The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Main Mechanisms of Remote Monitoring Programs for Cardiac Rehabilitation and Secondary Prevention: A SYSTEMATIC REVIEW.

PURPOSE: The objective of this report was to identify the main mechanisms of home-based remote monitoring programs for cardiac rehabilitation (RM CR) and examine how these mechanisms vary by context. METHODS: This was a systematic review using realist synthesis. To be included, articles had to be published in English between 2010 and November 2020 and contain specific data related to mechanisms of effect of programs. MEDLINE All (1946-) via Ovid, Embase (1974-) via Ovid, APA PsycINFO (1806-), CINAHL via EBSCO, Scopus databases, and gray literature were searched. RESULTS: From 13 747 citations, 91 focused on cardiac conditions, with 23 reports including patients in CR. Effective RM CR programs more successfully adapted to different patient home settings and broader lives, incorporated individualized patient health data, and had content designed specifically for patients in cardiac rehabilitation. Relatively minor but common technical issues could significantly reduce perceived benefits. Patients and families were highly receptive to the programs and viewed themselves as fortunate to receive such services. The RM CR programs could be improved via incorporating more connectivity to other patients. No clear negative effects on perceived utility or outcomes occurred by patient age, ethnicity, or sex. Overall, the programs were seen to best suit highly motivated patients and consolidated rather than harmed existing relationships with health care professionals and teams. CONCLUSIONS: Remote monitoring CR programs are perceived by patients to be beneficial and attractive. Future RM CR programs should consider adaptability to different home settings, incorporate individualized health data, and contain content specific to patient needs.

A scoping review and intersectionality-based analysis of heart failure telehealth interventions for vulnerable populations.

AIMS: To map the existing body of heart failure (HF) telehealth interventions for vulnerable populations, and to conduct an intersectionality-based analysis utilizing a structured checklist. DESIGN: A scoping review and intersectionality-based analysis. DATA SOURCES: The search was conducted in March 2022 in the following databases: MEDLINE, CINAHL, Scopus and the Cochrane Central Register of Controlled Trials, ProQuest Dissertations and Theses Global. REVIEW METHODS: First, the titles and abstracts were screened, and then the entire articles were screened against the inclusion criteria. Two of the investigators screened the articles independently in Covidence. The studies included and excluded at various stages of screening were depicted through a PRISMA flow diagram. The quality of the included studies was assessed based on the mixed methods appraisal tool (MMAT). Each study was read thoroughly and the intersectionality-based checklist by Ghasemi et al. (2021) was applied, whereby a yes/no response was marked for each question on the checklist and the relevant supporting data were extracted. RESULTS: A total of 22 studies were included in this review. About 42.2% of the responses indicated that studies incorporated the principles of intersectionality at the 'problem identification' stage, followed by 42.9% and 29.44% responses indicating incorporation of these principles at the 'design and implementation' and 'evaluation' stages respectively. CONCLUSIONS: The findings suggest that the research around HF telehealth interventions for vulnerable populations is not adequately grounded in appropriate theoretical underpinning. The principles of intersectionality have been applied mostly to the problem identification and the intervention development and implementation stages, and not so much at the evaluation stage. Future research must fill the identified gaps in this area of research. NO PATIENT OR PUBLIC CONTRIBUTION: Since this was a scoping, there was no patient contribution to this work; however, based on this study's findings, we are undertaking patient-centred studies with patient contribution.

Intersectionality and heart failure: what clinicians and researchers should know and do.

PURPOSE OF REVIEW: To review the application of intersectionality to heart failure. Intersectionality refers to the complex ways in which disenfranchisement and privilege intersect to reproduce and influence health and social outcomes. RECENT FINDINGS: Intersectionality challenges approaches that focus on a single or small number of socio-demographic characteristics, such as sex or age. Instead, approaches should take account of the nature and effects of a full range of socio-demographic factors linked to privilege, including: race and ethnicity, social class, income, age, gender identity, disability, geography, and immigration status. Although credible and well established across many fields - there is limited recognition of the effects of intersectionality in research into heart disease, including heart failure. This deficiency is important because heart failure remains a common and burdensome syndrome that requires complex pharmacological and nonpharmacological care and collaboration between health professionals, patients and caregivers during and at the end-of-life. SUMMARY: Approaches to heart failure clinical care should recognize more fully the nature and impact of patients' intersectionality- and how multiple factors interact and compound to influence patients and their caregivers' behaviours and health outcomes. Future research should explicate the ways in which multiple factors interact to influence health outcomes.

