Overcoming Pandemic-Related Challenges in Recruitment and Screening: Strategies and Representation of Older Women With Cardiovascular Disease for a Multidomain Lifestyle Trial to Prevent Cognitive Decline.

BACKGROUND: Recruiting participants with cardiovascular disease into research during the COVID-19 pandemic was challenging, particularly those at risk of health disparities. OBJECTIVE: During the pandemic, 12 cohorts of older women with cardiovascular disease were recruited from cardiology clinics into a lifestyle intervention trial to prevent cognitive decline. Objectives were to (a) describe the results of modified recruitment/screening strategies to overcome pandemic-related challenges and (b) evaluate differences in age, race, and ethnicity between patients recruited/randomized, recruited/not randomized (entered recruitment but not randomized because of being ineligible or not interested), and not recruited (clinic patients who met preliminary criteria but did not enter recruitment). METHODS: This was a cross-sectional descriptive analysis. In-person study strategies proposed before the COVID-19 pandemic were modified before study onset (September 2020). Women 65 years or older with cardiovascular disease were recruited from cardiology clinics by clinicians, posted flyers, and letters mailed to patients randomly selected from electronic health record data extractions. Patients were classified as recruited/randomized, recruited/not randomized, and not recruited. RESULTS: Of 5719 patients potentially eligible, 1689 patients entered recruitment via referral (49.1%), posted flyers (0.5%), or mailed letters (50.3%), and 253 patients were successfully recruited/randomized. Recruited/randomized participants were, on average, 72.4 years old (range, 65-90 years old), non-Hispanic White (54.2%), non-Hispanic Black (38.3%), Hispanic/Latinx (1.6%), and other/not reported (5.1%). The recruited/randomized group was significantly younger with fewer patients of Hispanic/Latinx ethnicity compared with those not recruited. CONCLUSIONS: During the pandemic, all recruitment/screening goals were met using modified strategies. Differences in sociodemographic representation indicate a need for tailored strategies.

DNP-PhD Collaboration in NINR-Funded Physical Activity Trials: A Series of Case Studies.

Collaboration between Doctor of Nursing Practice (DNP) scholars and Doctor of Philosophy (PhD) scholars is crucial to efficiently advance and disseminate nursing science. Also, DNP-PhD collaboration can help achieve priorities outlined in the recent National Institute of Nursing Research (NINR) Strategic Plan. The purpose of this series of case studies is to describe exemplars of ongoing DNP-PhD collaborations across three NINR-funded trials (1 completed, 2 ongoing) testing physical activity interventions for women at risk for cardiovascular disease. In our three physical activity intervention trials for women, we categorized examples of DNP-PhD collaboration by the four phases of the team-based research model (development, conceptualization, implementation, and translation). Across all three trials, DNP and PhD scholars contributed successfully to all phases of research in an iterative manner. Future work should focus on expanding DNP-PhD collaboration in behavioral trials, which can inform adapted, contemporary models of iterative DNP-PhD collaboration.

JCL Roundtable. The lipidology team.

Clinical lipidology practice works best when implemented by a health care team. The 3 discussants for this JCL Roundtable are National Lipid Association leaders representing essential areas on the team - Registered Dietitian Nutritionist, Advanced Practice Provider, and Clinical Pharmacist. The team approach has been shown more effective than traditional sole provider management for controlling chronic asymptomatic conditions like hypercholesterolemia. Teams also fit better as health care transitions away from fee-for-service into value-based reimbursement. It's worth noting that medicine and even surgery were never entirely solo endeavors. Here we discuss a more expansive team model, which began in the U.S. more than 2 decades ago in the Veterans Administration and certain managed care organizations such as Kaiser Permanente. These health care organizations place themselves at risk, comprising both normative and financial risk, for maintaining their patients' health. Academic medical centers and private health care groups increasingly are adopting the at-risk model and medical teams. Electronic health records facilitate the transition. Team members include not only licensed professionals like our discussants, but also medical assistants, front desk staff, and schedulers. All share decision making and responsibility. Ideally the patient becomes the central member, not merely the focal point, of the team. We explore specific roles within the lipidology team, and we identify continuing barriers to implementation.

High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better.

Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors.

BACKGROUND: Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors. OBJECTIVE: To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors. METHODS: This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors. RESULTS: A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%). CONCLUSION: Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

A study protocol for MindMoves: A lifestyle physical activity and cognitive training intervention to prevent cognitive impairment in older women with cardiovascular disease.

