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Background Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood. Design This study was based on a systematic review. Methods A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality. Results From 747 potential studies, nine were included. The total sample size was 6457 (range 53–2174), mean age range was 51.3–77.4 years, and range of proportions of males was 57–100%. Reported cognitive impairment prevalence rates varied substantially (9–85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools ( n = 9), cut-off scores and screening timepoints. Conclusions Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.

Funding Acknowledgements Type of funding sources: None. Background Patient education is recommended to increase disease-related knowledge and modify coronary heart disease (CHD) risk factors. Although the importance has been established, there is a lack of knowledge of its efficacy and relative impact of duration on disease-related knowledge and health behaviour outcomes. Purpose It aimed to assess the efficacy of structured patient education on those outcomes in adults with CHD for short-term (less than six months) and long-term (six to 12 months) effect. Methods Eligible randomised controlled trials published in English, Simplified Chinese, Spanish, and Portuguese were searched in seven electronic databases from database inception through 2020. Reference lists, relevant conference lists, and keywords from the Internet were also searched. Outcomes included disease-related knowledge, smoking cessation, medication adherence, physical activity, and healthy dietary behaviour. Results Overall, 73 studies reporting 71 unique trials were included. Participants (n = 24,985) were aged mean 60.5 ± 5.7 years, mostly male (72.5%). About 74% of studies used more than one mode for education delivery, with phone calls and booklets being used the most frequent. Patient education was associated with significant improvement in all outcomes measured in meta-analyses (P < 0.05). In addition, regression analyses showed that a prolonged intervention duration does not significantly improve the outcomes, except for the disease knowledge (p = 0.009) and physical activity (p = 0.026). Conclusions Structured patient education, in a variety of modes and intensities, improves disease-related knowledge and health behaviours in adults with CHD. The findings can be used to guide design of cardiac programs, particularly related to intervention duration in clinical practice. Abstract Figure 1. PRISMA flow diagram

Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation (CR) is a multi-disciplinary, evidence-based intervention, aimed to address modifiable risk factors for coronary artery disease. It is recommended worldwide for patients following myocardial infarction (MI), Percutaneous Coronary Intervention (PCI) and cardiac surgery. A growing body of evidence points towards a lack of uptake in CR in females and younger people. Purpose To examine the effectiveness of contemporary CR programs and assess whether they cater for all patients regardless of age, gender and prior level of fitness, via systematic review, meta-analysis and meta-regression. Methods MEDLINE was examined for studies involving exercise prescription or CR following MI, PCI and cardiac surgery from January 2010 to May 2020. RCTs and cohort studies of ≥10 patients were included for programs delivering phase II or III CR. Primary outcome measures were peakVO2max, 6-minute walk test (6MWT) and Metabolic Equivalent of Task (METs). Data were extracted using random effects meta-analysis. Epidemiological data were analysed for age, proportion of males to females and prior level of fitness. Baseline level of fitness was assessed by peakVO2max, 6MWT and METs values on entry into CR programs. Meta-regression was then used to determine change in fitness and the influence of age or gender. Results Thirty-three of the 713 studies (13 RCT, 20 cohort) were eligible and included in the review. Participants had a mean age of 60.0 years and 6/49 (12%) of study groups had a mean age CRF improved in all study groups by the end of CR programs (mean improvement in peakVO2 3.3mL/kg/min, 6MWT 90.8m and METs 1.7). Meta-regression analysis showed that males were more likely to have an increase in 6MWT distance compared to females (mean difference 3.16m (95% CI 0.44-5.89). However, gender and age did not independently affect peakVO2max or METs. Conclusion CR following MI, PCI or cardiac surgery improved mean CRF in all study groups. While males were more likely to show an improvement in 6MWT there was no appreciable difference in effect in other outcomes after controlling for age or gender differences. Females, younger people and those of average or above CRF appear to be under-represented in data and attendance at cardiac rehabilitation. Given that CR outcomes are equal across gender and age, more effort should be made to encourage female and younger patients to attend. A ‘Precision Medicine’ model of exercise prescription may assist in this aim.

Introduction: Despite cardiac rehabilitation (CR) being recommended in clinical practice guidelines internationally these services are under-utilised, programs are not standardised and quality improvement methods and outcomes are rarely published. National registries are an important strategy to characterise service delivery, quality and outcomes, yet the number, type and components of national CR registries has not been reported. Aims: To identify and describe national and international CR registries internationally, and summarise their key features. Methods: The literature reporting on CR registries used to monitor the quality of CR at a national and international-level was systematically reviewed. A search of four databases was conducted in July 2016, with two reviewers independently screening title/abstracts and full-texts for inclusion. Data were extracted from included studies, independently checked by a second reviewer and synthesised qualitatively. Results: Eleven articles were included in the review comprising seven national registries and one international registry (of 12 European countries) for a total sample of 265,608 patients. Data were most commonly provided to the registry via a web-based application, and included individual-level data (i.e., sociodemographic characteristics, medical history, and clinical measurements). When reported, service-level data most commonly included wait times, program enrolment and completion. The overarching governance, funding modes (e.g., industry (n=2), government (n=1)), and incentives for registry participation (e.g., benchmarking, financial reimbursement, or mandatory requirement) varied widely. Conclusion: The use of national and international registries for characterising CR and providing a benchmark for quality improvement is in its early stages but shows promise for national and global benchmarking. Keywords: Acute coronary syndrome; cardiovascular disease, health information systems; quality Improvement

