A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities.

Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.

Effects of stress management interventions on heart rate variability in adults with cardiovascular disease: a systematic review and meta-analysis.

Meta-analysis was used to investigate the potential benefits of stress management interventions (SMIs) on vagally-mediated heart rate variability (HRV) in adults with cardiovascular disease. Electronic bibliographic databases were searched through August 2022. Randomized controlled trials and quasi-experimental studies assessing effects of SMIs on HRV were included. Methodological quality was assessed with a standardized checklist. A pooled effect size was calculated for vagally-mediated HRV indices (standard deviation of normal-to-normal intervals, root mean square of the successive differences, and high frequency power) using random effects models. Fourteen studies (1202 participants, Mage: 59 ± 6.25 years; 25% ± 16% women; 61% ± 22% White) were included. Ten studies (11 effects) reported short-term HRV assessment; a small between-group difference emerged for vagally-mediated HRV (d+ = .27, 95% confidence interval [CI] 0.01-0.52, k = 11). Most interventions examined biofeedback; these studies yielded a small between-group difference on vagally-mediated HRV (d+ = 0.31, 95% CI 0.09-0.53, k = 7, Q [6] = 3.82, p = .70, I2 = 11%). This is the first systematic examination of the effect of SMIs on HRV in adults with CVD. Findings suggest a small effect of SMIs on vagally-mediated HRV, with biofeedback likely driving the effect. More research is required to fully understand whether this benefit on vagally-mediated HRV applies to other SMIs.

Sleep quality and mental health during COVID-19: the role of distress tolerance.

The coronavirus disease 2019 (COVID-19) pandemic has negatively impacted psychological health for many. This study aimed to investigate if distress tolerance, an individual's perceived or actual 'capacity to withstand negative psychological states', helps to explain the relationship between sleep and mental health problems during the COVID-19 pandemic. College students (N = 187) completed questionnaires using an online survey platform between 6 April 2020, and 6 June 2020, during the COVID-19 pandemic. Hierarchical multiple regression analyses were used to examine the indirect effect of distress tolerance on the relationship between sleep quality and mental health. Distress tolerance partially accounted for the relationship between sleep quality and perceived stress but did not help to explain the association between sleep quality and depression or anxiety. Two components of distress tolerance, absorption and appraisal, helped to explain the relationship between sleep quality and all mental health outcomes. These findings help explain how distress tolerance relates to mental health when sleep is negatively impacted. Prospective designs replicating these findings are needed and future research may inform how psychological interventions could target distress tolerance in the context of poor sleep, especially during major stressors.

Distress and Prevention Behaviors During the COVID-19 Pandemic Among College Students: the Moderating Role of Resilience.

BACKGROUND: Pandemics can generate considerable distress, which can affect prevention behaviors. Resilience may buffer the negative effects of distress on engagement in relevant prevention behaviors, which may also hold true for COVID-19 prevention behaviors. The objective of the current study was to evaluate whether resilience moderated the relationship between distress and COVID-19 prevention behaviors early in the pandemic. METHODS: Data were collected via surveys in which all students at a large midwestern university were emailed invitations beginning March 18, 2020. Surveys were completed by 5,530 individuals. In addition to demographic questions and items about COVID-19 prevention behaviors, distress was assessed using the K6 Distress Scale and resilience using the Brief Resilience Scale. Data were analyzed using moderator regression analysis. RESULTS: Resilience moderates the effects from distress to prevention behaviors, such that the relationship was stronger for individuals with higher resilience than for individuals with lower resilience. When resilience was one standard deviation below the mean, at the mean value of resilience, and when resilience was one standard deviation above the mean, there was a significant positive relationship between distress and COVID-19 prevention behaviors. However, the relationship was strongest for those with high resilience, and lowest for those with low resilience. CONCLUSIONS: In the current sample, resilience appeared to influence the strength of the relationship between distress and COVID-19 prevention behaviors. Having higher resilience may promote positive adaptation to distress, leading individuals to engage in a greater number of disease-related prevention behaviors. Future research should examine this relationship longitudinally and in relation to differing constructs of resilience.

