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The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional–led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single–time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Aims Secondary prevention reduces coronary heart disease (CHD) progression. Traditional prevention programs including cardiac rehabilitation are under-accessed, which smartphone apps may overcome. To evaluate the effect of a game-based mobile app intervention (MyHeartMate) to improve cardiovascular risk factors and lifestyle behaviours. Methods and results Single-blind randomized trial of CHD patients in Sydney, 2017–2021. Intervention group were provided the MyHeartMate app for 6 months. Co-designed features included an avatar of the patient’s heart and tokens earned by risk factor work (tracking, challenges, and quizzes). The control group received usual care. Primary outcome was self-reported physical activity [metabolic equivalents (METs), Global Physical Activity Questionnaire] and secondary outcomes included lipid levels, blood pressure (BP), body mass index, and smoking. Pre-specified sample size was achieved (n = 390), age 61.2 ± 11.5 years; 82.5% men and 9.2% current smokers. At 6 months, adjusted for baseline levels, the intervention group achieved more physical activity than control (median difference 329 MET mins/wk), which was not statistically significant (95% CI −37.4, 696; P = 0.064). No differences occurred between groups on secondary outcomes except for lower triglyceride levels in the intervention [mean difference −0.3 (95% CI −0.5, −0.1 mmoL/L, P = 0.004)]. Acceptability was high: 94.8% of intervention participants engaged by tracking exercise or BP and completing missions; 26.8% continued to engage for ≥30 days. Participants (n = 14) reported the app supported tracking behaviours and risk factors, reinforcing and improving self-care confidence, and decreasing anxiety. Conclusion A game-based app proved highly acceptable for patients with CHD but did not improve risk factors or lifestyle behaviours other than triglyceride levels.

This 2023 update of the Core Curriculum in Cardiovascular Nursing (2015) embraces the formation of the Association of Cardiovascular Nursing and Allied Professionals and reflects the diverse professional backgrounds of our members, including nurses, allied health professionals, and healthcare scientists (in this document referred to collectively as Nurses and Allied Professionals).

Background:The World Health Organisation (WHO) highlight a requirement to engage and empower people in improving and maintaining their own health and wellbeing, which underpins the ‘People as Partners in Care’ pillar of integrated care. Student nurses are the workforce of the future, but cardiovascular (CV) risk factors are highly prevalent across this group, despite ‘Health Promotion’ being a component of nursing curricula. This theory-practice gap diminishes student nurses’ personal health and their capacity to influence the adoption of cardioprotective lifestyles by others. Purpose: To conduct co-design workshops with undergraduate nursing students to create a user-friendly, digital intervention that empowers them with knowledge and skills regarding CV risk management and healthy lifestyle implementation. Methods:The co-design process comprised two steps: Step 1 (Design): Undergraduate nursing students (n=6) across two Universities in the UK agreed to participate in two virtual workshops, with each lasting approximately three hours and facilitated by members of the research team. Figure 1 displays the structure of each workshop.Step 2 (Prototype development): Information obtained in Step 1 was consolidated and used by the multidisciplinary research team (academics, students, and registered nurses) to draft, refine, and re-draft content and structure for the intervention, which were subsequently sent to expert digital resource designers for prototype development. Results: The co-design process resulted in development of a website that is ‘open for all’ (i.e., to enable users to complete different parts during different times and on different devices). The students identified the following topics as essential educational content: 1. Lifestyle behaviours and CV risk; 2. CV risk assessment; and 3. Motivational interviewing (see Figure 2). Students discussed their busy schedules (study and placement) and expressed a requirement for the information across these topics to be presented in an easily accessible format (i.e., short, comprehensible descriptions) to improve understanding and adherence. Moreover, students wanted the intervention to incorporate animations, quizzes, and simulated scenarios to facilitate enjoyable, interactive learning. In terms of intervention delivery, the consensus across students was for the beforementioned educational topics to be delivered via self-directed learning for one week (approximately 30 minutes to complete), followed by a group-work activity at a tutor-led, in-person workshop (approximately 90 minutes), which involves applying knowledge gained about CV risk assessment and motivational interviewing to simulated scenarios whilst receiving tailored guidance from the tutor. Conclusion: Through co-creation, this study has developed a prototype educational intervention that is tailored to the requirements of nursing students for improving the core skills underpinning effective CV risk management and healthy lifestyle implementation. This work will progress to user testing and refinement prior to large-scale evaluation of acceptability and effectiveness. If successful, the educational resource has the capacity for roll-out to student and qualified nurses, with the aim of empowering them to improve their CV health and enhancing the adoption of cardioprotective lifestyles by others. In addition, this resource may serve as a template / platform for adaptation to other populations (i.e., patients or different students and healthcare professionals) and educational objectives (i.e., self-management for patients).

