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• A multi-phase process was undertaken to develop Cardiac College for Women. • This is a co-designed education curriculum for CVD secondary prevention in women. • It can be delivered based on women's preferences for modalities and content. • It is hoped these resources will support women to reduce their risk of CV sequelae. Despite their differential risk factor burden, context and often different forms of heart disease, cardiac rehabilitation (CR) programs generally do not provide women with needed secondary prevention information specific to them. to co-design evidence-informed, theory-based comprehensive women-focused education, building from Health e-University's Cardiac College for CR. A multi-disciplinary, multi-stakeholder steering committee (N = 18) oversaw the four-phase development of the women-focused curriculum. Phase 1 involved a literature review on women's CR information needs and preferences, phase 2 a CR program needs assessment, phase 3 content development (including determining content and mode, assigning experts to create the content, plain language review and translation), and phase 4 will comprise evaluation and implementation. In phase 2, a focus group was conducted with Canadian CR providers; it was analyzed using Braun and Clarke's iterative approach. Nineteen providers participated in the focus group, with four themes emerging: current status of education, challenges to delivering women-focused education, delivery modes and topical resources. Results were consistent with those from our related global survey, supporting saturation of themes. Co-designed educational materials included 19 videos. These were organized across 5 webpages in English and French, specific to tests and treatments, exercise, diet, psychosocial well-being, and self-management. Twelve corresponding session slide decks with notes for clinicians were created, to support program delivery in CR flexibly. While further evaluation is underway, these open-access CR education resources will be disseminated for implementation, to support women in reducing their risk of cardiovascular sequelae. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2008.04.009 Byline: Yvonne W. Leung (a), Keerat Grewal (a), Donna E. Stewart (b)(c), Sherry L. Grace (a)(b)(c) Keywords: Cardiac rehabilitation; Gender; Female; Acute coronary syndrome; Mind-Body Therapy; Interpretive-descriptive Abstract: Over one-third of cardiac patients practice Mind-Body Therapy (MBT), particularly women. Considering women are less likely to engage in conventional physical activity, few studies have examined why MBT is well-accepted by women. Author Affiliation: (a) Kinesiology and Health Science, York University, 222B Bethune College, 4700 Keele Street, Toronto, ON M3J1P3, Canada (b) University of Health Network, Canada (c) University of Toronto, Canada

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2007.05.003 Byline: Yvonne W. Leung (a), Hala Tamim (a), Donna E. Stewart (b)(c), Heather M. Arthur (d), Sherry L. Grace (a)(b)(c) Keywords: Mind-body therapies; Women; Relaxation techniques; Cardiovascular disease; Acute coronary syndrome Abstract: While the benefits of mind-body therapy (MBT) for cardiac secondary prevention continues to be investigated, the prevalence of such practices by cardiac patients is not well known. The aim of this study was to quantitatively examine the prevalence of MBT practice and its sociodemographic, clinical, psychosocial and behavioral correlates among patients with acute coronary syndrome (ACS). Author Affiliation: (a) York University, Canada (b) University Health Network, Canada (c) University of Toronto, Canada (d) McMaster University, Canada

Objectives: To assess the effectiveness of cardiac rehabilitation (CR) in low- and middle-income countries (LMICs), given previous reviews have included scant trials from these settings and the great need there.Methods: Six electronic databases (PubMed, Medline, Embase, CINAHL, Cochrane Library, and APA PsycINFO) were searched from inception-May 2020. Randomised controlled CR (i.e., at least initial assessment and structured exercise; any setting; some Phase II) trials with any clinical outcomes (e.g., mortality and morbidity, functional capacity, risk factor control and psychosocial well-being) or cost, with usual care (UC) control or active comparison (AC), in acute coronary syndrome with or without revascularization or heart failure patients in LMICs were included. With regard to data extraction and data synthesis, two reviewers independently vetted identified citations and extracted data from included trials; Risk of bias was assessed using Cochrane's tool. Certainty of evidence was ascertained based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A random-effects model was used to calculate weighted mean differences and 95% confidence intervals (CI).Results: Twenty-six trials (6380 participants; 16.9% female; median follow-up = 3 months) were included. CR meaningfully improved functional capacity (VO2peak vs UC: 5 trials; mean difference [MD] = 3.13 ml/kg/min, 95% CI = 2.61 to 3.65; I2 = 9.0%); moderate-quality evidence), systolic blood pressure (vs UC: MD = -5.29 mmHg, 95% CI = -8.12 to -2.46; I2 = 45%; low-quality evidence), low-density lipoprotein cholesterol (vs UC: MD = -16.55 mg/dl, 95% CI = -29.97 to -3.14; I2 = 74%; very low-quality evidence), body mass index (vs AC: MD = -0.84 kg/m2, 95% CI = -1.61 to -0.07; moderate-quality evidence; I2 = 0%), and quality of life (QoL; vs UC; SF-12/36 physical: MD = 6.05, 95% CI = 1.77 to 10.34; I2 = 93%, low-quality evidence; mental: MD = 5.38, 95% CI = 1.13 to 9.63; I2 = 84%; low-quality evidence), among others. There were no evidence of effects on mortality or morbidity. Qualitative analyses revealed CR was associated with lower percutaneous coronary intervention, myocardial infarction, better cardiovascular function, and biomarkers, as well as return to life roles; there were other non-significant effects. Two studies reported low cost of home-based CR.Conclusions: Low to moderate-certainty evidence establishes CR as delivered in LMICs improves functional capacity, risk factor control and QoL. While more high-quality research is needed, we must augment access to CR in these settings.Systematic Review Registration: PROSPERO (CRD42020185296). [ABSTRACT FROM AUTHOR]

