JMIR Publications

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  Heart Failure Self-Management

  Apr 4, 2018

  A Novel Intelligent Two-Way Communication System for Remote Heart Failure Medication Uptitration (the CardioCoach Study): Randomized Controlled Feasibility...

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  Authors List:

  • Christophe JP Smeets  
  • Valerie Storms  
  • Pieter M Vandervoort  
  • Pauline Dreesen  
  • Julie Vranken  
  • Marita Houbrechts  
  • Hanne Goris  
  • Lars Grieten  
  • Paul Dendale  

  Abstract:

  Background: European Society of Cardiology guidelines for the treatment of heart failure (HF) prescribe uptitration of angiotensin-converting enzyme inhibitors (ACE-I) and β-blockers to the maximum-tolerated, evidence-based dose. Although HF prognosis can drastically improve when correctly implementing these guidelines, studies have shown that they are insufficiently implemented in clinical practice. Objective: The aim of this study was to verify whether supplementing the usual care with the CardioCoach follow-up tool is feasible and safe, and whether the tool is more efficient in implementing the guideline recommendations for β-blocker and ACE-I. Methods: A total of 25 HF patients were randomly assigned to either the usual care control group (n=10) or CardioCoach intervention group (n=15), and observed for 6 months. The CardioCoach follow-up tool is a two-way communication platform with decision support algorithms for semiautomatic remote medication uptitration. Remote monitoring sensors automatically transmit patient’s blood pressure, heart rate, and weight on a daily basis. Results: Patients’ satisfaction and adherence for medication intake (10,018/10,825, 92.55%) and vital sign measurements (4504/4758, 94.66%) were excellent. However, the number of technical issues that arose was large, with 831 phone contacts (median 41, IQR 32-65) in total. The semiautomatic remote uptitration was safe, as there were no adverse events and no false positive uptitration proposals. Although no significant differences were found between both groups, a higher number of patients were on guideline-recommended medication dose in both groups compared with previous reports. Conclusions: The CardioCoach follow-up tool for remote uptitration is feasible and safe and was found to be efficient in facilitating information exchange between care providers, with high patient satisfaction and adherence. Trial Registration: ClinicalTrials.gov NCT03294811; https://clinicaltrials.gov/ct2/show/NCT03294811 (Archived by WebCite at http://www.webcitation.org/6xLiWVsgM)

  • JMIR Cardio 2018;2(1):e8

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  Telemonitoring in Cardiology

  Mar 16, 2018

  Remote Monitoring of Patients Undergoing Transcatheter Aortic Valve Replacement: A Framework for Postprocedural Telemonitoring

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  Authors List:

  • Mathilde C Hermans  
  • Martijn S Van Mourik  
  • Hermie J Hermens  
  • Jan Baan Jr  
  • Marije M Vis  

  Abstract:

  Background: The postprocedural trajectory of patients undergoing transcatheter aortic valve replacement (TAVR) involves in-hospital monitoring of potential cardiac rhythm or conduction disorders and other complications. Recent advances in telemonitoring technologies create opportunities to monitor electrocardiogram (ECG) and vital signs remotely, facilitating redesign of follow-up trajectories. Objective: This study aimed to outline a potential set-up of telemonitoring after TAVR. Methods: A multidisciplinary team systematically framed the envisioned telemonitoring scenario according to the intentions, People, Activities, Context, Technology (iPACT) and Functionality, Interaction, Content, Services (FICS) methods and identified corresponding technical requirements. Results: In this scenario, a wearable sensor system is used to continuously transmit ECG and contextual data to a central monitoring unit, allowing remote follow-up of ECG abnormalities and physical deteriorations. Telemonitoring is suggested as an alternative or supplement to current in-hospital monitoring after TAVR, enabling early hospital dismissal in eligible patients and accessible follow-up prolongation. Together, this approach aims to improve rehabilitation, enhance patient comfort, optimize hospital capacity usage, and reduce overall costs. Required technical components include continuous data acquisition, real-time data transfer, privacy-ensured storage, automatic event detection, and user-friendly interfaces. Conclusions: The suggested telemonitoring set-up involves a new approach to patient follow-up that could bring durable solutions for the growing scarcities in health care and for improving health care quality. To further explore the potential and feasibility of post-TAVR telemonitoring, we recommend evaluation of the overall impact on patient outcomes and of the safety, social, ethical, legal, organizational, and financial factors.

