Cardiovascular and Noncardiovascular Prescribing and Mortality After Takotsubo Comparison With Myocardial Infarction and General Population.

Background: Takotsubo syndrome is an increasingly common cardiac emergency with no known evidence-based treatment. Objectives: The purpose of this study was to investigate cardiovascular mortality and medication use after takotsubo syndrome. Methods: In a case-control study, all patients with takotsubo syndrome in Scotland between 2010 and 2017 (n = 620) were age, sex, and geographically matched to individuals in the general population (1:4, n = 2,480) and contemporaneous patients with acute myocardial infarction (1:1, n = 620). Electronic health record data linkage of mortality outcomes and drug prescribing were analyzed using Cox proportional hazard regression models. Results: Of the 3,720 study participants (mean age, 66 years; 91% women), 153 (25%) patients with takotsubo syndrome died over the median of 5.5 years follow-up. This exceeded mortality rates in the general population (N = 374 [15%]; HR: 1.78 [95% CI: 1.48-2.15], P < 0.0001), especially for cardiovascular (HR: 2.47 [95% CI: 1.81-3.39], P < 0.001) but also noncardiovascular (HR: 1.48 [95% CI: 1.16-1.87], P = 0.002) deaths. Mortality rates were lower for patients with takotsubo syndrome than those with myocardial infarction (31%, 195/620; HR: 0.76 [95% CI: 0.62-0.94], P = 0.012), which was attributable to lower rates of cardiovascular (HR: 0.61 [95% CI: 0.44-0.84], P = 0.002) but not non-cardiovascular (HR: 0.92 [95% CI: 0.69-1.23], P = 0.59) deaths. Despite comparable medications use, cardiovascular therapies were consistently associated with better survival in patients with myocardial infarction but not in those with takotsubo syndrome. Diuretic (P = 0.01), anti-inflammatory (P = 0.002), and psychotropic (P < 0.001) therapies were all associated with worse outcomes in patients with takotsubo syndrome. Conclusions: In patients with takotsubo syndrome, cardiovascular mortality is the leading cause of death, and this is not associated with cardiovascular therapy use.

Six-Month Pilot Testing of a Digital Health Tool to Support Effective Self-Care in People With Heart Failure: Mixed Methods Study.

BACKGROUND: Digital tools may support people to self-manage their heart failure (HF). Having previously outlined the human-centered design development of a digital tool to support self-care of HF, the next step was to pilot the tool over a period of time to establish people's acceptance of it in practice. OBJECTIVE: This study aims to conduct an observational pilot study to examine the usability, adherence, and feasibility of a digital health tool for HF within the Irish health care system. METHODS: A total of 19 participants with HF were provided with a digital tool comprising a mobile app and the Fitbit Charge 4 and Aria Air smart scales for a period of 6 months. Changes to their self-care were assessed before and after the study with the 9-item European HF Self-care Behavior Scale (EHFScBS) and the Minnesota Living with HF Questionnaire (MLwHFQ) using a Wilcoxon signed rank test. After the study, 3 usability questionnaires were implemented and descriptively analyzed: the System Usability Scale (SUS), Wearable Technology Motivation Scale (WTMS), and Comfort Rating Scale (CRS). Participants also undertook a semistructured interview regarding their experiences with the digital tool. Interviews were analyzed deductively using the Theoretical Domains Framework. RESULTS: Participants wore their devices for an average of 86.2% of the days in the 6-month testing period ranging from 40.6% to 98%. Although improvements in the EHFScBS and MLwHFQ were seen, these changes were not significant (P=.10 and P=.70, respectively, where P>.03, after a Bonferroni correction). SUS results suggest that the usability of this system was not acceptable with a median score of 58.8 (IQR 55.0-60.0; range 45.0-67.5). Participants demonstrated a strong motivation to use the system according to the WTMS (median 6.0, IQR 5.0-7.0; range 1.0-7.0), whereas the Fitbit was considered very comfortable as demonstrated by the low CRS results (median 0.0, IQR 0.0-0.0; range 0.0-2.0). According to participant interviews, the digital tool supported self-management through increased knowledge, improved awareness, decision-making, and confidence in their own data, and improving their social support through a feeling of comfort in being watched. CONCLUSIONS: The digital health tool demonstrated high levels of adherence and acceptance among participants. Although the SUS results suggest low usability, this may be explained by participants uncertainty that they were using it fully, rather than it being unusable, especially given the experiences documented in their interviews. The digital tool targeted key self-management behaviors and feelings of social support. However, a number of changes to the tool, and the health service, are required before it can be implemented at scale. A full-scale feasibility trial conducted at a wider level is required to fully determine its potential effectiveness and wider implementation needs.

