Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease.

Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision-making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1-year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1-5), 39% had single-ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis "extremely well" or "well," 28% of physicians thought parents understood the prognosis only "a little," "somewhat," or "not at all." Better parent-reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4-21.7, P=0.02). There was poor parent-physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent-reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient-reported outcomes, parent education, and physician communication tools may be beneficial.

Suicide Risk Management Protocol for a Randomized Controlled Trial of Cardiac Patients Reporting Hopelessness.

BACKGROUND: Investigators conducting studies that include potentially suicidal individuals are obligated to develop a suicide risk management (SRM) protocol. There is little available in the literature to guide researchers in SRM protocol development. OBJECTIVES: The aim of the study was to describe an SRM protocol developed for a randomized controlled trial (RCT) currently enrolling cardiac patients who report moderate to severe levels of hopelessness. METHODS: The SRM protocol identifies suicidal ideation and measures ideation severity through use of the Columbia-Suicide Severity Rating Scale risk factor questions. Based on responses, study participants are deemed safe or at low, moderate, or high risk for suicide. The SRM protocol guides research staff through a plan of action based on risk level. The protocol further guides staff through a plan over the course of this prospective study-from hospital enrollment to home-based visits. RESULTS: Research staff are well trained to identify suicidal ideation risk factors, initiate specific questioning about suicidal intent, determine level of risk, identify protective factors and a safe environment, and make referrals if needed. Of the 51 patients hospitalized with cardiac disease who reported moderate to severe hopelessness, 43 scored at a safe suicide risk level and 8 scored at low risk. Thirty-five of the 51 patients enrolled in the RCT. Of the 35 participants who received home visits to date, there have been three instances of low and one instance of moderate suicide risk. The SRM protocol has been consistently and accurately used by research personnel in both hospital and home settings. One modification has been made to the protocol since study activation, namely, the addition of an assessment of counseling history and encouragement of continued counseling. Booster training sessions of research staff will continue throughout the course of the RCT. DISCUSSION: Use of the SRM protocol identifies study participants who are safe or at risk for suicide in both hospital and home settings, and research staff can refer participants accordingly. CONCLUSION: The SRM protocol developed for this RCT can serve as a model in the development of SRM protocols for future research in acute care, community, or home-based settings.

Cost-utility analysis of learning and coping versus standard education in cardiac rehabilitation: a randomised controlled trial with 3 years of follow-up.

Objectives: To enhance adherence to cardiac rehabilitation (CR), a patient education programme called 'learning and coping' (LC-programme) was implemented in three hospitals in Denmark. The aim of this study was to investigate the cost-utility of the LC-programme compared with the standard CR-programme. Methods: 825 patients with ischaemic heart disease or heart failure were randomised to the LC-programme or the standard CR-programme and were followed for 3 years.A societal cost perspective was applied and quality-adjusted life years (QALY) were based on SF-6D measurements. Multiple imputation technique was used to handle missing data on the SF-6D. The statistical analyses were based on means and bootstrapped SEs. Regression framework was employed to estimate the net benefit and to illustrate cost-effectiveness acceptability curves. Results: No statistically significant differences were found between the two programmes in total societal costs (4353 Euros; 95% CI -3828 to 12 533) or in QALY (-0.006; 95% CI -0.053 to 0.042). At a threshold of 40 000 Euros, the LC-programme was found to be cost-effective at 15% probability; however, for patients with heart failure, due to increased cost savings, the probability of cost-effectiveness increased to 91%. Conclusions: While the LC-programme did not appear to be cost-effective in CR, important heterogeneity was noted for subgroups of patients. The LC-programme was demonstrated to increase adherence to the rehabilitation programme and to be cost-effective among patients with heart failure. However, further research is needed to study the dynamic value of heterogeneity due to the small sample size in this subgroup.

Cancer patients in cardiology: how to communicate with patients with special psychological needs and manage their cardiac problems in daily clinical practice.

