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Publisher's version (útgefin grein), Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = .92, 95%CI = .91–.93) or public (OR = .83, 95%CI = .82–84) funding compared to hybrid sources. Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation., This research was supported by a grant from York University 's Faculty of Health. The funder had no role in study design, data collection, data analysis, interpretation or writing of the report.

Cardiovascular disease is one of the main causes of morbidity and mortality worldwide. Despite the availability of highly effective treatments, the contemporary burden of disease remains huge. Digital health interventions hold promise to improve further the quality and experience of cardiovascular care. This position paper provides a brief overview of currently existing digital health applications in different cardiovascular disease settings. It provides the reader with the most relevant challenges for their large-scale deployment in Europe. The potential role of different stakeholders and related challenges are identified, and the key points suggestions on how to proceed are given. This position paper was developed by the European Society of Cardiology (ESC) e-Cardiology working group, in close collaboration with the ESC Digital Health Committee, the European Association of Preventive Cardiology, the European Heart Rhythm Association, the Heart Failure Association, the European Association of Cardiovascular Imaging, the Acute Cardiovascular Care Association, the European Association of Percutaneous Cardiovascular Interventions, the Association of Cardiovascular Nursing and Allied Professions and the Council on Hypertension. It relates to the ESC's action plan and mission to play a pro-active role in all aspects of the e-health agenda in support of cardiovascular health in Europe and aims to be used as guiding document for cardiologists and other relevant stakeholders in the field of digital health. The author(s) received no financial support for the research, authorship, and/or publication of this article.

Background This eH ealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation ( AF ) screening using electronic screening prompts and improve treatment using electronic decision support ( EDS ) software. Methods and Results An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline‐based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA 2 DS 2 ‐ VAS c, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1–448 patients per general practitioner). The proportion of patients with AF who had CHA 2 DS 2 ‐ VAS c ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen‐detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study ( P EDS was accessed 111 times for patients with AF and for 4 of 19 screen‐detected patients. Conclusions The eH ealth tools showed promise. Adherence to guideline‐based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice. Clinical Trial Registration URL : www.anzctr.org.au . Unique identifier: ACTRN 12616000850471.

IntroductioneHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.MethodsMixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.ResultsSurveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.ConclusionIntervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

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.

ObjectiveCVD is a leading cause of mortality and morbidity, and nutrition is an important lifestyle factor. The aim of the present systematic review was to synthesise the literature relating to knowledge translation (KT) of dietary evidence for the prevention and treatment of CVD into practice in populations with or at high risk of CVD.DesignA systematic search of six electronic databases (CINAHL, Cochrane, EMBASE, MEDLINE, PsycINFO and Scopus) was performed. Studies were included if a nutrition or dietary KT was demonstrated to occur with a relevant separate measureable outcome. Quality was assessed using a tool adapted from two quality checklists.SubjectsPopulation with or at high risk of CVD or clinicians likely to treat this population.ResultsA total of 4420 titles and abstracts were screened for inclusion, with 354 full texts retrieved to assess inclusion. Forty-three articles were included in the review, relating to thirty-five separate studies. No studies specifically stated their aim to be KT. Thirty-one studies were in patient or high-risk populations and four targeted health professionals. Few studies stated a theory on which the intervention was based (n10) and provision of instruction was the most common behaviour change strategy used (n26).ConclusionsKT in nutrition and dietary studies has been inferred, not stated, with few details provided regarding how dietary knowledge is translated to the end user. This presents challenges for implementation by clinicians and policy and decision makers. Consequently a need exists to improve the quality of publications in this area.

Lifestyle changes are believed responsible for temporal trends of reduced population total cholesterol (TC), but it is uncertain whether this applies to patients with known coronary heart disease (CHD) often prescribed lipid lowering therapy (LLT). We studied temporal TC trends at presentation with acute coronary syndrome (ACS) to determine the contribution of LLT given for secondary prevention.TC and LLT were obtained in 5592 patients in annual surveys of ACS admissions in Australia between 1999 and 2013, and annual mean trends analysed by linear and segmented regression.TC declined from 5.13±1.1 to 4.53±1.2mmol/L (p0.001) and LLT (96% statin) use at presentation increased from 37.4% to 47.5% (p=0.005). TC decline was greater in those on LLT vs. those not on therapy, with LLT contributing to 57% of the TC decline. The decline in TC and increase in LLT use was non-linear and much steeper in those with, than without CHD history, and LLT contributed substantially more to the TC decline (79%, p0.001 vs. 27%, p=0.06 respectively). The rapid decline in TC and increase in LLT, plateauing after 2005 in those with CHD history differed markedly from trends in recent population studies, while TC trend for those without CHD history was slower, linear and consistent with population trends.Declining TC level at presentation for ACS was strongly associated with increasing LLT use in those with a history of CHD, indicating that increasing uptake of LLT for secondary prevention has impacted TC changes in the new millennium.

Increased exposure to green space has many health benefits. Scottish Green Health Partnerships (GHPs) have established green health referral pathways to enable community-based interventions to contribute to primary prevention and the maintenance of health for those with established disease. This qualitative study included focus groups and semi-structured telephone interviews with a range of professionals involved in strategic planning for and the development and provision of green health interventions (n = 55). We explored views about establishing GHPs. GHPs worked well, and green health was a good strategic fit with public health priorities. Interventions required embedding into core planning for health, local authority, social care and the third sector to ensure integration into non-medical prescribing models. There were concerns about sustainability and speed of change required for integration due to limited funding. Referral pathways were in the early development stages and intervention provision varied. Participants recognised challenges in addressing equity, developing green health messaging, volunteering capacity and providing evidence of success. Green health interventions have potential to integrate successfully with social prescribing and physical activity referral. Participants recommended GHPs engage political and health champions, embed green health in strategic planning, target mental health, develop simple, positively framed messaging, provide volunteer support and implement robust routine data collection to allow future examination of success.

