Abstract: Background Adults with heart failure (HF) experience a constellation of symptoms; however, understanding of gender differences in HF symptoms remain elusive. The aim of this study was to determine whether there are gender differences in physical and depressive symptoms and symptom patterns in HF using 2 different analytic techniques. Methods We performed a secondary analysis of combined data from 6 studies of adults with HF. Physical symptoms were measured with the HF Somatic Perception Scale, and depressive symptoms were measured with the Patient Health Questionnaire-9. First, we performed propensity matching with the nearest neighbor to examine the average treatment effect for HF Somatic Perception Scale and Patient Health Questionnaire-9 in the matched sample of women and men. Next, we used the entire data set in a latent class mixture model to determine patterns of symptoms. Finally, we calculated predictors of class membership with multinomial logistic regression. Results The sample (n = 524, 86.5% systolic HF) was 37% women with a mean age of 58.3 ± 13.9 years and mean number of years with HF of 6.9 ± 6.9. Three hundred sixty-six participants were matched on propensity scores; there were no significant gender differences in symptom scores between matched women (n = 183) and men (n = 183). Among all 524 participants, 4 distinct latent classes of symptom patterns indicate that many patients with HF are fatigued, some have more depressive symptoms, and others have significantly more edema or cough. Gender did not predict membership to any symptom pattern. Conclusions There were significant gender differences in sociodemographics, health behaviors, and clinical characteristics, but not HF symptoms or symptom patterns, using either analytic technique.

Abstract: Background Inadequate self-care management has been reported in patients with heart failure (HF) and their family caregivers. However, evidence on the influencing factors and corresponding action paths for self-care management within a dyadic context is limited. Objective The aim of this study was to examine dyadic associations between benefit finding and self-care management in HF patient-caregiver dyads and the mediating role of mutuality in these associations. Methods This cross-sectional study was conducted in China, and a convenience sample of 253 HF patient-caregiver dyads was included in the analysis. Dyadic benefit finding and mutuality, patients' self-care management, and caregivers' contributions to self-care management were measured using self-reported questionnaires. The actor-partner interdependence model and actor-partner interdependence mediation model were adopted to analyze the data. Results Patients' benefit finding had an actor effect on their own self-care management (β = 0.134, P < .05) and a partner effect on caregivers' contributions to self-care management (β = 0.130, P < .05). Similarly, caregivers' benefit finding had an actor effect on their contributions to self-care management (β = 0.316, P < .01) and a partner effect on patients' self-care management (β = 0.187, P < .01). Moreover, patients' mutuality completely mediated the actor effect of their benefit finding on self-care management (β = 0.127; 95% confidence interval, 0.032–0.233), and caregivers' mutuality partially mediated the actor effect of their benefit finding on contributions to self-care management (β = 0.060; 95% confidence interval, 0.012–0.124). In addition, caregivers' mutuality completely mediated the partner effect of patients' benefit finding on caregivers' contributions to self-care management (β = 0.036; 95% confidence interval, 0.009–0.081). Conclusions The findings revealed the importance of benefit finding and mutuality, 2 modifiable factors positively associated with dyadic HF self-care management. Dyadic interventions targeting on enhancing benefit finding and mutuality should be designed and implemented to improve HF self-care management.

Abstract: BACKGROUND Depressive symptoms are prevalent in patients with heart failure and their family caregivers. Given the interpersonal interactions between dyadic individuals with intimate relationship, it is essential to consider the dyads as a unit when exploring the factors associated with depressive symptoms in heart failure patient-caregiver dyads. OBJECTIVE The aims of this study were to explore the dyadic effects of burden on depressive symptoms in heart failure patient-caregiver dyads and investigate whether perceived stress acts as a mediator in these relationships. METHODS In this cross-sectional study, 237 heart failure patient-caregiver dyads were recruited from 3 hospitals in China between November 2018 and June 2019. Symptom burden, caregiving burden, perceived stress, and depressive symptoms were assessed using self-report questionnaires. The actor-partner interdependence model and actor-partner interdependence mediation model were used to analyze the data. RESULTS Patients' symptom burden had an actor effect on their own depressive symptoms and a partner effect on their caregivers' depressive symptoms. Similarly, caregivers' caregiving burden had an actor effect on their own depressive symptoms and a partner effect on patients' depressive symptoms. The actor effects between burden and depressive symptoms were partially mediated by their own perceived stress in heart failure patient-caregiver dyads. Furthermore, the partner effect between caregivers' caregiving burden and patients' depressive symptoms was completely mediated by patients' perceived stress. CONCLUSIONS Patients' symptom burden and caregivers' caregiving burden aggravated their depressive symptoms by increasing their own perceived stress. Moreover, patients' symptom burden led to caregivers' depressive symptoms, and caregivers' caregiving burden contributed to patients' depressive symptoms through patients' perceived stress. These interdependent relationships suggest that dyadic interventions focused on reducing burden and perceived stress may be beneficial for relieving depressive symptoms in heart failure patient-caregiver dyads.

Abstract: BACKGROUND Rural patients with heart failure (HF) have higher mortality and hospitalization rates compared with their urban counterparts. Although research supports the inclusion of informal caregivers in daily self-care activities, data are limited regarding the problems encountered by rural patient/caregiver dyads living with HF in managing HF in the home and how these problems are managed. OBJECTIVE The aim of this study was to identify and describe HF self-care problems experienced by rural dyads in the home and how these problems are managed. METHODS Using a descriptive qualitative design, data were collected from rural patient/caregiver dyads living with HF via individual, semistructured, telephone interviews and analyzed using schematic content analysis. Interviews and data analysis occurred concurrently until data saturation was reached. RESULTS Thematic data saturation was obtained with 11 dyads. On average, patients were 65.3 (±13.9) years old, and caregivers were 62 (±12.37) years old. Four themes illustrating dyadic HF self-care problems and management strategies emerged: (1) HF self-care components, namely, maintenance, symptom monitoring, and management (diet, exercise, activities, strategies); (2) environment (rural barriers, COVID-19); (3) caregiver contributors (confidence, role); and (4) dyadic contributors (dyadic relationship). Dyads described various self-care problems, with the type of relationship and presence of mutuality influencing the problem-solving process and development of management strategies. CONCLUSIONS The identified themes emphasize the self-care problems experienced by rural dyads living with HF and the contributions of both dyad members to effectively manage these challenges. Findings support the need for culturally sensitive, tailored interventions targeting self-care in rural dyads living with HF.