• A 5-phase process to culturally-adapt materials for natives, immigrants was tested. • Mandarin-speaking patients and experts were satisfied with the CR education. • Cardiac College™ is available for Mandarin-speaking patients in China and beyond. Cardiac rehabilitation (CR) is a proven model of secondary prevention in which patient education is a core component. to translate and culturally-adapt CR patient education for Mandarin-speaking patients living in China as well as immigrants, and offer recommendation for best practices in adaptation for both. these steps were undertaken in China and Canada: (1) preparation; (2) translation and adaptation; (3) review by healthcare providers based on PEMAT-P; (4) think-aloud review by patients; and (5) finalization. Two independent Mandarin translations were undertaken using best practices: one domestic (China) and one international (immigrants). Input by 23 experts instigated revisions. Experts rated the language and content as culturally-appropriate, and perceived the materials would benefit their patients. A revised version was then administered to 36 patients, based on which a few edits were made to optimize understandability. some important differences emerged between translations adapted for native versus immigrant settings. [ABSTRACT FROM AUTHOR]

Background: This study aimed to establish availability and characteristics of cardiac rehabilitation (CR) in Latin America and the Caribbean (LAC), where cardiovascular disease is highly prevalent.Methods: In this cross-sectional sub-analysis focusing on the 35 LAC countries, local cardiovascular societies identified CR programs globally. An online survey was administered to identified programs, assessing capacity and characteristics. CR need was computed relative to ischemic heart disease (IHD) incidence from the Global Burden of Disease study.Results: ≥1 CR program was identified in 24 LAC countries (68.5% availability; median = 3 programs/country). Data were collected in 20/24 countries (83.3%); 139/255 programs responded (54.5%), and compared to responses from 1082 programs in 111 countries. LAC density was 1 CR spot per 24 IHD patients/year (vs 18 globally). Greatest need was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed/year). In 62.8% (vs 37.2% globally P < .001) of CR programs, patients pay out-of-pocket for some or all of CR. CR teams were comprised of a mean of 5.0 ± 2.3 staff (vs 6.0 ± 2.8 globally; P < .001); Social workers, dietitians, kinesiologists, and nurses were significantly less common on CR teams than globally. Median number of core components offered was 8 (vs 9 globally; P < .001). Median dose of CR was 36 sessions (vs 24 globally; P < .001). Only 27 (20.9%) programs offered alternative CR models (vs 31.1% globally; P < .01).Conclusion: In LAC countries, there is very limited CR capacity in relation to need. CR dose is high, but comprehensiveness low, which could be rectified with a more multidisciplinary team. [ABSTRACT FROM AUTHOR]

• Maintenance CR results in significantly lower LDL and greater QoL than usual care. • For other pooled outcomes, when compared to usual care, no significant differences were observed. • There were no differences when maintenance CR was compared to active comparison. • Qualitatively, strength, medications, support, cognition, and depression were better. Phase III/IV cardiac rehabilitation (CR) is recommended to promote maintenance of benefits achieved during Phase II; there has been no meta-analysis to test this to date. This study determined the effects of maintenance CR on any outcome, with consideration of sex. Seven databases were searched from inception-January 2020. Randomized controlled trials on the effects of maintenance CR in cardiovascular disease patients who had graduated from CR were included. Level of evidence was evaluated with GRADEPro. 819 citations were identified, with 10 trials (21 papers) included (5238 participants; 859 [16.4%] female). Maintenance CR resulted in lower low-density lipoprotein (mean difference [MD]=-0.58; 95% confidence interval [CI]=-1.06–-0.10, n = 392) and greater quality of life (MD = 0.28, 95% CI = 0.05–0.52, n = 118) when compared to usual care only. Outcomes for women and sex differences were mixed. In conclusion, maintenance programs appear to sustain patient's quality of life, but more focus on women's outcomes is needed. [ABSTRACT FROM AUTHOR]