Accurate physical activity monitoring is important for cardiac patients. Novel activity monitoring devices may enable precise measurement of physical activity. This study aimed to validate Fitbit-Flex against Actigraph accelerometer for monitoring physical activity.A validation study with a comparative design.Cardiac patients and family members participating in community-based exercise programs wore Fitbit-Flex and Actigraph simultaneously over four days to monitor daily step counts and minutes of moderate to vigorous physical activity (MVPA).Participants (N = 48) comprised 52.1% males, with a mean age of 65.6 ± 6.9 years and 58.9% had a cardiac diagnosis. Fitbit-Flex and Actigraph were significantly correlated in males, females, total participants and cardiac patients for step counts (r = .96; r = .95; r = .95; r = .95), though less so for MVPA (r = .81; r = .65, r = .74; r = .71). As step counts increased the differences between Fitbit-Flex and Actigraph also increased. Fitbit-Flex over-estimated step counts in females (556 steps/day), males (1462 steps/day) and total participants (1038 steps/day) as well as for minutes of MVPA in females (4 min/day), males (15 min/day) and total participants (10 min/day). Fitbit-Flex had high sensitivity and specificity in classifying participants who achieved the recommended physical activity guidelines.Fitbit-Flex is accurate in assessing attainment of physical activity guideline recommendations and is useful for monitoring physical activity in cardiac patients. The device does, however, slightly over-estimate step counts and MVPA.

Atrial fibrillation is the most common sustained cardiac arrhythmia affecting 1-2% of the population; the prevalence of atrial fibrillation increases with ageing. The condition is associated with high morbidity and mortality, as well as reduced health-related quality of life, particularly in older people. A PubMed, CINAHL, EMBASE and CENTRAL search (January 2003 to April 2013) was conducted using the search terms atrial fibrillation, quality of life, health-related quality of life, older, aged, and over 65 years. In total, 572 papers were identified of which 15 were eligible, including three observational studies, five descriptive comparative studies and seven randomized control trials. Older atrial fibrillation patients (≥65 years) were significantly impaired in their health-related quality of life in both physical and mental domains compared to the general population or patients with sinus rhythm. Increasing age, being female or having severe symptoms resulted in poorer health-related quality of life particularly in the physical domain. The review also found that the current treatment of AF including rate and rhythm control strategies improved some aspects of health-related quality of life in atrial fibrillation patients but no specific strategy had a superior effect.

© 2016 European Society of Cardiology. Background Despite the compelling evidence of the benefits of cardiac rehabilitation (CR) on risk factor modification, quality of life and mortality reduction, a significant proportion of eligible patients are not referred or do not participate. Factors influencing CR referral and participation are complex and are likely patient, referral system and clinician-related. Little is known about clinician-related factors, which include attitudes, values and beliefs towards CR, or how these factors affect patient referral and attendance. This review examines the current evidence in the literature in relation to clinicians' attitudes, values and beliefs about CR. Methods A review of the literature was conducted on studies in relation to clinicians' attitudes, values and beliefs toward CR. An expert consensus methodology was used to develop the concepts presented in this paper. Results Besides guidelines, a range of other factors influence clinicians' view about CR. This review suggests that clinicians lacking cardiac qualifications may have limited knowledge and awareness of CR and its benefits. Low agreement among clinicians on who is more likely to benefit from CR was also identified. Clinicians' personal lifestyle and health belief, the availability and quality of local the CR programme, and the lack of a standard administrative process of referral can also hinder the referral of patients to CR. Conclusions Clinician-related factors are important to consider in relation to CR referral and participation. Education for clinicians, discussion of local services and the support of an efficacious system at programme and organisation levels are essential.

Background: The Healthy Eating and Exercise Lifestyle Program (HEELP) is a secondary risk factor intervention programme for people with heart disease and/or type 2 diabetes, which has proven benefits for weight loss and exercise. This secondary analysis evaluated the effects of HEELP on achieving recommended levels of exercise and the prevalence of depressive symptoms, and whether meeting exercise recommendations had an independent effect on depressive symptoms. Design: A randomized parallel controlled trial of patients (n=147) with body mass index 27-39 kg/m2 were recruited from cardiac rehabilitation and diabetes education programmes. Methods: HEELP participants received a 16-week group-based lifestyle intervention of twice-weekly supervised exercise and five information sessions; the control group received usual care. At 16 weeks, achievement of recommended levels of exercise (≥5 days/week, moderate or higher intensity, and total duration of ≥150 minutes/week) and depressive symptoms (Hospital Anxiety and Depression Scale) were assessed. Results: More HEELP participants met the recommendations for exercise frequency (71 vs. 50%, p=0.036), intensity (76 vs. 60%, p=0.05), and total duration (65 vs. 43%, p=0.047). The prevalence of depressive symptoms in HEELP was half that of the control group (17 vs. 34%; OR 0.397, 95% CI 0.18-0.86). Participants who met recommendations for total duration of exercise were less likely to report depressive symptoms (OR 0.29, 95% CI 0.112-0.717) after adjusting for treatment group and weight change. Conclusions: A group-based lifestyle intervention improves exercise and reduces depressive symptoms despite multiple risk factors. © 2013 The European Society of Cardiology.