Abstract: BACKGROUND Clinicians and researchers often assume that symptom burden is associated with self-care management (SCM) in patients with heart failure (HF). However, that association is often not borne out in simple regression analyses and may be because another variable mediates the association. Fatalism is an appropriate candidate for mediation and is the belief that circumstances are predetermined without opportunity for control by individuals. OBJECTIVE Our objective was to determine whether fatalism mediated the relationship of symptom burden with SCM among adults with HF. METHODS We conducted a secondary analysis (N = 95) from a clinical trial. We used Self-care of HF Index to measure SCM, the Memorial Symptom Assessment Scale-HF for symptom burden, and the Cardiovascular Disease Fatalism Instrument to measure fatalism. We used the PROCESS macro to evaluate mediation. RESULTS Symptom burden was not directly associated with SCM (effect coefficient [C'] = 0.0805; 95% confidence interval, -0.048 to 0.209; P = .217). There was, however, an indirect pathway between symptom burden and SCM through fatalism (ab = -0.040; 95% confidence interval, -0.097 to -0.002). Those with higher symptom burden were more fatalistic (a = 0.004, P = .015), and greater fatalism was associated with worse SCM (b = -9.132, P = .007). CONCLUSION Symptom burden, not directly associated with SCM, is associated through the mediator of fatalism. Interventions to improve SCM should include strategies to mitigate fatalistic views. Self-care management interventions should focus on promoting internal locus of control or increasing perceptions of perceived control to decrease fatalism and improve engagement in self-care.

Abstract: BACKGROUND Cardiovascular disease (CVD) risk reduction programs led by a nurse/community health worker team are effective in urban settings. This strategy has not been adequately tested in rural settings. OBJECTIVE A pilot study was conducted to examine the feasibility of implementing an evidence-based CVD risk reduction intervention adapted to a rural setting and evaluate the potential impact on CVD risk factors and health behaviors. METHODS A 2-group, experimental, repeated-measures design was used; participants were randomized to a standard primary care group (n = 30) or an intervention group (n = 30) where a registered nurse/community health worker team delivered self-management strategies in person, by phone, or by videoconferencing. Outcomes were measured at baseline and at 3 and 6 months. A sample of 60 participants was recruited and retained in the study. RESULTS In-person (46.3%) and telephone (42.3%) meetings were used more than the videoconferencing application (9%). Mean change at 3 months differed significantly between the intervention and control groups for CVD risk (-1.0 [95% confidence interval (CI), -3.1 to 1.1] vs +1.4 [95% CI, -0.4 to 3.3], respectively), total cholesterol (-13.2 [95% CI, -32.1 to 5.7.] vs +21.0 [95% CI, 4.1-38.1], respectively), and low-density lipoprotein (-11.5 [95% CI, -30.8 to 7.7] vs +19.6 [95% CI, 1.9-37.2], respectively). No between-group differences were seen in high-density lipoprotein, blood pressure, or triglycerides. CONCLUSIONS Participants receiving the nurse/community health worker-delivered intervention improved their risk CVD profiles, total cholesterol, and low-density lipoprotein levels at 3 months. A larger study to explore the intervention impact on CVD risk factor disparities experienced by rural populations is warranted.

Abstract: BACKGROUND Adverse neurodevelopment is a common comorbidity associated with congenital heart disease (CHD). The consequences of adverse neurodevelopment are seen across the life course. The cause of adverse neurodevelopment is multifactorial, and use of a life course perspective can assist with understanding and enhancing neurodevelopment in individuals with CHD. PURPOSE The purposes of this article are to (1) apply the Life Course Health Development framework to neurodevelopment in the population with CHD and (2) discuss how exposure to the pediatric cardiac intensive care unit (PCICU) environment during infancy is a point of intervention for improving neurodevelopmental outcomes. CONCLUSION Individuals with CHD are at an increased risk for adverse neurodevelopment across the life course. The PCICU environment is a point of intervention for improving neurodevelopmental outcomes. Stress can lead to changes in brain structure and function that are associated with negative outcomes in terms of outward behavioral and functional capacity, and the PCICU environment is a source of stressful stimuli. Infancy is a period of rapid brain growth, and the brain is more susceptible to stress during this period of the life course, putting infants receiving care in the PCICU at an increased risk of adverse neurodevelopment. CLINICAL IMPLICATIONS Interventions to support optimal neurodevelopment should focus on the PCICU environment during infancy. Developmentally supportive care models should be explored as a means of modifying the PCICU environment. In addition, more research is needed on the relationship between the PCICU and neurodevelopment. The conceptual model introduced can serve as a starting point for this research.