Background: Clinical registries are effective for monitoring clinical practice, yet manual data collection can limit their implementation and sustainability. The objective of this study was to assess the feasibility of using a data capture tool to collect cardiac rehabilitation (CR) minimum variables from electronic hospital administration databases to populate a new CR registry in Australia.Methods: Two CR facilities located in Melbourne, Australia participated, providing data on 42 variables including: patient socio-demographics, risk factors and co-morbidities, CR program information (e.g. number of CR sessions), process indicators (e.g. wait time) and patient outcomes (e.g. change in exercise capacity). A pre-programmed, automated data capture tool (GeneRic Health Network Information for the Enterprise [20]: https://www.grhanite.com/) (GRHANITE™) was installed at the sites to extract data available in an electronic format from hospital sites. Additionally, clinicians entered data on CR patients into a purpose-built web-based tool (Research Electronic Data Capture: https://www.project-redcap.org/) (REDCap). Formative evaluation including staff feedback was collected.Results: The GRHANITE™ tool was successfully installed at the two CR sites and data from 176 patients (median age = 67 years, 76% male) were securely extracted between September-December 2017. Data pulled electronically from hospital databases was limited to seven of the 42 requested variables. This is due to CR sites only capturing basic patient information (e.g. socio-demographics, CR appointment bookings) in hospital administrative databases. The remaining clinical information required for the CR registry was collected in formats (e.g. paper-based, scanned or Excel spreadsheet) deemed unusable for electronic data capture. Manually entered data into the web-tool enabled data collection on all remaining variables. Compared to historical methods of data collection, CR staff reported that the REDCap tool reduced data entry time.Conclusions: The key benefits of a scalable, automated data capture tool like GRHANITE™ cannot be fully realised in settings with under-developed electronic health infrastructure. While this approach remains promising for creating and maintaining a registry that monitors the quality of CR provided to patients, further investment is required in the digital platforms underpinning this approach. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend cardiac rehabilitation and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary prevention treatments is suboptimal.Methods: This is a multicenter, pragmatic, 3-arm randomized trial. Eligible patients (n = 2,742) with obstructive coronary artery disease are randomized post-MI to usual care or 1 of 2 intervention arms. Patients in the first intervention arm receive mail-outs sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system telephone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the interactive voice response system identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of cardiac rehabilitation. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned.Conclusions: We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions. [ABSTRACT FROM AUTHOR]

Background Technological advances are leading to the ability to autonomously monitor patient's health status in their own homes, to enable aging-in-place. Objectives To understand the perceptions of seniors with heart failure (HF) regarding smart-home systems to monitor their physiological parameters. Methods In this qualitative study, HF outpatients were invited to a smart-home lab, where they completed a sequence of activities, during which the capacity of 5 autonomous sensing modalities was compared to gold standard measures. Afterwards, a semi-structured interview was undertaken. These were transcribed and analyzed using an interpretive-descriptive approach. Results Five themes emerged from the 26 interviews: (1) perceptions of technology, (2) perceived benefits of autonomous health monitoring, (3) disadvantages of autonomous monitoring, (4) lack of perceived need for continuous health monitoring, and (5) preferences for autonomous monitoring. Conclusions Patient perception towards autonomous monitoring devices was positive, lending credence to zero-effort technology as a viable and promising approach. [ABSTRACT FROM AUTHOR]

Background This study examined whether cardiac inpatients recall depression screening and how it is related to depressive symptoms and treatment one year later. Methods 2635 cardiac inpatients from 11 hospitals completed a survey and were mailed a follow-up survey one year later; both surveys included the BDI-II. Results Of the 1809 (68.7%) retained participants, 513 (30.0%) recalled depression screening. Recall was not significantly related to depressive symptoms at either time point ( P > 0.05). Participants who were recommended antidepressants had higher BDI-II scores than those who were not, both as inpatients ( P < 0.01) and one year later ( P < 0.05). There was no significant change in depressive symptoms over time in patients who received any type of therapy. Conclusion Less than one-third of cardiac inpatients recalled being screened for depression. Recall of screening was not significantly related to depressive symptoms, and use of treatment was related to greater symptoms. [ABSTRACT FROM AUTHOR]

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine the factors affecting attendance at an adapted cardiac rehabilitation program for individuals poststroke.Methods: A convenience sample of ambulatory patients with hemiparetic gait rated 20 potential barriers to attendance on a 5-point Likert scale upon completion of a 6-month program of 24 prescheduled weekly sessions. Sociodemographic characteristics, depressive symptoms, cardiovascular fitness, and comorbidities were collected by questionnaire or medical chart.Results: Sixty-one patients attended 77.3 ± 12% of the classes. The longer the elapsed time from stroke, the lower the attendance rate (r = -.34, P = .02). The 4 greatest barriers influencing attendance were severe weather, transportation problems, health problems, and traveling distance. Health problems included hospital readmissions (n = 6), influenza/colds (n = 6), diabetes and cardiac complications (n = 4), and musculoskeletal issues (n = 2). Of the top 4 barriers, people with lower compared to higher income had greater transportation issues (P = .004). Greater motor deficits of the stroke-affected leg were associated with greater barriers related to health issues (r = .7, P = .001). The only sociodemographic factor associated with a higher total mean barrier score was non-English as the primary language spoken at home (P = .002); this factor was specifically related to the barriers of cost (P = .007), family responsibilities (P = .018), and lack of social support (P = .001). No other associations were observed.Conclusion: Barriers to attendance were predominantly related to logistic/transportation and health issues. People who were more disadvantaged socioeconomically (language, finances), and physically (stroke-related deficits) were more affected by these barriers. Strategies to reduce these barriers, including timely referral to exercise programs, need to be investigated. [ABSTRACT FROM AUTHOR]