A 20-year population study of peripartum cardiomyopathy.

BACKGROUND AND AIMS: The epidemiology of peripartum cardiomyopathy (PPCM) in Europe is poorly understood and data on long-term outcomes are lacking. A retrospective, observational, population-level study of validated cases of PPCM in Scotland from 1998 to 2017 was conducted. METHODS: Women hospitalized with presumed de novo left ventricular systolic dysfunction around the time of pregnancy and no clear alternative cause were included. Each case was matched to 10 controls. Incidence and risk factors were identified. Morbidity and mortality were examined in mothers and children. RESULTS: The incidence of PPCM was 1 in 4950 deliveries. Among 225 women with PPCM, obesity, gestational hypertensive disorders, and multi-gestation were found to be associated with having the condition. Over a median of 8.3 years (9.7 years for echocardiographic outcomes), 8% of women with PPCM died and 75% were rehospitalized for any cause at least once. Mortality and rehospitalization rates in women with PPCM were ∼12- and ∼3-times that of controls, respectively. The composite of all-cause death, mechanical circulatory support, or cardiac transplantation occurred in 14%. LV recovery occurred in 76% and, of those who recovered, 13% went on to have a decline in LV systolic function despite initial recovery. The mortality rate for children born to women with PPCM was ∼5-times that of children born to controls and they had an ∼3-times greater incidence of cardiovascular disease over a median of 8.8 years. CONCLUSIONS: PPCM affected 1 in 4950 women around the time of pregnancy. The condition is associated with considerable morbidity and mortality for the mother and child. There should be a low threshold for investigating at-risk women. Long term follow-up, despite apparent recovery, should be considered.

Cardiovascular disease behavioural risk factors in rural interventions: cross-sectional study.

This study aims to (1) assess the distribution of variables within the population and the prevalence of cardiovascular disease (CVD) behavioural risk factors in patients, (2) identify target risk factor(s) for behaviour modification intervention, and (3) develop an analytical model to define cluster(s) of risk factors which could help make any generic intervention more targeted to the local patient population. Study patients with at least one CVD behavioural risk factor living in a rural region of the Scottish Highlands. The study used the STROBE methodology for cross-sectional studies. Demographic and clinical data of patients (n = 2025) in NHS Highlands hospital were collected at the point of admission for PCI between 04.01.2016 and 31.12.2019. Collected data distributions were analysed by CVD behavioural risk factors for prevalence, associations, and direction of associations. Cluster definition was measured by assignment of a unit score each for the overall level of prevalence and significance of associations, and general logistics modelling for direction and significance of the risk. The mean (SD) age was 69.47(± 10.93) years [95% CI (68.99-69.94)]. The key risk factors were hyperlipidaemia, hypertension, and elevated body mass index (BMI). Approximately 40% of the population have multiple risk factor counts of two. Analytical measures revealed a population risk factor cluster with elevated BMI [77.5% (1570/2025)] that is mostly either hyperlipidaemic [9.43%, co-eff. (17), P = 0.007] or hypertensive [22.72%, co-eff. (17), P = 0.99] as key risk factor clusters. Carefully modelled analyses revealed clustered risk associated with elevated BMI. This information would support a strategy for targeting risk factor clusters in novel interventions to improve implementation efficiency. Exposure to and outcome of an elevated BMI is linked more to the population's socio-economic outcomes rather than to regional rurality or urbanity.

What do we mean by complex percutaneous coronary intervention? An assessment of agreement amongst interventional cardiologists for defining complexity.

BACKGROUND: In the last decade, percutaneous coronary intervention (PCI) has evolved toward the treatment of complex disease in patients with multiple comorbidities. Whilst there are several definitions of complexity, it is unclear whether there is agreement between cardiologists in classifying complexity of cases. Inconsistent identification of complex PCI can lead to significant variation in clinical decision-making. AIM: This study aimed to determine the inter-rater agreement in rating the complexity and risk of PCI procedures. METHOD: An online survey was designed and disseminated amongst interventional cardiologists by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) board. The survey presented four patient vignettes, with study participants assessing these cases to classify their complexity. RESULTS: From 215 respondents, there was poor inter-rater agreement in classifying the complexity level (k = 0.1) and a fair agreement (k = 0.31) in classifying the risk level. The experience level of participants did not show any significant impact on the inter-rater agreement of rating the complexity level and the risk level. There was good level of agreement between participants in terms of rating 26 factors for classifying complex PCI. The top five factors were (1) impaired left ventricular function, (2) concomitant severe aortic stenosis, (3) last remaining vessel PCI, (4) requirement fort calcium modification and (5) significant renal impairment. CONCLUSION: Agreement among cardiologists in classifying complexity of PCI is poor, which may lead to suboptimal clinical decision-making, procedural planning as well as long-term management. Consensus is needed to define complex PCI, and this requires clear criteria incorporating both lesion and patient characteristics.

