TY - JOUR AU - Flo, L. Gayle AU - Alzate Aguirre, Mateo AU - Gochanour, R. Benjamin AU - Hynes, J. Kristin AU - Scott, G. Christopher AU - Fink, L. Angela AU - M Arruda-Olson, Adelaide PY - 2025/3/28 TI - Pharmacist-Initiated Team-Based Intervention for Optimizing Guideline-Directed Lipid Therapy of Hospitalized Patients With Acute Coronary Syndrome: Pilot Study Using a Stepped-Wedge Cluster Design JO - JMIR Cardio SP - e58837 VL - 9 KW - coronary disease KW - follow-up studies KW - lipids KW - myocardial infarction KW - statins N2 - Background: Clinical guidelines recommend high-intensity statin therapy for patients with acute coronary syndrome (ACS). However, high-intensity statins have been underused in this population. Objective: The objective of this study was to evaluate the feasibility of a pharmacist-initiated, team-based intervention for the delivery of individualized, guideline-directed, lipid-lowering therapy for patients with ACS. Methods: Patients admitted with ACS to cardiology hospital services at Mayo Clinic from August 1, 2021, to June 19, 2022, were assigned to a pharmacist-initiated, team-based intervention group or control group using a stepped wedge cluster study design. For the intervention group, pharmacists reviewed electronic health records and provided recommendations for lipid lowering therapy in hospital and at follow-up. In the control group, patients received usual care. Neither care team, nor study team were blinded to study assignments. The primary outcome was the proportion of patients with ACS discharged on high-intensity statins in the intervention group compared to controls. Secondary outcomes were (1) proportion of patients in the intervention group with a specific templated pharmacist intervention note in their electronic health records, (2) frequency of low-density lipoprotein (LDL) measurements in hospital, (3) proportion of patients with information related to lipid follow-up in their discharge summary, and (4) proportion of patients that received LDL monitoring at the outpatient follow-up 4 to 12 weeks post discharge. Results: There were 410 patients included in this study (median age 68, IQR 60-78 years) of whom 285 (69.5%) were male. Of the 402 patients alive at discharge, 355 (88.3%) were discharged taking a high-intensity statin, with no significant difference (P=.89) observed between groups. Lipid levels were measured in the hospital for 176/210 (83.8%) patients in the intervention group and 155/200 (77.5%) patients in the control group (P=.14). Fifty-four of 205 (26.3%) intervention patients alive at discharge had lipid-related recommendations in their discharge summary compared to 27/197 (13.7%) controls (P=.002). Forty-seven of 81 (58%) patients with lipid management recommendations provided in the discharge summary had LDL measured in the follow-up period compared with only 119/321 (37.1%) patients without these recommendations (P=.001). Of the 402 patients who survived to discharge, 166 (41.3%) had LDL measured at follow-up; the median LDL level was 63.5 (IQR 49-79) mg/dL, and distributions were similar by group (P=.95). Only 101/166 (60.8%) patients had follow-up LDL values below the target of 70 mg/dL. Conclusions: During hospitalization, there was no group difference in the primary outcome of high-intensity statin therapy. Feasibility of an effective pharmacist-initiated intervention for improvement of lipid management was demonstrated by entry of recommendations in the discharge summary and related adjustment in outpatient statin therapy. The main opportunity for future improvement in lipid management of patients with ACS is in longitudinal patient follow-up. UR - https://cardio.jmir.org/2025/1/e58837 UR - http://dx.doi.org/10.2196/58837 ID - info:doi/10.2196/58837 ER - TY - JOUR AU - Zhang, Xinyue PY - 2025/3/28 TI - Authors? Reply: The SCeiP Model for Remote Rehabilitation in Homebound Patients With Coronary Heart Disease JO - J Med Internet Res SP - e70247 VL - 27 KW - exercise rehabilitation KW - coronary heart disease KW - promotion strategy KW - home rehabilitation UR - https://www.jmir.org/2025/1/e70247 UR - http://dx.doi.org/10.2196/70247 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/70247 ER - TY - JOUR AU - Zhang, Siqi AU - Chen, Tielong PY - 2025/3/28 TI - The SCeiP Model for Remote Rehabilitation in Homebound Patients With Coronary Heart Disease JO - J Med Internet Res SP - e69927 VL - 27 KW - remote exercise rehabilitation KW - SCeiP model KW - coronary heart disease KW - promotion strategy KW - home rehabilitation UR - https://www.jmir.org/2025/1/e69927 UR - http://dx.doi.org/10.2196/69927 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/69927 ER - TY - JOUR AU - Dubbala, Keerthi AU - Prizak, Roshan AU - Metzler, Ingrid AU - Rubeis, Giovanni PY - 2025/3/10 TI - Exploring Heart Disease?Related mHealth Apps in India: Systematic Search in App Stores and Metadata Analysis JO - J Med Internet Res SP - e53823 VL - 27 KW - mobile health apps KW - mHealth apps KW - heart disease KW - data collection methods KW - natural language processing KW - metadata analysis KW - Apple App Store KW - Google Play Store KW - mobile phone N2 - Background: Smartphone mobile health (mHealth) apps have the potential to enhance access to health care services and address health care disparities, especially in low-resource settings. However, when developed without attention to equity and inclusivity, mHealth apps can also exacerbate health disparities. Understanding and creating solutions for the disparities caused by mHealth apps is crucial for achieving health equity. There is a noticeable gap in research that comprehensively assesses the entire spectrum of existing health apps and extensively explores apps for specific health priorities from a health care and public health perspective. In this context, with its vast and diverse population, India presents a unique context for studying the landscape of mHealth apps. Objective: This study aimed to create a comprehensive dataset of mHealth apps available in India with an initial focus on heart disease (HD)?related apps. Methods: We collected individual app data from apps in the ?medical? and ?health and fitness? categories from the Google Play Store and the Apple App Store in December 2022 and July 2023, respectively. Using natural language processing techniques, we selected HD apps, performed statistical analysis, and applied latent Dirichlet allocation for clustering and topic modeling to categorize the resulting HD apps. Results: We collected 118,555 health apps from the Apple App Store and 108,945 health apps from the Google Play Store. Within these datasets, we found that approximately 1.7% (1990/118,555) of apps on the Apple App Store and 0.5% (548/108,945) on the Google Play Store included support for Indian languages. Using monograms and bigrams related to HD, we identified 1681 HD apps from the Apple App Store and 588 HD apps from the Google Play Store. HD apps make up only a small fraction of the total number of health apps available in India. About 90% (1496/1681 on Apple App Store and 548/588 on Google Play Store) of the HD apps were free of cost. However, more than 70% (1329/1681, 79.1% on Apple App Store and 423/588, 71.9% on Google Play Store) of HD apps had no reviews and rating-scores, indicating low overall use. Conclusions: Our study proposed a robust method for collecting and analyzing metadata from a wide array of mHealth apps available in India through the Apple App Store and Google Play Store. We revealed the limited representation of India?s linguistic diversity within the health and medical app landscape, evident from the negligible presence of Indian-language apps. We observed a scarcity of mHealth apps dedicated to HD, along with a lower level of user engagement, as indicated by reviews and app ratings. While most HD apps are financially accessible, uptake remains a challenge. Further research should focus on app quality assessment and factors influencing user adoption. UR - https://www.jmir.org/2025/1/e53823 UR - http://dx.doi.org/10.2196/53823 UR - http://www.ncbi.nlm.nih.gov/pubmed/40063078 ID - info:doi/10.2196/53823 ER - TY - JOUR AU - Dong, Jiale AU - Jin, Zhechuan AU - Li, Chengxiang AU - Yang, Jian AU - Jiang, Yi AU - Li, Zeqian AU - Chen, Cheng AU - Zhang, Bo AU - Ye, Zhaofei AU - Hu, Yang AU - Ma, Jianguo AU - Li, Ping AU - Li, Yulin AU - Wang, Dongjin AU - Ji, Zhili PY - 2025/3/6 TI - Machine Learning Models With Prognostic Implications for Predicting Gastrointestinal Bleeding After Coronary Artery Bypass Grafting and Guiding Personalized Medicine: Multicenter Cohort Study JO - J Med Internet Res SP - e68509 VL - 27 KW - machine learning KW - personalized medicine KW - coronary artery bypass grafting KW - adverse outcome KW - gastrointestinal bleeding N2 - Background: Gastrointestinal bleeding is a serious adverse event of coronary artery bypass grafting and lacks tailored risk assessment tools for personalized prevention. Objective: This study aims to develop and validate predictive models to assess the risk of gastrointestinal bleeding after coronary artery bypass grafting (GIBCG) and to guide personalized prevention. Methods: Participants were recruited from 4 medical centers, including a prospective cohort and the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. From an initial cohort of 18,938 patients, 16,440 were included in the final analysis after applying the exclusion criteria. Thirty combinations of machine learning algorithms were compared, and the optimal model was selected based on integrated performance metrics, including the area under the receiver operating characteristic curve (AUROC) and the Brier score. This model was then developed into a web-based risk prediction calculator. The Shapley Additive Explanations method was used to provide both global and local explanations for the predictions. Results: The model was developed using data from 3 centers and a prospective cohort (n=13,399) and validated on the Drum Tower cohort (n=2745) and the MIMIC cohort (n=296). The optimal model, based on 15 easily accessible admission features, demonstrated an AUROC of 0.8482 (95% CI 0.8328-0.8618) in the derivation cohort. In external validation, the AUROC was 0.8513 (95% CI 0.8221-0.8782) for the Drum Tower cohort and 0.7811 (95% CI 0.7275-0.8343) for the MIMIC cohort. The analysis indicated that high-risk patients identified by the model had a significantly increased mortality risk (odds ratio 2.98, 95% CI 1.784-4.978; P<.001). For these high-risk populations, preoperative use of proton pump inhibitors was an independent protective factor against the occurrence of GIBCG. By contrast, dual antiplatelet therapy and oral anticoagulants were identified as independent risk factors. However, in low-risk populations, the use of proton pump inhibitors (?21=0.13, P=.72), dual antiplatelet therapy (?21=0.38, P=.54), and oral anticoagulants (?21=0.15, P=.69) were not significantly associated with the occurrence of GIBCG. Conclusions: Our machine learning model accurately identified patients at high risk of GIBCG, who had a poor prognosis. This approach can aid in early risk stratification and personalized prevention. Trial Registration: Chinese Clinical Registry Center ChiCTR2400086050; http://www.chictr.org.cn/showproj.html?proj=226129 UR - https://www.jmir.org/2025/1/e68509 UR - http://dx.doi.org/10.2196/68509 UR - http://www.ncbi.nlm.nih.gov/pubmed/40053791 ID - info:doi/10.2196/68509 ER - TY - JOUR AU - Wu, Jia AU - Zeng, Youjia AU - Yang, Jun AU - Yao, Yutong AU - Xu, Xiuling AU - Song, Gaofeng AU - Yi, Wuyong AU - Wang, Taifen AU - Zheng, Yihou AU - Jia, Zhongwei AU - Yan, Xiangyu PY - 2025/3/3 TI - Daily Treatment Monitoring for Patients Receiving Home-Based Peritoneal Dialysis and Prediction of Heart Failure Risk: mHealth Tool Development and Modeling Study JO - JMIR Form Res SP - e56254 VL - 9 KW - peritoneal dialysis KW - mHealth KW - patient management KW - heart failure KW - prediction model N2 - Background: Peritoneal dialysis is one of the major renal replacement modalities for patients with end-stage renal disease. Heart failure is a common adverse event among patients who undergo peritoneal dialysis treatment, especially for those who undergo continuous ambulatory peritoneal dialysis at home, because of the lack of professional input-output volume monitoring and management during treatment. Objective: This study aims to develop novel mobile health (mHealth) tools to improve the quality of home-based continuous ambulatory peritoneal dialysis treatment and to build a prediction model of heart failure based on the system?s daily treatment monitoring data. Methods: The mHealth tools with a 4-layer system were designed and developed using Spring Boot, MyBatis Plus, MySQL, and Redis as backend technology stack, and Vue, Element User Interface, and WeChat Mini Program as front-end technology stack. Patients were recruited to use the tool during daily peritoneal dialysis treatment from January 1, 2017, to April 20, 2023. Logistic regression models based on real-time treatment monitoring data were used for heart failure prediction. The sensitivity, specificity, accuracy, and Youden index were calculated to evaluate the performance of the prediction model. In the sensitivity analysis, the ratio of patients with and without heart failure was set to 1:4 and 1:10, respectively, to better evaluate the stability of the prediction model. Results: A WeChat Mini Program named Futou Bao for patients and a patient data management platform for doctors was developed. Futou Bao included an intelligent data upload function module and an auxiliary function module. The doctor?s data management platform consisted of 4 function modules, that is, patient management, data visualization and marking, data statistics, and system management. During the study period, the records of 6635 patients who received peritoneal dialysis treatment were uploaded in Futou Bao, with 0.71% (47/6635) of them experiencing heart failure. The prediction model that included sex, age, and diastolic blood pressure was considered as the optimal model, wherein the sensitivity, specificity, accuracy, and Youden index were 0.75, 0.91, 0.89, and 0.66, respectively, with an area under the curve value of 0.879 (95% CI 0.772-0.986) using the validation dataset. The sensitivity analysis showed stable results. Conclusions: This study provides a new home-based peritoneal dialysis management paradigm that enables the daily