Usability and feasibility analysis of an mHealth-tool for supporting physical activity in people with heart failure.

BACKGROUND: Physical inactivity and a sedentary lifestyle are common among people with heart failure (HF), which may lead to worse prognosis. On an already existing mHealth platform, we developed a novel tool called the Activity coach, aimed at increasing physical activity. The aim of this study was to evaluate the usability of the Activity coach and assess feasibility of outcome measures for a future efficacy trial. METHODS: A mixed-methods design was used to collect data. People with a HF diagnosis were recruited to use the Activity coach for four weeks. The Activity coach educates the user about physical activity, provides means of registering daily physical activity and helps the user to set goals for the next week. The usability was assessed by analysing system user logs for adherence, reported technical issues and by interviews about user experiences. Outcome measures assessed for feasibility were objective physical activity as measured by an accelerometer, and subjective goal attainment. Progression criteria for the usability assessment and for the proposed outcomes, were described prospectively. RESULTS: Ten people with HF were recruited, aged 56 to 78 with median age 72. Data from nine of the ten study participants were included in the analyses. Usability: The Activity coach was used 61% of the time and during the first week two study participants called to seek technical support. The Activity coach was found to be intuitive and easy to use by all study participants. An increased motivation to be more physically active was reported by six of the nine study participants. However, in spite of feeling motivated, four reported that their habits or behaviours had not been affected by the Activity coach. FEASIBILITY: Data was successfully stored in the deployed hardware as intended and the accelerometers were used enough, for the data to be analysable. One finding was that the subjective outcome goal attainment, was challenging to collect. A proposed mitigator for this is to use pre-defined goals in future studies, as opposed to having the study participants be completely free to formulate the goals themselves. CONCLUSIONS: It was confirmed that the Activity coach was easy to use. Furthermore, it might stimulate increased physical activity in a population of people with HF, who are physically inactive. The outcomes investigated seem feasible to include in a future efficacy trial. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05235763. Date of first registration: 11/02/2022.

The Nurses' Role in the Cardiac Rehabilitation Team: Data From the Perfect-CR Study.

BACKGROUND: Nurses constitute a central profession in the cardiac rehabilitation (CR) team delivering comprehensive CR to individuals with cardiovascular disease. We aimed to identify specific components reflecting the nurses' role in the CR team associated with attainment of risk factor targets post myocardial infarction. METHODS: Center-level data (n = 78) was used from the Perfect-CR study, in which structure and processes applied at CR centers in Sweden (including details on the nurses' role) were surveyed. Patient-level data (n = 6755) was retrieved from the SWEDEHEART registry. Associations between structure/processes and target achievement for systolic blood pressure (BP) (<140 mm Hg) and low-density lipoprotein cholesterol (LDL-C, <1.8 mmol/L) at 1 year post myocardial infarction were assessed using logistic regression. RESULTS: Structure and processes reflecting nurses' autonomy and role in the CR team associated with patients achieving systolic BP and/or LDL-C targets included the following: nurses having treatment algorithms to adjust BP medication (odds ratio [95% confidence interval]: systolic BP, 1.22 [1.05-1.42]; LDL-C, 1.17 [1.03-1.34]) and lipid-lowering medication (systolic BP, 1.14 [1.00-1.29]; LDL-C, 1.17 [1.05-1.30]), patients having the same nurse throughout follow-up (systolic BP, 1.07 [1.03-1.11]; LDL-C, 1.10 [1.06-1.14]), number of follow-up hours with a nurse (systolic BP, 1.13 [1.07-1.19]), having regular case rounds to discuss patient cases during follow-up (LDL-C, 1.22 [1.09-1.35]), and nurses having training in counseling methods (systolic BP, 1.06 [1.03-1.10]). CONCLUSION: Components reflecting CR nurses' autonomy and role in the team are of importance for patients attaining risk factor targets post myocardial infarction. The results could provide guidance for optimizing nurses' competence and responsibilities within the CR team to improve patient care.