Perception on service quality in old age homes: A qualitative study in Karachi, Pakistan.

OBJECTIVE: The growing number of older people due to demographic transition is paving the way for nongovernmental organizations and the private sector for mushrooming of old age homes (OAHs). These homes function either free or fee for services and the services provided at these OAHs determines the quality of life of older people. The aim of the study was to explore the stakeholders' perception on the quality of services offered to people living in OAHs. METHODS: A descriptive qualitative study design was used to explore stakeholders' perception of elderly living experiences in old age homes. Three OAH were selected through purposive sampling for the study. Data collected from February-March 2015 through the structured interview guide. Participants' for FGDs were recruited through universal sampling, while purposive sampling was used for KIIs selection. Researcher ensured all ethical considerations for the entire study period. RESULTS: Two major themes were drawn including the reasons and experiences of older people living in OAH, secondly the need for caregivers' academic competencies. Majority of KIIs and FGDs reported common responses under the two themes. Also the elderly experiences varied from living comfortably to being depressed. KIIs and caregivers' FGD participants' strongly urged the need for caregivers' training and institutional accreditation. CONCLUSIONS: The results of the study on the older people's experiences and challenges of living in OAHs, strongly propose community support system and credentialing of the caregivers for age appropriate care. Moreover the capacity building of academia for offering specialized training in gerontology and geriatrics is also highlighted.

Sex differences in symptoms experienced, knowledge about symptoms, symptom attribution, and perceived urgency for treatment seeking among acute coronary syndrome patients in Karachi Pakistan.

BACKGROUND: Patients' experience of acute coronary syndrome (ACS) symptoms is important in determining their prehospital delay. OBJECTIVE: To explore gender differences in acute symptoms of ACS, knowledge about the symptoms, their attribution, and perception of urgency, among Pakistani ACS patients. METHODS: Comparative, cross-sectional study design with 249 ACS patients. RESULTS: The most commonly reported symptoms were ghabrahat (fidgetiness), chest pain, and chest heaviness. Most atypical symptoms were experienced more by women, such as nausea/vomiting (p < 0.001), backache (p < 0.001), palpitations (p = 0.004), and epigastric pain (p = 0.005). Chest pain and palpitations were the symptoms most commonly attributed to cardiac causes, whereas epigastric pain was most commonly attributed to non-cardiac causes by both men and women. Significantly more women than men perceived dyspnea (p = 0.026), nausea/vomiting (p = 0.027), sweating (p = 0.014), and palpitations (p = 0.01) as symptoms not at all urgent for treatment. CONCLUSIONS: Gender disparity in symptom experience along with the women's perception of non-urgency for their symptoms, could lead to delayed care seeking.

Level of knowledge among cardiac nurses regarding sexual counseling of post-MI patients in three tertiary care hospitals in Pakistan.

PURPOSE: The aim of this study is to measure the level of knowledge among cardiac nurses about sexual counseling of post-myocardial infarction (MI) patients. METHOD: This descriptive cross-sectional study was conducted among 153 nurses at three tertiary care hospitals of a large metropolitan city of Pakistan. RESULTS: The findings revealed that the majority nurses have moderate knowledge regarding post-MI sexual counseling. Additionally, nurses have lack of knowledge regarding effects of cardiac drugs on sexual life of post-MI patients. CONCLUSION: There is a need to improve nurses' knowledge in regard to sexual counseling among post-MI patients. Nurses should have knowledge to deal with such a sensitive issue as sexuality, in order to improve patients' quality of life. With respect to Pakistan, this was a baseline study and may provide insights for designing interventional or qualitative studies in the future.

Gender differences in factors associated with prehospital delay among acute coronary syndrome patients in Pakistan.

PURPOSE: To identify gender differences in prehospital delay time (PDT) and its associated factors among acute coronary syndrome (ACS) patients. DESIGN: Descriptive cross-sectional comparative study. METHODS: This study was conducted among 249 ACS patients at two tertiary care hospitals of a large metropolitan city of Pakistan. Data were collected through the modified Response to Symptoms Questionnaire. RESULTS: The median PDT of women was found to be 7 hours, compared to 3.5 hours among men (p = .001). Results of the regression analysis indicated that most women delayed because of social factors, such as attendants' responses to their symptoms (p = .002), and because they were worried about expenses required for the treatment (p = .002); yet, most men delayed owing to individual factors, such as waiting for symptoms to subside (p< .001), and not recognizing the symptoms as being cardiac related (p< .001). Having anxiety and lack of knowledge about symptoms was associated with extended PDT among both genders. CONCLUSION: Women delayed longer than men in seeking treatment for their ACS symptoms. Different factors were associated with PDT in women and men. This study may provide important insights for designing interventional studies to reduce PDT in Pakistani ACS patients.