monitoring and early warning of heart failure risk. This novel paradigm is of great value for improving the efficiency, security, and personalization of peritoneal dialysis. UR - https://formative.jmir.org/2025/1/e56254 UR - http://dx.doi.org/10.2196/56254 UR - http://www.ncbi.nlm.nih.gov/pubmed/40053710 ID - info:doi/10.2196/56254 ER - TY - JOUR AU - Schranz, Madlen AU - Rupprecht, Mirjam AU - Aigner, Annette AU - Benning, Leo AU - Schlump, Carmen AU - Charfeddine, Nesrine AU - Diercke, Michaela AU - Grabenhenrich, Linus AU - Ullrich, Alexander AU - Neuhauser, Hannelore AU - Maier, Birga AU - AU - Hans, Patricius Felix AU - Blaschke, Sabine PY - 2025/2/25 TI - Establishing Syndromic Surveillance of Acute Coronary Syndrome, Myocardial Infarction, and Stroke: Registry Study Based on Routine Data From German Emergency Departments JO - JMIR Public Health Surveill SP - e66218 VL - 11 KW - emergency medicine KW - routinely collected health data KW - public health surveillance KW - syndromic surveillance KW - acute coronary syndrome KW - myocardial infarction KW - stroke KW - routine data KW - Germany KW - emergency department KW - accuracy KW - syndrome KW - diagnosis KW - public health KW - health surveillance N2 - Background: Emergency department (ED) routine data offer a unique opportunity for syndromic surveillance of communicable and noncommunicable diseases (NCDs). In 2020, the Robert Koch Institute established a syndromic surveillance system using ED data from the AKTIN registry. The system provides daily insights into ED utilization for infectious diseases. Adding NCD indicators to the surveillance is of great public health importance, especially during acute events, where timely monitoring enables targeted public health responses and communication. Objective: This study aimed to develop and validate syndrome definitions for the NCD indicators of acute coronary syndrome (ACS), myocardial infarction (MI), and stroke (STR). Methods: First, syndrome definitions were developed with clinical experts combining ED diagnosis, chief complaints, diagnostic certainty, and discharge information. Then, using the multicenter retrospective routine ED data provided by the AKTIN registry, we conducted internal validation by linking ED cases fulfilling the syndrome definition with the hospital discharge diagnoses and calculating sensitivity, specificity, and accuracy. Lastly, external validation comprised the comparison of the ED cases fulfilling the syndrome definition with the federal German hospital diagnosis statistic. Ratios comparing the relative number of cases for all syndrome definitions were calculated and stratified by age and sex. Results: We analyzed data from 9 EDs, totaling 704,797 attendances from January 1, 2019, to March 5, 2021. Syndrome definitions were based on ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision-German Modification) diagnoses, chief complaints, and discharge information. We identified 4.3% of all cases as ACS, 0.6% as MI, and 3.2% as STR. Patients with ACS and MI were more likely to be male (58.3% and 64.7%), compared to the overall attendances (52.7%). For all syndrome definitions, the prevalence was higher in the older age groups (60?79 years and >80 years), and the highest proportions of cases were assigned an urgency level (3=urgent or 2=very urgent). The internal validation showed accuracy and specificity levels above 96% for all syndrome definitions. The sensitivity was 85.3% for ACS, 56.6% for MI, and 80.5% for STR. The external validation showed high levels of correspondence between the ED data and the German hospital statistics, with most ratios ranging around 1, indicating congruence, particularly in older age groups. The highest differences were noted in younger age groups, with the highest ratios in women aged between 20 and 39 years (4.57 for MI and 4.17 for ACS). Conclusions: We developed NCD indicators for ACS, MI, and STR that showed high levels of internal and external validity. The integration of these indicators into the syndromic surveillance system for EDs could enable daily monitoring of NCD patterns and trends to enhance timely public health surveillance in Germany. UR - https://publichealth.jmir.org/2025/1/e66218 UR - http://dx.doi.org/10.2196/66218 ID - info:doi/10.2196/66218 ER - TY - JOUR AU - Alves, Miguel João AU - Matos, Daniel AU - Martins, Tiago AU - Cavaco, Diogo AU - Carmo, Pedro AU - Galvão, Pedro AU - Costa, Moscoso Francisco AU - Morgado, Francisco AU - Ferreira, Miguel António AU - Freitas, Pedro AU - Dias, Camila Cláudia AU - Rodrigues, Pereira Pedro AU - Adragão, Pedro PY - 2025/2/11 TI - Predicting Atrial Fibrillation Relapse Using Bayesian Networks: Explainable AI Approach JO - JMIR Cardio SP - e59380 VL - 9 KW - artificial intelligence KW - atrial fibrillation KW - Bayesian networks KW - clinical decision-making KW - machine learning KW - prognostic models N2 - Background: Atrial fibrillation (AF) is a prevalent arrhythmia associated with significant morbidity and mortality. Despite advancements in ablation techniques, predicting recurrence of AF remains a challenge, necessitating reliable models to identify patients at risk of relapse. Traditional scoring systems often lack applicability in diverse clinical settings and may not incorporate the latest evidence-based factors influencing AF outcomes. This study aims to develop an explainable artificial intelligence model using Bayesian networks to predict AF relapse postablation, leveraging on easily obtainable clinical variables. Objective: This study aims to investigate the effectiveness of Bayesian networks as a predictive tool for AF relapse following a percutaneous pulmonary vein isolation (PVI) procedure. The objectives include evaluating the model?s performance using various clinical predictors, assessing its adaptability to incorporate new risk factors, and determining its potential to enhance clinical decision-making in the management of AF. Methods: This study analyzed data from 480 patients with symptomatic drug-refractory AF who underwent percutaneous PVI. To predict AF relapse following the procedure, an explainable artificial intelligence model based on Bayesian networks was developed. The model used a variable number of clinical predictors, including age, sex, smoking status, preablation AF type, left atrial volume, epicardial fat, obstructive sleep apnea, and BMI. The predictive performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC-ROC) metrics across different configurations of predictors (5, 6, and 7 variables). Validation was conducted through four distinct sampling techniques to ensure robustness and reliability of the predictions. Results: The Bayesian network model demonstrated promising predictive performance for AF relapse. Using 5 predictors (age, sex, smoking, preablation AF type, and obstructive sleep apnea), the model achieved an AUC-ROC of 0.661 (95% CI 0.603?0.718). Incorporating additional predictors improved performance, with a 6-predictor model (adding BMI) achieving an AUC-ROC of 0.703 (95% CI 0.652?0.753) and a 7-predictor model (adding left atrial volume and epicardial fat) achieving an AUC-ROC of 0.752 (95% CI 0.701?0.800). These results indicate that the model can effectively estimate the risk of AF relapse using readily available clinical variables. Notably, the model maintained acceptable diagnostic accuracy even in scenarios where some predictive features were missing, highlighting its adaptability and potential use in real-world clinical settings. Conclusions: The developed Bayesian network model provides a reliable and interpretable tool for predicting AF relapse in patients undergoing percutaneous PVI. By using easily accessible clinical variables, presenting acceptable diagnostic accuracy, and showing adaptability to incorporate new medical knowledge over time, the model demonstrates a flexibility and robustness that makes it suitable for real-world clinical scenarios. UR - https://cardio.jmir.org/2025/1/e59380 UR - http://dx.doi.org/10.2196/59380 ID - info:doi/10.2196/59380 ER - TY - JOUR AU - Cintora-Sanz, María Ana AU - Horrillo-García, Cristina AU - Quesada-Cubo, Víctor AU - Pérez-Alonso, María Ana AU - Gutiérrez-Misis, Alicia PY - 2025/1/16 TI - Prevalence and Economic Impact of Acute Respiratory Failure in the Prehospital Emergency Medical Service of the Madrid Community: Retrospective Cohort Study JO - JMIR Public Health Surveill SP - e66179 VL - 11 KW - acute respiratory failure KW - COVID-19 KW - chronic obstructive respiratory insufficiency KW - congestive heart failure KW - bronchospasm KW - emergency medical services costs KW - ambulances KW - SARS-CoV-2 KW - coronavirus KW - respiratory KW - pulmonary KW - pandemic KW - economic impact KW - observational KW - Madrid KW - community KW - medical records KW - health records KW - medical advanced life support KW - ALS KW - acute pulmonary edema KW - chronic obstructive pulmonary disease KW - COPD KW - prevalence N2 - Background: Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and acute pulmonary edema (APE) are serious illnesses that often require acute care from prehospital emergency medical services (EMSs). These respiratory diseases that cause acute respiratory failure (ARF) are one of the main reasons for hospitalization and death, generating high health care costs. The prevalence of the main respiratory diseases treated in a prehospital environment in the prepandemic period and during the COVID-19 pandemic in Spain is unknown. The Madrid Community EMS is a public service that serves all types of populations and represents an epidemiological reference for supporting a population of 6.4 million inhabitants. The high volume of patients treated by Madrid?s medical advanced life supports (ALSs) allows us to analyze this little-studied problem. Objectives: Our goal was to lay the groundwork for comprehensive data collection and surveillance of respiratory failure, with an emphasis on the most prevalent diseases that cause it, an aspect that has been largely overlooked in previous initiatives. By achieving these objectives, we hope to inform efforts to address respiratory failure and establish a standardized methodology and framework that can facilitate expansion to a continuous community-wide registry in Madrid, driving advances in emergency care and care practices in these pathologies. The aim of this retrospective observational study was to determine the pathologies that have mainly caused respiratory failure in patients and required medicalized ALS and to evaluate the cost of care for these pathologies collected through this pilot registry. Methods: A multicenter descriptive study was carried out in the Madrid Community EMS. The anonymized medical records of patients treated with medical ALS, who received any of the following medical diagnoses, were extracted: ARF not related to chronic respiratory disease, ARF in chronic respiratory failure, exacerbations of COPD, APE, CHF, and bronchospasm (not from asthma or COPD). The prevalence of each pathology, its evolution from 2014 to 2020, and the economic impact of the Medical ALSs were calculated. Results: The study included 96,221 patients. The most common pathology was exacerbation of COPD, with a prevalence of 0.07% in 2014; it decreased to 0.03% in 2020. CHF followed at 0.06% in 2014 and 0.03% in 2020. APE had a prevalence of 0.01% in 2014, decreasing to 0.005% in 2020 with the pandemic. The greatest economic impact was on exacerbation of COPD in 2015, with an annual cost of ?2,726,893 (which equals to US $2,864,628). Conclusions: COPD exacerbations had the higher prevalence in the Madrid region among the respiratory diseases studied. With the COVID-19 pandemic, the prevalence and costs of almost all these diseases decreased, except for ARF not related to chronic disease. The cost of these pathologies over 5 years was ?58,791,031 (US $61,832,879). UR - https://publichealth.jmir.org/2025/1/e66179 UR - http://dx.doi.org/10.2196/66179 ID - info:doi/10.2196/66179 ER - TY - JOUR AU - You, Yuzi AU - Liang, Wei AU - Zhao, Yajie PY - 2025/1/15 TI - Development and Validation of a Predictive Model Based on Serum Silent Information Regulator 6 Levels in Chinese Older Adult Patients: Cross-Sectional Descriptive Study JO - JMIR Aging SP - e64374 VL - 8 KW - aging KW - coronary artery disease KW - nomogram KW - SIRT6 KW - TyG index KW - silent information regulator 6 KW - triglyceride glucose index N2 - Background: Serum levels of silent information regulator 6 (SIRT6), a key biomarker of aging, were identified as a predictor of coronary artery disease (CAD), but whether SIRT6 can distinguish severity of coronary artery lesions in older adult patients is unknown. Objectives: This study developed a nomogram to demonstrate the functionality of SIRT6 in assessing severity of coronary artery atherosclerosis. Methods: Patients aged 60 years and older with angina pectoris were screened for this single-center clinical study between October 1, 2022, and March 31, 2023. Serum specimens of eligible patients were collected for SIRT6 detection by enzyme-linked immunosorbent assay. Clinical data and putative predictors, including 29 physiological characteristics, biochemical parameters, carotid artery ultrasonographic results, and complete coronary angiography findings, were evaluated, with CAD diagnosis as the primary outcome. The nomogram was derived from the Extreme Gradient Boosting (XGBoost) model, with logistic regression for variable selection. Model performance was assessed by examining discrimination, calibration, and clinical use separately. A 10-fold cross-validation technique was used to compare all models. The models? performance was further evaluated on the internal validation set to ensure that the obtained results were not due to overoptimization. Results: Eligible patients (n=222) were divided into 2 cohorts: the development cohort (n=178) and the validation cohort (n=44). Serum SIRT6 levels were identified as both an independent risk factor and a predictor for CAD in older adults. The area under the receiver operating characteristic curve (AUROC) was 0.725 (95% CI 0.653?0.797). The optimal cutoff value of SIRT6 for predicting CAD was 546.384 pg/mL. Predictors included in this nomogram were serum SIRT6 levels, triglyceride glucose (TyG) index, and apolipoprotein B. The model achieved an AUROC of 0.956 (95% CI 0.928?0.983) in the development cohort. Similarly, in the internal validation cohort, the AUROC was 0.913 (95% CI 0.828?0.999). All