Phenotyping Self-Reported Health Profiles in Octogenarians and Nonagenarians After Percutaneous Coronary Intervention: A Latent Profile Analysis.

BACKGROUND: Little is known about self-reported health in octogenarians (≥80 years) and nonagenarians (≥90 years) following percutaneous coronary intervention (PCI), including characteristics of different health outcomes. This study aimed to phenotype latent health profiles of self-reported health in older adults 2 months post-PCI. METHODS: A prospective, multicentre, real-world study (CONCARDPCI) of 270 octogenarians and nonagenarians was performed with five validated and standardised measures of self-reported health at 2 months post-PCI. Latent profile analysis was used to identify health profiles, and multinomial logistic regression analyses were used to investigate the associations between patient characteristics and health profiles. RESULTS: Three latent health profiles were identified: The Poor health profile included 29%, the Moderate health profile included 39%, and the Good health profile included 32% of the participants. Older adults who were frail (OR 2.50, 95% CI 1.17-5.33), had a low exercise level (OR 0.49, 95% CI 0.39-0.95), and low alcohol intake (OR 0.61, 95% CI 0.39-0.95) were more likely to belong to the Poor health profile relative to the Good health profile. Furthermore, older age (OR 1.19, 95% CI 1.03-1.37) and lower exercise level (OR 0.64, 95% CI 0.43-0.97) were associated with belonging to the Moderate health profile relative to the Good health profile. CONCLUSION: Two months after PCI, most participants displayed having Moderate to Good health profiles. Those with a Poor health profile were more likely to be frail and less active. These findings highlight that follow-up care has to be patient-centred and tailored to improve the health status of older adults.

Feasibility of the cardiac output response to stress test in suspected heart failure patients.

BACKGROUND: Diagnostic tools available to support general practitioners diagnose heart failure (HF) are limited. OBJECTIVES: (i) Determine the feasibility of the novel cardiac output response to stress (CORS) test in suspected HF patients, and (ii) Identify differences in the CORS results between (a) confirmed HF patients from non-HF patients, and (b) HF reduced (HFrEF) vs HF preserved (HFpEF) ejection fraction. METHODS: Single centre, prospective, observational, feasibility study. Consecutive patients with suspected HF (N = 105; mean age: 72 ± 10 years) were recruited from specialized HF diagnostic clinics in secondary care. The consultant cardiologist confirmed or refuted a HF diagnosis. The patient completed the CORS but the researcher administering the test was blinded from the diagnosis. The CORS assessed cardiac function (stroke volume index, SVI) noninvasively using the bioreactance technology at rest-supine, challenge-standing, and stress-step exercise phases. RESULTS: A total of 38 patients were newly diagnosed with HF (HFrEF, n = 21) with 79% being able to complete all phases of the CORS (91% of non-HF patients). A 17% lower SVI was found in HF compared with non-HF patients at rest-supine (43 ± 15 vs 51 ± 16 mL/beat/m2, P = 0.02) and stress-step exercise phase (49 ± 16 vs 58 ± 17 mL/beat/m2, P = 0.02). HFrEF patients demonstrated a lower SVI at rest (39 ± 15 vs 48 ± 13 mL/beat/m2, P = 0.02) and challenge-standing phase (34 ± 9 vs 42 ± 12 mL/beat/m2, P = 0.03) than HFpEF patients. CONCLUSION: The CORS is feasible and patients with HF responded differently to non-HF, and HFrEF from HFpEF. These findings provide further evidence for the potential use of the CORS to improve HF diagnostic and referral accuracy in primary care.