: Cancer patients are increasingly referred for cardiology evaluations. These patients differ from those routinely seen in cardiology clinics because of their psychological burden and because the therapies and cancer itself can cause cardiac symptoms. A humane approach is critical to managing these patients. Cardiologists may see patients who are newly diagnosed with cancer or are in various phases of treatment; these patients may or may not have preexisting cardiac disease, and may develop cardiotoxicity from chemoimmunotherapy or radiotherapy. Each of these situations presents unique communication challenges for cardiologists. Although some oncology centers provide training in communication skills for their personnel, including cardiologists, this training is not widely available to physicians in general hospitals or private practice. This article examines the psychological aspects of cardio-oncology. It offers practical suggestions on how to best communicate with cancer patients in different phases of oncology care, and discusses when professional psychological help is needed.

How Patient Perceptions Shape Responses and Outcomes in Inherited Cardiac Conditions.

At least one-third of adults living with an inherited cardiac condition report clinically-significant levels of psychological distress. Poorer health-related quality of life compared with population norms is also consistently reported. These outcomes are associated with younger patient age, having an implantable cardioverter defibrillator, and receipt of uncertain clinical test results, and can influence self-management behaviours, such as adherence to potentially critical life-preserving medications. According to the Common Sense Model of Illness, people use information from multiple sources to 'make sense' of their health condition, and how they conceptualise the condition can strongly influence adaptation and coping responses. Previous studies with people with inherited cardiac conditions show that illness perceptions, such as greater perceived consequences and a poorer understanding of the condition, are associated with greater psychological distress and poorer adherence to medication. The Common Sense Model provides one potential framework for identifying patients who may be more vulnerable to adverse health outcomes, and for developing early interventions to reduce the physical and psychosocial burden of these conditions. Interventions based on the Common Sense Model have successfully improved physical and psychosocial outcomes associated with other cardiac conditions, and could be tailored for use with patients with an inherited cardiac condition (ICC).

Stress-Associated Neurobiological Pathway Linking Socioeconomic Disparities to Cardiovascular Disease.

BACKGROUND: Lower socioeconomic status (SES) associates with a higher risk of major adverse cardiac events (MACE) via mechanisms that are not well understood. OBJECTIVES: Because psychosocial stress is more prevalent among those with low SES, this study tested the hypothesis that stress-associated neurobiological pathways involving up-regulated inflammation in part mediate the link between lower SES and MACE. METHODS: A total of 509 individuals, median age 55 years (interquartile range: 45 to 66 years), underwent clinically indicated whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging and met pre-defined inclusion criteria, including absence of known cardiovascular disease or active cancer. Baseline hematopoietic tissue activity, arterial inflammation, and in a subset of 289, resting amygdalar metabolism (a measure of stress-associated neural activity) were quantified using validated 18F-fluorodeoxyglucose positron emission tomography/computed tomography methods. SES was captured by neighborhood SES factors (e.g., median household income and crime). MACE within 5 years of imaging was adjudicated. RESULTS: Over a median 4.0 years, 40 individuals experienced MACE. Baseline income inversely associated with amygdalar activity (standardized ß: -0.157 [95% confidence interval (CI): -0.266 to -0.041]; p = 0.007) and arterial inflammation (ß: -0.10 [95% CI: -0.18 to -0.14]; p = 0.022). Further, income associated with subsequent MACE (standardized hazard ratio: 0.67 [95% CI: 0.47 to 0.96]; p = 0.029) after multivariable adjustments. Mediation analysis demonstrated that the path of: ↓ neighborhood income to ↑ amygdalar activity to ↑ bone marrow activity to ↑ arterial inflammation to ↑ MACE was significant (ß: -0.01 [95% CI: -0.06 to -0.001]; p < 0.05). CONCLUSIONS: Lower SES: 1) associates with higher amygdalar activity; and 2) independently predicts MACE via a serial pathway that includes higher amygdalar activity, bone marrow activity, and arterial inflammation. These findings illuminate a stress-associated neurobiological mechanism by which SES disparities may potentiate adverse health outcomes.