Aims Spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of myocardial infarction predominantly affecting women aged younger than 50 years. There is limited research addressing female and male SCAD survivors’ experience of, or requirements for, support post-SCAD. This study explored what SCAD survivors wanted to support recovery. Methods and results A qualitative study using semi-structured video and telephone interviews. Data were analysed through thematic analysis using the framework approach. We interviewed 20 participants (19 females) with a mean age of 54.6 (+/-SD 8.5 years). Three overarching themes encapsulated participants’ views about support requirements. (i) Education and information. Participants thought healthcare professionals involved in diagnosis and supporting recovery required greater awareness of SCAD and the psychological effect of SCAD. They wanted accessible SCAD information immediately post-event and during the educational component of cardiac rehabilitation. (ii) Physical activity. Requirements were for advice tailored to individuals’ specific needs, physical capabilities, and physical activity preferences. Participants suggested that utilizing wearable technology was helpful to encourage a safe return to activity. (iii) Psychosocial support. Participants wanted formal psychosocial support immediately post-event, during cardiac rehabilitation and in the longer term. Conclusion Better healthcare professional training may improve diagnosis, and increase support and awareness of SCAD. SCAD support programmes should provide early SCAD specific education utilizing online sources, individually tailor physical activity prescription, offer wearable technology to support a return to being active, and provide short- and long-term psychosocial support. As SCAD is predominately a female condition, programmes should consider female physical activity preferences.

From 2012-16, the oral anticoagulant (OAC) treatment determination for atrial fibrillation (AF) patients moved from the CHADS₂ to the CHA₂DS₂-VASc score. A dataset collated during previous studies (2011-2019) with deidentified data extracted from clinical records at a single-timepoint for active adult patients (n=285,635; 8,294 with AF) attending 164 general practices in Australia was analysed. The CHA₂DS₂-VASc threshold (score ≥2 men/≥3 women) captured a significantly higher proportion than CHADS₂≥2 (all ages: 85% vs 68%, p

Stroke experts discuss developments and challenges associated with stroke care, including the need to improve post-discharge services and the emergence of COVID-19-related stroke.

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From 2012-16, the oral anticoagulant (OAC) treatment determination for atrial fibrillation (AF) patients moved from the CHADS₂ to the CHA₂DS₂-VASc score. A dataset collated during previous studies (2011-2019) with deidentified data extracted from clinical records at a single-timepoint for active adult patients (n=285,635; 8,294 with AF) attending 164 general practices in Australia was analysed. The CHA₂DS₂-VASc threshold (score ≥2 men/≥3 women) captured a significantly higher proportion than CHADS₂≥2 (all ages: 85% vs 68%, p0.0001; ≥65 years: 96% vs 76%, p0.0001). The change from CHADS₂ to CHA₂DS₂-VASc resulted in a significantly higher proportion of AF patients being recommended OAC, driven by the revised scoring for age.

Realist reviews offer a method to understand why an intervention is successful or not. Many factors influence how complex healthcare interventions are delivered and this makes understanding what works difficult. Effectiveness depends on delivery context, and success in one setting does not guarantee the same result in alternate settings. How an intervention works (the underlying mechanisms) in a particular setting for one population group, may not work in the same way for a different group. A realist review provides an iterative theory-driven approach to help understand how and for whom and under what conditions an intervention works.