Heart failure (HF) is a global pandemic affecting 26 million people worldwide with an estimated 1 million people in the United Kingdom. Accurate early diagnosis of HF and the initiation of evidence-based treatment is essential to reduce morbidity and mortality and the associated burden on healthcare. As there are no state-of-the-art approaches, early diagnosis is challenging and often inaccurate, as initial signs and symptoms are nonspecific. We have developed an innovative test, named CORS (cardiac output response to stress test), to help general practitioners identify HF, which uses a method similar to an electrocardiogram and measures heart function at rest and during short step exercise. We recruited suspected HF patients from specialist HF diagnostic clinics in secondary care to complete the CORS test. We successfully demonstrated that 79% of patients with newly diagnosed HF (n = 38) and 91% of non-HF patients (n = 67) were able to complete all phases of the CORS test. Our findings demonstrate that newly diagnosed HF patients are able to complete this test, which provides further evidence for the potential use of the CORS test to improve HF diagnostic and referral accuracy in primary care.

Florence Nightingale's legacy for clinical academics: A framework analysis of a clinical professorial network and a model for clinical academia.

BACKGROUND: Clinical academic nursing roles are rare, and clinical academic leadership positions even more scarce. Amongst the United Kingdom (UK) academia, only 3% of nurses who are employed within universities are clinically active. Furthermore, access to research fellowships and research grant funding for nurses in clinical or academic practice is also limited. The work of Florence Nightingale, the original role model for clinical academic nursing, is discussed in terms of how this has shaped and influenced that of clinical academic nurse leaders in modern UK healthcare settings. We analysed case studies with a view to providing exemplars and informing a new model by which to visualise a trajectory of clinical academic careers. METHODS: A Framework analysis of seven exemplar cases was conducted for a network of Clinical Academic Nursing Professors (n = 7), using a structured template. Independent analysis highlighted shared features of the roles: (a) model of clinical academic practice, (b) infrastructure for the post, (c) capacity-building initiatives, (d) strategic influence, (e) wider influence, (f) local and national implementation initiatives, (g) research area and focus and (h) impact and contribution. FINDINGS: All seven of the professors of nursing involved in this discourse were based in both universities and healthcare organisations in an equal split. All had national and international profiles in their specialist clinical areas and were implementing innovation in their clinical and teaching settings through boundary spanning. We outline a model for career trajectories in clinical academia, and how leadership is crucial. CONCLUSION: The model outlined emphasises the different stages of clinical academic roles in nursing. Nursing as a discipline needs to embrace the value of these roles, which have great potential to raise the standards of healthcare and the status of the profession.

Changes in muscle strength and physical function in older patients during and after hospitalisation: a prospective repeated-measures cohort study.

AIM: to investigate changes in knee-extension strength and physical function in older adults during and after acute hospital admission, and the contributions of illness severity, frailty and sedentary activity to changes in knee-extension strength. METHODS: prospective repeated-measures cohort study on a sample of participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension, grip strength and functional mobility (de Morton Mobility Index, DEMMI) were measured at recruitment, day 7 (or discharge if earlier), and at follow-up 4-6 weeks later. During the first 7 days, continuous measurement of physical activity and daily measurements of muscle strength were taken. Participants recalled the functional ability they had 2-weeks before admission and self-reported it at follow-up (Barthel Index, BI). RESULTS: sixty-five of 70 participants (median age 84 years) had at least one repeated measure of muscle strength in hospital. Knee-extension strength declined during hospitalisation by 11% (P < 0.001), but did not change post-hospitalisation (P = 0.458). Grip strength did not change during hospitalisation (P = 0.665) or from discharge to follow-up (P = 0.508). General functional ability (BI) deteriorated between 2 weeks before admission and follow-up (P < 0.001). Functional mobility (DEMMI) improved during hospitalisation (P < 0.001), but did not change post-hospitalisation (P = 0.508). A repeated-measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty and baseline strength and lower baseline inflammatory levels. CONCLUSIONS: our observations add to a growing body of evidence on potential risk factors for hospital-associated deconditioning.

Predictors of physical activity in older adults early in an emergency hospital admission: a prospective cohort study.