Does social participation accelerate psychological adaptation to health shocks? Evidence from a national longitudinal survey in Japan.

PURPOSE: It is well-known that people psychologically adapt to health shocks over time and social participation (SP) has a favourable impact on health. Combining these two understandings, the current study addresses how psychological adaptation to major health shocks was affected by SP experience one year prior to the initial diagnosis. METHODS: Data were collected from a twelve-wave nationwide panel survey conducted from 2005 to 2016, starting with 34,240 individuals aged 50-59 years. Individuals who were initially diagnosed with cancer, stroke, heart disease or diabetes at any time between the second and twelfth waves and kept diagnosed as such were focused on. Random-effects models were estimated to examine how baseline SP prior to the diagnosis affected the pace of change in psychological distress, which was measured using Kessler 6 (K6) scores (range 0-24; M 3.3 SD 4.2), following immediate responses to the initial diagnosis. RESULTS: Baseline SP enabled or accelerated psychological adaptation to major health shocks. It is noted that the pace of decline of the K6 score per year after the immediate responses was 0.20 for cancer and 0.09 for diabetes (both p < 0.001) among men with baseline SP, in contrast with non-significant and limited changes among those without it. While the results for women were more mixed than those for men, the former results confirmed favourable impacts of baseline SP on psychological adaptation to health shocks in general. CONCLUSIONS: The results highlight a favourable impact of SP on psychological adaptation to health shocks.

The prognostic value of health-related quality of life in patients with Chagas heart disease.

PURPOSE: To verify the prognostic value of health-related quality of life (HRQoL) and the differences in HRQoL and clinical variables between groups of Chagas heart disease (CHD) patients with and without cardiovascular adverse events. METHODS: Seventy-five CHD patients were evaluated by echocardiography, maximal exercise testing, and Short-form of Health Survey (SF-36) Questionnaire. Patients were followed during 6 years. In the statistical analysis, uni- and multivariate Cox regression were performed to verify the accuracy of the HRQoL in predicting cardiovascular events. RESULTS: After the follow-up period (41 ± 12 months), 20 patients (27%) had adverse events. Those with poor outcome had lower left ventricular ejection fraction (LVEF) (p = 0.002), higher left ventricular end-diastolic diameter (LVDd) (p = 0.019), and worse scores in general health perceptions (p = 0.047), social role functioning (p = 0.026), and mental component summary (p = 0.043) of SF-36. Patients with lower LVEF (p = 0.003), higher LVDd (p = 0.022), worse HRQoL in the general heath perceptions domain (p = 0.022), and mental component summary (p = 0.031) were associated with worse prognosis. In the multivariate Cox regression, LVEF (HR 0.94, 95% CI from 0.90 to 0.98, p = 0.007) and mental component summary (HR 0.98, 95% CI from 0.94 to 1.00, p = 0.047) remained as independent predictors of adverse events in CHD patients. CONCLUSION: The assessment of HRQoL, especially the mental component, should be taken into account to provide an accurate prognosis in addition to other well-established predictors of poor outcomes in CHD patients.

Chronic morbidity and reported disability among older persons from the India Human Development Survey.

