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Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application. [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation remains the 'Cinderella' of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, 'hybrid') and according to stage of disease and patient preference. [ABSTRACT FROM AUTHOR]

Aims Caring for an out-of-hospital cardiac arrest (OHCA) survivor may impact family caregivers' lives due to the sudden onset of the illness and possible secondary cognitive, emotional, and physical challenges. However, experiences of caring for an OHCA survivor are sparsely described. Thus, this study aimed to explore how family caregivers of OHCA survivors experience the potential burden. Methods and results Using an explorative qualitative approach, six focus group interviews were conducted with a sample of 25 family caregivers of OHCA survivors and analysed using a phenomenological hermeneutic approach inspired by the philosophy of Ricoeur. The OHCA survivors attended a rehabilitation course, and the family caregivers were interviewed as part of the course. Based on the analysis, three themes emerged: (i) feeling unexpectedly alone and invisible; the family caregivers experienced an emotional burden that could not be shared—leading to caregiving being a lonely experience, (ii) fear of loss; the fear of losing a loved one was a constant companion contributing to the burden, and (iii) adjusting to a new everyday life; the family caregivers had difficulties adjusting to living their lives on the premise of the survivors' needs. Conclusion The findings of this study emphasize the burden experienced by family caregivers and how they can be trapped in competing emotions and tensions. The possible caregiver burden following OHCA should be acknowledged. Interventions to reduce the burden should be tested and implemented as part of the clinical care of OHCA survivors and their families. [ABSTRACT FROM AUTHOR]

Aims Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous meta-analyses of randomized controlled trials (RCTs) is questioned. Therefore, a contemporary updated meta-analysis was undertaken. Methods and results Database and trial registry searches were conducted to September 2020, seeking RCTs of exercise-based interventions with ≥6-month follow-up, compared with no-exercise control for adults with myocardial infarction, angina pectoris, or following coronary artery bypass graft, or percutaneous coronary intervention. The outcomes of mortality, recurrent clinical events, and health-related quality of life (HRQoL) were pooled using random-effects meta-analysis, and cost-effectiveness data were narratively synthesized. Meta-regression was used to examine effect modification. Study quality was assessed using the Cochrane risk of bias tool. A total of 85 RCTs involving 23 430 participants with a median 12-month follow-up were included. Overall, exercise-based CR was associated with significant risk reductions in cardiovascular mortality [risk ratio (RR): 0.74, 95% confidence interval (CI): 0.64–0.86, number needed to treat (NNT): 37], hospitalizations (RR: 0.77, 95% CI: 0.67–0.89, NNT: 37), and myocardial infarction (RR: 0.82, 95% CI: 0.70–0.96, NNT: 100). There was some evidence of significantly improved HRQoL with CR participation, and CR is cost-effective. There was no significant impact on overall mortality (RR: 0.96, 95% CI: 0.89–1.04), coronary artery bypass graft (RR: 0.96, 95% CI: 0.80–1.15), or percutaneous coronary intervention (RR: 0.84, 95% CI: 0.69–1.02). No significant difference in effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias. Conclusion This review confirms that participation in exercise-based CR by patients with coronary heart disease receiving contemporary medical management reduces cardiovascular mortality, recurrent cardiac events, and hospitalizations and provides additional evidence supporting the improvement in HRQoL and the cost-effectiveness of CR. [ABSTRACT FROM AUTHOR]