BACKGROUND: Reduced mobility may be responsible for functional decline and acute sarcopenia in older hospitalised patients. The drivers of reduced in-hospital mobility are poorly understood, especially during the early phase of acute hospitalisation. We investigated predictors of in-hospital activity during a 24-h period in the first 48 h of hospital admission in older adults. METHODS: This was a secondary analysis of a prospective repeated measures cohort study. Participants aged 75 years or older were recruited within the first 24 h of admission. At recruitment, patients underwent a baseline assessment including measurements of pre-morbid functional mobility, cognition, frailty, falls efficacy, co-morbidity, acute illness severity, knee extension strength and grip strength, and consented to wear accelerometers to measure physical activity during the first 7 days (or until discharge if earlier). In-hospital physical activity was defined as the amount of upright time (standing or walking). To examine the predictors of physical activity, we limited the analysis to the first 24 h of recording to maximise the sample size as due to discharge from hospital there was daily attrition. We used a best subset analysis including all baseline measures. The optimal model was defined by having the lowest Bayesian information criterion in the best-subset analyses. The model specified a maximum of 5 covariates and used an exhaustive search. RESULTS: Seventy participants were recruited but eight were excluded from the final analysis due to lack of accelerometer data within the first 24 h after recruitment. Patients spent a median of 0.50 h (IQR: 0.21; 1.43) standing or walking. The optimal model selected the following covariates: functional mobility as measured by the de Morton Mobility Index and two measures of illness severity, the National Early Warning Score, and serum C-reactive protein. CONCLUSIONS: Physical activity, particularly in the acute phase of hospitalisation, is very low in older adults. The association between illness severity and physical activity may be explained by symptoms of acute illness being barriers to activity. Interdisciplinary approaches are required to identify early mobilisation opportunities.

'Who does this patient belong to?' boundary work and the re/making of (NSTEMI) heart attack patients.

This ethnography within ten English and Welsh hospitals explores the significance of boundary work and the impacts of this work on the quality of care experienced by heart attack patients who have suspected non-ST segment elevation myocardial infarction (NSTEMI) /non-ST elevation acute coronary syndrome. Beginning with the initial identification and prioritisation of patients, boundary work informed negotiations over responsibility for patients, their transfer and admission to different wards, and their access to specific domains in order to receive diagnostic tests and treatment. In order to navigate boundaries successfully and for their clinical needs to be more easily recognised by staff, a patient needed to become a stable boundary object. Ongoing uncertainty in fixing their clinical classification, was a key reason why many NSTEMI patients faltered as boundary objects. Viewing NSTEMI patients as boundary objects helps to articulate the critical and ongoing process of classification and categorisation in the creation and maintenance of boundary objects. We show the essential, but hidden, role of boundary actors in making and re-making patients into boundary objects. Physical location was critical and the parallel processes of exclusion and restriction of boundary object status can lead to marginalisation of some patients and inequalities of care (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

"We're stuck with what we've got": The impact of lipodystrophy on body image.

AIMS AND OBJECTIVES: To evaluate the impact of lipodystrophy on body image and how this affects patients' daily lives. BACKGROUND: Lipodystrophy refers to a group of rare conditions characterised by generalised or partial lack of body fat and is associated with severe metabolic problems, for example, severe insulin resistance, diabetes and pancreatitis. In addition to its metabolic effect, lack of adipose tissue may have a major impact on appearance and cause distressing physical changes. While global research has focused on diagnosis and management, there is no published work investigating the psychological effects of lipodystrophy on body image. METHODS: Following ethical approval, participants with lipodystrophy were purposively sampled from the National Severe Insulin Resistance Service in Cambridge, UK, and invited to take part in a semi-structured interview. Eleven (10 female, one male) interviews were conducted and digitally recorded. Data were analysed using an inductive thematic approach. RESULTS: Four main themes were identified in the data set; "Always feeling appearance was different," "a better understanding of lipodystrophy is needed," "feeling accepted" and "there's more to lipodystrophy than managing symptoms." Participants spoke of distressing cosmetic effects related to lack of fat tissue and other changes related to lipodystrophy, contributing to negative body image. For some, negative body image led to feelings of worthlessness impacting daily life and adherence to treatment. Psychological support was lacking but desired by participants. CONCLUSION: Lipodystrophy contributes to negative body image affecting patients' daily lives. Patients wanted psychological support alongside medical management. Further research is needed to determine how best to deliver psychological support and to evaluate its impact on well-being and metabolic management. RELEVANCE TO CLINICAL PRACTICE: The effects of rare diseases such as lipodystrophy on appearance can be distressing for patients. Support beyond medical management is needed to improve patients' daily lives and help them to live well with appearance-altering conditions.