Introduction: Outpatient cardiac rehabilitation programs provide an ideal environment to deliver targeted cardiopulmonary resuscitation (CPR) training to cardiac patients and their family members. However, the prevalence of CPR training in Australian programs is low (24%). This study sought to identify the best strategy to implement CPR training into cardiac rehabilitation programs. Hypothesis: We hypothesise that coordinators who receive a higher level of education (information pack including two self-instructional CPR video training kits and a face-to-face education session) compared to those who only receive an information pack, will be more likely to incorporate CPR training into their cardiac rehabilitation programs. Methods: A two-arm randomised controlled implementation study is currently being conducted across Australia. One cardiac rehabilitation coordinator per cardiac rehabilitation program, where the program is not currently providing regular CPR training to patients and families, is eligible to participate. Coordinators will be randomised 1:1 to either receive an information pack or information pack plus face-to-face education session. Results: To date 23 coordinators (59% metropolitan programs, 41% rural programs) have been randomised. Few programs (19%) have previously offered CPR training and only 25% currently include information about CPR. Common barriers to incorporating CPR training into programs are time (71%), resources (67%) and a lack of awareness to include CPR training (24%). Motivations for including CPR training are driven by coordinators assessment that patients and families are interested in CPR training (81%). Implementation data will be presented including information on the level of implementation in addition to a sample of brief qualitative telephone interviews to further discuss enablers and barriers. Conclusions: Cardiac rehabilitation represents a logical location to provide targeted CPR training to high-risk cardiac groups at scale across Australia. This study will aid in better understanding how cardiac rehabilitation coordinators can be supported to enable more programs to incorporate CPR training.

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.

BackgroundHealth practitioners’ values, attitudes and beliefs largely determine their referrals to cardiac rehabilitation (CR).ObjectiveTo develop and test the Recommending Cardiac Rehabilitation scale (ReCaRe), designed to assess health professionals attitudes, values and beliefs to CR referral.MethodsReCaRe was appraised for: content validity (Delphi method, expert panel); interpretability and face validity (interview, health professionals); factor structure and internal consistency (survey, health professionals); and test-retest reliability (survey, health professionals). Normative scores were collated.ResultsReCaRe initially comprised 75 items. Initially, a Content Validity Index (CVI) was calculated for ratings of item relevance (CVI range; 0.27–1.0), which resulted in the removal of 19 items. After preliminary validation and psychometric testing, 34 items were factor-analysed (n = 24) providing a 17-item, four-factor scale: perceived severity and susceptibility (α = 0.93, κ = 0.37); perceived service accessibility (α = 0.91, κ = 0.67); perceived benefit (α = 0.97, κ = 0.47); perceived barriers and attitudes (α = 0.82, κ = 0.49). ReCaRe normative scores (n = 75) are reported.ConclusionsThis psychometric analysis found ReCaRe to demonstrate good face validity, internal consistency and fair to substantial test-retest reliability. The next step is to validate these initial findings on a larger sample size to confirm whether ReCaRe can enable identification of factors impacting CR referral.

Objective To understand the validity and reliability of consumer-grade activity trackers (consumer wearables) in older, community-dwelling adults. Methods A systematic review of studies involving adults aged over 65 years who underwent physical activity monitoring with consumer wearables. A total of 7 observational studies qualified, identified from electronic databases: MEDLINE, EMBASE, Cochrane Library and others (2014–2018). Validity was interpreted using correlation coefficients (CC) and percentage error for agreement between reference devices or gold-standard validation methods Reliability was compared using mean differences or ranges (under- or overestimation) of step count and activity time. Results Total sample size was 290 adults, mean age of 70.2 ± 4.8 years and females constituting 46.7 ± 26.1%. The studies evaluated eight different consumer wearables used by community-dwelling adults with a range of co-morbidities. Daily step count for all consumer wearables correlated highly with validation criterion, especially the ActiGraph device: intraclass correlation coefficients (ICC) were 0.94 for Fitbit One, 0.94 for Zip, 0.86 for Charge HR and 0.96 for Misfit Shine. Slower walking pace and impaired ambulation reduced the levels of agreement. Daily step count captured by Fitbit Zip was on average 7117 (±5,880.6), which was overestimated by five of the eight consumer wearables compared with reference devices (range 167.6–2,690.3 steps/day). Measurement of activity duration was accurate compared with reference devices, yet less so than step count. Conclusion In older, community-dwelling adults, consumer wearables accurately measure step count and activity duration, as confirmed by reference devices and validation methods Further research is required to understand how co-morbidities, gait and activity levels interact with monitoring in free-living environments.

Background: Understanding atrial fibrillation (AF) management in Scotland was identified as a key priority at the Cross Party Group (CPG) for Heart Disease and Stroke, which meets regularly at the Scottish Parliament. Therefore, a national inquiry was launched to provide clear recommendations to government to improve health for people living with AF. Methods: An advisory panel was convened comprising major third-sector representatives, academics, clinicians, Members of Scottish Parliament (MSPs), and people living with AF. Two questionnaires—one for clinicians, one for people living with AF—were circulated through multiple channels and four roundtable events were held. Results: In total, there were 262 responses to the questionnaires (n=203 clinician; n=59 people living with AF); and roundtables were attended by 35 people, including members of the advisory panel, MSPs, clinicians, academics and people living with AF. Ten key recommendations emerged relating to the detection and diagnosis of AF; initial treatment and subsequent management of AF; use of data to improve detection, diagnosis and treatment of AF in Scotland; and patient information and public awareness. Conclusions: It is hoped that the results of the inquiry discussed in the current article will provide the blueprint for change that will improve AF management across Scotland.