models demonstrated satisfactory calibration, with predicted outcomes closely aligning with actual results. Conclusions: SIRT6 shows promise in predicting CAD, with enhanced predictive abilities when combined with the TyG index. In clinical settings, monitoring fluctuations in SIRT6 and TyG may offer valuable insights for early CAD detection. The nomogram for CAD outcome prediction in older adult patients with angina pectoris may aid in clinical trial design and personalized clinical decision-making, particularly in institutions where SIRT6 is being explored as a biomarker for aging or cardiovascular health. UR - https://aging.jmir.org/2025/1/e64374 UR - http://dx.doi.org/10.2196/64374 ID - info:doi/10.2196/64374 ER - TY - JOUR AU - Prakash, Prita Madhu AU - Thiagalingam, Aravinda PY - 2024/12/31 TI - The Role of Clinician-Developed Applications in Promoting Adherence to Evidence-Based Guidelines: Pilot Study JO - JMIR Cardio SP - e55958 VL - 8 KW - computerized clinical decision support systems KW - acute coronary syndrome KW - clinical guidelines KW - chest pain pathway KW - decision support KW - coronary KW - heart KW - cardiac KW - cardiology KW - chest KW - pain KW - web-based KW - app KW - applications KW - computerized KW - guideline KW - emergency KW - usability N2 - Background: Computerized clinical decision support systems (CDSS) are increasingly being used in clinical practice to improve health care delivery. Mobile apps are a type of CDSS that are currently being increasingly used, particularly in lifestyle interventions and disease prevention. However, the use of such apps in acute patient care, diagnosis, and management has not been studied to a great extent. The Pathway for Acute Coronary Syndrome Assessment (PACSA) is a set of guidelines developed to standardize the management of suspected acute coronary syndrome across emergency departments in New South Wales, Australia. These guidelines, which risk stratify patients and provide an appropriate management plan, are currently available as PDF documents or physical paper-based PACSA documents. The routine use of these documents and their acceptability among clinicians is uncertain. Presenting the PACSA guidelines on a mobile app in a sequential format may be a more acceptable alternative to the current paper-based PACSA documents. Objective: This study aimed to assess the utility and acceptability of a clinician-developed app modeling the PACSA guidelines as an alternative to the existing paper-based PACSA documents in assessing chest pain presentations to the emergency department. Methods: An app modeling the PACSA guidelines was created using the Research Electronic Data Capture (REDCap) platform by a cardiologist, with a total development time of <3 hours. The app utilizes a sequential design, requiring participants to input patient data in a step-wise fashion to reach the final patient risk stratification. Emergency department doctors were asked to use the app and apply it to two hypothetical patient scenarios. Participants then completed a survey to assess if the PACSA app offered any advantages over the current paper-based PACSA documents Results: Participants (n=31) ranged from junior doctors to senior physicians. Current clinician adherence to the paper-based PACSA documents was low with 55% (N=17) never using it in their daily practice. Totally, 42% of participants found the PACSA app easier to use compared to the paper-based PACSA documents and 58% reported that the PACSA app was also faster to use. The perceived usefulness of the PACSA app was similar to the perceived usefulness of the paper-based PACSA documents. Conclusions: The PACSA app offers a more efficient and user-friendly alternative to the current paper-based PACSA documents and may promote clinician adherence to evidence-based guidelines. Additional studies with a larger number of participants are required to assess the transferability of the PACSA app to everyday practice. Furthermore, apps are relatively easy to develop using existing online platforms, with the scope for clinicians to develop such apps for other evidence-based guidelines and across different specialties. UR - https://cardio.jmir.org/2024/1/e55958 UR - http://dx.doi.org/10.2196/55958 ID - info:doi/10.2196/55958 ER - TY - JOUR AU - Zhu, Jinpu AU - Yang, Fushuang AU - Wang, Yang AU - Wang, Zhongtian AU - Xiao, Yao AU - Wang, Lie AU - Sun, Liping PY - 2024/11/18 TI - Accuracy of Machine Learning in Discriminating Kawasaki Disease and Other Febrile Illnesses: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e57641 VL - 26 KW - machine learning KW - artificial intelligence KW - Kawasaki disease KW - febrile illness KW - coronary artery lesions KW - systematic review KW - meta-analysis N2 - Background: Kawasaki disease (KD) is an acute pediatric vasculitis that can lead to coronary artery aneurysms and severe cardiovascular complications, often presenting with obvious fever in the early stages. In current clinical practice, distinguishing KD from other febrile illnesses remains a significant challenge. In recent years, some researchers have explored the potential of machine learning (ML) methods for the differential diagnosis of KD versus other febrile illnesses, as well as for predicting coronary artery lesions (CALs) in people with KD. However, there is still a lack of systematic evidence to validate their effectiveness. Therefore, we have conducted the first systematic review and meta-analysis to evaluate the accuracy of ML in differentiating KD from other febrile illnesses and in predicting CALs in people with KD, so as to provide evidence-based support for the application of ML in the diagnosis and treatment of KD. Objective: This study aimed to summarize the accuracy of ML in differentiating KD from other febrile illnesses and predicting CALs in people with KD. Methods: PubMed, Cochrane Library, Embase, and Web of Science were systematically searched until September 26, 2023. The risk of bias in the included original studies was appraised using the Prediction Model Risk of Bias Assessment Tool (PROBAST). Stata (version 15.0; StataCorp) was used for the statistical analysis. Results: A total of 29 studies were incorporated. Of them, 20 used ML to differentiate KD from other febrile illnesses. These studies involved a total of 103,882 participants, including 12,541 people with KD. In the validation set, the pooled concordance index, sensitivity, and specificity were 0.898 (95% CI 0.874-0.922), 0.91 (95% CI 0.83-0.95), and 0.86 (95% CI 0.80-0.90), respectively. Meanwhile, 9 studies used ML for early prediction of the risk of CALs in children with KD. These studies involved a total of 6503 people with KD, of whom 986 had CALs. The pooled concordance index in the validation set was 0.787 (95% CI 0.738-0.835). Conclusions: The diagnostic and predictive factors used in the studies we included were primarily derived from common clinical data. The ML models constructed based on these clinical data demonstrated promising effectiveness in differentiating KD from other febrile illnesses and in predicting coronary artery lesions. Therefore, in future research, we can explore the use of ML methods to identify more efficient predictors and develop tools that can be applied on a broader scale for the differentiation of KD and the prediction of CALs. UR - https://www.jmir.org/2024/1/e57641 UR - http://dx.doi.org/10.2196/57641 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57641 ER - TY - JOUR AU - Duran, T. Andrea AU - Cumella, M. Robin AU - Mendieta, Miguel AU - Keener-Denoia, Adrianna AU - López Veneros, David AU - Farris, G. Samantha AU - Moise, Nathalie AU - Kronish, M. Ian PY - 2024/11/12 TI - Leveraging Implementation Science at the Early-Stage Development of a Novel Telehealth-Delivered Fear of Exercise Program to Understand Intervention Feasibility and Implementation Potential: Feasibility Behavioral Intervention Study JO - JMIR Form Res SP - e55137 VL - 8 KW - behavioral intervention development KW - implementation science KW - acute coronary syndrome KW - exercise sensitivity KW - interoceptive exposure KW - digital health KW - mobile phone N2 - Background: To increase real-world adoption of effective telehealth-delivered behavioral health interventions among midlife and older adults with cardiovascular disease, incorporating implementation science (IS) methods at earlier stages of intervention development may be needed. Objective: This study aims to describe how IS can be incorporated into the design and interpretation of a study assessing the feasibility and implementation potential of a technology-delivered behavioral health intervention. Methods: We assessed the feasibility and implementation potential of a 2-session, remotely delivered, home-based behavioral intervention composed of psychoeducation, interoceptive exposure through low-to-moderate intensity walking, interoceptive counseling, and homework (Reducing Exercise Sensitivity with Exposure Training; RESET) among patients with recent acute coronary syndrome (ACS) and some fear of exercise. To assess intervention feasibility, we measured patient protocol adherence, intervention delivery fidelity, and completion of intervention outcome assessments using direct observations, fidelity checklists, surveys, and device-measured physical activity. To assess implementation potential, we measured implementation outcomes (feasibility, acceptability, and appropriateness) using 4-item measures, each rated from the patient perspective on a 1 to 5 Likert scale (1=completely disagree and 5=completely agree; criteria: ?4=agree or completely agree), and patient-perceived implementation determinants and design feedback using survey and interview data. Interview data underwent thematic analysis to identify implementation determinant themes, which were then categorized into Consolidated Framework for Implementation Research (CFIR) domains and constructs. Results: Of 31 patients approached during recruitment, 3 (10%) were eligible, enrolled, and completed the study (mean age 46.3, SD 14.0 y; 2/3, 67% male; 1/3, 33% Black; and 1/3, 33% Asian). The intervention was delivered with fidelity for all participants, and all participants completed the entire intervention protocol and outcome assessments. On average, participants agreed that the RESET intervention was feasible and acceptable, while appropriateness ratings did not meet implementation criteria (feasibility: mean 4.2, SD 0.4; acceptability: mean 4.3, SD 0.7; and appropriateness: mean 3.7, SD 0.4). Key patient-perceived implementation determinants were related to constructs in the innovation (design, adaptability, and complexity), inner setting (available resources [physical space, funding, materials, and equipment] and access to knowledge and information), and innovation recipient characteristics (motivation, capability, opportunity, and need) domains of the CFIR, with key barriers related to innovation design. Design feedback indicated that the areas requiring the most revisions were the interoceptive exposure design and the virtual delivery modality, and reasons why included low dose and poor usability. Conclusions: The RESET intervention was feasible but not implementable in a small sample of patients with ACS. Our theory-informed, mixed methods approach aided our understanding of what, how, and why RESET was not perceived as implementable; this information will guide intervention refinement. This study demonstrated how integrating IS methods early in intervention development can guide decisions regarding readiness to advance interventions along the translational research pipeline. UR - https://formative.jmir.org/2024/1/e55137 UR - http://dx.doi.org/10.2196/55137 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55137 ER - TY - JOUR AU - Saraya, Norah AU - McBride, Jonathon AU - Singh, Karandeep AU - Sohail, Omar AU - Das, Jeet Porag PY - 2024/11/8 TI - Comparison of Auscultation Quality Using Contemporary Digital Stethoscopes JO - JMIR Cardio SP - e54746 VL - 8 KW - auscultation KW - digital stethoscopes KW - valvular heart disease UR - https://cardio.jmir.org/2024/1/e54746 UR - http://dx.doi.org/10.2196/54746 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54746 ER - TY - JOUR AU - Xu, Dandan AU - Xu, Dongmei AU - Wei, Lan AU - Bao, Zhipeng AU - Liao, Shengen AU - Zhang, Xinyue PY - 2024/11/5 TI - The Effectiveness of Remote Exercise Rehabilitation Based on the ?SCeiP? Model in Homebound Patients With Coronary Heart Disease: Randomized Controlled Trial JO - J Med Internet Res SP - e56552 VL - 26 KW - coronary heart disease KW - exercise rehabilitation KW - promotion strategy KW - home rehabilitation N2 - Background: While exercise rehabilitation is recognized as safe and effective, medium- to long-term compliance among patients with coronary heart disease (CHD) remains low. Therefore, promoting long-term adherence to exercise rehabilitation for these patients warrants significant attention. Objective: This study aims to investigate the impact of remote exercise rehabilitation on time investment and related cognitive levels in homebound patients with CHD. This study utilizes the SCeiP (Self-Evaluation/Condition of Exercise-Effect Perception-Internal Drive-Persistence Behavior) model, alongside WeChat and exercise bracelets. Methods: A total of 147 patients who underwent percutaneous coronary intervention in the cardiovascular department of a grade III hospital in Jiangsu Province from June 2022 to March 2023 were selected as study participants through convenience sampling. The patients were randomly divided into an experimental group and a control group. The experimental group received an exercise rehabilitation promotion strategy based on the ?SCeiP? model through WeChat and exercise bracelets, while the control group followed rehabilitation training according to a standard exercise rehabilitation guide. The days and duration of exercise, levels of cardiac rehabilitation cognition, exercise planning, and exercise input were analyzed before the intervention and at 1 month and 3 months after the intervention. Results: A total of 81 men (55.1%) and 66 women (44.9%) were recruited for the study. The completion rate of exercise days was significantly higher in the experimental group compared with the control group at both 1 month (t145=5.429, P<.001) and 3 months (t145=9.113, P<.001) after the intervention. Similarly, the completion rate of exercise duration was significantly greater in the experimental group (t145=3.471, P=.001) than in the control group (t145=5.574, P<.001). The levels of autonomy, exercise planning, and exercise input in the experimental group were significantly higher than those in the control group at both 1 month and 3 months after the intervention (P<.001). Additionally, the experimental group exhibited a significant reduction in both process anxiety and outcome anxiety scores (P<.001). Repeated measures ANOVA revealed significant differences in the trends of cognitive function related to cardiac rehabilitation between the 2 patient groups over time: autonomy, F1,145(time×group)=9.055 (P<.001); process anxiety, F1,145(time×group)=30.790 (P<.001); and outcome anxiety, F1,145(time×group)=28.186 (P<.001). As expected, the scores for exercise planning (t145=2.490, P=.01 and t145=3.379, P<.001, respectively) and exercise input (t145=2.255, P=.03 and t145=3.817, P<.001, respectively) consistently demonstrated superiority in the experimental group compared with the control group at both 1 and 3 months after the intervention. Interestingly, we observed that the levels of exercise planning and exercise input in both groups initially increased and then slightly decreased over time, although both remained higher than the preintervention levels (P<.001). Conclusions: The remote health intervention based on the ?SCeiP? model effectively enhances exercise compliance, exercise planning, exercise input, and cognitive levels during cardiac rehabilitation in patients with CHD. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300069463; https://www.chictr.org.cn/showproj.html?proj=192461 UR - https://www.jmir.org/2024/1/e56552 UR - http://dx.doi.org/10.2196/56552 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56552 ER - TY - JOUR AU - Waranski, Melina AU - Garbsch, René AU - Kotewitsch, Mona AU - Teschler, Marc AU - Schmitz, Boris AU - Mooren, C. Frank PY - 2024/10/8 TI - A Behavioral Change?Based Mobile Intervention for Promoting Regular Physical Activity in Medical Rehabilitation Maintenance of Patients With Coronary Artery Disease: Controlled Trial JO - J Med Internet Res SP - e56480 VL - 26 KW - rehabilitation KW - eHealth KW - mobile health KW - mHealth KW - telemedicine KW - cardiovascular disease KW - behavioral change KW - mobile phone N2 - Background: Cardiac rehabilitation is known to reduce coronary artery disease (CAD) severity and symptoms, but adoption of a healthy postrehabilitation lifestyle remains challenging. Innovative eHealth solutions could help, but behavioral change?based eHealth maintenance programs for patients with CAD are scarce. RehaPlus+ aims to improve postrehabilitation outcomes with a personalized eHealth intervention built on behavioral change concepts emphasizing healthy lifestyle changes, especially regular physical activity (PA). Objective: This study aims to evaluate the effectiveness of the personalized eHealth program RehaPlus+ for promoting regular PA against usual care. Methods: A total of 169 patients with CAD who had undergone stent implantation or bypass surgery were recruited after completing center-based phase II rehabilitation. They were then divided, without blinding, into 2 groups using a quasi-experimental approach: a case manager?assisted 24-week eHealth program (RehaPlus+; n=84) and a conventional physician-assisted outpatient program (usual care; n=85). The study was designed as a noninferiority trial. RehaPlus+ participants received motivational messages twice weekly for 6 months, and the usual care group engaged in a 6-month outpatient program (twenty-four 90-minute strength and endurance training sessions). The primary outcomes, evaluated using the self-assessed Bewegungs- und Sportaktivität questionnaire, were regular PA (?150 min/wk) and weekly activities of daily living (ADLs) 6 months after rehabilitation. Secondary outcomes involved PA during work and floors climbed weekly (measured by Bewegungs- und Sportaktivität questionnaire), psychological well-being (assessed by the 5-item World Health Organization Well-Being Index), cardiac self-efficacy, health-related quality of life (measured by the 36-Item Short Form Survey), and work ability (using the Work Ability Index). Results: Data of 105 patients (RehaPlus+: n=44, 41.9%; usual care: n=61, 58.1%; male patients: n=80, 76.2%; female patients: n=25, 23.8%; mean age 56.0, SD 7.3 years) were available at the 6-month follow-up. At 6 months after discharge from phase II cardiac rehabilitation, the RehaPlus+ group exhibited 182 (SD 208) minutes per week of PA and the usual care group exhibited 119 (SD 175) minutes per week of PA (P=.15), with no interaction effect (P=.12). The RehaPlus+ group showed an ADL level of 443 (SD 538) minutes per week compared to the usual care group with 308 (SD 412) minutes per week at the 6-month follow-up, with no interaction effect (P=.84). The differences observed in PA and ADL levels between the RehaPlus+ and usual care groups were within the predefined 1-sided noninferiority margin, indicating that the RehaPlus+ intervention is not inferior to usual care based on these outcomes. There were no differences between the groups for all secondary outcomes (P>.05). Conclusions: RehaPlus+ is not inferior to the usual care program, as both groups improved PA and ADLs to a similar extent. These findings emphasize the potential of eHealth interventions to assist in maintaining healthy lifestyles after rehabilitation. Trial Registration: ClinicalTrials.gov NCT06162793; https://clinicaltrials.gov/study/NCT06162793 UR - https://www.jmir.org/2024/1/e56480 UR - http://dx.doi.org/10.2196/56480 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56480 ER - TY - JOUR AU - Hertz, T. Julian AU - Sakita, M. Francis AU - Rahim, O. Faraan AU - Mmbaga, T. Blandina AU - Shayo, Frida AU - Kaboigora, Vivian AU - Mtui, Julius AU - Bloomfield, S. Gerald AU - Bosworth, B. Hayden AU - Bettger, P. Janet AU - Thielman, M. Nathan PY - 2024/9/24 TI - Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial JO - JMIR Res Protoc SP - e59917 VL - 13 KW - myocardial infarction KW - Tanzania KW - sub-Saharan Africa KW - implementation science KW - quality improvement N2 - Background: Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI. Objective: This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania. Methods: This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment. Results: Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024. Conclusions: This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability. Trial Registration: ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546 International Registered Report Identifier (IRRID): DERR1-10.2196/59917 UR - https://www.researchprotocols.org/2024/1/e59917 UR - http://dx.doi.org/10.2196/59917 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59917 ER - TY - JOUR AU - Gong, Xun AU - Chen, Meijuan AU - Ning, Lihong AU - Zeng, Lingzhong AU - Dong, Bo PY - 2024/9/3 TI - The Quality of Short Videos as a Source of Coronary Heart Disease Information on TikTok: Cross-Sectional Study JO - JMIR Form Res SP - e51513 VL - 8 KW - coronary heart disease KW - content quality KW - social media KW - short-video platform KW - TikTok N2 - Background: Coronary heart disease (CHD) is a leading cause of death worldwide and imposes a significant economic burden. TikTok has risen as a favored platform within the social media sphere for disseminating CHD-related information and stands as a pivotal resource for patients seeking knowledge about CHD. However, the quality of such content on TikTok remains largely unexplored. Objective: This study aims to assess the quality of information conveyed in TikTok CHD-related videos. Methods: A comprehensive cross-sectional study was undertaken on TikTok videos related to CHD. The sources of the videos were identified and analyzed. The comprehensiveness of content was assessed through 6 questions addressing the definition, signs and symptoms, risk factors, evaluation, management, and outcomes. The quality of the videos was assessed using 3 standardized evaluative instruments: DISCERN, the Journal of the American Medical Association (JAMA) benchmarks, and the Global Quality Scale (GQS). Furthermore, correlative analyses between video quality and characteristics of the uploaders and the videos themselves were conducted. Results: The search yielded 145 CHD-related videos from TikTok, predominantly uploaded by health professionals (n=128, 88.3%), followed by news agencies (n=6, 4.1%), nonprofit organizations (n=10, 6.9%), and for-profit organizations (n=1, 0.7%). Content comprehensiveness achieved a median score of 3 (IQR 2-4). Median values for the DISCERN, JAMA, and GQS evaluations across all videos stood at 27 (IQR 24-32), 2 (IQR 2-2), and 2 (IQR 2-3), respectively. Videos from health professionals and nonprofit organizations attained significantly superior JAMA scores in comparison to those of news agencies (P<.001 and P=.02, respectively), whereas GQS scores for videos from health professionals were also notably higher than those from news agencies (P=.048). Within health professionals, cardiologists demonstrated discernibly enhanced performance over noncardiologists in both DISCERN and GQS assessments (P=.02). Correlative analyses unveiled positive correlations between video quality and uploader metrics, encompassing the positive correlations between the number of followers; total likes; average likes per video; and established quality indices such as DISCERN, JAMA, or GQS scores. Similar investigations relating to video attributes showed correlations between user engagement factors?likes, comments, collections, shares?and the aforementioned quality indicators. In contrast, a negative correlation emerged between the number of days since upload and quality indices, while a longer video duration corresponded positively with higher DISCERN and GQS scores. Conclusions: The quality of the videos was generally poor, with significant disparities based on source category. The content comprehensiveness coverage proved insufficient, casting doubts on the reliability and quality of the information relayed through these videos. Among health professionals, video contributions from cardiologists exhibited superior quality compared to noncardiologists. As TikTok?s role in health information dissemination expands, ensuring accurate and reliable content is crucial to better meet patients? needs for CHD information that conventional health education fails to fulfill. UR - https://formative.jmir.org/2024/1/e51513 UR - http://dx.doi.org/10.2196/51513 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/51513 ER - TY - JOUR AU - Ghasemi, Peyman AU - Lee, Joon PY - 2024/7/26 TI - Unsupervised Feature Selection to Identify Important ICD-10 and ATC Codes for Machine Learning on a Cohort of Patients With Coronary Heart Disease: Retrospective Study JO - JMIR Med Inform SP - e52896 VL - 12 KW - unsupervised feature selection KW - ICD-10 KW - International Classification of Diseases KW - ATC KW - Anatomical Therapeutic Chemical KW - concrete autoencoder KW - Laplacian score KW - unsupervised feature selection for multicluster data KW - autoencoder-inspired unsupervised feature selection KW - principal feature analysis KW - machine learning KW - artificial intelligence KW - case study KW - coronary artery disease KW - artery disease KW - patient cohort KW - artery KW - mortality prediction KW - mortality KW - data set KW - interpretability KW - International Classification of Diseases, Tenth Revision N2 - Background: The application of machine learning in health care often necessitates the use of hierarchical codes such as the International Classification of Diseases (ICD) and Anatomical Therapeutic Chemical (ATC) systems. These codes classify diseases and medications, respectively, thereby forming extensive data dimensions. Unsupervised feature selection tackles the ?curse of dimensionality? and helps to improve the accuracy and performance of supervised learning models by reducing the number of irrelevant or redundant features and avoiding overfitting. Techniques for unsupervised feature selection, such as filter, wrapper, and embedded methods, are implemented to select the most important features with the most intrinsic information. However, they face challenges due to the sheer volume of ICD and ATC codes and the hierarchical structures of these systems. Objective: The objective of this study was to compare several unsupervised feature selection methods for ICD and ATC code databases of patients with coronary artery disease in different aspects of performance and complexity and select the best set of features representing these patients. Methods: We compared several unsupervised feature selection methods for 2 ICD and 1 ATC code databases of 51,506 patients with coronary artery disease in Alberta, Canada. Specifically, we used the Laplacian score, unsupervised feature selection for multicluster data, autoencoder-inspired unsupervised feature selection, principal feature analysis, and concrete autoencoders with and without ICD or ATC tree weight adjustment to select the 100 best features from over 9000 ICD and 2000 ATC codes. We assessed the selected features based on their ability to reconstruct the initial feature space and predict 90-day mortality following discharge. We also compared the complexity of the selected features by mean code level in the ICD or ATC tree and the interpretability of the features in the mortality prediction task using Shapley analysis. Results: In feature space reconstruction and mortality prediction, the concrete autoencoder?based methods outperformed other techniques. Particularly, a weight-adjusted concrete autoencoder variant demonstrated improved reconstruction accuracy and significant predictive performance enhancement, confirmed by DeLong and McNemar tests (P<.05). Concrete autoencoders preferred more general codes, and they consistently reconstructed all features accurately. Additionally, features selected by weight-adjusted concrete autoencoders yielded higher Shapley values in mortality prediction than most alternatives. Conclusions: This study scrutinized 5 feature selection methods in ICD and ATC code data sets in an unsupervised context. Our findings underscore the superiority of the concrete autoencoder method in selecting salient features that represent the entire data set, offering a potential asset for subsequent machine learning research. We also present a novel weight adjustment approach for the concrete