The remote exercise SWEDEHEART study-Rationale and design of a multicenter registry-based cluster randomized crossover clinical trial (RRCT).

BACKGROUND: Despite proven benefits of exercise-based cardiac rehabilitation (EBCR), few patients with myocardial infarction (MI) participate in and complete these programs. STUDY DESIGN AND OBJECTIVES: The Remote Exercise SWEDEHEART study is a large multicenter registry-based cluster randomized crossover clinical trial with a planned enrollment of 1500 patients with a recent MI. Patients at intervention centers will be offered supervised EBCR, either delivered remotely, center-based or as a combination of both modes, as self-preferred choice. At control centers, patients will be offered supervised center-based EBCR, only. The duration of each time period (intervention/control) for each center will be 15 months and then cross-over occurs. The primary aim is to evaluate if remotely delivered EBCR, offered as an alternative to center-based EBCR, can increase participation in EBCR sessions. The proportion completers in each group will be presented in a supportive responder analysis. The key secondary aim is to investigate if remote EBCR is as least as effective as center-based EBCR, in terms of physical fitness and patient-reported outcome measures. Follow-up of major adverse cardiovascular events (cardiovascular- and all-cause mortality, recurrent hospitalization for acute coronary syndrome, heart failure hospitalization, stroke, and coronary revascularization) will be performed at 1 and 3 years. Safety monitoring of serious adverse events will be registered, and a cost-effectiveness analysis will be conducted to estimate the cost per quality-adjusted life-year (QALY) associated with the intervention compared with control. CONCLUSIONS: The cluster randomized crossover clinical trial Remote Exercise SWEDEHEART study is evaluating if participation in EBCR sessions can be increased, which may contribute to health benefits both on a group level and for individual patients including a more equal access to health care. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (Identifier: NCT04260958).

Impact of walk advice alone or in combination with supervised or home-based structured exercise on patient-reported physical function and generic and disease-specific health related quality of life in patients with intermittent claudication, a secondary analysis in a randomized clinical trial.

BACKGROUND: Supervised exercise is an integral part of the recommended first-line treatment for patients with intermittent claudication (IC). By reflecting the patients' perspectives, patient-reported outcome measurements provide additional knowledge to the biomedical endpoints and are important outcomes to include when evaluating exercise interventions in patients with IC. We aimed to evaluate the one-year impact of three strategies: unsupervised Nordic pole walk advice (WA), WA + six months of home-based structured exercise (HSEP) or WA + six months of hospital-based supervised exercise (SEP) on health-related quality of life and patient-reported physical function in patients with IC. METHODS: This secondary exploratory analysis of a multi-center, randomized clinical trial compared three exercise strategies. The primary outcome of the secondary analysis was the one-year change in the 36-Item Short-Form (SF-36). Secondary outcomes were three- and six-months SF-36 changes alongside three, six- and 12-months changes in the disease-specific Vascular Quality of Life instrument (VascuQoL) and the Patient-Specific Functional Scale (PSFS). The Kruskal-Wallis test with Bonferroni-adjusted post-hoc tests were used for between-group comparisons. Effect size calculations were used to describe the size of observed treatment effects, and the clinical meaningfulness of observed changes in the VascuQoL summary score at one year was studied using established minimally important difference (MID) thresholds. RESULTS: A total of 166 patients with IC, mean age: 72.1 (SD 7.4) years, 41% women, were randomized. No significant between-group differences were observed over time for the SF-36 or the PSFS scores whereas some significant between-group differences were observed in the VascuQoL domain and summary scores over time, favoring SEP and/or HSEP over WA. The observed SF-36 and VascuQoL domain and summary score effect sizes were small to moderate, and many domain score effect sizes also remained unchanged over time. A significantly higher proportion of the patients in the SEP group reached the VascuQoL summary score MID of improvement in one year. CONCLUSION: Clinically important improvements were observed in SEP using the VascuQoL, while we did not observe any significant between-group differences using the SF-36. Whereas effect sizes for the observed changes over time were generally small, a significantly higher proportion of patients in SEP reached the VascuQoL MID of improvement. TRIAL REGISTRATION: NCT02341716, January 19, 2015 (retrospectively registered).

