Exercise Self-efficacy Improvements During Cardiac Rehabilitation: IMPACT OF SOCIAL DISPARITIES.

PURPOSE: The objective of this study was to determine exercise self-efficacy improvements during cardiac rehabilitation (CR) and identify predictors of exercise self-efficacy change in CR participants. METHODS: Patients with coronary heart disease at four metropolitan CR sites completed the Exercise Self-efficacy Scale at entry and completion. A general linear model identified independent predictors of change in exercise self-efficacy. RESULTS: The mean age of patients (n = 194) was 65.9 ± 10.5 yr, and 81% were males. The majority (80%) were married or partnered, 76% were White, and 24% were from an ethnic minority background. Patients received CR in-person (n = 91, 47%) or remote-delivered (n = 103, 54%). Exercise self-efficacy mean scores improved significantly from 25.2 ± 5.8 at CR entry to 26.2 ± 6.3 points at completion ( P = .025). The majority of patients (59%) improved their self-efficacy scores, 34% worsened, and 7% had no change. Predictors of reduced exercise self-efficacy change were being from an ethnic minority (B =-2.96), not having a spouse/partner (B =-2.42), attending in-person CR (B =1.75), and having higher exercise self-efficacy at entry (B =-0.37) (adjusted R2 = 0.247). CONCLUSIONS: Confidence for self-directed exercise improves in most, but not all, patients during CR. Those at risk for poor improvement (ethnic minorities, single patients) may need extra or tailored support, and screening for exercise self-efficacy at CR entry and completion is recommended. Differences identified from CR delivery mode need exploration using robust methods to account for complex factors.

Validation of the PROMIS-29v2 Health-Related Quality-of-Life Questionnaire in Patients With Coronary Heart Disease Participating in Remote Cardiac Rehabilitation.

PURPOSE: The aim of this study was to validate the 29-item Patient-Reported Outcomes Measurement Information System version 2.0 (PROMIS-29v2) health-related quality-of-life (HRQL) questionnaire for use in patients with coronary heart disease (CHD) participating in remotely delivered cardiac rehabilitation (CR). METHODS: Patients commencing remote CR across four sites in New South Wales, Australia, answered the PROMIS-29v2 and 12-item Short Form Health Survey version 2.0 (SF-12v2) questionnaires at CR entry and completion (6 wk). The data were analyzed for validity, reliability, and responsiveness to change. RESULTS: Patients (N = 89) had a mean age of 66.9 ± 9.3 yr; 83% were male and were referred to CR for elective percutaneous coronary intervention (PCI) (42%), myocardial infarction (36%), and coronary artery bypass grafting (22%). Internal consistency reliability was adequate, with the Cronbach α ranging from 0.78-0.98. Convergent validity between the PROMIS-29v2 and SF-12v2 summary scores showed significantly strong correlations for physical ( r = 0.62) and moderate for mental ( r = 0.36) health. Discriminant validity was confirmed for sex (women reported lower physical and mental health) and referral diagnosis (patients who had elective PCI reported better physical health). Effect size (ES) comparisons confirmed responsiveness to change from CR entry to completion in physical health (ES = 0.51) and demonstrated evidence of more responsiveness than SF-12v2 for mental health (ES = 0.70). CONCLUSION: The PROMIS-29v2 is reliable, valid, and responsive to changes in patients with CHD attending remotely delivered CR and allows for baseline HRQL assessment, between-diagnosis comparisons, and evaluation of changes over time.

Remote-delivered cardiac rehabilitation during COVID-19: a prospective cohort comparison of health-related quality of life outcomes and patient experiences.

AIMS: Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes. METHODS AND RESULTS: Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10-21) vs. 25 (IQR 16-38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times). CONCLUSION: Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.

Target Audience and Preferences Related to an Australian Coronary Heart Disease Specific Mobile App: A Mixed Methods Study.