Objectives To test whether a theoretically-based education curriculum results in more sustained knowledge, higher scores on Health Action Process Approach (HAPA) constructs, and greater exercise behavior 6 months post-cardiac rehabilitation (CR) when compared to traditional CR education. Background Patient education is a core component of CR. No research has examined whether this education results in sustained improvements post-program. Methods In this quasi-experimental study, participants exposed to the traditional vs HAPA-based education completed surveys pre, post-CR, and 6 months post-discharge assessing knowledge, HAPA constructs, and exercise. Results Ninety-three participants completed the final survey. Knowledge increases post-CR were sustained 6 months post-program, with no differences by curriculum. Many improvements in HAPA constructs observed post-CR were sustained, except for some decay in self-efficacy. Minutes of exercise per week were significantly greater in participants exposed to the HAPA-based curriculum 6 months post-program. Conclusions HAPA-based education in CR has sustained effects on exercise. [ABSTRACT FROM AUTHOR]

Objectives To (1) test the effect of a health action process approach (HAPA) theory-based education program in cardiac rehabilitation (CR) compared to traditional education on patient knowledge and HAPA constructs; and, (2) investigate the theoretical correlates of exercise behavior among CR patients receiving theory-based education. Methods CR patients were exposed to an existing or HAPA-based 6 month education curriculum in this quasi-experimental study. Participants completed a survey assessing exercise behavior, HAPA constructs, and knowledge pre and post-program. Results 306 patients consented to participate, of which 146 (47.7%) were exposed to the theory-based educational curriculum. There was a significant improvement in patients’ overall knowledge pre- to post-CR, as well as in some HAPA constructs and exercise behavior, regardless of curriculum ( p < 0.05). Path analysis revealed that knowledge was significantly related to intention formation, and intentions to engage in exercise were not directly related to behavior, which required action planning. Conclusions The theoretically-informed education curriculum was not associated with greater knowledge or exercise behavior as expected. Education in CR improves knowledge, and theoretical constructs related to exercise behavior. Practice implications Educational curricula should be designed to not only increase patients’ knowledge, but also enhance intentions, self-efficacy, and action planning. [ABSTRACT FROM AUTHOR]

Objectives To develop and psychometrically-validate a revised version of the Coronary Artery Disease Education Questionnaire (CADE-Q) – a tool to assess patients’ knowledge about CAD in cardiac rehabilitation (CR). Methods After a needs assessment, a literature review and focus group with CR experts, the revised questionnaire was developed. It underwent pilot-testing in 30 patients, which lead to further refinement. The questionnaire was then psychometrically-tested in 307 CR patients. Internal consistency was assessed using Cronbach's alpha, the dimensional structure through exploratory factor analysis, and criterion validity with regard to educational level. Results Cronbach's alpha was 0.91. Criterion validity was supported by significant differences in mean scores by educational level ( p < 0.001). Factor analysis revealed four factors, which were internally-consistent (0.65–0.77), and well-defined by items. The mean total score was 64.2 ± 18.1/93. Patients with a history of heart failure, cardiomyopathy and percutaneous coronary intervention ( p < 0.05) had significantly higher knowledge scores compared with patients without such a history. Knowledge about exercise and their medical condition was significantly higher than risk factors, nutrition and psychosocial risk. Conclusions The CADE-QII has good reliability and validity. Practical implications This tool may be useful to assess CR participants’ knowledge gaps, and to evaluate the efficacy of educational delivery in CR. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To translate, culturally adapt and psychometrically validate the Information Needs in Cardiac Rehabilitation (INCR) tool to Portuguese. Background: The identification of information needs is considered the first step to improve knowledge that ultimately could improve health outcomes. Methods: The Portuguese version generated was tested in 300 cardiac rehabilitation patients (CR) (34% women; mean age = 61.3 ± 2.1 years old). Test-retest reliability was assessed using intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and the criterion validity was assessed with regard to patients' education and duration in CR. Results: All 9 subscales were considered internally consistent (á > 0.7). Significant differences between mean total needs and educational level (p < 0.05) and duration in CR (p = 0.03) supported criterion validity. The overall mean (4.6 ± 0.4), as well as the means of the 9 subscales were high (emergency/safety was the greatest need). Conclusion: The Portuguese INCR was demonstrated to have sufficient reliability, consistency and validity. [Copyright &y& Elsevier]