  • JMIR Cardio 2018;2(1):e9

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  Novel Sensors and Data Acquisition...

  Mar 8, 2018

  Handheld Ultrasound as a Novel Predictive Tool in Atrial Fibrillation: Prediction of Outcomes Following Electrical Cardioversion

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  Authors List:

  • Devin Kehl  
  • Raymond Zimmer  
  • Madhuri Sudan  
  • Ilan Kedan  

  Abstract:

  Background: Atrial fibrillation (AF) recurrence after successful direct current cardioversion (CV) is common, and clinical predictors may be useful. We evaluated the risk of early AF recurrence according to inferior vena cava (IVC) measurements by handheld ultrasound (HHU) at the time of CV. Objective: Assess HHU and objectively obtained measurements acquired at the point of care as potential clinical predictors of future clinical outcomes in patients with AF undergoing CV. Methods: Maximum IVC diameter (IVCd) and collapsibility with inspiration were measured by the Vscan HHU (General Electric Healthcare Division) in 128 patients immediately before and after successful CV for AF. Patients were followed by chart review for recurrence of AF. Results: Mean IVCd was 2.16 cm in AF pre-CV and 2.01 cm in sinus rhythm post-CV (P<.001). AF recurred within 30 days of CV in 34 of 128 patients (26.6%). Among patients with IVCd <2.1 cm pre-CV and decrease in IVCd post-CV, AF recurrence was 12.1%, compared to 31.6% in patients not meeting these parameters (odds ratio [OR] 0.299, P=.04). This association persisted after adjustment for age, ejection fraction <50%, left atrial enlargement, and amiodarone use (adjusted OR 0.185, P=.01). Among patients with IVCd post-CV <1.7 cm, AF recurrence was 13.5%, compared to 31.9% in patients not meeting this parameter (OR 0.185, P=.01). IVC parameters did not predict AF recurrence at 180 or 365 days. Conclusions: The presence of a normal IVCd pre-CV that becomes smaller post-CV and the presence of a small IVCd post-CV were each independently associated with reduced likelihood of early, but not late, AF recurrence. HHU assessment of IVCd at the time of CV may be useful to identify patients at low risk of early recurrence of AF after CV.

  • JMIR Cardio 2018;2(1):e7

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  Novel Sensors and Data Acquisition...

  Feb 28, 2018

  Measuring Moderate-Intensity Exercise with the Apple Watch: Validation Study

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  Authors List:

  • Grant Abt  
  • James Bray  
  • Amanda Clare Benson  

  Abstract:

  Background: Moderate fitness levels and habitual exercise have a protective effect for cardiovascular disease, stroke, type 2 diabetes, and all-cause mortality. The Apple Watch displays exercise completed at an intensity of a brisk walk or above using a green “exercise” ring. However, it is unknown if the exercise ring accurately represents an exercise intensity comparable to that defined as moderate-intensity. In order for health professionals to prescribe exercise intensity with confidence, consumer wearable devices need to be accurate and precise if they are to be used as part of a personalized medicine approach to disease management. Objective: The aim of this study was to examine the validity and reliability of the Apple Watch for measuring moderate-intensity exercise, as defined as 40-59% oxygen consumption reserve (VO2R). Methods: Twenty recreationally active participants completed resting oxygen consumption (VO2rest) and maximal oxygen consumption (VO2 max) tests prior to a series of 5-minute bouts of treadmill walking at increasing speed while wearing an Apple Watch on both wrists, and with oxygen consumption measured continuously. Five-minute exercise bouts were added until the Apple Watch advanced the green “exercise” ring by 5 minutes (defined as the treadmill inflection speed). Validity was examined using a one-sample t-test, with interdevice and intradevice reliability reported as the standardized typical error and intraclass correlation. Results: The mean %VO2R at the treadmill inflection speed was 30% (SD 7) for both Apple Watches. There was a large underestimation of moderate-intensity exercise (left hand: mean difference = -10% [95% CI -14 to -7], d=-1.4; right hand: mean difference = -10% [95% CI -13 to -7], d=-1.5) when compared to the criterion of 40% VO2R. Standardized typical errors for %VO2R at the treadmill inflection speed were small to moderate, with intraclass correlations higher within trials compared to between trials. Conclusions: The Apple Watch threshold for moderate-intensity exercise was lower than the criterion, which would lead to an overestimation of moderate-intensity exercise minutes completed throughout the day.

