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Patients with heart failure (HF) who contract SARS-CoV-2 infection are at a higher risk of cardiovascular and non-cardiovascular morbidity and mortality. Regardless of therapeutic attempts in COVID-19, vaccination remains the most promising global approach at present for controlling this disease. There are several concerns and misconceptions regarding the clinical indications, optimal mode of delivery, safety and efficacy of COVID-19 vaccines for patients with HF. This document provides guidance to all healthcare professionals regarding the implementation of a COVID-19 vaccination scheme in patients with HF. COVID-19 vaccination is indicated in all patients with HF, including those who are immunocompromised (e.g. after heart transplantation receiving immunosuppressive therapy) and with frailty syndrome. It is preferable to vaccinate against COVID-19 patients with HF in an optimal clinical state, which would include clinical stability, adequate hydration and nutrition, optimized treatment of HF and other comorbidities (including iron deficiency), but corrective measures should not be allowed to delay vaccination. Patients with HF who have been vaccinated against COVID-19 need to continue precautionary measures, including the use of facemasks, hand hygiene and social distancing. Knowledge on strategies preventing SARS-CoV-2 infection (including the COVID-19 vaccination) should be included in the comprehensive educational programmes delivered to patients with HF. This article is protected by copyright. All rights reserved. [Abstract copyright: This article is protected by copyright. All rights reserved.]

Aims Exergaming is a new tool to increase physical activity. This study aimed to determine the effects of access to a home-based exergame (Nintendo Wii) in patients with heart failure (HF) on exercise capacity, self-reported physical activity and patient-reported outcome measures. Methods and results We enrolled 605 HF patients in New York Heart Association functional class I-IV, independent of ejection fraction, in an international multicentre randomized controlled trial. Patients were randomized to exergame (intervention) or motivational support (control). The primary endpoint was change in submaximal aerobic exercise capacity as measured by the distance walked in 6 min (6MWT) between baseline and 3 months. Secondary endpoints included long-term submaximal aerobic exercise capacity, muscle function, self-reported physical activity, exercise motivation, exercise self-efficacy at 3, 6 and 12months. At baseline, patients on average walked 403142m on the 6MWT. Patients in the exergame group walked further compared to controls at 3 months (454123 vs. 420 +/- 127m, P = 0.005), at 6 months (452 +/- 123 vs. 426 +/- 133m, P = 0.015) and 12months (456 +/- 122 vs. 420 +/- 135m, P = 0.004). However, correcting for baseline 6MWT values by means of a linear mixed-effects model revealed no main effect for the intervention on 6MWT. Small significant effects on muscle function were found. Statistically significant treatment effects were found for muscle function but after correction for baseline and confounders, only the treatment effect for the heel-rise left at 6 months was significant (PFunding Agencies|Swedish National Science Council [K2013-69X-22302-01-3, 2016-01390]; Swedish National Science Council/Swedish Research Council for Health, Working Life and Welfare, VR-FORTE [2014-4100]; Swedish Heart and Lung AssociationSwedish Heart-Lung Foundation [E085/12]; Swedish Heart and Lung FoundationSwedish Heart-Lung Foundation [20130340, 20160439]; Vardal Foundation [2014-0018]; Medical Research Council of Southeast Sweden [FORSS 474681]

Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway. Mullens, W (corresponding author), Ziekenhuis Oost Limburg, Dept Cardiol, Schiepse Bos 6, B-3600 Genk, Belgium. wilfried.mullens@zol.be

© 2021 European Society of Cardiology, Despite guideline recommendations and available evidence, implementation of treatment in heart failure (HF) is poor. The majority of patients are not prescribed drugs at target doses that have been proven to positively impact morbidity and mortality. Among others, tolerability issues related to low blood pressure, heart rate, impaired renal function or hyperkalaemia are responsible. Chronic kidney disease plays an important role as it affects up to 50% of patients with HF. Also, dynamic changes in estimated glomerular filtration rate may occur during the course of HF, resulting in inappropriate dose reduction or even discontinuation of decongestive or neurohormonal modulating therapy in clinical practice. As patients with HF are rarely naïve to pharmacologic therapies, the challenge is to adequately prioritize or select the most appropriate up-titration schedule according to patient profile. In this consensus document, we identified nine patient profiles that may be relevant for treatment implementation in HF patients with a reduced ejection fraction. These profiles take into account heart rate (70 bpm), the presence of atrial fibrillation, symptomatic low blood pressure, estimated glomerular filtration rate (30 mL/min/1.73 m2 ) or hyperkalaemia. The pre-discharge patient, frequently still congestive, is also addressed. A personalized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.