Health Literacy, Cognitive Function, and Mortality in Patients With Heart Failure.

BACKGROUND: Health literacy has predicted mortality in heart failure. However, the role of cognitive functioning in this relationship has not been evaluated. We hypothesized that health literacy would predict all-cause mortality but that cognitive functioning would modify the relationship between health literacy and mortality in heart failure. OBJECTIVE: The aim of this study was to examine the association between health literacy, cognitive functioning, and mortality in patients with heart failure. METHODS: This secondary analysis of a larger study included 298 patients with heart failure with reduced ejection fraction (trial identifier: NCT01461629). Health literacy was evaluated using the Rapid Estimate of Adult Literacy in Medicine (REALM) and Medical Term Recognition Test (METER), and cognitive functioning was evaluated using the Modified Mini-Mental Status Examination (3MS). Cox proportional hazards regression was used with time-until-death as the dependent variable. RESULTS: After controlling for age, sex, and race, neither METER nor REALM scores predicted mortality in heart failure (Ps ≥ .37). However, 3MS predicted mortality in models using the METER (Δχ2 = 9.20, P < .01; B = -.07; hazard ratio, 0.94 [95% confidence interval, 0.89-0.98]; P < .01) and REALM (Δχ2 = 9.77, P < .01; B = -0.07; hazard ratio, 0.94 [95% confidence interval, 0.90-0.97]; P < .01). Furthermore, adding the 3MS improved model fit. CONCLUSIONS: Cognitive functioning predicted mortality in heart failure better than health literacy. Results suggest the need to further evaluate the contribution of cognitive functioning to increased risk of mortality in those with heart failure.

Exploring How Trait Mindfulness Relates to Perceived Stress and Cardiovascular Reactivity.

BACKGROUND: Mindfulness interventions have been associated with less global perceived stress as well as attenuated cardiovascular reactivity. The aim of the present study was to evaluate whether high levels of trait mindfulness would also be associated with these benefits. METHODS: Participants were 99 healthy young adults aged 18-25 years. Self-report measures included the Five Facet Mindfulness Questionnaire and the Perceived Stress Scale. Participants completed a laboratory stress protocol comprised of a resting baseline, a mental arithmetic stress task, and a resting recovery period. Blood pressure, heart rate, and heart rate variability were measured throughout the protocol. Regressions were used to analyze whether trait mindfulness predicted global perceived stress, cardiovascular reactivity, and cardiovascular recovery. RESULTS: Two trait mindfulness facets were found to be associated with less global perceived stress, Acting with Awareness (ß = - .306, p = .002) and Nonjudgment (ß = - .342, p < .001). Exploratory analyses also revealed an interaction between the Observe and Nonreactivity facets (p = .002), such that the Observe facet was associated with less stress only when Nonreactivity scores were also high. Although trait mindfulness was not a significant predictor of the physiological variables (p > .05, Cohen's f2 < .060), exploratory analyses revealed an interaction between the Awareness and Nonjudgment facets (p < .001), such that Awareness is associated with lower diastolic blood pressure reactivity only when Nonjudgment scores are also high. CONCLUSIONS: Like mindfulness interventions, trait mindfulness is associated with less global perceived stress. Interactions between trait mindfulness facets that reflect attention monitoring and acceptance might predict physiological reactivity in certain contexts, though a mindful state might be necessary for most real-time cardiovascular benefits.

Depressive Symptoms are Associated with Heart Rate Variability Independently of Fitness: A Cross-Sectional Study of Patients with Heart Failure.