  • JMIR Cardio 2018;2(1):e6

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  Mobile Apps for Cardiology

  Feb 27, 2018

  Smartphone Apps Using Photoplethysmography for Heart Rate Monitoring: Meta-Analysis

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  Authors List:

  • Benjamin De Ridder  
  • Bart Van Rompaey  
  • Jarl K Kampen  
  • Steven Haine  
  • Tinne Dilles  

  Abstract:

  Background: Smartphone ownership is rising at a stunning rate. Moreover, smartphones prove to be suitable for use in health care due to their availability, portability, user-friendliness, relatively low price, wireless connectivity, far-reaching computing capabilities, and comprehensive memory. To measure vital signs, smartphones are often connected to a mobile sensor or a medical device. However, by using the white light-emitting diode as light source and the phone camera as photodetector, a smartphone could be used to perform photoplethysmography (PPG), enabling the assessment of vital signs. Objective: The objective of this meta-analysis was to evaluate the available evidence on the use of smartphone apps to measure heart rate by performing PPG in comparison with a validated method. Methods: PubMed and ISI Web of Knowledge were searched for relevant studies published between January 1, 2009 and December 7, 2016. The reference lists of included studies were hand-searched to find additional eligible studies. Critical Appraisal Skills Programme (CASP) Diagnostic Test Study checklist and some extra items were used for quality assessment. A fixed effects model of the mean difference and a random effects model of Pearson correlation coefficient were applied to pool the outcomes of the studies. Results: In total, 14 studies were included. The pooled result showed no significant difference between heart rate measurements with a smartphone and a validated method (mean difference −0.32; 99% CI −1.24 to 0.60; P=.37). In adults, the Pearson correlation coefficient of the relation between heart rate measurement with a smartphone and a validated method was always ≥.90. In children, the results varied depending on measuring point and heart rate. The pooled result showed a strong correlation that was significant (correlation coefficient .951; 95% CI 0.906-0.975; P<.001). The reported limits of agreement showed good agreement between a smartphone and a validated method. There was a moderately strong significant negative correlation between the year of publication of the included studies and the mean difference (r=−.69; P<.001). Conclusions: Smartphone apps measuring heart rate by performing PPG appear to agree with a validated method in an adult population during resting sinus rhythm. In a pediatric population, the use of these apps is currently not validated.

  • JMIR Cardio 2018;2(1):e4

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  Implantable Cardioverter...

  Feb 21, 2018

  Monitoring Patients With Implantable Cardioverter Defibrillators Using Mobile Phone Electrocardiogram: Case Study

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  Authors List:

  • Caley Kropp  
  • Jordan Ellis  
  • Rajasekhar Nekkanti  
  • Samuel Sears  

  Abstract:

  Background: Preventable poor health outcomes associated with atrial fibrillation continue to make early detection a priority. A one-lead mobile electrocardiogram (mECG) device given to patients with an implantable cardioverter defibrillator (ICD) allowed users to receive real-time ECG readings in 30 seconds. Objective: Three cases were selected from an institutional review board-approved clinical trial aimed at assessing mECG device usage and satisfaction, patient engagement, quality of life (QoL), and cardiac anxiety. These three specific cases were selected to examine a variety of possible patient presentations and user experiences. Methods: Three ICD patients with mobile phones who were being seen in an adult device clinic were asked to participate. The participants chosen represented individuals with varying degrees of reported education and patient engagement. Participants were instructed to use the mECG device at least once per day for 30 days. Positive ECGs for atrial fibrillation were evaluated in clinic. At follow-up, information was collected regarding their frequency of use of the mECG device and three psychological outcomes in the domains of patient engagement, QoL, and cardiac anxiety. Results: Each patient used the technology approximately daily or every other day as prescribed. At the 30-day follow-up, usage reports indicated an average of 32 readings per month per participant. At 90-day follow-up, usage reports indicated an average of 34 readings per month per participant. Two of the three participants self-reported a significant improvement in their physical QoL from baseline to completion, while simultaneously self-reporting a significant decrease in their mental QoL. All three participants reported high levels of device acceptance and technology satisfaction. Conclusions: This case study demonstrates that ICD patients with varying degrees of education and patient engagement were relatively active in their use of mECGs. All three participants using the mECG technology reported high technology satisfaction and device acceptance. High sensitivity, specificity, and accuracy of mECG technology may allow routine atrial fibrillation screening at lower costs, in addition to improving patient outcomes.