OBJECTIVE: To (1) describe cardiac rehabilitation (CR) participant information needs, (2) investigate whether CR providers are cognizant of patient's information needs and preferred delivery formats, and (3) investigate whether patient information needs change over the course of CR. METHODS: In this cross-sectional study, 306 CR patients and 28 CR providers completed a survey. The survey consisted of the Information Needs in CR (INCR) questionnaire, and items about preferred education delivery formats. RESULTS: Low-income CR participants had significantly greater information needs than high-income participants. CR providers were cognizant of patient information needs, except patients did desire more information on diagnosis and treatment than providers perceived (p<0.01). Books, lectures and discussion were identified as the preferred delivery formats by both patients and providers. There were some significant differences in patient information needs over the course of the program, particularly in relation to concerns and risk factors. CONCLUSION: CR patients desire information in many areas, particularly regarding emergency/safety and diagnosis/treatment. CR providers were highly cognizant of patient information needs; however, these do change over time. PRACTICE IMPLICATIONS: These findings could inform evaluation and improvement of CR education programming, to ensure programs are meeting patient information needs across all stages of recovery. [ABSTRACT FROM AUTHOR]

Abstract: Cardiovascular disease is among the leading causes of mortality and morbidity in Canada. Cardiac rehabilitation (CR) has a long robust history here, and there are established clinical practice guidelines. While the effectiveness of CR in the Canadian context is clear, only 34% of eligible patients participate, and strategies to increase access for under-represented groups (e.g., women, ethnic minority groups) are not yet universally applied. Identified CR barriers include lack of referral and physician recommendation, travel and distance, and low perceived need. Indeed there is now a national policy position recommending systematic inpatient referral to CR in Canada. Recent development of 30 CR quality indicators and the burgeoning national CR registry will enable further measurement and improvement of the quality of CR care in Canada. Finally, the Canadian Association of CR is one of the founding members of the International Council of Cardiovascular Prevention and Rehabilitation, to promote CR globally. [Copyright &y& Elsevier]

Abstract: Objective: To develop and psychometrically validate a tool to assess information needs in cardiac rehabilitation (CR) patients. Methods: After a literature search, 60 information items divided into 11 areas of needs were identified. To establish content validity, they were reviewed by an expert panel (N =10). Refined items were pilot-tested in 34 patients on a 5-point Likert-scale from 1 “really not helpful” to 5 “very important”. A final version was generated and psychometrically tested in 203 CR patients. Test–retest reliability was assessed via the intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and criterion validity was assessed with regard to patient's education and duration in CR. Results: Five items were excluded after ICC analysis as well as one area of needs. All 10 areas were considered internally consistent (Cronbach's alpha>0.7). Criterion validity was supported by significant differences in mean scores by educational level (p <0.05) and duration in CR (p <0.001). The mean total score was 4.08±0.53. Patients rated safety as their greatest information need. Conclusion: The INCR Tool was demonstrated to have good reliability and validity. Practice implications: This is an appropriate tool for application in clinical and research settings, assessing patients’ needs during CR and as part of education programming. [Copyright &y& Elsevier]

Abstract: Marzolini S, Oh PI, Alter D, Stewart DE, Grace SL; on behalf of the Cardiac Rehab: Care Continuity through Automatic Referral Evaluation Investigators. Musculoskeletal comorbidities in cardiac patients: prevalence, predictors, and health services utilization. Objectives: To describe the prevalence of musculoskeletal conditions (MSKC) in patients with coronary artery disease (CAD); to examine the sociodemographic, clinical, and psychosocial predictors of these comorbidities; and to describe health care utilization by musculoskeletal comorbidity status. Design: This was a cross-sectional, observational study in which patients were administered a questionnaire in the hospital and 1 year later. Setting: Eleven hospitals in Ontario, Canada. Participants: CAD patients (N=1803). Interventions: Not applicable. Main Outcome Measures: Sociodemographic, MSKC, clinical, and psychosocial factors were ascertained via questionnaire and in-hospital chart extraction. A health care utilization questionnaire was mailed 1 year later. Results: Over half (56%) of the patients with CAD had MSKCs, with arthritis/joint pain accounting for 64.4% of these MSKCs. Patients who were older (odds ratio [OR]=1.03), women (OR=1.87), white (OR=1.80), with higher body mass index (OR=1.05), depressive symptoms (OR=1.92), and lower family income (OR=1.46) were more likely to present with MSKCs. One year posthospitalization, a greater proportion of those with MSKCs reported ≥1 cardiac-related emergency department visit (33.2% vs 28.3%, P=.03), hospital admission (30.7% vs 22%, P=.006), more primary care physician visits (6.6±5.6 vs 5.7±4.6, P<.001), and fewer cardiac rehabilitation referrals (61.5% vs 70%, P<.001). After adjusting for depressive symptoms, body mass index, age, income, ethnicity, and sex, MSKCs predicted only hospital readmissions. Conclusions: Over half of the patients hospitalized for CAD have MSKCs. Those with MSKCs have a physical and psychosocial profile that places them at greater cardiovascular risk than those with CAD only, explaining, in part, their greater health care utilization. Despite a greater need for comprehensive risk factor management in patients with MSKCs, fewer were referred to cardiac rehabilitation. [Copyright &y& Elsevier]