Background Chinese immigrants are at an increased risk for cardiovascular diseases (CVDs) compared with Chinese nationals partly because of lifestyle changes and knowledge deficits. Translated patient resources are available on the Internet and are often provided by health professionals; however, the quality and cultural sensitivity of these resources have not been reported. Objective The aim of this study was to assess the availability, quality, and cultural sensitivity of Chinese-language information available from national "Heart Foundations" (cardiac research bodies, nongovernmental organisations) of the 5 most popular destinations of Chinese immigration. Methods This study is a descriptive research in which national "Heart Foundation" websites were systematically searched for Chinese-language CVD patient education resources. Quality (content, identification, structure) was assessed using the Ensuring Quality Information for Patients instrument. Cultural sensitivity was evaluated using the Cultural Sensitivity Assessment Tool. Results From 107 identified resources, 33 were CVD specific: coronary heart disease (n = 20), arrhythmias (n = 7), and heart failure (n = 6). Quality of resources was adequate (mean Ensuring Quality Information for Patients score, 69%), but scores varied significantly (min, 60%; max, 85%). Although all resources were classified as culturally sensitive (Cultural Sensitivity Assessment Tool score ≥ 2.5), 2 resources scored low (≤2.5) for visual impact, and across all resources, written and visual domains were assessed as least culturally sensitive. Most resources lacked culturally specific references. Conclusions Chinese-language CVD resources were inconsistent in the supply of key information. Quality and level of cultural sensitivity were adequate, but most resources lacked culturally specific references. Comprehensive, high-quality CVD resources powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation tailored for Chinese immigrants are urgently needed for healthcare providers to support CVD education and care of patients belonging to this population.

Background Mobile technologies are innovative, scalable approaches to reducing risk of cardiovascular disease but evidence related to effectiveness and acceptability remains limited. We aimed to explore the effectiveness, acceptability and usefulness of mobile applications (apps) for cardiovascular disease self-management and risk factor control. Design Systematic review with meta-synthesis of quantitative and qualitative data. Methods Comprehensive search of multiple databases (Medline, Embase, CINAHL, SCOPUS and Cochrane CENTRAL) and grey literature. Studies were included if the intervention was primarily an app aimed at improving at least two lifestyle behaviours in adults with cardiovascular disease. Meta-synthesis of quantitative and qualitative data was performed to review and evaluate findings. Results Ten studies of varying designs including 607 patients from five countries were included. Interventions targeted hypertension, heart failure, stroke and cardiac rehabilitation populations. Factors that improved among app users were rehospitalisation rates, disease-specific knowledge, quality of life, psychosocial well-being, blood pressure, body mass index, waist circumference, cholesterol and exercise capacity. Improved physical activity, medication adherence and smoking cessation were also characteristic of app users. Appealing app features included tracking healthy behaviours, self-monitoring, disease education and personalised, customisable content. Small samples, short duration and selection bias were noted limitations across some studies, as was the relatively low overall scientific quality of evidence. Conclusions Multiple behaviours and cardiovascular disease risk factors appear modifiable in the shorter term with use of mobile apps. Evidence for effectiveness requires larger, controlled studies of longer duration, with emphasis on process evaluation data to better understand important system- and patient-level characteristics.

Cardiac rehabilitation is a multifactorial approach to supporting patients in their recovery from a cardiovascular event and reducing their risk of recurrent events (secondary prevention) through risk factor modification and adherence to evidence-based therapy. Although the incidence of cardiovascular disease increases with age, and the ageing demographic of industrialized societies means that many older people are living with cardiovascular disease, older people have historically been underrepresented in cardiac rehabilitation programmes. A challenge faced by contemporary cardiac rehabilitation providers is to offer flexible options to suit the requirements of different patient groups, including older people. This chapter explores best-practice cardiac rehabilitation and how it can be applied to suit the requirements of the geriatric patient, as well as the important role that physicians hold as an essential member of the multidisciplinary cardiac rehabilitation team.

In our special December edition of the British Journal of Cardiac Nursing honouring the contribution of our peer reviewers and the integral role of the peer review process, Consultant Editor, Lis Neubeck interviews longstanding Board Member, David Thompson, and Consultant Editor, Michael Sampson, about the benefits of peer review, various approaches, and why it isn't always a perfect science

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Mobile technology might enable increased access to effective prevention of CVDs. Given the high penetration of smartphones into groups with low socioeconomic status, health-related mobile applications might provide an opportunity to overcome traditional barriers to cardiac rehabilitation access. The huge increase in low-cost health-related apps that are not regulated by health-care policy makers raises three important areas of interest. Are apps developed according to evidenced-based guidelines or on any evidence at all? Is there any evidence that apps are of benefit to people with CVD? What are the components of apps that are likely to facilitate changes in behaviour and enable individuals to adhere to medical advice? In this Review, we assess the current literature and content of existing apps that target patients with CVD risk factors and that can facilitate behaviour change. We present an overview of the current literature on mobile technology as it relates to prevention and management of CVD. We also evaluate how apps can be used throughout all age groups with different CVD prevention needs.

This editorial refers to ‘Yield of screening for atrial fibrillation in primary care with a hand-held, single-lead electrocardiogram device during influenza vaccination’ by F. Kaasenbrood et al. , doi:10.1093/europace/euv426. Atrial fibrillation (AF) affects ∼6% of people aged ≥65 years1 and is associated with significant cardiovascular complications including a five-fold increased risk of stroke.2 Stroke is one of the most feared complications because AF-related strokes are more often fatal, with a 28-day mortality rate of 19%; and the likelihood of remaining disabled is increased by 50% compared with strokes from other causes.3 The severity of disability from AF-related strokes impacts significantly on the health system. Costs of AF-related strokes are ∼€10 billion each year in Europe,4 and health system costs are likely to further escalate with the predicted doubling in AF prevalence over the next 30 years.5 Health system costs related to AF could be substantially reduced if AF-related strokes could be prevented. Stroke prevention relies firstly on early and timely identification and diagnosis of AF, and secondly on appropriate guideline-directed anticoagulation to substantially reduce the risk of ischaemic stroke. However, as AF is often asymptomatic, many people are unaware that they have AF, with first diagnosis being made when they are admitted to hospital with a stroke or transient ischaemic attack.6 Therefore, screening, either opportunistic or systematic, is necessary to identify these people before they suffer fatal or debilitating consequences. Many screening programmes and solutions are being examined, as it is now well established that screening for previously unknown AF in people over 65 years is fruitful and is likely to be associated with prevention of strokes.2 Thus, since 2012, the European …