autoencoders specifically tailored for ICD and ATC code data sets to enhance the generalizability and interpretability of the selected features. UR - https://medinform.jmir.org/2024/1/e52896 UR - http://dx.doi.org/10.2196/52896 ID - info:doi/10.2196/52896 ER - TY - JOUR AU - Cruz-Cobo, Celia AU - Bernal-Jiménez, Ángeles María AU - Calle, Germán AU - Gheorghe, Luciana Livia AU - Gutiérrez-Barrios, Alejandro AU - Cañadas, Dolores AU - Tur, A. Josep AU - Vázquez-García, Rafael AU - Santi-Cano, José María PY - 2024/7/25 TI - Efficacy of a Mobile Health App (eMOTIVA) Regarding Compliance With Cardiac Rehabilitation Guidelines in Patients With Coronary Artery Disease: Randomized Controlled Clinical Trial JO - JMIR Mhealth Uhealth SP - e55421 VL - 12 KW - coronary event KW - coronary heart disease KW - eHealth KW - lifestyle KW - mHealth KW - mobile health N2 - Background: Cardiac rehabilitation is fundamental among patients recovering from a coronary event, and mHealth technology may constitute a useful tool that provides guidelines based on scientific evidence in an entertaining, attractive, and user-friendly format. Objective: This study aimed to compare the efficacy of an mHealth intervention involving the eMOTIVA app and that of usual care regarding compliance with cardiac rehabilitation guidelines in terms of lifestyle, cardiovascular risk factors, and satisfaction among patients with acute coronary syndrome. Methods: A randomized controlled clinical trial with a parallel group design was conducted. It included 300 patients (mHealth group, 150; control group, 150) who underwent percutaneous coronary intervention for acute coronary syndrome. Both groups underwent evaluations initially (during hospitalization) and after 3 and 6 months (face-to-face consultations). The eMOTIVA app incorporates a virtual classroom providing audio and video information about a healthy lifestyle, a section for self-recording cardiovascular risk factors, and a section for feedback messages and gamification. The primary outcome variables were (1) adherence to the Mediterranean diet and the frequency of consumption of food; (2) physical activity level, sedentary time, and exercise capacity; (3) smoking cessation and nicotine dependence; (4) level of knowledge about cardiovascular risk factors; and (5) app satisfaction and usability. Results: The study analyzed 287 patients (mHealth group, 145; control group, 142). Most participants were male (207/300, 69.0%), and the mean age was 62.53 (SD 8.65) years. Significant improvements were observed in the mHealth group compared with the control group at 6 months in terms of (1) adherence to the Mediterranean diet (mean 11.92, SD 1.70 vs 8.92, SD 2.66 points; P<.001) and frequency of eating foods (red meat [?1/week]: 141/143, 97.9% vs 96/141, 68.1%; industrial pastries [<2/week]: 129/143, 89.6% vs 80/141, 56.8%; oily fish [?2/week]: 124/143, 86.1% vs 64/141, 41.4%; vegetables [?2/day]: 130/143, 90.3% vs 78/141, 55.3%; fruit [?2/day]: 128/143, 88.9% vs 85/141, 60.2%; all P<.001); (2) physical activity (mean 2112.66, SD 1196.67 vs 1372.60, SD 944.62 metabolic equivalents/week; P<.001) and sedentary time (mean 8.38, SD 1.88 vs 9.59, SD 2.09 hours; P<.001); (3) exercise capacity (distance: mean 473.49, SD 102.28 vs 447.25, SD 93.68 meters; P=.04); and (4) level of knowledge (mean 117.85, SD 3.83 vs 111.00, SD 7.11 points; P<.001). App satisfaction was high (mean 42.53, SD 6.38 points), and its usability was excellent (mean 95.60, SD 4.03 points). Conclusions: With the eMOTIVA app, favorable results were obtained in the intervention group in terms of adherence to the Mediterranean diet, frequency of eating certain foods, physical activity, sedentary time, exercise capacity, knowledge level, systolic blood pressure, heart rate, and blood sugar level. Furthermore, participants reported high app satisfaction and rated its usability as excellent. Thus, this innovative tool is very promising. Trial Registration: ClinicalTrials.gov NCT05247606; https://clinicaltrials.gov/study/NCT05247606 UR - https://mhealth.jmir.org/2024/1/e55421 UR - http://dx.doi.org/10.2196/55421 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55421 ER - TY - JOUR AU - Agyei, Frimponmaa Eunice Eno Yaa AU - Ekpezu, Akon AU - Oinas-Kukkonen, Harri PY - 2024/6/19 TI - Persuasive Systems Design Trends in Coronary Heart Disease Management: Scoping Review of Randomized Controlled Trials JO - JMIR Cardio SP - e49515 VL - 8 KW - coronary heart disease KW - persuasive systems design KW - behavior change KW - randomized controlled trial KW - RCT KW - controlled trials KW - heart KW - CHD KW - cardiovascular N2 - Background: Behavior change support systems (BCSSs) have the potential to help people maintain healthy lifestyles and aid in the self-management of coronary heart disease (CHD). The Persuasive Systems Design (PSD) model is a framework for designing and evaluating systems designed to support lifestyle modifications and health behavior change using information and communication technology. However, evidence for the underlying design principles behind BCSSs for CHD has not been extensively reported in the literature. Objective: This scoping review aims to identify existing health BCSSs for CHD, report the characteristics of these systems, and describe the persuasion context and persuasive design principles of these systems based on the PSD framework. Methods: Using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, 3 digital databases (Scopus, Web of Science, and MEDLINE) were searched between 2010 to 2022. The major inclusion criteria for studies were in accordance with the PICO (Population, Intervention, Comparison, and Outcome) approach. Results: Searches conducted in the databases identified 1195 papers, among which 30 were identified as eligible for the review. The most interesting characteristics of the BCSSs were the predominant use of primary task support principles, followed by dialogue support and credibility support and the sparing use of social support principles. Theories of behavior change such as the Social Cognitive Theory and Self-Efficacy Theory were used often to underpin these systems. However, significant trends in the use of persuasive system features on par with behavior change theories could not be established from the reviewed studies. This points to the fact that there is still no theoretical consensus on how best to design interventions to promote behavior change in patients with CHD. Conclusions: Our results highlight key software features for designing BCSSs for the prevention and management of CHD. We encourage designers of behavior change interventions to evaluate the techniques that contributed to the success of the intervention. Future research should focus on evaluating the effectiveness of the interventions, persuasive design principles, and behavior change theories using research methodologies such as meta-analysis. UR - https://cardio.jmir.org/2024/1/e49515 UR - http://dx.doi.org/10.2196/49515 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/49515 ER - TY - JOUR AU - Hou, Ling Qiao AU - Liu, Yang Le AU - Wu, Ying PY - 2024/6/11 TI - The Effects of mHealth Interventions on Quality of Life, Anxiety, and Depression in Patients With Coronary Heart Disease: Meta-Analysis of Randomized Controlled Trials JO - J Med Internet Res SP - e52341 VL - 26 KW - mobile health KW - coronary heart disease KW - quality of life KW - anxiety KW - depression KW - meta-analysis KW - mobile phone N2 - Background: Coronary heart disease (CHD) is the leading cause of death globally. In addition, 20% to 40% of the patients with CHD have comorbid mental health issues such as anxiety or depression, affecting the prognosis and quality of life (QoL). Mobile health (mHealth) interventions have been developed and are widely used; however, the evidence for the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD is currently ambiguous. Objective: In this study, we aimed to assess the effects of mHealth interventions on QoL, anxiety, and depression in patients with CHD. Methods: We searched the Cochrane Library, PubMed, Embase, CINAHL, Web of Science, China National Knowledge Infrastructure, and Wanfang databases from inception to August 12, 2023. Eligible studies were randomized controlled trials that involved patients with CHD who received mHealth interventions and that reported on QoL, anxiety, or depression outcomes. We used the Cochrane risk-of-bias tool for randomized trials to evaluate the risk of bias in the studies, ensuring a rigorous and methodologically sound analysis. Review Manager (desktop version 5.4; The Cochrane Collaboration) and Stata MP (version 17.0; StataCorp LLC) were used to conduct the meta-analysis. The effect size was calculated using the standardized mean difference (SMD) and its 95% CI. Results: The meta-analysis included 23 studies (5406 participants in total) and showed that mHealth interventions significantly improved QoL in patients with CHD (SMD 0.49, 95% CI 0.25-0.72; Z=4.07; P<.001) as well as relieved their anxiety (SMD ?0.46, 95% CI ?0.83 to ?0.08; Z=2.38; P=.02) and depression (SMD ?0.34, 95% CI ?0.56 to ?0.12; Z=3.00; P=.003) compared to usual care. The subgroup analyses indicated a significant effect favoring the mHealth intervention on reducing anxiety and depressive symptoms compared to usual care, especially when (1) the intervention duration was ?6 months (P=.04 and P=.001), (2) the mHealth intervention was a simple one (only 1 mHealth intervention was used) (P=.01 and P<.001), (3) it was implemented during the COVID-19 pandemic (P=.04 and P=.01), (4) it was implemented in low- or middle-income countries (P=.01 and P=.02), (5) the intervention focused on mental health (P=.01 and P=.007), and (6) adherence rates were high (?90%; P=.03 and P=.002). In addition, comparing mHealth interventions to usual care, there was an improvement in QoL when (1) the mHealth intervention was a simple one (P<.001), (2) it was implemented in low- or middle-income countries (P<.001), and (3) the intervention focused on mental health (P<.001). Conclusions: On the basis of the existing evidence, mHealth interventions might be effective in improving QoL and reducing anxiety and depression in patients with CHD. However, large sample, high-quality, and rigorously designed randomized controlled trials are needed to provide further evidence. Trial Registration: PROSPERO CRD42022383858; https://tinyurl.com/3ea2npxf UR - https://www.jmir.org/2024/1/e52341 UR - http://dx.doi.org/10.2196/52341 UR - http://www.ncbi.nlm.nih.gov/pubmed/38861710 ID - info:doi/10.2196/52341 ER - TY - JOUR AU - Li, ming Yi AU - Jia, Yuheng AU - Bai, Lin AU - Yang, Bosen AU - Chen, Mao AU - Peng, Yong PY - 2024/6/7 TI - U-Shaped Relationship Between Fibrinogen Level and 10-year Mortality in Patients With Acute Coronary Syndrome: Prospective Cohort Study JO - JMIR Public Health Surveill SP - e54485 VL - 10 KW - fibrinogen KW - acute coronary syndrome KW - 10-year mortality KW - risk factor KW - coronary artery disease KW - myocardial KW - heart disease KW - inflammatory factor KW - retrospective study KW - Kaplan-Meier analysis KW - mortality KW - all-cause mortality KW - cubic-spline curve KW - regression model UR - https://publichealth.jmir.org/2024/1/e54485 UR - http://dx.doi.org/10.2196/54485 UR - http://www.ncbi.nlm.nih.gov/pubmed/38848124 ID - info:doi/10.2196/54485 ER - TY - JOUR AU - Bernal-Jiménez, Ángeles María AU - Calle, German AU - Gutiérrez Barrios, Alejandro AU - Gheorghe, Luciana Livia AU - Cruz-Cobo, Celia AU - Trujillo-Garrido, Nuria AU - Rodríguez-Martín, Amelia AU - Tur, A. Josep AU - Vázquez-García, Rafael AU - Santi-Cano, José María PY - 2024/4/22 TI - Effectiveness of an Interactive mHealth App (EVITE) in Improving Lifestyle After a Coronary Event: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e48756 VL - 12 KW - coronary artery disease KW - healthy lifestyle KW - mHealth KW - mobile health KW - percutaneous coronary intervention KW - randomized controlled trial KW - secondary prevention KW - therapeutic adherence N2 - Background: Coronary heart disease is one of the leading causes of mortality worldwide. Secondary prevention is essential, as it reduces the risk of further coronary events. Mobile health (mHealth) technology could become a useful tool to improve lifestyles. Objective: This study aimed to evaluate the effect of an mHealth intervention on people with coronary heart disease who received percutaneous coronary intervention. Improvements in lifestyle regarding diet, physical activity, and smoking; level of knowledge of a healthy lifestyle and the control of cardiovascular risk factors (CVRFs); and therapeutic adherence and quality of life were analyzed. Methods: This was a randomized controlled trial with a parallel group design assigned 1:1 to either an intervention involving a smartphone app (mHealth group) or to standard health care (control group). The app was used for setting aims, the self-monitoring of lifestyle and CVRFs using measurements and records, educating people with access to information on their screens about healthy lifestyles and adhering to treatment, and giving motivation through feedback about achievements and aspects to improve. Both groups were assessed after 9 months. The primary outcome variables were adherence to the Mediterranean diet, frequency of food consumed, patient-reported physical activity, smoking, knowledge of healthy lifestyles and the control of CVRFs, adherence to treatment, quality of life, well-being, and satisfaction. Results: The study analyzed 128 patients, 67 in the mHealth group and 61 in the control group; most were male (92/128, 71.9%), with a mean age of 59.49 (SD 8.97) years. Significant improvements were observed in the mHealth group compared with the control group regarding adherence to the Mediterranean diet (mean 11.83, SD 1.74 points vs mean 10.14, SD 2.02 points; P<.001), frequency of food consumption, patient-reported physical activity (mean 619.14, SD 318.21 min/week vs mean 471.70, SD 261.43 min/week; P=.007), giving up smoking (25/67, 75% vs 11/61, 42%; P=.01), level of knowledge of healthy lifestyles and the control of CVRFs (mean 118.70, SD 2.65 points vs mean 111.25, SD 9.05 points; P<.001), and the physical component of the quality of life 12-item Short Form survey (SF-12; mean 45.80, SD 10.79 points vs mean 41.40, SD 10.78 points; P=.02). Overall satisfaction was higher in the mHealth group (mean 48.22, SD 3.89 vs mean 46.00, SD 4.82 