  • JMIR Cardio 2018;2(1):e5

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  Cardiac Disease Management

  Feb 9, 2018

  Enhancing User Experience Through User Study: Design of an mHealth Tool for Self-Management and Care Engagement of Cardiovascular Disease Patients

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  Authors List:

  • Hyunyoung Baek  
  • Jung-Won Suh  
  • Si-Hyuck Kang  
  • Seungjin Kang  
  • Tae Ho Lim  
  • Hee Hwang  
  • Sooyoung Yoo  

  Abstract:

  Background: As patient communication, engagement, personal health data tracking, and up-to-date information became more efficient through mobile health (mHealth), cardiovascular diseases (CVD) and other diseases that require behavioral improvements in daily life are now capable of being managed and prevented more effectively. However, to increase patient engagement through mHealth, it is important for the initial design to consider functionality and usability factors and accurately assess user demands during the developmental process so that the app can be used continuously. Objective: The purpose of the study was to provide insightful information for developing mHealth service for patients with CVD based on user research to help enhance communication between patients and doctors. Methods: To drive the mobile functions and services needed to manage diseases in CVD patients, user research was conducted on patients and doctors at a tertiary general university hospital located in the Seoul metropolitan area of South Korea. Interviews and a survey were performed on patients (35 participants) and a focus group interview was conducted with doctors (5 participants). A mock-up mobile app was developed based on the user survey results, and a usability test was then conducted (8 participants) to identify factors that should be considered to improve usability. Results: The majority of patients showed a positive response in terms of their interest or intent to use an app for managing CVD. Functional features, such as communication with doctors, self-risk assessment, exercise, tailored education, blood pressure management, and health status recording had a score of 4.0 or higher on a 5-point Likert scale, showing that these functions were perceived to be useful to patients. The results of the mock-up usability test showed that inputting and visualizing blood pressure and other health conditions was required to be easier. The doctors requested a function that offered a comprehensive view of the patient’s daily health status by linking the mHealth app data with the hospital’s electronic health record system. Conclusions: Insights derived from a user study for developing an mHealth tool for CVD management, such as self-assessment and a communication channel between patients and doctors, may be helpful to improve patient engagement in care.

  • JMIR Cardio 2018;2(1):e3

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  Viewpoints and Proposals

  Jan 18, 2018

  Digital Health Innovation: A Toolkit to Navigate From Concept to Clinical Testing

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  Authors List:

  • Francoise Adeline Marvel  
  • Jane Wang  
  • Seth Shay Martin  

  Abstract:

  Digital health technologies such as smartphone apps, Web-based platforms, and wearable devices are rapidly emerging as promising interventions for acute and chronic disease management, particularly in the field of cardiovascular medicine. However, there is limited guidance on how to effectively develop and rigorously test digital health interventions (DHIs). Through our experience with innovating Corrie, a smartphone-based app paired with a smartwatch and blood pressure monitor for myocardial infarction recovery in the acute setting, we aim to provide a toolkit for navigating the digital health technology development and clinical testing processes. The toolkit consists of 6 steps: step one emphasizes concept generation by defining a specific clinical problem and the existing solutions aimed to address it; step two aims to recruit a multidisciplinary team within an academic institution; step three leverages technology accelerators and industry partnerships; step four develops the digital health technology with continuous feedback from patient and family end-users; step five solicits feedback from a diverse array of stakeholders; and step six performs a clinical study at a single site that, if successful, rapidly scales to multiple sites. DHI development is often a complex and vastly uncharted territory. By exploring the steps we took from concept to clinical testing with the first cardiology CareKit app, we hope to provide useful insights to teams that are starting out on their path to digital health innovation. We emphasize the central importance of embracing transdisciplinary work to move from silos to synergy.

  • JMIR Cardio 2018;2(1):e2

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  Novel Sensors and Data Acquisition...