Aims Infective endocarditis is a complex and highly mortal disease requiring lengthy treatment. Physical and mental deconditioning is common. Nonetheless, rehabilitation is virtually unexplored in this population. The aim of this trial was therefore to investigate the effects of cardiac rehabilitation in patients following endocarditis. Methods and results In a randomized trial, adults with left-sided or cardiac device endocarditis were randomized 1:1 to 12 weeks of physical exercise training and five psycho-educational consultations (cardiac rehabilitation) vs. usual care without rehabilitation (control). Primary outcome was mental health measured by SF-36 Mental Component Summary (MCS) at 6 months. Secondary outcome was physical capacity measured by peak oxygen uptake (VO2) at 4 months. Exploratory outcomes were investigated. Low inclusion rate resulted in trial termination before reaching the target sample size. A total of 117 participants (mean age: 60 years, 81% male) were randomized to cardiac rehabilitation (n  = 58) or to control (n  = 59). Mental health and physical capacity at baseline were generally poor (MCS: 38.9–42.2 points, VO2 peak: 16.1–16.6 mL/kg/min). Cardiac rehabilitation compared with control showed no effect on mental health (MCS: 44.6 points vs. 48.8 points, P  = 0.41) or physical capacity (VO2 peak: 19.9 mL/kg/min vs. 18.0 mL/kg/min, P  = 0.09). Effects favouring the intervention were identified in exploratory outcomes including general fatigue (P  = 0.005), and physical capacity as maximal power (W) (P  = 0.005). Adherence to the intervention was 28%. Conclusions Results indicate no effect of cardiac rehabilitation in patients following endocarditis; however, lack of statistical power and poor adherence render findings inconclusive. Valuable insight into patients' capabilities and safety was gained, and further investigations into rehabilitation needs and modes of delivery in this high-need population should be a future priority. Registration The trial is registered at ClinicalTrials.gov, NCT01512615 [ABSTRACT FROM AUTHOR]

Aim To quantify the provision of standard cardiac rehabilitation to Danish survivors of cardiac arrest at a programme level, and to analyse whether organizational factors influenced the provision. Method We mapped the provision of cardiac rehabilitation core components to survivors of cardiac arrest and compared this with a reference group of patients after acute myocardial infarction using data from a cross-sectional programme-level survey among all hospitals (n = 34) and municipalities (n = 98) in Denmark. Organizational factors of potential importance to service provision were considered: health care region, size of catchment area/population, type of department/municipality and socioeconomic index. Results Response rates for the provision of each core component of cardiac rehabilitation ranged from 64% to 98%. All hospitals and municipalities provided some aspect of cardiac rehabilitation to survivors of cardiac arrest. Across hospitals, provision of four core components of cardiac rehabilitation to survivors of cardiac arrest was lower compared with post acute myocardial infarction patients: patient education (relative risk (RR) = 0.45 (95% confidence interval (CI) 0.27 to 0.75)), exercise training (RR = 0.69 (95% CI 0.49 to 0.98)), screening for anxiety and depression (RR = 0.64 (95% CI 0.46 to 0.90) and nutritional counselling RR = 0.76 (95% CI 0.62 to 0.93)). No difference was found in the provision of core components across municipalities. Overall, the provision of cardiac rehabilitation to survivors of cardiac arrest was not affected by organizational factors. Conclusion This study indicates a need for future research to inform the development, adoption and implementation of equal access to all components of cardiac rehabilitation for survivors of cardiac arrest in Denmark. [ABSTRACT FROM AUTHOR]

Aims The aim of this article is to assess initiation and discontinuation of preventive medication and use of nonpharmacological prevention interventions after acute coronary syndrome (ACS) among migrants to Denmark compared to the local-born Danish population, taking differences in comorbidity and sociodemographic factors into account. Methods and results In this large cohort study, we selected the population (n = 33 199) from nationwide registers and followed each individual among migrants and Danish-born 180 days after ACS. We identified the initiation and discontinuation of medications and the initiation and number of contacts for non-pharmacological interventions in the Register of Medicinal Products Statistics and the National Patient Register, and adjusted for comorbidity and sociodemographic factors. Non-Western migrants had lower relative risks for initiating adenosine diphosphate receptor (ADP)- and angiotensin-converting enzyme (ACE)-inhibitors (0.93, CI: 0.90; 0.96, and 0.91, CI: 0.87; 0.96) and patient education (0.95, CI: 0.92; 0.98). Further, non-Western migrants had higher hazard ratios for discontinuing medications (statins: 1.64, CI: 1.45; 1.86, ADP-inhibitors: 1.72, CI: 1.50; 1.97, β-blockers: 1.52, CI: 1.40; 1.64, and ACE-inhibitors: 1.72, CI: 1.46; 2.02), and fewer contacts for physical exercise and patient education (P < 0.001 and P = 0.011). Conclusion We identified differences between non-Western migrants and Danish-born in initiation and discontinuation of preventive medications and use of non-pharmacological interventions after ACS. These differences could not be explained by differences in comorbidity or sociodemographic factors. [ABSTRACT FROM AUTHOR]

