European Journal of Cardiovascular Nursing

Atrial fibrillation, the most common arrhythmia worldwide, continues to increase as the population ages. Patients with atrial fibrillation, particularly those newly diagnosed or who have multiple comorbidities, have high healthcare utilisation rates. Nurse-led atrial fibrillation clinics have developed to improve care and guidance for atrial fibrillation patients, with the potential to reduce hospital presentations and healthcare utilisation. Atrial fibrillation clinics that provide specialised and patient-centred care have improved patient symptom management, quality of life and reduced healthcare utilisation and costs.

The aim of this study was to provide the first synthesis of evidence for the impact of nurse-led atrial fibrillation clinics on patient, healthcare utilisation, and quality of care outcomes.

This systematic mixed studies review examined citations from three databases: Medline, CINAHL and Embase, using the search terms ‘atrial fibrillation’ and ‘clinic’, and related concepts. Seventeen moderate to high quality articles were selected.

Overall, atrial fibrillation clinics were more cost effective, had shorter wait times and reduced hospitalisation and emergency department visits. Symptoms and sinus rhythm restoration were comparable in the nurse-led compared to physician-led cardioversion clinics. Findings related to patient knowledge and patient satisfaction were mixed, while mortality rates were lower, and patient medication adherence was higher in nurse-led atrial fibrillation compared to usual care. Quality of life and guideline adherence was increased in patients receiving nurse-led atrial fibrillation care compared to usual care.

Nurse-led clinics improved healthcare, patient and quality care outcomes. Future research might examine the role of technology in delivery of nurse-led clinics in rural/remote areas as well as patient experiences with nurse-led clinics.

Rapid contact with emergency medical services is imperative to save the lives of acute myocardial infarction patients. However, many patients turn to a telehealth advisory nurse instead, where the delivery of urgent and safe care largely depends on how the interaction in the call is established.

The purpose of this study was to explore the interaction between tele-nurses and callers with an evolving myocardial infarction after contacting a national telehealth advisory service number as their first medical contact.

Twenty men and 10 women (aged 46–89 years) were included. Authentic calls were analysed using inductive content analysis.

One overall category, Movement towards directed level of care, labelled the whole interaction between the tele-nurse and the caller. Four categories conceptualised the different interactions: a distinct, reasoning, indecisive or irrational interaction. The interactions described how tele-nurses and callers assessed and elaborated on symptoms, context and actions. The interaction was pivotal for progress in the dialogue and affected the achievement of mutual understanding in the communicative process. An indecisive or irrational interaction could increase the risk of failing to recommend or call for acute care.

The interaction in the communication could either lead or mislead the level of care directed in the call. This study adds new perspectives to the communicative process in the acute setting in order to identify a myocardial infarction and the level of urgency from both individuals experiencing myocardial infarction and professionals in the health system.

The purpose of the current study was to describe the participants’ experiences of a structured lifestyle program for persons with high cardiovascular risk.

Sixteen participants with high cardiovascular risk participating in a one-year structured lifestyle intervention program were interviewed regarding their experiences of the program. The interviews were analyzed using content analyses.

The participants’ (mean age 58 ± 9) experiences were categorized into three categories: “How to know,” based on the participants’ experience from both individual counselling and group sessions with tools to strengthen self-care; “Staff who know how,” based on experience from the meeting with, and the importance of, competent health professionals; “Why feedback is essential,” based on the participants’ experience and effects of person-centered feedback. Several factors were deemed important in the structure of the program: an individual visit with shared goal setting, a group education session with interactive discussion, a competent, educated, and respectful health professional who gives continuous feedback, and the right tools to support self-care at home between visits.

Individuals participating in a structured lifestyle program experienced several factors as important: an individual visit with shared goal setting, a group education session with interactive discussion, a competent, educated, and respectful healthcare professional who gives continuous feedback, and the right tools to support self-care at home between visits.

The circadian rhythm of onset of myocardial infarction shows an increased risk during the morning hours. However, it is not clear whether habits, culture and sunshine hours differentiate circadian rhythm. The aim of this study was to investigate the influence of cultural factors on the circadian rhythm of acute myocardial infarction with ST segment elevation in a Mediterranean island.

The study was a retrospective correlational survey. It included 123 patients with ST elevation myocardial infarction (mean age 60.7±12.6; 82% men). The 24 h of a day were divided into four six-hour periods of time for study purposes (00:01–06:00; 06:01–12:00; 12:01–18:00; and 18:01–24:00) and the chi-square test was used for the analysis.