Abstract: BACKGROUND Many perinatal people experienced pandemic-related distress and changes in health behaviors at the onset of the COVID-19 pandemic, but less is known about how the pandemic continued to impact their health. OBJECTIVE The authors of this study examined the influence of pandemic-related distress and maternal mental health on postpartum lifestyle behaviors of mothers with a previous hypertensive disorder of pregnancy. METHODS Between September 2021 and March 2022, 82 postpartum (19.2 ± 5.5 months) mothers with a hypertensive disorder of pregnancy completed measures of pandemic-related distress and pandemic-related disruption in lifestyle behaviors from the Coronavirus Perinatal Experiences Impact Survey. A Patient Health Questionnaire-9 score ≥ 10 and a score ≥ 3 on the Breslau scale indicated significant depressive and posttraumatic stress disorder (PTSD) symptoms, respectively. RESULTS Twenty-two (27.2%) and 30 (36.6%) participants had significant depressive or PTSD symptoms, respectively. In models adjusted for education, income, parity, delivery prepandemic or peripandemic, intervention group, and prepregnancy mental health history, both PTSD symptoms (B = 0.229, P = .029) and pandemic-related distress (B = 0.492, P < .001) associated with greater disruption in health behaviors. Depressive symptoms did not associate with greater disruption in health behaviors (B = 0.169, P = .135). CONCLUSION Monitoring PTSD symptoms may be vital in supporting mothers with hypertensive disorders of pregnancy in making lifestyle changes to prevent cardiovascular disease.

Abstract: Background Caregiving for persons with heart failure (HF) varies based on the individual, family, and home contexts of the dyad, yet the dyadic context of HF caregiving is poorly understood. Objective The aim of this study was to explore dyadic perspectives on the context of caregiving for persons with HF. Methods Family caregivers and persons with HF completed surveys and semistructured interviews. Investigators also photographed caregiving areas to complement home environment data. Descriptive qualitative analysis resulted in 7 contextual domains, and each domain was rated as strength, need, or neutral. We grouped dyads by number of challenging domains of context, categorizing dyads as high (≥3 domains), moderate (1–2 domains), or minimal (0 domains) needs. Quantitative instruments included the 36-item Short Form Health Survey, ENRICHD Social Support, HF Symptom Severity, and Zarit Burden Interview. We applied the average score of each quantitative measure to the groups derived from the qualitative analysis to integrate data in a joint display. Results The most common strength was the dyadic relationship, and the most challenging domain was caregiving intensity. Every dyad had at least 2 domains of strengths. Of 12 dyads, high-needs dyads (n = 3) had the worst average score for 7 of 10 instruments including caregiver and patient factors. The moderate-needs dyads (n = 6) experienced the lowest caregiver social support and mental health, and the highest burden. Conclusion Strengths and needs were evident in all patient-caregiver dyads with important distinctions in levels of need based on assessment of multiple contextual domains. Comprehensive dyadic and home assessments may improve understanding of unmet needs and improve intervention tailoring.

Abstract: BACKGROUND Patients with heart failure (HF) must engage in self-care, yet their self-care is often poor. Cognitive function commonly is impaired in HF and is associated with poor self-care. Heart failure knowledge and self-care confidence also are needed to preform self-care. Few investigators have examined mediators of the association of cognitive function with self-care. OBJECTIVES The aim of this study was to determine whether HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance and management among patients with HF. METHODS This was a cross-sectional observational study of 164 patients with HF. Cognitive function was assessed using the Montreal Cognitive Assessment. Self-care maintenance and self-care management behaviors and self-care confidence were measured using the Self-care of Heart Failure Index. Heart failure knowledge was measured using the Dutch Heart Failure Knowledge Scale. We conducted 2 parallel mediation analyses using the PROCESS macro in SPSS, one for self-care maintenance and one for self-care management. RESULTS Cognitive function was indirectly associated with self-care maintenance through HF knowledge (indirect effect, 0.54; 95% confidence interval, 0.10-1.02) and self-care confidence (indirect effect, 0.26; 95% confidence interval, 0.04-0.54). Those with better cognitive function had more HF knowledge and self-care confidence. Better cognitive function was not directly associated with self-care management but indirectly associated with better self-care management through higher self-care confidence (indirect effect, 0.50; 95% confidence interval, 0.04-1.05). CONCLUSIONS Both HF knowledge and self-care confidence mediated the association of cognitive function with self-care maintenance, and only self-care confidence mediated the association between cognitive function and self-care management. Interventions targeting HF knowledge and self-care confidence may improve self-care even for those with lower cognitive function and need to be developed and tested.

Abstract: Comorbidities are risk factors for poor clinical outcomes in patients with heart failure. However, no consensus has been reached on how to assess comorbidities related to clinical outcomes in patients with heart failure.The aims of this study were to review (1) how comorbidities have been assessed, (2) what chronic conditions have been identified as comorbidities and (3) the rationale for choosing the comorbidity instruments and/or specific comorbidities when exploring clinical outcomes in patients with heart failure.The clinical outcomes of interest were mortality, hospitalization, quality of life, and self-care. Three electronic databases and reference list searches were used in the search.In this review, we included 39 articles using 3 different ways to assess comorbidities in the relationship with clinical outcomes: using an instrument (ie, Charlson Comorbidity Index), disease count, and including individual comorbidities. A total of 90 comorbidities were investigated in the 39 articles; however, definitions and labels for the diseases were inconsistent across the studies. More than half of the studies (n = 22) did not provide a rationale for selecting the comorbidity instruments and/or all of the specific comorbidities. Some of the rationale for choosing the instruments and/or specific comorbidities was inappropriate.We found several issues related to measuring comorbidities when examining clinical outcomes in patients with heart failure. Researchers need to consider these methodological issues when measuring comorbidities in patients with heart failure. Further efforts are needed to develop guidelines on how to choose proper measures for comorbidities.

