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Background: To date, claims data have not been used to study outcome differences between low and high socioeconomic status (SES) patients surviving ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) in the Netherlands., Aim: To evaluate STEMI and NSTEMI care among patients with low and high SES in the referral area of three Dutch percutaneous coronary intervention (PCI) centres, using claims data as a source., Methods: STEMI and NSTEMI patients treated in 2015-2017 were included. Patients' SES scores were collected based on their postal code via an open access government database. In patients with low (SES1) and high (SES4) status, revascularisation strategies and secondary prevention medication were compared., Results: A total of 2065 SES1 patients (age 68 ± 13 years, 58% NSTEMI) and 1639 SES4 patients (age 68 ± 13 years, 63% NSTEMI) were included. PCI use was lower in SES1 compared to SES4 in both STEMI (80% vs 84%, p < 0.012) and NSTEMI (42% vs 48%, p < 0.002) patients. Coronary artery bypass grafting was performed more often in SES1 than in SES4 in both STEMI (7% vs 4%, p = NS) and NSTEMI (11% vs 7%, p < 0.001) patients. Optimal medical therapy use in STEMI patients was higher in SES1 compared to SES4 (52% vs 46%, p = 0.01) but comparable among NSTEMI patients (39% vs 40%, p = NS). One-year mortality was comparable in SES1 and SES4 patients following STEMI (14% vs 16%, p = NS) and NSTEMI (10% vs 11%, p = NS)., Conclusion: Combined analysis of claims data and area-specific socioeconomic statistics can provide unique insight into how to improve myocardial infarction care for low and high SES patients., (© 2023. The Author(s).)

Background: Pre- and postoperative anxiety is a common phenomenon associated with negative postoperative outcomes. Symptoms of posttraumatic stress disorder, such as fear, nightmares, and sleep deprivation, are prevalent in approximately 30% to 50% of patients following discharge from intensive care units after cardiac surgery. Preliminary evidence suggests a promising role of virtual reality (VR) in preventing stress-related reactions using stress inoculation training. Such training enables cognitive preparation of individuals for stressful situations, thereby becoming more tolerant and resistant to stress, subsequently reducing the risk of potential negative psychological consequences. This study investigated a preoperative VR app-Pre-View-aimed at better informing and preparing patients for cardiac catheterization., Objective: This study aims to assess the feasibility, usability, and acceptability of Pre-View in patients undergoing cardiac catheterization., Methods: Eligible participants were adults scheduled for elective cardiac catheterization. Pre-View comprised an interactive virtual representation of the whole care process related to cardiac catheterization, from entering the hospital for admission to postprocedural stay and discharge. These processes were represented through 360° videos and interactive photos. Self-report questionnaires were completed at baseline (ie, before catheterization and after undergoing the VR experience) and after cardiac catheterization. Outcome measures included user experience and satisfaction, VR presence and immersive tendencies, and user friendliness. The perceived effectiveness was assessed exploratively., Results: A total of 8 individuals, with a mean age of 67 (SD 7.5) years, participated in this study. Half of them underwent the VR experience at the hospital and the other half at home. Participants reported high levels of presence in the virtual environment (Presence Questionnaire score: mean 129.1, SD 13.4). The usability of Pre-View was well evaluated (System Usability Scale score: mean 89.1, SD 12.0), and patient satisfaction was high (Client Satisfaction Questionnaire score: mean 27.1, SD 3.2). Usability and satisfaction scores were higher for participants who underwent Pre-View at home versus those who underwent Pre-View at the hospital, although the latter group was significantly older; 72.8 versus 61.3, respectively. All participants reported Pre-View to be effective in terms of feeling better informed about the care process of cardiac catheterization. Most participants (7/8, 88%) reported Pre-View to be effective in terms of feeling better prepared for cardiac catheterization, acknowledging the potential of Pre-View in reducing negative psychological consequences after catheterization., Conclusions: The results provide initial support for the feasibility and acceptability of a preoperative VR app, creating a virtual environment that supports patient education and preparation for upcoming cardiac catheterization. More studies are needed to further investigate the effects of VR as a tool to better prepare patients for medical procedures, its effectiveness in reducing negative patient outcomes (eg, anxiety, stress, and postoperative recovery outcomes), and the generalizability of effects across different settings and patient populations., (©Jiska J Aardoom, Alexander D Hilt, Tamar Woudenberg, Niels H Chavannes, Douwe E Atsma. Originally published in JMIR Cardio (https://cardio.jmir.org), 22.02.2022.)