BACKGROUND Barriers to attending cardiac rehabilitation (CR), including cultural and linguistic differences, may be addressed by recent technological developments. However, the feasibility of using these approaches in culturally and linguistically diverse patients is yet to be determined. OBJECTIVE This study aims to assess the use of mobile technologies and features, as well as confidence in utilization across patients speaking different languages at home (ie, English, Mandarin Chinese, and a language other than English and Mandarin [other]) and are both eligible and physically suitable for CR. In addition, the study aims to determine the sociodemographic correlates of the mobile technology/feature use, including language spoken at home in the three groups mentioned above. METHODS This is a descriptive, case matched, comparative study. Age and gender-matched patients speaking English, Mandarin and other languages (n=30/group) eligible for CR were surveyed for their mobile technology and mobile feature use. RESULTS ‘Participants had a mean age of 66.7 years (SD 13, n=90, range 46-95), with 53.3% (48/90) male. The majority (82/90, 91.1%) used at least one technology device, with 87.8% (79/90) using mobile devices, the most common being smartphones (57/90, 63.3%), tablets (28/90, 31.1%), and text/voice-only phones (24/90, 26.7%). More English-speaking participants used computers than Mandarin or “other” language speaking participants (P=.003 and .02) and were more confident in doing so compared to Mandarin-speaking participants (P=.003). More Mandarin-speaking participants used smartphones compared with “other” language speaking participants (P=.03). Most commonly used mobile features were voice calls (77/82, 93.9%), text message (54/82, 65.9%), the internet (39/82, 47.6%), email (36/82, 43.9%), and videoconferencing (Skype or FaceTime [WeChat or QQ] 35/82, 42.7%). Less Mandarin-speaking participants used emails (P=.001) and social media (P=.007) than English-speaking participants. Speaking Mandarin was independently associated with using smartphone, emails, and accessing the web-based medication information (OR 7.238, 95% CI 1.262-41.522; P=.03, OR 0.089, 95% CI 0.016-0.490; P=.006 and OR 0.191, 95% CI 0.037-0.984; P=.05). CONCLUSIONS This study reveals a high usage of mobile technology among CR patients and provides further insights into differences in the technology use across CALD patients in Australia. The findings of this study may inform the design and implementation of future technology-based CR.

Background Acculturation is associated with increased prevalence of cardiovascular disease (CVD) risk-factors among immigrants in Western countries. Little is known about acculturation effects on CVD risks among Chinese immigrants, one of the fastest growing populations in Western countries. In this study, we aim to examine the association between acculturation and CVD risk-factors among Chinese immigrants, Australia's third-largest foreign-born group. Methods We accessed a subsample of Chinese immigrants ( n = 3220) within the 45-and-Up Study (2006-2009). Poisson regression model with a robust error variance examined the association between acculturation and CVD risk-factors, and prevalence ratios were reported, adjusted for socio-demographic characteristics. Indicators of acculturation included age at migration, length of Australian residence and language spoken at home. The outcomes were self-reported CVD diagnosis and six risk-factors (hypertension, diabetes, high cholesterol, smoking, overweight/obesity, physical inactivity). Results Mean age of Chinese participants was 58.9-years (SD = 10.7) and 55.5% were women. Chinese migrating to Australia aged18 years were significantly more likely to report diabetes (prevalence ratio = 1.71; p 0.01), overweight/obesity (prevalence ratio = 1.49; p 0.001) and ≥ 3 CVD risk-factors (prevalence ratio = 1.47; p 0.05) compared with those who migrated after 18-years-old. Chinese immigrants who lived in Australia for ≥ 30 years were significantly more likely to have diabetes (prevalence ratio = 1.84; p 0.01) and ≥ 3 CVD risk-factors (prevalence ratio = 1.84; p 0.01). There were no significant differences by language spoken at home. The association between indicators of acculturation and CVD risk-factors appeared to differ by sex. Conclusion Greater acculturation was associated with adverse CVD risk-factors among Chinese immigrants in Australia.

© 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ) Background: Globally, attendance at cardiac rehabilitation (CR) is between 15 and 30%. Alternative models of individualised care are recommended to promote participation in CR, however there has been no prospective testing of different durations of such models. We aimed to replicate the previously proven Choice of Health Options In prevention of Cardiovascular Events (CHOICE) intervention, and to determine if an extended version (CHOICEplus) would confer additional benefits. Methods: Acute coronary syndrome (ACS) survivors not accessing centre-based CR (n = 203) were randomised to CHOICE for 3 months (n = 100) or CHOICEplus for 24 months (n = 103) at four urban hospitals. The program comprised telephone-based tailored risk-factor reduction. Results: CHOICE and CHOICEplus were equivalent demographically and in risk profile at baseline. At 24 months, lipid profiles improved significantly and fewer patients had ≥3 risk factors above target compared to baseline in both groups. There were no significant differences between groups. Conclusions: The 24-month CHOICEplus program did not confer additional benefit above the brief 3-month CHOICE intervention. However, participation in either CHOICE and CHOICEplus significantly improved cardiovascular risk profile in ACS survivors. Importantly, the study was feasible, and the intervention translated readily across four hospitals. Overall, this study adds to the existing evidence for brief individualised approaches to CR.

