Physical activity in patients with heart failure: barriers and motivations with special focus on sex differences

Sex Differences in Physical Activity Levels and Sitting Time in Patients With Atrial Fibrillation

PURPOSE

While research demonstrates low levels of physical activity (PA) among adults living with atrial fibrillation (AF), there is limited evidence investigating sex differences in moderate to vigorous intensity physical activity (MVPA) and sedentary time in this population. The primary aim was to examine sex differences in MVPA levels and sitting time between women and men with AF. Secondary aims explored sex differences in sociodemographic factors, outcome expectations, and task self-efficacy toward PA levels.

METHODS

This was a subanalysis of the CHAMPLAIN-AF cohort study. Women and men with AF completed a survey, including the Short-Form International Physical Activity Questionnaire.

RESULTS

A total of 210 women (median = 66.0 yr: 95% CI, 63.5-68.0) and 409 men (median = 66.0 yr: 95% CI, 64.0-67.0) were included. No sex differences were observed in median weekly MVPA (60 min/wk: 95% CI, 0-120 in women vs 120 min/wk: 95% CI, 85-150 in men) and daily sitting time (5.5 hr/d: 95% CI, 5.0-6.0 in women vs 6.0 hr/d: 95% CI, 5.0-6.0 in men). Women engaged in significantly less vigorous-intensity PA than men ( P = .03) and demonstrated significantly lower task self-efficacy ( P < .01). Significant positive correlations in PA levels with outcome expectations (mostly weak) and task self-efficacy (mostly strong) were observed in both sexes.

CONCLUSION

Most women and men with AF did not meet the global MVPA guidelines but met the sitting time recommendation. Women presented with lower vigorous-intensity physical activity levels and confidence than men. Strategies to increase physical activity behavior, considering sociodemographic factors and task self-efficacy, are needed and may differ between sexes.

Physical activity changes and related factors in chronic heart failure patients during the postdischarge transition period: a longitudinal study

BACKGROUND

Physical activity (PA) is essential and effective for chronic heart failure (CHF) patients. A greater understanding of the longitudinal change in PA and its influencing factors during the postdischarge transition period may help create interventions for improving PA. The aims of this study were (1) to compare the change in PA, (2) to examine the influencing factors of PA change, and (3) to verify the mediating pathways between influencing factors and PA during the postdischarge transition period in CHF patients.

METHODS

A total of 209 CHF patients were recruited using a longitudinal study design. The Chinese version of the International Physical Activity Questionnaire (IPAQ), Patient-reported Outcome Measure for CHF (CHF-PRO), and the Chinese version of the Tampa Scale for Kinesiophobia Heart (TSK-Heart) were used to assess PA, CHF-related symptoms, and kinesiophobia. The IPAQ score was calculated (1) at admission, (2) two weeks after discharge, (3) two months after discharge, and (4) three months after discharge. Two additional questionnaires were collected during admission. Generalized estimating equation (GEE) models were fitted to identify variables associated with PA over time. We followed the STROBE checklist for reporting the study.

RESULTS

The PA scores at the four follow-up visits were 1039.50 (346.50-1953.00) (baseline/T1), 630.00 (1.00-1260.00) (T2), 693.00 (1-1323.00) (T3) and 693.00 (160.88-1386.00) (T4). The PA of CHF patients decreased unevenly, with the lowest level occurring two weeks after discharge, and gradually improving at two and three months after discharge. CHF-related symptoms and kinesiophobia were significantly associated with changes in PA over time. Compared with before hospitalization, an increase in CHF-related symptoms at two weeks and two months after discharge was significantly associated with decreased PA. According to our path analysis, CHF-related symptoms were positively and directly associated with kinesiophobia, and kinesiophobia was negatively and directly related to PA. Moreover, CHF-related symptoms are indirectly related to PA through kinesiophobia.

CONCLUSION

PA changed during the postdischarge transition period and was associated with CHF-related symptoms and kinesiophobia in CHF patients. Reducing CHF-related symptoms helps improve kinesiophobia in CHF patients. In addition, the reduction in CHF-related symptoms led to an increase in PA through the improvement of kinesiophobia.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (11/10/2022 ChiCTR2200064561 retrospectively registered).

Prevalence and predictors of poor self-care behaviors in patients with chronic heart failure

Despite the indispensable role of self-care behavior in managing heart failure, the practice of self-care behavior remains poor, especially in developing countries. There is a scarcity of research focusing on poor self-care behavior and its determinants within our specific context. Therefore, the objective of this study was to investigate the prevalence and predictors of poor self-care behavior among ambulatory heart failure patients. A facility-based cross-sectional study was conducted at a tertiary care hospital in Ethiopia, involving patients with heart failure. We utilized the European Heart Failure Self-Care Behavior Scale (EHFScBS-9) to evaluate adherence to self-care behaviors. Data were gathered through patient interviews and a review of medical records. A binary logistic regression analysis was performed to identify predictors of poor self-care behavior in heart failure patients. We included a total of 343 participants in the final analysis of this study. The findings revealed that a majority of the patients (73.8%) demonstrated poor overall self-care behavior. Specifically, the majority of patients did not engage in regular exercise (76.1%), failed to consult doctors in case of rapid weight gain (75.6%), did not monitor weight daily (71.5%), did not restrict fluid intake (69.9%), and did not contact doctors in case of experiencing fatigue (68.6%). Additionally, 32.4% of patients did not reach out to doctors when experiencing shortness of breath, 30% did not restrict salt intake, 29% did not adhere to prescribed medication, and only 7% did not consult doctors if edema occurred. Our findings indicated that rural residence (AOR: 5.76, 95% CI: 2.47-13.43), illiteracy (AOR: 2.64, 95% CI: 1.52-6.31), prior hospitalization (AOR: 2.09, 95% CI: 1.21-3.61), and taking five or more medications (AOR: 1.83, 1.01-3.33) were significant predictors of poor self-care behavior. In conclusion, a majority of the participants in our study demonstrated poor self-care behavior. Risk factors for this behavior included rural residence, illiteracy, prior hospitalization, and taking five or more medications. Therefore, it is crucial to prioritize these high-risk patients and implement interventional programs aimed at improving self-care behaviors and overall treatment outcomes in heart failure patients.

Expectations of Tele-Yoga in Persons With Long-Term Illness: Qualitative Content Analysis

BACKGROUND

Yoga is a mind-body exercise that has demonstrated its feasibility and safety even for individuals with severe long-term illness. Engaging in yoga has the potential to yield positive effects on both physical and mental well-being. Tele-yoga is a novel approach to rehabilitation in which participants practice group yoga with a live-streamed yoga instructor digitally via a tablet. This is especially beneficial for individuals who may find it difficult to leave their homes to participate in an exercise session. As part of our ongoing evaluation of the tele-yoga intervention in individuals with long-term illness, we have undertaken an exploration of participants' expectations regarding yoga in general and tele-yoga specifically. Understanding these expectations is crucial, as they can significantly impact their satisfaction with treatment and care and influence overall intervention outcomes.

OBJECTIVE

This study aims to explore the expectations of tele-yoga among individuals with long-term illness before starting a tele-yoga intervention.

METHODS

The study employed an inductive qualitative design and is part of a process evaluation within an ongoing randomized controlled trial. A total of 89 participants were interviewed before the start of the tele-yoga intervention. The interview guide encompassed questions about their general perceptions of yoga and the specific expectations they held for the upcoming tele-yoga sessions. The interviews were transcribed and analyzed using inductive qualitative content analysis.