Nursing in an age of multimorbidity.

BACKGROUND: A changing sociodemographic landscape has seen rising numbers of people with two or more long-term health conditions. Multimorbidity presents numerous challenges for patients and families and those who work in healthcare services. Therefore, the nursing profession needs to understand the issues involved in supporting people with multiple chronic conditions and how to prepare the future workforce to care for them. METHODS: A descriptive, exploratory study was used to examine the future of nursing in an age of multimorbidity. An hour-long Twitter chat was organised and run by the Florence Nightingale Foundation Chairs of Clinical Nursing Practice Research to discuss this important area of practice and identify what needs to be done to adequately upskill and prepare the nursing profession to care for individuals with more than one long-term illness. Questions were formulated in advance to provide some structure to the online discussion. Data were collected and analysed from the social media platform using NVivo and an analytics tool called Keyhole. Descriptive statistics were used to describe participants and thematic analysis aided the identification of key themes. RESULTS: Twenty-four people, from a range of nursing backgrounds and organisations, took part in the social media discussion. Five themes encompassing coping with treatment burden, delivering holistic care, developing an evidence base, stimulating learning and redesigning health services were seen as key to ensuring nurses could care for people with multimorbidity and prevent others from developing chronic health conditions. CONCLUSIONS: Multimorbidity is a pressing health issue in today's society. Changes in nursing research, education and practice are required to help the profession work collaboratively with patients, families and multidisciplinary teams to better manage and prevent chronic illness now and in the future.

Can Communicating Personalised Disease Risk Promote Healthy Behaviour Change? A Systematic Review of Systematic Reviews.

BACKGROUND: The assessment and communication of disease risk that is personalised to the individual is widespread in healthcare contexts. Despite several systematic reviews of RCTs, it is unclear under what circumstances that personalised risk estimates promotes change in four key health-related behaviours: smoking, physical activity, diet and alcohol consumption. PURPOSE: The present research aims to systematically identify, evaluate and synthesise the findings of existing systematic reviews. METHODS: This systematic review of systematic reviews followed published guidance. A search of four databases and two-stage screening procedure with good reliability identified nine eligible systematic reviews. RESULTS: The nine reviews each included between three and 15 primary studies, containing 36 unique studies. Methods of personalising risk feedback included imaging/visual feedback, genetic testing, and numerical estimation from risk algorithms. The reviews were generally high quality. For a broad range of methods of estimating and communicating risk, the reviews found no evidence that risk information had strong or consistent effects on health-related behaviours. The most promising effects came from interventions using visual or imaging techniques and with smoking cessation and dietary behaviour as outcomes, but with inconsistent results. Few interventions explicitly used theory, few targeted self-efficacy or response efficacy, and a limited range of Behaviour Change Techniques were used. CONCLUSIONS: Presenting risk information on its own, even when highly personalised, does not produce strong effects on health-related behaviours or changes which are sustained. Future research in this area should build on the existing knowledge base about increasing the effects of risk communication on behaviour.

The experiences of myocardial infarction patients readmitted within six months of primary percutaneous coronary intervention.