BACKGROUND: Widespread availability of mobile technologies offers the opportunity to support secondary prevention of coronary heart disease (CHD) via mobile apps, however, the target audience and their app preferences are unknown. This study aims to identify the potential audience for an Australian CHD specific app and their recommendations and preferences. METHODS: A two-phase mixed methods study: Phase 1: CHD patients (n=282) were surveyed on mobile app engagement. Phase 2: Four focus groups with regular app users (n=12) identified preferences and recommendations generated after using a CHD-specific publicly available app (MyHeartMyLife) for 2 weeks. Data were thematically analysed. RESULTS: Survey participants were aged ≥56 years (238/282, 84.4%) and male (204/282, 72.3%). More than one third (108/282, 38.3%) were regular app users, of whom 83/108, (76.9%) used health apps. Regular app users were more likely to be <56 years (versus ≥70 years; OR 4.70, 95% CI 1.92, 11.51), employed (OR 3.07, 95% CI 1.63, 5.77) and had completed high school education (OR 2.37, 95% CI 1.30, 4.34). Focus group participants using the CHD-specific app were aged 41-79 years (mean 62.2 SD 5.3 years) and 10/12 were male. Coronary heart disease specific app preferences generated included: immediate access to relevant and practical health information and records; behaviour change motivation; more experienced app users located and used app features readily and provided support for less experienced users. In addition, ensuring ease of reading and interpreting data, adding physical activity tracking, the ability to integrate and synchronise with other apps and devices, and capacity to store additional personal medical records were also recommended. CONCLUSIONS: The target audience for CHD-specific apps is aged <56 years, employed, has completed high school and is an experienced app user. User preferences and recommendations identified features present in publicly available apps, but many features need development.

Mobile Technology Use Across Age Groups in Patients Eligible for Cardiac Rehabilitation: Survey Study.

BACKGROUND: Emerging evidence indicates mobile technology-based strategies may improve access to secondary prevention and reduce risk factors in cardiac patients. However, little is known about cardiac patients' use of mobile technology, particularly for health reasons and whether the usage varies across patient demographics. OBJECTIVE: This study aimed to describe cardiac patients' use of mobile technology and to determine variations between age groups after adjusting for education, employment, and confidence with using mobile technology. METHODS: Cardiac patients eligible for attending cardiac rehabilitation were recruited from 9 hospital and community sites across metropolitan and rural settings in New South Wales, Australia. Participants completed a survey on the use of mobile technology devices, features used, confidence with using mobile technology, willingness and interest in learning, and health-related use. RESULTS: The sample (N=282) had a mean age of 66.5 (standard deviation [SD] 10.6) years, 71.9% (203/282) were male, and 79.0% (223/282) lived in a metropolitan area. The most common diagnoses were percutaneous coronary intervention (33.3%, 94/282) and myocardial infarction (22.7%, 64/282). The majority (91.1%, 257/282) used at least one type of technology device, 70.9% (200/282) used mobile technology (mobile phone/tablet), and 31.9% (90/282) used all types. Technology was used by 54.6% (154/282) for health purposes, most often to access information on health conditions (41.4%, 117/282) and medications (34.8%, 98/282). Age had an important independent association with the use of mobile technology after adjusting for education, employment, and confidence. The youngest group (<56 years) was over 4 times more likely to use any mobile technology than the oldest (>69 years) age group (odds ratio [OR] 4.45, 95% CI 1.46-13.55), 5 times more likely to use mobile apps (OR 5.00, 95% CI 2.01-12.44), and 3 times more likely to use technology for health-related reasons (OR 3.31, 95% CI 1.34-8.18). Compared with the older group, the middle age group (56-69 years) was more than twice as likely to use any mobile technology (OR 2.42, 95% CI 1.27-4.59) and mobile technology for health-related purposes (OR 1.92, 95% CI 1.04-3.53). Participants who had completed high school were twice as likely to use mobile technology (OR 2.62, 95% CI 1.45-4.70), mobile apps (OR 2.05, 95% CI 1.09-3.84), and mobile technology for health-related reasons (OR 5.09, 95% CI 2.89-8.95) than those who had not completed high school. Associations were also present between participants living in metropolitan areas and mobile technology use (OR 1.07, 95% CI 1.07-4.24) and employment and mobile app use (OR 2.72, 95% CI 1.44-5.140). CONCLUSIONS: Mobile technology offers an important opportunity to improve access to secondary prevention for cardiac patients, particularly when modified to suit subgroups. High levels of mobile technology use and health motivation need to be harnessed for secondary prevention.