BACKGROUND: Depression is associated with reduced heart rate variability (HRV) in healthy and cardiac samples, which may be accounted for by physical fitness. In a small sample of cardiac patients, activity and fitness levels attenuated the relationship between HRV and depression. In the current study of heart failure (HF) patients, we hypothesized that depressive symptoms and HRV would be inversely related and physical fitness would attenuate this association. PURPOSE: To determine if previous associations among depressive symptoms, physical fitness, and HRV would replicate in a sample of HF patients. METHODS: The sample consisted of HF patients (N = 125) aged 68.55 ± 8.92 years, 68.8% male, and 83.2% Caucasian. The study was cross-sectional and a secondary analysis of a nonrandomized clinical trial (Trial Identifier: NCT00871897). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI)-II, fitness with the 2 min step test (2MST), and HRV during a 10 min resting laboratory psychophysiology protocol. The dependent variable in hierarchical linear regressions was the root mean square of successive differences. RESULTS: Controlling for sex, age, ß-blocker use, hypertension, and diabetes, higher BDI-II scores significantly predicted lower HRV, ß = -.29, t(92) = -2.79, p < .01. Adding 2MST did not attenuate the relationship in a follow-up regression. CONCLUSION: Depressive symptoms were associated with lower HRV in HF patients, independent of physical fitness. Given the prevalence of depression and suppressed HRV common among HF patients, interventions addressing depressive symptoms and other predictors of poor outcomes may be warranted.

The Contribution of Living Arrangements, Social Support, and Self-efficacy to Self-management Behaviors Among Individuals With Heart Failure: A Path Analysis.

BACKGROUND: Living arrangements, social support, and self-efficacy have significant implications for self-management science. Despite the theoretical linkages among the 3 concepts, there is limited empirical evidence about their interplay and the subsequent influence on heart failure (HF) self-management. OBJECTIVE: The aim of this study was to validate components of the Individual and Family Self-management Theory among individuals with HF. METHODS: This is a secondary analysis of cross-sectional data generated from a sample of 370 individuals with HF. A path analysis was conducted to examine the indirect and direct associations among social environment (living arrangements), social facilitation (social support) and belief (self-efficacy) processes, and self-management behaviors (HF self-care maintenance) while accounting for individual and condition-specific factors (age, sex, race, and HF disease severity). RESULTS: Three contextual factors (living arrangements, age, and HF disease severity) had direct associations with perceived social support and self-efficacy, which in turn were positively associated with HF self-management behaviors. Living alone (ß = -.164, P = .001) was associated with lower perceived social support, whereas being an older person (ß = .145, P = .004) was associated with better support. Moderate to severe HF status (ß = -.145, P = .004) or higher levels of perceived social support (ß = .153, P = .003) were associated with self-efficacy. CONCLUSIONS: Our results support the Individual and Family Self-management Theory, highlighting the importance of social support and self-efficacy to foster self-management behaviors for individuals with HF. Future research is needed to further explore relationships among living arrangements, perceived and received social support, self-efficacy, and HF self-management.

Depressive symptoms moderate the relationship between medication regimen complexity and objectively measured medication adherence in adults with heart failure.

Patients with heart failure (HF) take many medications to manage their HF and comorbidities, and 20-50% experience depression. Depressed individuals with more complex medication regimens may be at greater risk for poor adherence. The aim of this study was to assess depressive symptoms as a moderator of the relationship between medication regimen complexity and medication adherence in an observational study of patients with HF. In hierarchical linear regression with the final sample of 299, the interaction of medication regimen complexity and depressive symptoms predicted medication adherence, p < .05. For individuals with higher levels of depressive symptoms [1 standard deviation (SD) above the mean], more regimen complexity was associated with lower adherence. For individuals with low (1 SD below the mean) or average levels of depressive symptoms, regimen complexity was unrelated to medication adherence. Care management strategies, including pillboxes and caregiver involvement, may be valuable in HF patients with depression.

Cognitive Function Predicts Risk for Clinically Significant Weight Gain in Adults With Heart Failure.