INTRODUCTION: Cognitive impairment (CI) and cardiovascular disease (CVD) disproportionately affect women compared to men, and CVD increases risk of CI. Physical activity and cognitive training can improve cognition in older adults and may have additive or synergistic effects. However, no combined intervention has targeted women with CVD or utilized a sustainable lifestyle approach. The purpose of the trial is to evaluate efficacy of MindMoves, a 24-week multimodal physical activity and cognitive training intervention, on cognition and serum biomarkers in older women with CVD. Three serum biomarkers (brain-derived neurotrophic factor [BDNF], vascular endothelial growth factor [VEGF], and insulin-like growth factor 1 [IGF-1]) were selected as a priori hypothesized indicators of the effects of physical activity and/or cognitive training on cognition. METHODS: The study design is a randomized controlled trial with a 2 × 2 factorial design, to determine independent and combined efficacies of Mind (tablet-based cognitive training) and Move (lifestyle physical activity with goal-setting and group meetings) on change in cognition (primary outcome) and serum biomarkers (secondary outcomes). We will recruit 254 women aged ≥65 years with CVD and without CI from cardiology clinics. Women will be randomized to one of four conditions: (1) Mind, (2) Move, (3) MindMoves, or (4) usual care. Data will be obtained from participants at baseline, 24, 48, and 72 weeks. DISCUSSION: This study will test efficacy of a lifestyle-focused intervention to prevent or delay cognitive impairment in older women with CVD and may identify relevant serum biomarkers that could be used as early indicators of intervention response.

The Feasibility of a Combined Lifestyle Physical Activity and Cognitive Training Intervention to Prevent Cognitive Impairment in Older Women With Cardiovascular Disease.

BACKGROUND: Cognitive impairment disproportionately affects older women with cardiovascular disease (CVD). Physical activity (PA) and cognitive training (CT) may have synergistic effects in combined interventions. However, no combined intervention has targeted women with CVD or utilized a sustainable and preferable lifestyle approach. The purpose was to test feasibility and acceptability of the 24-week MindMoves program, a lifestyle intervention that combined PA and CT developed for older women with CVD. METHODS: The PA component included goal setting with Fitbits and 5 behavioral group meetings. The CT component was evidence-based BrainHQ delivered on a tablet in three 30-minute weekly sessions. Participants included 10 women aged ≥65 years with CVD. Exclusion criteria were cognitive impairment, regular PA, and CT use. Measures were feasibility (recruitment, attendance, participation, retention, and acceptability), change in PA (Fitbit min/steps), and change in cognitive function (NIH Toolbox®). RESULTS: Of the 10 participants, 70% attended ≥4/5 group meetings, and overall attendance was 76%. Participants completed 2.3/3 CT sessions weekly. Participant retention was 100%. Over 90% of participants rated MindMoves with the highest levels of satisfaction. Participants had significant improvements in steps, light PA, and moderate PA, and there was a trend for improved cognition. CONCLUSIONS: Findings support testing MindMoves in an efficacy trial.

Supporting Primary Care Access and Use among Homeless Persons.

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

Genetic testing in dyslipidemia: A scientific statement from the National Lipid Association.

The genetic basis for more than 2 dozen monogenic dyslipidemias has largely been defined. Genetic technologies, such as DNA sequencing, can detect both rare and common DNA variants underlying dyslipidemias, and these methods are increasingly available. Although patients with extreme abnormalities in low-density lipoprotein cholesterol, triglycerides, or high-density lipoprotein cholesterol may be considered for genetic testing, it is only in a minority of patients that the results will alter treatment or outcomes. Currently, there is potential clinical utility of genetic testing for familial hypercholesterolemia, familial chylomicronemia syndrome, sitosterolemia, lysosomal acid lipase deficiency, and a few other rare disorders, and this will increase the demand for reliable genetic diagnostic methods at lower cost. Clinical indications for genetic testing for most dyslipidemias are not clearly established and currently no guidelines exist. A shared decision-making model between the patient and the provider is essential as patient values and preferences play a very strong role. Potential benefits of genetic testing include providing a firm diagnosis in many cases, guiding optimal management and prevention strategies, advancing care strategies beyond currently available treatments, and contributing to overall scientific progress. Understanding the limitations and risks of genetic testing techniques is also important, as is careful interpretation of genetic test results to achieve the greatest benefit. Here we review laboratory methods, as well as technical, biological, clinical, and ethical implications and applications of genetic testing in dyslipidemias.

Palliative Care in Heart Transplantation.