points; P=.002) and app satisfaction and usability were high (mean 44.38, SD 6.18 out of 50 points and mean 95.22, SD 7.37 out of 100). Conclusions: The EVITE app was effective in improving the lifestyle of patients in terms of adherence to the Mediterranean diet, frequency of healthy food consumption, physical activity, giving up smoking, knowledge of healthy lifestyles and controlling CVRFs, quality of life, and overall satisfaction. The app satisfaction and usability were excellent. Trial Registration: Clinicaltrials.gov NCT04118504; https://clinicaltrials.gov/study/NCT04118504 UR - https://mhealth.jmir.org/2024/1/e48756 UR - http://dx.doi.org/10.2196/48756 UR - http://www.ncbi.nlm.nih.gov/pubmed/38648103 ID - info:doi/10.2196/48756 ER - TY - JOUR AU - Hu, Zhao AU - Wang, Min AU - Zheng, Si AU - Xu, Xiaowei AU - Zhang, Zhuxin AU - Ge, Qiaoyue AU - Li, Jiao AU - Yao, Yan PY - 2024/3/26 TI - Clinical Decision Support Requirements for Ventricular Tachycardia Diagnosis Within the Frameworks of Knowledge and Practice: Survey Study JO - JMIR Hum Factors SP - e55802 VL - 11 KW - clinical decision support system KW - requirements analysis KW - ventricular tachycardia KW - knowledge KW - clinical practice KW - questionnaires N2 - Background: Ventricular tachycardia (VT) diagnosis is challenging due to the similarity between VT and some forms of supraventricular tachycardia, complexity of clinical manifestations, heterogeneity of underlying diseases, and potential for life-threatening hemodynamic instability. Clinical decision support systems (CDSSs) have emerged as promising tools to augment the diagnostic capabilities of cardiologists. However, a requirements analysis is acknowledged to be vital for the success of a CDSS, especially for complex clinical tasks such as VT diagnosis. Objective: The aims of this study were to analyze the requirements for a VT diagnosis CDSS within the frameworks of knowledge and practice and to determine the clinical decision support (CDS) needs. Methods: Our multidisciplinary team first conducted semistructured interviews with seven cardiologists related to the clinical challenges of VT and expected decision support. A questionnaire was designed by the multidisciplinary team based on the results of interviews. The questionnaire was divided into four sections: demographic information, knowledge assessment, practice assessment, and CDS needs. The practice section consisted of two simulated cases for a total score of 10 marks. Online questionnaires were disseminated to registered cardiologists across China from December 2022 to February 2023. The scores for the practice section were summarized as continuous variables, using the mean, median, and range. The knowledge and CDS needs sections were assessed using a 4-point Likert scale without a neutral option. Kruskal-Wallis tests were performed to investigate the relationship between scores and practice years or specialty. Results: Of the 687 cardiologists who completed the questionnaire, 567 responses were eligible for further analysis. The results of the knowledge assessment showed that 383 cardiologists (68%) lacked knowledge in diagnostic evaluation. The overall average score of the practice assessment was 6.11 (SD 0.55); the etiological diagnosis section had the highest overall scores (mean 6.74, SD 1.75), whereas the diagnostic evaluation section had the lowest scores (mean 5.78, SD 1.19). A majority of cardiologists (344/567, 60.7%) reported the need for a CDSS. There was a significant difference in practice competency scores between general cardiologists and arrhythmia specialists (P=.02). Conclusions: There was a notable deficiency in the knowledge and practice of VT among Chinese cardiologists. Specific knowledge and practice support requirements were identified, which provide a foundation for further development and optimization of a CDSS. Moreover, it is important to consider clinicians? specialization levels and years of practice for effective and personalized support. UR - https://humanfactors.jmir.org/2024/1/e55802 UR - http://dx.doi.org/10.2196/55802 UR - http://www.ncbi.nlm.nih.gov/pubmed/38530337 ID - info:doi/10.2196/55802 ER - TY - JOUR AU - Zou, Huijing AU - Chair, Ying Sek AU - Feng, Bilong AU - Liu, Qian AU - Liu, Jia Yu AU - Cheng, Xin Yu AU - Luo, Dan AU - Wang, Qin Xiao AU - Chen, Wei AU - Huang, Leiqing AU - Xianyu, Yunyan AU - Yang, Xiang Bing PY - 2024/2/20 TI - A Social Media?Based Mindfulness Psycho-Behavioral Intervention (MCARE) for Patients With Acute Coronary Syndrome: Randomized Controlled Trial JO - J Med Internet Res SP - e48557 VL - 26 KW - acute coronary syndrome KW - psychological distress KW - depression KW - anxiety KW - mindfulness KW - mindfulness-based intervention KW - quality of life KW - risk factors KW - cardiac rehabilitation KW - social media N2 - Background: Psychological distress is common among patients with acute coronary syndrome (ACS) and has considerable adverse impacts on disease progression and health outcomes. Mindfulness-based intervention is a promising complementary approach to address patients? psychological needs and promote holistic well-being. Objective: This study aims to examine the effects of a social media?based mindfulness psycho-behavioral intervention (MCARE) on psychological distress, psychological stress, health-related quality of life (HRQoL), and cardiovascular risk factors among patients with ACS. Methods: This study was a 2-arm, parallel-group randomized controlled trial. We recruited 178 patients (mean age 58.7, SD 8.9 years; 122/178, 68.5% male) with ACS at 2 tertiary hospitals in Jinan, China. Participants were randomly assigned to the MCARE group (n=89) or control group (n=89). The 6-week intervention consisted of 1 face-to-face session (phase I) and 5 weekly WeChat (Tencent Holdings Ltd)?delivered sessions (phase II) on mindfulness training and health education and lifestyle modification. The primary outcomes were depression and anxiety. Secondary outcomes included psychological stress, HRQoL, and cardiovascular risk factors (ie, smoking status, physical activity, dietary behavior, BMI, blood pressure, blood lipids, and blood glucose). Outcomes were measured at baseline (T0), immediately after the intervention (T1), and 12 weeks after the commencement of the intervention (T2). Results: The MCARE group showed significantly greater reductions in depression (T1: ?=?2.016, 95% CI ?2.584 to ?1.449, Cohen d=?1.28, P<.001; T2: ?=?2.089, 95% CI ?2.777 to ?1.402, Cohen d=?1.12, P<.001) and anxiety (T1: ?=?1.024, 95% CI ?1.551 to ?0.497, Cohen d=?0.83, P<.001; T2: ?=?0.932, 95% CI ?1.519 to ?0.346, Cohen d=?0.70, P=.002). Significantly greater improvements were also observed in psychological stress (?=?1.186, 95% CI ?1.678 to ?0.694, Cohen d=?1.41, P<.001), physical HRQoL (?=0.088, 95% CI 0.008-0.167, Cohen d=0.72, P=.03), emotional HRQoL (?=0.294, 95% CI 0.169-0.419, Cohen d=0.81, P<.001), and general HRQoL (?=0.147, 95% CI 0.070-0.224, Cohen d=1.07) at T1, as well as dietary behavior (?=0.069, 95% CI 0.003-0.136, Cohen d=0.75, P=.04), physical activity level (?=177.542, 95% CI ?39.073 to 316.011, Cohen d=0.51, P=.01), and systolic blood pressure (?=?3.326, 95% CI ?5.928 to ?0.725, Cohen d=?1.32, P=.01) at T2. The overall completion rate of the intervention (completing ?5 sessions) was 76% (68/89). Positive responses to the questions of the acceptability questionnaire ranged from 93% (76/82) to 100% (82/82). Conclusions: The MCARE program generated favorable effects on psychological distress, psychological stress, HRQoL, and several aspects of cardiovascular risk factors in patients with ACS. This study provides clues for guiding clinical practice in the recognition and management of psychological distress and integrating the intervention into routine rehabilitation practice. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000033526; https://www.chictr.org.cn/showprojEN.html?proj=54693 UR - https://www.jmir.org/2024/1/e48557 UR - http://dx.doi.org/10.2196/48557 UR - http://www.ncbi.nlm.nih.gov/pubmed/38376899 ID - info:doi/10.2196/48557 ER - TY - JOUR AU - Zhang, Pin AU - Wu, Lei AU - Zou, Ting-Ting AU - Zou, ZiXuan AU - Tu, JiaXin AU - Gong, Ren AU - Kuang, Jie PY - 2024/1/3 TI - Machine Learning for Early Prediction of Major Adverse Cardiovascular Events After First Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction: Retrospective Cohort Study JO - JMIR Form Res SP - e48487 VL - 8 KW - acute myocardial infarction KW - percutaneous coronary intervention KW - machine learning KW - early prediction KW - cardiovascular event N2 - Background: The incidence of major adverse cardiovascular events (MACEs) remains high in patients with acute myocardial infarction (AMI) who undergo percutaneous coronary intervention (PCI), and early prediction models to guide their clinical management are lacking. Objective: This study aimed to develop machine learning?based early prediction models for MACEs in patients with newly diagnosed AMI who underwent PCI. Methods: A total of 1531 patients with AMI who underwent PCI from January 2018 to December 2019 were enrolled in this consecutive cohort. The data comprised demographic characteristics, clinical investigations, laboratory tests, and disease-related events. Four machine learning models?artificial neural network (ANN), k-nearest neighbors, support vector machine, and random forest?were developed and compared with the logistic regression model. Our primary outcome was the model performance that predicted the MACEs, which was determined by accuracy, area under the receiver operating characteristic curve, and F1-score. Results: In total, 1362 patients were successfully followed up. With a median follow-up of 25.9 months, the incidence of MACEs was 18.5% (252/1362). The area under the receiver operating characteristic curve of the ANN, random forest, k-nearest neighbors, support vector machine, and logistic regression models were 80.49%, 72.67%, 79.80%, 77.20%, and 71.77%, respectively. The top 5 predictors in the ANN model were left ventricular ejection fraction, the number of implanted stents, age, diabetes, and the number of vessels with coronary artery disease. Conclusions: The ANN model showed good MACE prediction after PCI for patients with AMI. The use of machine learning?based prediction models may improve patient management and outcomes in clinical practice. UR - https://formative.jmir.org/2024/1/e48487 UR - http://dx.doi.org/10.2196/48487 UR - http://www.ncbi.nlm.nih.gov/pubmed/38170581 ID - info:doi/10.2196/48487 ER - TY - JOUR AU - Bhagavathula, Srikanth Akshaya AU - Aldhaleei, Ali Wafa AU - Atey, Mehari Tesfay AU - Assefa, Solomon AU - Tesfaye, Wubshet PY - 2023/12/19 TI - Efficacy of eHealth Technologies on Medication Adherence in Patients With Acute Coronary Syndrome: Systematic Review and Meta-Analysis JO - JMIR Cardio SP - e52697 VL - 7 KW - medication adherence KW - eHealth KW - secondary prevention KW - acute coronary syndrome KW - heart disease KW - text messaging KW - mobile app KW - cardiology KW - cardioprotective KW - prevention KW - efficacy KW - statins N2 - Background: Suboptimal adherence to cardiac pharmacotherapy, recommended by the guidelines after acute coronary syndrome (ACS) has been recognized and is associated with adverse outcomes. Several randomized controlled trials (RCTs) have shown that eHealth technologies are useful in reducing cardiovascular risk factors. However, little is known about the effect of eHealth interventions on medication adherence in patients following ACS. Objective: The aim of this study is to examine the efficacy of the eHealth interventions on medication adherence to selected 5 cardioprotective medication classes in patients with ACS. Methods: A systematic literature search of PubMed, Embase, Scopus, and Web of Science was conducted between May and October 2022, with an update in October 2023 to identify RCTs that evaluated the effectiveness of eHealth technologies, including texting, smartphone apps, or web-based apps, to improve medication adherence in patients after ACS. The risk of bias was evaluated using the modified Cochrane risk-of-bias tool for RCTs. A pooled meta-analysis was performed using a fixed-effect Mantel-Haenszel model and assessed the medication adherence to the medications of statins, aspirin, P2Y12 inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and ?-blockers. Results: We identified 5 RCTs, applicable to 4100 participants (2093 intervention vs 2007 control), for inclusion in the meta-analysis. In patients who recently had an ACS, compared to the control group, the use of eHealth intervention was not associated with improved adherence to statins at different time points (risk difference [RD] ?0.01, 95% CI ?0.03 to 0.03 at 6 months and RD ?0.02, 95% CI ?0.05 to 0.02 at 12 months), P2Y12 inhibitors (RD ?0.01, 95% CI ?0.04 to 0.02 and RD ?0.01, 95% CI ?0.03 to 0.02), aspirin (RD 0.00, 95% CI ?0.06 to 0.07 and RD ?0.00, 95% CI ?0.07 to 0.06), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (RD ?0.01, 95% CI ?0.04 to 0.02 and RD 0.01, 95% CI ?0.04 to 0.05), and ?