Abstract: Background Heart failure (HF) prevalence has risen for more than a decade. Effective patient and family education strategies for HF are needed on a global scale. One widely used method of education is the teach-back method, where learners are provided information, then their understanding assessed by “teaching it back” to the educator. Purpose This state-of-the-art review article seeks to examine the evidence focusing on the teach-back method of patient education and patient outcomes. Specifically, this article describes (1) the teach-back process, (2) teach-back's effect on patient outcomes, (3) teach-back in the context of family care partners, and (4) recommendations for future research and practice. Conclusions Study investigators report the use of teach-back, but few describe how teach-back was utilized. Study designs vary widely, with few having a comparison group, making conclusions across studies challenging. The effect of teach-back on patient outcomes is mixed. Some studies showed fewer HF readmissions after education using teach-back, but different times of measurement obscure understanding of longitudinal effects. Heart failure knowledge improved across most studies after teach-back interventions; however, results related to HF self-care were mixed. Despite family care partner involvement in several studies, how they were included in teach-back or the associated effects are unclear. Clinical implications Future clinical trials that evaluate the effect of teach-back education on patient outcomes, such as short- and long-term readmission rates, biomarkers, and psychological measures, are needed, as patient education is the foundation for self-care and health-related behaviors.

Abstract: BACKGROUND International guidelines have promoted palliative care (PC) for stroke survivors, but definition and implementation have been less than ideal. This practice gap is more prominent in China, where discussion of death remains taboo. AIM The aim of this study was to explore the perspectives of PC among caregivers of hospitalized patients with stroke. DESIGN AND SETTING A descriptive qualitative study design was used. Seventeen in-depth interviews with bedside caregivers in a first-rank tertiary hospital (general hospital with bed capacity exceeding 500) in China were analyzed thematically. RESULTS "Promoting comfort" stands at the core of PC and was operationalized by "meeting physical care needs," "ensuring communication," "providing psychoemotional care," "providing cognitive stimulation," and "avoiding discussion on death and dying." Caregivers who took care of older adults for a long time have described the use of "cognitive stimulation" to promote patients' positive emotional and cognitive reactions. All interviewees avoided mentioning "death" to protect patients' feelings, because they believed discussion of death was hurtful. CONCLUSIONS The high care demand for patients with stroke is a defining feature of stroke PC and should be recognized in addition to its prognosis estimation to promote this concept. The healthcare system should integrate PC as part of the regular service for patients with severe stroke to shift the focus of care from survival to promotion of comfort. A discussion of the dying process requires sensitivity and should be approached in a discussion of advanced PC planning, which views death as a meaningful transition.

Abstract: BACKGROUND Health-related quality of life (HRQoL) is worse in patients with atrial fibrillation (AF) compared with other populations. Factors affecting HRQoL in patients with AF are not fully clarified. Illness perceptions are important determinants of disease management and may affect HRQoL. OBJECTIVE The aims of this study were to describe illness perceptions and HRQoL in women and men with AF and to explore the relationship between illness perceptions and HRQoL in patients with AF. METHODS This cross-sectional study included 167 patients with AF. Patients completed the Revised Illness Perception Questionnaire and HRQoL questionnaires: Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias, the three-level version of the EuroQol 5-dimensional questionnaire, and EuroQol visual analog scale. Subscales of the Revised Illness Perception Questionnaire significant in correlation analysis with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias HRQoL total scale were included in a multiple linear regression model. RESULTS Mean age was 68.7 ± 10.4 years, and 31.1% were women. Women reported lower personal control (P = .039) and worse HRQoL measured with the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmias physical subscale (P = .047) and the EuroQol visual analog scale (P = .044) compared with men. Illness identity (P < .001), consequences (P = .031), emotional representation (P = .014), and timeline cyclical (P = .022) were related to and adversely affected HRQoL. CONCLUSIONS This study found a relationship between illness perceptions and HRQoL. Some subscales of illness perceptions negatively affected HRQoL in patients with AF, which indicates that efforts to change illness perceptions may be helpful in improving HRQoL. Patients should be given the opportunity to talk about the disease, their symptoms, their emotions, and the consequences of the disease to enable increased HRQoL. A challenge for healthcare will be to design support for each patient based on his/her illness perceptions.

Abstract: Background Medical management and surgical improvement techniques permit persons with congenital heart conditions to live longer. Adults with congenital heart disease (CHD) have more childbearing options than previously available to them. However, there is an increased childbearing risk associated with certain types of CHD. Minimal investigation has been given to the childbearing decision-making experiences and adaptation of women with CHD. Objective The aim of this study was to gain insight into the childbearing decision-making and adaptation experiences of women with CHD. Methods Using a narrative inquiry approach, 17 adult women with CHD of any severity, of childbearing age, who had, within the last 5 years, made a decision regarding childbearing, were interviewed. In this study, we applied the key components of the Roy Adaptation Model to understand childbearing decision-making experiences and their adaptation. Data were analyzed using thematic analysis. Results Data analysis revealed 5 stages of childbearing decision making: (1) prologue: stimulus to consider childbearing; (2) exploring childbearing options; (3) considering childbearing options; (4) choosing to bear or not to bear a child; and (5) epilogue: adapting to the childbearing decision. Adaptation occurred in the areas of self-concept (ie, emotional adaptation), role function (ie, relational adaptation), and interdependence (ie, interactional adaptation). Conclusion Childbearing decision making is a complex personal decision that is carefully and deliberately made. Women with CHD long for children and seek childbearing information from various resources and may experience grief regarding the inability to bear children. A greater understanding of childbearing decision making can be useful in addressing women's childbearing emotions and assist with adaptation to childbearing needs.

