The Role of Nursing in the Delivery of Cardio-Oncology.

OPINION STATEMENT: Nurses are the "heart of patient care" and in the forefront of the health care delivery for cardio-oncology patients. Nurses play a critical central role in maximizing longitudinal health of cancer patients and survivors through the prevention of cardiovascular complications throughout the patient's cancer care journey. Nurses function in a variety of roles such as nurse clinicians, advanced practice nurses (APNs)or nurse practitioners (NPs), patient educators, managers, nurse navigators or nurse researchers. The role of nurses, particularly the advanced practice nurses as key members in delivering cardio-oncology care is evolving. However, despite the rapidly increasing growth of cardio oncology programs globally, a pivotal need remains to develop and provide formalized training programs for nurses, NPs and APNs. At present, no formal academic cardio-oncology nurse training program or certification exists. There is clearly more work to be done on the role of nurses in cardio-oncology care. As cardio-oncology evolves to become a key specialty with dedicated services being established across the globe, the role of the nurse in delivering this service is critical and a concerted collaborative approach between the two distinct specialties of cardiology and oncology needs to ensure the nursing workforce is educationally prepared and confident to treat and manage cardio-oncology patients.

Patients' and caregivers' perceptions of the quality of hospital-at-home service: A scoping review.

AIM: This scoping review aims to provide an overview of patients and caregivers perceptions of hospital-at-home (HaH) services. BACKGROUND: HaH services provide patients with hospital-level care at home and are central to integrated healthcare systems. Despite favourable data from individual studies in the literature, in-depth analysis from patient and caregivers perspectives is lacking. This understanding is essential for the dissemination and scaling of HaH services. DESIGN: The scoping review was performed using the PRISMA-ScR checklist and PAGER framework for the findings report and research recommendations. METHOD: Literature from PubMed, Web of Science, Ovid, CINAHL, Cochrane and Mednar databases were searched. Relevant studies published between 1st January 2005 and 31st December 2022 were identified. The conceptual model of the development of patient perceptions of quality was used for data extraction and tabulation. RESULTS: The review included 24 articles. Expectation attributions were identified as needs, types of service, hospitalisation experiences, family care preferences, social-demographics and coping skills. From patient's and caregiver's perspectives, HaH was safe, effective and viewed positively. Perceived concerns/barriers and enablers/facilitators were associated with individual, caregiver and system factors, but demonstrated an overall satisfaction in the HaH service. CONCLUSION: HaH provides an excellent service according to patients' and caregivers' perceptions. However, gaps in care were identified such as prioritising patient-centred care, along with improved multidisciplinary continuity of care and future studies should incorporate these into their research of HaH. RELEVANCE TO CLINICAL PRACTICE: Patients' and caregivers' HaH needs should be embedded in the design, development and implementation of HaH services. PATIENT AND PUBLIC CONTRIBUTION: Not applicable for the study design of this scoping review.

Patients' perceptions on the facilitators and barriers using injectable therapies in dyslipidaemia: An empirical qualitative descriptive international study.

BACKGROUND: Injectable medicines are increasingly used to manage abnormal levels of lipids, which is a major risk factor for cardiovascular events. Enhancing our understanding of patients' perceptions of these injectables, can inform practice with the aim of increasing uptake and medication adherence. AIM: To explore patient's experiences of using injectables and to identify potential facilitators and barriers to using injectable therapies in dyslipidaemia. DESIGN: A qualitative descriptive study using semi-structured interviews was conducted with patients who were using injectables to manage their cardiovascular conditions. METHODS: A total of 56 patients, 30 from the United Kingdom and 26 from Italy, were interviewed online from November 2020 to June 2021. Interviews were transcribed and schematic content analysis performed. RESULTS: Four distinct themes emerged from interviews with patients and caregivers: (i) Their behaviours and personal beliefs; (ii) Knowledge and education about injectable medication; (iii) Clinical skills and previous experiences and (iv) Organizational and governance. Participants expressed initial fears such as needle phobia, and their concerns about commencing therapy were compounded by a lack of accessible information. However, patients' pre-existing knowledge of lipid lowering medication, previous experience with statins and history of adverse side effects informed their decision-making regarding using injectables. Organization and governance-related issues were primarily around the distribution and management of medication supply within primary care, and the lack of a standardized clinical support monitoring system. CONCLUSION: Changes are needed in clinical practice to better educate and support patients to improve the uptake of injectables and optimize their use of these medications in the management of dyslipidaemia. IMPACT: This study suggests that injectable therapies were acceptable to people with cardiovascular disease. However, healthcare professionals need to play a key role in improving education and providing support to aid patients' decision-making regarding commencing and adhering to injectable therapies. REPORTING METHOD: The study adhered to the Consolidated Criteria for Reporting Qualitative Research. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Advanced practice and clinical supervision: An exploration of perceived facilitators and barriers in practice.

