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Telerehabilitation approaches have been successful in supporting coronary artery disease (CAD) patients to rehabilitate at home after hospital-based rehabilitation. However, on completing a telerehabilitation program, the effects are not sustained beyond the intervention period because of the lack of lifestyle adaptations. Furthermore, decline in patients' motivation lead to recurrence of disease and increased rehospitalization rates. We developed HeartHab, using persuasive design principles and personalization, to enable sustenance of rehabilitation effects beyond the intervention period. HeartHab promotes patients' understanding, motivates them to reach personalized rehabilitation goals, and helps to maintain positive lifestyle adaptations during telerehabilitation. This study aimed to investigate the impact of the HeartHab app on patients' overall motivation, increasing physical activities, reaching exercise targets, quality of life, and modifiable risk factors in patients with CAD during telerehabilitation. The study also investigated carryover effects to determine the maintenance of effects after the conclusion of the intervention. A total of 32 CAD patients were randomized on a 1:1 ratio to telerehabilitation or usual care. We conducted a 4-month crossover study with a crossover point at 2 months using a mixed-methods approach for evaluation. We collected qualitative data on users' motivation, user experience, and quality of life using questionnaires, semistructured interviews and context-based sentiment analysis. Quantitative data on health parameters, exercise capacity, and risk factors were gathered from blood tests and ergo-spirometry tests. Data procured during the app usage phase were compared against baseline values to assess the impact of the app on parameters such as motivation, physical activity, quality of life, and risk factors. Carryover effects were used to gather insights on the maintenance of effects. The qualitative data showed that 75% (21/28) of patients found the HeartHab app motivating and felt encouraged to achieve their rehabilitation targets. 84% (21/25) of patients either reached or exceeded their prescribed physical activity targets. We found positive significant effects on glycated hemoglobin (P=.01; d=1.03; 95% CI 0.24-1.82) with a mean decrease of 1.5 mg/dL and high-density lipoprotein (HDL) cholesterol (P=.04; d=0.78; 95% CI 0.02-1.55) with a mean increase of 0.61 mg/dL after patients used the HeartHab app. We observed significant carryover effects on weight, HDL cholesterol, and maximal oxygen consumption (VO max), indicating the maintenance of effects. Persuasive design techniques integrated in HeartHab and tailoring of exercise targets were effective in motivating patients to reach their telerehabilitation targets. This study demonstrated significant effects on glucose and HDL cholesterol and positive carryover effects on weight, HDL cholesterol, and VO max. There was also a perceived improvement in quality of life. A longer-term evaluation with more patients could possibly reveal effectiveness on other risk factors and maintenance of the positive health behavior change. ClinicalTrials.gov NCT03102671; https://clinicaltrials.gov/ct2/show/NCT03102671 (Archived by WebCite at http://www.webcitation.org/76gzI9Pvd).

Digital health is becoming more integrated in daily medical practice. In cardiology, patient care is already moving from the hospital to the patients’ homes, with large trials showing positive results in the field of telemonitoring via cardiac implantable electronic devices (CIEDs), monitoring of pulmonary artery pressure via implantable devices, telemonitoring via home-based non-invasive sensors, and screening for atrial fibrillation via smartphone and smartwatch technology. Cardiac rehabilitation and secondary prevention are modalities that could greatly benefit from digital health integration, as current compliance and cardiac rehabilitation participation rates are low and optimisation is urgently required. This viewpoint offers a perspective on current use of digital health technologies in cardiac rehabilitation, heart failure and secondary prevention. Important barriers which need to be addressed for implementation in medical practice are discussed. To conclude, a future ideal digital tool and integrated healthcare system are envisioned. To overcome personal, technological, and legal barriers, technological development should happen in dialog with patients and caregivers. Aided by digital technology, a future could be realised in which we are able to offer high-quality, affordable, personalised healthcare in a patient-centred way.