Using the theoretical domains framework to explore behavioural determinants for medication taking in patients following percutaneous coronary intervention.

OBJECTIVES: To investigate relationships between factors influencing medication taking and behavioural determinants in patients who have undergone percutaneous coronary intervention (PCI). METHODS: A cross-sectional survey using a postal questionnaire distributed to PCI patients. The questionnaire was iteratively developed by the research team with reference to the theoretical domains framework (TDF) of behavioural determinants, reviewed for face and content validity and piloted. Data were analysed using descriptive and principal component analysis (PCA). Inferential analysis explored relationships between PCA component scores and factors influencing medicating taking behaviour. KEY FINDINGS: Adjusted response rate was 62.4% (325/521). PCA gave three components: (C1) Self-perceptions of knowledge and abilities in relation to medication taking; (C2) Aspects relating to activities and support in medication taking; (C3) Emotional aspects in taking medication. Generally, respondents held very positive views. Statistically significant relationships between all three components and self-reported chest pain/discomfort indicated patients with ongoing chest pain/discomfort post-PCI are more likely to have behavioural determinants and beliefs which make medication taking challenging. Respondents who were on 10 or more medications had lower levels of agreement with the C2 and C3 statements indicating challenges associated with their activities/support and anxieties in medication taking. CONCLUSIONS: PCI patients show links between TDF behavioural determinants and factors influencing medication taking for those reporting chest pain or polypharmacy. Further research needs to explore the effective design and implementation of behavioural change interventions to reduce the challenge of medication taking.

Clinical and health economic evaluation of a post-stroke arrhythmia monitoring service.

Atrial fibrillation (AF) is a major cause of recurrent stroke and transient ischaemic attack (TIA) in the UK. As many patients can have asymptomatic paroxysmal AF, prolonged arrhythmia monitoring is advised in selected patients following a stroke or TIA. This service evaluation assessed the clinical and potential health economic impact of prolonged arrhythmia monitoring post-stroke using R-TEST monitoring devices. This was a prospective, case-controlled, service evaluation in a single health board in the North of Scotland. Patients were included if they had a recent stroke or TIA, were in sinus rhythm, and did not have another indication for, or contraindication to, oral anticoagulation. A health economic model was developed to estimate the clinical and economic value delivered by the R-TEST monitoring. Approval to use anonymised patient data in this service evaluation was obtained. During the evaluation period, 100 consecutive patients were included. The average age was 70 ± 11 years, 46% were female. Stroke was the presenting complaint in 83% of patients with the other 17% having had a TIA. AF was detected in seven of 83 (8.4%) patients who had had a stroke and one of 17 (5.9%) patients with a TIA. Health economic modelling predicted that adoption of R-TEST monitoring has a high probability of demonstrating both clinical and economic benefits. In conclusion, developing a post-stroke arrhythmia monitoring service using R-TEST devices is feasible, effective at detecting AF, and represents a probable clinical and economic benefit.

Machine learning and the electrocardiogram over two decades: Time series and meta-analysis of the algorithms, evaluation metrics and applications.

BACKGROUND: The application of artificial intelligence to interpret the electrocardiogram (ECG) has predominantly included the use of knowledge engineered rule-based algorithms which have become widely used today in clinical practice. However, over recent decades, there has been a steady increase in the number of research studies that are using machine learning (ML) to read or interrogate ECG data. OBJECTIVE: The aim of this study is to review the use of ML with ECG data using a time series approach. METHODS: Papers that address the subject of ML and the ECG were identified by systematically searching databases that archive papers from January 1995 to October 2019. Time series analysis was used to study the changing popularity of the different types of ML algorithms that have been used with ECG data over the past two decades. Finally, a meta-analysis of how various ML techniques performed for various diagnostic classifications was also undertaken. RESULTS: A total of 757 papers was identified. Based on results, the use of ML with ECG data started to increase sharply (p < 0.001) from 2012. Healthcare applications, especially in heart abnormality classification, were the most common application of ML when using ECG data (p < 0.001). However, many new emerging applications include using ML and the ECG for biometrics and driver drowsiness. The support vector machine was the technique of choice for a decade. However, since 2018, deep learning has been trending upwards and is likely to be the leading technique in the coming few years. Despite the accuracy paradox, accuracy was the most frequently used metric in the studies reviewed, followed by sensitivity, specificity, F1 score and then AUC. CONCLUSION: Applying ML using ECG data has shown promise. Data scientists and physicians should collaborate to ensure that clinical knowledge is being applied appropriately and is informing the design of ML algorithms. Data scientists also need to consider knowledge guided feature engineering and the explicability of the ML algorithm as well as being transparent in the algorithm's performance to appropriately calibrate human-AI trust. Future work is required to enhance ML performance in ECG classification.