Aims OUTSTEP-HF compared the effect of sacubitril/valsartan vs. enalapril on 6-min walk test (6MWT) distance, non-sedentary daytime physical activity and heart failure (HF) symptoms in patients with HF with reduced ejection fraction (HFrEF). Methods and results Ambulatory patients (n = 621) with stable symptomatic HFrEF were randomised 1:1 to sacubitril/valsartan (n = 310) or enalapril (n = 311). Changes in physical activity and mean daily non-sedentary daytime activity from baseline to Week 12 were measured using 6MWT and a wrist-worn accelerometer device, respectively. After 12 weeks, 6MWT improved by 35.09 m with sacubitril/valsartan [97.5% confidence interval (CI) 27.85, 42.32] and by 26.11 m with enalapril (97.5% CI 18.78, 33.43); however, there was no significant difference between groups [least squares means treatment difference: 8.98 m (97.5% CI -1.31, 19.27); P = 0.0503]. Mean daily non-sedentary daytime activity decreased by 27 min with sacubitril/valsartan and by 21 min with enalapril [least squares means treatment difference: -6 min (97.5% CI -25.7, 13.4), P = 0.4769] after 12 weeks. 6MWT improved by >= 30 m in 51% of patients in the sacubitril/valsartan group vs. 44% of patients treated with enalapril (odds ratio 1.251, 95% CI 0.895, 1.748). At Week 4, non-sedentary daytime activity increased by >= 10% in 58% of patients treated with sacubitril/valsartan vs. 64% with enalapril; 58% of patients treated with sacubitril/valsartan reported improved HF symptoms as assessed by patient global assessment vs. 43% with enalapril. However, these differences did not persist at Week 12. Conclusion After 12 weeks of treatment, there was no significant benefit of sacubitril/valsartan on either 6MWT or daytime physical activity measured by actigraphy compared with enalapril. Funding Agencies|Novartis Pharma AG

Background: Theories can provide a foundation to explain behavior, investigate relationships, and to predict the effect of interventions. The aim of the study was to clarify the use of theories in studies testing interventions to promote self-care. Method: A scoping review. PubMed, EMBASE, PsychINFO, and CINAHL were searched from January 2008 through January 2019. Nine common chronic conditions were included. We included studies testing a self-care intervention if they used a randomized controlled trial design. The study was registered in PROSPERO (#123719). Results: The search retrieved 9309 potential studies, of which 233 were included in the review. In total, 76 (33%) of the 233 studies used a theory and 24 different theories were used. Banduras social cognitive theory was the most frequently used (48 studies), but 22 other theories were used in a minority of studies. Most studies used theories minimally to justify or provide a rationale for the study, to develop the intervention, to select outcomes, and/or to explain the results. Only eight studies fully used a theory in the rationale, intervention development, choice of outcomes, and discussion. Conclusion: The use of theories to guide self-care research is limited, which may pose a barrier in accumulating knowledge underlying self-care interventions. Funding Agencies|Australian Catholic University; National Institutes of Health/National Institute for Nursing Research (NINR) [R01NR018196]; Swedish National Science Council/Swedish Research Council for Health, Working Life and Welfare (VR-FORTE); Center of Excellence for Nursing Scholarship; Linkoping University

Introduction: Self-care requires behavior change in patients and healthcare providers play a pivotal role in supporting those changes. Examination of the behavior change techniques used by providers in self-care interventions can provide insights into how self-care behavior is enhanced in patients with a chronic condition. Objective: To quantify the behavior change techniques used to enhance healthy behavior in self-care interventions for patients with a chronic condition. Methods: Studies from a scoping review (n=233) were reviewed to identify behavior change techniques used in studies testing self-care interventions in adults with nine chronic conditions, most of which were CVDs. All studies were published between January 2008 and January 2019. Nine techniques from the Behavior Change Technique Taxonomy V1 (with 93 consensually agreed, distinct techniques) were selected for review because they are commonly used by a broad range of disciplines and have previously been shown to influence behavior change. Results: The 233 studies represent 59,950 patients, mean age 59.5 (±8.3) years, 44% female. Study sample sizes ranged from 24 to 2,445 patients. Most studies focused on DM2 (n=85; 36%), HTN (n=32; 14%) or HF (n=27; 12%). Most interventions targeted only patients (n=207; 89%). Goal setting (n=113; 48%) and problem solving (n=92; 40%) were the behavior change techniques used predominantly. Action planning, feedback and review of behavioral goals were used in 46-60 (20%-26%) studies and most commonly in patients with DM2 or CAD and rarely in patients with HTN or HF. Information about health consequences was used in 46 (20%) studies. Social support (n=17; 7%) and reminders (n=13; 6%) were rarely used. Conclusions: Few behavior change techniques were specified in the published self-care intervention trials. In future research, behavior change techniques and the associated mechanisms of actions need to be specified to support self-care intervention research.

