number of patients who had a medical history of transient ischemic attack (TIA)/cerebrovascular accident (CVA) and artery disease (coronary artery disease and peripheral artery disease) in the EHRs and mobile app-based questionnaire (11.4% vs 12.2%, p=0.608 and 14.8% vs 13.3%, p=0.366, respectively). Heart failure was more frequently reported in the mobile app-based questionnaire compared to the EHRs (33.4% vs 14.0%, p&lt;0.001). A total of 260 (48.0%) patients had a diagnosis of hypertension verified in EHRs and only 239 (44.1%) patients reported hypertension in the mobile app-based questionnaire (p=0.044). There was no significant difference in number of patients with CHA2DS2-VASc-score ≥2 between the EHRs and mobile app-based questionnaire (64.2% vs 66.1%, p=0.275). The accuracy of mobile app-based assessment of diabetes mellitus was 85.4%, of TIA/CVA 78.9%, of artery disease 60.9%, of heart failure 78.8%, and of hypertension 89.3%.

Conclusion

Patient self-reported AF risk factors by a remote mobile app-based assessment is feasible and may be useful for future digital trials and comprehensive remote AF management through teleconsultation.

Funding Acknowledgement

Type of funding sources: None.