Abstract: BACKGROUND Smartphone apps used in research offer a variety of capabilities to track and influence behavior; however, they often do not translate well into real-world use. Implementation strategies for using apps to reduce sedentary behavior in cardiac rehabilitation are currently unknown. OBJECTIVE The aim of this study was to explore (1) barriers and enablers for use of a behavioral smartphone app (Vire and ToDo-CR program) for reducing sedentary behavior in cardiac rehabilitation participants and (2) implementation strategies for future smartphone apps aimed at reducing sedentary behavior in this population. METHODS In-depth semistructured interviews were conducted with cardiac rehabilitation participants in the ToDo-CR randomized controlled trial. Participants had used the Vire app and a wearable activity tracker for 6 months. Interviews were audio recorded and transcribed. The researchers used thematic analysis and deductive mapping of themes to the Theoretical Domains Framework and the Capability, Opportunity, and Motivation-Behavior model. Sociodemographic and clinical variables were recorded. RESULTS Fifteen participants aged 59 ± 14 years were interviewed. Most were male, tertiary educated, and employed, and had varying experiences with smartphone apps and wearable activity trackers. Five core themes explaining the user experiences of cardiac rehabilitation participants with the Vire app were identified: (1) being tech savvy can be both an enabler and a barrier, (2) app messaging needs to be clear-set expectations from the beginning, (3) get to know me-personalization is important, (4) curious to know more instant feedback, and (5) first impression is key. The themes and subthemes mapped to 12 of the 14 Theoretical Domains Framework domains. Improving engagement and implementation of future smartphone apps for sedentary behavior may be aided by building psychological capability, physical opportunity, and reflective motivation. CONCLUSIONS Shifting to in-the-moment behavioral nudges, setting clear expectations, assisting participants to monitor their sitting time, increasing the frequency of tailoring, and understanding more about the participant as well as their experiences and needs for reducing sedentary behavior in cardiac rehabilitation are important future directions.

Abstract: Background Return to work (RTW) is a critical component of rehabilitation for most young and middle-aged patients after an acute myocardial infarction (AMI). Its success is related to the quality of life and social psychological function of patients, and their social economic growth. However, healthcare professionals often do not deeply understand the patients' experience and their difficulties and coping methods during this process, which limits their ability to institute effective management and support. Objective In this study, we aimed to explore the lived experiences and change processes of young and middle-aged patients with AMI at the different stages of RTW. Methods A descriptive qualitative approach was used. Patients aged 20 to 59 years with AMI were recruited from the Department of Cardiology of 3 general hospitals. Data were collected via semistructured interviews. Data analysis was performed by conventional content analysis methods. Results In total, 18 participants were included. Five main themes emerged: (1) “chaos,” (2) “rebuilding,” (3) “conflict,” (4) “coping,” and (5) “benefits.” Patients may be more concerned about physical recovery during the initial clinical event. They then begin to plan and adjust for an RTW. Patients in the maintenance phase need strategies to prevent, identify, and respond to conflicts and challenges to maintain long-term stable work. Conclusion We identified several post-AMI stages spanning from the initial illness event to the maintenance of stable work. We described their perceived barriers, coping strategies, and support needs at these various stages. These data are crucial for healthcare professionals to develop improved vocational rehabilitation strategies for patients with AMI.

Abstract: Background Physical and psychological symptoms are prevalent in patients with heart failure (HF) and are associated with poor quality of life (QOL) and high hospitalization rates. Thus, it is critical to identify symptom clusters to better manage patients with high-risk symptom cluster(s) and to reduce adverse effects. Objective The aims of this study were to identify clusters of physical HF symptoms (ie, dyspnea during daytime, dyspnea when lying down, fatigue, chest pain, edema, sleeping difficulty, and dizziness) and depressive symptoms and to examine their association with QOL in patients with HF. Methods In this secondary analysis of a cross-sectional study, data on physical HF symptoms (Symptom Status Questionnaire), depressive symptoms (Patient Health Questionnaire-9), and general QOL (European Quality of Scale-Visual Analog Scale) were collected. We identified clusters based on the physical HF symptoms and depressive symptoms using 2-step and k -means cluster analysis methods. Results Chest pain was removed from the model because of the low importance value. Two clusters were revealed (cluster 1, severe symptom cluster, vs cluster 2, less severe symptom cluster) based on the 7 symptoms. In cluster 1, all of the 7 symptoms were more severe, and QOL was poorer than those in cluster 2 (all P s < .001). All the mean and median scores of the 7 symptoms in cluster 1 were higher than those in cluster 2. Conclusions Patients with HF were clearly divided into 2 clusters based on physical HF symptoms and depressive symptoms, which were associated with QOL. Clinicians should assess these symptoms to improve patient outcomes.

Abstract: BACKGROUND Diabetes complications are prevalent and cause adverse effects on the physical, psychological, and economic status of adult patients with type 2 diabetes. Meditation may positively affect self-management and, in turn, reduce diabetes complications. However, the systematic examination of the effects of meditation without additional components on self-management in this population have been rarely examined. PURPOSE The aim of this study was to examine the effects of meditation interventions on self-management (ie, control of glucose, blood pressure, cholesterol, and obesity and self-management) among adult patients with type 2 diabetes in randomized controlled trials. METHODS In this systematic review and meta-analysis, 6 electronic databases were searched using major keywords of meditation, diabetes, and self-management during March 2022. RESULTS Eight studies (9 articles) using mindfulness-based meditation were included. The meta-analysis showed that meditation improved hemoglobin A1c (effect size = -0.75; 95% confidence interval, -1.30 to -0.21; P = .007) but not fasting blood glucose. Only a few studies examined meditation effects on other types of self-management (eg, blood pressure, body mass index, cholesterol, diet, exercise, foot care, and monitoring of blood glucose), and the effects were inconsistent. In 1 study, meditation improved diabetes self-management. CONCLUSIONS Mindfulness-based meditation reduced hemoglobin A1c levels in adult patients with type 2 diabetes but did not consistently improve other types of self-management in a few studies examined. This may imply the need for additional intervention components to improve different types of self-management. Further studies are needed to examine the effects of different types of meditations with additional components on different types of self-management.

