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Purpose To review the literature on health-related quality of life (HRQoL) outcomes for exercise-based cardiac rehabilitation (EBCR) in contemporary acute coronary syndrome (ACS) patients. Methods Electronic databases (CENTRAL, MEDLINE, Embase, and CINAHL) were searched from January 2000 to March 2019 for randomised controlled trials (RCTs) comparing EBCR to a no-exercise control in ACS patients recruited after year 2000, follow-up of at least 6 months, and HRQoL as outcome. Potential papers were independently screened by two reviewers. Risks of bias were assessed using the Cochrane Tool. Data analyses were performed using RevMan v5.3, random effects model. Results Fourteen RCTs (1739 participants) were included, with eight studies suitable for meta-analyses. EBCR resulted in statistically significant and clinically important improvements in physical performance (mean difference [MD] 7.09, 95% CI 0.08, 14.11) and general health (MD 5.08, 95% CI 1.03, 9.13) (SF-36) at 6 months, and in physical functioning (MD 9.82, 95% CI 1.46, 18.19) at 12 months. Statistically significant and sustained improvements were also found in social and physical functioning. Meta-analysis of two studies using the MacNew Heart Disease HRQoL instrument did not show any significant benefits. Of the six studies unsuitable for meta-analyses, five reported significant changes in overall HRQoL, general physical activity levels and functional capacity, or quality-adjusted life-years (QALYs). Conclusions In an era where adherence to clinical practice guidelines has improved survival, EBCR still achieves clinically meaningful improvements in physical performance, general health, and physical functioning in the short and long term in contemporary ACS patients.

Background: For older adults with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR), recovery of physical function is important, yet few studies objectively measure it in real-world environments. This exploratory study explored the acceptability and feasibility of using wearable trackers to measure incidental physical activity (PA) in AS patients before and after AVR. Methods: Fifteen adults with severe AS wore an activity tracker at baseline, and ten at one month follow-up. Functional capacity (six-minute walk test, 6MWT) and HRQoL (SF 12) were also assessed. Results: At baseline, AS participants (n = 15, 53.3% female, mean age 82.3 ± 7.0 years) wore the tracker for four consecutive days more than 85% of the total prescribed time, this improved at follow-up. Before AVR, participants demonstrated a wide range of incidental PA (step count median 3437 per day), and functional capacity (6MWT median 272 m). Post-AVR, participants with the lowest incidental PA, functional capacity, and HRQoL at baseline had the greatest improvements within each measure; however, improvements in one measure did not translate to improvements in another. Conclusion: The majority of older AS participants wore the activity trackers for the required time period before and after AVR, and the data attained were useful for understanding AS patients’ physical function.

Background: We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients.Methods: In this cross-sectiol study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the Intertiol Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and persol contacts facilitated program identification.Results: Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Altertive models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) persol protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption.Conclusion: Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges.Highlights:* COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe.* In this cross-sectiol study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries.* The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training.* There is also significant psychosocial and economic impact on CR providers.* Altertive CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

Nurses and midwives (nurses) are the principle role models and health educators for the wider population. This study sought to identify the health-related behaviors of the nursing workforce of New South Wales (NSW), Australia, compared to contemporary recommendations for healthy living and to the Australian general population, matched by gender and age. An electronic cross-sectional survey delivered in 2014–2015 recruited 5041 nurses through the NSW Nurses and Midwives Association and professional networks. Validated health behavior measures were collected and compared to Australian National Health Survey data. Compared with younger nurses, older nurses reported greater adherence to fruit and vegetable guideline recommendations, but were more likely to be overweight or obese. Younger nurses (25–34 years) had the highest risk of harmful drinking. Compared with the Australian general population, slightly higher percentages of nurses met dietary recommendations and slightly fewer were obese, had central adiposity or smoked. Nurses had lower physical activity levels and higher levels of risky drinking across most gender and age groups. Many nurses have lifestyle health behaviors that place them at high risk for developing non-communicable diseases, sometimes at higher risk than the Australian population to whom they deliver health education. Health promotion strategies for nurses are urgently required.

When implemented in practice, digital technologies have shown improvements in morbidity and mortality outcomes in patients with cardiovascular disease (CVD). For scholars, research into digital technologies in cardiovascular care has been relatively recent, thus it is important to understand the history of digital health technology in cardiovascular research—its emergence, rate of growth, hot topics, and its temporal evolution. The aim of this study was to analyse more than 16,000 articles in this domain based on their scientometric indicators. Web of Science (WoS) Core Collection was accessed and searched at several levels, including titles, abstracts, keywords, authors, sources and individual articles. Analysis examined the temporal shifts in research and scholarly focus based on keywords, networks of collaboration, topical divisions in relation to digital technologies, and influential publications. Findings showed this research area is growing exponentially. Co-citation analysis revealed twenty prominent research streams and identified variation in the magnitude of activities in each stream. A recent emergence of research activities in digital technology in cardiovascular rehabilitation (CR), out-of-hospital cardiac arrest (OHCA), and arrythmia research was also demonstrated. Conversely, wearable technologies, activity tracking and electronic medical records research are now past their peak of reported research activity. With increasing amounts of novel technologies becoming available and more patients taking part in remote health care monitoring, further evaluation and research into digital technologies, including their long-term effectiveness, is needed. Furthermore, emerging technologies, which are evaluated and/or validated should be considered for implementation into clinical practice as treatment and prevention modalities for CVD.