RESULTS

Participants expressed their expectations for tele-yoga, focusing on the anticipated improvements in physical function and overall health. These expectations included hopes for reduced respiratory issues; relief from discomfort, aches, and pains; as well as increased physical flexibility, coordination, and overall well-being. Besides, they expected to achieve improved psychological well-being and performance; to acquire strategies to manage stress, anger, and anxiety; and to have their motivational drive strengthened and influence other activities. Participants described tele-yoga as a new and exciting technical solution that would facilitate the delivery of yoga. A few participants remained a little hesitant toward the use of technology, with some expectations based on previous experiences. When asked about expectations, some had no idea about what to expect. Participants also had varying perspectives on yoga, with some finding it mysterious and difficult to understand. Participants expressed thoughts that they found the idea of tele-yoga taking place in groups exciting and enjoyable. They also had expectations that being part of a group would provide opportunities for mutual inspiration and encouragement among the group members.

CONCLUSIONS

Expectations before an intervention can provide valuable insights into understanding the factors influencing adherence to tele-yoga and its outcomes. Our findings provide a wide range of expectations for tele-yoga, spanning both physical and mental aspects. Moreover, the technology's potential to facilitate yoga delivery and the supportive nature of digital group interactions were evident from the results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03703609; https://clinicaltrials.gov/ct2/show/NCT03703609.

Healthy hearts healthy minds: A randomized trial of online interventions to improve physical activity

INTRODUCTION

Depressed individuals are more likely to die from cardiovascular disease (CVD) than those without depression. People with CVD have higher rates of depression than those without and have higher mortality rates if they have comorbid depression. While physical activity (PA) improves both, few people engage in enough. We compared self-guided internet-based cognitive behavior therapy (CBT) + Fitbit or mindfulness-based cognitive therapy (MBCT) + Fitbit, with Fitbit only to increase daily steps for participants with depression who have low PA.

METHODS

Adult participants (N = 340) were recruited from two online patient-powered research networks and randomized to one of three study interventions for 8 weeks with an additional 8 weeks of follow-up. Using linear mixed effects models, we evaluated the effect of the intervention on average daily steps (NCT03373110).

RESULTS

Average daily steps increased 2.8 steps per day in MBCT+Fitbit, 2.9 steps/day in CBT + Fitbit, but decreased 8.2 steps/day in Fitbit Only. These changes were not statistically different between the MBCT+Fitbit and CBT + Fitbit groups, but were different from Fitbit Only across the initial 8-week period. Group differences were not maintained across follow-up. Exploratory analyses identified comorbid anxiety disorders, self-reported PA, and employment status as moderators.

DISCUSSION

Changes in daily steps over both 8- and 16-week periods-regardless of intervention group-were minimal. The results emphasize the limits of using self-guided web-based psychotherapy with an activity tracker to increase PA in participants with a history of depression and low PA.

Prognostic factors of adherence to home-based exercise therapy in patients with chronic diseases: A systematic review and meta-analysis

Background

Patients with a chronic disease may have an increased risk of non-adherence to prescribed home-based exercise therapy. We performed a systematic review with the aim to identify variables associated with adherence to home-based exercise therapy in patients with chronic diseases and to grade the quality of evidence for the association between these prognostic factors and adherence.

Methods

Cohort studies, cross-sectional studies and the experimental arm of randomized trials were identified using a search strategy applied to PubMed, Embase, PsychINFO and CINAHL from inception until August 1, 2022. We included studies with participants ≥18 years with a chronic disease as an indication for home-based exercise therapy and providing data on prognostic factors of adherence to home-based exercise. To structure the data, we categorized the identified prognostic factors into the five WHO-domains; (1) Patient-related, (2) Social/economic, (3) Therapy-related, (4) Condition-related, and (5) Health system factors. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Prognostic factors of adherence were identified and the quality of the evidence between the prognostic factors and adherence were graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for predictor studies. We performed a meta-analysis of the obtained information.

Results

A total of 57 studies were included. Within patient-related factors moderate- and high-quality evidence suggested that more self-efficacy, exercise history, motivation and perceived behavioral control predicted higher adherence. Within social-economic factors moderate-quality evidence suggested more education and physical health to be predictive of higher adherence and within condition-related factors moderate- and low-quality evidence suggested that less comorbidities, depression and fatigue predicted higher adherence. For the domains therapy-related and health-system factors there was not enough information to determine the quality evidence of the prognostic factors.

Conclusion

These findings might aid the development of future home-based exercise programs as well as the identification of individuals who may require extra support to benefit from prescribed home-based exercise therapy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277003, identifier PROSPERO CRD42021277003.

Physical Activity Readiness in Patients with Heart Failure

The aim of this study was to explore the readiness for physical activity (PA) and its related factors in patients with heart failure. This cross-sectional study included 163 patients with heart failure (mean age 66 ± 16, 50% female). The ability to safely engage in PA was assessed with the PA Readiness Questionnaire (PAR-Q). Psychological readiness was measured using two questionnaires, namely: Exercise Self-efficacy Scale and the Motivation for PA and Exercise/Working Out. A multivariate analysis of covariance was conducted to test the effect of background variables on readiness for PA. 64% (n = 105) of patients reported not being able to safely engage in PA, 80% (n = 129) reported low self-efficacy, and 45% (n = 74) were extrinsically motivated indicating external factors drove their motivation. Factors that positively influenced the PA readiness included lower age (p < 0.01), being male (p < 0.01), being married (p < 0.01), having higher education (p < 0.01), being in NYHA-class I compared with II (p < 0.01), less time since diagnosis (p < 0.01), lower BMI (p = 0.02), and not suffering from COPD (p = 0.02). Prior to recommending exercise, assessment of safety to engage in PA along with self-efficacy and motivation in patients with heart failure is essential.

Nurses’ Beliefs and Barriers of Delivering Cardiopulmonary Rehabilitation for Heart Failure Patients in Saudi Arabia: A Cross-Sectional Study

Background: Patients with heart failure (HF) may benefit greatly from cardiopulmonary rehabilitation (CR), which is provided by a team of healthcare professionals that often includes nurses. There has been no research on how nurses perceive providing CR or the hurdles that may affect referrals. Methods: All registered nurses in Saudi Arabia’s Eastern Province were given access to a cross-sectional online survey consisting of nine multiple-choice questions that address attitudes, beliefs, and barriers to CR for HF patients in Saudi Arabia. Descriptive statistics were used to characterize the respondents. Results: Altogether, 439 registered nurses participated in the online survey, with men making up 194 (44%) and women 245 (56%). The mean and SD of years of clinical experience in caring for patients with HF were 6 ± 5 years. Out of 439 nurses, 107 (24%) strongly agree, and 255 (58%) agree that CR will enhance the physical fitness of patients. However, 94 (21.1%) strongly agree, and 248 (56.4%) agree that CR might alleviate dyspnea in HF patients. The vast majority of the nurses either strongly agree (90 (20.5%)) or agree (240 (55%)), that CR would help reduce palpitations and fatigue in HF patients. Indeed, 87 (19.81%) strongly agree, and 262 (59.68%) agree that CR would help improve HF patients’ ability to perform daily activities, while 51 (11.6%) strongly agree and 223 (51%) agree that CR would help in reducing hospital readmission. It was shown that 360 (82%) of the 439 nurses favored the delivery of CR programs in hospital-supervised programs, while 368 (83.8%) ranked information on HF disease as the most important aspect of the CR program, followed by information about medications at 305 (69.4%). The availability of CR facilities (36%), the cost of therapy (35%), and the absence of an established standardized referring strategy (34%) were identified as the most significant barriers affecting the referral of patients with HF for CR by nurses. Conclusion: Generally, nurses believed CR helped improve desired clinical outcomes in HF patients. Although a hospital-based program with close supervision is optimal for administering CR, few such options exist. Referrals of patients with HF were hampered by the lack of CR facilities, the cost of intervention, and the lack of a systematic approach to referrals.