Adult childhood cancer survivors' perceptions of factors that influence their ability to be physically active.

PURPOSE: Studies indicate that adult childhood cancer survivors do not achieve recommended physical activity levels. A deeper understanding of factors that influence their ability to be physically active is essential to identify individuals in need of support. The aim was to explore factors that influence adult childhood cancer survivor's ability to be physically active. METHOD: Semi-structured interviews were conducted from June to October 2020 with 20 adult childhood cancer survivors with a median age of 31 (min-max 20-47) years. Interviews were transcribed verbatim and analyzed with qualitative content analysis. RESULTS: Four main categories: "The impact of environmental factors," "Personal factors of importance," "Consequences of the treatment or disease," and "The impact of support from healthcare" and 10 sub-categories, were identified. Participants described how family habits and encouragement from others influenced their present ability to be physically active. Experienced benefits of physical activity were described as a facilitator for current physical activity while suffering from late complications was identified as a barrier. Participants highlighted the importance of specific and individualized physical activity recommendations. CONCLUSION: This study includes adult childhood cancer survivors several years after completion of treatment, hence highlighting the importance for support both during treatment and follow-up to sustain their physical activity. Healthcare providers need to identify individuals suffering from late complications, even several years after treatment; provide individualized physical activity recommendations; and educate families and schools about the importance of physical activity in childhood cancer survivorship. TRIAL REGISTRATION: This research project was registered in the Swedish National Database of Research and Development, identifier 273320, December 6, 2019 ( https://www.researchweb.org/is/vgr/project/273320 ).

Healthcare professionals' perceptions of using a digital patient educational programme as part of cardiac rehabilitation in patients with coronary artery disease - a qualitative study.

BACKGROUND: Participation in cardiac rehabilitation in patients with coronary artery disease (CAD) remains underutilised. Digital educational programmes, as part of cardiac rehabilitation, are emerging as a means of increasing accessibility, but healthcare professionals' perceptions of implementing and using these programmes are not known. The aim of the study was therefore to explore healthcare professionals ̓ perceptions and experiences of implementing and using a digital patient educational programme (DPE) as part of cardiac rehabilitation after acute CAD. METHODS: Individual semi-structured interviews were performed with 12 nurses and physiotherapists, ten women with a median age of 49.5 (min 37- max 59) years, with experience of using the DPE as part of a phase II cardiac rehabilitation programme in Region Västra Götaland, Sweden. The interviews were transcribed verbatim and analysed with inductive content analysis according to Graneheim and Lundman. RESULTS: An overall theme was identified throughout the unit of analysis: "Digital patient education - a complement yet not a replacement". Within this theme, three main categories were identified: "Finding ways that make implementation work", "Accessibility to information for confident and involved patients" and "Reaching one another in a digital world". Each main category contains a number of sub-categories. CONCLUSIONS: This study adds new knowledge on healthcare professionals' perceptions of a digital patient educational programme as a valuable and accessible alternative to centre-based education programmes as part of cardiac rehabilitation for patients with CAD. The participants highlighted the factors necessary for a successful implementation, such as support through the process and sufficient time from the employer to learn the system and to create new routines in daily practice. Future research is needed to further understand the impact of digital education systems in the secondary prevention of CAD. Ultimately, hybrid models, where the choice of delivery depends on the preferences of the individual patient, would be the optimal model of care for the future.

Effect of a Lifestyle-Focused Web-Based Application on Risk Factor Management in Patients Who Have Had a Myocardial Infarction: Randomized Controlled Trial.