Background: Delay in seeking timely medical care by patients with acute coronary syndrome and stroke has been well established in the literature, but less is known about delay in care-seeking behavior by patients with heart failure (HF). The purpose of this narrative review was to synthesize the literature regarding non-symptom-related factors that contribute to delay in seeking medical care for HF symptoms.Methods and Results: A literature search of Scopus, Medline, and Pubmed was conducted for published articles from database inception to July 2009. Available evidence has shown that non-symptom-related factors, such as HF severity, HF history, age, and ethnocultural background, were related to delay in certain studies; however, null results have also been reported. Other non-symptom-related factors, such as male gender, initial contact with a primary care physician, arriving in the emergency department by means other than ambulance, and patient responses such as self-care, low anxiety, and hopelessness, may play a role in longer delay.Conclusions: Although this review identified several non-symptom-related factors that may be implicated in care-seeking delay, health care professionals should be vigilant in identifying all high-risk individuals and educating them about warning signs of HF. Moreover, access to outpatient chronic disease management programs that may have potential to reduce care-seeking delay behavior should be explored. [ABSTRACT FROM AUTHOR]

Abstract: Despite the preponderance of evidence on the numerous benefits of CR, it remains largely under-utilized in women. The objective of this narrative review was to summarize and synthesize the literature on women and CR with regard to outcomes, adherence, and preferences for alternative models of CR. Studies of the effectiveness of CR have generally revealed no major differences between men and women. However, female-specific data are lacking on the effect of CR on mortality and morbidity. Research suggests that women and men may be equally likely to prefer home-based to hospital-based CR services. Women''s preferences for and outcomes in, women-only CR are beginning to be uncovered. Discussing program model options with female cardiac patients and referring to preferred types may be the appropriate approach until further evidence is available. [Copyright &y& Elsevier]

Purpose: South Asians experience high rates of cardiovascular disease, yet participate in cardiac rehabilitation (CR) at low rates. Drawing on the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, this qualitative descriptive study sought to identify cultural factors facilitating South Asians'' participation in CR programs. Methods: Two semistructured interviews were conducted with each of 16 Canadian South Asian participants enrolled in a 12-month CR program. Transcribed data were analyzed for common themes, and categorized in terms of predisposing, enabling, and reinforcing factors. Results: Primary cultural facilitators included descriptions of CR as a “medically supervised” program, family and physician support, and previous knowledge of CR via members of the South Asian community. Conclusion: Previous research identified barriers to CR participation in the South Asian community, and this study is the first to identify facilitators. Results suggest that families should be included in patient-education sessions, CR should be reinforced by healthcare providers, and the provider team should recognize cultural preferences. [Copyright &y& Elsevier]

Objective: Social support and illness perceptions may affect recovery from a cardiac event or procedure. Previous research has found that patients of South Asian origin with coronary artery disease (CAD) have lower levels of social support and may perceive different causes of their condition. The purpose of this study was to quantitatively investigate differences in social support and illness perceptions between Caucasian and South Asian patients with CAD. Methods: A total of 562 inpatients with CAD (53 [9%] South Asian) were recruited from 2 hospitals. The Medical Outcomes Study social support scale and Illness Perception Questionnaire were administered to examine ethnocultural differences in total social support and subscales, and in illness perceptions subscales, including causes of illness. Results: South Asian participants had significantly lower levels of tangible (P =.001) and emotional/informational support (P < .001) compared with Caucasian participants. South Asians were less likely than Caucasians to believe they have personal control over their illness (P < .001). Trends were observed, with South Asian participants being more likely to attribute their condition to stress/worry (P =.04) and poor medical care in the past (P =.02) and less likely to attribute their illness to aging (P =.03) compared with Caucasian participants. Conclusion: Lower levels of social support among South Asians in Canada may have negative effects on recovery and prognosis. Our results support qualitative findings suggesting South Asians perceive their illness to be a result of fate or related to stress. Future studies should investigate interventions targeted at modifying illness perceptions among this group in an attempt to improve risk-reducing behavior and secondary prevention use. [Copyright &y& Elsevier]

Previous research has established a relation between depression at the time of cardiac hospitalization and patient mortality. The objective of this study was to examine the role of depressive history and symptomatology during hospitalization on 5-year all-cause mortality after admission for an acute coronary syndrome. We recruited 750 patients who had unstable angina pectoris and myocardial infarction from 12 coronary care units between 1997 and 1999. Measurements included sociodemographic and clinic data and the Beck Depression Inventory (BDI). Data were linked to an administrative database to determine 5-year all-cause mortality. Survival data were adjusted using a Cox’s proportional hazards model. One hundred seventy-four participants (23.2%) self-reported a history of depressed mood for >2 weeks, 235 (31.3%) had elevated BDI scores at index hospitalization, with 105 (14.0%) reporting persistent depressive symptomatology. One hundred fifteen participants (15.3%) died by 5 years after hospitalization. After adjusting for prognostic indicators, such as cardiac disease severity, medical history, and smoking, depressive symptomatology during hospitalization was significantly predictive of mortality, but depressive history was not. Hazard ratios associated with BDI scores <10 versus those ≥10 at hospitalization ranged from 1.90 (95% confidence interval 1.12 to 3.24) at 2 years to 1.53 (95% confidence interval 1.04 to 2.24) at 5 years. In conclusion, the significance of depressive symptomatology at the time of, but not before, hospitalization underlines the need for early identification of increased distress and renews calls to identify treatments that not only improve quality of life but also decrease the risk of mortality. [Copyright &y& Elsevier]