AIMS: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a key risk factor for ischaemic stroke. Following AF detection, treatment with oral anticoagulation can significantly lower mortality and morbidity rates associated with this risk. The availability of several hand-held devices which can detect AF may enable trained health professionals to adopt AF screening approaches which do not interfere with people's daily routines. This study aims to investigate the effectiveness of a hand-held device (the MyDiagnostick single-lead Electrocardiogram (ECG) sensor) in screening for AF when embedded into the handles of supermarket trolleys.METHODS: A mixed methods two-phase approach will be taken. The quantitative first phase will involve the recruitment of 2000 participants from a convenience sample at four large supermarkets with pharmacies. Prospective participants will be asked to conduct their shopping using a trolley embedded with a MyDiagnostick sensor. If the device identifies a participant with AF, the in-store pharmacist will be dispatched to take a manual pulse measurement and a static control sensor reading and offer a cardiologist consultation referral. When the sensor does not detect AF, a researcher will confirm the reading with a manual pulse measurement. ECGs will be compiled, and the sensitivity, specificity and positive and negative predictive values will be determined. A qualitative second phase will consist of semi-structured interviews carried out with those pharmacists and store managers in-store during the running of the trial period. These will explore the perceptions of staff regarding the merits of embedding sensors in the handles of supermarket trolleys to detect AF.CONCLUSION: This feasibility study will inform a larger future definitive trial.

PURPOSE This study sought to determine current practice regarding nutrition care within cardiac rehabilitation (CR) programs, including perceived barriers and facilitators to providing nutrition care in this setting. METHODS A cross-sectional survey was conducted in October and November 2019. Potential participants were program coordinators, identified through the Australian Cardiovascular Health and Rehabilitation Association program directory and invited to participate via e-mail. RESULTS Forty-nine respondents (response rate: 13%) are included in this analysis. Programs provided group (n = 42, 86%) and/or individual (n = 25, 51%) nutrition education, and most were supported by a dietitian (63%). However, the availability of dietitians and nutrition care provided at CR was variable. For example, individual education was consistently provided at 13 programs and usually by health professionals other than dietitians. Eight programs (16%) used a formal behavior change framework for nutrition care. Generally, respondents were positive about the role of nutrition; CR coordinators perceived nutrition as a valuable component of the program, and that they had good nutrition knowledge. An identified barrier was the financial resources available to support the provision of nutrition care. CONCLUSIONS To ensure that patients receive the benefits of evidence-based nutrition care, program staff may require additional support, particularly regarding the use of evidence-based behavior change techniques. Key facilitators that may be leveraged to achieve this include the high value and priority that CR program coordinators place on nutrition care.

BackgroundAtrial fibrillation (AF) affects over 1.4 million people in the UK, resulting in a five-fold increased stroke risk and a three to four times greater risk of severe, disabling stroke. AF, a chronic disease, requires monitoring, medication and lifestyle measures. A self-management approach supported by mobile health (mHealth) may empower AF self-care. AimsTo assess the need to develop new mHealth self-management interventions for those with AF. This review aimed to identify commercially available AF self-management apps, analyse and synthesise a) characteristics b) functions c) privacy/security d) incorporated behaviour change techniques, and e) quality and usability. MethodsWe searched app stores for “atrial fibrillation” and “anticoagulation”, and included apps focused on AF self-management in the review. We examined app functions, privacy statements against best practice recommendations, the inclusion of behaviour change techniques using the App Behaviour Change Scale, and app quality/usability using the Mobile App Rating Scale.ResultsFrom an initial search of 555 apps, five apps were included in the review. Common functions were educational content, medication trackers and communication with healthcare professionals. Apps contained limited behaviour change techniques, lacked intuitive functions and were difficult to use. Privacy policies were difficult to read. App quality rated from poor to acceptable and no app had been evaluated in a clinical trial. ConclusionThe review reports a lack of commercially available AF self-management apps of sufficient standard for use in healthcare settings. This highlights the need for clinically validated mHealth interventions incorporating evidence-based behaviour change techniques to support AF self-management.