BACKGROUND: Few investigators have examined whether cognitive deficits predict poorer self-care of weight management recommendations and weight gain in adults with heart failure. OBJECTIVE: The purposes of this study were (1) to examine whether cognition is associated with adherence to daily weighing and weight gain incidence and (2) to explore self-reported symptom perception and management when a weight increase occurs. METHODS: In this observational study, participants completed neuropsychological testing, were given an electronic scale, and were instructed to record their weight for 21 days. Data for 301 participants were collected at baseline and 3 weeks after weight monitoring. RESULTS: At baseline, only 35% of the enrolled respondents knew when to call their physician for increased weight gain, and 37% of the analyzed sample (n = 110/301) experienced a clinically significant weight gain. Regressions tested whether baseline attention, executive function, or memory predicted adherence to daily weighing and the likelihood of weight gain incidence. In unadjusted and adjusted covariate analyses, none of the cognitive domains predicted adherence to daily weighing (P ≥ .375); however, all 3 cognitive domains predicted an increased risk of a clinically significant weight gain (P ≤ .05). Importantly, 65% of participants with a weight gain did not identify this symptom on self-report questions. CONCLUSIONS: Although cognitive deficits are not associated with adherence to daily weighing, adults with cognitive deficits may be at an increased risk for experiencing a clinically significant weight gain, and most do not perceive symptoms. CLINICAL IMPLICATIONS: Adults with heart failure require more than directions on self-care related to weight monitoring.

Internal health locus of control predicts willingness to track health behaviors online and with smartphone applications.

Given rising technology use across all demographic groups, digital interventions offer a potential strategy for increasing access to health information and care. Research is lacking on identifying individual differences that impact willingness to use digital interventions, which may affect patient engagement. Health locus of control, the amount of control an individual believes they have over their own health, may predict willingness to use mobile health (mHealth) applications ('apps') and online trackers. A cross-sectional study (n = 276) was conducted to assess college students' health locus of control beliefs and willingness to use health apps and online trackers. Internal and powerful other health locus of control beliefs predicted willingness to use health apps and online trackers while chance health locus of control beliefs did not. Individuals with internal and powerful other health locus of control beliefs are more willing than those with chance health locus of control beliefs to utilize a form of technology to monitor or change health behaviors. Health locus of control is an easy-to-assess patient characteristic providers can measure to identify which patients are more likely to utilize mHealth apps and online trackers.

Executive function moderates the relationship between depressive symptoms and resting heart rate variability in heart failure.

Heart failure (HF) is associated with high rates of depression. In turn, depression is associated with reduced heart rate variability (HRV), a marker of parasympathetic dysfunction and poorer cardiac outcomes. Cognitive impairment--especially executive dysfunction--is also highly prevalent in HF, but it is unknown whether executive function (EF) impacts the depression-HRV relationship. The primary objective of this paper is to examine whether EF moderates the relationship between depression and HRV in HF. Participants were 109 HF patients. Depressive symptoms were measured using the Beck Depression Inventory-II. EF was assessed using a composite of age-adjusted T scores on the Frontal Assessment Battery, Trail Making Test B, and Stroop Color Word subtest. Parasympathetic function was assessed using resting high frequency HRV (HF-HRV). Multiple hierarchical regression was used to conduct BDI × EF moderation analyses. BDI scores were associated with reduced resting HF-HRV (p < .05). No main effects were detected between EF and resting HF-HRV (p > .05). However, EF moderated the relationship between BDI scores and resting HF-HRV (ß = 0.59, p < .01). Simple slope analyses revealed that among participants with poorer EF, higher BDI scores were associated with lower resting HF-HRV (p < .001). Structural brain changes common in HF may contribute to lower EF, increased depression, and poorer autonomic functioning. Alternatively, the results may indicate that individuals with intact EF engage in self-care strategies that negate the detrimental impact of depression on autonomic function. Additional work is needed to clarify these possibilities and the potential benefits of treating depression in HF patients with different cognitive abilities.