Abstract: Objective: This study examined cardiovascular disease (CVD) illness perceptions and how they relate to depressive symptomatology among women and men. Methods: Acute coronary syndrome (ACS) patients at two hospitals were approached, and 661 consented to participate (504 men, 157 women; 75% response rate). Participants completed a survey including the Hospital Anxiety and Depression Scale (HADS) and Illness Perception Questionnaire (IPQ). Results: Women perceived a significantly more chronic course (P<.001) and more cyclical episodes (P<.05) than men did, while men perceived greater personal control (P<.001) and treatability (P<.05) than women did. Participants perceived diet, heredity, and stress as the greatest CVD causes. For women (F=5.49, P<.001), greater depressive symptomatology was significantly related to younger age (P<.05), lower activity status (P<.001), and perceiving a chronic time course (P<.01). For men (F=7.68, P<.001), greater depressive symptomatology was significantly related to being non-white (P<.05), lower activity status (P<.001), less exercise behavior (P=.01), and three illness perceptions, namely, perceiving a chronic course (P<.05), greater consequences (P<.001), and lower treatability (P<.05). Conclusion: Women, compared with men, are more likely to attribute CVD to causes beyond their control and to perceive CVD as a chronic, untreatable condition. Illness perceptions were related to depressive symptomatology, which suggests that interventions to reframe these perceptions may be warranted to improve emotional health in the context of CVD. [Copyright &y& Elsevier]

Background: This study seeks to explore gender-relevant factors of medical history, sociodemographics, symptom presentation, and delay on thrombolysis administration (or recorded contraindication) in a sample of men and women with confirmed myocardial infarction (MI).Methods: Cross-sectional examination of self and nurse-report data collected in the coronary care unit (CCU) from 12 hospitals across south-central Ontario, Canada. A total of 482 MI patients (347 males, 135 females; 63% response rate) were recruited.Main findings: There was no gender difference in the report of chest pain (χ2(1) = 3.78, p = .052), or in prehospital delay time (median = 96.5 minutes). Thrombolysis was administered in 158 males (68.4%) and 50 females (50.0%) without reported contraindication. Females (median = 27 minutes) had a significantly longer interval between diagnostic electrocardiogram (ECG) and administration of a thrombolytic than males (median = 22, U = 3,056). No contraindication was indicated for not administering a thrombolytic (i.e., too late, risk of bleed) in approximately 40% of females. In accordance with clinical practice guidelines, thrombolysis was more often administered in participants with a shorter time interval between symptom onset and hospital arrival. For females, thrombolysis was more often administered in younger participants (Kruskal Wallis = 5.88).Conclusions: Reducing gender, age, and socioeconomic disparities in access to thrombolysis treatment is imperative. Hospital delays with female cardiac patients may be precluding thrombolysis administration. [Copyright &y& Elsevier]

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. Substantial health risks continue following ischemic coronary events (ICEs), but secondary prevention efforts, including cardiac rehabilitation (CR), have beneficial effects on both early and late mortality and morbidity. This prospective study examined the relationship among psychosocial factors and CR referral and participation patterns in 906 (586 men, 320 women) patients from the coronary intensive care unit (CICU) over the course of six months. Only 30% of participants were referred to CR programs, with significantly fewer women being referred. A logistic regression analysis was used to determine whether depression, anxiety, self-efficacy, or social support predicted CR participation six months following an ICE, while controlling for sociodemographic factors. Results show that higher family income, greater anxiety symptomatology, and higher self-efficacy were significantly predictive of CR participation at six months. Implications for women’s recovery from an ICE are discussed. [Copyright &y& Elsevier]

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. There are gender differences in recovery from coronary events, which may be due physiological, sociodemographic, or psychosocial factors. Cardiac rehabilitation programs have beneficial effects on coronary recovery. The following presents a review of the literature from MedLine (1997–2001) and PsychInfo (1984–2001) on gender differences in participation in cardiac rehabilitation programs, with a focus on depression, anxiety, self-efficacy and social support. A critical analysis of gaps in the literature as well as areas for future research are presented. [Copyright &y& Elsevier]

