Design of a Multiple-Behavior Change Intervention for Supporting Self-management in Patients With Chronic Heart Failure: An Intervention Mapping Approach.

BACKGROUND: Nonadherence to medication and low physical activity contribute to morbidity, mortality, and decreased quality of life among patients with chronic heart failure (CHF). Effective interventions that can be delivered during routine clinical care are lacking. OBJECTIVE: We aimed to adapt the feasible and cost-effective Adherence Improving self-Management Strategy (AIMS) for patients with human immunodeficiency virus (HIV) to CHF treatment. Subsequently, we determined its acceptability and feasibility. METHODS: Adherence Improving self-Management Strategy is a systematic, nurse-delivered counseling intervention blended with eHealth to facilitate patient self-management. We used the intervention mapping framework to systematically adapt AIMS-HIV to AIMS-CHF, while preserving essential intervention elements. Therefore, we systematically consulted the scientific literature, patients with CHF and nurses, and pretested intervention materials. RESULTS: Adherence Improving self-Management Strategy-HIV was modified to AIMS-CHF: a multiple-behavior change intervention, focused on medication adherence and physical activity. Key self-management determinants (such as attitudes, self-efficacy, and self-regulatory skills) and organization of care (such as specialized nurses delivering AIMS) were similar for HIV and heart failure care. The AIMS protocol, as well as material content and design, was systematically adapted to CHF. Preliminary testing suggests that AIMS-CHF is likely feasible and acceptable to patients with CHF and care providers. CONCLUSION: Using the intervention mapping protocol, AIMS-HIV could be systematically adapted to AIMS-CHF and seems acceptable and feasible. Evidence from the literature, behavioral theory, and input from nurses and patients were essential in this process. Adherence Improving self-Management Strategy-CHF should now be tested for feasibility and effectiveness in routine care.

Rapid Improvements in Physical Activity and Sedentary Behavior in Patients With Acute Myocardial Infarction Immediately Following Hospital Discharge.

Background Little is known about changes in physical activity (PA) and sedentary behavior (SB) patterns in the acute phase of a myocardial infarction (MI). We objectively assessed PA and SB during hospitalization and the first week after discharge. Methods and Results Consecutively admitted patients hospitalized with an MI were approached to participate in this prospective cohort study. SB, light-intensity PA, and moderate-vigorous intensity PA were objectively assessed for 24 h/d during hospitalization and up to 7 days after discharge in 165 patients. Changes in PA and SB from the hospital to home phase were evaluated using mixed-model analyses, and outcomes were stratified for predefined subgroups based on patient characteristics. Patients (78% men) were aged 65±10 years and diagnosed with ST-segment-elevation MI (50%) or non-ST-segment-elevation MI (50%). Sedentary time was high during hospitalization (12.6 [95% CI, 11.8-13.7] h/d) but substantially decreased following transition to the home environment (-1.8 [95% CI, -2.4 to -1.3] h/d). Furthermore, the number of prolonged sedentary bouts (≥60 minutes) decreased between hospital and home (-1.6 [95% CI, -2.0 to -1.2] bouts/day). Light-intensity PA (1.1 [95% CI, 0.8-1.6] h/d) and moderate-vigorous intensity PA (0.2 [95% CI, 0.1-0.3] h/d) were low during hospitalization but significantly increased following transition to the home environment (light-intensity PA: 1.8 [95% CI, 1.4-2.3] h/d; moderate-vigorous intensity PA: 0.4 [95% CI, 0.3-0.5] h/d; both P<0.001). Improvements in PA and SB were similar across groups, except for patients who underwent coronary artery bypass grafting and who did not improve their PA patterns after discharge. Conclusions Patients with MI demonstrate high levels of SB and low PA volumes during hospitalization, which immediately improved following discharge at the patient's home environment. Registration URL: trialsearch.who.int/; Unique identifier: NTR7646.

Sitting patterns in cardiovascular disease patients compared with healthy controls and impact of cardiac rehabilitation.

PURPOSE: To identify how and when to intervene in cardiovascular disease (CVD) patients' sedentary behavior, we moved beyond studying total volume of sitting and examined sitting patterns. By analyzing the timing of stand-to-sit and sit-to-stand transitions, we compared sitting patterns (a) between CVD patients and healthy controls, and (b) before and after cardiac rehabilitation (CR). METHODS: One hundered twenty nine CVD patients and 117 age-matched healthy controls continuously wore a tri-axial thigh-worn accelerometer for 8 days (>120 000 posture transitions). CVD patients additionally wore the accelerometer directly and 2 months after CR. RESULTS: With later time of the day, both CVD patients and healthy controls sat down sooner (i.e., shorter standing episode before sitting down; HR = 1.01, 95% CI [1.011, 1.015]) and remained seated longer (HR = 0.97, CI [0.966, 0.970]). After more previous physical activity, both groups sat down later (HR = 0.97, CI [0.959, 0.977]), and patients remained seated longer (HR = 0.96; CI [0.950, 0.974]). Immediately and 2-months following CR, patients sat down later (HRpost-CR  = 0.96, CI [0.945, 0.974]; HRfollow-up  = 0.96, CI [0.948, 0.977]) and stood up sooner (HRpost-CR  = 1.04, CI [1.020, 1.051]; HRfollow-up  = 1.03, CI [1.018, 1.050]). These effects were less pronounced with older age, higher BMI, lower sedentary behavior levels, and/or higher physical activity levels at baseline. CONCLUSION: Cardiac rehabilitation programs could be optimized by targeting CVD patients' sit-to-stand transitions, by focusing on high-risk moments for prolonged sitting (i.e., in evenings and after higher-than-usual physical activity) and attending to the needs of specific patient subgroups.