BackgroundEmerging evidence indicates mobile technology–based strategies may improve access to secondary prevention and reduce risk factors in cardiac patients. However, little is known about cardiac patients’ use of mobile technology, particularly for health reasons and whether the usage varies across patient demographics. ObjectiveThis study aimed to describe cardiac patients’ use of mobile technology and to determine variations between age groups after adjusting for education, employment, and confidence with using mobile technology. MethodsCardiac patients eligible for attending cardiac rehabilitation were recruited from 9 hospital and community sites across metropolitan and rural settings in New South Wales, Australia. Participants completed a survey on the use of mobile technology devices, features used, confidence with using mobile technology, willingness and interest in learning, and health-related use. ResultsThe sample (N=282) had a mean age of 66.5 (standard deviation [SD] 10.6) years, 71.9% (203/282) were male, and 79.0% (223/282) lived in a metropolitan area. The most common diagnoses were percutaneous coronary intervention (33.3%, 94/282) and myocardial infarction (22.7%, 64/282). The majority (91.1%, 257/282) used at least one type of technology device, 70.9% (200/282) used mobile technology (mobile phone/tablet), and 31.9% (90/282) used all types. Technology was used by 54.6% (154/282) for health purposes, most often to access information on health conditions (41.4%, 117/282) and medications (34.8%, 98/282). Age had an important independent association with the use of mobile technology after adjusting for education, employment, and confidence. The youngest group (69 years) age group (odds ratio [OR] 4.45, 95% CI 1.46-13.55), 5 times more likely to use mobile apps (OR 5.00, 95% CI 2.01-12.44), and 3 times more likely to use technology for health-related reasons (OR 3.31, 95% CI 1.34-8.18). Compared with the older group, the middle age group (56-69 years) was more than twice as likely to use any mobile technology (OR 2.42, 95% CI 1.27-4.59) and mobile technology for health-related purposes (OR 1.92, 95% CI 1.04-3.53). Participants who had completed high school were twice as likely to use mobile technology (OR 2.62, 95% CI 1.45-4.70), mobile apps (OR 2.05, 95% CI 1.09-3.84), and mobile technology for health-related reasons (OR 5.09, 95% CI 2.89-8.95) than those who had not completed high school. Associations were also present between participants living in metropolitan areas and mobile technology use (OR 1.07, 95% CI 1.07-4.24) and employment and mobile app use (OR 2.72, 95% CI 1.44-5.140). ConclusionsMobile technology offers an important opportunity to improve access to secondary prevention for cardiac patients, particularly when modified to suit subgroups. High levels of mobile technology use and health motivation need to be harnessed for secondary prevention.

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Postoperative atrial fibrillation (POAF) is associated with increased stroke risk and mortality post-discharge. POAF is often considered transient; however, recurrence is likely under-recognized as symptoms are an unreliable guide. Surveillance post-discharge may identify asymptomatic POAF recurrences in patients discharged in sinus rhythm. Therefore, we performed a systematic review and meta-analysis of studies investigating POAF recurrence post-discharge, in patients with new-onset POAF following cardiac surgery who reverted to sinus rhythm prior to discharge. Two independent reviewers searched medical databases, clinical trial registries, reference lists and the Internet. After screening from 6525 studies, 8 studies were identified (n = 1157 participants, mean age 66 ± 10 years and 73% men). Monitoring methods included the following: telemetry during twice-daily exercise sessions (n = 2), continuous telemetry for 3 weeks (n = 1), daily 20-s electrocardiography (ECG) using wearable event recorder (n = 1), 30-s single-lead ECG, 4 times/day (n = 1) and implanted continuous monitoring (n = 2). The incidence rate of POAF recurrence identified through non-invasive monitoring in the first 4 weeks post-discharge was 28.3% [confidence interval (CI) 23.0-33.6%]; recurring 12 ± 5 days (mean ± SD) post-surgery. The incidence rate identified through implanted continuous monitoring was 61-100% within 2 years. Between 40% and 93% of episodes were asymptomatic. In one small study reporting stroke risk, 8 of 10 patients with recurrence were guideline-indicated (CHA2DS2-VASc score ≥2) for oral anticoagulation for stroke prevention. Monitoring for POAF recurrence post-hospital discharge identifies significant numbers of early asymptomatic recurrences in patients at high risk of stroke who may benefit from anticoagulation for stroke prevention. More intense monitoring is more likely to identify POAF recurrence. Future research is required to investigate the prognostic significance of POAF recurrence, especially stroke and mortality risk.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Background: Evidence-based guidelines recommend strategies for reducing risk factors for secondary prevention of acute coronary syndromes, yet referral to and completion of programs to deliver this advice are poor. Purpose: In this article we describe the complexity of factors that influence referral and delivery of evidence-based cardiac rehabilitation (CR) programs through an Australian context and provide direction for solutions for clinicians and policy makers to consider. The Ecological Approach is used as a framework to synthesize evidence. The approach has 5 categories, the characteristics of which may act as barriers and enablers to the promotion and adoption of health behaviors and includes (a) interpersonal factors, (b) interpersonal factors, (c) institutional factors, (d) community networks, and (e) public policy. Conclusions: Despite the context of strong evidence for efficacy, this review highlights systematic flaws in the implementation of CR, an important intervention that has been shown to improve patient outcomes and prevent cardiac events. Recommendations from this review include standardization of program delivery, improvement of data capture, use of technological innovations and social networks to facilitate delivery of information and support, and establishment of a cohesive, consistent message through interorganizational collaboration involved in CR. Clinical Implications: These avenues provide direction for potential solutions to improve the uptake of CR and secondary prevention.

© 2017, Springer Science+Business Media New York. Health outcomes and impact of cardiovascular disease vary between populations, where ethnic minorities and immigrant groups are more likely to be disadvantaged. Compared with the majority residents, health outcomes, especially short-term mortality from coronary heart disease event are worse in people of Chinese ethnicity, potentially due to poor self-management and experiences with the healthcare system in host countries. A scoping review was conducted. Four overarching themes were found: (1) understanding of heart disease, risk factors and symptom recognition, (2) adherence to medication and lifestyle modification, (3) health service/information choice, and (4) family role in disease self-management and decision making. All themes were greatly influenced by English language proficiency and cultural practices. English language proficiency and cultural practices should be taken into consideration when providing healthcare services for people of Chinese ethnicity, as it plays an important role in self-management and experiences with the healthcare system.