Aims: Statin treatment is one of the hallmarks of secondary prevention after myocardial infarction. Adherence to statins tends to be difficult and can be improved by patient education. Novel technologies such as mixed reality (MR) expand the possibilities to support this process. To assess if an MR medication-application supports patient education focused on function of statins after myocardial infarction., Methods and Results: A human-centred design-approach was used to develop an MR statin tool for Microsoft HoloLens™. Twenty-two myocardial infarction patients were enrolled; 12 tested the application, 10 patients were controls. Clinical, demographic, and qualitative data were obtained. All patients performed a test on statin knowledge. To test if patients with a higher tendency to become involved in virtual environments affected test outcome in the intervention group, validated Presence- and Immersive Tendency Questionnaires (PQ and ITQ) were used. Twenty-two myocardial infarction patients (ST-elevation myocardial infarction, 18/22, 82%) completed the study. Ten out of 12 (83%) patients in the intervention group improved their statin knowledge by using the MR application (median 8 points, IQR 8). Test improvement was mainly the result of increased understanding of statin mechanisms in the body and secondary preventive effects. A high tendency to get involved and focused in virtual environments was moderately positive correlated with better test improvement ( r  = 0.57, P  < 0.05). The median post-test score in the control group was poor (median 6 points, IQR 4)., Conclusions: An MR statin education application can be applied effectively in myocardial infarction patients to explain statin function and importance., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Cerebral amyloid angiopathy (CAA) is an important cause of cognitive impairment and spontaneous lobar intracerebral haemorrhage in older individuals. When necessary, anticoagulant treatment in these patients comes with two dilemmas; significant intracerebral bleeding risk with treatment vs. high risk of embolic stroke with no treatment., Case Summary: A 66-year-old female patient presented to the emergency clinic with a ST-elevation myocardial infarction. Her past medical history revealed cognitive problems associated with lobar cerebral microbleeds on magnetic resonance imaging suspect for probable CAA. A primary percutaneous coronary intervention of the left anterior descending artery with implantation of drug eluting stent was performed. Dual antiplatelet treatment was started initially. During hospitalization, an impaired left ventricular (LV) function was observed with an apical aneurysm. Six months after the initial event, LV function remained stable however a LV thrombus was observed. Apixaban 5 mg twice daily was started based on multidisciplinary consensus and on its efficacy and safety profile in patients with atrial fibrillation. Despite treatment, patient suffered a new ischaemic stroke probably from the LV thrombus, for which vitamin K antagonist treatment was initiated and Apixaban discontinued., Discussion: Evidence for LV thrombus treatment with direct oral anticoagulants in CAA patients is scarce, however feasible based on its efficacy and safety profile. For CAA patients, the cardinal role of both clinical and radiological characteristics in determining the risk-benefit ratio for anticoagulant initiation in this specific subset of patients, is crucial. The clinical course described highlights the therapeutical dilemma of coexisting CAA and the clinical challenge it creates., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aim: To analyse non-ST-elevation myocardial infarction (NSTEMI) care in the Netherlands and to identify modifiable factors to improve NSTEMI healthcare., Methods: This retrospective cohort study analysed hospital and pharmacy claims data of all NSTEMI patients in the Netherlands in 2015. The effect of percutaneous coronary intervention (PCI) during hospitalisation on 1‑year mortality was investigated in the subcohort alive 4 days after NSTEMI. The effect of medical treatment on 1‑year mortality was assessed in the subcohort alive 30 days after NSTEMI. The effect of age, gender and co-morbidities was evaluated. PCI during hospitalisation was defined as PCI within 72 h after NSTEMI and optimal medical treatment was defined as the combined use of an aspirin species, P2Y 12 inhibitor, statin, beta-blocker and angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, started within 30 days after NSTEMI., Results: Data from 17,997 NSTEMI patients (age 69.6 (SD = 12.8) years, 64% male) were analysed. Of the patients alive 4 days after NSTEMI, 43% had a PCI during hospitalisation and 1‑year mortality was 10%. In the subcohort alive 30 days after NSTEMI, 47% of patients were receiving optimal medical treatment at 30 days and 1‑year mortality was 7%. PCI during hospitalisation (odds ratio (OR) 0.42; 95% confidence interval (CI) 0.37-0.48) and optimal medical treatment (OR 0.59; 95% CI 0.51-0.67) were associated with a lower 1‑year mortality., Conclusion: In Dutch NSTEMI patients, use of PCI during hospitalisation and prescription of optimal medical treatment are modest. As both are independently associated with a lower 1‑year mortality, this study provides direction on how to improve the quality of NSTEMI healthcare in the Netherlands.