While questionnaires for assessing digital literacy exist, there is still a need for an easy-to-use and implementable questionnaire for assessing digital readiness in a broader sense. Additionally, learnability should be assessed to identify those patients who need additional training to use digital tools in a health care setting. The aim of the development of the Digital Health Readiness Questionnaire (DHRQ) was to create a short, usable, and freely accessible questionnaire that was designed from a clinical practice perspective. It was a prospective single-center survey study conducted in Jessa Hospital Hasselt in Belgium. The questionnaire was developed with a panel of field experts with questions in following 5 categories: digital usage, digital skills, digital literacy, digital health literacy, and digital learnability. All participants who were visiting the cardiology department as patients between February 1, 2022, and June 1, 2022, were eligible for participation. Cronbach α and confirmatory factor analysis were performed. A total number of 315 participants were included in this survey study, of which 118 (37.5%) were female. The mean age of the participants was 62.6 (SD 15.1) years. Cronbach α analysis yielded a score of >.7 in all domains of the DHRQ, which indicates acceptable internal consistency. The fit indices of the confirmatory factor analysis showed a reasonably good fit: standardized root-mean-square residual=0.065, root-mean-square error of approximation=0.098 (95% CI 0.09-0.106), Tucker-Lewis fit index=0.895, and comparative fit index=0.912. The DHRQ was developed as an easy-to-use, short questionnaire to assess the digital readiness of patients in a routine clinical setting. Initial validation demonstrates good internal consistency, and future research will be needed to externally validate the questionnaire. The DHRQ has the potential to be implemented as a useful tool to gain insight into the patients who are treated in a care pathway, tailor digital care pathways to different patient populations, and offer those with low digital readiness but high learnability appropriate education programs in order to let them take part in the digital pathways.

The six-minute walk test (6MWT) provides an objective measurement of a person’s functional exercise capacity. In this study, we developed a smartphone application that allows cardiac patients to do a self-administered 6MWT at home on a random trajectory. In a prospective study with 102 cardiovascular disease patients, we aimed to identify the optimal circumstances to perform a smartphone-measured 6MWT, i.e., the best algorithm and the best position to wear the smartphone during the test. Furthermore, we investigated if a random walk is as accurate as a standardized 6MWT. When considering both the reliability and accuracy of the distance walked, the best circumstances to perform a standardized smartphone-measured 6MWT are wearing the smartphone in a strap around the patient’s arm and using an algorithm that relies on the processed step count data acquired from Google Fit. Furthermore, we demonstrated that a smartphone-measured walk along a random trajectory is as accurate to determine a cardiac patient’s functional exercise capacity as a standardized (smartphone-measured) 6MWT. We conclude this paper by presenting how our 6MWT application can be used in a home setting to remotely follow up on cardiac patients’ functional exercise capacity.

Endoscopic coronary artery bypass grafting (Endo-CABG) is a minimally invasive CABG procedure with retrograde arterial perfusion. The main objective of this study is to assess neurocognitive outcome after Endo-CABG. In this prospective observational cohort study, patients were categorised into: Endo-CABG (n = 60), a comparative Percutaneous Coronary Intervention (PCI) group (n = 60) and a healthy volunteer group (n = 60). A clinical neurological examination was performed both pre- and postoperatively, delirium was assessed postoperatively. A battery of 6 neurocognitive tests, Quality of life (QoL) and the level of depressive feelings were measured at baseline and after 3 months. Patient Satisfaction after Endo-CABG was assessed at 3-month follow-up. Primary endpoints were incidence of postoperative cognitive dysfunction (POCD), stroke and delirium after Endo-CABG. Secondary endpoints were QOL, patient satisfaction and the incidence of depressive feelings after Endo-CABG. In total, 1 patient after Endo-CABG (1.72%) and 1 patient after PCI (1.67%) suffered from stroke during the 3-month follow-up. POCD in a patient is defined as a Reliable Change Index ≤-1.645 or Z-score ≤-1.645 in at least two tests, and was found in respectively 5 and 6 patients 3 months after Endo-CABG and PCI. Total incidence of POCD/stroke was not different (PCI: n= 7 [15.9%]; Endo-CABG: n= 6 [13.0%], p = 0.732). ICU delirium after Endo-CABG was found in 5 (8.6%) patients. QoL increased significantly three months after Endo-CABG and was comparable with QoL level after PCI and in the control group. Patient satisfaction after Endo-CABG and PCI was comparable. At follow-up, the level of depressive feelings was decreased in all groups. The incidence of poor neurocognitive outcome, including stroke, POCD and postoperative ICU delirium until three months after Endo-CABG is low and comparable with PCI. Registered on ClinicalTrials.gov (NCT02979782).