BACKGROUND: The burden of disability and chronic morbidity among the elderly has been increasing substantially in India in recent years. Yet, the use of nationally representative data to investigate the relationship between chronic morbidity and reported disability in the country has been minimal. The objective of this study is twofold: i) to quantify the association between chronic morbidities and overall disabilities in the activities of daily living (ADLs) among elderly people in India, and ii) to understand how various chronic morbidities influence individual ADLs, specifically, walking, toileting and dressing. METHODS: We used data from the India Human Development Survey-II (IHDS-II) as a basis for this study. We computed the Katz Index of independence in ADL to examine the burden of disability among the elderly. Ordered logistic regression was carried out to examine the effect of chronic morbidities on: i) the disability index (where 0 = no disability; 1 = disability in 1 or 2 ADLs; and 2 = disability in 3 ADLs), and ii) disabilities in three ADLs in the population over-60 years of age in India. RESULTS: The percentage of people scoring lower Katz index (indicating severe and mild disability) in at least one of the three ADLs is very high in India (17.91% for males and 26.21% for females). Irrespective of the type of ADL, the Katz score is lower in elderly females than in elderly males. Elderly people who are illiterate and belong to the poorest wealth quintile report lower Katz scores in ADL. Both bivariate and multivariate analyses confirm that all three types of chronic morbidities are positively and significantly associated with a disability condition in the ADLs. Yet, the effects of morbidities vary greatly according to the type of disability. For instance, while diabetes affect walking (OR: 2.56; 95% CI: 2.29-2.86), and toileting (OR: 2.63; 95% CI: 2.26-3.07), high blood pressure mainly affects walking (OR: 2.29, 95% CI: 2.09-2.5) and dressing disabilities (OR: 2.13, 95% CI: 1.84-2.46). CONCLUSIONS: Chronic morbidity is a decisive factor in old age disability. It is crucial to reduce chronic morbidity in a timely way to minimise the enormous associated burden of disability.

Experiences of women with cardiac disease in pregnancy: a systematic review and metasynthesis.

OBJECTIVE: Cardiac disease in pregnancy is a leading cause of maternal death in high-income countries. Evidence-based guidelines to assist in planning and managing the healthcare of affected women is lacking. The objective of this research was to produce the first qualitative metasynthesis of the experiences of pregnant women with existing or acquired cardiac disease to inform improved healthcare services. METHOD: We conducted a systematic search of peer-reviewed publications in five databases to investigate the decision-making processes, supportive strategies and healthcare experiences of pregnant women with existing or acquired cardiac disease, or of affected women contemplating pregnancy. Identified publications were screened for duplication and eligibility against selection criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We then undertook a thematic analysis of the data relating to women's experiences extracted from each publication to inform new healthcare practices and communication. RESULTS: Eleven studies from six countries were included in our meta-synthesis. Four themes were revealed. Women with congenital and acquired heart disease identified situations where they had either taken charge of decision-making, lacked control or experienced emotional uncertainty when making decisions. Some women were risk aware and determined to take care of themselves in pregnancy while others downplayed the risks. Women with heart disease acknowledged the importance of specific social support measures during pregnancy and after child birth, and reported a spectrum of healthcare experiences. CONCLUSIONS: There is a lack of integrated and tailored healthcare services and information for women with cardiac disease in pregnancy. The experiences of women synthesised in this research has the potential to inform new evidence-based guidelines to support the decision-making needs of women with cardiac disease in pregnancy. Shared decision-making must consider communication across the clinical team. However, coordinated care is challenging due to the different specialists involved and the limited clinical evidence concerning effective approaches to managing such complex care.

Effects of Emotion on Medical Decisions Involving Tradeoffs.

Risk perceptions for a disease can motivate use of medications that reduce disease risk. However, these medications are often accompanied by elevated risks for other adverse health effects, and perceived risk of these side effects may also influence decisions. Emotions experienced at the time of a decision influence risk judgments and decision making, and they may be important to examine in these tradeoff contexts. This study examined the effect of experimentally induced fear and anger on risk perceptions and willingness to use a hypothetical medical treatment that attenuates risk of one condition but increases the risk for another. Participants ( N = 1948) completed an induction of fear, anger, or neutral emotion and then read about a hypothetical medication that reduced risk for one health condition but increased risk for another, and they indicated their willingness to use it. Deliberative, experiential, and affective risk perceptions about both health conditions were measured, conditional on taking and not taking the medication. Fear condition participants were more willing to take the medication than those in the neutral condition (ß = 0.14; P = 0.009; 95% confidence interval, 0.036-0.25). Fear also increased deliberative, experiential, and affective risk when conditioned on not using the medication, Ps < 0.05. In contrast, anger did not influence willingness to use the medication ( P = 0.22) and increased deliberative and affective risk of side effects when conditioned on using the medication ( P < 0.05). As one of the first studies to examine how emotion influences tradeoff decision making, these findings extend our understanding of how fear and anger influence such decisions.