Introduction Electronic health (eHealth) strategies are evolving making it important to have valid scales to assess eHealth and health literacy. Item response theory methods, such as the Rasch measurement model, are increasingly used for the psychometric evaluation of scales. This paper aims to examine the internal construct validity of an eHealth and health literacy scale using Rasch analysis in a population with moderate to high cardiovascular disease risk. Methods The first 397 participants of the CONNECT study completed the electronic health Literacy Scale (eHEALS) and the Health Literacy Questionnaire (HLQ). Overall Rasch model fit as well as five key psychometric properties were analysed: unidimensionality, response thresholds, targeting, differential item functioning and internal consistency. Results The eHEALS had good overall model fit (χ2 = 54.8, p = 0.06), ordered response thresholds, reasonable targeting and good internal consistency (person separation index (PSI) 0.90). It did, however, appear to measure two constructs of eHealth literacy. The HLQ subscales (except subscale 5) did not fit the Rasch model (χ2: 18.18–60.60, p: 0.00–0.58) and had suboptimal targeting for most subscales. Subscales 6 to 9 displayed disordered thresholds indicating participants had difficulty distinguishing between response options. All subscales did, nonetheless, demonstrate moderate to good internal consistency (PSI: 0.62–0.82). Conclusion Rasch analyses demonstrated that the eHEALS has good measures of internal construct validity although it appears to capture different aspects of eHealth literacy (e.g. using eHealth and understanding eHealth). Whilst further studies are required to confirm this finding, it may be necessary for these constructs of the eHEALS to be scored separately. The nine HLQ subscales were shown to measure a single construct of health literacy. However, participants’ scores may not represent their actual level of ability, as distinction between response categories was unclear for the last four subscales. Reducing the response categories of these subscales may improve the ability of the HLQ to distinguish between different levels of health literacy.

Background Although Chinese form the largest non-English speaking group in Australia, cardiovascular disease (CVD) risk profiles among Chinese Australians have not been comprehensively examined, nor has the effect of mixed-Chinese ethnicity been adequately explored. This study is to investigate cardiovascular risk among Chinese, mixed-Chinese, and non-Chinese Australians. Methods Using data from 266,696 Australian participants from the 45 and Up Study (2006–2009), this study investigated cardiovascular risk among Chinese ( n =3454), mixed-Chinese ( n =1062), and non-Chinese ( n =262,180) participants. Poisson regression models with a robust error variance were used to estimate prevalence ratio (PR) and 95% confidence intervals (CI) for CVD (coronary heart disease (CHD) and stroke) and six major risk factors (hypertension, diabetes, high cholesterol, smoking, overweight/obesity, and physical inactivity) by ethnicity using non-Chinese participants as the reference group. Each outcome was adjusted for sociodemographic characteristics. Results Compared with non-Chinese Australians, Chinese had lower prevalence of CHD (PR=0.67; 95% CI=0.59–0.75) and stroke (PR=0.67; 95% CI=0.51–0.88). Of the risk factors, Chinese had higher prevalence of diabetes (PR=1.25; 95% CI=1.12–1.39), smoking (PR=1.22; 95% CI=1.04–1.43) and physical inactivity (PR=1.48; 95% CI=1.41–1.55) but lower prevalence of hypertension (PR=0.90; 95% CI=0.86–0.95), high cholesterol (PR=0.87; 95% CI=0.79–0.95), and overweight/obesity (PR=0.46; 95% CI=0.43–0.48). Mixed-Chinese had higher prevalence of CVD and worse CVD risk profiles compared with Chinese. Conclusions There are marked differences in the prevalence of CVD and risk factors among three groups. The noticeable variations in CVD risk between Chinese and mixed-Chinese indicate that conventional classification of treating all Chinese as homogeneous could be misleading. More investigation into the health outcomes of mixed ancestry is warranted.

© Stephanie R Partridge, Anne C Grunseit, Patrick Gallagher, Becky Freeman, Blythe J O'Hara, Lis Neubeck, Sarah Due, Glenn Paull, Ding Ding, Adrian Bauman, Philayrath Phongsavan, Kellie Roach, Leonie Sadler, Helen Glinatsis, Robyn Gallagher. Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients who are eligible for cardiac rehabilitation but unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patients’ experiences and perspectives on using social media to support their health. Objective: The aim of this study was to describe cardiac rehabilitation patients’ experiences in using social media in general and their perspective on using social media, particularly Facebook, to support their cardiac health and secondary prevention efforts. Methods: A mixed-methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas. First, this study included a survey (n=284) on social media use and capability. Second, six focus group interviews were conducted with current Facebook users (n=18) to elucidate Facebook experience and perspectives. Results: Social media use was low (28.0%, 79/282) but more common in participants who were under 70 years of age, employed, and had completed high school. Social media users accessed Web-based information on general health issues (65%, 51/79), medications (56%, 44/79), and heart health (43%, 34/79). Participants were motivated to invest time in using Facebook for “keeping in touch” with family and friends and to be informed by expert cardiac health professionals and fellow cardiac participants if given the opportunity. It appeared that participants who had a higher level of Facebook capability (understanding of features and the consequences of their use and efficiency in use) spent more time on Facebook and reported higher levels of “liking,” commenting, or sharing posts. Furthermore, higher Facebook capability appeared to increase a participants’ willingness to participate in a cardiac Facebook support group. More capable users were more receptive to the use of Facebook for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation Facebook group included a closed group, expert cardiac professional involvement, provision of cardiac health information, and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalize on cardiac patients’ motivations and social media, mostly Facebook, as well as the capability for supporting cardiac rehabilitation and secondary prevention. Participants’ favored purposeful time spent on Facebook and their cardiac health provides such a purpose for a Facebook intervention. The study results will inform the development of a Facebook intervention for secondary prevention of cardiovascular disease.