Introduction: Novel interventions, such as exergaming, might be promising to increase physical activity (PA). We aim to explore the difference in PA in patients with heart failure (HF) who have access to exergaming compared to patients who received motivational support and to explore predictors of PA increase. Methods: This study is part of the HF-Wii study (patients randomized to exergaming or to motivational support) in which a group of HF patients (n=64, mean age 69±9, 27% female, 80% NYHA I/II) wore an accelerometer (Actigraph GT9X). Ten minutes change in daily non-sedentary PA was defined as clinically relevant change. Potential predictors of PA change were, i.e. demographic and clinical variables, self-efficacy (ESS), exercise motivation (EMI), depression (HADs) and Health-related Quality of Life (MLHFQ) analyzed by independent sample t-tests and chi-square. Factors with a significance of 0.15 in the univariate analysis were tested in a logistic regression analysis, corrected for randomization, age, gender and NYHA-class and baseline values for light PA and moderate- to vigorous physical activity (MVPA). Results: No differences were found between the exergame group and the control group at 3 months in activity counts (p=0.27), sedentary time (p=0.16), light PA (p=0.69) or MVPA (p=0.17). At baseline, patients had a mean of 173718 (±100545) PA counts/day; 9 hours and 43 minutes a day (±1h 23min) were spent sedentary, 3 hours and 29 minutes a day (±1h 6min) on light PA and 43 minutes a day (±1h 5min) on MVPA ) and 28 patients increased their PA. History of stroke (p=0.05), having grandchildren (p=0.04), recently diagnosed HF (p=0.04), total motivation (p=0.12) and social motivation (p=0.05) were included for the multivariate analysis. Only recently diagnosed HF (p=0.01), a higher social motivation (p=0.02) and a lower amount of light PA at baseline were independent predictors of increasing PA. Conclusions: Exergaming did not significantly change PA. A recently diagnosed HF, higher social motivation and lower baseline light PA are factors that need to be considered when developing PA interventions and when motivating patients to become more physically active.

The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) has recently issued a position paper on the role of sodium-glucose co-transporter 2 (SGLT2) inhibitors in heart failure (HF). The present document provides an update of the position paper, based of new clinical trial evidence. Accordingly, the following recommendations are given: • Canagliflozin, dapagliflozin empagliflozin, or ertugliflozin are recommended for the prevention of HF hospitalization in patients with type 2 diabetes mellitus and established cardiovascular disease or at high cardiovascular risk. • Dapagliflozin or empagliflozin are recommended to reduce the combined risk of HF hospitalization and cardiovascular death in symptomatic patients with HF and reduced ejection fraction already receiving guideline-directed medical therapy regardless of the presence of type 2 diabetes mellitus.

Aims A cardiopulmonary exercise (CPX) test is considered the gold standard in evaluating maximal oxygen uptake. This study aimed to evaluate the predictive validity of equations provided by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. in predicting peak VO2 from 6 min walk test (6MWT) distance in patients with heart failure (HF). Methods and Results New York Heart Association Class I-III HF patients performed a maximal effort CPX test and two 6MWTs. Correlations between CPX VO2 peak and the predicted VO2 peak, coefficient of determination (R-2), and mean absolute percentage error (MAPE) scores were calculated. P-values were set at 0.05. A total of 106 participants aged 62.5 +/- 11.5 years completed the tests. The mean VO2 peak from CPX testing was 16.4 +/- 3.9 mL/kg/min, and the mean 6MWT distance was 419.2 +/- 93.0 m. The predicted mean VO2 peak (mL/kg/min) by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. was 22.8 +/- 8.8, 14.6 +/- 2.1, 8.30 +/- 1.4, and 16.6 +/- 2.8. A significant correlation was observed between the CPX test VO2 peak and predicted values. The mean difference (0.1 mL/kg/min), R-2 (0.97), and MAPE (0.14) values suggest that the Cahalin et al. equation provided the best predictive validity. Conclusions The equation provided by Cahalin et al. is simple and has a strong predictive validity, and researchers may use the equation to predict mean VO2 peak in patients with HF. Based on our observation, equations to predict individual maximal oxygen uptake should be used cautiously. Funding Agencies|NHLBI of the National Institutes of HealthUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Heart Lung & Blood Institute (NHLBI) [R01HL112979]

Background: Self-care is important in chronic diseases such as heart failure. The cultural background of health care providers might influence their view on self-care behaviour and education they provide. The aim of this study was to describe health care providers&rsquo, perceptions of the role of culture in self-care and how those perceptions shape their experiences and their practices. Methods: A qualitative study was performed in Israel, a country with a culturally diverse population. Data were collected using semi-structured interviews with 12 healthcare providers from different cultural backgrounds. Interviews were recorded and transcribed verbatim and analysed using content analysis. Results: Healthcare providers experienced cultural background influenced their patients&rsquo, self-care behaviour. Perceived culture-specific barriers to self-care such as dietary traditions interfering with the recommended diet, willingness to undertake self-care and beliefs conflicting with medical treatment were identified. Healthcare providers described that they adapted patient education and care based on the cultural background of the patients. Shared cultural background, awareness and knowledge of differences were described as positively influencing self-care education, while cultural differences could complicate this process. Conclusions: Cultural-specific barriers for self-care were perceived by health care providers and they identified that their own cultural background shapes their experiences and their practices.

BackgroundAlthough attention is focused on addressing the acute situation created by the COVID-19 illness, it is imperative to continue our efforts to prevent cardiovascular morbidity and mortality, particularly during a period of prolonged social isolation which may limit physical activity, adversely affect mental health and reduce access to usual care. One option may be to deliver healthcare interventions remotely through digital healthcare solutions. Therefore, the aim of this paper is to bring together the evidence for remote healthcare during a quarantine situation period to support people living with cardiovascular disease during COVID-19 isolation.MethodsThe PubMed, CINAHL and Google Scholar were searched using telehealth OR digital health OR mHealth OR eHealth OR mobile apps AND COVID-19 OR quarantine search terms. We also searched for literature relating to cardiovascular disease AND quarantine.ResultsThe literature search identified 45 potentially relevant publications, out of which nine articles were included. Three overarching themes emerged from this review: (1) preparing the workforce and ensuring reimbursement for remote healthcare, (2) supporting mental and physical health and (3) supporting usual care.ConclusionTo support people living with cardiovascular disease during COVID-19 isolation and to mitigate the effects of quarantine and adverse effect on mental and physical well-being, we should offer remote healthcare and provide access to their usual care.