Content Validity of a Tool Measuring Medication Errors.

The objective of this study was to determine content and face validity of a tool measuring medication errors among nursing students in baccalaureate nursing education. Data was collected from the Aga Khan University School of Nursing and Midwifery (AKUSoNaM), Karachi, from March to August 2014. The tool was developed utilizing literature and the expertise of the team members, expert in different areas. The developed tool was then sent to five experts from all over Karachi for ensuring the content validity of the tool, which was measured on relevance and clarity of the questions. The Scale Content Validity Index (S-CVI) for clarity and relevance of the questions was found to be 0.94 and 0.98, respectively. The tool measuring medication errors has an excellent content validity. This tool should be used for future studies on medication errors, with different study populations such as medical students, doctors, and nurses.

Who is responsible for the consequences? A case of stent thrombosis subsequent to noncompliance with post angioplasty treatment regimen.

Coronary artery disease (CAD) is a major cause of mortality internationally and in Pakistan. Angioplasty has been proven to be an effective treatment for CAD. Stent thrombosis is a known but preventable complication of angioplasty. Several factors may lead to stent thrombosis with non-compliance with the prescribed drug regimen, being one of the most important factors. We report a case of stent thrombosis after four months of angioplasty. After exploring of patient's post angioplasty routines, it was found that the patient was non-compliant with the prescribed anti- platelets and other prescribed drugs. This time the patient presented with another acute myocardial infarction, and he went through angioplasty again.

Psychosocial experiences of women with vesicovaginal fistula: a qualitative approach.

Vesicovaginal fistula (VVF) is a condition associated with a number of physical and psychological consequences. In order to gain a deeper understanding of the issues faced by women diagnosed with VVF, a qualitative exploratory study was carried out to explore the experiences of women suffering from VVF. The study included 8 women hospitalized with the diagnosis of vesicovaginal fistula at Kohi Goth Women's Hospital, Karachi, Pakistan. Semi structured interviews of each participant were conducted, recorded, and transcribed. Five major themes were identified, among which all of the participants experienced physical discomforts, psychological disturbances, issues with social and interpersonal relationships and financial constraints. However, concerns with religious practices were experienced by 87.5% of the participants. Pakistani women who are suffering through VVF face many challenges. Combined efforts should be made to offer supportive services to women suffering from this condition.

Validity and reliability testing: Urdu translated modified Response to Symptoms Questionnaire.

OBJECTIVE: To determine validity and reliability of the Urdu translated, modified "Response to symptoms questionnaire" (RSQ) among acute coronary syndrome (ACS) patients in Karachi. STUDY DESIGN: A qualitative, tool validation study. PLACE AND DURATION OF STUDY: Two tertiary care hospitals in Karachi, the Aga Khan University Hospital, Karachi and the Karachi Institute of Heart Diseases, from December 2010 to April 2011. METHODOLOGY: After making certain modifications, the original tool in English was translated into Urdu. Next, five cardiology experts evaluated the tool for its content and face validity. Test retest and inter rater reliabilities were computed for the RSQ using 5% of the total sample size of the parent study. RESULTS: Sufficient conceptual and semantic equivalence was found between the Urdu and English versions of the modified RSQ. Content validity index was calculated to be 1 for both relevance and linguistic clarity. Test retest and inter rater reliabilities were calculated to be 95.9% and K = 0.97, respectively. CONCLUSION: The Urdu translated modified RSQ has sufficiently acceptable content validity, test retest and inter rater reliability; hence, it should be used by the researchers for the evaluation of factors associated with pre-hospital delay among Urdu speaking ACS patient populations.

An unusual presentation of infective endocarditis.

This paper reports a case of a 22 years old young male who presented in emergency department with some non-specific symptoms such as abdominal pain, vomiting, chest heaviness and shortness of breath. Chest x-ray revealed a combined picture of pneumonia and congestive heart failure. Echocardiogram showed ventricular septal defect, aortic regurgitation and mitral stenosis. Later on diagnosed with infective endocarditis and the culprit was his native valves. He went through aortic valve replacement and discharged after full recovery.