Abstract: Background Telomere length is reduced in persons with heart failure (HF). Inflammation is a putative mechanism contributing to telomere shortening. Although physical activity is known to increase telomere length, its effects in HF are unknown. Objective The aim of this study was to examine the effects of exercise on telomere length and its relationship with interleukin (IL)-1β in persons with HF. Methods This secondary analysis of a 3-month home-based aerobic exercise intervention measured total telomere length and IL-1β levels in persons with HF (69% with reduced ejection fraction). Results Total telomere length increased and plasma IL-1β levels decreased in the exercise group from baseline to 3 months. Total telomere length was negatively associated with IL-1β at baseline (r = −0.441 P = .001). Conclusions The association between telomere length and IL-1β suggests a relationship between inflammation and cellular aging. Moderate-intensity exercise may help maintain cellular functions. Further research is needed to examine the effects on outcomes in persons with HF.

Abstract: The Relationship Between Sleep Quality, Coronavirus Anxiety

Abstract: Approximately 20 million individuals in the United States are now considered cancer survivors.1 The notable improvement in cancer survival over the past several decades has been attributed in large part to a surge in effective novel anticancer therapies. Of note, cardiovascular disease (CVD) has emerged as a leading cause of nonmalignant morbidity and mortality risk in patients with cancer.2 As highlighted in a recent scientific statement from the American Heart Association (AHA), the specialty of cardio-oncology is now dedicated to increasing awareness and management of cardiovascular sequelae associated with anticancer therapies.3 Many chemotherapy drugs and radiation therapies used to treat oncological conditions are associated with cardiovascular toxicities. The major chemotherapy drug classifications that can lead to cardiovascular toxicities include some alkylating agents (eg, cyclophosphamide), anthracyclines (eg, daunorubicin), monoclonal antibodies (eg, trastuzumab), tyrosine kinase inhibitors, vascular endothelial growth factor signaling pathway inhibitors (eg, bevacizumab), checkpoint inhibitors, hormonal therapies, and corticosteroids. Radiation therapy to the mediastinum or left chest may result in myocardial damage.4 There is a gap in understanding of the mechanisms of the adverse effects, and much research is being conducted to prevent, identify, and treat these cardiovascular complications.5 Unfortunately, evidence suggests that the risk of cardiotoxicity with selected anticancer therapies may be increased among women and underrepresented populations.3 This growing body of evidence prompted the AHA statement with emphasis on promoting equity in cardio-oncology care as well as research.3 Inequity in Cardio-oncology The AHA has offered a general definition of health disparities and inequities with health disparities defined as differences among groups of people closely linked with social, economic, and environmental disadvantages.6 Healthcare inequity in cardio-oncology includes and encompasses medical, genetic, and societal issues and intrinsic cultural barriers that ultimately lead to disparate outcomes. As highlighted in the AHA statement, CVD toxicities associated with anticancer therapies (myocarditis, pericarditis, hypertension, dysrhythmias, heart failure) have been observed to differ by biological sex, race, ethnicity, socioeconomic status, and related social determinants of health (SDOH).3 Population-Specific Considerations: Sex Differences in Cardiotoxicity Risk Emerging data suggest differences in the toxicity profile of several immune and targeted anticancer therapies. For example, in phase 2 and 3 clinical trials, women demonstrated a 34% increased risk of severe, adverse events with anticancer therapy including a 60% higher risk of immune checkpoint inhibitor–associated toxicities.7 The mechanisms of these observed sex differences merit additional investigation at the preclinical and patient levels to determine the biological differences in cardiotoxicity outcomes. Differences in cardiovascular risk factors have also been documented among women treated with more traditional chemotherapies (eg, anthracyclines), commonly used in the treatment of breast cancer.3 Relatedly, a recent report from the Women's Health Initiative estimated the incidence of heart failure subtypes in racially diverse postmenopausal breast cancer survivors and examined associations between lifestyle factors and the subtypes (heart failure with preserved ejection fraction [HFpEF] and heart failure with reduced ejection fraction [HFrEF]).8 The cumulative incidences of hospitalized HFpEF and HFrEF were 6.68% and 3.96%, respectively, over a median of 7.2 years. For HFpEF, previous myocardial infarction, greater waist circumference, and smoking history were the strongest risk factors. Similar patterns with the exception of waist circumference were observed for HFrEF; however, none was significant in multivariate models. Of note, the risk of overall mortality in breast cancer survivors with hospitalized HFpEF was 5.65 (95% confidence interval, 4.11–7.76), and that in those with HFrEF was 3.77 (95% confidence interval, 2.51–5.66). In exploratory analysis, a significant difference in anthracycline-associated risk between the 2 heart failure subtypes was observed with an increased risk observed only for HFrEF. As emphasized in this report, the need to monitor for clinical heart failure overall and going beyond assessment of left ventricular ejection fraction in survivors of breast cancer is warranted, as is need for additional research linking central adiposity and subsequent HFpEF in breast cancer survivors.8 Population-Specific Considerations: Race and Ethnic Differences Documented in clinical and population level data, African American/Black patients have a substantially higher risk for severe cardiotoxicity. Of note, most of the available research has focused on women with breast cancer, with reports indicating a 3-fold increased risk of cardiotoxicity after anthracycline therapies.7,9 One study of patients treated with immune checkpoint inhibitor therapy observed in Black women a 3- to 4-fold increased risk of cardiotoxic events compared with non-Hispanic White counterparts.10 Although the reasons for these observed differences remain to be fully explicated, Black women present with later stages of cancer requiring greater intensity of anticancer therapies. Other research suggests that Black patients experience increased CVD and mortality post cancer diagnosis, even accounting for cancer stage, and socioeconomic and treatment-related factors.11 Cardiovascular risk factor burden has been identified to contribute to global cancer therapy–related CVD risk in all populations. Black men and women in the National Health and Nutrition Examination Survey community cohort had up to a 40% prevalence of hypertension compared with less than 30% among White counterparts.12 Data from cancer survivor studies indicate disproportionately higher rates of