A morning peak of symptoms onset of ST-elevation myocardial infarction was detected during the period 06:01–12:00 (p=0.044). In patients who were smokers, a bimodal pattern involving a morning (06:01–12:00) and an afternoon-to-night peak (18:01–24:00) (p=0.005) was detected. For patients with a history of hypertension, a morning peak of their symptoms was also detected (p=0.028). Different circadian variations were found between patients over the age of 60 years old and patients under the age of 60 years old (p=0.025).

Patients with ST elevation myocardial infarction seem to follow a circadian rhythm with a peak of onset of symptoms in the morning. In the smokers’ subgroup, a different circadian pattern was found. The habit of smoking is likely to affect the circadian rhythm of the onset of ST elevation myocardial infarction in the Mediterranean area and culture.

Young black women have an increased risk of cardiovascular disease, and thus identifying innovative prevention strategies is essential. A potential preventive strategy is mobile health; however, few studies have tested this strategy in young black women.

The purpose of this study was to assess the feasibility of a mobile health intervention through a digital application to reduce cardiovascular disease risk factors in young black women, and identify benefits and barriers to participation.

Forty black women aged 25–45 years completed four sessions of cardiovascular disease risk reduction education and a six-month smartphone cardiovascular disease risk reduction monitoring and coaching intervention, targeting heart-healthy behavior modifications. At follow-up, women responded to a semi-qualitative online survey assessing the user-friendliness and perceived helpfulness of the intervention.

Of 40 women, 38 completed the follow-up survey. Sixty per cent of participants reported that the applications were easy or very easy to maintain, 90% reported that the application was easy or very easy to use. Over 60% observed that their family’s nutrition improved “a lot” or “a medium amount,” and many participants noted positive changes in their children’s diets. Only 8% of participants cited time or cost required to prepare healthy foods as barriers to implementing dietary changes.

The m-Health intervention was feasible as a means of cardiovascular disease risk reduction for young black women. In addition, we found that targeting women provided indirect benefits for other family members, especially children. Most of the participants did not encounter systemic barriers to participation, suggesting that mobile health interventions can be effective tools to improve health behaviors in vulnerable populations.

Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams.

Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare.

The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis.

The CES was found to offer possibilities for meeting in an ethical ‘free-zone’ where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints.

Participating in CES was experienced as meeting in an ethical ‘free-zone’ and seemed to be a means of facilitating integration of palliative and heart-failure care.

Health promotion for cardiovascular disease risk factors management is essential to secondary prevention of cardiovascular disease events. In Ireland, post-cardiac rehabilitation patients are discharged into the care of community public health nurses, who have a health promotion role. Little is known of the public health nurses’ perceptions or knowledge surrounding their role in cardiovascular disease risk factor management. Underpinned by a constructivist viewpoint, this study aims to generate empirical evidence on the phenomenon directly from public health nurses’ encounters within the context of the current health service.

This qualitative cross-sectional analysis involved face-to-face, semi-structured interviews with a purposeful sample of 17 public health nurses. Interviews were audio-recorded, transcribed, subjected to thematic content analysis and subsequently reported incorporating verbatim quotes.

A significant gap exists between evidence-based guidelines for cardiovascular disease prevention and current practices. Variations in public health nurses’ training, experience and knowledge result in inconsistent practices, and public health nurses feel this is specialised area for which they are not equipped. The changing public health nurse role and increasing workloads result in prioritisation of other nursing duties over health promotion. Ineffective systems for care delivery and a lack of community-based rehabilitation programmes also negatively impact on secondary prevention practices.

Findings support the need to develop a community cardiovascular disease specialist role to effectively support ongoing cardiovascular disease risk factor management. Evaluation of the mechanisms of current service delivery is required to ensure a quality-assured equitable service, in line with community needs and current evidence-based guidelines for practice. A quantitative triangulation study is recommended.

Transcatheter aortic valve implantation may be indicated for patients with aortic stenosis and high risk of postoperative mortality. The assessment of suitability for transcatheter aortic valve implantation requires consensus agreement of a team of cardiologists and cardiac surgeons. The burden of comorbidities, frailty and cognitive impairment are factors included when risks for transcatheter aortic valve implantation are balanced against the expected benefits. Although transcatheter aortic valve implantation is a possibility for many, there are still ineligible patients. Knowledge of their experiences of being deemed ineligible are lacking.

The aim of this study was to explore patients’ experiences of being considered for transcatheter aortic valve implantation but judged ineligible.

Individual in-depth interviews were performed with eight persons, and qualitative content analysis was used for the analysis.