AIM AND OBJECTIVES: The aim of this study was to investigate current advanced practice Masters students' experience of clinical supervision, to explore how clinical supervision works in practice and to identify students' perceptions of the facilitators and barriers to clinical supervision in their workplace. BACKGROUND: Advanced practitioners, and in particular nurses, play a pivotal role in delivering health care across acute and primary care settings. These non-medical professionals fulfil a rapidly expanding proportion of roles traditionally undertaken by medically qualified staff within the National Health Service in the United Kingdom and often lead specialist clinics and services. To prepare for the advanced practice role, individuals are required to undertake a Master's in advanced practice to develop the required skills and knowledge and work in clinical practice with a clinical assessor/supervisor to demonstrate competence and performance. DESIGN: A mixed method study using an online descriptive cross-sectional survey and qualitative data were collected via focus groups and has been reported using the Good Reporting of a Mixed Methods Study checklist. RESULTS: A total of 79 students completed the online survey (from 145 AP students), a response rate of 55%. Most respondents were nurses (n = 73) with 49 (62%) in a formal advanced practice trainee role, and the majority believed their clinical supervisor had a good understanding of advanced practice and the advanced practice role. Two focus groups were held with 16 participants in total. Thematic analysis revealed five themes: (a) perceived level and amount of support from clinical supervisors, (b) skill level of clinical supervisors, (c) physicians and their perceptions on supervising, Advanced practitioners (d) clinical supervisors' preparation for the role and (e) transition from trainee to qualified advanced practitioner. CONCLUSION: The survey revealed that advanced practitioner students perceived that clinical supervisors and workplace colleagues had a good understanding of the advanced practice role with good levels of support in practice. A more coherent approach is required for clinical supervision and an implementation framework that can be formally evaluated. RELEVANCE TO CLINICAL PRACTICE: Several significant barriers to clinical supervision for advanced practitioner students were identified, and there are currently more barriers (including COVID-19) than facilitators.

Research placements: are they a suitable alternative for student nurses?

COVID-19 has affected those undertaking courses in higher education, especially programmes in health care with clinical placements. Many student nurses were unable to undertake their planned clinical placements and had to adjust to self-directed learning and an increase in simulated learning. As a suitable alternative to clinical placements, a research placement for two second-year BSc adult nursing students was trialled, and this article presents an account from one placement. The academic team devised specific questions for students to consider for their research electives and provided a template for their written work with the aim of writing up a weekly report to reflect their learning. In particular, the students had to identify how their learning related to the UK Nursing and Midwifery Council code of conduct. The research placement was successful and shows great potential, offering students tangible opportunities to seek out the evidence for themselves and use it to inform their clinical practice.

The challenge of managing multimorbid atrial fibrillation: a pan-European European Heart Rhythm Association (EHRA) member survey of current management practices and clinical priorities.

As part of the EHRS-PATHS study examining comorbidities in atrial fibrillation (AF) across Europe, the aim was (i) to evaluate how multimorbidity is currently addressed by clinicians during AF treatment to characterize the treatment structure and (ii) to assess how the interdisciplinary management of multimorbid AF is currently conducted. An online survey was distributed among European Heart Rhythm Association (EHRA) members in Europe that included 21 questions and a free-text option for comments on detection, assessment, and management of AF-related comorbidities. A total of 451 responses were received with 339 responses eligible for inclusion. Of these, 221 were male (66%), 300 (91.5%) were physicians, and 196 (57.8%) were working in academic university teaching hospitals. Half of the respondents managed between 20 and 50 patients per month with multimorbid AF. Varying rates of specialist services and referral to these services were available at each location (e.g. heart failure and diabetes), with a greater number of specialist services available at academic university teaching hospitals compared with non-teaching hospitals [e.g. anticoagulation clinic 92 (47%) vs. 50 (35%), P < 0.03]. Barriers to referring to specialist services for AF comorbidities included lack of integrated care model (n = 174, 51%), organizational or institutional issues (n = 145, 43%), and issues with patient adherence (n = 126, 37%), highlighting the need for organizational restructuring and developing an integrated collaborative evidenced-based approach to multimorbid AF care. The survey and analyses of free-text comments demonstrated the need for systematic, integrated management of AF-related comorbidities, and these results will inform the next phases of the EHRA-PATHS study.