AIMS AND OBJECTIVES: To explore the experiences of patients readmitted due to potential ischaemic heart disease symptoms within six months of primary percutaneous coronary intervention. BACKGROUND: Following myocardial infarction and primary percutaneous coronary intervention, some patients experience potential ischaemic heart disease symptoms that may lead to readmission. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition. DESIGN: A qualitative study involving semistructured, in-depth interviews conducted once, mean 196 (50-384) days following readmission (at least six months following original ST-elevation myocardial infarction and primary percutaneous coronary intervention). This is the qualitative part of a mixed methods study. METHODS: Participants were purposefully selected, and concurrent sampling, data collection and data analysis were performed. Data were organised using framework analysis; constant comparative analysis involving deduction and induction led to identification of cogent themes and subthemes. RESULTS: Twenty-five participants (14 men, 27-79 years) experienced 1-4 readmissions; discharge diagnoses were cardiac, psychological, indeterminate, pulmonary and gastric. Three main themes emerged: (1) anxiety, uncertainty and inability to determine cause of symptoms, (2) fear of experiencing further myocardial infarction and (3) insufficient opportunity to validate self-construction of illness. CONCLUSION: Fear of dying or experiencing a further myocardial infarction led to patients seeking help at the time of potential ischaemic heart disease symptoms. Participants were anxious and lacked understanding regarding symptom attribution at the time of readmission and generally following their heart attack. Additionally, original heart attack symptoms were used as a comparator for future symptoms. Participants reported feeling well immediately after primary percutaneous coronary intervention but later experiencing fatigue and debilitation often linked to potential ischaemic heart disease symptoms. RELEVANCE TO CLINICAL PRACTICE: Increased education and information related to symptom attribution post-primary percutaneous coronary intervention and postreadmission are worthy of exploration and may lead to increased understanding and reassurance for this patient group.

An evaluation of the effectiveness of self-management interventions for people with type 2 diabetes after an acute coronary syndrome: a systematic review.

BACKGROUND: Type 2 diabetes is highly prevalent in patients with acute coronary syndrome and impacts negatively on health outcomes and self-management. Both conditions share similar risk factors. However, there is insufficient evidence on the effectiveness of combined interventions to promote self-management behaviour for people with diabetes and cardiac problems. Identifying critical features of successful interventions will inform future integrated self-management programmes for patients with both conditions. OBJECTIVES: To assess the evidence on the effectiveness of existing interventions to promote self-management behaviour for patients presenting with acute coronary syndrome and type 2 diabetes in secondary care settings and postdischarge. DESIGN: We searched MEDLINE, PubMed, CINAHL Plus, PsycInfo, Cochrane Library and AMED for randomised controlled trials published between January 2005-December 2014. The search was performed using the following search terms of 'acute coronary syndrome', 'type 2 diabetes' and 'self-management intervention' and their substitutes combined. RESULTS: Of 4275 articles that were retrieved, only four trials met all the inclusion criteria (population, intervention, comparison and outcome) and were analysed. Overall, the results show that providing combined interventions for patients with both conditions including educational sessions supported by multimedia or telecommunication technologies was partially successful in promoting self-management behaviours. Implementation of these combined interventions during patient's hospitalisation and postdischarge was feasible. Intervention group subjects reported a significant improvement in self-efficacy, level of knowledge, glycated haemoglobin, blood pressure and fasting glucose test. However, there are many threats have been noticed around internal validity of included studies that could compromise the conclusions drawn. CONCLUSION: With limited research in this area, there was no final evidence to support effectiveness of combined interventions to promote self-management behaviour for patients with type 2 diabetes and acute coronary syndrome. Sufficiently powered, good quality, well-conducted and reported randomised controlled trials are required.

Prevalence and Measurement of Anxiety in Samples of Patients With Heart Failure: Meta-analysis.