Canoe polo Athletes' Anthropometric, Physical, Nutritional, and Functional Characteristics and Performance in a Rowing Task: Cross-Sectional Study

Understanding the physical, functional, mental, and nutritional attributes of canoe polo athletes is essential for training and development. Forty-three canoe polo athletes (mean age: 21.54 ± 6.03) participated in the study and were assessed for: anthropometric measurements, exercise motivation, eating habits, adherence to the Mediterranean Diet, and physical and functional abilities. Correlation and multivariate analysis were conducted. Individual performance in a rowing task showed body mass index (β = 0.41) and female gender (β = 0.34) to be the strongest anthropometric predictors, whereas body fat (β = -0.35) and triceps brachii skinfold fatty tissue (β = -0.35) were the strongest negative predictors. Pushing strength (β = 0.37) and range of motion with internal rotation (β = 0.30) were the strongest physical predictors. The physical dimension of the Exercise Motivation Index was a significant psychosocial predictor (β = 0.27). Senior participants had a higher waist-hip ratio (p = 0.04, d = 0.66), arm circumference (p = 0.03, d = 0.68), handgrip strength (p < 0.01, d = 1.27), and push strength (p < 0.01, d = 1.42) than under 21-year-olds. Understanding the highlighted sport-specific characteristics of canoe polo athletes can help trainers to design programs at all levels to optimize performance.

Cultural influences on physical activity and exercise beliefs in patients with chronic kidney disease: 'The Culture-CKD Study'-a qualitative study

OBJECTIVES

This study used a mixed-method approach to explore cultural and ethnic influences on the perception of, and decision to engage with or not to engage with, physical activity and exercise therapy in patients with chronic kidney disease (CKD).

DESIGN

Qualitative research was conducted through the use of semistructured interviews and focus groups. Self-reported physical activity levels were measured using the General Practice Physical Activity Questionnaire (GPPAQ), and self-efficacy for exercise with Bandura's Self-Efficacy for Exercise Scale.

SETTING

This study was conducted in a non-clinical setting of a single National Health Service Hospital Trust between April 2018 and July 2019.

PARTICIPANTS

Participants >18 years of age with a diagnosis of CKD, from black African, black Caribbean, South Asian or white ethnicity were eligible for the study. 84 patients with a diagnosis of CKD (stages 2-5), aged 25-79 (mean age 57) were recruited. Semistructured interviews (n=20) and six single-sex, ethnic-specific focus group discussions were undertaken (n=36).

OUTCOMES

Primary outcome was to explore the perceptions, attitudes and values about exercise and physical activity in different ethnic groups through qualitative interviews, analysed using an inductive thematic analysis approach. Questionnaires were analysed using Pearson correlation to determine if there was a significant relationship between the self-efficacy and GPPAQ levels.

RESULTS

Qualitative analysis provided four primary themes: I am who I am, Change of identity, Influences to physical activity and exercise and Support and education. Quantitative analysis using Pearson correlation revealed a significant correlation between GPPAQ levels of activity and self-efficacy to regulate exercise behaviour (r=-0.40, p=0.001).

CONCLUSION

Understanding the cultural, attitudes and beliefs of individuals with CKD from a variety of ethnic backgrounds is complex. Understanding of patients' experiences, thoughts and beliefs may be of relevance to clinicians when designing CKD exercise services.

TRIAL REGISTRATION NUMBER

NCT03709212; Pre-results.

Objectively measured physical activity in patients with heart failure: a sub-analysis from the HF-Wii study

AIMS

Physical activity (PA) is important in patients with heart failure (HF) to improve health outcomes. The adherence to PA is low, and therefore, novel approaches are necessary to increase PA. We aimed to determine the difference in PA in patients with HF who have access to exergaming compared to patients who received motivational support and to explored predictors of a clinically relevant change in non-sedentary time between baseline and 3 months.

METHODS AND RESULTS

In total, 64 patients (mean age 69 ± 9 years, 27% female) wore an accelerometer 1 week before and 1 week after the intervention. Data were analysed using logistic regression analysis. Patients spent 9 h and 43 min (±1 h 23 min) during waking hours sedentary. There were no significant differences in PA between patients who received an exergame intervention or motivational support. In total, 30 of 64 patients achieved a clinically relevant increase in non-sedentary time. Having grandchildren [odds ratio (OR) 7.43 P = 0.03], recent diagnosis of HF (OR 0.93 P = 0.02), and higher social motivation (OR 2.31 P = 0.03) were independent predictors of a clinically relevant increase of non-sedentary time.

CONCLUSION

Clinicians should encourage their patients to engage in alternative approaches to improve PA and reduce sedentary habits. Future exergaming interventions should target individuals with chronic HF who have low social motivation and a low level of light PA that may benefit most from exergaming. Also (non-familial), intergenerational interaction is important to enabling patients in supporting patients in becoming more active.

Exploring factors related to non-adherence to exergaming in patients with chronic heart failure

AIMS

This study aimed to explore factors related to non-adherence to exergaming in patients with heart failure.

METHODS AND RESULTS

Data from patients in the exergame group in the HF-Wii trial were used. Adherence to exergaming was defined as playing 80% or more of the recommended time. Data on adherence and reasons for not exergaming at all were collected during phone calls after 2, 4, 8, and 12 weeks. Logistic regression was performed between patients who were adherent and patients who were non-adherent. Secondly, a logistic regression was performed between patients who not exergamed at all and patients who were adherent to exergaming. Finally, we analysed the reasons for not exergaming at all with manifest content analysis. Almost half of the patients were adherent to exergaming. Patients who were adherent had lower social motivation [odds ratio (OR) 0.072; 95% confidence interval (CI) 0.054-0.095], fewer sleeping problems (OR 0.84; 95% CI 0.76-0.092), and higher exercise capacity (OR 1.003; 95% CI 1.001-1.005) compared with patients who were non-adherent. Patients who not exergamed at all had lower cognition (OR 1.18; 95% CI 1.06-1.31) and more often suffered from peripheral vascular disease (OR 3.74; 95% CI 1.01-13.83) compared with patients who were adherent to exergaming. Patients most often cited disease-specific barriers as a reason for not exergaming at all.

CONCLUSIONS

A thorough baseline assessment of physical function and cognition is needed before beginning an exergame intervention. It is important to offer the possibility to exergame with others, to be able to adapt the intensity of physical activity.