Exercise barriers and the relationship to self-efficacy for exercise over 12 months of a lifestyle-change program for people with heart disease and/or diabetes.

BACKGROUND: Barriers to exercise are common in people with coronary heart disease (CHD) and/or diabetes mellitus (DM), and may influence self-efficacy for exercise. PURPOSE: The purpose of this study was to describe the exercise barriers experienced by people who have CHD and/or DM participating in the Healthy Eating and Exercise Lifestyle Program and to determine whether these barriers influence self-efficacy. METHODS: Participants ( n = 134) identified their barriers to exercise and completed the self-efficacy for exercise survey at baseline, at 4 months (following structured and supervised exercise) and at 12 months (following home-based exercise with three follow-up calls). RESULTS: The sample mean age was 63.6 years (SD 8.5) and 58% were male. Barriers to exercise were reported by 88% at baseline, 76% at 4 months, and 47% at 12 months. The most common barriers were lack of motivation (40.3%), lack of time overall (30.6%), and lack of time due to family commitments (17.2%). Only motivation changed significantly over time from baseline (40%) to 4 months (23%, p = 0.040). Lower self-efficacy for exercise was associated with lack of motivation at 12 months only, more depressive symptoms at baseline and 4 months, and a CHD diagnosis and higher body mass index at 12 months. In contrast, male gender and having higher self-efficacy at baseline were associated with higher self-efficacy for exercise at 4 and 12 months. CONCLUSION: Patients identified many exercise barriers despite participating in a lifestyle-change program. Lack of motivation negatively influenced self-efficacy for exercise at 12 months. Other factors needing attention include baseline self-efficacy, depressive symptoms, being female, being more overweight, and having CHD.

Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram.

OBJECTIVES: Postoperative atrial fibrillation (POAF) occurs in 25-40% of patients following cardiac surgery, and is associated with a significant increased risk of stroke and mortality. Routine surveillance is not performed post-discharge; however, recurrence of POAF can occur in up to 30% of patients discharged in sinus rhythm. This study aimed to determine the feasibility of patients self-monitoring with an iPhone handheld electrocardiogram (iECG) to identify recurrence of POAF in the post-discharge period following cardiac surgery. METHODS: Patients with POAF following cardiac surgery were eligible for participation if they had no prior history of atrial fibrillation (AF) and were discharged home in stable sinus rhythm. Participants were provided with an iECG and asked to record a 30-s iECG, four times per day for 4 weeks post-discharge. iECGs were automatically transmitted to a secure server, and reviewed for the presence of AF by the research team and a validated algorithm. All participants also received brief education on AF. RESULTS: Forty-two participants completed the intervention (mean age 69 ± 9 years, 80% male). Self-monitoring for POAF recurrence using an iECG was feasible and acceptable, and participants felt empowered. Self-monitoring identified 24% (95% confidence interval, 12-39%) with an AF recurrence within 17 days of hospital discharge. These participants were significantly younger than those without AF recurrence (64 ± 7 vs 70 ± 10 years; P = 0.025), and had a significantly lower CHA2DS2-VASc score (2.3 ± 1.2 vs 3.7 ± 2.3; P = 0.007). However, 80% were at high enough stroke risk to warrant consideration of anticoagulation, i.e. CHA2DS2-VASc score ≥2. Only 30% of recurrences were associated with palpitations. Participation also improved AF knowledge from 6.4 ± 1.8 to 7.3 ± 1.8 (P = 0.02), of a total score of 10. CONCLUSIONS: Providing patients with an iECG is a non-invasive, inexpensive, convenient and feasible way to monitor for AF recurrence in post-cardiac surgery patients. It also provides a mechanism to provide knowledge about the condition and also potentially reduce anxiety. The success of patients using this technology also has implications for extending the use of iECG self-monitoring to other patient groups such as those undergoing antiarrhythmic interventions for AF.