Being ineligible for transcatheter aortic valve implantation may induce both hope and despair. Hope was linked to experiences of acceptance, relief of symptoms, support and control; despair was associated with feelings of being missed and abandoned, and of grief and insecurity. Some expressed great anxiety, since their incurable heart disease meant an imminent death. Others were more concerned over practical problems that affected everyday life.

Being ineligible for transcatheter aortic valve implantation does not necessarily lead to despair. Hope is built through relationships, continuity and support. A combination of person-centred care and palliative care during the end-of-life phase should be offered to patients in order to help clients re-conceptualise hope during this stage of their illness. Cardiovascular nurses in the transcatheter aortic valve implantation team are suitable to facilitate continued care based on the patient’s needs, desires and local conditions.

The role of clinical guidelines is to provide patients with the best quality, evidence-based care. Nurses are actively involved in the development of the European Society of Cardiology guidelines. A number of the guidelines include specific recommendations relating to nursing duties and, hence, nurses require necessary knowledge and skills for their implementation. Inclusion of the guidelines in the curricula for university nursing programmes could facilitate their implementation to everyday practice.

The purpose of this study was to determine the awareness and opinions of Polish nursing students who participated in a guideline-based Master of Science education programme about the usefulness of the European Society of Cardiology guidelines.

A prospective and cross-sectional research design was used and Strengthening the Reporting of Observational studies in Epidemiology guidelines were followed. A total of 188 nursing students (mean age 31.18±10.41 years) who met the inclusion criteria were invited to complete the BeGuideWell survey. This instrument included 16 questions: five on participants’ demographics and 11 addressing the issues associated with the European Society of Cardiology guidelines. The Yates chi-squared test or Fisher exact test were used for statistical analysis.

The majority of students had become familiar with the diagnostics and treatment of acute and chronic heart failure. Nearly half of the students documented that they had never heard of the European Society of Cardiology guidelines before starting the Master of Science programme. Most students found the European Society of Cardiology guidelines helpful for their university education. Most respondents stated that the guidelines were useful in their everyday practice and believed that they contributed to better quality of patient care.

Students can become more familiar with the European Society of Cardiology guidelines during the course of their post-graduate education, preparing them to implement the European Society of Cardiology guidelines in their everyday practice.

Caregivers frequently provide support to people living with long-term conditions. However, there is paucity of evidence of interventions that support caregivers in their role. Rehabilitation EnAblement in Chronic Heart Failure (REACH-HF) is a novel home-based, health-professional-facilitated, self-management programme for patients with heart failure (HF) and their caregivers.

Based on the random allocation of individual adult patients with reduced ejection fraction (HFrEF) and left ventricular ejection fraction <45% within the past five years, the caregiver of patients was allocated to receive the REACH-HF intervention over 12 weeks (REACH-HF group) or not (control group). Caregiver outcomes were generic health-related quality of life (EQ-5D-5L), Family Caregiver Quality of Life Scale questionnaire (FamQol), Caregiver Burden Questionnaire HF (CBQ-HF), Caregiver Contribution to Self-care of HF Index questionnaire (CC-SCHFI) and Hospital Anxiety and Depression Scale (HADS). Outcomes were compared between groups at 4, 6 and 12 months follow-up. Twenty caregivers receiving REACH-HF were purposively selected for qualitative interviews at 4 and 12 months.

Compared with controls (44 caregivers), the REACH-HF group (53 caregivers) had a higher mean CC-SCHFI confidence score at 12 months (57.5 vs 62.8, adjusted mean difference: 9.3, 95% confidence interval: 1.8–16.8, p = 0.016). No significant between group differences were seen in other caregiver outcomes. Qualitative interviews showed that most caregivers who received the REACH-HF intervention made positive changes to how they supported the HF patient they were caring for, and perceived that they had increased their confidence in the caregiver role over time.

Provision of the REACH-HF intervention for caregivers of HF patients improved their confidence of self-management and was perceived for some to be helpful in supporting their caregiver role.

Heart failure with preserved ejection fraction is a clinical syndrome characterised by reduced exercise capacity. Some evidence has shown that a simple and home-based programme of inspiratory muscle training offers promising results in terms of aerobic capacity improvement in patients with heart failure with preserved ejection fraction. This study aimed to investigate whether the baseline inspiratory muscle function predicts the changes in aerobic capacity (measured as peak oxygen uptake; peak VO₂) after a 12-week home-based programme of inspiratory muscle training in patients with heart failure with preserved ejection fraction.