Effects of different exercise programs on cardiorespiratory reserve in HFpEF: a systematic review and meta-analysis

HFpEF represents an heterogeneous syndrome with complex pathophysiologic substrate and multiple clinical manifestations. Much attention has been recently focused on cardiac rehabilitation programs for HFpEF patients and studies have examined the effects of exercise training on this specific population. This systematic review and meta-analysis included studies of adult patients with HFpEF and evaluated the impact of exercise on cardiorespiratory fitness variables measured during CPET. The primary outcome was the difference between groups in the change of peak oxygen uptake (Δpeak VO₂). Literature search involved PubMed/MEDLINE, Cochrane/CENTRAL and Scopus databases. From an initial 5,143 literature records, we identified 18 studies fulfilling inclusion criteria; 11 studies with 515 patients were finally included in primary outcome analysis. Δpeak VO₂ between baseline and study-end was significantly higher in the groups of exercise training versus control (WMD 2.25 ml/kg/min, 95%CI 1.81-2.70). Exercise training resulted in greater change in the 6MWT distance (WMD 2.25 meters, 95%CI 1.81-2.70). Health related quality of life (WMD: -3.36, 95%CI -9.42-2.70, I²=14%, p=0.33) and echocardiographic indexes of diastolic function showed no differences between exercise and control groups at study end. In subgroup analysis, no difference between resistance versus aerobic exercise was noted on Δpeak VO₂, but high intensity interval training showed greater increase in peak VO₂ versus aerobic exercise (WMD 1.62 ml/kg/min, 95%CI 0.96-2.29, I²=0%, p=0.82). Exercise training in HFpEF results in significant improvements in peak VO₂ and 6MWT distance compared to controls. High intensity interval training may offer greater enhancement of exercise capacity of these patients than standard aerobic exercise.

Effectiveness of Distance Technology in Promoting Physical Activity in Cardiovascular Disease Rehabilitation: Cluster Randomized Controlled Trial, A Pilot Study

BACKGROUND

Physical activity is beneficial for cardiovascular rehabilitation. Digitalization suggests using technology in the promotion of physical activity and lifestyle changes. The effectiveness of distance technology interventions has previously been found to be similar to that of conventional treatment, but the added value of the technology has not been frequently studied.

OBJECTIVE

The aim of this pilot study was to investigate whether additional distance technology intervention is more effective in promoting physical activity than non-technology-based treatment in 12 months of cardiac rehabilitation.

METHODS

The cardiovascular disease rehabilitation intervention consisted of three 5-day inpatient periods in a rehabilitation center and two 6-month self-exercise periods at home in between. Participants were recruited from among cardiac patients who attended the rehabilitation program and were cluster-randomized into unblinded groups: conventional rehabilitation control clusters (n=3) and similar rehabilitation with additional distance technology experimental group clusters (n=3). Experimental groups used Fitbit Charge HR for self-monitoring, and they set goals and reported their activity using Movendos mCoach, through which they received monthly automated and in-person feedback. Physical activity outcomes for all participants were measured using the Fitbit Zip accelerometer and the International Physical Activity Questionnaire.

RESULTS

During the first 6 months, the experimental group (n=29) engaged in light physical activity more often than the control group (n=30; mean difference [MD] 324.2 minutes per week, 95% CI 77.4 to 571.0; P=.01). There were no group differences in the duration of moderate to vigorous physical activity (MD 12.6 minutes per week, 95% CI -90.5 to 115.7; P=.82) or steps per day (MD 1084.0, 95% CI -585.0 to 2752.9; P=.20). During the following 6 months, no differences between the groups were observed in light physical activity (MD -87.9 minutes per week, 95% CI -379.2 to 203.3; P=.54), moderate to vigorous physical activity (MD 70.9 minutes per week, 95% CI -75.7 to 217.6; P=.33), or steps per day (MD 867.1, 95% CI -2099.6 to 3833.9; P=.55).

CONCLUSIONS

The use of additional distance technology increased the duration of light physical activity at the beginning of cardiac rehabilitation (for the first 6 months), but statistically significant differences were not observed between the two groups for moderate or vigorous physical activity or steps per day for both 6-month self-exercise periods.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN61225589; https://doi.org/10.1186/ISRCTN61225589.

Patients' and carers' perspective of the impact of heart failure on quality of life: a qualitative study

Heart failure (HF) is a syndrome associated with high mortality and morbidity. HF patients tend to be at a high risk of poor clinical and psychosocial outcomes. This study aimed to capture patients' and carers perspectives of HF, the impact on their health reported QoL, and the factors associated with their poor health outcomes. To explore HF patients' and carers' views on their QoL since diagnosis. This study used a cross-sectional, qualitative design with semi-structured interviews conducted with participating patients and carers. Thirteen adults (> 18 years) with HF and 21 carers were interviewed over the telephone, following a semi-structured interview schedule. Interviews were transcribed verbatim and analysed using inductive thematic analysis. Three main themes were identified, with an overarching theme . Themes included impact on patients' lifestyle including diet, smoking and inability to part-take in social activities, adjusting to HF diagnosis and co-morbidity management, and psychological/mental health issues such as anxiety and depression. Patients with HF are at high-risk of various issues which can negatively impact their QoL. Additionally, Carers play a vital role in the management of HF patients. Effective patient centred care and better communication between patients, carers and healthcare professionals is vital in HF management.

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers

OBJECTIVES

This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil.

METHODS

The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment.

RESULTS

Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment.

CONCLUSION

HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.

Exercise Motivation and Self-Efficacy Vary Among Patients with Heart Failure - An Explorative Analysis Using Data from the HF-Wii Study

PURPOSE

To examine profiles in patients with heart failure (HF) regarding their exercise motivation and self-efficacy.

PATIENTS & METHODS

The baseline data of patients with HF participating in the HF-Wii study were analysed. In total, 517 patients were divided into four groups based on their exercise motivation (exercise motivation index) and self-efficacy (exercise self-efficacy scale). To describe the differences in demographic and clinical variables between the groups, chi-square cross-tabulations and ANOVAs were conducted.

RESULTS

The four groups were labelled as insecure avoiders (25%), laid-back strugglers (10%), conscientious self-doubters (42%) and determined achievers (22%). Patients' profiles differ according to their motivations and self-efficacy towards exercise. Most patients were conscientious self-doubters (high motivation and low self-efficacy), and these patients had more comorbidities and lower exercise capacity compared to the other groups, which could decrease their confidence in exercising. However, only half of the patients who were determined achievers (high motivation and high self-efficacy) reached the recommended amount of physical activity per week. This indicates that motivation and self-efficacy are crucial determinants, but more factors are important for becoming more physically active.

CONCLUSION

Understanding patients' motivations and self-efficacy are necessary in order to provide meaningful physical activity counselling and promotion.

Barriers to Self-care Among Patients with Heart Failure: A Qualitative Study

Introduction: Heart failure is the most prevalent cardiovascular disease. It is the end stage of most cardiovascular diseases and is characterized by the reduced ability of the heart to pump enough blood to fulfill the metabolic needs of the body. Self-care is the basis of the management of chronic diseases such as heart failure. The aim of this study was to explore the barriers to self-care among patients with heart failure. Methods: This was a qualitative content analysis. Participants were fourteen patients with heart failure and three healthcare providers who were purposively recruited from cardiac care centers in Zanjan, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional qualitative content analysis approach proposed by Elo and Kyngäs. Results: Self-care barriers -care among patients with HF were categorized into three main categories, namely personal factors, disease burden, and inefficient support system. Each category had three subcategories which were respectively lack of self-care knowledge, heart failure-related negative emotions, the difficulty of changing habits, progressive physical decline, comorbid conditions, financial strain, inadequate social support, healthcare providers' inattention to self-care, and limited access to healthcare providers. Conclusion: Patients with heart failure face different personal, disease-related, and support-related barriers to self-care. Based on these barriers, healthcare providers can develop interventions for promoting self-care among patients with heart failure.