Aims Evidence from longitudinal studies on the influence of area deprivation in cardiac mortality is limited. We aimed to examine the impact of area deprivation on cardiac mortality in a large representative Scottish population. We also examined differences between women and men. Methods and results Retrospective analysis was performed by using linked data from Scottish Longitudinal Study from 1991 to 2010. The main exposure variable was socioeconomic status using the Carstairs deprivation scores, a composite score of area-level factors. Cox proportional-hazards models were constructed to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiac mortality and all-cause mortality associated with area-based deprivation. Subgroup analyses were stratified by sex. In a representative population of 217 965 UK adults, a total of 58 770 deaths occurred over a median of 10 years of follow-up period. The risk of cardiac mortality and all-cause mortality showed a consistent graded increased across the deprived groups. Compared to the least deprived group, the adjusted HR of cardiac mortality in the most deprived group was 1.27 (1.15–1.39, P Conclusion Our study demonstrated area deprivation was the strong predictor of long-term cardiac mortality and all-cause mortality. The inequalities were substantially greater in women from more deprived areas than men from the same background.

Europace : the European journal of pacing, arrhythmias and cardiac electrophysiology euac062 (2022). doi:10.1093/europace/euac062, Published by Oxford Univ. Press, Oxford

Aim We aimed to systematically review the available literature on mobile Health (mHealth) solutions, including handheld and wearable devices, implantable loop recorders (ILRs), as well as mobile platforms and support systems in atrial fibrillation (AF) detection and management. Methods This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The electronic databases PubMed (NCBI), Embase (Ovid), and Cochrane were searched for articles published until 10 February 2021, inclusive. Given that the included studies varied widely in their design, interventions, comparators, and outcomes, no synthesis was undertaken, and we undertook a narrative review. Results We found 208 studies, which were deemed potentially relevant. Of these studies included, 82, 46, and 49 studies aimed at validating handheld devices, wearables, and ILRs for AF detection and/or management, respectively, while 34 studies assessed mobile platforms/support systems. The diagnostic accuracy of mHealth solutions differs with respect to the type (handheld devices vs wearables vs ILRs) and technology used (electrocardiography vs photoplethysmography), as well as application setting (intermittent vs continuous, spot vs longitudinal assessment), and study population. Conclusion While the use of mHealth solutions in the detection and management of AF is becoming increasingly popular, its clinical implications merit further investigation and several barriers to widespread mHealth adaption in healthcare systems need to be overcome. Graphic abstract Mobile health solutions for atrial fibrillation detection and management: a systematic review.

Objectives Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios. Design Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach. Setting AF screening stakeholders in 11 European countries. Participants Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation. Intervention Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening. Primary outcome measures Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system. Results Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed. Conclusions There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities. RS has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation program (grant agreement no. 648131); the German Center for Cardiovascular Research (DZHK) (81Z1710103); the European Union’s Horizon 2020 research and innovation programme (grant agreement no. 847770, AFFECT-EU) and ERACoSysMed3 (031L0239). We thank the participants and dedicated study staff of the AFFECT-EU studies for their generous contribution of time and efforts.