The adoption of telemonitoring in patients with heart failure (HF) is influenced by technology-related skills and self-efficacy, as well as psychological, clinical, and demographic factors. However, the relative importance of these factors with regard to willingness to use telemonitoring is insufficiently understood. This cross-sectional observational study examines the extent to which technology-related skills and self-efficacy are related to willingness to participate in telemonitoring in patients with HF. Patients completed questionnaires during hospitalization. Associations of technological skills and self-efficacy with willingness to participate in telemonitoring (dichotomous and continuous scale) were examined using regression models. Mediation-moderation analyses were used to investigate the role of self-efficacy in the association of technological skills with willingness to participate. This study recruited 61 patients admitted for decompensated HF (mean age 79.9, SD 9.5 years; 24 women). Higher levels of technological skills were associated with higher willingness to participate in telemonitoring (odds ratio [OR] 1.073 per scale unit, 95% CI 1.031-1.117). Technological self-efficacy and learnability were also related to willingness to participate (OR 1.141, 95% CI 1.039-1.252; OR 1.029, 95% CI 1.006-1.052) but did not mediate the association of technological skills with willingness to participate in telemonitoring. Psychological factors (anxiety, depressive symptoms, and perceived social support), age, and cognitive and physical functioning did not moderate the association of technological skills with willingness to participate in telemonitoring. Technological skills, self-efficacy, and learnability are interrelated factors that need to be considered in patients with HF who are eligible for telemonitoring. Future intervention studies that target these factors could increase patients' willingness and competence in using telemonitoring after admission for HF.

Introduction Digital technology creates the opportunity to develop and evaluate new tools, such as smartphone applications, to support integrated atrial fibrillation management. This study aimed to develop, evaluate, and validate a new, integrated care application (AF-EduApp) mainly focusing on targeted atrial fibrillation education to improve patient self-care capabilities and therapy adherence. Methods The newly developed AF-EduApp, available for Android and iOS, consists of six different modules. The prototype was validated and optimized for its usability and functionality at Jessa Hospital Hasselt and Antwerp University Hospital in two phases: (1) validity evaluation with interviews of an expert panel with 15 healthcare professionals and 10 atrial fibrillation patients, and (2) a pilot study of 1 month with 20 atrial fibrillation patients. Results Both experts and patients found that the application aids atrial fibrillation management. Based on the input of patients and experts, the main optimizations concerned the medication module (patient choice on setting reminder; interactivity of reminders with a “taken” or “snooze” function) and development of a clinical dashboard for the caregivers allowing telemonitoring of measurements and feedback to the patients. After the pilot study (n = 20), 16 patients indicated they wanted to use the app for a longer period. The measurement (27%) and education (17%) modules were the two most used modules with a significant improvement in knowledge (71.9% to 87.5%; P = 0.013). Discussion The AF-EduApp received a positive evaluation from health professionals and atrial fibrillation patients. Further development should be focused on the medication module and improvement of the clinical dashboard.