Metacognitive therapy home-based self-help for cardiac rehabilitation patients experiencing anxiety and depressive symptoms: study protocol for a feasibility randomised controlled trial (PATHWAY Home-MCT).

BACKGROUND: Anxiety and depression are common among patients attending cardiac rehabilitation services. Currently available pharmacological and psychological interventions have limited effectiveness in this population. There are presently no psychological interventions for anxiety and depression integrated into cardiac rehabilitation services despite emphasis in key UK National Health Service policy. A new treatment, metacognitive therapy, is highly effective at reducing anxiety and depression in mental health settings. The principal aims of the current study are (1) to evaluate the acceptability of delivering metacognitive therapy in a home-based self-help format (Home-MCT) to cardiac rehabilitation patients experiencing anxiety and depressive symptoms and conduct a feasibility trial of Home-MCT plus usual cardiac rehabilitation compared to usual cardiac rehabilitation; and (2) to inform the design and sample size for a full-scale trial. METHODS: The PATHWAY Home-MCT trial is a single-blind feasibility randomised controlled trial comparing usual cardiac rehabilitation (control) versus usual cardiac rehabilitation plus home-based self-help metacognitive therapy (intervention). Economic and qualitative evaluations will be embedded within the trial. Participants will be assessed at baseline and followed-up at 4 and 12 months. Patients who have been referred to cardiac rehabilitation programmes and have a score of ≥ 8 on the anxiety and/or depression subscales of the Hospital Anxiety and Depression Scale will be invited to take part in the study and written informed consent will be obtained. Participants will be recruited from the National Health Service in the UK. A minimum of 108 participants will be randomised to the intervention and control arms in a 1:1 ratio. DISCUSSION: The Home-MCT feasibility randomised controlled trial will provide evidence on the acceptability of delivering metacognitive therapy in a home-based self-help format for cardiac rehabilitation patients experiencing symptoms of anxiety and/or depression and on the feasibility and design of a full-scale trial. In addition, it will provide provisional point estimates, with appropriately wide measures of uncertainty, relating to the effectiveness and cost-effectiveness of the intervention. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03129282 , Submitted to Registry: 11 April 2017.

2017 Writing Contest Undergraduate Winner: Pathways to Preventable Hospitalizations for Filipino Patients with Diabetes and Heart Disease in Hawai'i.

Filipinos are one of the fastest growing Asian ethnic groups in the United States, yet little is known about how to specifically address the varying health needs of the Filipino community with diabetes and heart disease. This is a problem because rates of potentially preventable hospitalizations (PPH) are high for Filipinos with these conditions. A PPH is a hospitalization that could potentially have been avoided with better access to quality primary care. Patients over 21 years of age with heart disease or diabetes and who were hospitalized at the Queen's Medical Center with a PPH were recruited to complete a face-to-face interview eliciting the patients' perspectives on key factors leading to this hospitalization (n=102). This study focused on a subset of Filipino patients (n=21). Two independent coders reviewed interviews to identify factors leading to their PPH. A majority of the Filipino respondents identified social vulnerabilities as the most common factor that led to their hospitalization, including financial challenges, limited social support, and life instability. Many respondents also noted challenges with the healthcare system as precipitating their hospitalization, including poor communication/coordination, management plan issues, and bad experience with their healthcare providers. Cultural and language barriers were also identified by Filipino patients as challenges leading to their hospitalizations. These findings emphasize the importance of considering patients' perspectives of the barriers they face inside and outside of healthcare facilities.