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This article refers to `The impact of palliative care on clinical and patient-centred outcomes in patients with advanced heart failure: a systematic review of randomized controlled trials by N. Sahlollbey et al., published in this issue on pages xxx.

Background: Self-care is recognized as important behaviour in chronic diseases such as heart failure (HF). The cultural background of patients with HF is one of the factors that can be considered to affect their adherence to self-care. The cultural background of the health care providers might also influence their view on self-care behaviour and the education they provide. The aim of this study was to describe health care providers' perceptions of the role of culture in self-care and how those perceptions shape their experiences and their practices.Methods: A qualitative study was performed in Israel, a country with a culturally diverse population. Data was collected using semi-structured interviews with 12 healthcare providers from different cultural backgrounds, selected by purposeful sampling, from two hospitals in Israel. Interviews were audio recorded and transcribed verbatim. Data was analysed using content analysis.Results: Healthcare providers experienced cultural background influenced their patients’ self-care behaviour. Perceived cultural-specific barriers to self-care such as: dietary traditions interfering with the recommended HF diet, willingness to undertake self-care and beliefs conflicting with medical treatment were identified. Healthcare providers described that they adapted their patient education and care based on the cultural background of the patients. Shared cultural background, awareness and knowledge of differences were described as positively influencing self-care education, while cultural differences could complicate this process. These findings are encapsulated within four categories regarding perceptions of health care providers: ‘Culture permeates self-care behaviours’, ‘Culture influence the way care is provided’, ‘Mutual cultural background impacts the mindset to address self-care’ and ‘Culture is only a small piece of the puzzle...’Conclusions: Cultural-specific barriers for self-care were perceived by health care providers and they identified that their own cultural background shapes their experiences and their practices.

In PARADIGM-HF, sacubitril/valsartan demonstrated superiority to enalapril in reducing mortality and morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Several patient-centred outcomes like improved physical activity and quality of life have been emphasised as important treatment goals in HF management. OUTSTEP-HF has been designed to evaluate the effect of sacubitril/valsartan compared with enalapril on non-sedentary daytime physical activity in patients with HFrEF.OUTSTEP-HF is a randomised, actively controlled, double-blind, double-dummy study that plans to enrol 600 ambulatory patients with symptomatic HFrEF in 19 European countries. Patients will be randomised 1:1 to receive sacubitril/valsartan 97/103 mg bid or enalapril 10 mg bid. The primary objective of the study is to assess changes from baseline (Week 0) to Week 12 in exercise capacity measured by the 6-min walk test and in daily non-sedentary daytime activity. Physical activity and objective sleep parameters will be measured by accelerometry using a wrist-worn device, worn continuously from screening (Week -2) until the end of study (Week 12). As a co-primary outcome, changes from baseline in sub-maximal exercise capacity will be assessed by the 6-min walk test. Patient- and physician-reported questionnaires will be used to assess quality of life, changes in signs and symptoms of HF and sleep parameters.OUTSTEP-HF will be the largest randomised trial in HF to date to use non-invasive accelerometry to assess whether treatment with sacubitril/valsartan improves patients' daily physical activity and exercise capacity compared with enalapril.

Background and objective The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field. Method During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research. Results In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components. Conclusion Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

Background: Patients’ self-care behaviour is still suboptimal in many heart failure (HF) patients and underlying mechanisms on how to improve self-care need to be studied. Aims: (1) To describe the trajectory of patients’ self-care behaviour over 1 year, (2) to clarify the relationship between the trajectory of self-care and clinical outcomes, and (3) to identify factors related to changes in self-care behaviour. Methods: In this secondary analysis of the COACH-2 study, 167 HF patients (mean age 73 years) were included. Self-care behaviour was assessed at baseline and after 12 months using the European Heart Failure Self-care Behaviour scale. The threshold score of ⩾70 was used to define good self-care behaviour. Results: Of all patients, 21% had persistent poor self-care behaviour, and 27% decreased from good to poor. Self-care improved from poor to good in 10%; 41% had a good self-care during both measurements. Patients who improved self-care had significantly higher perceived control than those with persistently good self-care at baseline. Patients who decreased their self-care had more all-cause hospitalisations (35%) and cardiovascular hospitalisations (26%) than patients with persistently good self-care (2.9%, p < 0.05). The prevalence of depression increased at 12 months in both patients having persistent poor self-care (0% to 21%) and decreasing self-care (4.4% to 22%, both p < 0.05). Conclusion: Perceived control is a positive factor to improve self-care, and a decrease in self-care is related to worse outcomes. Interventions to reduce psychological distress combined with self-care support could have a beneficial impact on patients decreasing or persistently poor self-care behaviour.