Long-term outcomes from Healthy Eating and Exercise Lifestyle Program for overweight people with heart disease and diabetes.

BACKGROUND: The benefits of exercise and weight reduction for overweight or obese people with coronary heart disease and/or diabetes mellitus are well recognised. The Healthy Eating and Exercise Lifestyle Program demonstrated these outcomes at 4 months, but longer-term outcomes are not yet reported. AIM: To determine whether positive weight, body mass index, waist and exercise duration outcomes were sustained in the long term (12 months) and to identify the independent predictors of these outcomes at 4 and 12 months. METHODS: Longitudinal design, combining data of all Healthy Eating and Exercise Lifestyle Program participants (intervention and wait-list control, n = 134). Participants had a body mass index between 27 and 39 kg/m(2) and had completed cardiac rehabilitation and/or diabetes education programmes. Healthy Eating and Exercise Lifestyle Program intervention included an active phase of two 1-hour group-based supervised structured exercise sessions every week for 4 months and four 90-minute group information and support sessions. The maintenance phase included one 90-minute group-based booster information session and three 15-minute goal-focused telephone follow-up calls over 8 months. RESULTS: Participants had statistically significant reductions from baseline in weight, body mass index and waist circumference and improvements in exercise duration and capacity at 4 and 12 months. Time, self-efficacy, depressive symptoms and male gender were independent predictors for body mass index, waist and/or exercise duration (p < 0.05). CONCLUSION: The Healthy Eating and Exercise Lifestyle Program was an effective programme to achieve and sustain weight loss and increase exercise participation over 1 year.

Who gets stroke prevention? Stroke prevention in atrial fibrillation patients in the inpatient setting.

BACKGROUND: Current guidelines strongly recommend antithrombotic therapy, particularly warfarin, for stroke prevention in atrial fibrillation (AF) patients at high risk of stroke. Despite this, use of these medications is far from optimal. The aim of this study was to describe the use of stroke prevention medication in inpatients and identify factors associated with prescription in one local health district in Sydney, Australia. METHODS: A prospective audit of medical records for patients admitted with an AF diagnosis to five hospitals in the health district and excluding cardiac surgery patients was undertaken. Patients were classified as high or low for stroke risk as well as for risk of bleeding and predictors were identified by logistic regression. RESULTS: A total of 204 patients were enrolled from July 2012 to April 2013, with a mean age of 75 years (SD 13) and half (50%) were male. Valve disease was present in 17% and 15% received a procedure for their AF (cardioversion/ablation/pulmonary vein isolation). Patients were least likely to be prescribed warfarin/novel oral anticoagulant (NOAC) if they were non-valvular and did not undergo cardioversion/ablation (p=.03), and least likely to be prescribed aspirin if they had no AF procedure (p=.01). In non-valvular patients who did not have cardioversion/ablation the odds of being prescribed warfarin/NOAC were increased by being classified at high risk of stroke (OR 3.1, 95% CI 1.0 -9.5) and decreased if there was a prescription for aspirin (OR .3. 95% CI .1 -.6). CONCLUSIONS: Overall use of stroke prevention medication indicates that gaps remain in translation of evidence into clinical practice.

Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol.

INTRODUCTION: Postoperative atrial fibrillation (AF) occurs in 30-40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is often asymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge. METHODS AND ANALYSIS: This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECG recordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomes include proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patient's use of the iECG and sustainability of the screening programme beyond the trial setting will also be collected. ETHICS AND DISSEMINATION: Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will be disseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences. TRIAL REGISTRATION NUMBER: ACTRN12614000383662.

Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns.

Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes.

Impact of the Healthy Eating and Exercise Lifestyle Programme on depressive symptoms in overweight people with heart disease and diabetes.