  Jan 4, 2018

  Consumer Wearable Devices for Activity Monitoring Among Individuals After a Stroke: A Prospective Comparison

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  Authors List:

  • Gabriela M Rozanski  
  • Anthony Aqui  
  • Shajicaa Sivakumaran  
  • Avril Mansfield  

  Abstract:

  Background: Activity monitoring is necessary to investigate sedentary behavior after a stroke. Consumer wearable devices are an attractive alternative to research-grade technology, but measurement properties have not been established. Objective: The purpose of this study was to determine the accuracy of 2 wrist-worn fitness trackers: Fitbit Charge HR (FBT) and Garmin Vivosmart (GAR). Methods: Adults attending in- or outpatient therapy for stroke (n=37) wore FBT and GAR each on 2 separate days, in addition to an X6 accelerometer and Actigraph chest strap monitor. Step counts and heart rate data were extracted, and the agreement between devices was determined using Pearson or Spearman correlation and paired t or Wilcoxon signed rank tests (one- and two-sided). Subgroup analyses were conducted. Results: Step counts from FBT and GAR positively correlated with the X6 accelerometer (ρ=.78 and ρ=.65, P<.001, respectively) but were significantly lower (P<.01). For individuals using a rollator, there was no significant correlation between step counts from the X6 accelerometer and either FBT (ρ=.42, P=.12) or GAR (ρ=.30, P=.27). Heart rate from Actigraph, FBT, and GAR demonstrated responsiveness to changes in activity. Both FBT and GAR positively correlated with Actigraph for average heart rate (r=.53 and .75, P<.01, respectively) and time in target zone (ρ=.49 and .74, P<.01, respectively); these measures were not significantly different, but nonequivalence was found. Conclusions: FBT and GAR had moderate to strong correlation with best available reference measures of walking activity in individuals with subacute stroke. Accuracy appears to be lower among rollator users and varies according to heart rhythm. Consumer wearables may be a viable option for large-scale studies of physical activity.

  • JMIR Cardio 2018;2(1):e1

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  Novel Sensors and Data Acquisition...

  Dec 19, 2017

  Assessing the Use of Wrist-Worn Devices in Patients With Heart Failure: Feasibility Study

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  Authors List:

  • Yasbanoo Moayedi  
  • Raghad Abdulmajeed  
  • Juan Duero Posada  
  • Farid Foroutan  
  • Ana Carolina Alba  
  • Joseph Cafazzo  
  • Heather Joan Ross  

  Abstract:

  Background: Exercise capacity and raised heart rate (HR) are important prognostic markers in patients with heart failure (HF). There has been significant interest in wrist-worn devices that track activity and HR. Objective: We aimed to assess the feasibility and accuracy of HR and activity tracking of the Fitbit and Apple Watch. Methods: We conducted a two-phase study assessing the accuracy of HR by Apple Watch and Fitbit in healthy participants. In Phase 1, 10 healthy individuals wore a Fitbit, an Apple Watch, and a GE SEER Light 5-electrode Holter monitor while exercising on a cycle ergometer with a 10-watt step ramp protocol from 0-100 watts. In Phase 2, 10 patients with HF and New York Heart Association (NYHA) Class II-III symptoms wore wrist devices for 14 days to capture overall step count/exercise levels. Results: Recorded HR by both wrist-worn devices had the best agreement with Holter readings at a workload of 60-100 watts when the rate of change of HR is less dynamic. Fitbit recorded a mean 8866 steps/day for NYHA II patients versus 4845 steps/day for NYHA III patients (P=.04). In contrast, Apple Watch recorded a mean 7027 steps/day for NYHA II patients and 4187 steps/day for NYHA III patients (P=.08). Conclusions: Both wrist-based devices are best suited for static HR rate measurements. In an outpatient setting, these devices may be adequate for average HR in patients with HF. When assessing exercise capacity, the Fitbit better differentiated patients with NYHA II versus NYHA III by the total number of steps recorded. This exploratory study indicates that these wrist-worn devices show promise in prognostication of HF in the continuous monitoring of outpatients.