Sex-specific differences in access and response to medical and device therapies in heart failure: State of the art

Women with heart failure (HF) are more symptomatic than their male counterparts. Despite deriving similar benefits from both medical and devices therapies, women continue to be underrepresented in clinic trials. Important sex-based disparities exist in enrollment in clinical trials and access to medical and device-based therapies, in part stemming from differences in medical and psychosocial comorbidities. Disparities in access to beneficial interventions likely contribute to the greater symptom burden identified in women with HF. Improved focus on the enrollment of women in clinical trials will allow a better understanding of the underpinnings of these disparities and improve the care of women with HF.

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study

Aim

The primary objective of this non-randomized feasibility study was to test a 1-year model programme for sustaining/increasing patients' motivation to perform daily physical activity.

Design

Non-randomized longitudinal feasibility study with a one-group repeated measures design.

Methods

The study took place at a primary care centre in mid-Sweden in 2017-2018. The model programme included individual and group-based support, individualized physical activity prescriptions, a wrist-worn activity tracker and an activity diary. The main outcomes were the participants' perceptions of programme feasibility and scores on the Exercise Self-Efficacy Scale.

Results

Seven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self-Efficacy Scale improved 3 months after participants completed the programme.

Patient-Reported Compliance in older age patients with chronic heart failure

METHODS AND RESULTS

475 patients (including 222 women), mean age 69.7±7.7, with HF, hospitalized at University Hospital between January and December 2018 were included in the study. The patients were selected by a physician specializing in cardiology. A cardiac nurse assessed the non-pharmacological level of compliance using the Revised Heart Failure Compliance Questionnaire (RHFCQ). The socio-clinical data were obtained from medical records. The majority of the study group were patients in NYHA II (62.4%) and NYHA III (28.3%), the mean duration of the disease was 6.2±4.9 years, and the mean ejection fraction of the left ventricle (EF) was 48.6±12.6. The average level of compliance in the study group measured on a scale from 0 to 4 points was: median = 2.7, IQR [2.32; 3.25]. Only 6.9% of the respondents adhere to recommendations totally (all dimensions of RHFCQ). In univariate analysis, predictors negatively affecting compliance were: female gender (rho = -0.325), age below 65 years (rho = -0.014)), loneliness (rho = -0.559), number of hospitalizations (rho = -0.242), higher stage of NYHA (rho = -1.612), co-morbidities (rho = -0.729), re-hospitalizations (rho = -0.729), beta-blockers treatment (rho = -1.612) and diuretics treatment (rho = -0.276). Factors positively affecting compliance were: EF≥45% (rho = 0.020) and treatment with ACEI/ARB (rho = 0.34), whereas compliance was negatively affected by-EF<45% (β = 0.009). Independent predictors influencing the level of compliance were: loneliness (β = -1.816), number of hospitalizations (β = -0.117), NYHA III and IV and number of co-morbidities (β = -0.676).

CONCLUSIONS

Patients with HF do not adhere to therapeutic recommendations. The lowest compliance levels were found for exercise and daily weighing, and the highest for follow-up appointment-keeping and medication. Loneliness and age are the strongest predictors which influence the level of compliance.

Characterization of Sedentary Behavior in Heart Failure Patients With Arthritis

Background

Arthritis is one of the most common comorbidities in heart failure (HF) patients, and is associated with decreased activity levels. Few studies have examined sedentary behavior (SB) in HF patients with arthritis, and little is known about the factors that may influence SB in this population.

Methods

This is a retrospective, secondary analysis using data collected from a randomized control trial. SB was measured by the daily sedentary time collected by accelerometers. Structural equation modeling was performed to examine relationships between key concepts based on social cognitive theory, and elucidate the potential pathways by which demographic, clinical and sociobehavioral factors that influence SB.

Results

A total of 101 participants’ data were used for this analysis. Participants were mainly female (n = 64, 63%) with a mean age of 70 years (standard deviation (SD) = 12.2) and an average of 13 years of education (SD = 2.3). SB was highly prevalent at baseline (mean value: 21.0 h/day), 3 months (mean value: 20.6 h/day) and 6 months (mean value: 20.8 h/day) in study participants. Factors with statistically significant positive association with sedentary time include age and retirement, while significant negative association was found with current employment. HF self-care efficacy and behavior were also significantly associated with SB.

Conclusions

Most HF patients with arthritis in this study lived a sedentary lifestyle. Additional studies are needed to identify feasible and effective exercise programs for HF participants with arthritis.

Clinical and functional patient characteristics predict medical needs in older patients at risk of functional decline

Background

The rising number of older multimorbid in-patients has implications for medical care. There is a growing need for the identification of factors predicting the needs of older patients in hospital environments. Our aim was to evaluate the use of clinical and functional patient characteristics for the prediction of medical needs in older hospitalized patients.

Methods

Two hundred forty-two in-patients (57.4% male) aged 78.4 ± 6.4 years, who were consecutively admitted to internal medicine departments of the University Hospital Essen between July 2015 and February 2017, were prospectively enrolled. Patients were assessed upon admission using the Identification of Seniors at Risk (ISAR) screening followed by comprehensive geriatric assessment (CGA). The CGA included standardized instruments for the assessment of activities of daily living (ADL), cognition, mobility, and signs of depression upon admission. In multivariable regressions we evaluated the association of clinical patient characteristics, the ISAR score and CGA results with length of hospital stay, number of nursing hours and receiving physiotherapy as indicators for medical needs. We identified clinical characteristics and risk factors associated with higher medical needs.

Results

The 242 patients spent [median(Q1;Q3)]:9.0(4.0;16.0) days in the hospital, needed 2.0(1.5;2.7) hours of nursing each day, and 34.3% received physiotherapy.

In multivariable regression analyses including clinical patient characteristics, ISAR and CGA domains, the factors age (β = − 0.19, 95% confidence interval (CI) = − 0.66;-0.13), number of admission diagnoses (β = 0.28, 95% CI = 0.16;0.41), ADL impairment (B = 6.66, 95% CI = 3.312;10.01), and signs of depression (B = 6.69, 95% CI = 1.43;11.94) independently predicted length of hospital stay. ADL impairment (B = 1.14, 95%CI = 0.67;1.61), cognition impairment (B = 0.57, 95% CI = 0.07;1.07) and ISAR score (β =0.26, 95% CI = 0.01;0.28) independently predicted nursing hours. The number of admission diagnoses (risk ratio (RR) = 1.06, 95% CI = 1.04;1.08), ADL impairment (RR = 3.54, 95% CI = 2.29;5.47), cognition impairment (RR = 1.77, 95% CI = 1.20;2.62) and signs of depression (RR = 1.99, 95% CI = 1.39;2.85) predicted receiving physiotherapy.

Conclusion

Among older in-patients at risk for functional decline, the number of comorbidities, reduced ADL, cognition impairment and signs of depression are important predictors of length of hospital stay, nursing hours, and receiving physiotherapy during hospital stay.