High Levels of Sedentary Time in Patients with COVID-19 after Hospitalisation.

Many patients with COVID-19 experience severe and even fatal disease. Survivors may have long-term health consequences, but data on physical activity and sedentary behaviour are scarce. Therefore, we objectively assessed physical activity (PA) patterns among post-hospitalised patients with COVID-19 and explored associations with patient characteristics, disease severity and cardiac dysfunction. We objectively assessed PA, sedentary behaviour and sleep duration for 24 h/day during 8 days at 3-6 months after COVID-19 hospitalisation. PA and sedentary time were compared across pre-defined subgroups based on patient and disease characteristics, cardiac biomarker release during hospitalisation, abnormal transthoracic echocardiogram at 3-6 months post-hospitalisation and persistence of symptoms post-discharge. PA and sedentary behaviour were assessed in 37 patients (60 ± 10 years old; 78% male). Patients spent 4.2 [3.2; 5.3] h/day light-intensity PA and 1.0 [0.8; 1.4] h/day moderate-to-vigorous intensity PA. Time spent sitting was 9.8 [8.7; 11.2] h/day, which was accumulated in 6 [5; 7] prolonged sitting bouts (≥30 min) and 41 [32; 48] short sitting bouts (<30 min). No differences in PA and sedentary behaviour were found across subgroups, but sleep duration was higher in patients with versus without persistent symptoms (9.1 vs. 8.3 h/day, p = 0.02). Taken together, high levels of sedentary time are common at 3-6 months after COVID-19 hospitalisation, whilst PA and sedentary behaviour are not impacted by patient or disease characteristics.

Changes in Physical Activity and Sedentary Behaviour in Cardiovascular Disease Patients during the COVID-19 Lockdown.

The COVID-19 lockdown has been associated with physical inactivity. We prospectively evaluated changes in moderate-to-vigorous physical activity (MVPA) and sedentary time (ST) among 1565 cardiovascular disease (CVD) patients using validated questionnaires at 5 weeks after lockdown initiation (i.e., baseline, April 2020) and at every 4 subsequent weeks, until July 2020. Multivariate mixed model analyses were performed to identify whether age, sex, CVD-subtype, lockdown adherence and mental health factors impacted changes in physical (in)activity. Patients were 67 (interquartile range: 60-73) years and primarily diagnosed with coronary artery disease. Time spent in MVPA was 143 min/day (95% confidence interval (CI) 137; 148) at baseline. Female sex, heart-failure, fear of COVID-19 infection and limited possibilities for physical activity were independently associated with lower levels of MVPA across time. After adjusting for confounders, overall MVPA did not change. ST was 567 (95% CI 555; 578) min/day at baseline. Lack of social contact, limited possibilities for physical activity and younger age were independently associated with higher levels of ST. After adjusting for confounders, ST progressively increased following 8 (Δ+19.7 (95% CI 0.4; 39.0)) and 12 weeks (Δ+25.2 (95% CI 5.4; 47.1) min/day) of lockdown. Despite a phased relaxation of the lockdown, CVD patients progressively increased ST and reported no change in MVPA. This highlights the need to target physical inactivity during and beyond the COVID-19 pandemic.

Sedentary behaviour in cardiovascular disease patients: Risk group identification and the impact of cardiac rehabilitation.

BACKGROUND: Sedentary behaviour (SB) is potentially an important target to improve cardiovascular health. This study 1) compared SB between cardiovascular disease (CVD) patients and age-matched controls, 2) identified characteristics associated with high SB levels, and 3) determined the impact of contemporary cardiac rehabilitation (CR) on SB. METHODS: For objective 1, we recruited 131 CVD patients and 117 controls. All participants were asked about their general characteristics and medical history. SB was assessed by an objective accelerometer (activPAL3 micro). For objective 2, 2584 CVD patients were asked to fill in a questionnaire about their general characteristics, lifestyle, medical history and their SB. For objective 3, 131 CVD patients were followed over time and measured, pre-, directly post- and 2 months post-CR. RESULTS: Objective 1. CVD patients spent 10.4 h/day (Q25 9.5; Q75 11.2) sedentary which was higher compared to healthy controls (9.4 h/day [Q25 8.4; Q75 10.29]). Objective 2. CVD patients being male, single or divorced, employed, physically inactive, reporting high alcohol consumption, living in an urban environment, having comorbidities and cardiac anxiety demonstrated a greater odds for large amounts of SB. Objective 3. The CR program significantly reduced sedentary time (-0.4 h/day [95%CI -0.7; -0.1]), which remained lower at 2-months post-CR (-0.3 h/day [95%CI -0.6; -0.03]). CONCLUSIONS: CVD patients had greater amounts of objectively measured sedentary time compared to healthy controls. Sedentarism was associated with personal- and lifestyle characteristics, and comorbidities. Participation in a contemporary CR program slightly reduced sedentary time, but tailored interventions are needed to target SB in CVD patients.

Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival.

BACKGROUND/OBJECTIVES: Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short- and long-term survival. DESIGN: Prospective cohort study. SETTING: Academic medical center. PARTICIPANTS: A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017. MEASUREMENTS: Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria. Outcomes were postprocedural clinical outcome and short- and long-term survival (30 days and 5 years, respectively). RESULTS: POD was observed in 16.5% (116/703), was the strongest independent predictor of long-term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36-2.70), and was associated with impaired 30-day and 5-year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52-4.31) and aortic valve area less than 0.75 cm2 (OR = 2.39; 95% CI = 1.53-3.74). CONCLUSION: One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long-term mortality and was associated with impaired short- and long-term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325-2330, 2019.