BACKGROUND The use of digital technologies is increasing in health care. However, studies evaluating digital health technologies can be characterized by selective nonparticipation of older people, although older people represent one of the main user groups of health care. OBJECTIVE We examined whether and how participation in an exergame intervention study was associated with age, gender, and heart failure (HF) symptom severity. METHODS A subset of data from the HF-Wii study was used. The data came from patients with HF in institutional settings in Germany, Italy, the Netherlands, and Sweden. Selective nonparticipation was examined as resulting from two processes: (non)recruitment and self-selection. Baseline information on age, gender, and New York Heart Association Functional Classification of 1632 patients with HF were the predictor variables. These patients were screened for HF-Wii study participation. Reasons for nonparticipation were evaluated. RESULTS Of the 1632 screened patients, 71% did not participate. The nonrecruitment rate was 21%, and based on the eligible sample, the refusal rate was 61%. Higher age was associated with lower probability of participation; it increased both the probabilities of not being recruited and declining to participate. More severe symptoms increased the likelihood of nonrecruitment. Gender had no effect. The most common reasons for nonrecruitment and self-selection were related to physical limitations and lack of time, respectively. CONCLUSIONS Results indicate that selective nonparticipation takes place in digital health research and that it is associated with age and symptom severity. Gender effects cannot be proven. Such systematic selection can lead to biased research results that inappropriately inform research, policy, and practice. CLINICALTRIAL ClinicalTrial.gov NCT01785121, https://clinicaltrials.gov/ct2/show/NCT01785121

Self-care monitoring at home can be a challenge for patients with heart failure (HF). Tools that leverage information and communication technology (ICT), comprise medical devices, or have written material may support their efforts at home. The aim of this study was to describe HF patients&rsquo, experiences and their prioritization of tools that support, or could support, self-care monitoring at home. A descriptive qualitative design employing semi-structured interviews was used with HF patients living at home and attending an HF outpatient clinic in Norway. We used a deductive analysis approach, using the concept of self-care monitoring with ICT tools, paper-based tools, medical devices, and tools to consult with healthcare professionals (HCPs) as the categorization matrix. Nineteen HF patients with a mean age of 64 years participated. ICT tools are used by individual participants to identify changes in their HF symptoms, but are not available by healthcare services. Paper-based tools, medical devices, and face-to-face consultation with healthcare professionals are traditional tools that are available and used by individual participants. HF patients use traditional and ICT tools to support recognizing, identifying, and responding to HF symptoms at home, suggesting that they could be used if they are available and supplemented by in-person consultation with HCPs.

Background This study aimed to identify factors associated with health-related quality of life (HRQoL) and the burden on the relatives of older people with multi-morbidity. Methods A secondary analysis of baseline data from 296 dyads, including older patients with multimorbidity and their relatives, which were previously collected in a randomized study. The analysis was conducted to select correlated independent variables to enter a final linear regression analysis of two models with different endpoints: the relatives’ HRQoL (EQ5D index) and burden (COPE index: Negative impact scale). Results Sixteen variables correlated with the relatives’ HRQoL, and 15 with the relatives’ burden. Both the HRQoL and burden correlated with both patient and relative variables. A high HRQoL was associated with relatives’ working/studying. A high burden was associated with caring for an older person with changed behaviour. A low burden was associated with the relatives’ high scores on positive values of caring, quality of support and HRQoL. Conclusion Older persons and their relatives should be considered as a unit in the development of support of older people in order to increase the health and quality of life of both groups. To support and protect relatives from a high burden, potential measures could include improving the relative’s HRQoL and strengthening their ability to find positive values in care and strengthening reliable and good support from others. The relatives’ HRQoL explained the variation in the burden. However, the burden did not explain the variation in the HRQoL, which suggests that the relatives’ HRQoL is not so readily affected by their burden, whereas the relatives’ HRQoL can influence their burden. The variables used in the regression analyses where chosen to reflect important aspects of the relatives’ and older persons’ situations. The final models explained 38% of the variation in the relatives’ burden but only 10% of the variation in their HRQoL. This could be important to consider when choosing outcome assessments in future studies.

Background The aim of this study was to optimize a Question Prompt List which is designed to improve communication about the heart failure trajectory among patients, family members, and health care professionals. Methods Data were collected in a two-round Delphi survey and a cross-sectional survey, including patients with heart failure, their family members, and health care professionals working in heart failure care in Sweden and the Netherlands. Acceptability for and demand of the Question Prompt List were assessed. Results A total of 96 patients, 63 family members and 26 health care professionals participated in the study. Regarding acceptability, most of the original questions were found to be relevant by the participants for inclusion in the Question Prompt List but some cultural differences exist, which resulted in two versions of the list: a Swedish version including 33 questions and a Dutch version including 38 questions. Concerning demand, participants reported that they were interested in discussing the questions in the revised Question Prompt List with a physician or a nurse. Few patients and family members reported that they were worried by the questions in the Question Prompt List and hence did not want to discuss the questions. Conclusions This Question Prompt List has successfully been adapted into a Swedish version and a Dutch version and includes questions about the HF trajectory which patients, their families, and health care professionals perceived to be relevant for discussion in clinical practice. Overall, patients and family members were not worried about the content in the Question Prompt List and if used in accordance with patients’ and family members’ preferences, the Question Prompt List can help to improve communication about the heart failure trajectory.