Background Non-adherence to medications is common in patients with atrial fibrillation (AF), increasing the risk of stroke, co-morbidities, and AF symptoms. Understanding factors influencing medication adherence is important in providing holistic care to patients with AF. This study aimed to explore medication adherence in patients with AF, and explore associations with health literacy, cognition, or AF knowledge. Methods A single-centre pilot study, using survey questionnaires and open questions. Patients with a primary cardiac diagnosis, with AF as primary or secondary diagnosis, were eligible for recruitment. During hospitalisation, adherence to cardiac medications was assessed using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS). Health literacy, cognition, and AF knowledge were assessed through validated questionnaires. Facilitators and barriers for medication adherence were obtained through open-ended question and coded using a content analysis approach. Results Fifty-four (54) patients were recruited (61% male, mean age 71±11). Twenty-two (22) participants (41%) were classified as non-adherent using the BAASIS; with a corresponding self-reported adherence of 87.7% in non-adherent participants compared to 97.8% in adherent participants. No associations were identified between medication adherence and cognition, health literacy, or AF knowledge. Facilitators for adherence included external assistance, routines, and medication knowledge, and these were reported by both adherent and non-adherent participants. Non-adherent participants reported more barriers including medication concerns, forgetfulness, and lifestyle factors. Conclusions Large numbers of AF patients are likely to be non-adherent to medications. Medication adherence is influenced by multiple factors, individual to each patient. Diverse strategies are required to ensure adherence to cardiac medications.

Objective Health literacy measurement can identify healthcare consumers’ needs and help inform healthcare service delivery. The objective of this review is to identify and evaluate tools to measure health literacy among Chinese speakers. Methods A systematic literature search was undertaken in nine databases, both English and Chinese, on articles published from the databases’ inception to May 2018, addressing health literacy among Chinese speakers. Results Ten health literacy instruments in the Chinese language were reported in 17 studies, of which ten were published in English and seven in Chinese. Of the 17 studies, six reported on a new instrument, while the remainder reported on derivative instruments. All, except for one, are self-administered. These studies applied various implicit or explicit conceptual or operational health literacy definitions. The psychometric strength varied across the instruments. Conclusions A number of instruments are available for assessing health literacy among Chinese speakers. Careful selection is recommended, given the variation in components and psychometric properties assessed. Practice implications This review can be used by healthcare providers and researchers to select effective health literacy tools to examine patients’ ability to understand and apply health information so that services can be more appropriately tailored to Chinese speaking patients.

Atrial fibrillation (AF) is the most common heart arrhythmia. Current estimates are that 1.4% of people aged ≥65 years have undiagnosed AF [1]. AF is associated with a five-fold higher likelihood o...

Background Atrial fibrillation (AF) is a growing epidemic. Current models of care delivery are inadequate in meeting the needs of the population with AF. Furthermore, quality of life is known to be poor in patients with AF and is associated with adverse patient outcomes. Objective The aim of this study was to determine if nurse-led education and cardiovascular risk factor modification, undertaken using the principles of motivational interviewing, facilitated by an electronic decision support tool to ensure the appropriate use of oral anticoagulation (OAC), could improve health-related quality of life (HRQoL), guideline adherence to OAC, and cardiovascular risk factor profiles in individuals with AF. Methods This was a multicenter, prospective, randomized controlled feasibility study of 72 individuals with AF. The intervention involved 1 face-to-face nurse-delivered education and risk factor management session with 4 follow-up telephone calls over a 3-month period to monitor progress. The primary outcome measure was HRQoL as assessed by the Short Form-12 survey. Results A total of 72 participants were randomized, with 36 individuals in each arm completing follow-up. Mean age was 65 ± 11 years and 44% were women. At 3 months follow-up, no significant differences between groups were observed for the physical or mental component summary scores of the Short Form-12, nor any of the subscales. Appropriate use of OAC did not differ between groups at final follow-up. Conclusions A brief nurse-delivered educational intervention did not significantly impact on HRQoL or risk factor status in individuals with AF. Further research should focus on interventions of greater intensity to improve outcomes in this population. Trial registration ACTRN12615000928516.