Background: Patient education is crucial in the secondary prevention of cardiovascular disease. Novel technologies such as augmented reality or mixed reality expand the possibilities for providing visual support in this process. Mixed reality creates interactive digital three-dimensional (3D) projections overlaying virtual objects on the real-world environment. While augmented reality only overlays objects, mixed reality not just overlays but anchors virtual objects to the real world. However, research on this technology in the patient domain is scarce., Objective: The aim of this study was to understand how patients perceive information provided after myocardial infarction and examine if mixed reality can be supportive in this process., Methods: In total, 12 patients that experienced myocardial infarction and 6 health care professionals were enrolled in the study. Clinical, demographic, and qualitative data were obtained through semistructured interviews, with a main focus on patient experiences within the hospital and the knowledge they gained about their disease. These data were then used to map a susceptible timeframe to identify how mixed reality can contribute to patient information and education., Results: Knowledge transfer after myocardial infarction was perceived by patients as too extensive, not personal, and inconsistent. Notably, knowledge on anatomy and medication was minimal and was not recognized as crucial by patients, whereas professionals stated the opposite. Patient journey analysis indicated the following four critical phases of knowledge transfer: at hospital discharge, at the first outpatient visit, during rehabilitation, and during all follow-up outpatient visits. Important patient goals were understanding the event in relation to daily life and its implications on resuming daily life. During follow-up, understanding physical limitations and coping with the condition and medication side effects in daily life emerged as the most important patient goals. The professionals' goals were to improve recovery, enhance medication adherence, and offer coping support., Conclusions: There is a remarkable difference between patients' and professionals' goals regarding information and education after myocardial infarction. Mixed reality may be a practical tool to unite perspectives of patients and professionals on the disease in a more even manner, and thus optimize knowledge transfer after myocardial infarction. Improving medication knowledge seems to be a feasible target for mixed reality. However, further research is needed to create durable methods for education on medication through mixed reality interventions., (©Alexander D Hilt, Kevin Mamaqi Kapllani, Beerend P Hierck, Anne C Kemp, Armagan Albayrak, Marijke Melles, Martin J Schalij, Roderick W C Scherptong. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 23.06.2020.)

Background: Improving teamwork in surgery is a complex goal and difficult to achieve. Human factors questionnaires, such as the Safety Attitudes Questionnaire (SAQ), can help us understand medical teamwork and may assist in achieving this goal., Objective: This paper aimed to assess local team and safety culture in a cardiovascular surgery setting to understand how purposeful teamwork improvements can be reached., Methods: Two cardiovascular surgical teams performing complex aortic treatments were assessed: an endovascular-treatment team (ETT) and an open-treatment team (OTT). Both teams answered an online version of the SAQ Dutch Edition (SAQ-NL) consisting of 30 questions related to six different domains of safety: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. In addition, one open-ended question was posed to gain more insight into the completed questionnaires., Results: The SAQ-NL was completed by all 23 ETT members and all 13 OTT members. Team composition was comparable for both teams: 57% and 62% males, respectively, and 48% and 54% physicians, respectively. All participants worked for 10 years or more in health care. SAQ-NL mean scores were comparable between both teams, with important differences found between the physicians and nonphysicians of the ETT. Nonphysicians were less positive about the safety climate, job satisfaction, and working climate domains than were the physicians (P<.05). Additional education on performed procedures, more conjoined team training, as well as a hybrid operating room were suggested by participants as important areas of improvement., Conclusions: Nonphysicians of a local team performing complex endovascular aortic aneurysm surgery perceived safety climate, job satisfaction, and working conditions less positively than did physicians from the same team. Open-ended questions suggested that this is related to a lack of adequate conjoined training, lack of adequate education, and lack of an adequate operating room. With added open-ended questions, the SAQ-NL appears to be an assessment tool that allows for developing strategies that are instrumental in improving quality of care., (©Alexander D Hilt, Ad A Kaptein, Martin J Schalij, Jan van Schaik. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 08.04.2020.)