The Efficacy of Psychological Interventions on Health-Related Quality of Life for Patients With Heart Failure and Depression: A Systematic Review.

BACKGROUND: Depression is prevalent among adults with chronic heart failure (CHF) and is associated with higher rates of morbidity and mortality and higher healthcare costs. OBJECTIVES: The aim of this study was to explore the efficacy of psychological interventions in reducing depression and improving quality of life and clinical outcomes (mortality, hospitalization) among adults with CHF. METHODS: This study performed a systematic review involving searches of 6 databases (MEDLINE, CINAHL, EMBASE, PsycINFO, ASSIA, and SSCI), the Cochrane library, and gray literature, completed in January 2020. Experimental and nonexperimental quantitative studies of psychological interventions for adults with CHF were included. Each study was quality appraised, and key data were extracted and tabled. Overall findings are presented as a narrative synthesis. RESULTS: Nine studies met eligibility. Study authors sampled 757 participants and evaluated 4 psychological interventions: cognitive behavioral therapy alone or combined with exercise, mindfulness-based psychoeducation, coping skills training, and innovative holistic meditation. Cognitive behavioral therapy was significantly associated with improved depression and quality of life, and reduced hospitalization risk. Mindfulness-based psychoeducation, holistic meditation, and coping skills training positively impacted depression and quality of life. Coping skills training also reduced hospitalization and mortality risks. CONCLUSION: Although this review indicates that psychological interventions can be beneficial to adults with CHF who have depression, the overall weight of evidence contains a number of biases. Larger, higher-powered studies are needed to confirm or refute these findings and to better understand how specific intervention and sample characteristics relate to outcomes.

Saving the Exposed Deep Brain Stimulation Implant: A Comprehensive Review of Implant Extrusion and Reconstructive Options.

INTRODUCTION: Deep brain stimulation (DBS) for the treatment of Parkinson disease is susceptible to complications, such as hardware extrusion, most commonly at the scalp and chest. The authors describe their experience with the management of hardware extrusion and reconstruction with one of the largest single-institution experience and suggest an evidence-based treatment algorithm for the management of such cases. METHODS: A retrospective review of hospital records was performed to identify patients who underwent DBS-related surgery and reconstruction from January 2015 to April 2020. Management of these patients involved culture-directed antibiotics, local wound debridement, various forms of reconstruction, and hardware removal when indicated. RESULTS: Ninety-four patients with 131 DBS-related procedures were included. Twelve patients (12.8%) had hardware extrusion, of which 6 occurred primarily at the scalp and 6 occurred primarily at the chest. Primary closure of scalp wounds (odds ratio, 0.05 [0.004-0.71], P = 0.035) was negatively associated with treatment success. The type of reconstruction of chest wounds did not affect its success ( P = 0.58); however, none of them involved a new surgical bed, such as contralateral or hypochondrial placement. CONCLUSIONS: Hardware extrusion is a significant complication of DBS-related surgery. Management of extrusion at the scalp should involve the use of tension-free, well-vascularized locoregional flaps as opposed to primary closure. Implantable pulse generator extrusions at the chest can be managed with both primary closure and repositioning in a new surgical bed. Extruded DBS implants may be salvaged with appropriate reconstructive considerations, and the authors suggest an evidence-based treatment algorithm.

Single-centre survey of women reflecting on recent experiences and preferences of oral intake during labour.

BACKGROUND: Consensus-based recommendations guiding oral intake during labour are lacking. AIMS: We surveyed women at a tertiary women's hospital about preferences for and experiences of oral intake during labour, gastrointestinal symptoms during labour and recalled advice about oral intake. MATERIALS AND METHODS: Women who experienced labour completed a postpartum survey with responses as free text, yes-no questions and five-point Likert scales. We identified demographic data and risk factors for surgical or anaesthetic intervention at delivery from medical records. We summarised free text comments using conventional content analysis. RESULTS: One hundred and forty-nine women completed the survey (47% response rate). Their mean (SD) age was 31 (four) years, birthing at median gestation of 39 weeks (interquartile range: 38-40). One hundred and twenty-two (83%) and 44 (30%) women strongly agreed or agreed they felt like drinking and eating respectively during labour. Ninety women (61%) reported nausea and 47 women (32%) reported vomiting in labour. Forty-one women (28%) did not receive advice on oral intake during labour. Maternal risk factors for surgical intervention were identified in 72 (48%) women and fetal risk factors in 27 (18%) women. Thirty-one women (21%) delivered by emergency caesarean section. CONCLUSION: Pregnant women received variable advice regarding oral intake during labour, from variable sources. Most women felt like drinking but not eating during labour. Guidelines on oral intake in labour may be beneficial to women, balancing the preferences of women with risks of surgical intervention.