The Heart as a Psychoneuroendocrine and Immunoregulatory Organ.

The heart can be viewed not just as muscle pump but also as an important checkpoint for a complex network of nervous, endocrine, and immune signals. The heart is able to process neurological signals independently from the brain and to crosstalk with the endocrine and immune systems. The heart communicates with the psyche through the neuro-endocrine-immune system in a highly integrated way, in order to maintain the homeostasis of the whole body with peculiarities specific to males and females.

Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial.

BACKGROUND: Anxiety and depression are prevalent among cardiac rehabilitation patients but pharmacological and psychological treatments have limited effectiveness in this group. Furthermore, psychological interventions have not been systematically integrated into cardiac rehabilitation services despite being a strategic priority for the UK National Health Service. A promising new treatment, metacognitive therapy, may be well-suited to the needs of cardiac rehabilitation patients and has the potential to improve outcomes. It is based on the metacognitive model, which proposes that a thinking style dominated by rumination, worry and threat monitoring maintains emotional distress. Metacognitive therapy is highly effective at reducing this thinking style and alleviating anxiety and depression in mental health settings. This trial aims to evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy for cardiac rehabilitation patients with elevated anxiety and/or depressive symptoms. METHODS/DESIGN: The PATHWAY Group-MCT trial is a multicentre, two-arm, single-blind, randomised controlled trial comparing the clinical- and cost-effectiveness of group-based metacognitive therapy plus usual cardiac rehabilitation to usual cardiac rehabilitation alone. Cardiac rehabilitation patients (target sample n = 332) with elevated anxiety and/or depressive symptoms will be recruited across five UK National Health Service Trusts. Participants randomised to the intervention arm will receive six weekly sessions of group-based metacognitive therapy delivered by either cardiac rehabilitation professionals or research nurses. The intervention and control groups will both be offered the usual cardiac rehabilitation programme within their Trust. The primary outcome is severity of anxiety and depressive symptoms at 4-month follow-up measured by the Hospital Anxiety and Depression Scale total score. Secondary outcomes are severity of anxiety/depression at 12-month follow-up, health-related quality of life, severity of post-traumatic stress symptoms and strength of metacognitive beliefs at 4- and 12-month follow-up. Qualitative interviews will help to develop an account of barriers and enablers to the effectiveness of the intervention. DISCUSSION: This trial will evaluate the effectiveness and cost-effectiveness of group-based metacognitive therapy in alleviating anxiety and depression in cardiac rehabilitation patients. The therapy, if effective, offers the potential to improve psychological wellbeing and quality of life in this large group of patients. TRIAL REGISTRATION: UK Clinical Trials Gateway, ISRCTN74643496 , Registered on 8 April 2015.

Patients' knowledge and attitudes regarding living with implantable electronic devices: results of a multicentre, multinational patient survey conducted by the European Heart Rhythm Association.

The purpose of this patient survey was to analyse the knowledge, experiences, and attitudes regarding cardiac implantable electronic devices (CIED) in patients with pacemakers, implantable cardioverter-defibrillators (ICDs), or cardiac resynchronization devices. Of the 1644 patients with CIEDs from seven European countries, 88% were over 50 years of age. Most patients (90%) knew what device they were implanted with and felt sufficiently informed about the indications for therapy. As many as 42% of patients needed additional information on the battery replacement and limitations in physical activity. The self-reported incidence of complications was 9%, and among these, a quarter of the respondents felt insufficiently informed about the possibility of complications and their management. The majority of patients (83%) were followed by face-to-face visits, which was the most commonly preferred follow-up strategy by the patients. Nearly 75% of the patients reported improved quality of life after device implantation, but about 40% had worries about their device. Less than 20% had discussed with their physician or thought about device handling in the end-of-life circumstances or end-stage disease. Notably, almost 20% of the ICD patients did not wish to answer the question regarding what they wanted to be done with their ICD in case of end-stage disease, indicating the challenges in approaching these issues.