Fear of Physical Activity, Anxiety, and Depression

Abstract. Background: Physical activity (PA) is recommended by heart failure treatment guidelines. Adherence to exercise prescriptions is low and not much is known about everyday PA in this patient group. Aims: This study describes objectively assessed everyday PA/sedentary behavior in men and women with chronic heart failure and examines associations of potential barriers for engaging in PA, namely fear of physical activity (FoPA), general anxiety, and depression, with indicators of PA and sedentary behavior. Method: In 61 outpatients with heart failure (67.5 ± 10.7 years of age) the impact of FoPA, trait anxiety, and depression on 6-day accelerometer measures was evaluated using linear regression models. Results: Sedentary behavior was prevalent in men and women alike, with lying down and sitting/standing as predominant activity classes during daytime. Men had higher PA energy expenditure (726 vs. 585 kcal/d, Cohen’s effect size d = 0.74) and walked up/down more often (0.21% vs. 0.12% of total PA, d = 0.56) than women. FoPA did not differ between sexes. FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates (β-values between −0.26 and −0.44, p-values < 0.024). Limitations: The self-selected sample included few women. Medical data were assessed via self-reports. Conclusion: FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates. These preliminary findings highlight FoPA as a barrier to everyday PA in patients with heart failure.

Self-efficacy Mediates the Relationship Between Motivation and Physical Activity in Patients With Heart Failure

BACKGROUND

Motivation is necessary in patients with heart failure (HF) who are attempting to become more physically active but may not be sufficient to initiate physical activity. Self-efficacy might explain the relationship between motivation and physical activity.

OBJECTIVE

The aim of this study was to examine the role of exercise self-efficacy in the relationship between exercise motivation and physical activity in patients with HF.

METHODS

A total of 100 stable patients with HF (88% in New York Heart Association class II/III; mean age, 67 ± 13 years; 62% men) were studied. Self-efficacy was measured with the Exercise Self-Efficacy Scale; motivation, with the Exercise Motivation Index; and physical activity, with a self-report questionnaire. Logistic regression analyses were made to examine the mediation effect of exercise self-efficacy on the relationship between exercise motivation and physical activity.

RESULTS

Forty-two percent of the 100 patients reported engaging in less than 60 minutes per week of physical activity. Motivation predicted physical activity (b = 0.58, P < .05), but after controlling for self-efficacy, the relationship between motivation and physical activity was no longer significant (b = 0.76, P = .06), indicating full mediation.

CONCLUSION

Motivation to be physically active is important but not sufficient. In addition to a high level of motivation to be physically active, it is important that patients with HF have a high degree of self-efficacy.

Accelerometer-Measured Daily Activity Levels and Related Factors in Patients With Heart Failure

BACKGROUND

Few studies report objective accelerometer-measured daily physical activity levels in patients with heart failure (HF).

OBJECTIVE

We examined baseline accelerometer-measured physical activity from the Heart Failure Exercise and Resistance Training Camp trial, a federally funded (R01-HL112979) 18-month intervention study to promote adherence to exercise in patients with HF. Factors associated with physical activity levels were also explored.

METHODS

Patients with diagnosed HF (stage C chronic HF confirmed by echocardiography and clinical evaluation) were recruited from 2 urban medical centers. Physical activity energy expenditure and the number of minutes of moderate or vigorous physical activity (MVPA) were obtained from 7 full days of measurement with the accelerometer (Actigraph Model GT3X, Pensacola, Florida) for 182 subjects who met minimum valid wear time parameters. Additional measures of health-related factors were included to explore the association with physical activity levels.

RESULTS

Subjects had 10.2 ± 10.5 minutes of MVPA per day. Total physical activity energy expenditure was 304 ± 173 kcal on average per day. There were 23 individuals (12.6%) who met the recommended goal of 150 minutes of MVPA per week. Men, whites, New York Heart Association class II, and subjects with better physical function had significantly higher levels of activity.

CONCLUSIONS

Consistent with previous research, patients with HF are not meeting recommended guidelines for 150 minutes of MVPA per week.

Impact of exercise training program attendance and physical activity participation on six minute walk distance in patients with heart failure

Background: Exercise training is recommended for all people with stable heart failure (HF) however adherence is poor. This study sought to describe exercise participation in recently hospitalized HF patients who participated in a 12-week exercise training program. The association between exercise training variables and improvement in 6-min walk distance (6MWD) was also investigated.Methods: This study is a secondary analysis of results from the intervention arm of the EJECTION-HF trial (ACTRN12608000263392), (n = 140). Exercise program attendance was defined according to session frequency (< 12 sessions vs ≥ 12 sessions) and attendance duration (< 6 weeks attendance vs ≥ 6 weeks) over the 12 weeks. Physical activity at baseline and follow up were reported according to self-report of 150 min of moderate intensity exercise per week. Primary outcome was change in 6MWD at 12 weeks.Results: Being physically active (OR 3.8, CI 1.3-11.5) and frequent program attendance (OR 2.7, CI 1.2-5.9) were associated with significant improvements in 6MWD. Program duration and baseline physical activity were not significantly associated with the outcome.Conclusions: Attainment of 150 min of moderate intensity exercise per week and at least weekly attendance at the program, were associated with significant improvements in 6MWD at follow up. Efforts should be made to assist patients with HF to achieve these targets.

Heart failure awareness in the Korean general population: Results from the nationwide survey

BACKGROUND

For a better heart failure outcome, it is fundamental to improve the awareness of heart failure at the general population level. We conducted this study to identify the current status of awareness of heart failure in the Korean general population.

METHODS

This cross-sectional nationwide survey recruited a total of 1,032 participants aged 30 years or older, based on a stratification systematic sampling method. A 23-item questionnaire was surveyed through telephone interviews.

RESULTS

Although 80% of the participants had heard of heart failure, 47% exactly defined what heart failure is. A minority of participants correctly recognized the lifetime risk of developing heart failure (21%) as well as the mortality (16%) and readmission risk (18%) of heart failure and the cost burden of heart failure admission (28%). Regarding preferred treatment options, 71% of the participants chose a treatment option that could improve the quality of life. Approximately two-thirds of the participants agreed that current medical treatment could reduce mortality and improve the quality of life. More than half of the participants (59%) thought that heart failure patients should live quietly and reduce all physical activities. Across survey items, we found a lower awareness state in the elderly groups and people at lower income and educational levels.

CONCLUSIONS

The current awareness status of heart failure in the Korean general population is still low. Proactive educational efforts should be made to improve public awareness with special attention to individuals with lower disease awareness.

Depressed Mood, Perceived Health Competence and Health Behaviors: aCross-Sectional Mediation Study in Outpatients with Coronary Heart Disease

BACKGROUND

Identifying potential mechanisms that link depressed mood with worse health behaviors is important given the prevalence of depressed mood in patients with coronary heart disease (CHD) and its relationship with subsequent mortality. Perceived health competence is an individual's confidence in his/her ability to successfully engineer solutions to achieve health goals and may explain how depressed mood affects multiple health behaviors.

OBJECTIVE

Examine whether or not perceived health competence mediates the relationship between depressed mood and worse health behaviors.

DESIGN

A cross-sectional study conducted by the Patient-Centered Outcomes Research Institute-funded Mid-South Clinical Data Research Network between August 2014 and September 2015. Bootstrapped mediation was used.

PARTICIPANTS

Patients with coronary heart disease (n = 2334).

MAIN MEASURES

Two items assessing perceived health competence, a single item assessing depressed mood, and a Health Behaviors Index including: the International Physical Activity Questionnaire (IPAQ); select items from the National Adult Tobacco Survey and the Alcohol Use Disorder Inventory Test; and single items assessing diet and medication adherence.