ispartof: European Journal Of Cardiovascular Nursing vol:19 issue:6 pages:465-468 ispartof: location:England status: published

Objective Even though continuity is essential after discharge, there is a lack of reliable questionnaires to measure and assess patients perceptions of continuity of care. The Patient Continuity of Care Questionnaire (PCCQ) addresses the period before and after discharge from hospital. However, previous studies show that the factor structure needs to be confirmed and validated in larger samples, and the aim of this study was to evaluate the psychometric properties of the PCCQ with focus on factor structure, internal consistency and stability. Design A psychometric evaluation study. The questionnaire was translated into Swedish using a forward-backward technique and culturally adapted through cognitive interviews (n=12) and reviewed by researchers (n=8). Setting Data were collected in four healthcare settings in two Swedish counties. Participants A consecutive sampling procedure included 725 patients discharged after hospitalisation due to angina, acute myocardial infarction, heart failure or atrial fibrillation. Measurement To evaluate the factor structure, confirmatory factor analyses based on polychoric correlations were performed (n=721). Internal consistency was evaluated by ordinal alpha. Test-retest reliability (n=289) was assessed with intraclass correlation coefficient (ICC). Results The original six-factor structure was overall confirmed, but minor refinements were required to reach satisfactory model fit. The standardised factor loadings ranged between 0.68 and 0.94, and ordinal alpha ranged between 0.82 and 0.95. All subscales demonstrated satisfactory test-retest reliability (ICC=0.76-0.94). Conclusion The revised version of the PCCQ showed sound psychometric properties and is ready to be used to measure perceptions of continuity of care. High ordinal alpha in some subscales indicates that a shorter version of the questionnaire can be developed. Funding Agencies|Centre for Clinical Research Sormland/Uppsala University, Eskilstuna, Sweden [FoU-centrum/CKF Sormland-642411, FoU-centrum/CKF Sormland-742221, FoU-centrum/CKF Sormland-859581]; Linkoping University Sweden; Medical Research Council of Southeast Sweden [FORSS-607341, FORSS-749931, FORSS-846301]

The aim of this study is to increase evidence-based interventions by investigating the feasibility of an intervention using an interactive digital calendar with mobile phone reminders (RemindMe) as support in everyday life. Qualitative and quantitative data were collected from participating patients (n = 8) and occupational therapists (n = 7) from three rehabilitation clinics in Sweden. The intervention consisted of delivering the interactive digital calendar RemindMe, receiving an individualized introduction, a written manual, and individual weekly conversations for two months with follow-up assessments after two and four months. Feasibility areas of acceptability, demand, implementation, practicality, and integration were examined. Patients expressed their interest and intention to use RemindMe and reported a need for reminders and individualized support. By using reminders in activities in everyday life their autonomy was supported. The study also demonstrated the importance of confirming reminders and the possible role of habit-forming. Occupational therapists perceived the intervention to be useful at the rehabilitation clinics and the weekly support conversations enabled successful implementation. This study confirmed the importance of basing and tailoring the intervention to patients needs and thus being person-centered. Funding Agencies|VR-FORTE [2014-4100]; Research and scholarship management in Region Ostergotland [LIO-815111]; Swedish Stroke Association (STROKE-Riksforbundet)

Let the games begin : serious games in prevention and rehabilitation to improve outcomes in patients with cardiovascular disease

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus-driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high-quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in-hospital management. Chioncel, O (corresponding author), Univ Med & Pharm Carol Davila, Inst Emergency Cardiovasc Dis Prof CC Iliescu, Bucharest 950474, Romania. ochioncel@yahoo.co.uk

The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a good death. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure. Funding Agencies|Patient Forum of the European Society of Cardiology

The instrument called Families Importance in Nursing Care–Nurses’ Attitudes (FINC-NA) is used to measure nurses’ attitudes toward involving families in their nursing care. The aim of this study is to evaluate the FINC-NA scale in a population of Dutch nurses and add new psychometric information to existing knowledge about this instrument. Using a cross-sectional design, 1,211 nurses received an online application in 2015. Psychometric properties were based on polychoric correlations and the Generalized Partial Credit Model. A total of 597 (49%) nurses responded to the online application. Results confirmed a four-subscale structure. All response categories were utilized, although some ceiling effects occurred. Most items increase monotonically, and the majority of items discriminate well between different latent trait scores of nurses with some items providing more information than others. This study reports the psychometric properties of the Dutch language FINC-NA instrument. New insights into the construct and content of items enable the possibility of a more generic instrument that could be valid across several cultures.