Life-Threatening Coronary Vasospasm Treated by Implantable Cardioverter Defibrillator: The Warning Signs.

Coronary artery vasospasm is the sudden narrowing of an artery caused by rapid prolonged contraction. It reduces blood supply to the heart and can present with typical cardiac chest pain symptoms. Vasospasm can lead to fatal arrhythmic complications such as ventricular fibrillation. Our case report describes an example of this occurring in a 53-year-old female, and the management plan that ensued. We look at the importance of accurate and prompt diagnosis of vasospasm and how this can have implications for treatment options. One of the available treatments for vasospasm is placement of an implantable cardioverter defibrillator (ICD). This delivers a shock in the event of future life-threatening arrhythmia, with the aim of preventing cardiac arrest. ICD placement, however, is not always a suitable option. This case report discusses the various challenges that arose while making the decision for ICD placement and gives insight into the best available treatment options for coronary artery vasospasm. We also highlight early warning signs that predict life-threatening vasospastic events and how this can be diagnosed and treated appropriately.

Human-Centered Design of a Digital Health Tool to Promote Effective Self-care in Patients With Heart Failure: Mixed Methods Study.

BACKGROUND: Effective self-care is an important factor in the successful management of patients with heart failure (HF). Despite the importance of self-care, most patients with HF are not adequately taught the wide range of skills required to become proficient in self-care. Digital health technology (DHT) may provide a novel solution to support patients at home in effective self-care, with the view to enhancing the quality of life and ultimately improving patient outcomes. However, many of the solutions developed to date have failed to consider users' perspectives at the point of design, resulting in poor effectiveness. Leveraging a human-centered design (HCD) approach to the development of DHTs may lead to the successful promotion of self-care behaviors in patients with HF. OBJECTIVE: This study aimed to outline the HCD, development, and evaluation process of a DHT designed to promote effective self-care in patients with HF. METHODS: A design thinking approach within the HCD framework was undertaken, as described in the International Organization for Standardization 9241-210:2019 regulations, using a 5-step process: empathize, ideate, design, develop, and test. Patients with HF were involved throughout the design and evaluation of the system. The designed system was grounded in behavior change theory using the Theoretical Domains Framework and included behavior change techniques. Mixed methods were used to evaluate the DHT during the testing phase. RESULTS: Steps 1 to 3 of the process resulted in a set of evidence- and user-informed design requirements that were carried forward into the iterative development of a version 1 system. A cross-platform (iOS and Android) mobile app integrated with Fitbit activity trackers and smart scales was developed. A 2-week user testing phase highlighted the ease of use of the system, with patients demonstrating excellent adherence. Qualitative analysis of semistructured interviews identified the early potential for the system to positively influence self-care. Specifically, users perceived that the system increased their confidence and motivation to engage in key self-care behaviors, provided them with skills and knowledge that made them more aware of the importance of self-care behaviors, and might facilitate timely help seeking. CONCLUSIONS: The use of an HCD methodology in this research has resulted in the development of a DHT that may engage patients with HF and potentially affect their self-care behaviors. This comprehensive work lays the groundwork for further development and evaluation of this solution before its implementation in health care systems. A detailed description of the HCD process used in this research will help guide the development and evaluation of future DHTs across a range of disease use cases.

Barriers and facilitators to participating in cardiac rehabilitation and physical activity: A cross-sectional survey.