KEY RESULTS

Depressed mood was associated with lower perceived health competence (a = - 0.21, p < .001) and lower perceived health competence was associated with worse performance on a Health Behaviors Index(b = 0.18, p < .001). Perceived health competence mediated the influence of depressed mood on health behaviors (ab = - 0.04, 95% CI = - 0.05 to - 0.03). The ratio of the indirect effect to the total effect was used as a measure of effect size (P_M = 0.26, 95% CI: 0.18 to 0.39).

CONCLUSIONS

Depressed mood is associated with worse health behaviors directly and indirectly via lower perceived health competence. Interventions to increase perceived health competence may lessen the deleterious impact of depressed mood on health behaviors and cardiovascular outcomes.

The relationship between physical activity and appetite in patients with heart failure: A prospective observational study

INTRODUCTION

Physical activity and appetite are important components for maintaining health. Yet, the association between physical activity and appetite in heart failure (HF) populations is not completely understood. The aim of the present study was to investigate the relationship between physical activity, functional capacity, and appetite in patients with HF.

METHODS

This was a prospective observational study. In total, 186 patients diagnosed with HF, New York Heart Association (NYHA) class II-IV (mean age 70.7, 30% female), were included. Physical activity was measured using a multi-sensor actigraph for seven days and with a self-reported numeric rating scale. Physical capacity was measured by the six-minute walk test. Appetite was measured using the Council on Nutrition Appetite Questionnaire. Data were collected at inclusion and after 18 months. A series of linear regression analyses, adjusted for age, NYHA class, and B-type natriuretic peptide were conducted.

RESULTS

At baseline, higher levels of physical activity and functional capacity were significantly associated with a higher level of appetite in the unadjusted models. In the adjusted models, number of steps ( p = 0.019) and the six-minute walk test ( p = 0.007) remained significant. At the 18-month follow-up, all physical activity variables and functional capacity were significantly associated with appetite in the unadjusted regression models. In the adjusted models, number of steps ( p = 0.001) and metabolic equivalent daily averages ( p = 0.040) remained significant.

CONCLUSION

A higher level of physical activity measured by number of steps/day was associated with better self-reported appetite, both at baseline and the 18-month follow-up. Further research is needed to establish causality and explore the intertwined relationship between activity and appetite in patients with HF.

Self-monitoring to increase physical activity in patients with cardiovascular disease: a systematic review and meta-analysis

BACKGROUND AND AIMS

It is important to encourage physical activity in patients with cardiovascular disease (CVD), and self-monitoring is considered to contribute to increased physical activity. However, the effects of self-monitoring on CVD patients remain to be established. In this study, we examined the influence of self-monitoring on physical activity of patients with CVD via a systematic review and meta-analysis.

METHODS

Screening of randomized controlled trials only was undertaken twice on PubMed (date of appraisal: August 29, 2017). The inclusion criteria included outpatients with CVD, interventions for them, daily step counts as physical activity included in the outcome, and self-monitoring included in the intervention. Assessments of the risk of bias and meta-analysis in relation to the mean change of daily step counts were conducted to verify the effects of self-monitoring.

RESULTS

From 205 studies retrieved on PubMed, six studies were included, with the oldest study published in 2005. Participants included 693 patients of whom 541 patients completed each study program. Their mean age was 60.8 years, and the ratio of men was 79.6%. From these 6 studies, a meta-analysis was conducted with 269 patients of 4 studies including only RCTs with step counts in the intervention group and the control group, and self-monitoring significantly increased physical activity (95% confidence interval, 1916-3090 steps per day, p < 0.05). The average intervention period was about 5 months. Moreover, four studies involved intervention via the internet, and five studies confirmed the use of self-monitoring combined with other behavior change techniques.

CONCLUSION

The results suggest that self-monitoring of physical activity by patients with CVD has a significantly positive effect on their improvement. Moreover, the trend toward self-monitoring combined with setting counseling and activity goals, and increased intervention via the internet, may lead to the future development and spread of self-monitoring for CVD patients.

Exploring the impact of sleep and stress on daily physical activity of cardiac patients: a preliminary study

BACKGROUND

Current approaches to cardiac rehabilitation services tailoring are often based on patient demographics or readiness for behavior change. However, the success of interventions acceptance and improved adherence to recommendations could be much higher when considering and adapting to a patient's lifestyle, such as sleep and stress.

AIMS

We aimed to analyze the potential associations between patient sleep and stress and daily moderate-intensity activity in patients with cardiovascular disease and to gain experience on the methods to collect and analyze a combination of qualitative and quantitative data.

METHODS

Patients with cardiovascular disease enrolled for an outpatient cardiac rehabilitation program were assessed at the study baseline regarding sociodemographic, clinical profile, and perceived level of stress. To collect daily physical activity and sleep data, all participants had two-week long diaries. Collected data was analyzed through correlation analysis, linear regression, and one-way ANOVA analysis.

RESULTS

The mean age of the participants (n =11) was 67.3 ± 9.6 years old. The patients were mainly male (82 %), married (91 %), and having at least one comorbid disease (64 %). The results of the analysis revealed that the night sleep duration is associated with moderate-intensity physical activity [F(1,6) =7.417, p =0.034]. Stress was not associated with patients' moderate-intensity daily physical activity.

CONCLUSION

The outcomes of the study can support the development of e-health and home-based interventions design and strategies to promote adherence to physical activity. Tailoring an intervention to a daily behavioral pattern of a patient, such as sleep, can support the planning of the physical activity in a form to be easier accepted by the patient. This finding emphasizes the need for further investigation of the association with a larger population sample and the use of objective physical activity and sleep-related measure instruments. HIPPOKRATIA 2019, 23(1): 15-20.

The suitability of motivational interviewing versus cognitive behavioural interventions on improving self-care in patients with heart failure: A literature review and discussion paper

BACKGROUND

Chronic heart failure remains a major public health concern due to its high prevalence and disease burden. Although self-care has been advocated as the sustainable solution, it remains inadequate. Recent studies have shown the potential of integrating structured counselling elements into traditional educational programs to enhance self-care but the optimal counselling method remains unclear.

AIM

To compare the applicability of cognitive behavioural interventions and motivational interviewing on improving self-care behaviours in patients with chronic heart failure.

METHOD

A systematic three-step search strategy was used to identify studies that incorporated cognitive behavioural interventions and/or motivational interviewing to improve heart failure self-care. Quantitative and qualitative trial studies that met the inclusion criteria were appraised using the Joanna Brigg's Institute criteria.

RESULTS

Motivational interviewing showed higher potential in improving HF self-care behaviours, but sustainability remains unclear. Cognitive behavioural interventions only showed effectiveness when applied to patients with comorbid depressive symptoms. Statistically significant results were only elucidated upon statistical adjustments and examination of behaviours individually. Potential effective components of CBI include setting up environmental reminders, addressing misconceptions and skills-training while that of MI was the communication style.

CONCLUSION

MI and CBI could be used synergistically by extracting their key effective components to strengthen the intention-behaviour link in improving HF self-care behaviours. MI could be used to enhance the intention to change by evoking ambivalence and change talk. CBI could be used to enhance problem-solving skills and set environmental reminders to strengthen the translation of intention to behaviour.

Relationships between exercise capacity and anxiety, depression, and cognition in patients with heart failure

BACKGROUND

Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity.

OBJECTIVES

The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients.

METHODS

This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment.

RESULTS

The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT.

CONCLUSIONS

The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients.

Mobile Phone Apps to Support Heart Failure Self-Care Management: Integrative Review

Background

With an explosive growth in mobile health, an estimated 500 million patients are potentially using mHealth apps for supporting health and self-care of chronic diseases. Therefore, this review focused on mHealth apps for use among patients with heart failure.