To compare traditional (1-month supervised) vs hybrid cardiac rehabilitation (CR; usual care) with an additional 3 months offered remotely based on the continuous care model (intervention) in patients who have undergone coronary artery bypass graft (CABG). Randomized controlled trial, with blinded outcome assessment. A major heart center in a middle-income country. Of 107 eligible patients who were referred to CR during the period of study, 82.2% (N=88) were enrolled (target sample size). Participants were randomly assigned 1:1 (concealed; 44 per parallel arm). There was 92.0% retention. After CR, participants were given a mobile application and communicated biweekly with the nurse from months 1-4 to control risk factors. Quality of life (QOL, Short Form-36, primary outcome); functional capacity (treadmill test); and the Depression, Anxiety and Stress Scale were evaluated pre-CR, after 1 month, and 3 months after CR (end of intervention), as well as rehospitalization. The analysis of variance interaction effects for the physical and mental component summary scores of QOL were <.001, favoring intervention (per protocol); there were also significant increases from pre-CR to 1 month, and from 1 month to the final assessment in the intervention arm (P <.001), with change in the control arm only to 1 month. The effect sizes were 0.115 and 0.248, respectively. Similarly, the interaction effect for functional capacity was significant (P <.001), with a clinically significant 1.5 metabolic equivalent of task increase in the intervention arm. There were trends for group effects for the psychosocial indicators, with paired t tests revealing significant increases in each at both assessment points in the intervention arm. At 4 months, there were 4 (10.3%) rehospitalizations in the control arm and none in intervention (P =.049). Intended theoretical mechanisms were also affected by the intervention. Extending CR in this accessible manner, rendering it more comprehensive, was effective in improving outcomes. [ABSTRACT FROM AUTHOR]

Objective: Patient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW.Methods: We used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women's health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7.Results: The response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6).Conclusion: The recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular Disease (CVD) is the leading burden of disease worldwide. Moreover, CVD-related death rates are considered an epidemic in low- and middle-income countries (LMICs). Research shows that cardiac rehabilitation (CR) participation reduces death and improves disability and quality of life. Given the growing epidemic of CVD in LMICs and the insufficient evidence about CR programs in these countries, a Randomized Control Trial (RCT) in Latin America is warranted. Objective: To investigate the effects of comprehensive CR on functional capacity and cardiovascular risk factors. Method: The design is a single-blinded RCT with three parallel arms: comprehensive CR (exercise + education) versus exercise-based CR versus wait-list control (no CR). The primary outcome will be measured by the Incremental Shuttle Walk Test. Secondary outcomes are risk factors (blood pressure, dyslipidemia, dysglycemia, body mass index and waist circumference); tertiary outcomes are heart health behaviors (exercise, medication adherence, diet, and smoking), knowledge, and depressive symptoms. The CR program is six months in duration. Participants randomized to exercise-based CR will receive 24 weeks of exercise classes. The comprehensive CR group will also receive 24 educational sessions, including a workbook. Every outcome will be assessed at baseline and 6-months later, and mortality will be ascertained at six months and one year. Conclusion: This will be the first RCT to establish the effects of CR in Latin America. If positive, results will be used to promote broader implementation of comprehensive CR and patient access in the region and to inform a larger-scale trial powered for mortality. [ABSTRACT FROM AUTHOR]

Introduction One-third of North American adults with congenital heart disease (CHD) have diagnosable mood or anxiety disorders and most do not receive mental health treatment. There are no published interventions targeting the psychosocial needs of patients with CHD of any age. We describe the development of a group psychosocial intervention aimed at improving the psychosocial functioning, quality of life, and resilience of adults with CHD and the design of a study protocol to determine the feasibility of a potential full-scale randomized controlled trial (RCT). Methods/design Drawing upon our quantitative and qualitative research, we developed the Adult CHD-Coping And REsilience (ACHD-CARE) intervention and designed a feasibility study that included a 2-parallel arm non-blinded pilot RCT. Eligible participants (CHD, age ≥ 18 years, no planned surgery, symptoms suggestive of a mood and/or anxiety disorder) were randomized to the ACHD-CARE intervention or Usual Care (1:1 allocation ratio). The group intervention was delivered during eight 90-minute weekly sessions. Feasibility will be assessed in the following domains: (i) process (e.g. recruitment and retention), (ii) resources, (iii) management, (iv) scientific outcomes, and (v) intervention acceptability. Discussion This study underscores the importance of carefully developing and testing the feasibility of psychosocial interventions in medical populations before moving to full-scale clinical trials. At study conclusion, we will be poised to make one of three determinations for a full-scale RCT: (1) feasible, (2) feasible with modifications, or (3) not feasible. This study will guide the future evaluation and provision of psychosocial treatment for adults with CHD. [ABSTRACT FROM AUTHOR]

Abstract: Objective: (1) To investigate the impact of education on patients’ knowledge; (2) to determine if educational interventions are related to health behavior change in cardiac patients; and (3) to describe the nature of educational interventions. Methods: A literature search of several electronic databases was conducted for published articles from database inception to August 2012. Eligible articles included cardiac patients, and described delivery of educational interventions by a healthcare provider. Outcomes were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently. Results: Overall, 42 articles were included, of which 23 (55%) were randomized controlled trials, and 16 (38%) were considered “good” quality. Eleven studies (26%) assessed knowledge, and 10 showed a significant increase with education. With regard to outcomes, educational interventions were significantly and positively related to physical activity, dietary habits, and smoking cessation. The nature of interventions was poorly described and most frequently delivered post-discharge, by a nurse, and in groups. Conclusions: Findings support the benefits of educational interventions in CHD, though increase in patients’ knowledge and behavior change. Practice implications: Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed. [Copyright &y& Elsevier]