Edita Lycholip,1,2 Ina Thon Aamodt,3,4 Irene Lie,3 Toma Šimbelytė,5 Roma Puronaitė,2,6,7 Hans Hillege,8 Arjen de Vries,8 Imke Kraai,9 Anna Stromberg,10 Tiny Jaarsma,11 Jelena Čelutkienė1,2 1Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; 2Center of Cardiology and Angiology, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania; 3Centre for Patient-Centered Heart and Lung Research, Department of Cardiothoracic Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Oslo, Norway; 4Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; 5Clinic of Internal Medicine, Centre of Family and Internal Medicine, Vilnius University Santaros Clinics, Vilnius University, Vilnius, Lithuania; 6Centre of Informatics and Development, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania; 7Institute of Mathematics and Informatics, Vilnius University, Vilnius, Lithuania; 8Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; 9PRA Health Sciences – Early Development Services, Groningen, the Netherlands; 10Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden; 11Department of Social and Welfare Studies, Linkoping University, Norrkoping, Sweden Introduction: Self-care is an important patient-reported outcome (PRO) for heart failure (HF) patients, which might be affected by disease management and/or telemonitoring (TM). The number of studies reporting the influence of TM on self-care is limited.Aims: This study aimed: to assess whether TM, in addition to information-and-communication-technology (ICT)-guided disease management system (ICT-guided DMS), affects self-care behavior; to evaluate the dynamics of self-care during the study; to investigate factors contributing to self-care changes; and to identify a patient profile that predisposes the patient to improvement in self-care. Methods: In the INnovative ICT-guided-DMS combined with Telemonitoring in OUtpatient clinics for Chronic HF patients (IN TOUCH) study, 177 patients were randomized to either ICT-guided DMS or TM+ICT-guided DMS, with a follow-up of 9months. The current analysis included 118 participants (mean age: 69±11.5years; 70% male) who filled the following PRO instruments: the nine-item European Heart Failure Self-care Behaviour scale (EHFScBs), Hospital Anxiety and Depression scale (HADs), and Minnesota Living with HF Questionnaire (MLHFQ). Results: The baseline level of self-care was better in the TM+ICT-guided-DMS group (n=58) compared to ICT-guided-DMS group (n=60, p=0.023). Self-care behavior improved in the ICT-guided-DMS group (p28, or from 17 to 28 with concomitant HADs depression subscale (HADs_D) score ≤8, demonstrated the greatest potential to improve self-care during the study. Conclusion: TM did not have an advantage on self-care improvement. Poor physical aspect of quality of life, lower LVEF, and lower NYHA class were associated with self-care worsening. The greatest self-care improvement may be achieved in those patients who have low or medium initial self-care level in the absence of depression. Keywords: heart failure, self-care, telemonitoring, disease management, patient-reported outcomes

Aims N-terminal pro-B-type natriuretic peptide (NT-proBNP) is the most frequently used biomarker in heart failure (HF), but its prognostic utility across ethnicities is unclear. Methods and results This study included 546 Caucasians with HF from the Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure and 578 Asians with HF from the Singapore Heart Failure Outcomes and Phenotypes study. NT-proBNP was measured at discharge after HF hospitalization. The studied outcome was a composite of all-cause mortality and HF hospitalization at 18 months. Compared with Caucasian patients, Asian patients were younger (63 +/- 12 vs. 71 +/- 11 years); less often female (26% vs. 39%); and had lower body mass index (26 vs. 27 kg/m(2)), better renal function (61 +/- 37 vs. 54 +/- 20 mL/min/1.73 m(2)), lower rates of atrial fibrillation (25% vs. 46%), strikingly higher rates of diabetes (59% vs. 30%), and higher rates of hypertension (76% vs. 44%). Despite these clear inter-group differences in individual drivers of NT-proBNP, average levels were similar in Asians [2709 (1350, 6302) pg/mL] and Caucasians [2545 (1308, 5484) pg/mL] (P = 0.514). NT-proBNP was strongly associated with outcome [hazard ratio 1.28 (per doubling), 95% confidence interval 1.18-1.39, P

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Aims In 2007, the Heart Failure Association of the European Society of Cardiology (ESC) launched the information website heartfailurematters.org (HFM site) with the aim of creating a practical tool through which to provide advice and guidelines for living with heart failure to patients, their carers, health care professionals and the general public worldwide. The website is managed by the ESC at the European Heart House and is currently available in nine languages. The aim of this study is to describe the background, objectives, use, lessons learned and future directions of the HFM site. Methods and results Data on the number of visitor sessions on the site as measured by Google Analytics were used to explore use of the HFM site from 2010 to 2015. Worldwide, the annual number of sessions increased from 416 345 in 2010 to 1 636 368 in 2015. Most users (72–75%) found the site by using a search engine. Desktops and, more recently, smartphones were used to visit the website, accounting for 50% and 38%, respectively, of visits to the site in 2015. Conclusions Although its use has increased, the HFM site has not yet reached its full potential: fewer than 2 million users have visited the website, whereas the number of people living with heart failure worldwide is estimated to be 23 million. Uptake and use could be further improved by a continuous process of qualitative assessment of users' preferences, and the provision of professional helpdesk facilities, comprehensive information technology, and promotional support.