  • JMIR Cardio 2017;1(2):e8

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  Cardiac Disease Management

  Dec 12, 2017

  The Atrial Fibrillation Health Literacy Information Technology System: Pilot Assessment

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  Authors List:

  • Jared W Magnani  
  • Courtney L Schlusser  
  • Everlyne Kimani  
  • Bruce L Rollman  
  • Michael K Paasche-Orlow  
  • Timothy W Bickmore  

  Abstract:

  Background: Atrial fibrillation (AF) is a highly prevalent heart rhythm condition that has significant associated morbidity and requires chronic treatment. Mobile health (mHealth) technologies have the potential to enhance multiple aspects of AF care, including education, monitoring of symptoms, and encouraging and tracking medication adherence. We have previously implemented and tested relational agents to improve outcomes in chronic disease and sought to develop a smartphone-based relational agent for improving patient-centered outcomes in AF. Objective: The objective of this study was to pilot a smartphone-based relational agent as preparation for a randomized clinical trial, the Atrial Fibrillation Health Literacy Information Technology Trial (AF-LITT). Methods: We developed the relational agent for use by a smartphone consistent with our prior approaches. We programmed the relational agent as a computer-animated agent to simulate a face-to-face conversation and to serve as a health counselor or coach specific to AF. Relational agent’s dialogue content, informed by a review of literature, focused on patient-centered domains and qualitative interviews with patients with AF, encompassed AF education, common symptoms, adherence challenges, and patient activation. We established that the content was accessible to individuals with limited health or computer literacy. Relational agent content coordinated with use of the smartphone AliveCor Kardia heart rate and rhythm monitor. Participants (N=31) were recruited as a convenience cohort from ambulatory clinical sites and instructed to use the relational agent and Kardia for 30 days. We collected demographic, social, and clinical characteristics and conducted baseline and 30-day assessments of health-related quality of life (HRQoL) with the Atrial Fibrillation Effect on Quality of life (AFEQT) measure; self-reported medication adherence with the Morisky 8-item Medication Adherence Scale (MMAS-8); and patient activation with the Patient Activation Measure (PAM). Results: Participants (mean age 68 [SD 11]; 39% [12/31] women) used the relational agent for an average 17.8 (SD 10.0) days. The mean number of independent log-ins was 19.6 (SD 10.7), with a median of 20 times over 30 days. The mean number of Kardia uses was 26.5 (SD 5.9), and participants using Kardia were in AF for 14.3 (SD 11.0) days. AFEQT scores improved significantly from 64.5 (SD 22.9) at baseline to 76.3 (SD 19.4) units at 30 days (P<.01). We observed marginal but statistically significant improvement in self-reported medication adherence (baseline: 7.3 [SD 0.9], 30 days: 7.7 [SD 0.5]; P=.01). Assessments of acceptability identified that most of the participants found the relational agent useful, informative, and trustworthy. Conclusions: We piloted a 30-day smartphone-based intervention that combined a relational agent with dedicated content for AF alongside Kardia heart rate and rhythm monitoring. Pilot participants had favorable improvements in HRQoL and self-reported medication adherence, as well as positive responses to the intervention. These data will guide a larger, enhanced randomized trial implementing the smartphone relational agent and the Kardia monitor system.

  • JMIR Cardio 2017;1(2):e7

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  Patient-Views on Cardiology...

  Sep 26, 2017

  Patients With Implantable Cardioverter Defibrillators on Social Media Report More Shock Anxiety Than Clinic Patients: Results From an Online Survey

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  Authors List:

  • Linda Kramer Freeman  
  • Keith Richards  
  • Jamie B Conti  
  • Samuel F Sears  

  Abstract:

  Background: Coping with heart disease and the potential for implantable cardioverter defibrillator (ICD) shocks challenges the psychological adjustment of patients with ICDs. Social media use may be used to seek education and support from others. Objective: The aim of this study was to examine the content of information sought online and whether a social media sample of patients with ICDs report more device-specific anxiety than clinic-based normative samples. Methods: A total of 196 participants were recruited via social media messages and invited to complete an online survey. Results: It was found that the information most often sought by online users (62.4%, 123/196) involved both emotional support (eg, gaining emotional support from other patients with ICDs) and technical information (52.6%, 103/196) (eg, dealing with magnetic interference). The online sample reported more shock anxiety than a typical clinical sample with mean values of 22.75 (SD 10.06) and 15.18 (SD 6.50), respectively (P<.001). Conclusions: Collectively, these results suggest that patients with ICDs that are online are seeking emotional information and support, and that they report increased shock anxiety relative to typical clinic-based patients. Future research should examine how online information and clinical-based information form a composite understanding and adjustment for patients ICDs.

  • JMIR Cardio 2017;1(2):e6

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