Background: Increased physical capacity after comprehensive rehabilitation in patients with atrial fibrillation (AF) undergoing ablation has been found in the CopenHeartRFA trial. The purpose of this study was to investigate: (a) sex differences in health status, psychological distress and quality of life, (b) sex differences in rehabilitation outcomes and (c) predictors of effect of rehabilitation. Methods: We conducted an exploratory analysis of data from the randomized CopenHeartRFA trial, where patients treated with ablation were randomized with 1:1 to comprehensive rehabilitation consisting of a physical exercise program and psycho-educational consultations versus usual care. Sex disparities in health status were tested using Chi-square and t-tests. Results: Included were: 151 men (median age 59.25 years) and 59 women (median age 62.5 years). At hospital discharge, women reported lower physical health status compared with men. Among women, significant differences were found in the 6-min walk test [rehabilitation: 496.8 meters (SD 98.5) versus 559.3meters (SD 55.5) and usual care: 521.9 meters (SD 97.8) versus 530.9 meters (SD 102.2), p = 0.01] and exercise time [rehabilitation: 387.6 s (SD 126.0) versus 463.2 s (SD 121.8) and usual care: 353.4 s (SD 145.2) versus 355.8 s (SD 154.8), p < 0.004] and among men in the sit-to-stand test. Significant differences were found in mental health outcomes among men and in quality of life scores among women. Patients with a European Heart Rhythm Association (EHRA) score I-II had a positive effect of rehabilitation. Conclusion: The results suggest that sex differences exist in self-reported health after rehabilitation in patients ablated for AF. Patients with an I–II EHRA score seem more likely to gain from the rehabilitation programme compared with those with a III–IV score. [ABSTRACT FROM AUTHOR]

Background: Approximately 30–40% of heart patients develop anxiety and/or depression, which might influence recovery and long-term survival. Research has suggested that support from relatives may decrease anxiety and depression among heart patients; however, the results are inconsistent and often based on small study populations. Aim: The paper aimed to investigate the association between having supportive relatives and the occurrence of anxiety and depression in heart patients. Methods: A population-based cross-sectional study among Danish patients diagnosed with ischemic heart disease, atrial fibrillation, heart failure, or heart valve disease. Presence of supportive relatives was measured as the degree to which the patients felt that they had relatives they could count on, while symptoms of anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS). Multiple logistic regression analyses accounting for confounders were used to examine the association between supportive relatives and anxiety/depression. Results: The questionnaire was answered by 2496 heart patients, corresponding to 50% of the invited population. Patients with low or some degree of supportive relatives had a higher odds ratio (OR) of anxiety than patients with a high degree (OR = 2.20, 95% confidence interval (CI): 1.28–2.37; OR = 1.75, 95% CI: 1.57–3.08, respectively). Likewise, patients with low or some degree of supportive relatives had a higher OR of depression than patients with a high degree (OR = 1.96, 95% CI: 1.40–2.66; OR = 1.93, 95% CI: 1.37–2.60, respectively). Conclusions: The presence of supportive relatives was found to be associated with lower occurrence of anxiety and depression. Health professionals should focus on including relatives in the treatment and rehabilitation of heart patients. [ABSTRACT FROM AUTHOR]

PURPOSE: Evaluating rehabilitation programmes from the patient's perspective is much needed, as the patients are the most important stakeholders in the health care system. A comprehensive rehabilitation programme, COPE-ICD programme, consists of exercise training and nursing consultations during a one year period post ICD implantation. The purpose of this paper is to describe the experience and meaning of participating in a comprehensive ICD-specific rehabilitation programme. METHODS: Qualitative interviews were conducted with 10 patients representing the participating population, and later transcribed. The analysis was inspired by Ricoeur's theory of interpretation, which consists of three levels: naive reading, structured analysis and critical interpretation and discussion. RESULTS: The overall concept was that participating in the COPE-ICD programme meant feeling inspired and secure through individualized care. Four themes emerged: Knowledge: patients gained much needed understanding; Physical attention: patients interpreted body signals and adjusted their exercise behaviour; Trust: patients regained trust, felt secure and dared to live again; Strategies of living: patients' coping was supported through reflection and professional dialogue, and they dealt with the risk of shock or death. CONCLUSION: Participating in an ICD-specific rehabilitation programme can make patients feel inspired and secure through individualized care. They discover that they have to rethink some of their strategies of living and they gain support in the reflection and coping needed for that. Patients gain insight and they develop a special physical attention whereby they continue healthy activities through interpreting body signals and adjusting exercise behaviour. They learn to trust their body again. [ABSTRACT FROM AUTHOR]