BACKGROUND: Cardiac rehabilitation is central in reducing mortality and morbidity after myocardial infarction. However, the fulfillment of guideline-recommended cardiac rehabilitation targets is unsatisfactory. eHealth offers new possibilities to improve clinical care. OBJECTIVE: This study aims to assess the effect of a web-based application designed to support adherence to lifestyle advice and self-control of risk factors (intervention) in addition to center-based cardiac rehabilitation, compared with cardiac rehabilitation only (usual care). METHODS: All 150 patients participated in cardiac rehabilitation. Patients randomized to the intervention group (n=101) received access to the application for 25 weeks where information about lifestyle (eg, diet and physical activity), risk factors (eg, weight and blood pressure [BP]), and symptoms could be registered. The software provided feedback and lifestyle advice. The primary outcome was a change in submaximal exercise capacity (Watts [W]) between follow-up visits. Secondary outcomes included changes in modifiable risk factors between baseline and follow-up visits and uptake and adherence to the application. Regression analysis was used, adjusting for relevant baseline variables. RESULTS: There was a nonsignificant trend toward a larger change in exercise capacity in the intervention group (n=66) compared with the usual care group (n=40; +14.4, SD 19.0 W, vs +10.3, SD 16.1 W; P=.22). Patients in the intervention group achieved significantly larger BP reduction compared with usual care patients at 2 weeks (systolic -27.7 vs -16.4 mm Hg; P=.006) and at 6 to 10 weeks (systolic -25.3 vs -16.4 mm Hg; P=.02, and diastolic -13.4 vs -9.1 mm Hg; P=.05). A healthy diet index score improved significantly more between baseline and the 2-week follow-up in the intervention group (+2.3 vs +1.4 points; P=.05), mostly owing to an increase in the consumption of fish and fruit. At 6 to 10 weeks, 64% (14/22) versus 46% (5/11) of smokers in the intervention versus usual care groups had quit smoking, and at 12 to 14 months, the respective percentages were 55% (12/22) versus 36% (4/11). However, the number of smokers in the study was low (33/149, 21.9%), and the differences were nonsignificant. Attendance in cardiac rehabilitation was high, with 96% (96/100) of patients in the intervention group and 98% (48/49) of patients receiving usual care only attending 12- to 14-month follow-up. Uptake (logging data in the application at least once) was 86.1% (87/101). Adherence (logging data at least twice weekly) was 91% (79/87) in week 1 and 56% (49/87) in week 25. CONCLUSIONS: Complementing cardiac rehabilitation with a web-based application improved BP and dietary habits during the first months after myocardial infarction. A nonsignificant tendency toward better exercise capacity and higher smoking cessation rates was observed. Although the study group was small, these positive trends support further development of eHealth in cardiac rehabilitation. TRIAL REGISTRATION: ClinicalTrials.gov NCT03260582; https://clinicaltrials.gov/ct2/show/NCT03260582. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-018-3118-1.

Test-retest reliability, agreement, and minimal detectable change in the 6-minute walk test in patients with intermittent claudication.