Cognitive Function Does Not Impact Self-reported Health-Related Quality of Life in Heart Failure Patients.

BACKGROUND: Adults with heart failure (HF) often demonstrate impairment across multiple domains of cognitive functioning and report poor health-related quality of life (HRQoL). Previous researchers have found that cognitive deficits were generally not associated with HRQoL in a carefully evaluated sample. The exception was memory, which was only weakly associated with HRQoL. However, cognitive deficits interfere with self-care and disease self-management, which could be expected to affect HRQoL. OBJECTIVE: We sought to verify this counterintuitive finding in a large well-characterized sample of HF patients using a well-validated neuropsychological battery. METHODS: Participants were 302 adults (63% male) predominately white (72.5%) HF patients (68.7 ± 9.6 years) recruited from 2 medical centers. Self-reported HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire. Participants completed a neuropsychological battery examining attention, executive function, memory, and visuospatial functioning. Hierarchical multiple linear regression was used for analyses. RESULTS: Mild global cognitive impairment was observed in 29.5% of the sample (Modified Mini-Mental State [3MS] Examination score <90). Controlling for gender, depression, HF severity, premorbid IQ, comorbidities, and education, only executive function predicted HRQoL, ß = .17, P < .05. However, executive function accounted for only 0.6% of the variance in HRQoL. CONCLUSION: Cognitive function generally did not predict HRQoL in HF patients. The correlates of HRQoL in HF do not appear to include mild cognitive impairment. Other factors may play a bigger role such as disease severity, age, and depressive symptoms. Future studies should investigate modifiable determinants of HRQoL in HF patients, toward the goal of finding interventions that preserve HRQoL during this chronic illness.

Dietary sodium adherence is poor in chronic heart failure patients.

BACKGROUND: We sought to determine the rates and predictors of dietary sodium restriction and to evaluate the reliability of 24-hour urine collection as a tool to estimate dietary sodium intake in heart failure (HF) patients. METHODS AND RESULTS: We evaluated the 24-hour urinary sodium excretion of 305 outpatients with HF and reduced ejection fraction who were educated on following a <2 g sodium diet. The mean sodium excretion according to a single sample from each participant was 3.15 ± 1.58 g, and 23% were adherent to the <2 g recommendation. One hundred sixty-eight participants provided 2 samples with urinary creatinine excretion within normative range. Averaging both resulted in a mean sodium excretion of 3.21 ± 1.20 g and lower adherence rates to the <2-gram diet: 14% versus 23% (P = .019). Multivariate logistic regression showed only male sex and higher body mass index (BMI) to be associated with nonadherence (male: odds ratio [OR] 2.20, 95% confidence interval [CI] 1.25-3.88; 1 unit BMI: OR 1.05, 95% CI 1.01-1.10). Bland-Altman plots of urinary sodium and creatinine showed poor reproducibility between samples. CONCLUSIONS: In this chronic HF population, sodium consumption probably exceeds recommended amounts, particularly in men and those with higher BMI. Urine analyses were not highly reproducible, suggesting variation in both diet and urine collection.

Cognitive Function in Heart Failure Is Associated With Nonsomatic Symptoms of Depression But Not Somatic Symptoms.