Cardiac patients after an acute event and/or with chronic heart disease deserve special attention to restore their quality of life and to maintain or improve functional capacity. They require counselling to avoid recurrence through a combination of adherence to a medication plan and adoption of a healthy lifestyle. These secondary prevention targets are included in the overall goal of cardiac rehabilitation (CR). Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. The CR approach is delivered in tandem with a flexible follow-up strategy and easy access to a specialized team. To promote implementation of cardiac prevention and rehabilitation, the CR Section of the EACPR (European Association of Cardiovascular Prevention and Rehabilitation) has recently completed a Position Paper, entitled ‘Secondary prevention through cardiac rehabilitation: A condition-oriented approach’. Components of multidisciplinary CR for seven clinical presentations have been addressed. Components include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. Cardiac rehabilitation services are by definition multi-factorial and comprehensive, with physical activity counselling and exercise training as central components in all rehabilitation and preventive interventions. Many of the risk factor improvements occurring in CR can be mediated through exercise training programmes. This call-for-action paper presents the key components of a CR programme: physical activity counselling and exercise training. It summarizes current evidence-based best practice for the wide range of patient presentations of interest to the general cardiology community. [ABSTRACT FROM PUBLISHER]

Background Ischemic heart disease and heart failure often lead to sexual difficulties in men, but little is known about the sexual difficulties in women and patients with other heart diagnoses or the level of information patients receive about the risk of sexual difficulties. Aim To investigate perceived sexual difficulties and associated factors in a mixed population of men and women newly diagnosed with heart disease and provide insight into sexual counseling and information given by health care professionals. Methods This article reports on a cross-sectional, questionnaire study sent to a randomly selected sample of men and women newly diagnosed with heart failure, ischemic heart disease, atrial fibrillation, or heart valve surgery. Eligible patients were identified by diagnosis using the Danish National Patient Register, which contains all diagnoses. Outcomes Sexual difficulties were self-reported using single-item questions, and factors associated with sexual difficulties were collected from the survey and national registers. Results The study population consisted of 1,549 men and 807 women (35–98 years old) with heart failure (n = 243), ischemic heart disease (n = 1,036), heart valve surgery (n = 375), and atrial fibrillation (n = 702). Sexual difficulties were reported by 55% of men and 29% of women. In a multiple regression analysis, difficulties in men were associated with being older (≥75 years old; odds ratio [OR] = 1.97, 95% CI = 1.13–3.43), having heart failure (OR = 2.07, 95% CI = 1.16–3.71), diabetes (OR = 1.80, 95% CI = 1.15–2.82), hypertension (OR = 1.43, 95% CI = 1.06–1.93), receiving β-blockers (OR = 1.37, 95% CI = 1.02–1.86), or having anxiety (OR = 2.25, 95% CI = 1.34–3.80) or depression (OR = 2.74, 95% CI = 1.38–5.43). In women, difficulties were significantly associated with anxiety (OR = 3.00, 95% CI = 1.51–5.95). A total of 48.6% of men and 58.8% of women did not feel informed about sexuality, and 18.1% of men and 10.3% of women were offered sexual counseling. Clinical Implications Heart disease increases the risk of sexual difficulties and there is a need for improved information and counseling about sex and relationships for patients. Strengths and Limitations This large nationwide survey of men and women combined a survey with administrative data from national registries. However, this study used non-validated single-item questions to assess sexual difficulties without addressing sexual distress. Conclusion More than half the men and one fourth the women across common heart diagnoses had sexual difficulties. No difference was found among diagnoses, except heart failure in men. Despite guidelines recommending sexual counseling, sexual difficulties were not met by sufficient information and counseling. Rundblad L, Zwisler AD, Johansen PP, et al. Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study. J Sex Med 2017;14:785–796. [ABSTRACT FROM AUTHOR]