hypertension in Black populations, which may increase the risk of cancer therapy–related CVD, especially related to heart failure.3 Taken together, available data and anecdotal observations indicate knowledge gaps in cardiotoxic risks and outcomes among Black survivors of cancer and point to the need for research focused on factors and mechanistic drivers behind these differences. In the United States, Hispanic individuals are diverse in origin, heritage, sociodemographic characteristics, patterns of immigration, and degree of acculturation. Cardiovascular disease and cancer are the major causes of morbidity and mortality. Hispanic patients are less likely to be given a diagnosis of cancer early compared with non-Hispanic White counterparts.3 As such, they have a more complex CVD cancer diagnosis at later stages and restrictions to more cardiotoxic regimens attributable, in part, to lack of eligibility for novel treatments.3 Taken together, this contributes to a higher incidence of treatment complications, cardiac dysfunction, and adverse patient outcomes and suggests the need for additional research focused on the constellation of modifiable and nonmodifiable factors that contribute to inequities in diagnosis and treatment of cancer in Hispanic/Latino populations.3 As underscored in the AHA statement, there are similarities between Hispanic and Asian and Pacific Islander populations; cancer and CVD are the major causes of morbidity and mortality.3 Available data are in the aggregate and do not capture the similarities and differences in exposures and outcomes between and among the diverse Asian and Pacific Islander populations. Noted in a recent study documenting age-adjusted mortality rates in cardio-oncology patients were higher in countries with greater social vulnerability; the role of social factors in contributing to cancer therapy–related CVDs is a critically important consideration in comprehensive treatment for patients presenting with a diagnosis of cancer.13 Over the last 2 decades, survival rates for an array of pediatric cancers, particularly acute lymphocytic leukemia, have increased substantially. Global studies have indicated improved survival outcomes after a primary cancer diagnosis, but more adverse long-term outcomes compared with general populations of children and youth.3 Of note, long-term survivors have a 7-to-9 times higher risk of death from cardiac-related events compared with the general population.14,15 Such events included heart failure, valvular disease, and coronary artery disease. Survivors of pediatric cancers have also demonstrated increased rates of hypertension, dyslipidemias, and vascular diseases compared with the general population.14,15 From the perspective of primordial and primary prevention, available data support the need for monitoring and periodic assessment of CVD risk factors in children and youth presenting with a diagnosis of cancer and beg the need for additional research focused on the determinants of risk and health outcomes for this special population of cancer survivors. Social Determinants of Health: Important Considerations Social determinants of health, the circumstances in which individuals are born, grow, school, live, work, and age, are recognized as foundational contexts for promoting optimal health across the life course.16 Substantial clinical and epidemiologic data link adverse SDOH reflecting individuals' economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context to health disparities and suboptimal health across the life course.3,16 Studies have demonstrated the adverse impact of healthcare disparities on outcomes of individuals with CVD. The AHA issued a statement addressing SDOH in CVD and suggested interventions to address economic profile, healthcare coverage, health literacy, and ethnic and racial disparities.17 Similar to CVD, the role of SDOH in the risks, rates, and survival of multiple cancers is increasingly emphasized; the American Cancer Society recently released a framework of practice, research, and policy to better recognize and address the SDOH in cancer.18 Emerging evidence suggests that SDOH play a vital role in the health of cardio-oncology patients.19 Taken together, available and emerging evidence supports the need to assess SDOH in the practice of caring for cardio-oncology patients as well as attention to the strategies designed to improve equity (discussed below). Strategies Designed to Improve Equity in Cardio-oncology Care and Research On the basis of the collective evidence and observations, the AHA's statement on improving equity in cardio-oncology care and research highlights several strategies (not in rank order)3: Investigating biological mechanisms including potential biological pathways and factors (eg, gene variation) with the aim of enabling tailoring of care in an era of increasing focus on precision medicine. Intentionally diversifying clinical trials including promoting enrollment of women and individuals from underrepresented groups in cardio-oncology clinical trials as well as in leadership of such trials. Integrating SDOH into clinical care delivery with aims of raising awareness of the social and financial inequities in cardio-oncology and increasing local and public advocacy for treatment pathways that provide fiscally conscious optimal care that can help address inequities and improve patient outcomes. Improving access to care with the aim of exploring the effectiveness of including equitable telehealth/remote access in cardio-oncology care. Cardiovascular nurses functioning in clinical and community-based settings have critically important roles in providing evidence-based care for cardio-oncology patients. As members of multidisciplinary teams in cardio-oncology programs, cardiovascular nurses have opportunities to identify, assess, and manage cardiovascular risk factors including lifestyle behaviors central to optimal health as well as SDOH that impact preventive and ongoing care for cardio-oncology patients.20–22 Patients should have a thorough baseline cardiovascular risk assessment before undergoing cancer therapy.4,22 For those with preexisting CVD or risk factors, guidelines-directed management is recommended. Choosing chemotherapy drugs with lower cardiovascular toxicities may be considered if possible. Consultation between oncology and cardiology providers is strongly recommended.22 Preventive adjuvant therapies are emerging based on the cancer treatment regimen.4 Patients who have had a previous cancer diagnosis and treatment should be followed across the life span to identify cardiovascular complications that may develop in the future. Aware of the potential short- and long-term adverse effects of selected cancer therapies, particularly for women and underrepresented groups, cardiovascular nurses have opportunities across healthcare and community settings to provide evidence-based holistic care that includes and encompasses primordial, primary, and secondary prevention. As highlighted in the AHA statement3 and in this Prevention Column, substantial knowledge gaps exist in promoting equity in cardio-oncology with opportunities for nurse scientists and nursing.