Objective: In a secondary prevention of coronary artery disease (CAD), nutritional management is an integral part of lifestyle optimisation. However, few studies have investigated the potential of remote nutritional follow-up using digital solutions. This study investigates the effectiveness of a smartphone application for nutrition education and feedback with pictures of meals by a dietitian for patients with CAD. Methods: Sixty participants with CAD were randomised to either a TeleDiet group or a control group. Participants in the TeleDiet group participated in dietary education using a messaging application. The primary outcome was the change of the Mediterranean diet score (MedDietScore). The Nutrition-Score, a modification of the MedDietScore, blood tests (blood lipids, blood glucose and kidney function), body mass index, self-efficacy, medication adherence and health-related quality of life during the observation period were analysed as secondary outcomes. Results: Sixty participants participated in the study. The difference in the MedDietScore in the TeleDiet group was greater than in the control group, but not significant (2.0 [−1.0, 4.0] vs. 0.0 [−3.0, 1.5], p = 0.066). The difference in the Nutrition-Score in the TeleDiet group was significantly greater than in the control group (3.0 [1.0, 3.5] vs. 0.0 [−3.0, 2.0], p = 0.029). Nutrition knowledge of the TeleDiet group improved significantly compared to the control group (1.9 ± 1.7 vs. 0.8 ± 2.1, p = 0.048). Conclusions: A feedback system using a simple messaging application that allows patients with CAD to simply send a picture of their food has a positive effect on nutrition knowledge. It could be a hint for the implementation of the Mediterranean diet.

Introduction Many patients with cardiovascular diseases are only seen by a physician once or twice a year unless urgent symptoms. Recent years have shown an increase in digital technologies to follow patients remotely, that is, telemedicine. Telemedicine can be supportive for follow-up of patients at continuous risk. This study investigated patients’ attitude toward telemedicine, the defined features they consider important and future willingness to pay. Methods Cardiology patients with various types of prior telemedicine follow-up or who never had a telemonitoring follow-up were included. A new self-developed survey was implemented electronically and took 5–10 min to complete. Results In total, 231 patients (191 telemedicine [T] and 40 controls [C]), were included. Most participants owned a smartphone (84.8%) and only 2.2% of the total participants did not own any digital device. The most important feature of telemedicine cited in both groups was personalization (i.e., personalized health tips based on medical history, 89.6%; personalized feedback on entered health parameters 86.1%). The most important motivating factor for the use of telemedicine is recommendation by a physician (84.8%), while the reduction of in-person visits is a minor reason (24.7%). Only half of the participants (67.1%) would be willing to pay for telemedicine tools in the future. Conclusion Patients with cardiovascular disease have a positive attitude to telemedicine, especially when it allows for more personalized care, and when it is advocated by the physician. Participants expect that telemedicine becomes part of reimbursed care. This calls for interactive tools with proven efficacy and safety, while guarding unequal access to care.

Introduction Digital health has the potential to support health care in rural areas by overcoming the problems of distance and poor infrastructure, however, rural areas have extremely low use of digital health because of the lack of interaction with technology. There is no existing tool to measure digital health literacy in rural China. This study aims to test and validate the digital health readiness questionnaire for assessing digital readiness among patients in rural China. Methods Due to the different Internet environments in China compared to Belgium, a cultural adaptation is needed to optimize the use of Digital Health Readiness Questionnaire in China. Then, a prospective single-center survey study was conducted in rural China among patients with hypertension. Confirmatory factor analysis was computed to test the measurement models. Results A total of 330 full questionnaires were selected and included in the analysis. The model-fit measures were used to assess the model's overall goodness of fit (Chi-square/degrees of freedom = 5.060, comparative fit index = 0.889, Tucker–Lewis index (TLI) = 0.869, root mean square error of approximation (RMSEA) = 0.111, standardized root mean square residual (SRMR) = 0.0880). TLI is a little bit lower than the borderline (more than 0.9) and RMSEA is higher than it (less than 0.08 means good model fit). We deleted two items 2 and 4 and the result shows a better goodness of fit (Chi-square/degrees of freedom = 4.897, comparative fit index = 0.914, TLI = 0.895, RMSEA = 0.109, SRMR = 0.0765) Conclusion To increase applicability and generalizability in rural areas, it should be considered to use the calculation of only the parts Digital skills, Digital literacy and Digital health literacy which are equally applicable in a Belgian population as in a rural Chinese population.