The purpose of this article is to describe palliative care incorporation within the care of heart transplant patients. Palliative care is a holistic approach to care that includes symptom management and goal setting to improve patients' quality of life. Palliative care is designed to be used with patients who have chronic illness that impacts quality of life and should be incorporated early in the disease. All providers have a responsibility to be knowledgeable in palliative care approaches and to know when to refer a patient for specialty palliative care services. This article will describe palliative care, research study findings, and current professional guideline recommendations for patients. The article also describes challenges and barriers to the use of palliative care in heart transplant patients and strategies to address these challenges and barriers.

Reducing the Clinical and Public Health Burden of Familial Hypercholesterolemia: A Global Call to Action.

Importance: Familial hypercholesterolemia (FH) is an underdiagnosed and undertreated genetic disorder that leads to premature morbidity and mortality due to atherosclerotic cardiovascular disease. Familial hypercholesterolemia affects 1 in 200 to 250 people around the world of every race and ethnicity. The lack of general awareness of FH among the public and medical community has resulted in only 10% of the FH population being diagnosed and adequately treated. The World Health Organization recognized FH as a public health priority in 1998 during a consultation meeting in Geneva, Switzerland. The World Health Organization report highlighted 11 recommendations to address FH worldwide, from diagnosis and treatment to family screening and education. Research since the 1998 report has increased understanding and awareness of FH, particularly in specialty areas, such as cardiology and lipidology. However, in the past 20 years, there has been little progress in implementing the 11 recommendations to prevent premature atherosclerotic cardiovascular disease in an entire generation of families with FH. Observations: In 2018, the Familial Hypercholesterolemia Foundation and the World Heart Federation convened the international FH community to update the 11 recommendations. Two meetings were held: one at the 2018 FH Foundation Global Summit and the other during the 2018 World Congress of Cardiology and Cardiovascular Health. Each meeting served as a platform for the FH community to examine the original recommendations, assess the gaps, and provide commentary on the revised recommendations. The Global Call to Action on Familial Hypercholesterolemia thus represents individuals with FH, advocacy leaders, scientific experts, policy makers, and the original authors of the 1998 World Health Organization report. Attendees from 40 countries brought perspectives on FH from low-, middle-, and high-income regions. Tables listing country-specific government support for FH care, existing country-specific and international FH scientific statements and guidelines, country-specific and international FH registries, and known FH advocacy organizations around the world were created. Conclusions and Relevance: By adopting the 9 updated public policy recommendations created for this document, covering awareness; advocacy; screening, testing, and diagnosis; treatment; family-based care; registries; research; and cost and value, individual countries have the opportunity to prevent atherosclerotic heart disease in their citizens carrying a gene associated with FH and, likely, all those with severe hypercholesterolemia as well.

Feasibility of a Lifestyle Physical Activity Intervention to Prevent Memory Loss in Older Women With Cardiovascular Disease: A Mixed-Methods Approach.

BACKGROUND: Memory loss in older age affects women more than men and cardiovascular disease is a leading risk factor. Physical activity can improve memory in healthy older adults; however, few physical activity interventions have targeted women with cardiovascular disease, and none utilized lifestyle approaches. PURPOSE: The purpose of this study was to examine feasibility, acceptability, and preliminary effects of a 24-week lifestyle physical activity intervention (physical activity prescription, five group meetings, and nine motivational interviewing calls). METHODS: A sequential mixed-methods approach was used. Participants were 18 sedentary women ≥65 years with cardiovascular disease and without cognitive impairment recruited in August 2017. Feasibility, acceptability, self-reported health, accelerometer-assessed physical activity, and neurocognitive memory tests were measured using a pre-post test design. Two post-intervention focus groups (n = 8) were conducted in June 2018. Concept analysis was used to identify barriers/motivators of intervention participation. RESULTS: Meeting attendance was >72% and retention was 94%. Participants rated the program with high satisfaction. There were significant improvements at 24 weeks in self-rated physical health, objective daily steps, and estimated cardiorespiratory fitness (d = .30-.64). Focus group themes generated recommendations for modifying the intervention. CONCLUSION: Findings support adapting the intervention further for women with cardiovascular disease and testing it in an efficacy trial.

"Now that you've got that coverage": Promoting use of a regular source of primary care among homeless persons.