Background: Understanding representations of disease in various art genres provides insights into how patients and health care providers view the diseases. It can also be used to enhance patient care and stimulate patient self-management., Methods: This paper reviews how cardiovascular diseases are represented in novels, films, and paintings: myocardial infarction, aneurysm, hypertension, stroke, heart transplantation, Marfan's disease, congestive heart failure. Various search systems and definitions were used to help identify sources of representations of different cardiovascular diseases. The representations of the different diseases were considered separately. The Common Sense Model was used a theoretical model to outline illness perceptions and self-management in the various identified novels, films, and paintings., Results: Myocardial infarction followed by stroke were the most frequently detailed diseases in all three art genres. This reflects their higher prevalence. Representations ranged from biomedical details through to social and psychological consequences of the diseases., Conclusions: Artistic representations of cardiovascular diseases reflect cognitions, emotions, and images of prevalent disease. These representations shape views and behaviour of ill and healthy persons regarding heart diseases. As these representations are amenable to change, they deserve further research, which may be instrumental in improving the quality of life of persons struck by cardiovascular diseases. Changing illness perceptions appears to be a method to improve self-management and thereby quality of life in patients with various cardiovascular diseases.

Background Following myocardial infarction, medication is, besides lifestyle interventions, the cornerstone treatment to improve survival and minimize the occurrence of new cardiovascular events. Still, data on nationwide medication adherence are scarce. This study assesses medical adherence during one year following myocardial infarction, stratifying per type of infarct, age and gender. Design Retrospective cohort study. Methods In The Netherlands, all inhabitants are by law obliged to have health insurance and all claims data are centrally registered. In 2012 and 2013, all national diagnosis-codings of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) were acquired. Furthermore, information on retrieved medication was extracted from the Dutch Pharmacy Information System. Twelve months after discharge, the retrieved medication at the pharmacy of each pharmacological therapy (aspirin-species, P2Y12-inhibitor, statin, beta-blocker, angiotensin-converting enzyme-/angiotensin 2-inhibitor, vitamin-K antagonists or novel oral anticoagulant) were analysed. Results In total, 59,534 patients (67 ± 13 years, 39,545 (66%) male, 57% NSTEMI) were included, of whom 52,672 (88%) patients were analysed for one-year medical adherence. STEMI patients more often achieved optimal medical adherence than NSTEMI patients (60% vs. 40%, p ≤ 0.001). In both STEMI and NSTEMI, use of all five indicated drugs was higher in male patients compared with female (STEMI male 61% vs. female 57%, p ≤ 0.001; NSTEMI male 43% vs. female 37%, p ≤ 0.001. With increasing age, a gradual decrease was observed in the use of aspirin, P2Y12-inhibitors and statins. Conclusion Age and gender differences existed in medical adherence after myocardial infarction. Medical adherence was lower in women, young patients and elderly patients, specifically in NSTEMI patients.

Introduction: Orthostatic hypotension has been associated with impaired cognitive function, but cognitive function during orthostatic hypotension has hardly been studied. We studied the effect of orthostatic hypotension, induced by head-up tilt (HUT), on sustained attention in patients with autonomic failure., Methods: We studied the sustained attention to response task (SART) in the supine position and during HUT in 10 patients with autonomic failure and 10 age-matched and sex-matched controls. To avoid syncope, the tilting angle was tailored to patients to reach a stable systolic blood pressure below 100 mm Hg. Controls were all tilted at an angle of 60°. Cerebral blood flow velocity, blood pressure and heart rate were measured continuously., Results: In patients, systolic blood pressure was 61.4 mm Hg lower during HUT than in the supine position (p<0.001). Patients did not make more SART errors during HUT than in the supine position (-1.3 errors, p=0.3). Controls made 2.3 fewer errors during SART in the HUT position compared to the supine position (p=0.020). SART performance led to an increase in systolic blood pressure (+11.8 mm Hg, p=0.018) and diastolic blood pressure (+5.8 mm Hg, p=0.017) during SART in the HUT position, as well as to a trend towards increased cerebral blood flow velocity (+3.8 m/s, p=0.101)., Discussion: Orthostatic hypotension in patients with autonomic failure was not associated with impaired sustained attention. This might partly be explained by the observation that SART performance led to a blood pressure increase. Moreover, the upright position was associated with better performance in controls and, to a lesser extent, also in patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)