BACKGROUND: The Healthy Eating and Exercise Lifestyle Program (HEELP) is a secondary risk factor intervention programme for people with heart disease and/or type 2 diabetes, which has proven benefits for weight loss and exercise. This secondary analysis evaluated the effects of HEELP on achieving recommended levels of exercise and the prevalence of depressive symptoms, and whether meeting exercise recommendations had an independent effect on depressive symptoms. DESIGN: A randomized parallel controlled trial of patients (n = 147) with body mass index 27-39 kg/m(2) were recruited from cardiac rehabilitation and diabetes education programmes. METHODS: HEELP participants received a 16-week group-based lifestyle intervention of twice-weekly supervised exercise and five information sessions; the control group received usual care. At 16 weeks, achievement of recommended levels of exercise (≥ 5 days/week, moderate or higher intensity, and total duration of ≥ 150 minutes/week) and depressive symptoms (Hospital Anxiety and Depression Scale) were assessed. RESULTS: More HEELP participants met the recommendations for exercise frequency (71 vs. 50%, p = 0.036), intensity (76 vs. 60%, p = 0.05), and total duration (65 vs. 43%, p = 0.047). The prevalence of depressive symptoms in HEELP was half that of the control group (17 vs. 34%; OR 0.397, 95% CI 0.18-0.86). Participants who met recommendations for total duration of exercise were less likely to report depressive symptoms (OR 0.29, 95% CI 0.112-0.717) after adjusting for treatment group and weight change. CONCLUSIONS: A group-based lifestyle intervention improves exercise and reduces depressive symptoms despite multiple risk factors.

Evaluation of a brief educational intervention to improve knowledge of sublingual nitroglycerin in cardiac rehabilitation patients.

OBJECTIVE: This study aimed to evaluate the impact of a brief educational intervention delivered in cardiac rehabilitation (CR) on patients' knowledge of sublingual nitroglycerin (SLN). METHODS: Patients (n=86) commencing CR were provided with a brief educational intervention tailored to deficits identified in an assessment of SLN knowledge using the Sublingual Nitroglycerin Questionnaire, with reassessment at the end of program completion (6-8 weeks). RESULTS: The mean age of patients was 64.95 years (standard deviation (SD) 10.87); 74% were male, 78% were married and 60% had not completed high school. Most (70%) had no prior coronary heart disease (CHD) history and 80% had been referred to CR following percutaneous coronary intervention. SLN knowledge scores increased from baseline to outcome. Patients were significantly more likely to know: the name of their SLN medication (11% increase, p=0.001), the recommended timing between doses (29% increase, p=0.02), the maximum number of doses (27% increase, p=0.005), to have SLN on their person at the time of the interview (25% increase, p<0.001) and to know the interaction between SLN and sildenafil (36% increase, p=0.001). The independent predictors of SLN knowledge included having better knowledge at baseline (ß=0.28) and having consulted a general practitioner post discharge and before commencing CR (ß=1.48). CONCLUSION: A brief standardised knowledge intervention, individually tailored to identified deficits in a knowledge screen and delivered during CR, shows promise for improving patient knowledge of SLNs. The role of general practitioners in delivering medication education needs further investigation.

A pre-test post-test study of a brief educational intervention demonstrates improved knowledge of potential acute myocardial infarction symptoms and appropriate responses in cardiac rehabilitation patients.