Abstract: Black race, inadequate health literacy, and poor perceived control are predictors of increased cardiovascular disease (CVD) risk. The purpose of this study was to explore the relationships among race, health literacy, perceived control, and CVD risk while controlling for known risk factors in incarcerated men.We included data from 349 incarcerated men to examine race and CVD risk (Framingham Risk Score) using a serial mediation model with health literacy and perceived control using 95% confidence intervals (CIs) from 5000 bootstrap samples.Of the participants (age, 36 ± 10; education, 12 ± 2; body mass index, 28.3 ± 5.0), 64.2% were White and 35.8% were Black. Black incarcerated men were younger (P = .047) with lower levels of health literacy (P < .001). All 3 indirect effects of race on CVD were significant, whereas the direct effect of race was not. Black incarcerated men had higher levels of CVD risk through health literacy (a1b1 = 0.3571; 95% CI, 0.0948-0.7162) and lower levels of CVD risk through perceived control (a2b2 = -0.1855; 95% CI, -0.4388 to -0.0077). Black incarcerated men had higher levels of CVD risk through health literacy influenced by perceived control (a1b2d21 = 0.0627; 95% CI, 0.0028-0.1409), indicating that despite the protective effect of higher levels of perceived control in Black incarcerated men, CVD risk remained higher compared with their White counterparts.Future CVD risk reduction interventions in incarcerated men, specifically Black incarcerated men, should include goals of improving health literacy and perceived control as modifiable risk factors.

Abstract: BACKGROUND Despite significant family caregiver (FCG) burnout, there are currently no tested interventions to support the FCG role after left ventricular assist device (LVAD) implantation or formalized training for clinicians to support FCGs. OBJECTIVE We adapted the existing ENABLE (Educate, Nurture, Advise Before Life Ends) intervention to LVAD clinicians and FCGs and assessed clinical implementation and dissemination. METHODS ENABLE-LVAD is an interactive, self-paced clinician training coupled with FCG-facing guidebooks and resources. Implementation and dissemination were evaluated by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS As of May 2023, 187 clinicians registered for the training, and 41 completed all modules (22.0% completion rate). Of those who completed the training and responded to a 6-month survey, one-third (n = 10, 33.3%) used ENABLE-LVAD with FCGs, and 100% of those planned to continue using it. The primary barrier to completing the training was time. CONCLUSIONS The ENABLE-LVAD clinician training was successfully disseminated and implemented as a useful resource to support LVAD FCGs.

Abstract: BACKGROUND Hypertension has become a major public problem. One of every 4 adults has hypertension. Medications are critical in controlling blood pressure, but patient medication adherence is low. Therefore, it is very crucial to promote medication adherence. However, the complexity and variety of interventions cause clinical decision-making difficulties for health managers and patients. OBJECTIVE The aim of this study was to compare the effectiveness of different interventions to improve medication adherence in patients with hypertension. METHODS We searched PubMed, Cochrane Library, Web of Science, EMBASE, Wan Fang, China National Knowledge Infrastructure, China Science and Technology Journal Database, and China Biology Medicine disc databases for eligible studies. Medication adherence rate and medication adherence difference were assessed as outcomes. Sensitivity analysis and inconsistency detection were performed to evaluate whether the exclusion of high-risk studies affected the validity. The risk of bias was assessed using the risk of bias table in Review Manager 5.4. The surface under the cumulative ranking curve was used to estimate the rankings among different interventions. RESULTS Twenty-seven randomized controlled trials were included, and the interventions involved were categorized into 8 different categories. The network meta-analysis showed that the health intervention was the best to promote medication compliance in patients with hypertension. CONCLUSIONS Health intervention is recommended to improve medication adherence in patients with hypertension. CLINICAL IMPLICATIONS Health managers are recommended to provide health intervention to patients with hypertension to improve their medication adherence. This approach reduces morbidity, mortality, and healthcare costs for patients with cardiovascular disease.

Abstract: BACKGROUND Growing evidence suggests maternal stress contributes to the development of adverse pregnancy outcomes that are associated with cardiovascular and cardiometabolic risk in birthing persons. Mindfulness-based interventions may positively affect psychological stress in pregnancy and, in turn, reduce stress. However, few study authors have examined the effects of mindfulness-based interventions on adverse pregnancy outcomes that heighten cardiovascular risk. OBJECTIVE The aim of this study was to appraise available literature examining the effects of mindfulness-based interventions delivered during pregnancy on adverse pregnancy outcomes associated with future cardiovascular and cardiometabolic disease risk. METHODS In this systematic review, multiple electronic databases were searched using major keywords, including "mindfulness-based intervention," "pregnancy," "preterm delivery," "gestational diabetes," "small for gestational age," "preeclampsia," and "hypertension in pregnancy" during February 2023. RESULTS Six studies using mindfulness-based interventions during pregnancy were included. The review indicated that these interventions were largely effective at reducing prenatal stress; however, the overall effects of interventions were mixed concerning their impact on pregnancy complications. Study authors examining the effects on gestational diabetes-related outcomes reported significant improvements in blood glucose levels, hemoglobin A1c, and oral glucose tolerance. Outcomes were mixed or inconclusive related to the effects of interventions on the incidence of preterm birth, birth of a small-for-gestational-age newborn, and preeclampsia. CONCLUSIONS Mitigating cardiovascular and cardiometabolic risk-associated adverse pregnancy outcomes through mindfulness-based approaches may represent an emerging field of study. The few studies and limited, mixed findings synthesized in this review indicate that high-validity studies are warranted to examine the effects of mindfulness-based interventions on pregnancy complications that contribute to cardiovascular-related maternal morbidity and suboptimal life course health for diverse birthing persons.