BACKGROUND: The growing number of homeless persons in the United States demonstrates greater morbidity and mortality than the population as a whole. Homeless persons are often without a regular source of primary care. Homeless persons use emergency departments and are hospitalized at higher rates than nonhomeless persons. In 2010, the enactment of the Affordable Care Act expanded access to primary care services. Nurse practitioners were at the forefront of its subsequent implementation. PURPOSE: The purpose of this qualitative study was to explore the factors that influence establishing and maintaining a regular source of primary care among homeless persons. METHODOLOGICAL ORIENTATION: In 2017, semistructured interviews were conducted in a federally qualified health center that serves predominately homeless persons. SAMPLE: A purposive convenience sample included adult health center users (N = 20). The majority of participants were insured (90%), African American (70%), and male (65%). CONCLUSIONS: Thematic analysis revealed five facilitators: sense of community, mutual patient-provider respect, financial assurance, integrated health services, and patient care teams. To establish and maintain use of a regular primary care source, homeless persons desire to experience a sense of community, feel respected by their provider/staff, and have certainty that costs will not exceed their capacity to pay. Integrated care models that leverage a multidisciplinary team approach support the use of a regular primary care source. IMPLICATIONS FOR PRACTICE: Actualizing achievable strategies that promote the consistent use of a regular primary care source can reduce use of avoidable emergency and hospital-based services, thereby improving health outcomes among homeless persons.

Randomized Controlled Trial of Lifestyle Walking for African American Women: Blood Pressure Outcomes.

The aim of this study was to test the effects of a lifestyle physical activity intervention (group meetings alone vs supplemented by personal or automated calls) on changes in systolic/diastolic blood pressures from baseline to 24 and 48 weeks among African American women. This was a randomized controlled trial with intervention conditions randomly assigned across 6 community health care sites. Participants were 288 sedentary African American women without major signs/symptoms of cardiovascular disease. Each intervention had 6 group meetings over 48 weeks, with 1 of 3 options between meetings: (1) no calls, (2) personal motivational calls, or (3) automated motivational calls. Blood pressures were taken at baseline, 24 weeks, and 48 weeks. Separate analyses were conducted using blood pressure classifications from the 2003 and 2017 high blood pressure guidelines. Average blood pressures decreased approximately 3 mm Hg for systolic and 2 mm Hg for diastolic from baseline to 48 weeks, with no differences between conditions. For both 2003 and 2017 blood pressure classifications, the risk ratio (odds of moving to a lower classification) was 1.44 for each assessment (P < .001). This lifestyle walking intervention appears beneficial in lowering blood pressure across blood pressure classifications in midlife African American women.

JCL roundtable. The 2018 AHA/ACC/Multisociety Cholesterol Guidelines: Process and product.

In this NLA Roundtable four members of the writing committee join the Editor to discuss the process of developing the AHA/ACC/Multisociety Cholesterol Guidelines, which were unveiled in November 2018. They also provide personal insights on the finished product. Highlights include 1) the committee's decision to summarize 10 take-home messages providing rapid communication of key points, 2) emphasis on clinician -patient discussion, which may bring up issues specific to women or other population groups at risk, 3) personalizing risk with risk-enhancing factors such as LDL-C ≥ 160 mg/dl, metabolic syndrome, chronic kidney disease, pre-eclampsia, premature menopause, high risk ethnicity, inflammatory diseases, hypertriglyceridemia and in selected cases, Lp(a), hs-CRP and apoB; 4) using coronary artery calcium scoring when a risk decision is uncertain in intermediate risk patients 5) monitoring for goals of moderate or intensive LDL cholesterol reduction, 6) thresholds for adding nonstatin LDL-lowering therapy in those at very high risk or for heterozygous familial hypercholesterolemia and 7) cost value assessment for expensive treatment.

Life-Saving Medications: The Urgent Need for Guideline Adherence and Patient Acceptance.

See Article by Bradley et al.

Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology.

Risk assessment is a critical step in the current approach to primary prevention of atherosclerotic cardiovascular disease. Knowledge of the 10-year risk for atherosclerotic cardiovascular disease identifies patients in higher-risk groups who are likely to have greater net benefit and lower number needed to treat for both statins and antihypertensive therapy. Current U.S. prevention guidelines for blood pressure and cholesterol management recommend use of the pooled cohort equations to start a process of shared decision-making between clinicians and patients in primary prevention. The pooled cohort equations have been widely validated and are broadly useful for the general U.S. clinical population. But, they may systematically underestimate risk in patients from certain racial/ethnic groups, those with lower socioeconomic status or with chronic inflammatory diseases, and overestimate risk in patients with higher socioeconomic status or who have been closely engaged with preventive healthcare services. If uncertainty remains for patients at borderline or intermediate risk, or if the patient is undecided after a patient-clinician discussion with consideration of risk enhancing factors (e.g., family history), additional testing with measurement of coronary artery calcium can be useful to reclassify risk estimates and improve selection of patients for use or avoidance of statin therapy. This special report summarizes the rationale and evidence base for quantitative risk assessment, reviews strengths and limitations of existing risk scores, discusses approaches for refining individual risk estimates for patients, and provides practical advice regarding implementation of risk assessment and decision-making strategies in clinical practice.