BACKGROUND: Patient delay in recognizing and responding to potential acute myocardial infarction (AMI) symptoms is an international issue. Cardiac rehabilitation provides an ideal opportunity to deliver an intervention. AIMS: This study examines an individual educational intervention on knowledge of heart attack warning signs and specific chest pain action plans for people with coronary heart disease. METHODS: Cardiac rehabilitation participants at five hospitals were assessed at program entry and tailored education was provided using the Heart Foundation of Australia's Heart Attack Warning Signs campaign educational tool. Participants (n=137) were reassessed at program conclusion (six to eight weeks). RESULTS: Study participants had a mean age of 64.48 years (SD 12.22), were predominantly male (78%) and most commonly presented with a current referral diagnosis of a percutaneous coronary intervention (PCI) (80%) and/or AMI (60%). There were statistically significant improvements in the reporting of 11 of the 14 warning signs of heart attack, with patients reporting 2.56 more warning signs on average at outcome (p<.0001). Patients reported more heart attack warning signs if they had completed high school education (ß=1.14) or had better knowledge before the intervention (ß=.57). There were statistically significant improvements in reporting of all appropriate actions in response to potential AMI symptoms, with patients reporting an average of 1.3 more actions at outcome (p<.001), with no change in the median time they would tolerate symptoms (p=.16). CONCLUSIONS: A brief education session using a single standardised tool and adapted to a patient assessment is effective in improving knowledge of potential AMI symptoms and appropriate responses in cardiac rehabilitation up to two months following.

Collaboration: a solution to the challenge of conducting nursing research in cardiac rehabilitation.

Clinical nurse leaders such as clinical nurse consultants are required to conduct research and incorporate outcomes of this research into their every day practice. However, undertaking research presents issues for cardiac rehabilitation clinical nurse consultants because they may have competing demands, difficulty with finding replacements and may be relatively isolated from other researchers. The solution to this situation is the formation of a collaborative research team with other cardiac rehabilitation clinical nurse consultants, with the inclusion of an experienced university academic as a mentor for the cardiac rehabilitation clinical nurse consultants working in an Area Health Service encompassing both rural and metropolitan hospitals in New South Wales, Australia. The related research project aimed to evaluate and improve the clients' knowledge and practices related to the use of sublingual glyceryl trinitrate. The team's experiences and suggestions for clinical nurse Leaders are presented in this paper. Essential team characteristics include having shared motivation, good communication practices, flexibility and tolerance, an effective team size, achieving success, willingness to accept challenges and an experienced mentor. The benefits of developing a collaborative team for research led by clinical nurse consultants in cardiac rehabilitation by far outweigh the time and effort involved in the process.

A randomised trial of a weight loss intervention for overweight and obese people diagnosed with coronary heart disease and/or type 2 diabetes.

BACKGROUND: Weight reduction limits disease progression in obese people with coronary heart disease (CHD) and/or type 2 diabetes mellitus (T2DM). PURPOSE: To test a 16-week group-based weight reduction intervention combining exercise, diet and behaviour change strategies aimed to increase self-efficacy (Healthy Eating and Exercise Lifestyle Program-HEELP) on weight, body mass index (BMI), waist circumference and exercise. METHODS: Participants with CHD and/or T2DM and BMI between 27 to 39 kg/m(2) were randomised to HEELP (n=83) or usual care (n=65). RESULTS: Participants were aged a mean 63.47 years (SD 8.9), male (58 %) and Caucasian (79 %). HEELP participants lost significantly more weight, BMI and waist circumference and exercised more days/week for a longer duration/week than usual care. Clinically significant weight loss (≥5 %) was more common in HEELP than usual care. CONCLUSION: The HEELP resulted in weight loss and improved exercise behaviour in obese people with CHD and T2DM.

Weight management issues and strategies for people with high cardiovascular risk undertaking an Australian weight loss program: a focus group study.

Obesity is particularly hazardous for people with multiple cardiovascular risk factors and existing cardiovascular disease, although few studies investigate experiences and perceptions of weight loss in this population. This study provides an understanding of participants' knowledge, attitudes, and experiences of managing multiple risk factors and/or existing cardiovascular disease of participants who were undertaking a weight loss program. Thirty-five participants were recruited from the first 50 completing a multicomponent group-based weight loss intervention designed to follow cardiovascular disease and diabetes disease management programs. Four focus group interviews were conducted using a semistructured interview schedule. Data were analyzed using an inductive approach, and themes developed. Participants found the process of weight loss to be complex, dynamic, and challenging, as the conflicting needs of existing health conditions, social support, ambivalence, and time limitations required careful balance. In response, participants determinedly developed and tested strategies based on simplified principles, establishing routines for new health habits and portion control, and going back to basics in food selection. Therefore, weight loss programs for this population need to be specifically tailored to support patients' efforts and strategies.