OBJECTIVES: Rates of anxiety in patients with heart failure (HF) vary widely, and not all assessment instruments used in this patient population are appropriate. It is timely to consolidate the evidence base and establish the prevalence and variance of anxiety in HF samples. METHODS: A systematic review, meta-analysis, and meta-regression were conducted to identify the prevalence, variance, and measurement of anxiety in patients with HF. RESULTS: A total of 14,367 citations were identified, with 73 studies meeting inclusion criteria. A random effects pooled prevalence of 13.1% (95% confidence interval [CI], 9.25%-16.86%) for anxiety disorders, 28.79% (95% CI, 23.30%-34.29) for probable clinically significant anxiety, and 55.5% (95% CI, 48.08%-62.83%) for elevated symptoms of anxiety was identified. Rates of anxiety were highest when measured using the Brief Symptom Scale-Anxiety scale (72.3%) and lowest when measured using the Generalised Anxiety Disorder-7 (6.3%). CONCLUSION: Many patients with HF would benefit if screened for anxiety and treated. The conceptualization and measurement of anxiety accounted for most variance in prevalence rates. The Generalised Anxiety Disorder-7 or the Hospital Anxiety and Depression Scale appear to be the most appropriate instruments for this clinical population, with evidence to suggest they can discriminate between depression and anxiety, omit somatic items that may contaminate identification of anxiety in a population with physical comorbidities, and provide thresholds with which to differentiate patients and target treatments. Although there are limitations with the collation of diverse measurement methods, the current review provides researchers and clinicians with a more granular knowledge of prevalence estimates of anxiety in a population of HF patients.

A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context.

BACKGROUND: There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist's domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care? METHODS: Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data. RESULTS: We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation. CONCLUSIONS: When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis.

BACKGROUND: Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community. AIM: To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England. METHODS: We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie. RESULTS: Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs. CONCLUSIONS: There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.

'When age is not a barrier': an explorative study of nonagenarian patients' experiences of undergoing percutaneous coronary intervention.

AIMS: The recent rise in the number of nonagenarians (age ≥ 90 years) undergoing percutaneous coronary intervention (PCI) has revealed gaps in research, in particular on patients' experiences. Therefore, the aim of the study was to explore and describe nonagenarians' internal resources and their experiences of the in-hospital pathway. METHODS AND RESULTS: Nineteen nonagenarian patients (women n = 9), mean age 91 years, 9 acutely, and 10 electively treated, were consecutively enrolled from a tertiary university hospital from June 2021 to February 2023. In-depth interviews were conducted during hospitalization, audiotaped and transcribed. The interviews were analysed using qualitative content analysis. Three sub-themes emerged from the nonagenarians' experiences with the PCI treatment trajectory: (i) Taking lifelong responsibility for own physical and mental health describes a population striving to live a healthy life and to stay independent. Physical and mental activities including healthy food choices had been an integral aspect of their lives from early childhood. (ii) Individual internal resources influenced the PCI pathway describes how their internal resources were used, from actively engaging in the decision-making process to withstanding discomfort during the PCI procedure. (iii) The post-PCI pathway was multifaceted describes a short stay at the cardiac ward with individual post-procedural experiences, close monitoring, and preparation for discharge including cardiac rehabilitation. CONCLUSION: Nonagenarians undergoing PCI demonstrated a personal incentive to stay healthy and independent. Their internal resources of independence, stoicism, and resilience were used during their in-hospital stay contributing to a successful PCI procedure. Individual cardiac rehabilitation strategies were highlighted after discharge from hospital.

Development steps of multimodal exercise interventions for older adults with multimorbidity: A systematic review.

Background and Aims: Multicomponent exercise interventions are recommended for older adults and for those with chronic diseases. While multiple programs have been tested, no one has yet explored how these programs were developed. This review set out to determine what development steps multicomponent exercise intervention studies that include older adults with multimorbidity have taken. Methods: Systematic review and narrative synthesis. Results: One hundred and thirty-eight studies meeting review criteria (Population: adults ≥60 years with multimorbidity; Intervention: exercise interventions with ≥2 components; Comparator: any considered; Outcome: any considered) were retrieved. Most studies (70%) do not report intervention development actions as suggested by available guidance. Notable deviations from recommendations include limited performance of systematic review of previously published evidence, lack of engagement with theory, and few examples of design then refine. Conclusions: Exercise interventions for older adults with multimorbidity do not appear to follow best practice in terms of their developing. Disregard of development recommendations risks contributing to research redundancy and/or avoidable waste, as important steps that make sure the intervention is warranted, suitable for the population in question, and tested using optimal methods and outcome measures are overlooked.

Heart failure among South Asians: a narrative review of risk, nature, outcomes and management.