OBJECTIVE: Standardized walk tests are important for objective assessment of walking distance in patients with intermittent claudication (IC). The 6-minute walk test (6MWT) has been suggested to correlate more closely than testing on a treadmill with everyday ambulatory function, but its measurement properties have hardly been studied in IC. The aim of this study was to determine the test-retest reliability, agreement, standard error of measurement (SEM), and minimal detectable change of the 6MWT in patients with IC. METHODS: This reliability and agreement study recruited 102 patients with stable IC (mean age, 72 ± 7.4 years; 43 women) from the vascular surgery outpatient clinic at Sahlgrenska University Hospital in Sweden. The patients performed the 6MWT twice, with at least 30 minutes of rest between tests. To determine test-retest reliability, the intraclass correlation coefficient was calculated. Bland-Altman plots were used to measure agreement. RESULTS: The mean walking distance in both test and retest was 397.8 m (standard deviation, 81.2 m; N = 100), and the individual walking distance varied from 175 to 600 m. Excellent test-retest reliability for the 6MWT (intraclass correlation coefficient, 0.95; 95% confidence interval, 0.9-0.97) was observed. The SEM was 16.6 m (95% confidence interval, 14.6-19.3), the SEM percentage was 4.2%, and the minimal detectable change was 46 m. Five observations (5%) were positioned outside the limits of agreement; there was a small proportional bias, and the scatter of values for differences decreased as the average values increased. CONCLUSIONS: The excellent test-retest reliability implies that it is sufficient for a patient with IC to perform the 6MWT once, at every test occasion. For the individual, an improvement or deterioration in maximum walking distance of >46 m after an intervention would be required to be 95% confident that the change is significant. Being a simple and clinically useful test, the 6MWT can be widely used to evaluate the effects of different interventions in patients with IC.

Percutaneous coronary intervention in the very elderly with NSTE-ACS: the randomized 80+ study.

Objective: The treatment strategy in the very elderly with NSTE-ACS is debated, as they are often under-represented in clinical trials. The aim of this multicenter randomized controlled trial was to compare invasive and conservative strategies in the very elderly with NSTE-ACS.Methods: We randomly assigned patients ≥ 80 years of age with NSTE-ACS to an invasive strategy with coronary angiography and optimal medical treatment or a conservative strategy with only optimal medical treatment. The primary outcome was the combined endpoint of major adverse cardiac and cerebrovascular events (MACCE). Sample size was powered for a 50% reduction of event rate in MACCE with an invasive strategy. We used intention-to-treat analysis.Results: Altogether, 186 patients were included between 2009 and 2017. The study was terminated prematurely due to slow enrollment. At 12-month follow-up, the primary outcome occurred in 31 (33.3%) of the invasive treatment group and 34 (36.6%) of the conservative treatment group, with a hazard ratio (HR) of 0.90 (95% CI 0.55‒1.46; p = 0.66) for the invasive group relative to the conservative group. The corresponding HR value for urgent revascularization was 0.29 (95% CI 0.10‒0.85; p = 0.02), 0.56 (95% CI 0.27‒1.18; p = 0.13) for myocardial infarction, 0.70 (95% CI 0.31‒1.58; p = 0.40) for all-cause mortality, 1.35 (95% CI 0.23‒7.98; p = 0.74) for stroke, and 1.62 (95% CI 0.67‒3.90; p = 0.28) for recurrent hospitalization for cardiac reasons.Conclusion: In the very elderly with NSTE-ACS, we did not find any significant difference in MACCE between invasive and conservative treatment groups at 12-month follow-up, possibly due to small sample size. ClinicalTrials.gov: NCT02126202.

A balance between meaningfulness and risk of harm - frail elderly patients' perceptions of physical activity and exercise - an interview study.

BACKGROUND: There is growing evidence of the benefits of physical activity and exercise for frail elderly patients with comorbidity. In order to improve participation in physical activity and exercise interventions, there is a need to increase our understanding of the patient's perspective. AIM: The aim of this study is to explore the perceptions of physical activity and exercise among frail elderly patients with a severe comorbidity burden. METHOD: Face-to-face, in-depth interviews were conducted with eighteen frail elderly patients with a severe comorbidity burden, median age 85.5 years (min-max 75-94). The interviews were transcribed verbatim and analyzed according to content analysis inspired by Krippendorf. RESULTS: An overall theme, defined as "Meaningfulness and risk of harm in an aging body" was identified, followed by three main categories, labeled physical activity in daily life, goals of physical activity and exercise and prerequisites for physical activity and exercise, and eight sub-categories. CONCLUSION: This study suggests that, in frail elderly patients with severe multimorbidity, physical activity and exercise is a balance between what is perceived as meaningful and the risk of harm. Patients perceived aging as an inevitable process that they needed to accept and gradually adapt their physical activities in daily life to match. As patients said they were unclear about the benefits and risks of exercise and referred to their previous life and experiences when describing physical activity and exercise, it is likely that the communication relating to this within the healthcare system needs to be further developed To promote physical activity and exercise to maintain or improve physical fitness in this frail population, healthcare providers need to use extended, personalized information to tailor the type of physical activities, goals and prerequisites for each patient.