Context\ud The increasing number of people living with multiple chronic conditions in addition to an index condition has become an international healthcare priority. Health education curricula have been developed alongside single condition frameworks in health service policy and practice and need redesigning to incorporate optimal management of multiple conditions.\ud \ud Aim\ud Our aims were to evaluate current teaching and learning about comorbidity care amongst the global population of healthcare students from different disciplines and to develop an International Comorbidity Education Framework (ICEF) for incorporating comorbidity concepts into health education.\ud \ud Methods\ud We surveyed nursing, medical and pharmacy students from England, India, Italy and Sweden to evaluate their understanding of comorbidity care. A list of core comorbidity content was constructed by an international group of higher education academics and clinicians from the same disciplines, by searching current curricula and analysing clinical frameworks and the student survey data. This list was used to develop the International Comorbidity Education Framework.\ud \ud Results\ud The survey sample consisted of 917 students from England (42%), India (48%), Italy (8%) and Sweden (2%). The majority of students across all disciplines said that they lacked knowledge, training and confidence in comorbidity care and were unable to identify specific teaching on comorbidities. All student groups wanted further comorbidity training. The health education institution representatives found no specific references to comorbidity in current health education curricula. Current clinical frameworks were used to develop an agreed list of core comorbidity content and hence an International Comorbidity Education Framework.\ud \ud Conclusions\ud Based on consultation with academics and clinicians and on student feedback we developed an International Comorbidity Education Framework to promote the integration of comorbidity concepts into current healthcare curricula.

Background Relationship satisfaction is generally positively correlated with sexual satisfaction, but this relation has been poorly examined in people with cardiovascular disease who are at increased risk of sexual problems compared with the general population. Aim To document reported changes to sex after a diagnosis of cardiac disease and determine whether there is an association between sexual function and relationship satisfaction. Methods Semistructured telephone interviews focused on relationship satisfaction and sexual problems were conducted with 201 people with cardiovascular disease who were currently in a sexual relationship with one main partner and were recruited from six hospital cardiac rehabilitation centers in Ireland. Comparisons between groups were conducted using t-tests and multivariate analysis of variance for continuous variables and χ2 tests for categorical variables. Predictors of relationship satisfaction were assessed using multiple linear regression analysis. Outcomes Data were gathered on demographic and clinical variables, sexual problems, and relationship satisfaction, including satisfaction with the physical, emotional, affection, and communication aspects of relationships. Results Just less than one third of participants (n = 61, 30.3%) reported that sex had changed for the worse since their cardiac event or diagnosis, with approximately half of these stating that this was a serious problem for them. Satisfaction with relationships was high among patients surveyed; more than 70% of the sample reported being very or extremely satisfied with the physical and emotional aspects and showing affection during sex. Satisfaction with communication about sex was lower, with only 58% reporting being very or extremely satisfied. We did not find significant associations between reporting of sexual problems or deterioration of sex as a result of disease and relationship satisfaction. Clinical Implications Cardiac rehabilitation programs should address these sexual problems, potentially by enhancing communication within couples about sex. Strengths and Limitations The strength is that data are presented on the sexual experiences and relationship satisfaction of a relatively large sample of people diagnosed with cardiac disease, a relatively underexplored research area. Limitations include the possibility of selection bias of study participants and bias associated with self-report measurement. Conclusions Sexual problems were significant in this population but were not related to relationship satisfaction in this cross-sectional survey.

Objective Circulating microRNAs (miRNAs) have been implicated in both heart failure and atherosclerotic disease. The aim of this study was to examine associations between heart failure specific circulating miRNAs, atherosclerotic disease and cardiovascular-related outcome in patients with heart failure. Methods The levels of 11 heart failure-specific circulating miRNAs were compared in plasma of 114 heart failure patients with and without different manifestations of atherosclerotic disease. We then studied these miRNAs in relation to biomarkers associated to atherosclerosis and to cardiovascular-related rehospitalizations during 18 months of follow-up. Results At least one manifestation of atherosclerotic disease was found in 70 (61%) of the heart failure patients. A consistent trend was found between an increasing number of manifestations of atherosclerosis (peripheral arterial disease in specific), and lower levels of miR-18a-5p, miR27a-3p, miR-199a-3p, miR-223-3p and miR-652-3p (all P amp;lt; 0.05). Target prediction and network analyses identified several interactions between miRNA targets and biomarkers related to inflammation, angiogenesis and endothelial dysfunction. Lower miRNA levels were associated with higher levels of these atherosclerosis-related biomarkers. In addition, lower miRNA levels were significantly associated with rehospitalizations due to cardiovascular causes within 18 months, with let-7i-5p as strongest predictor [HR 2.06 (95% CI 1.29-3.28), C-index 0.70, P = 0.002]. Conclusions A consistent pattern of lower levels of circulating miRNAs was found in heart failure patients with atherosclerotic disease, in particular peripheral arterial disease. In addition, lower levels of miRNAs were associated with higher levels of biomarkers involved in atherosclerosis and an increased risk of a cardiovascular-related rehospitalization. Funding Agencies|Netherlands CardioVascular Research Initiative: the Netherlands Heart Foundation; Dutch Federation of University Medical Centres; Netherlands Organization for Health Research and Development; Royal Netherlands Academy of Sciences; Netherlands Heart Foundation: Approaching Heart Failure By Translational Research Of RNA Mechanisms (ARENA) [CVON-2011-11]; Netherlands Heart Foundation [2000Z003]; Biosite France SAS, Jouy-en-Josas, France; Roche Diagnostics Nederland BV, Venlo, the Netherlands; Novartis Pharma BV, Arnhem, the Netherlands