Text4Heart II - improving medication adherence in people with heart disease: a study protocol for a randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is an essential component of contemporary management for patients with coronary heart disease, including following an acute coronary syndrome (ACS). CR typically involves education and support to assist people following an ACS to make lifestyle changes and prevent subsequent events. Despite its benefits, uptake and participation in tradition CR programs is low. The use of mobile technologies (mHealth) offers the potential to improve reach, access, and delivery of CR support. We aim to determine the effectiveness and cost-effectiveness of a text-messaging intervention (Text4Heart II) to improve adherence to medication and lifestyle change in addition to usual care in people following an ACS. A second aim is to use the RE-AIM framework to inform the potential implementation of Text4Heart II within health services in New Zealand. METHODS: Text4Heart II is a two-arm, parallel, superiority randomized controlled trial conducted in two large metropolitan hospitals in Auckland, New Zealand. Three hundred and thirty participants will be randomized to either a 24-week theory- and evidence-based personalized text message program to support self-management in addition to usual CR, or usual CR alone (control). Outcomes are assessed at 6 and 12 months. The primary outcome is the proportion of participants adhering to medication at 6 months as measured by dispensed records. Secondary outcomes include medication adherence at 12 months, the proportion of participants adhering to self-reported healthy behaviors (physical activity, fruit and vegetable consumption, moderating alcohol intake and smoking status) measured using a composite health behavior score, self-reported medication adherence, cardiovascular risk factors (lipids, blood pressure), readmissions and related hospital events at 6 and 12 months. A cost-effectiveness analysis will also be conducted. Using the RE-AIM framework, we will determine uptake and sustainability of the intervention. DISCUSSION: The Text4Heart II trial will determine the effectiveness of a text-messaging intervention to improve adherence to medication and lifestyle behaviors at both 6 and 12 months. Using the RE-AIM framework this trial will provide much needed data and insight into the potential implementation of Text4Heart II. This trial addresses many limitations/criticisms of previous mHealth trials; it builds on our Text4Heart pilot trial, it is adequately powered, has sufficient duration to elicit behavior change, and the follow-up assessments (6 and 12 months) are long enough to determine the sustained effect of the intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ID: ACTRN12616000422426 . Registered retrospectively on 1 April 2016.

Medication adherence among cardiac patients in Khartoum State, Sudan: a cross-sectional study.

INTRODUCTION: Non-adherence to medication among cardiac patients is often the major risk factor for poor clinical outcomes, increased mortality rates and higher healthcare costs. The literature evaluating the prevalence of and reasons for non-adherence in resource-poor settings is extremely limited compared to resource-rich settings. There is a scarcity of data about medication adherence in Sudan hence this study was performed to identify prevalence, predictors and barriers of non-adherence to medication among cardiac patients in Khartoum State. METHODS: A descriptive, cross-sectional survey was performed using a pre-tested, self-administered questionnaire on a sample of 433 randomly selected cardiac patients attending the largest three cardiac centres located in Khartoum State. Descriptive and multivariate logistic regression analyses were used for data analysis. RESULTS: The response rate was 89.1%. The mean (± SD) number of chronic diseases among respondents was 2.3 ( ± 1.3) and that of medication use was 4.2 ( ± 1.9). The mean ( ± SD) duration of medication use among participants was 6.4 ( ± 5.4) years. Optimal adherence was defined as having a score of greater than six on the eight-item Morisky medication adherence scale. Using this cut-off point, 49% (95% CI: 43.9-54.1) of respondents had optimal adherence and 51% (95% CI: 45.9-56.1) had poor adherence. Respondents with a high level of education, low and middle income levels, and those taking five or more medications daily were found to be significantly more non-adherent to medication use than those with low to intermediate education levels (p < 0.001), those with high income levels (p < 0.001), and those taking one to four medications daily (p = 0.039). The top four barriers for poor medication adherence among the study participants were the high cost of drugs, polypharmacy and lack of pharmacist and physician communication with patients about their drug therapy. CONCLUSIONS: The current findings highlight the need for urgent, multifaceted interventions, given the burden of cardiovascular diseases and the clinical and economic consequences of medication non-adherence. These interventions include affordable medications, easy-to-use medication regimens with fewer daily doses, ongoing communication between patients and healthcare providers, and improvement of the patient-provider partnership.