-blockers (RD 0.00, 95% CI ?0.03 to 0.03 and RD ?0.01, 95% CI ?0.05 to 0.03). The intervention was also not associated with improved adherence irrespective of the adherence assessment method used (self-report or objective). Conclusions: This review identified limited evidence on the effectiveness of eHealth interventions on adherence to guideline-recommended medications after ACS. While the pooled analyses suggested a lack of effectiveness of such interventions on adherence improvement, further studies are warranted to better understand the role of different eHealth approaches in the post-ACS context. UR - https://cardio.jmir.org/2023/1/e52697 UR - http://dx.doi.org/10.2196/52697 UR - http://www.ncbi.nlm.nih.gov/pubmed/38113072 ID - info:doi/10.2196/52697 ER - TY - JOUR AU - Gajate, Luis AU - de la Hoz, Inés AU - Espiño, Mercedes AU - Martin Gonzalez, Carmen Maria del AU - Fernandez Martin, Cristina AU - Martín-Grande, Ascensión AU - Parise Roux, Diego AU - Pastor, Oscar AU - Villahoz, Judith AU - Rodriguez-Gandía, Ángel Miguel AU - Nuño Vazquez, Javier PY - 2023/12/15 TI - Intravenous Ascorbic Acid for the Prevention of Postreperfusion Syndrome in Orthotopic Liver Transplantation: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e50091 VL - 12 KW - antioxidant therapy KW - antioxidant KW - ascorbic acid KW - blood KW - controlled trials KW - hepatic KW - ischemia KW - ischemic KW - liver transplantation KW - liver KW - postreperfusion syndrome KW - randomization KW - randomized controlled trial KW - RCT KW - reperfusion injury KW - reperfusion KW - surgery KW - surgical KW - transplant KW - transplantation KW - vascular KW - vitamin C KW - vitamin KW - vitamins N2 - Background: Liver transplantation is the last therapeutic option for patients with end-stage liver disease. Postreperfusion syndrome (PRS), defined as a fall in mean arterial pressure of more than 30% within the first 5 minutes after reperfusion of at least 1 minute, can occur in liver transplantation as a deep hemodynamic instability with associated hyperfibrinolysis immediately after reperfusion of the new graft. Its incidence has remained unchanged since it was first described in 1987. PRS is related to ischemia-reperfusion (I/R) injury, whose pathophysiology involves the release of several mediators from both the donor and the recipient. The antioxidant effect of ascorbic acid has been studied in resuscitating patients with septic shock and burns. Even today, there are publications with conflicting results, and there is a need for further studies to confirm or rule out the usefulness of this drug in this group of patients. The addition of ascorbic acid to preservation solutions used in solid organ transplantation is under investigation to harness its antioxidant effect and mitigate I/R injury. Since PRS could be considered a manifestation of I/R injury, we believe that the possible beneficial effect of ascorbic acid on the occurrence of PRS should be investigated. Objective: The aim of this randomized controlled trial is to assess the benefits of ascorbic acid over saline in the development of PRS in adult liver transplantation. Methods: We plan to conduct a single-center randomized controlled trial at the Hospital Universitario Ramo?n y Cajal in Spain. A total of 70 participants aged 18 years or older undergoing liver transplantation will be randomized to receive either ascorbic acid or saline. The primary outcome will be the difference between groups in the incidence of PRS. The randomized controlled trial will be conducted under conditions of respect for fundamental human rights and ethical principles governing biomedical research involving human participants and in accordance with the international recommendations contained in the Declaration of Helsinki and its subsequent revisions. Results: The enrollment process began in 2020. A total of 35 patients have been recruited so far. Data cleaning and analysis are expected to occur in the first months of 2024. Results are expected around the middle of 2024. Conclusions: We believe that this study could be particularly relevant because it will be the first to analyze the clinical effect of ascorbic acid in liver transplantation. Moreover, we believe that this study fills an important gap in the knowledge of the potential benefits of ascorbic acid in the field of liver transplantation, particularly in relation to PRS. Trial Registration: European Union Drug Regulating Authorities Clinical Trials Database 2020-000123-39; https://tinyurl.com/2cfzddw8; ClinicalTrials.gov NCT05754242; https://tinyurl.com/346vw7sm International Registered Report Identifier (IRRID): DERR1-10.2196/50091 UR - https://www.researchprotocols.org/2023/1/e50091 UR - http://dx.doi.org/10.2196/50091 UR - http://www.ncbi.nlm.nih.gov/pubmed/38100226 ID - info:doi/10.2196/50091 ER - TY - JOUR AU - de Koning, Enrico AU - van der Haas, Yvette AU - Saguna, Saguna AU - Stoop, Esmee AU - Bosch, Jan AU - Beeres, Saskia AU - Schalij, Martin AU - Boogers, Mark PY - 2023/10/31 TI - AI Algorithm to Predict Acute Coronary Syndrome in Prehospital Cardiac Care: Retrospective Cohort Study JO - JMIR Cardio SP - e51375 VL - 7 KW - cardiology KW - acute coronary syndrome KW - Hollands Midden Acute Regional Triage?cardiology KW - prehospital KW - triage KW - artificial intelligence KW - natural language processing KW - angina KW - algorithm KW - overcrowding KW - emergency department KW - clinical decision-making KW - emergency medical service KW - paramedics N2 - Background: Overcrowding of hospitals and emergency departments (EDs) is a growing problem. However, not all ED consultations are necessary. For example, 80% of patients in the ED with chest pain do not have an acute coronary syndrome (ACS). Artificial intelligence (AI) is useful in analyzing (medical) data, and might aid health care workers in prehospital clinical decision-making before patients are presented to the hospital. Objective: The aim of this study was to develop an AI model which would be able to predict ACS before patients visit the ED. The model retrospectively analyzed prehospital data acquired by emergency medical services' nurse paramedics. Methods: Patients presenting to the emergency medical services with symptoms suggestive of ACS between September 2018 and September 2020 were included. An AI model using a supervised text classification algorithm was developed to analyze data. Data were analyzed for all 7458 patients (mean 68, SD 15 years, 54% men). Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for control and intervention groups. At first, a machine learning (ML) algorithm (or model) was chosen; afterward, the features needed were selected and then the model was tested and improved using iterative evaluation and in a further step through hyperparameter tuning. Finally, a method was selected to explain the final AI model. Results: The AI model had a specificity of 11% and a sensitivity of 99.5% whereas usual care had a specificity of 1% and a sensitivity of 99.5%. The PPV of the AI model was 15% and the NPV was 99%. The PPV of usual care was 13% and the NPV was 94%. Conclusions: The AI model was able to predict ACS based on retrospective data from the prehospital setting. It led to an increase in specificity (from 1% to 11%) and NPV (from 94% to 99%) when compared to usual care, with a similar sensitivity. Due to the retrospective nature of this study and the singular focus on ACS it should be seen as a proof-of-concept. Other (possibly life-threatening) diagnoses were not analyzed. Future prospective validation is necessary before implementation. UR - https://cardio.jmir.org/2023/1/e51375 UR - http://dx.doi.org/10.2196/51375 UR - http://www.ncbi.nlm.nih.gov/pubmed/37906226 ID - info:doi/10.2196/51375 ER - TY - JOUR AU - Bani Hani, Salam AU - Ahmad, Muayyad PY - 2023/7/20 TI - Effective Prediction of Mortality by Heart Disease Among Women in Jordan Using the Chi-Squared Automatic Interaction Detection Model: Retrospective Validation Study JO - JMIR Cardio SP - e48795 VL - 7 KW - coronary heart disease KW - mortality KW - artificial intelligence KW - machine learning KW - algorithms KW - algorithm KW - women KW - death KW - predict KW - prediction KW - predictive KW - heart KW - cardiology KW - coronary KW - CHD KW - cardiovascular disease KW - CVD KW - cardiovascular N2 - Background: Many current studies have claimed that the actual risk of heart disease among women is equal to that in men. Using a large machine learning algorithm (MLA) data set to predict mortality in women, data mining techniques have been used to identify significant aspects of variables that help in identifying the primary causes of mortality within this target category of the population. Objective: This study aims to predict mortality caused by heart disease among women, using an artificial intelligence technique?based MLA. Methods: A retrospective design was used to retrieve big data from the electronic health records of 2028 women with heart disease. Data were collected for Jordanian women who were admitted to public health hospitals from 2015 to the end of 2021. We checked the extracted data for noise, consistency issues, and missing values. After categorizing, organizing, and cleaning the extracted data, the redundant data were eliminated. Results: Out of 9 artificial intelligence models, the Chi-squared Automatic Interaction Detection model had the highest accuracy (93.25%) and area under the curve (0.825) among the build models. The participants were 62.6 (SD 15.4) years old on average. Angina pectoris was the most frequent diagnosis in the women's extracted files (n=1,264,000, 62.3%), followed by congestive heart failure (n=764,000, 37.7%). Age, systolic blood pressure readings with a cutoff value of >187 mm Hg, medical diagnosis (women diagnosed with congestive heart failure were at a higher risk of death [n=31, 16.58%]), pulse pressure with a cutoff value of 98 mm Hg, and oxygen saturation (measured using pulse oximetry) with a cutoff value of 93% were the main predictors for death among women. Conclusions: To predict the outcomes in this study, we used big data that were extracted from the clinical variables from the electronic health records. The Chi-squared Automatic Interaction Detection model?an MLA?confirmed the precise identification of the key predictors of cardiovascular mortality among women and can be used as a practical tool for clinical prediction. UR - https://cardio.jmir.org/2023/1/e48795 UR - http://dx.doi.org/10.2196/48795 UR - http://www.ncbi.nlm.nih.gov/pubmed/37471126 ID - info:doi/10.2196/48795 ER - TY - JOUR AU - Park, Jiesuck AU - Yoon, Yeonyee AU - Cho, Youngjin AU - Kim, Joonghee PY - 2023/5/2 TI - Feasibility of Artificial Intelligence?Based Electrocardiography Analysis for the Prediction of Obstructive Coronary Artery Disease in Patients With Stable Angina: Validation Study JO - JMIR Cardio SP - e44791 VL - 7 KW - artificial intelligence KW - AI KW - coronary artery disease KW - coronary stenosis KW - electrocardiography KW - stable angina N2 - Background: Despite accumulating research on artificial intelligence?based electrocardiography (ECG) algorithms for predicting acute coronary syndrome (ACS), their application in stable angina is not well evaluated. Objective: We evaluated the utility of an existing artificial intelligence?based quantitative electrocardiography (QCG) analyzer in stable angina and developed a new ECG biomarker more suitable for stable angina. Methods: This single-center study comprised consecutive patients with stable angina. The independent and incremental value of QCG scores for coronary artery disease (CAD)?related conditions (ACS, myocardial injury, critical status, ST-elevation myocardial infarction, and left ventricular dysfunction) for predicting obstructive CAD confirmed by invasive angiography was examined. Additionally, ECG signals extracted by the QCG analyzer were used as input to develop a new QCG score. Results: Among 723 patients with stable angina (median age 68 years; male: 470/723, 65%), 497 (69%) had obstructive CAD. QCG scores for ACS and myocardial injury were independently associated with obstructive CAD (odds ratio [OR] 1.09, 95% CI 1.03-1.17 and OR 1.08, 95% CI 1.02-1.16 per 10-point increase, respectively) but did not significantly improve prediction performance compared to clinical features. However, our new QCG score demonstrated better prediction performance for obstructive CAD (area under the receiver operating characteristic curve 0.802) than the original QCG scores, with incremental predictive value in combination with clinical features (area under the receiver operating characteristic curve 0.827 vs 0.730; P<.001). Conclusions: QCG scores developed for acute conditions show limited performance in identifying obstructive CAD in stable angina. However, improvement in the QCG analyzer, through training on comprehensive ECG signals in patients with stable angina, is feasible. UR - https://cardio.jmir.org/2023/1/e44791 UR - http://dx.doi.org/10.2196/44791 UR - http://www.ncbi.nlm.nih.gov/pubmed/37129937 ID - info:doi/10.2196/44791 ER - TY - JOUR AU - Moon, Tae In AU - Kim, Sun-Hwa AU - Chin, Yeon Jung AU - Park, Hun Sung AU - Yoon, Chang-Hwan AU - Youn, Tae-Jin AU - Chae, In-Ho AU - Kang, Si-Hyuck PY - 2023/4/26 TI - Accuracy of Artificial Intelligence?Based Automated Quantitative Coronary Angiography Compared to Intravascular Ultrasound: Retrospective Cohort Study JO - JMIR Cardio SP - e45299 VL - 7 KW - artificial intelligence KW - AI KW - coronary angiography KW - coronary stenosis KW - interventional ultrasonography KW - coronary KW - machine learning KW - angiography KW - stenosis KW - automated analysis KW - computer vision N2 - Background: An accurate quantitative analysis of coronary artery stenotic lesions is essential to make optimal clinical decisions. Recent advances in computer vision and machine learning technology have enabled the automated analysis of coronary angiography. Objective: The aim of this paper is to validate the performance of artificial intelligence?based quantitative coronary angiography (AI-QCA) in comparison with that of intravascular ultrasound (IVUS). Methods: This retrospective study included patients who underwent IVUS-guided coronary intervention at a single tertiary center in Korea. Proximal and distal reference areas, minimal luminal area, percent plaque burden, and lesion length were measured by AI-QCA and human experts using IVUS. First, fully automated QCA analysis was compared with IVUS analysis. Next, we adjusted the proximal and distal margins of AI-QCA to avoid geographic mismatch. Scatter plots, Pearson correlation coefficients, and Bland-Altman were used to analyze the data. Results: A total of 54 significant lesions were analyzed in 47 patients. The proximal and distal reference areas, as well as the minimal luminal area, showed moderate to strong correlation between the 2 modalities (correlation coefficients of 0.57, 0.80, and 0.52, respectively; P<.001). The correlation was weaker for percent area stenosis and lesion length, although statistically significant (correlation coefficients of 0.29 and 0.33, respectively). AI-QCA tended to measure reference vessel areas smaller and lesion lengths shorter than IVUS did. Systemic proportional bias was not observed in Bland-Altman plots. The biggest cause of bias originated from the geographic mismatch of AI-QCA with IVUS. Discrepancies in the proximal or distal lesion margins were observed between the 2 modalities, which were more frequent at the distal margins. After the adjustment of proximal or distal margins, there was a stronger correlation of proximal and distal reference areas between AI-QCA and IVUS (correlation coefficients of 0.70 and 0.83, respectively). Conclusions: AI-QCA showed a moderate to strong correlation compared with IVUS in analyzing coronary lesions with significant stenosis. The