BACKGROUND: Cardiovascular diseases (CVD) have been shown to be the greatest cause of death worldwide and rates continue to increase. It is recommended that CVD patients attend cardiac rehabilitation (CR) following a cardiac event to reduce mortality, improve recovery and positively influence behaviour around CVD risk factors. Despite the recognised benefits and international recommendations for exercise-based CR, uptake and attendance remain suboptimal. A greater understanding of CR barriers and facilitators is required, not least to inform service development. Through understanding current cardiac patients' attitudes and opinions around CR and physical activity (PA) could inform patient-led improvements. Moreover, through understanding aspects of CR and PA that participants like/dislike could provide healthcare providers and policy makers with information around what elements to target in the future. AIM: To investigate participants' attitudes and opinions around CR and PA. METHODS: This study employed a cross-sectional survey design on 567 cardiac patients. Cardiac patients who were referred for standard CR classes at a hospital in the Scottish Highlands, from May 2016 to May 2017 were sampled. As part of a larger survey, the current study analysed the free-text responses to 5 open-ended questions included within the wider survey. Questions were related to the participants' experience of CR, reasons for non-attendance, ideas to increase attendance and their opinions on PA. Qualitative data were analysed using a 6-step, reflexive thematic analysis. RESULTS: Two main topic areas were explored: "Cardiac rehabilitation experience" and "physical activity". Self-efficacy was increased as a result of attending CR due to exercising with similar individuals and the safe environment offered. Barriers ranged from age and health to distance and starting times of the classes which increased travel time and costs. Moreover, responses demonstrated a lack of information and communication around the classes. Respondents highlighted that the provision of more classes and classes being held out with working hours, in addition to a greater variety would increase attendance. In terms of PA, respondents viewed this as different to the CR experience. Responses demonstrated increased freedom when conducting PA with regards to the location, time and type of exercise conducted. CONCLUSION: Changes to the structure of CR may prove important in creating long term behaviour change after completing the rehabilitation programme.

Using latent class analysis to identify clinical features of patients with occlusive myocardial infarction: Preangiogram prediction remains difficult.

BACKGROUND: Treatment decisions in myocardial infarction (MI) are currently stratified by ST elevation (ST-elevation myocardial infarction [STEMI]) or lack of ST elevation (non-ST elevation myocardial infarction [NSTEMI]) on the electrocardiogram. This arose from the assumption that ST elevation indicated acute coronary artery occlusion (OMI). However, one-quarter of all NSTEMI cases are an OMI, and have a higher mortality. The purpose of this study was to identify features that could help identify OMI. METHODS: Prospectively collected data from patients undergoing percutaneous coronary intervention (PCI) was analyzed. Data included presentation characteristics, comorbidities, treatments, and outcomes. Latent class analysis was undertaken, to determine patterns of presentation and history associated with OMI. RESULTS: A total of 1412 patients underwent PCI for acute MI, and 263 were diagnosed as OMI. Compared to nonocclusive MI, OMI patients are more likely to have fewer comorbidities but no difference in cerebrovascular disease and increased acute mortality (4.2% vs. 1.1%; p < .001). Of OMI, 29.5% had delays to their treatment such as immediate reperfusion therapy. With latent class analysis, while clusters of similar patients are observed in the data set, the data available did not usefully identify patients with OMI compared to non-OMI. CONCLUSION: Features between OMI and STEMI are broadly very similar. However, there was no difference in age and risk of cerebrovascular disease in the OMI/non-OMI group. There are no reliable characteristics therefore for identifying OMI versus non-OMI. Delays to treatment also suggest that OMI patients are still missing out on optimal treatment. An alternative strategy is required to improve the identification of OMI patients.

Brief Digital Interventions to Support the Psychological Well-being of NHS Staff During the COVID-19 Pandemic: 3-Arm Pilot Randomized Controlled Trial.