Background/aims The cardiac catheter laboratory offers services to patients with a variety of conditions. These may include coronary heart disease, structural heart disorders and cardiac electrophysiological syndromes. Owing to the complex nature of an evolving health service and the increasing demands placed on healthcare workers, it is essential that innovative paradigms of service delivery are identified. This scoping review examines the state of knowledge regarding the rationale for change, solutions and potential consequences of expanding the roles of nurses in the cardiac catheter lab. Methods An exploratory scoping study approach was employed, using an established framework. Databases searched included the Cumulative Index to Nursing and Allied Health Literature, Medline and Google Scholar. A systematic search strategy spanning a date range from 1988–2018 was formulated. Titles and abstracts of 172 papers were screened; a total of 20 papers were identified for full review, including 16 from the UK, one from the United States, two from Europe and one from Australia. Results Literature to date concentrated on seven key areas: (1) drivers for change, (2) principles underpinning change, (3) ways of developing the workforce, (4) appropriate change management, (5) recommendations for practice, (6) barriers and facilitators, and (7) outcomes. Conclusions The cardiac catheter lab is under pressure to meet the variable demands placed upon it. There is documented evidence of a shortage of cardiac physiologists, which has a direct and measurable impact on operational efficiency and patient care. The concept of expanding the nurse's role to incorporate aspects of the cardiac physiologist's role has been explored and could be a potential solution. Role expansion and advanced practice is a well-explored model in nursing. There are many themes associated with this issue, which are outlined in this paper. There needs to be more evidence surrounding the patient's perceptions in relation to professional roles in the workplace. An economic evaluation of the costs and benefits of a multiskilled workforce would be a challenging but worthwhile endeavour.

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

There is a global imperative for the prevention of cardiovascular disease which includes primordial, primary, and secondary prevention. Prevention requires a multifactor risk reduction approach because of the multifaceted aetiology of cardiovascular disease. Components of cardiovascular disease prevention include behavioural strategies to encourage the adoption of healthy lifestyle habits (abstaining from tobacco, adopting a cardioprotective diet, achieving optimal physical activity and exercise levels, and achieving a healthy body weight and shape), the use of medications to manage biological risk factors, and strategies to manage psychological conditions such as anxiety and depression. Nurses have an important role to play in the implementation of prevention programmes which, when led by this professional group working in interdisciplinary models with physicians and allied professionals, are successful in reducing total mortality. Risk estimation allows the detection of those at highest risk, so they can be identified for management as a priority. Settings for the delivery of prevention and rehabilitation programmes include hospital-based conventional cardiac rehabilitation and initiatives based in primary care and the community. All have been shown to be successful when all of the components described previously are included. Integrating digital technology can address barriers to participation in programmes and improve adherence. Professional societies, associations, and heart foundations play an important role in supporting healthcare professionals, patients, and caregivers to maximize the effectiveness of prevention initiatives.

Contemporary challenges for holistic care include frailty and ageing, multimorbidity, polypharmacy, caregiver involvement, palliative and supportive care, cultural and socioeconomic issues, and gender inequalities. Frailty is a growing health problem among older people, especially women, and linked with an increased risk in mortality, disability, and cognitive decline. Patients with cardiovascular disease (CVD) often present with other comorbidities such as diabetes, obesity, cancer, depression, arthritis, frailty, and cognitive impairment, which require a tailored ‘person-centred’ holistic approach using skilled clinical judgement and good communication and should draw upon a range of resources, including informal carers, friends, and family, who often provide considerable support to people with multimorbidity. Polypharmacy, the concurrent use of multiple medications by a person, is a growing issue, especially among older people with multimorbidity. Problematic polypharmacy occurs where the benefits of one or more of these medicines are not realized, patients experience inappropriate or avoidable adverse drug reactions, or patients are non-adherent. Regular medicines review, evaluation of adherence, and appropriate deprescribing are essential. Many patients with advanced CVD and serious symptoms require palliative care which should be integrated with usual cardiovascular care from diagnosis. Cultural and socioeconomic issues are increasingly being recognized as important determinants of the cause and outcome of CVD and should be considered in any intervention, such as health behaviour change, when holistically assessing a patient with CVD. Females with CVD should be provided with equal access to care, a prompt diagnosis, and treatments based on the guidelines and recommendations at the same rate and intensity as their male counterparts.