Individuals of South Asian descent have a high prevalence of comorbidities that are risk factors for the development of heart failure (HF), including diabetes mellitus and metabolic syndrome. However, little is known about the prevalence of HF, its management and prognosis for this population compared to Caucasians. Therefore, a literature review relating to the nature, outcome and treatment of HF in South Asian patients compared to Caucasians was conducted. It was anticipated that collating existing studies in this manner would be useful for guiding professionals in managing HF within this ethnic group, given that to achieve optimal care, regimens need to take into account cultural differences that may impact on adherence. Reviewed literature showed that South Asians with HF were more likely to be younger and have diabetes and hypertension. These papers also implied that outcomes for South Asians with HF were similar or even better than for Caucasians. The review highlighted the under-representation of South Asians in HF trials, meaning that evidence-based recommendations tailored to this specific population are limited. This is an important consideration because ethnic differences in response to medication have been reported; it cannot be assumed that treatments shown to work for Caucasians will be efficacious for those from minority ethnic groups.

'Keeping the plates spinning': a qualitative study of the complexity, barriers, and facilitators to caregiving in heart failure with preserved ejection fraction.

AIMS: Heart failure with preserved ejection fraction (HFpEF) accounts for 50% of all heart failure cases; yet remains poorly understood, diagnosed, and managed, which adds complexity to the carer role. No study to date has investigated the experiences of informal carers of people with HFpEF. The aim of this study was to explore the role and experiences of informal carers of people with HFpEF. METHODS AND RESULTS: A qualitative study using semi-structured interviews involving carers alone, patients alone, or carer/patient dyads. The interviews were part of a larger programme of research in HFpEF. Participants were recruited from three regions of England. Interviews were recorded, transcribed verbatim, and analysed thematically. Twenty-two interviews were conducted with 38 participants, 17 were informal carers. Three inter-related themes were identified: Theme 1, the complex nature of informal caregiving ('spinning plates'); Theme 2, the barriers to caregiving ('the spinning falters'); and Theme 3, the facilitators of caregiving ('keeping the plates spinning'). CONCLUSIONS: Informal carers play an important role in supporting people with HFpEF. The experience of caregiving in HFpEF is similar to that described for Heart Failure with reduced Ejection Fraction, but complicated by challenges of limited information and support specific to HFpEF, and high burden of multi-morbidity. Healthcare providers should assess the needs of informal carers as part of patient care in HFpEF. Carers and patients would benefit from improved information and co-ordinated management of HFpEF and multi-morbidities. Helping carers 'keep the plates spinning' will require innovative approaches and co-ordination across the care continuum.

What dietary interventions have been tested in heart failure with preserved ejection fraction? A systematic scoping review.

AIMS: To determine what dietary interventions have been tested in heart failure with preserved ejection fraction (HFpEF), the modulation method, and outcomes employed and to summarize any evidence for benefit. METHODS AND RESULTS: We performed key word searches in five bibliographic databases from 2001 to 2021, to identify randomized or experimental dietary interventions tested in HFpEF or mixed heart failure (HF) samples. Study characteristics were summarized according to population, intervention, comparator, outcome categories and intervention complexity was assessed. Twenty-five clinical investigations were retrieved; only 10 (40%) were conducted exclusively in HFpEF; the remainder enrolled mixed HF samples. Most studies employed either highly tailored prescribed diets (n = 12, 48%) or dietary supplementation (n = 10, 40%) modalities. Dietary pattern interventions (n = 3, 12%) are less well represented in the literature. CONCLUSION: Heterogeneity made pooling studies challenging. Better reporting of baseline characteristics and the use of standardized HF lexicon would ensure greater confidence in interpretation of studies involving mixed HF populations. The field would benefit greatly from explicit reporting of the biological mechanism of action (e.g. the causal pathway) that an intervention is designed to modulate so that studies can be synthesized via their underlying mechanism of action by which diet may affect HF. An extension of the current set of core outcomes proposed by the European Society of Cardiology Heart Failure Association would ensure dietary clinical endpoints are more consistently defined and measured. REGISTRATION: PROSPERO: CRD42019145388.