Introduction Technology-mediated strategies have potential to engage patients in modifying unhealthy behaviour and improving medication adherence to reduce morbidity and mortality from cardiovascular disease (CVD). Furthermore, electronic tools offer a medium by which consumers can more actively navigate personal healthcare information. Understanding how, why and among whom such strategies have an effect can help determine the requirements for implementing them at a scale. This paper aims to detail a process evaluation that will (1) assess implementation fidelity of a multicomponent eHealth intervention; (2) determine its effective features; (3) explore contextual factors influencing and maintaining user engagement; and (4) describe barriers, facilitators, preferences and acceptability of such interventions. Methods and analysis Mixed-methods sequential design to derive, examine, triangulate and report data from multiple sources. Quantitative data from 3 sources will help to inform both sampling and content framework for the qualitative data collection: (1) surveys of patients and general practitioners (GPs); (2) software analytics; (3) programme delivery records. Qualitative data from interviews with patients and GPs, focus groups with patients and field notes taken by intervention delivery staff will be thematically analysed. Concurrent interview data collection and analysis will enable a thematic framework to evolve inductively and inform theory building, consistent with a realistic evaluation perspective. Eligible patients are those at moderate-to-high CVD risk who were randomised to the intervention arm of a randomised controlled trial of an eHealth intervention and are contactable at completion of the follow-up period; eligible GPs are the primary healthcare providers of these patients. Ethics and dissemination Ethics approval has been received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council (AH&MRC) of New South Wales. Results will be disseminated via scientific forums including peer-reviewed publications and national and international conferences. Trial registration number ANZCTR 12613000715774.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Background: Cardiac rehabilitation is one of the most widely recommended strategies to reduce the burden of cardiovascular disease. The multicomponent nature of cardiac rehabilitation programs requires a multidisciplinary team of healthcare professionals including nurses who are equipped with extensive knowledge and skills. However, there is a lack of a comprehensive, explicit career pathway that contains academic and clinical development to prepare nurses to become cardiac rehabilitation specialists. Objective: The aim of this study is to identify the 3 essential components for cardiac rehabilitation professionals: (1) educational preparation, (2) role/responsibility, and (3) competency to inform the framework of career development for cardiac rehabilitation nurses. Methods: Through scoping review, 4 stages from the methodological framework of scoping review by Arksey and O'Malley (Int J Soc Methodol. 2005;8:19-32) were used. Results: Some attempts have been made in developing frameworks of career development for cardiac rehabilitation professionals with these 3 components through guidelines/standards and core curriculum development worldwide, among which the United States is the only country with a well-established system including guidelines for cardiac rehabilitation/secondary prevention programs, a position statement in terms of competencies, and certification examination for cardiac rehabilitation professionals. Nevertheless, further development and integration of these efforts, specifically for cardiac rehabilitation nurses, are required. Conclusions: It is vital to raise the awareness of the significant contribution that appropriately educated and trained nurses make in reducing the global burden of cardiovascular disease through cardiac rehabilitation. Therefore, action on establishing a system of comprehensive, clearly defined career development pathway for cardiac rehabilitation nurses worldwide is of immediate priority.

Physical inactivity is the fourth most important risk factor contributing to global non-communicable disease (NCD) deaths, occurring in high-, middle- and low-income countries. Building capacity in NCD prevention is a daunting task, and toward this end, an introductory open online course about physical activity (PA), exercise, and NCD prevention was developed. This was led by academics from the University of Sydney and the WHO Collaborating Centre for Physical Activity, Nutrition and Obesity. The course was designed to address the needs of participants from areas where geography and economy would often prevent them from participating in NCD training programs. Around 120 participants from four continents signed up for the six-week online course, with the greatest numbers from the host country (Australia) followed by participants from Pacific Island nations and from the Middle East. The course consisted of video lectures, quizzes, and online discussions facilitated by experts. More than a third of the participants fully completed the course, which received very positive participant evaluations. This also included completion of relevant quiz questions on each section of the PA course, and averaged over 70% correct responses. This successful online course has the potential to increase knowledge and skills about PA and prevention, as part of building global capacity in NCD prevention at low cost, and importantly within easy reach of potentially isolated practitioners.

Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes.

Background: Two-thirds of Australians do not meet nutritional recommendations. Unfortunately, nutritional screening is often overlooked in cardiac assessments, possibly because of competing time demands and perceived complexity of nutritional assessments. Aims: To establish the validity of a simple nutritional screening tool. Method: A six-item categorical nutritional screening tool was completed by acute coronary syndrome patients following hospital discharge. A multiple-pass diet assessment was subsequently administered by a dietitian blinded to the screening tool results. Dietary assessment results for the screening tool and the multiple-pass method were compared to determine agreement. Results: 34 participants were recruited (76% male; mean age: 65±11 years). Sensitivity, specificity and Kappa were highest for categorical items (e.g. fruit, 100%, 69% K=0.69); lower for complex items (e.g. monounsaturated fats, 92%, 25% K=0.29); and good for identifying requirement for further dietary intervention (96%, 50%, K=0.54). Conclusions: This brief tool shows potential to identify selected nutritional variables and the need for further dietary intervention as part of cardiac patient assessment.

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.

People with unknown atrial fibrillation (AF), who are often asymptomatic, have a substantially increased risk of stroke. Although recommended in European guidelines, AF screening is not routinely performed. Screening at the time of influenza vaccination presents an ideal opportunity to detect AF in large numbers in a primary care medical setting, with an existing annual recall system for patients aged ≥65 years.Cross-sectional pilot study of handheld smartphone electrocardiogram (iECG) screening to identify unknown AF.General practices in Sydney, Australia, were recruited during the influenza-vaccination period of April-June 2015. Practice nurses screened patients aged ≥65 years with a 30-second iECG, which has a validated algorithm for detecting AF in real time. In order to confirm the accuracy of the algorithm, two research cardiologists reviewed de-identified iECGs. In order to explore barriers and enablers, semi-structured interviews were conducted with selected nurses, practice managers and general practitioners.Five general practices were recruited, and 973/2476 (39%) patients attending influenza vaccination were screened. Screening took an average of 5 minutes (range 1.5-10 minutes); however, abnormal iECGs required additional time. Newly identified AF was found in 8/973 patients (0.8%). The sensitivity of the iECG automated algorithm was 95% (95% confidence interval: 83-99%) and the specificity was 99% (95% confidence interval: 98-100%). Screening by practice nurses was well accepted by practice staff. Key enablers were the confidence and competence of nurses and a 'designated champion' to lead screening at the practice. Barriers were practice specific, and mainly related to staff time and funding.Screening with iECG during influenza vaccination by primary care nurses is feasible and well accepted by practice staff. Addressing barriers is likely to increase uptake.