Obstructive sleep apnoea testing and management in atrial fibrillation patients: a joint survey by the European Heart Rhythm Association (EHRA) and the Association of Cardiovascular Nurses and Allied Professions (ACNAP).

Obstructive sleep apnoea (OSA) is highly prevalent in atrial fibrillation (AF) patients and associated with reduced response to rhythm control strategies. However, there is no practical guidance on testing for OSA in AF patients and for OSA treatment implementation. We sought to evaluate current practices and identify challenges of OSA management in AF. A descriptive cross-sectional study was performed with a content-validated survey to evaluate OSA management in AF by healthcare practitioners. Survey review, editing, and dissemination occurred via the European Heart Rhythm Association and the Association of Cardiovascular Nursing and Allied Professions and direct contact with arrhythmia centres. In total, 186 responses were collected. OSA-related symptoms were ranked as the most important reason to test for OSA in AF patients. The majority (67.7%) indicated that cardiologists perform 'ad-hoc' referrals. Only 11.3% initiated systematic testing by home sleep test or respiratory polygraphy and in addition, 10.8% had a structured OSA assessment pathway in place at the cardiology department. Only 6.7% of the respondents indicated that they test >70% of their AF patients for OSA as a component of rhythm control therapy. Various barriers were reported: no established collaboration between cardiology and sleep clinic (35.6%); lack in skills and knowledge (23.6%); lack of financial (23.6%) and personnel-related resources (21.3%). Structured testing for OSA occurs in the minority of AF patients. Centres apply varying methods. There is an urgent need for increased awareness and standardized pathways to allow OSA testing and treatment integration in the management of AF.

The interpretation of CHA2DS2-VASc score components in clinical practice: a joint survey by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, the EHRA Young Electrophysiologists, the Association of Cardiovascular Nursing and Allied Professionals, and the European Society of Cardiology Council on Stroke.

This European Heart Rhythm Association (EHRA) Scientific Initiatives Committee, EHRA Young Electrophysiologists, Association of Cardiovascular Nursing and Allied Professionals, and European Society of Cardiology (ESC) Council on Stroke joint survey aimed to assess the interpretation of the CHA2DS2-VASc score components and preferred resources for calculating the score. Of 439 respondents, most were general cardiologists (46.7%) or electrophysiologists (EPs) (42.1%). The overall adherence to the ESC-defined scoring criteria was good. Most variation was observed in the interpretation of the significance of left ventricular ejection fraction and brain natriuretic peptide in the scoring for the 'C' component, as well as the 'one-off high reading of blood pressure' to score on the 'H' component. Greater confidence was expressed in scoring the 'H' component (72.3%) compared with the 'C' (46.2%) and 'V' (45.9%) components. Respondents mainly relied on their recall for the scoring of CHA2DS2-VASc score (64.2%). The three most favoured referencing resources varied among different professionals, with pharmacists and physicians relying mainly on memory or web/mobile app, whereas nurses favoured using a web/mobile app followed by memory or guidelines/protocol. In conclusion, this survey revealed overall good adherence to the correct definition of each component in scoring of the 'C', 'H', and 'V' elements of the CHA2DS2-VASc score, although the variation in their interpretations warrants further clarifications. The preferred referencing resources to calculate the score varied among different healthcare professionals. Guideline education to healthcare professionals and updated and unified online/mobile scoring tools are suggested to improve the accuracy in scoring the CHA2DS2-VASc score.

A prospective cohort study of two predictor models for 30-day emergency readmission in older patients.

AIM: To undertake a prospective study of the accuracy of two models (LACE and BOOST) in predicting unplanned hospital readmission in older patients (>75 years). METHODS: Data were collected from a single centre prospectively on 110 patients over 75 years old admitted to the acute medical unit. Follow-up was conducted at 30 days. The primary outcome was the c-statistic for both models. RESULTS: The readmission rate was 32.7% and median age 82 years, and both BOOST and LACE scores were significantly higher in those readmitted compared with those who were not. C-statistics were calculated for both tools with BOOST score 0.667 (95% CI 0.559-0.775, P = .005) and LACE index 0.685 (95% CI 0.579-0.792, P = .002). CONCLUSION: In this prospective study, both the BOOST and LACE scores were found to be significant yet poor, predictive models of hospital readmission. Recent hospitalisation (within the previous 6 months) was found to be the most significant contributing factor.