Objective

The aim of this integrative review was to identify and assess the functionalities of mHealth apps that provided usability and efficacy data and apps that are commercially available without supporting data, all of which are to support heart failure self-care management and thus impact heart failure outcomes.

Methods

A search of published, peer-reviewed literature was conducted for studies of technology-based interventions that used mHealth apps specific for heart failure. The initial database search yielded 8597 citations. After filters for English language and heart failure, the final 487 abstracts was reviewed. After removing duplicates, a total of 18 articles that tested usability and efficacy of mobile apps for heart failure self-management were included for review. Google Play and Apple App Store were searched with specified criteria to identify mHealth apps for heart failure. A total of 26 commercially available apps specific for heart failure were identified and rated using the validated Mobile Application Rating Scale.

Results

The review included studies with low-quality design and sample sizes ranging from 7 to 165 with a total sample size of 847 participants from all 18 studies. Nine studies assessed usability of the newly developed mobile health system. Six of the studies included are randomized controlled trials, and 4 studies are pilot randomized controlled trials with sample sizes of fewer than 40. There were inconsistencies in the self-care components tested, increasing bias. Thus, risk of bias was assessed using the Cochrane Collaboration’s tool for risk of selection, performance, detection, attrition, and reporting biases. Most studies included in this review are underpowered and had high risk of bias across all categories. Three studies failed to provide enough information to allow for a complete assessment of bias, and thus had unknown or unclear risk of bias. This review on the commercially available apps demonstrated many incomplete apps, many apps with bugs, and several apps with low quality.

Conclusions

The heterogeneity of study design, sample size, intervention components, and outcomes measured precluded the performance of a systematic review or meta-analysis, thus introducing bias of this review. Although the heart failure–related outcomes reported in this review vary, they demonstrated trends toward making an impact and offer a potentially cost-effective solution with 24/7 access to symptom monitoring as a point of care solution, promoting patient engagement in their own home care.

Relation of Perceived Health Competence to Physical Activity in Patients With Coronary Heart Disease

Physical inactivity is highly associated with mortality, especially in patients with coronary heart disease. We evaluated the effect of perceived health competence, a patient's belief in his or her ability to achieve health-related goals, on cumulative physical activity levels in the Mid-South Coronary Heart Disease Cohort Study. The Mid-South Coronary Heart Disease Cohort Study consists of 2,587 outpatients (32% were female) with coronary heart disease at an academic medical center network in the United States. Cumulative physical activity was quantified in metabolic equivalent (MET)-minutes per week with the International Physical Activity Questionnaire. We investigated associations between the 2-item Perceived Health Competence Scale (PHCS-2) and MET-minutes/week after adjusting for co-morbidities and psychosocial factors with linear regression. Nearly half of participants (47%) exhibited low physical activity levels (<600 MET-minutes/week). Perceived health competence was highly associated with physical activity after multivariable adjustment. A nonlinear relation was observed, with the strongest effect on physical activity occurring at lower levels of perceived health competence. There was effect modification by gender (p = 0.03 for interaction). The relation between perceived health competence and physical activity was stronger in women compared with men; an increase in the PHCS-2 from 3 to 4 was associated with a 73% increase in MET-minutes/week in women (95% confidence interval 43% to 109%, p <0.0001) compared with a 53% increase in men (95% confidence interval 27% to 84%, p <0.0001). In conclusion, low perceived health competence was strongly associated with less physical activity in patients with coronary heart disease and may represent a potential target for behavioral interventions.

Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study

OBJECTIVE

To assess patient perspectives on secondary lifestyle modification and knowledge of 'heart attack' after percutaneous coronary intervention (PCI) for coronary artery disease (CAD).

DESIGN

Observational cross-sectional study.

SETTING

A single university-based hospital centre in Japan.

PARTICIPANTS

In total, 236 consecutive patients with CAD who underwent PCI completed a questionnaire (age, 67.4±10.1 years; women, 14.8%; elective PCI, 75.4%). The survey questionnaire included questions related to confidence levels about (1) lifestyle modification at the time of discharge and (2) appropriate recognition of heart attack symptoms and reactions to these symptoms on a four-point Likert scale (1=not confident to 4=completely confident).

PRIMARY OUTCOME MEASURE

The primary outcome assessed was the patients' confidence level regarding lifestyle modification and the recognition of heart attack symptoms.

RESULTS

Overall, patients had a high level of confidence (confident or completely confident,>75%) about smoking cessation, alcohol restriction and medication adherence. However, they had a relatively low level of confidence (<50%) about the maintenance of blood pressure control, healthy diet, body weight and routine exercise (≥3 times/week). After adjustment, male sex (OR 3.61, 95% CI 1.11 to 11.8) and lower educational level (OR 3.25; 95% CI 1.70 to 6.23) were identified as factors associated with lower confidence levels. In terms of confidence in the recognition of heart attack, almost all respondents answered 'yes' to the item 'I should go to the hospital as soon as possible when I have a heart attack'; however, only 28% of the responders were confident in their ability to distinguish between heart attack symptoms and other conditions.

CONCLUSIONS

There were substantial disparities in the confidence levels associated with lifestyle modification and recognition/response to heart attack. These gaps need to be studied further and disseminated to improve cardiovascular care.

Factors Related to Self-Care in Heart Failure Patients According to the Middle-Range Theory of Self-Care of Chronic Illness: a Literature Update

Purpose of the Review

As described in the theory of self-care in chronic illness, there is a wide range of factors that can influence self-care behavior. The purpose of this paper is to summarize the recent heart failure literature on these related factors in order to provide an overview on which factors might be suitable to be considered to make self-care interventions more successful.

Recent Findings

Recent studies in heart failure patients confirm that factors described in the theory of self-care of chronic illness are relevant for heart failure patients.

Summary

Experiences and skills, motivation, habits, cultural beliefs and values, functional and cognitive abilities, confidence, and support and access to care are all important to consider when developing or improving interventions for patients with heart failure and their families. Additional personal and contextual factors that might influence self-care need to be explored and included in future studies and theory development efforts.

Effect of diabetes mellitus on walking distance parameters after supervised exercise therapy for intermittent claudication: A systematic review

Some believe that certain patients with intermittent claudication may be unsuitable for supervised exercise therapy (SET), based on the presence of comorbidities and the possibly increased risks. We conducted a systematic review (MEDLINE, EMBASE and CENTRAL) to summarize evidence on the potential influence of diabetes mellitus (DM) on the response to SET. Randomized and nonrandomized studies that investigated the effect of DM on walking distance after SET in patients with IC were included. Considered outcome measures were maximal, pain-free and functional walking distance (MWD, PFWD and FWD). Three articles met the inclusion criteria ( n = 845). In one study, MWD was 111 meters (128%) longer in the non-DM group compared to the DM group after 3 months of follow-up ( p = 0.056). In a second study, the non-DM group demonstrated a significant increase in PFWD (114 meters, p ⩽ 0.05) after 3 months of follow-up, whereas there was no statistically significant increase for the DM group (54 meters). On the contrary, the largest study of this review did not demonstrate any adverse effect of DM on MWD and FWD after SET. In conclusion, the data evaluating the effects of DM on SET were inadequate to determine if DM impairs the exercise response. While trends in the data do not suggest an impairment, they are not conclusive. Practitioners should consider this limitation when making clinical decisions.