BACKGROUND: Health and social care staff are at high risk of experiencing adverse mental health (MH) outcomes during the COVID-19 pandemic. Hence, there is a need to prioritize and identify ways to effectively support their psychological well-being (PWB). Compared to traditional psychological interventions, digital psychological interventions are cost-effective treatment options that allow for large-scale dissemination and transcend social distancing, overcome rurality, and minimize clinician time. OBJECTIVE: This study reports MH outcomes of a Consolidated Standards of Reporting Trials (CONSORT)-compliant parallel-arm pilot randomized controlled trial (RCT) examining the potential usefulness of an existing and a novel digital psychological intervention aimed at supporting psychological health among National Health Service (NHS) staff working through the COVID-19 pandemic. METHODS: NHS Highland (NHSH) frontline staff volunteers (N=169) were randomly assigned to the newly developed NHSH Staff Wellbeing Project (NHSWBP), an established digital intervention (My Possible Self [MPS]), or a waitlist (WL) group for 4 weeks. Attempts were made to blind participants to which digital intervention they were allocated. The interventions were fully automated, without any human input or guidance. We measured 5 self-reported psychological outcomes over 3 time points: before (baseline), in the middle of (after 2 weeks), and after treatment (4 weeks). The primary outcomes were anxiety (7-item General Anxiety Disorder), depression (Patient Health Questionnaire), and mental well-being (Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes included mental toughness (Mental Toughness Index) and gratitude (Gratitude Questionnaire-6). RESULTS: Retention rates mid- and postintervention were 77% (n=130) and 63.3% (n=107), respectively. Postintervention, small differences were noted between the WL and the 2 treatment groups on anxiety (vs MPS: Cohen d=0.07, 95% CI -0.20 to 0.33; vs NHSWBP: Cohen d=0.06, 95% CI -0.19 to 0.31), depression (vs MPS: Cohen d=0.37, 95% CI 0.07-0.66; vs NHSWBP: Cohen d=0.18, 95% CI -0.11 to 0.46), and mental well-being (vs MPS: Cohen d=-0.04, 95% CI -0.62 to -0.08; vs NHSWBP: Cohen d=-0.15, 95% CI -0.41 to 0.10). A similar pattern of between-group differences was found for the secondary outcomes. The NHSWBP group generally had larger within-group effects than the other groups and displayed a greater rate of change compared to the other groups on all outcomes, except for gratitude, where the rate of change was greatest for the MPS group. CONCLUSIONS: Our analyses provided encouraging results for the use of brief digital psychological interventions in improving PWB among health and social care workers. Future multisite RCTs, with power to reliably detect differences, are needed to determine the efficacy of contextualized interventions relative to existing digital treatments. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN) ISRCTN18107122; https://www.isrctn.com/ISRCTN18107122.

The mental health of NHS staff during the COVID-19 pandemic: two-wave Scottish cohort study.

BACKGROUND: Health and social care workers (HSCWs) are at risk of experiencing adverse mental health outcomes (e.g. higher levels of anxiety and depression) because of the COVID-19 pandemic. This can have a detrimental effect on quality of care, the national response to the pandemic and its aftermath. AIMS: A longitudinal design provided follow-up evidence on the mental health (changes in prevalence of disease over time) of NHS staff working at a remote health board in Scotland during the COVID-19 pandemic, and investigated the determinants of mental health outcomes over time. METHOD: A two-wave longitudinal study was conducted from July to September 2020. Participants self-reported levels of depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7) and mental well-being (Warwick-Edinburgh Mental Well-being Scale) at baseline and 1.5 months later. RESULTS: The analytic sample of 169 participants, working in community (43%) and hospital (44%) settings, reported substantial levels of depression and anxiety, and low mental well-being at baseline (depression, 30.8%; anxiety, 20.1%; well-being, 31.9%). Although mental health remained mostly constant over time, the proportion of participants meeting the threshold for anxiety increased to 27.2% at follow-up. Multivariable modelling indicated that working with, and disruption because of, COVID-19 were associated with adverse mental health changes over time. CONCLUSIONS: HSCWs working in a remote area with low COVID-19 prevalence reported substantial levels of anxiety and depression, similar to those working in areas with high COVID-19 prevalence. Efforts to support HSCW mental health must remain a priority, and should minimise the adverse effects of working with, and disruption caused by, the COVID-19 pandemic.

Transitions in Technology-Mediated Cardiac Rehabilitation and Self-management: Qualitative Study Using the Theoretical Domains Framework.

BACKGROUND: An acute cardiac incident is a life-changing event that often necessitates surgery. Although surgery has high success rates, rehabilitation, behavioral changes, and self-care are critical to long-term health. Recent systematic reviews have highlighted the potential of technology in this area; however, significant shortcomings have also been identified, particularly with regard to patient experience. OBJECTIVE: This study aims to improve future systems and to explore the experiences of cardiac patients during key phases after hospitalization: recuperation, initial rehabilitation, and long-term self-management. The key objective is to provide a holistic understanding of behavioral factors that impact people across these phases, understand how experiences evolve over time, and provide user-centered recommendations to improve the design of cardiac rehabilitation and self-management technologies. METHODS: Semistructured interviews were conducted with people who attended rehabilitation programs following hospitalization for acute cardiac events. Interviews were developed and data were analyzed via the Theoretical Domains Framework, a pragmatic framework that synthesizes prior theories of behavioral change. RESULTS: Three phases that arise posthospitalization were examined, namely, recuperation, rehabilitation, and long-term self-management. Through these phases, we describe the impact of key factors and important changes that occur in patients' experiences over time, including the desire for and redefinition of normal life, the need for different types of formal and informal knowledge, the benefits of safe zoning and connectedness, and the need to recognize capability. The use of the Theoretical Domains Framework allows us to show how factors that influence behavior evolve over time and to identify potential sources of tension. CONCLUSIONS: This study provides empirically grounded recommendations for the design of technology-mediated cardiac rehabilitation and self-management systems. Key recommendations include the use of technology to support a normal life, leveraging social influences to extend participants' sense of normality, the use of technology to provide a safe zone, the need to support both emotional and physical well-being, and a focus on recognizing capability and providing recommendations that are positive and reinforce this capability.