Progress and challenges for advanced practice nursing in Mexico and the United Kingdom.

AIM: The aim of this study is to compare the advanced practice nursing development in Mexico with the United Kingdom. BACKGROUND: In spite of the involvement of global and local bodies to establish and develop advanced practice nursing worldwide, progress remains variable due to the lack of homogeneity in health care systems and policies. EVALUATION: Using thematic analysis from interviews of 29 health care professionals in Mexico, we identified four major issues that impact on the development of advanced practice nursing: (a) workforce, (b) organizational and institutional, (c) regulatory and legal and (d) academic and educational. KEY ISSUES: Learning from the UK experience in relation to overcoming some of these issues has been insightful in terms of how advanced practice nursing skills in Mexican nurses can be developed. CONCLUSIONS: Mexico is still in early stages of the development of APN. Based on the UK experience, the government may have to move forward to support higher level training, create labour market positions, establish new nursing functions, promote task-shifting and particularly implement solid regulation. IMPLICATIONS FOR NURSING MANAGEMENT: The development of advanced practice nursing represents important challenges for training and practice of nursing in Mexico and the United Kingdom; therefore, interested actors will have to reach key agreements that could work as the foundations of an assertive planning process.

A new tool to measure acuity in the community: a case study.

The provision of acute healthcare within patients own home (i.e. hospital in the home) is an important method of providing individualised patient-centred care that reduces the need for acute hospital admissions and enables early hospital discharge for appropriate patient groups. The Hospital in the Home (HitH) model of care ensures that this approach maximises patient safety and limits potential risk for patients. As HitH services have seen record numbers of patient referrals in the past 2 years, there is now a greater need to measure and understand the acuity and dependency levels of the caseload. Through an expert clinician development process at one NHS trust, aspects of procedural complexity, interdisciplinary working, risk stratification and comorbidities were used to quantify acuity and dependency. This paper uses a case study approach to present a new method of measuring this important concept.

Deep brain stimulation reduces pain in children with dystonia, including in dyskinetic cerebral palsy.

AIM: To establish the prevalence of dystonic pain in children and their response to deep brain stimulation (DBS). METHOD: Dystonic pain was assessed in a cohort of 140 children, 71 males and 69 females, median age 11 years 11 months (range 3y-19y 1mo), undergoing DBS in our centre over a period of 10 years. The cohort was divided into aetiological dystonia groups: 1a, inherited; 1b, heredodegenerative; 2, acquired; and 3, idiopathic. Motor responses were measured with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). RESULTS: Dystonic pain was identified in 63 (45%) patients, 38% of whom had a diagnosis of cerebral palsy (CP). Dystonic pain improved in 90% of children and in all aetiological subgroups 1 year after DBS, while the BFMDRS motor score improved in 70%. Statistically significant improvement (p<0.01) was noted for the whole cohort on the Numerical Pain Rating Scale (n=27), Paediatric Pain Profile (n=17), and Caregivers Priorities and Child Health Index of Life with Disabilities questionnaire (n=48). There was reduction of pain severity, frequency, and analgesia requirement. Findings were similar for the whole cohort and aetiological subgroups other than the inherited heredodegenerative group where the improvement did not reach statistical significance. INTERPRETATION: Dystonic pain is frequent in children with dystonia, including those with CP, who undergo DBS; this can be an important, realizable goal of surgery irrespective of aetiology. We encourage the use of multimodal approach in pain research to reduce the risk of bias.

A rapid review of educational preparedness of advanced clinical practitioners.

AIM: The aim of this study was to synthesize available data on current educational provision related to preparation for the advanced clinical practice role. DESIGN: A mixed methods rapid review of the literature. DATA SOURCES: A search of Ovid Medline and Ovid EMBASE for English language papers published 2006-2018 resulted in 38 publications, which met the criteria for inclusion. REVIEW METHODS: Using Tricco's seven-stage process, following an identification of relevant papers and data extraction, a data-based convergent synthesis was used to convert quantitative papers into qualitative data prior to completing a narrative synthesis. RESULTS: The four themes identified from data synthesis were consolidation; theory to practice gap; competency and mentoring. A lack of preparedness for new advanced clinical practitioners completing an educational programme was noted with a need identified for a clinically focussed consolidation period to enable practitioners to develop their skills under supervision in the clinical environment. CONCLUSION: As the needs for different models of health care evolve with the expansion of advanced practice, appropriate education and clinical supervision are important aspects in the delivery of programmes that allow individuals to be competent and confident practitioners providing safe and effective health care. IMPACT: There is a paucity of papers on educational preparedness of advanced clinical practitioners. Our findings demonstrate a lack of preparedness and the need for a clinically focussed consolidation period with good role models and mentors following completion of a Master's programme. Employers and higher education institutions need to ensure a protected period of time is available for newly qualified advanced clinical practitioners to allow consolidation of clinical practice.