Background The dose–response relationship between physical activity and sedentary behaviour (SB) with mortality in people with coronary heart disease (CHD) is unclear. The aim was to identify moderate-to-vigorous physical activity (MVPA) and SB thresholds for mortality risk. Methods This prospective cohort study comprised Australian participants aged ≥ 45 years with self-reported CHD (2006–2020). Self-reported MVPA (min/wk) and SB (hr/day) were the exposures. Cardiac and all-cause mortality were the main outcomes. Survival regression trees identified MVPA and SB thresholds influencing mortality survival rate. Cox regression models and the C-statistic were used to examine the thresholds, comparing them to public health guidelines. Results The cohort included 40,156 participants (mean (SD) age, 70.3(10.3) years; 15,278 females (38%)). During a median follow-up of 11.1 (IQR,6.2–14.4) years, 2,497 cardiac and 12,240 all-cause deaths were recorded. The threshold for MVPA and all-cause and cardiac mortality was ≥ 146 min/wk and ≥ 96 min/wk, respectively. For SB, the threshold for mortality was < 5–6 h/day. Sex-specific differences in thresholds for MVPA and SB were found. All MVPA and SB thresholds had equivalent associated risk reductions and predictive abilities for cardiac and all-cause mortality to the public health guidelines. Conclusion The newly identified thresholds suggest that the public health physical activity guidelines are suitable for reducing risks of all-cause mortality in people with CHD. For reducing risks of cardiac mortality, the threshold is suggested to be much lower. The SB suggested thresholds for reducing risks of mortality are 5–6 h/day. Further research is required to explore these thresholds and sex-specific differences.

IntroductionActive self-management by patients following acute coronary syndrome (ACS) can reduce recurrent events. Patient education for transitioning from hospital to home promotes effective self-management but can be limited in the acute setting due to time and resource pressures. Patients from ethnic minority and immigrant backgrounds face additional language, cultural and health literacy barriers to receiving patient education. Self-administered virtual patient education presents an innovative solution to these challenges. This study aims to evaluate a co-adapted, virtual avatar nurse-guided, discharge education application (app) for Chinese-speaking patients following ACS.Methods and analysisThis multicentre, assessor-blinded, randomised controlled trial will recruit 98 Chinese-speaking inpatients following ACS with evaluation at 1 and 3 months postdischarge. Control participants in the control group will receive the usual ward-based patient discharge education. Intervention participants will additionally receive the education app installed on their devices before hospital discharge with unlimited access during the study period. Cultural relevance and linguistic accuracy for this Chinese version of an existing app were ensured through co-adaptation with Chinese-speaking consumers; the primary outcome will be coronary heart disease (CHD) knowledge, and secondary outcomes will include knowledge, attitudes and beliefs regarding heart attack symptoms and responses, CHD self-management behaviours, utilisation of healthcare services and quality of life. A process evaluation will be conducted alongside the trial to assess the acceptability and feasibility of the app. Between-group comparisons will be made using 95% CIs, accounting for baseline differences using linear mixed effects or mixed effects logistic regression models.Ethics and disseminationThe Western Sydney Local Health District Human Research Ethics Committee has approved this study protocol (26 February 2024, amendment number 2) (2024/STE00147), with site-specific authorisations obtained from each participating hospital. The results will be disseminated through peer-reviewed journal articles and presentations at scientific conferences.Trial registration numberACTRN12624000408583.