Knowledge and cardiovascular disease risk perception from the perspectives of prisoners and staff in a Scottish prison: a qualitative study.

PURPOSE: Prisoners have an increased risk of cardiovascular disease (CVD) compared to the general population. Knowledge and risk perception of CVD can influence engagement in preventative behaviours that lower an individual's CVD risk. This paper aims to explore prisoners' knowledge of CVD, and prisoners and staff's perceptions of prisoners' CVD risk. DESIGN/METHODOLOGY/APPROACH: This was a qualitative study in which semi-structured interviews were conducted with 16 prisoners and 11 prison and National Health Services staff in a Scottish prison. Data were analysed thematically using the framework method. FINDINGS: Most prisoners had limited knowledge of CVD as they could not describe it or could only identify one or two risk factors or cardiovascular events. Both prisoners and staff viewed prisoners' CVD risk as either pertaining to one individual, or pertaining to the general prisoner population. Unhealthy behaviours that were believed to increase CVD risk were linked to three perceived consequences of imprisonment: mental health problems, boredom and powerlessness. ORIGINALITY/VALUE: To the best of the authors' knowledge, this is the first study to explore the CVD knowledge of prisoners, and perceptions of CVD risk from the perspectives of prisoners and prison staff. Findings from this study indicate that CVD education needs to be a priority for prisoners, addressing knowledge of CVD, its risk and risk perceptions. Additionally, the findings indicate that individual and socio-environmental factors linked to prisoners' CVD risk need to be targeted to reduce this risk. Future research should focus on socio-environmental interventions that can lead to reducing the CVD risk of prisoners.

Comparing Single-Page, Multipage, and Conversational Digital Forms in Health Care: Usability Study.

BACKGROUND: Even in the era of digital technology, several hospitals still rely on paper-based forms for data entry for patient admission, triage, drug prescriptions, and procedures. Paper-based forms can be quick and convenient to complete but often at the expense of data quality, completeness, sustainability, and automated data analytics. Digital forms can improve data quality by assisting the user when deciding on the appropriate response to certain data inputs (eg, classifying symptoms). Greater data quality via digital form completion not only helps with auditing, service improvement, and patient record keeping but also helps with novel data science and machine learning research. Although digital forms are becoming more prevalent in health care, there is a lack of empirical best practices and guidelines for their design. The study-based hospital had a definite plan to abolish the paper form; hence, it was not necessary to compare the digital forms with the paper form. OBJECTIVE: This study aims to assess the usability of three different interactive forms: a single-page digital form (in which all data input is required on one web page), a multipage digital form, and a conversational digital form (a chatbot). METHODS: The three digital forms were developed as candidates to replace the current paper-based form used to record patient referrals to an interventional cardiology department (Cath-Lab) at Altnagelvin Hospital. We recorded usability data in a counterbalanced usability test (60 usability tests: 20 subjects×3 form usability tests). The usability data included task completion times, System Usability Scale (SUS) scores, User Experience Questionnaire data, and data from a postexperiment questionnaire. RESULTS: We found that the single-page form outperformed the other two digital forms in almost all usability metrics. The mean SUS score for the single-page form was 76 (SD 15.8; P=.01) when compared with the multipage form, which had a mean score of 67 (SD 17), and the conversational form attained the lowest scores in usability testing and was the least preferred choice of users, with a mean score of 57 (SD 24). An SUS score of >68 was considered above average. The single-page form achieved the least task completion time compared with the other two digital form styles. CONCLUSIONS: In conclusion, the digital single-page form outperformed the other two forms in almost all usability metrics; it had the least task completion time compared with those of the other two digital forms. Moreover, on answering the open-ended question from the final customized postexperiment questionnaire, the single-page form was the preferred choice.