Patient satisfaction with a hospital-in-the-home service.

The hospital-in-the-home (HitH) model is an alternative model of healthcare that allows patients to return home and receive short-term treatment in a familiar environment. The objective of the present study was to evaluate patient satisfaction with the GSTT@home service in the London boroughs of Southwark and Lambeth. A questionnaire comprising 20 questions was developed with 5-point Likert response and free text options. A total of 1426 questionnaires were distributed, of which 206 (14%) were returned. The majority of respondents said they would recommend the @home service (n=200, 97%) and were very satisfied or satisfied with the service (n=203, 99%). Only 48 respondents provided qualitative free text comments, and overall, these were very positive and supportive of the @home service. The findings support the benefits of the @home model of care from the patients' perspective.

Internet-Delivered Self-management Support for Improving Coronary Heart Disease and Self-management-Related Outcomes: A Systematic Review.

INTRODUCTION: Coronary heart disease (CHD) is associated with significant morbidity and mortality, including mental health comorbidity, which is associated with poor outcomes. Self-management is key, but there is limited access to self-management support. Internet-delivered interventions may increase access. OBJECTIVE: The aim of this study was to conduct a systematic review to (1) determine the effectiveness of Internet-delivered CHD self-management support for improving CHD, mood, and self-management related outcomes and (2) identify and describe essential components for effectiveness. METHOD: Randomized controlled trials that met prespecified eligibility criteria were identified using a systematic search of 3 healthcare databases (Medline, PsychINFO, and Embase). RESULTS: Seven trials, which included 1321 CHD patients, were eligible for inclusion. There was considerable heterogeneity between studies in terms of the intervention content, outcomes measured, and study quality. All 7 of the studies reported significant positive between-group effects, in particular for lifestyle-related outcomes. Personalization of interventions and provision of support to promote engagement may be associated with improved outcomes, although more data are required to confirm this. The theoretical basis of interventions was poorly developed though evidence-based behavior change interventions were used. CONCLUSION: More well-designed randomized controlled trials are needed. These should also explore how interventions work and how to improve participant retention and satisfaction and examine the role of personalization and support within interventions.

A minimal or maximal ablation strategy to achieve pulmonary vein isolation for paroxysmal atrial fibrillation: a prospective multi-centre randomized controlled trial (the Minimax study).

AIMS: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF). The intervenous ridge (IVR) may be incorporated into ablation strategies to achieve PVI; however, randomized trials are lacking. We performed a randomized multi-centre international study to compare the outcomes of (i) circumferential antral PVI (CPVI) alone (minimal) vs. (ii) CPVI with IVR ablation to achieve individual PVI (maximal). METHODS AND RESULTS: Two hundred and thirty-four patients with paroxysmal AF underwent CPVI and were randomized to a minimal or maximal ablation strategy. The primary outcome of recurrent atrial arrhythmia was assessed with 7-day Holter monitoring at 6 and 12 months. PVI was achieved in all patients. Radiofrequency ablation time was longer in the maximal group (46.6 ± 14.6 vs. 41.5 ± 13.1 min; P < 0.01), with no significant differences in procedural or fluoroscopy times. At mean follow-up of 17 ± 8 months, there was no difference in freedom from AF after a single procedure between a minimal (70%) and maximal ablation strategy (62%; P = 0.25). In the minimal group, ablation was required on the IVR to achieve electrical isolation in 44%, and was associated with a significant reduction in freedom from AF (57%) compared with the minimal group without IVR ablation (80%; P < 0.01). CONCLUSION: There was no statistically significant difference in freedom from AF between a minimal and maximal ablation strategy. Despite attempts to achieve PVI with antral ablation, IVR ablation is commonly required. Patients in whom antral isolation can be achieved without IVR ablation have higher long-term freedom from AF (the Minimax study; ACTRN12610000863033).