When Blue-Collars Feel Blue: Depression and Low Occupational Grade as Synergistic Predictors of Incident Cardiac Events in Middle-Aged Working Individuals.

BACKGROUND: The association of psychological variables with cardiovascular health might depend on socioeconomic status. We examined the moderating effect of occupational grade on the association between depression and incident cardiac events among middle-aged workers from the GAZEL cohort. METHODS AND RESULTS: A total of 10 541 participants (7855 men, mean age: 47.8±3.5 years) free of cardiovascular diseases completed the Center of Epidemiologic Studies Depression scale in 1993. Age, sex, and occupational grade (low, medium, and high) were obtained from company records. Classical cardiovascular risk factors were self-reported. All participants were followed-up for medically certified cardiac events from January 1994 to December 2014. Associations between baseline variables and incident cardiac events were estimated with hazard ratios and 95% confidence intervals computed in Cox regressions. After a median follow-up of 21 years, 592 (5.6%) participants had a cardiac event. There was a significant interaction between depression and occupational grade in both age- and sex-adjusted (P=0.008) and multiadjusted (P=0.009) models. This interaction was mainly explained by an association between depression and incident cardiac events that prevailed among participants of low occupational grade (3.71 versus 1.96 events per 1000 person-years among those depressed versus nondepressed, multiadjusted hazard ratios [95% confidence intervals], 1.99 [1.12-3.48]). CONCLUSIONS: From a research perspective, these results may account for previous conflicting results and constitute an impetus for reanalyzing previous data sets, taking into account the moderating role of socioeconomic status. From a clinical perspective, they urge clinicians and policy makers to consider depressive symptoms and low socioeconomic status as synergistic cardiovascular risk factors.

Psychometric assessment of the Cardiac Depression Scale Short Form in cardiac outpatients.

BACKGROUND: Depression is common in patients with cardiovascular disease and is a risk marker for increased mortality. The valid and reliable detection of depression is fundamental to the appropriate management of these patients. AIM: The aim of this study was to evaluate the psychometric characteristics of the Cardiac Depression Scale Short Form 1 (DS-SF1) and the Cardiac Depression Scale Short Form 2 (DS-SF2) for screening cardiac outpatients in clinical settings. METHODS: Adult cardiac outpatients attending a cardiovascular clinic completed the Cardiac Depression Scale (CDS), two versions of the DS-SF (DS-SF1 and DS-SF2) and the Physical Health Questionnaire 2 (PHQ2-Y/N) prior to their cardiac consultation. RESULTS: Data from 326 patients (224 men; mean±SD age 66.25±14.39 years) were analysed. The DS-SF1 (mean score 16.28±5.70) had good construct validity with the CDS ( r=0.77; p<0.0001), adequate convergence with the PHQ2-Y/N ( r=0.59; p<0.0001) and good internal consistency (α=0.73). The DS-SF2 (mean score 15.80±6.80) had a better construct validity with the CDS ( r=0.84; p<0.0001) and the PHQ2-Y/N ( r=0.69; p<0.0001) and better internal consistency (α=0.82). The DS-SF2 showed strong criterion validity with the CDS with a DS-SF2 ⩾15 cut-point yielding 90% sensitivity and 73% specificity (area under the curve 0.92) for detecting depression (CDS ⩾95). CONCLUSION: These findings confirm the excellent psychometric properties of the DS-SF2 as an ideal tool for screening depression in cardiac patients in clinical practice. The DS-SF2 should be regarded as the definitive version of the DS-SF.