Important aspects in relation to patients' attendance at exercise-based cardiac rehabilitation - facilitators, barriers and physiotherapist's role: a qualitative study.

BACKGROUND: In order to improve attendance at exercise-based cardiac rehabilitation (CR), a greater insight into patients' perspectives is necessary. The aim of the study was to explore aspects that influence patients' attendance at exercise-based CR after acute coronary artery disease (CAD) and the role of the physiotherapist in patients' attendance at exercise-based CR. METHODS: A total of 16 informants, (5 women; median age 64.5, range 47-79 years), diagnosed with CAD, were included in the study at the Cardiology Department, Linköping University Hospital, Sweden. Qualitative interviews were conducted and analysed according to inductive content analysis. RESULTS: Four main categories were identified: (i) previous experience of exercise, (ii) needs in the acute phase, (iii) important prerequisites for attending exercise-based CR and (iv) future ambitions. The categories demonstrate that there are connections between the past, the present and the future, in terms of attitudes to facilitators, barriers and the use of strategies for managing exercise. An overall theme, defined as existential thoughts, had a major impact on the patients' attitudes to attending exercise-based CR. The interaction and meetings with the physiotherapists in the acute phase were described as important factors for attending exercise-based CR. Moreover, informants could feel that the physiotherapists supported them in learning the right level of effort during exercise and reducing the fear of exercise. CONCLUSIONS: This study adds to previous knowledge of barriers and facilitators for exercise-based CR that patients with CAD get existential thoughts both related to exercise during the rehabilitation process and for future attitudes to exercise. This knowledge might necessitate greater attention to the physiotherapist-patient interaction. To be able to tailor exercise-based CR for patients, physiotherapists need to be aware of patients' past experiences of exercise and previous phases of the rehabilitation process as these are important for how patients' perceive their need and ability of exercise.

The role of a behavioural medicine intervention in physiotherapy for the effects of rehabilitation outcomes in exercise-based cardiac rehabilitation (ECRA) - the study protocol of a randomised, controlled trial.

BACKGROUND: To help patients with coronary artery disease (CAD) benefit from the positive health effects attained by exercise-based cardiac rehabilitation (CR), adherence to these programmes according to international guidelines is important. Strategies to increase adherence to exercise-based CR are mainly an unexplored area. The objective of this study is to investigate the effects of a behavioural medicine intervention in physiotherapy, containing goal-setting, self-monitoring and feedback, with the aim of improving rehabilitation outcomes for exercise-based CR, compared with usual care. METHODS: This is a randomised, controlled trial. A total of 160 patients with CAD will be included consecutively at the Coronary Care Unit at a university hospital in Sweden. Patients are randomised 1:1 using sealed envelopes to usual care or a behavioural medicine intervention in physiotherapy, in addition to usual care for 4 months. Outcome assessment at baseline, 4 and 12 months includes submaximal aerobic capacity (primary outcome), exercise adherence, muscle endurance, level of physical activity, biomarkers, anxiety and depression, health-related quality of life, patient enablement and self-efficacy (secondary outcomes). DISCUSSION: This is the first study to evaluate the role of an integrated behavioural medicine intervention in exercise-based CR in the effects of rehabilitation outcomes. The results of this study will provide valuable information about the effect of these interventions in exercise-based CR and it has the potential to inform and assist in further treatment in secondary prevention for patients with CAD. TRIAL REGISTRATION: The study include all items from the World Health Organization Trial Registration Data Set. TRIAL REGISTRATION NUMBER: NCT02895451, 2016-08-16, retrospectively registered.