Participants' perspectives of a multi-component, group-based weight loss programme supplement for cardiac rehabilitation: a qualitative study.

Addressing overweight and obesity in people with cardiovascular risk factors is an important aspect of cardiac rehabilitation, but minimal implementation of targeted strategies has occurred. The aim of this study was to describe participants' perspectives of a multi-component, group-based weight loss supplement to cardiac rehabilitation programmes. Four focus groups of participants completing the intervention (n = 16) and maintenance phases (n = 19) of the Healthy Eating and Exercise Lifestyle Program (HEELP) were conducted. Interviews were transcribed and thematically analyzed using an inductive process. The overall theme of participants' responses was that HEELP helped them reprogramme their lifestyle behaviours to achieve weight loss. The programme was unique compared with other weight loss programmes because it was delivered and developed by familiar and expert health professionals who tailored the programme to participants' health status. Themes included the process of recognizing and deciding to make a commitment to managing their weight problem and feeling supported by the group and the staff to do this. Participants valued the group-based structure and the specific tools used in the programme. The programme content and structure provides a framework for the development of supplemental programmes for overweight and obese people at high cardiovascular risk.

Sublingual nitroglycerin practices in patients with coronary artery disease in Australia.

BACKGROUND AND RESEARCH OBJECTIVE: Sublingual nitroglycerin (SLNTG) medications are a recommended treatment for people with coronary artery disease (CAD); however, prescription and knowledge may be suboptimal. This study set out to determine how often SLNTG is prescribed and the knowledge and factors associated in patients with CAD. SUBJECTS AND METHODS: Patients (n = 142) were recruited from cardiac rehabilitation and surveyed regarding SLNTG prescription and key knowledge areas related to SLNTG in those prescribed (n = 89). Multiple regression analysis was used to determine independent predictors of knowledge. RESULTS AND CONCLUSIONS: Despite having CAD, 37% were not prescribed SLNTG, and of those prescribed, only 43% received related instruction. Knowledge of SLNTG was low at a mean 7.11 (SD, 2.05) points of a possible 14. Most participants (96%) knew to use SLNTG to treat chest pain/discomfort, and no participant described inappropriate symptoms for treatment. Although most patients (80%) knew to have the SLNTG available at all times, only 46% did so in reality. One in 5 participants reported that they would not call an ambulance if chest pain was unrelieved by SLNTG. Participants had more SLNTG knowledge if they were married, were male, and had been instructed about SLNTG and had less knowledge if their hospital discharge diagnosis included angina. The reporting of calling an ambulance for unrelieved symptoms was increased by having more knowledge of SLNTG, but decreased if participants had prior use of SLNTG, were married, or had more comorbidities. Consideration of prescription for SLNTG and related instruction, particularly for their chest-pain action plan, needs to be provided more systematically for patients with CAD.

Age-specific differences in women with implantable cardioverter defibrillators: an international multi center study.

BACKGROUND: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers. METHODS: Eighty-eight female ICD patients were recruited at three medical centers: Shands Hospital at the University of Florida, Brigham and Women's Hospital in Boston, and Royal North Shore Hospital in Sydney, Australia. Women completed individual psychological assessment batteries, measuring the constructs of shock anxiety, death anxiety, and body image concerns. Medical record review was conducted for all patients regarding cardiac illnesses and ICD-specific data. RESULTS: Multivariate and univariate analyses of variance revealed that younger women reported significantly higher rates of shock and death anxiety (Pillai's F=3.053, P=0.018, eta2p=0.067) and significantly greater body image concerns (Pillai's F=4.198, P=0.018, eta2p=0.090) than middle- and older-aged women. CONCLUSIONS: Women under the age of 50 appear to be at greater risk for the development of psychosocial distress associated with shock anxiety, death anxiety, and body image. Clinical-based strategies and interventions targeting these types of adjustment difficulties in younger women may allow for improved psychosocial and quality of life outcomes.