BACKGROUND: Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others. OBJECTIVE: The aim of this study was to identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF. METHODS: Participants were 326 HF patients (40.5% women, 26.7% non-white race-ethnicity, aged 68.6 ± 9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnaire-9. Somatic and nonsomatic subscale scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and clinical factors were conducted. RESULTS: Regressions revealed that Patient Health Questionnaire-9 total was associated with attention (ß = -.14, P = .008) and executive function (ß = -.17, P = .001). When analyzed separately, the nonsomatic subscale, but not the somatic symptoms subscale (P values ≥ .092), was associated with attention scores (ß = -.15, P = .004) and memory (ß = -.11, P = .044). Both nonsomatic (ß = -.18, P < .001) and somatic (ß = -.11, P = .048) symptoms were related to executive function. When included together, only the nonsomatic symptom cluster was associated with attention (ß = -.15, P = .020) and executive function (ß = -.19, P = .003). CONCLUSIONS: Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression. CLINICAL IMPLICATIONS: These findings suggest that screening explicitly for nonsomatic depressive symptoms may be warranted and that the mechanisms underlying the depression-cognitive function relationship in HF are not solely related to sleep or appetite disturbance. Thus, interventions that target patients' somatic symptoms only (eg, poor appetite or fatigue) may not yield maximum cognitive benefit compared with a comprehensive treatment that targets depressed mood, anhedonia, and other nonsomatic symptoms.

What is your patient's cognitive profile? Three distinct subgroups of cognitive function in persons with heart failure.

PURPOSE: The aim of this study was to determine whether patients with heart failure (HF) have distinct profiles of cognitive impairment. BACKGROUND: Cognitive impairment is common in HF. Recent work found three cognitive profiles in HF patients-(1) intact, (2) impaired, and (3) memory-impaired. We examined the reproducibility of these profiles and clarified mechanisms. METHODS: HF patients (68.6 ± 9.7 years; N=329) completed neuropsychological testing. Composite scores were created for cognitive domains and used to identify clusters via agglomerative-hierarchical cluster analysis. RESULTS: A 3-cluster solution emerged. Cluster 1 (n=109) had intact cognition. Cluster 2 (n=123) was impaired across all domains. Cluster 3 (n=97) had impaired memory only. Clusters differed in age, race, education, SES, IQ, BMI, and diabetes (ps ≤ .026) but not in mood, anxiety, cardiovascular, or pulmonary disease (ps ≥ .118). CONCLUSIONS: We replicated three distinct patterns of cognitive function in persons with HF. These profiles may help providers offer tailored care to patients with different cognitive and clinical needs.

Greater body mass index is associated with poorer cognitive functioning in male heart failure patients.

BACKGROUND: Heart failure (HF) and obesity are associated with cognitive impairment. However, few studies have investigated the relationship between adiposity and cognitive functioning in HF for each sex, despite observed sex differences in HF prognosis. We tested the hypothesis that greater body mass index (BMI) would be associated with poorer cognitive functioning, especially in men, in sex-stratified analyses. METHODS AND RESULTS: Participants were 231 HF patients (34% female, 24% nonwhite, average age 68.7 ± 7.3 years). Height and weight were used to compute BMI. A neuropsychology battery tested global cognitive function, memory, attention, and executive function. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and medical factors were conducted. The sample was predominantly overweight/obese (76.2%). For men, greater BMI predicted poorer attention (ΔR(2) = 0.03; ß = -0.18; P = .01) and executive function (ΔR(2) = 0.02; ß = -0.13; P = .04); these effects were largely driven by men with severe obesity (BMI ≥40 kg/m(2)). BMI did not predict memory (P = .69) or global cognitive functioning (P = .08). In women, greater BMI was not associated with any cognitive variable (all P ≥ .09). DISCUSSION: Higher BMI was associated with poorer attention and executive function in male HF patients, especially those with severe obesity. These patients may therefore have more difficulties with the HF treatment regimen and may have poorer outcomes.

Sleep is Essential for Cardiovascular Health: An Analytic Review of the Relationship Between Sleep and Cardiovascular Mortality.