Reliability and validity of self-report questions for assessing levels of physical activity and sedentary time in adult childhood cancer survivors.

BACKGROUND: Regular physical activity and limited sedentary time are recommended for adult childhood cancer survivors. The Swedish National Board of Health and Welfare designed a questionnaire to assess levels of physical activity (BHW-Q), including two questions: one on vigorous physical activity (BHW-Q VPA) and one on moderate physical activity (BHW-Q MPA). Furthermore, a single-item question was developed to measure sedentary time (SED-GIH-Q). These questions are recommended for clinical practice and have been found valid for the general population but have so far not been tested in adult childhood cancer survivors. The aim of the study was to assess test-retest reliability, agreement and criterion-related validity of the BHW-Q and the SED-GIH-Q in adult childhood cancer survivors. METHOD: A non-experimental methodological study. In total 60 participants (50% women), median age 28 (min-max 18-54) years were included at the Long-Term Follow-Up Clinic at Sahlgrenska University Hospital. Participants were instructed to wear an accelerometer for seven days, and to answer the BHW-Q and the SED-GIH-Q before and after the seven days. Test-retest reliability and criterion-related validity comparing the BHW-Q and SED GIH-Q with accelerometer data were calculated with weighted Kappa (k) (agreement) and by using Spearman´s rho (r) (correlation). RESULTS: Test-retest reliability regarding the SED-GIH-Q showed a high agreement (k = 0.88) and very strong correlation (r = 0.93), while the BHW-Q showed a moderate agreement and moderately strong correlation, BHW-Q VPA (k = 0.50, r = 0.64), BHW-Q MPA (k = 0.47, r = 0.58). Both the agreement and the correlation of the criterion-related validity were interpreted as fair for the BHW-Q VPA (k = 0.29, r = 0.45), while the agreement for BHW-Q MPA was interpreted as low (k = 0.07), but the correlation as fair (r = 0.37). The agreement of the SED-GIH-Q (k = 0.13) was interpreted as low and the correlation as poor (r = 0.26). CONCLUSION: These simple questions assessing physical activity and sedentary time can be used as screening tools in clinical practice to identify adult childhood cancer survivors in need of support to increase physical activity level. Further development is needed on the design of a sufficiently valid question measuring sedentary time. TRIAL REGISTRATION: This research project was registered in the Swedish National Database of Research and Development; identifier 275251, November 25, 2020. https://www.researchweb.org/is/vgr/project/275251 .

The effect of audit and feedback and implementation support on guideline adherence and patient outcomes in cardiac rehabilitation: a study protocol for an open-label cluster-randomized effectiveness-implementation hybrid trial.

BACKGROUND: Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs. METHODS: The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation. DISCUSSION: Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23.

Cardiovascular disease as part of Long COVID: A systematic review.

BACKGROUND: Long COVID syndrome has had a major impact on million patients' lives worldwide. The cardiovascular system is an important aspect of this multifaceted disease that may manifest in many ways. We have hereby performed a narrative review in order to identify the extent of the cardiovascular manifestations of the Long COVID syndrome. METHODS AND RESULTS: An in-depth systematic search of the literature has been conducted for this narrative review. The systematic search of PubMed and Cochrane databases yielded 3,993, of which 629 underwent full text screening. A total of 78 studies were included in the final qualitative synthesis and data evaluation. The pathophysiology of the cardiovascular sequelae of Long COVID syndrome and the cardiac manifestations and complications of Long COVID syndrome are critically evaluated. In addition, potential cardiovascular risk factors are assessed, and preventive methods and treatment options are examined in this review. CONCLUSIONS: This systematic review poignantly summarises the evidence from the available literature regarding the cardiovascular manifestations of Long COVID syndrome and reviews potential mechanistic pathways, diagnostic approaches, preventive measures and treatment options.