A total of 45 stable symptomatic patients with heart failure with preserved ejection fraction and New York Heart Association II–III received a 12-week home-based programme of inspiratory muscle training between June 2015 and December 2016. They underwent cardiopulmonary exercise testing and measurements of maximum inspiratory pressure pre and post-inspiratory muscle training. Maximum inspiratory pressure and peak VO₂ were registered in both visits. Multivariate linear regression analysis was used to assess the association between changes in peak VO₂ (Δ-peakVO₂) and baseline predicted maximum inspiratory pressure (pp-MIP).

The median (interquartile range) age was 73 (68–77) years, 47% were women and 35.6% displayed New York Heart Association III. The mean peak VO₂ at baseline and Δ-peakVO₂ post-training were 10.4±2.8 ml/min/kg and +2.2±1.3 ml/min/kg (+21.3%), respectively. The median (interquartile range) of pp-MIP and Δ-MIP were 71% (64–92) and 39.2 (26.7–80.4) cmH₂O, respectively. After a multivariate analysis, baseline pp-MIP was not associated with Δ-peakVO₂ (β coefficient 0.005, 95% confidence interval −0.009–0.019, P=0.452).

In symptomatic and deconditioned older patients with heart failure with preserved ejection fraction, a home-based inspiratory muscle training programme improves aerobic capacity regardless of the baseline maximum inspiratory pressure.

Promoting self-care is the cornerstone of heart failure management. The number of hospitalizations and unscheduled visits could be reduced in elderly patients with heart failure by the patients’ active involvement in self-care.

The aim of this study was to measure the level of self-care in elderly patients with heart failure, to examine the influence of socio-clinical variables on the level of self-care, and identify the socio-clinical variables that are predictors of self-care.

The study included 100 heart failure patients (48 female, 52 male) aged between 60 and 88 years, treated at the Oleśno Health Care Center (Poland). The European Heart Failure Self-care Behavior Scale-9 and Mini-Mental State Examination were used.

The total classic European Heart Failure Self-care Behavior Scale-9 score was 22.76 points (standard deviation=8.49), and the standardised European Heart Failure Self-care Behavior Scale-9 score was 61.78 (standard deviation=23.59). Patients who were in a relationship, did not take digoxin or diuretics, were in New York Heart Association classes I and II, and had normal scores or cognitive impairment in the Mini-Mental State Examination, had significantly higher levels of self-care. Self-care was also correlated with patient age (r_s=−0.36, p<0.001) and left ventricle ejection fraction (r_s=0.23, p=0.019). Linear regression analysis demonstrated that only the New York Heart Association class has a significant impact on European Heart Failure Self-care Behavior Scale-9 scores. Compared to classes I and II, New York Heart Association class IV decreases the standardised European Heart Failure Self-care Behavior Scale-9 score by a mean of 23.60 points.

Intensified self-care education should be provided to patients living alone, taking digoxin and diuretics, suffering from moderate dementia, and classified in New York Heart Association class IV. These patients may require specific educational strategies to gain the knowledge required for effective self-care.

Hypertension and cognitive impairment often coexist in older people. Office blood pressure measurement is a poor indicator for diagnosing hypertension in the general population. However, its diagnostic accuracy has not been substantially studied in patients with cognitive impairment.

The aim of this study was to determine the proportion of misdiagnosis of hypertension in patients with mild cognitive impairment and dementia compared to no cognitive impairment, by comparing office blood pressure measurement with home blood pressure measurement.

A cross-sectional study including consecutive patients visiting a memory clinic between 2014 and 2017. Home blood pressure was measured for one week according to the European guidelines. Office blood pressure was assessed during routine clinical practice. Using guideline definitions for normal blood pressure and hypertension, we investigated the proportion of disagreement between office blood pressure measurement and home blood pressure measurement. Univariable and multivariable logistic regression compared disagreement in diagnosis between patients with dementia, mild cognitive impairment and no cognitive impairment.

Of 213 patients (aged 73.4±9.0 years, 42% women) 82 had dementia, 65 had mild cognitive impairment and 66 had no cognitive impairment. Mean office blood pressure was 156/84±23/11 mmHg and mean home blood pressure was 139/79±16/10 mmHg. In 31% of patients, there was disagreement in hypertension diagnosis. This proportion was higher for mild cognitive impairment (38.5%) and dementia (35.4%) compared to no cognitive impairment (18.2%), with adjusted odds ratios of 3.7 (95% confidence interval 1.5–9.0), P=0.005 for mild cognitive impairment and 3.4 (1.3–8.6), P=0.011 for dementia.

In memory clinic patients with dementia and mild cognitive impairment, the diagnostic accuracy of office blood pressure measurement is lower compared to patients without cognitive impairment. To avoid the risk of making improper treatment decisions in this vulnerable group, a diagnosis of hypertension should be based on home blood pressure measurement, not office blood pressure measurement.