The American Heart Association recently included sleep health as one of eight factors that define cardiovascular health. Restorative sleep is a pillar of lifestyle medicine influenced by sleep duration, quality, and disorders. Short and long sleep duration are associated with greater risk of cardiovascular disease. Short sleep appears causally related to cardiovascular risk. Long sleep is more strongly predictive of cardiovascular risk, which may be due to comorbidities and other risk factors. Good-quality sleep appears to protect against the increased risk and is independently associated with risk of cardiovascular disease (CVD). Insomnia, particularly difficulty falling asleep and non-restorative sleep, is associated with an increase in cardiac events. Obstructive sleep apnea (OSA) is associated with cardiac risk and outcomes, which is typically observed in the context of contributing comorbidities. However, treating OSA with continuous positive airway pressure (CPAP) may not improve prognosis. Further research is needed to understand the causal mechanisms connecting sleep health with CVD and whether modifying sleep can improve outcomes. Sleep health should be considered as part of a holistic approach to improving cardiovascular health, as reflected in the scoring of LE8 and as one of the interrelated components of lifestyle medicine.

The protective roles of coping self-efficacy and social support for posttraumatic stress during the COVID-19 pandemic.

OBJECTIVE: This study examined the roles of social support and coping self-efficacy (CSE) in attenuating posttraumatic stress (PTS) symptoms during the COVID-19 pandemic among a nonclinical university student sample. METHOD: Participants (n = 610; 59% female) completed questionaries assessing psychological distress (Kessler Psychological Distress Scale) at baseline and 6-month follow-up, and social support (Interpersonal Support Evaluation List-12), CSE Scale, and PTS symptoms (Impact of Event Scale-Revised) at 6 months. A path analysis was conducted using SPSS Amos to examine the direct and indirect pathways from psychological distress to PTS symptoms that are accounted for by social support and CSE, controlling for gender. RESULTS: All direct effects in the path analysis were significant except for the relationship between social support and PTS symptoms. Notably, CSE was directly related to PTS symptoms (CSE: ß = -.30, p < .001). There was a significant indirect effect of early psychological distress on PTS symptoms 6 months into the pandemic through social support and CSE (ß = .14, p < .001). CONCLUSIONS: Individuals with higher levels of social support are more likely to have greater confidence in their coping capabilities, which helps to explain PTS symptom severity after controlling for initial levels of psychological distress and gender. These findings suggest that following a potentially traumatic event, CSE may be one factor to screen for to better identify individuals who are at higher risk for significant psychological difficulties and may benefit from interventions that bolster protective factors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Randomized controlled trial of mindfulness-based stress reduction for prehypertension.

OBJECTIVE: Mindfulness-based stress reduction (MBSR) is an increasingly popular practice demonstrated to alleviate stress and treat certain health conditions. MBSR may reduce elevated blood pressure (BP). Treatment guidelines recommend life-style modifications for BP in the prehypertensive range (systolic BP [SBP] 120-139 mm Hg or diastolic BP [DBP] 80-89 mm Hg), followed by antihypertensives if BP reaches hypertensive levels. MBSR has not been thoroughly evaluated as a treatment of prehypertension. A randomized clinical trial of MBSR for high BP was conducted to determine whether BP reductions associated with MBSR exceed those observed for an active control condition consisting of progressive muscle relaxation (PMR) training. METHODS: Fifty-six men (43%) and women (57%) averaging (standard deviation) 50.3 (6.5) years of age (91% white) with unmedicated BP in the prehypertensive range were randomized to 8 weeks of MBSR or PMR delivered in a group format. Treatment sessions were administered by one treatment provider and lasted approximately 2.5 hours each week. Clinic BP was the primary outcome measure. Ambulatory BP was a secondary outcome measure. RESULTS: Analyses were based on intent to treat. Patients randomized to MBSR exhibited a 4.8-mm Hg reduction in clinic SBP, which was larger than the 0.7-mm Hg reduction observed for PMR (p = .016). Those randomized to MBSR exhibited a 1.9-mm Hg reduction in DBP compared with a 1.2-mm Hg increase for PMR (p = .008). MBSR did not result in larger decreases in ambulatory BP than in PMR. CONCLUSIONS: MBSR resulted in a reduction in clinic SBP and DBP compared with PMR. Trial Registration ClinicalTrials.gov identifier: NCT00440596.