Peer support (ie, sharing experiences and providing support with others with the same condition) improves health outcomes among people with cardiovascular disease (CVD), including self-management behaviors and self-efficacy. However, current peer support interventions are diverse, and evidence is lacking on the perceptions of benefits and the elements considered priorities by peer support attenders, especially regarding digital interventions. The study aimed to (1) describe perceived benefits and recommendations for CVD peer support programs from people attending in-person peer support, (2) identify priorities for digital peer support from consumers and clinicians testing a peer support app prototype, and (3) develop a framework to inform future peer support intervention development. A qualitative study design was used across 2 components to address the objectives. In Component 1, semistructured focus groups were conducted with attenders of established in-person CVD peer support groups to explore the perceived benefits of peer support and recommendations for future programs. In Component 2, semistructured workshops with consumers with CVD and semistructured interviews with CVD clinicians/researchers were conducted to obtain feedback and recommendations for digital peer support using an exploratory digital CVD peer support application prototype. Data were digitally recorded, transcribed verbatim, and analyzed thematically. Findings from both components were iteratively synthesized to inform the development of a digital peer support framework. In Component 1, a total of 22 participants (age range 29-84 years, 45% male) took part in focus groups. The overarching theme was that peer support provides benefits through the sharing of experiences. Five themes were refined and defined: (1) peer support provides a way of coping; (2) peers learn from each other; (3) peers understand what each other is going through; (4) the peer community uplifts mood and builds confidence; and (5) awareness, flexibility, and resources are important for engagement. In Component 2, five participants (age range 55-74 years, 60% male) attended 2 workshops, and 8 clinicians-researchers (age range 30-65 years, 10% male) were interviewed. Three themes were refined and defined: (1) autonomy is essential to promote engagement; (2) safeguarding is important to both users and clinicians; and (3) interfaces that are simple, easy to use, and visually attractive enable use. Priorities identified from both components included greater peer support awareness and uptake, flexibility with timing and family participation, health care professional involvement, provision of resources, autonomous features enabling choice, checklists and clinician moderation for safeguarding, and simple-to-use interfaces. Participants in peer support programs derive benefit from sharing their experience of living with CVD, which enables coping, learning, feeling understood, and a sense of community. Priorities were synthesized to create a framework for digital peer support development, with recommendations to focus on 6 key areas: uptake, flexibility, resources, autonomy, safeguarding, and interface.

Many hospital presentations for acute coronary syndrome (ACS) occur in people previously hospitalised with coronary heart disease (CHD), leading to increased costs and health burden. Secondary prevention education including a prehospital discharge plan is recommended for all individuals to reduce the risk of recurrence. However, many clinicians lack the time or support to provide education, and patients' uptake of secondary prevention programmes is limited. An avatar-based education app is a novel and engaging way to provide self-delivered, evidence-based secondary prevention information during the hospital admission and remains accessible after discharge. This protocol aims to evaluate the effect of an avatar-based education app on individuals with ACS. This protocol describes a prospective, randomised controlled trial with 3-month follow-up and blinded assessment of 72 participants. Intervention group participants will download the app onto their own device during the hospital admission and independently complete six interactive education modules based on the National Heart Foundation's six steps to cardiac recovery. All participants will receive a text message reminder of the study after 3 weeks. Both groups will receive usual care consisting of bedside education and a pamphlet about cardiac rehabilitation. The primary outcome is knowledge of CHD, assessed using the Coronary Artery Disease Education Questionnaire II. Secondary outcomes include quality of life, response to heart attack symptoms, cardiac-related readmissions and mortality and modifiable cardiac risk factors. Engagement with the app will be evaluated objectively. Intention-to-treat analysis will be conducted, with between-group comparisons and 95% CIs of the primary outcome analysed using analysis of covariance, adjusting for baseline values. This study protocol has been approved by the Western Sydney Local Health District Human Research Ethics Committee. The results of this study will be disseminated via a peer-reviewed journal and research thesis. Australian New Zealand Clinical Trials Registry (ACTRN12622001436763).

Background Coronary heart disease (CHD) is the leading cause of deaths and disability worldwide. Cardiac rehabilitation (CR) effectively reduces the risk of future cardiac events and is strongly recommended in international clinical guidelines. However, CR program quality is highly variable with divergent data systems, which, when combined, potentially contribute to persistently low completion rates. The QUality Improvement in Cardiac Rehabilitation (QUICR) trial aims to determine whether a data-driven collaborative quality improvement intervention delivered at the program level over 12 months: (1) increases CR program completion in eligible patients with CHD (primary outcome), (2) reduces hospital admissions, emergency department presentations and deaths, and costs, (3) improves the proportion of patients receiving guideline-indicated CR according to national and international benchmarks, and (4) is feasible and sustainable for CR staff to implement routinely. Methods QUICR is a multi-centre, type-2, hybrid effectiveness-implementation cluster-randomized controlled trial (cRCT) with 12-month follow-up. Eligible CR programs ( n  = 40) and the individual patient data within them ( n  ~ 2,000) recruited from two Australian states (New South Wales and Victoria) are randomized 1:1 to the intervention (collaborative quality improvement intervention that uses data to identify and manage gaps in care) or control (usual care with data collection only). This sample size is required to achieve 80% power to detect a difference in completion rate of 22%. Outcomes will be assessed using intention-to-treat principles. Mixed-effects linear and logistic regression models accounting for clusters within allocated groupings will be applied to analyse primary and secondary outcomes. Discussion Addressing poor participation in CR by patients with CHD has been a longstanding challenge that needs innovative strategies to change the status-quo. This trial will harness the collaborative power of CR programs working simultaneously on common problem areas and using local data to drive performance. The use of data linkage for collection of outcomes offers an efficient way to evaluate this intervention and support the improvement of health service delivery. Ethics Primary ethical approval was obtained from the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH01093), along with site-specific governance approvals. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001239651 (30/11/2023) ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386540&isReview=true ).