Introduction There is a 10-year gap in life expectancy between Aboriginal and non-Aboriginal Australians. The leading cause of death for Aboriginal Australians is cardiovascular disease, including myocardial infarction and stroke. Although atrial fibrillation (AF) is a known precursor to stroke there are no published studies about the prevalence of AF for Aboriginal people and limited evidence about AF in indigenous populations globally. Methods and analysis This mixed methods study will recruit and train Aboriginal health workers to use an iECG device attached to a smartphone to consecutively screen 1500 Aboriginal people aged 45 years and older. The study will quantify the proportion of people who presented for follow-up assessment and/or treatment following a non-normal screening and then estimate the prevalence and age distribution of AF of the Australian Aboriginal population. The study includes semistructured interviews with the Aboriginal health workers about the effectiveness of the iECG device in their practice as well as their perceptions of the acceptability of the device for their patients. Thematic analysis will be undertaken on the qualitative data collected in the study. If the device and approach are acceptable to the Aboriginal people and widely adopted, it may help prevent the effects of untreated AF including ischaemic stroke and early deaths or impairment in Aboriginal people. Ethics and dissemination This mixed methods study received ethics approval from the Aboriginal Health and Medical Research Council (1135/15) and the Australian Health Council of Western Australia (HREC706). Ethics approval is being sought in the Northern Territory. The findings of this study will be shared with Aboriginal communities, in peer reviewed publications and at conferences. There are Aboriginal investigators in each state/territory where the study is being conducted who have been actively involved in the study. They will also be involved in data analysis, dissemination and research translation. Trial registration number ACTRN12616000459426.

Twitter is a social media platform often used by cardiac professional associations to engage and inform their members and the public. However, the effectiveness of the strategy is seldom assessed or published. Aim: This study evaluates the Twitter activities of nine cardiac professional associations. Each organisation's purpose and stakeholders were described individually and classified. Extracted Tweets (n=3920) were content-analysed and metrics were determined. Results: There was alignment between the associations' mission statements and their Twitter activities. However, most Tweets were one-directional, disseminating research-based evidence/professional education materials and communicating association events and activities, as well as using hashtags to enable searching. Conclusion: Social media communication by cardiac professional associations through Tweets is an important activity; however, at present, the use of dialogue and conversations are not fully realised and could be used more strategically.

© 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ) Background Assessment of physical activity (PA) for cardiac rehabilitation (CR) participants is critical to monitor changes. However, the validity and reliability of PA measures to assess PA throughout the day, not only during exercise training, is poorly investigated. Aim To establish a reliable and valid measure to assess overall PA in CR participants. Methods A narrative literature review was performed based on a systematic search of Embase, CINAHL, MEDLINE and PubMed databases. Eight studies comparing two or more PA measures with at least one direct measure met the inclusion criteria. Results Methodological designs were heterogeneous. Correlations and levels of agreement between self-reported measures and direct measures were weak to moderate, while the correlations between direct measures were high. Of the direct measures, the SenseWear armband (BodyMedia Inc., Pittsburgh, PA, USA) had the highest validity, and the PA diary and MobilePAL questionnaires performed better than other self-reported PA measures. Conclusion Direct measures were more valid and reliable than self-reported measures. No recommendation for a definitive PA measure was made due to lack of strong evidentiary support for one PA measure over another. There is a need for accurate measures of overall PA in evaluating current and changing PA levels following CR.

Obstructive sleep apnoea is highly prevalent in acute coronary syndrome patients eligible for enrolment in cardiac rehabilitation programmes. This condition is an independent predictor of increased morbidity and comorbid conditions in the general population and can lead to an increase in major adverse cardiac events such as revascularization, heart failure and hospital readmission in cardiac patients. There is convincing evidence that treatments such as continuous positive airway pressure or mandibular advancement devices can successfully treat obstructive sleep apnoea and these conditions can be improved or negated resulting in improved cardiac rehabilitation outcomes and improved health related quality of life. Given the potential benefits of obstructive sleep apnoea treatment it would make sense to screen for this condition upon entry to out-patient cardiac rehabilitation programmes. A two-stage approach to screening is recommended, where patients are initially evaluated for the probability of having obstructive sleep apnoea using a brief questionnaire (The STOP-Bang) and then followed up with objective evaluation (portable home monitor or polysomnography) where necessary. Potential barriers to further referral and treatment could be partly mitigated by the training of cardiac rehabilitation staff in sleep disorders and screening.

In this chapter we show that qualitative evidence is needed to understand and address some of the most burdensome problems created by cardiac conditions. Cardiac care is often dominated—even obfuscated—by technology, pharmacology and technical prowess. Yet the health care of people with cardiac conditions should address, respond to, and incorporate patients’ perspectives, beliefs, attitudes and preferences. In this chapter we discuss how qualitative research has contributed to this knowledge in relation to a range of important topics—from how patients make decisions about whether to have potentially life-saving electronic devices implanted into their bodies down to whether they should use a health service or even take a tablet.

Aims and Objectives To investigate whether using the ‘think aloud’ technique during standard quality of life surveys provides useful additional information about patients’ experiences of living with atrial fibrillation (AF) and health related quality of life (HRQoL). Background Atrial fibrillation is the most common cardiac arrhythmia and has serious health consequences, particularly ischaemic stroke, high rates of morbidity and mortality and poor HRQoL. Standard quality-of-life questionnaires are often used but may not provide sufficient detail of patients’ experiences living with AF. Design A qualitative interpretative study based on semi-structured interviews. Methods Patients with AF (n = 12) were recruited from the Choice of Health Options in Prevention of Cardiovascular Events-in Atrial Fibrillation (CHOICE-AF), a risk factor management program. Participants were interviewed using a ‘think aloud’ technique with questions guided by the AF Effects on Quality Of Life Questionnaire (AFEQT) and the Short Form-12 (SF-12). Interviews were audio-recorded, transcribed and analysed thematically. Results Participants had a median age of 71 years (interquartile range 52 to 77 years), and included four women and eight men. Four themes were identified related to experiences of living with AF and HRQoL including: (1) the adverse impact of atrial fibrillation symptoms, treatments, and related knowledge; (2) loss of function or independence; (3) the influence of age; and (4) approach to life. Conclusions Atrial fibrillation, especially in older adults, creates an additional layer of requirements for self-management onto existing self-care needs. Even for patients with relatively high HRQoL, the ‘think aloud’ technique together with standard HRQoL questionnaires can help identify additional issues that can be addressed by health professionals to improve the HRQoL of these patients.