Remote monitoring of implantable defibrillators is associated with fewer inappropriate shocks and reduced time to medical assessment in a remote and rural area.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy with defibrillators (CRT-D) reduce mortality in certain cardiac patient populations. However, inappropriate shocks pose a problem, having both adverse physical and psychological effects on the patient. The advances in device technology now allow remote monitoring (RM) of devices to replace clinic follow up appointments. This allows real time data to be analysed and actioned and this may improve patient care. AIM: To determine if RM in patients with an ICD is associated with fewer inappropriate shocks and reduced time to medical assessment. METHODS: This was a single centre, retrospective observational study, involving 156 patients implanted with an ICD or CRT-D, followed up for 2 years post implant. Both appropriate and inappropriate shocks were recorded along with cause for inappropriate shocks and time to medical assessment. RESULTS: RM was associated with fewer inappropriate shocks (13.6% clinic vs 3.9% RM; P = 0.030) and a reduced time to medical assessment (15.1 ± 6.8 vs 1.0 ± 0.0 d; P < 0.001). CONCLUSION: RM in patients with an ICD is associated with improved patient outcomes.

Human-Computer Agreement of Electrocardiogram Interpretation for Patients Referred to and Declined for Primary Percutaneous Coronary Intervention: Retrospective Data Analysis Study.

BACKGROUND: When a patient is suspected of having an acute myocardial infarction, they are accepted or declined for primary percutaneous coronary intervention partly based on clinical assessment of their 12-lead electrocardiogram (ECG) and ST-elevation myocardial infarction criteria. OBJECTIVE: We retrospectively determined the agreement rate between human (specialists called activator nurses) and computer interpretations of ECGs of patients who were declined for primary percutaneous coronary intervention. METHODS: Various features of patients who were referred for primary percutaneous coronary intervention were analyzed. Both the human and computer ECG interpretations were simplified to either "suggesting" or "not suggesting" acute myocardial infarction to avoid analysis of complex heterogeneous and synonymous diagnostic terms. Analyses, to measure agreement, and logistic regression, to determine if these ECG interpretations (and other variables such as patient age, chest pain) could predict patient mortality, were carried out. RESULTS: Of a total of 1464 patients referred to and declined for primary percutaneous coronary intervention, 722 (49.3%) computer diagnoses suggested acute myocardial infarction, whereas 634 (43.3%) of the human interpretations suggested acute myocardial infarction (P<.001). The human and computer agreed that there was a possible acute myocardial infarction for 342 out of 1464 (23.3%) patients. However, there was a higher rate of human-computer agreement for patients not having acute myocardial infarctions (450/1464, 30.7%). The overall agreement rate was 54.1% (792/1464). Cohen κ showed poor agreement (κ=0.08, P=.001). Only the age (odds ratio [OR] 1.07, 95% CI 1.05-1.09) and chest pain (OR 0.59, 95% CI 0.39-0.89) independent variables were statistically significant (P=.008) in predicting mortality after 30 days and 1 year. The odds for mortality within 1 year of referral were lower in patients with chest pain compared to those patients without chest pain. A referral being out of hours was a trending variable (OR 1.41, 95% CI 0.95-2.11, P=.09) for predicting the odds of 1-year mortality. CONCLUSIONS: Mortality in patients who were declined for primary percutaneous coronary intervention was higher than the reported mortality for ST-elevation myocardial infarction patients at 1 year. Agreement between computerized and human ECG interpretation is poor, perhaps leading to a high rate of inappropriate referrals. Work is needed to improve computer and human decision making when reading ECGs to ensure that patients are referred to the correct treatment facility for time-critical therapy.

A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being.

BACKGROUND: Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis. METHODS: We undertook a rapid review of the literature following guidelines by the WHO and the Cochrane Collaboration's recommendations. We searched across 14 databases, executing the search at two different time points. We included published, observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic. RESULTS: The 24 studies included in this review reported data predominantly from China (18 out of 24 included studies) and most sampled urban hospital staff. Our study indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes. CONCLUSIONS: The evidence to date suggests that female nurses with close contact with COVID-19 patients may have the most to gain from efforts aimed at supporting psychological well-being. However, inconsistencies in findings and a lack of data collected outside of hospital settings, suggest that we should not exclude any groups when addressing psychological well-being in health and social care workers. Whilst psychological interventions aimed at enhancing resilience in the individual may be of benefit, it is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Further research including social care workers and analysis of wider societal structural factors is recommended.