main discrepancy was in the perception of the distal margins by AI-QCA, and the correction of margins improved the correlation coefficients. We believe that this novel tool could provide confidence to treating physicians and help in making optimal clinical decisions. UR - https://cardio.jmir.org/2023/1/e45299 UR - http://dx.doi.org/10.2196/45299 UR - http://www.ncbi.nlm.nih.gov/pubmed/37099368 ID - info:doi/10.2196/45299 ER - TY - JOUR AU - Giggins, M. Oonagh AU - Doyle, Julie AU - Smith, Suzanne AU - Vavasour, Grainne AU - Moran, Orla AU - Gavin, Shane AU - Sojan, Nisanth AU - Boyle, Gordon PY - 2023/2/10 TI - Remotely Delivered Cardiac Rehabilitation Exercise for Coronary Heart Disease: Nonrandomized Feasibility Study JO - JMIR Cardio SP - e40283 VL - 7 KW - cardiac rehabilitation KW - exercise KW - coronary heart disease KW - CHD KW - coronary KW - cardiovascular KW - virtual rehabilitation KW - remote rehabilitation KW - digital health KW - heart KW - rehabilitation KW - cardiac KW - digital platform KW - digital KW - intervention KW - program KW - physical activity KW - fitness N2 - Background: Exercise-based cardiac rehabilitation (CR) is recommended for coronary heart disease (CHD). However, poor uptake of and poor adherence to CR exercise programs have been reported globally. Delivering CR exercise classes remotely may remove some of the barriers associated with traditional hospital- or center-based CR. Objective: We have developed a bespoke platform, Eastern Corridor Medical Engineering Centre?Cardiac Rehabilitation (ECME-CR), to support remotely delivered CR exercise. This pilot trial sought to test the ECME-CR platform and examine the efficacy and feasibility of a remote CR exercise program compared to a traditional center-based program. Methods: In all, 21 participants with CHD were recruited and assigned to either the intervention or control group. Both groups performed the same 8-week exercise program. Participants in the intervention group took part in web-based exercise classes and used the ECME-CR platform during the intervention period, whereas participants in the control group attended in-person classes. Outcomes were assessed at baseline and following the 8-week intervention period. The primary outcome measure was exercise capacity, assessed using a 6-minute walk test (6MWT). Secondary outcomes included measurement of grip strength, self-reported quality of life, heart rate, blood pressure, and body composition. A series of mixed between-within subjects ANOVA were conducted to examine the mean differences in study outcomes between and within groups. Participant adherence to the exercise program was also analyzed. Results: In all, 8 participants (male: n=5; age: mean 69.7, SD 7.2 years; height: mean 163.9, SD 5.4 cm; weight: mean 81.6, SD 14.1 kg) in the intervention group and 9 participants (male: n=9; age: mean 69.8, SD 8.2 years; height: mean 173.8, SD 5.2 cm; weight: mean 94.4, SD 18.0 kg) in the control group completed the exercise program. Although improvements in 6MWT distance were observed from baseline to follow-up in both the intervention (mean 490.1, SD 80.2 m to mean 504.5, SD 93.7 m) and control (mean 510.2, SD 48.3 m to mean 520.6, SD 49.4 m) group, no significant interaction effect (F1,14=.026; P=.87) nor effect for time (F1,14=2.51; P=.14) were observed. No significant effects emerged for any of the other secondary end points (all P>.0275). Adherence to the exercise program was high in both the intervention (14.25/16, 89.1%) and control (14.33/16, 89.6%) group. No adverse events or safety issues were reported in either group during the study. Conclusions: This pilot trial did not show evidence of significant positive effect for either the remotely delivered or center-based program. The 6MWT may not have been sufficiently sensitive to identify a change in this cohort of participants with stable CHD. This trial does provide evidence that remote CR exercise, supported with digital self-monitoring, is feasible and may be considered for individuals less likely to participate in traditional center-based programs. International Registered Report Identifier (IRRID): RR2-10.2196/31855 UR - https://cardio.jmir.org/2023/1/e40283 UR - http://dx.doi.org/10.2196/40283 UR - http://www.ncbi.nlm.nih.gov/pubmed/36763453 ID - info:doi/10.2196/40283 ER - TY - JOUR AU - Cruz-Cobo, Celia AU - Bernal-Jiménez, Ángeles María AU - Vázquez-García, Rafael AU - Santi-Cano, José María PY - 2022/12/2 TI - Effectiveness of mHealth Interventions in the Control of Lifestyle and Cardiovascular Risk Factors in Patients After a Coronary Event: Systematic Review and Meta-analysis JO - JMIR Mhealth Uhealth SP - e39593 VL - 10 IS - 12 KW - coronary disease KW - acute coronary syndrome KW - mobile health KW - smartphone KW - mobile apps KW - mobile phone N2 - Background: Coronary artery disease is the main cause of death and loss of disability-adjusted life years worldwide. Information and communication technology has become an important part of health care systems, including the innovative cardiac rehabilitation services through mobile phone and mobile health (mHealth) interventions. Objective: In this study, we aimed to determine the effectiveness of different kinds of mHealth programs in changing lifestyle behavior, promoting adherence to treatment, and controlling modifiable cardiovascular risk factors and psychosocial outcomes in patients who have experienced a coronary event. Methods: A systematic review of the literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A thorough search of the following biomedical databases was conducted: PubMed, Embase, Web of Science, SciELO, CINAHL, Scopus, The Clinical Trial, and Cochrane. Articles that were randomized clinical trials that involved an intervention consisting of an mHealth program using a mobile app in patients after a coronary event were included. The articles analyzed some of the following variables as outcome variables: changes in lifestyle behavior, cardiovascular risk factors, and anthropometric and psychosocial variables. A meta-analysis of the variables studied was performed with the Cochrane tool. The risk of bias was assessed using the Cochrane Collaboration tool; the quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation tool; and heterogeneity was measured using the I2 test. Results: A total of 23 articles were included in the review, and 20 (87%) were included in the meta-analysis, with a total sample size of 4535 patients. Exercise capacity measured using the 6-minute walk test (mean difference=21.64, 95% CI 12.72-30.55; P<.001), physical activity (standardized mean difference [SMD]=0.42, 95% CI 0.04-0.81; P=.03), and adherence to treatment (risk difference=0.19, 95% CI 0.11-0.28; P<.001) were significantly superior in the mHealth group. Furthermore, both the physical and mental dimensions of quality of life were better in the mHealth group (SMD=0.26, 95% CI 0.09-0.44; P=.004 and SMD=0.27, 95% CI 0.06-0.47; P=.01, respectively). In addition, hospital readmissions for all causes and cardiovascular causes were statistically higher in the control group than in the mHealth group (SMD=?0.03, 95% CI ?0.05 to ?0.00; P=.04 vs SMD=?0.04, 95% CI ?0.07 to ?0.00; P=.05). Conclusions: mHealth technology has a positive effect on patients who have experienced a coronary event in terms of their exercise capacity, physical activity, adherence to medication, and physical and mental quality of life, as well as readmissions for all causes and cardiovascular causes. Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42022299931; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299931 UR - https://mhealth.jmir.org/2022/12/e39593 UR - http://dx.doi.org/10.2196/39593 UR - http://www.ncbi.nlm.nih.gov/pubmed/36459396 ID - info:doi/10.2196/39593 ER - TY - JOUR AU - Simon, Steven AU - Mandair, Divneet AU - Albakri, Abdel AU - Fohner, Alison AU - Simon, Noah AU - Lange, Leslie AU - Biggs, Mary AU - Mukamal, Kenneth AU - Psaty, Bruce AU - Rosenberg, Michael PY - 2022/11/2 TI - The Impact of Time Horizon on Classification Accuracy: Application of Machine Learning to Prediction of Incident Coronary Heart Disease JO - JMIR Cardio SP - e38040 VL - 6 IS - 2 KW - coronary heart disease KW - risk prediction KW - machine learning KW - heart KW - heart disease KW - clinical KW - risk KW - myocardial KW - gender N2 - Background: Many machine learning approaches are limited to classification of outcomes rather than longitudinal prediction. One strategy to use machine learning in clinical risk prediction is to classify outcomes over a given time horizon. However, it is not well-known how to identify the optimal time horizon for risk prediction. Objective: In this study, we aim to identify an optimal time horizon for classification of incident myocardial infarction (MI) using machine learning approaches looped over outcomes with increasing time horizons. Additionally, we sought to compare the performance of these models with the traditional Framingham Heart Study (FHS) coronary heart disease gender-specific Cox proportional hazards regression model. Methods: We analyzed data from a single clinic visit of 5201 participants of a cardiovascular health study. We examined 61 variables collected from this baseline exam, including demographic and biologic data, medical history, medications, serum biomarkers, electrocardiographic, and echocardiographic data. We compared several machine learning methods (eg, random forest, L1 regression, gradient boosted decision tree, support vector machine, and k-nearest neighbor) trained to predict incident MI that occurred within time horizons ranging from 500-10,000 days of follow-up. Models were compared on a 20% held-out testing set using area under the receiver operating characteristic curve (AUROC). Variable importance was performed for random forest and L1 regression models across time points. We compared results with the FHS coronary heart disease gender-specific Cox proportional hazards regression functions. Results: There were 4190 participants included in the analysis, with 2522 (60.2%) female participants and an average age of 72.6 years. Over 10,000 days of follow-up, there were 813 incident MI events. The machine learning models were most predictive over moderate follow-up time horizons (ie, 1500-2500 days). Overall, the L1 (Lasso) logistic regression demonstrated the strongest classification accuracy across all time horizons. This model was most predictive at 1500 days follow-up, with an AUROC of 0.71. The most influential variables differed by follow-up time and model, with gender being the most important feature for the L1 regression and weight for the random forest model across all time frames. Compared with the Framingham Cox function, the L1 and random forest models performed better across all time frames beyond 1500 days. Conclusions: In a population free of coronary heart disease, machine learning techniques can be used to predict incident MI at varying time horizons with reasonable accuracy, with the strongest prediction accuracy in moderate follow-up periods. Validation across additional populations is needed to confirm the validity of this approach in risk prediction. UR - https://cardio.jmir.org/2022/2/e38040 UR - http://dx.doi.org/10.2196/38040 UR - http://www.ncbi.nlm.nih.gov/pubmed/36322114 ID - info:doi/10.2196/38040 ER - TY - JOUR AU - van Steenbergen, Gijs AU - van Veghel, Dennis AU - van Lieshout, Dideke AU - Sperwer, Merel AU - ter Woorst, Joost AU - Dekker, Lukas PY - 2022/8/26 TI - Effects of Video-Based Patient Education and Consultation on Unplanned Health Care Utilization and Early Recovery After Coronary Artery Bypass Surgery (IMPROV-ED): Randomized Controlled Trial JO - J Med Internet Res SP - e37728 VL - 24 IS - 8 KW - e-Health KW - eHealth KW - digital health KW - patient education KW - coronary artery bypass surgery KW - cardiac surgery KW - health care utilization KW - costs KW - cost KW - economic KW - coronary KW - cardiology KW - heart KW - surgery KW - bypass KW - RCT KW - randomized controlled trial KW - video consultation KW - telehealth KW - telemedicine KW - patient-reported KW - recovery KW - expense N2 - Background: Health care utilization after coronary artery bypass graft (CABG) surgery is high and is partly of an unplanned nature. eHealth applications have been proposed to reduce care consumption, which involve and assist patients in their recovery. In this way, health care expenses could be reduced and quality of care could be improved. Objective: The aim of this study was to evaluate if an eHealth program can reduce unplanned health care utilization and improve mental and physical health in the first 6 weeks after CABG surgery. Methods: A single-blind randomized controlled trial was performed, in which patients scheduled for nonacute CABG surgery were included from a single center in the Netherlands between February 2020 and October 2021. Participants in the intervention group had, alongside standard care, access to an eHealth program consisting of online education videos and video consultations developed in conjunction with the Dutch Heart Foundation. The control group received standard care. The primary outcome was the volume and costs of a composite of unplanned health care utilization, including emergency department visits, outpatient clinic visits, rehospitalization, patient-initiated telephone consultations, and visits to a general practitioner, measured using the Medical Technology Assessment Medical Consumption Questionnaire. Patient-reported anxiety and recovery were also assessed. Intention-to-treat and ?users-only? analyses were used. Results: During the study period, 280 patients were enrolled and randomly allocated at a 1:1 ratio to the intervention or control group. The intention-to-treat analysis consisted of 136 and 135 patients in the intervention and control group, respectively. At 6 weeks, the primary endpoint had occurred in 43 of 136 (31.6%) patients in the intervention group and in 61 of 135 (45.2%) patients in the control group (hazard ratio 0.56, 95% CI 0.34-0.92). Recovery was faster in the intervention group, whereas anxiety was similar between study groups. ?Users-only? analysis yielded similar results. Conclusions: An eHealth strategy comprising educational videos and video consultations can reduce unplanned health care utilization and can aid in faster patient-reported recovery in patients following CABG surgery. Trial Registration: Netherlands Trial Registry NL8510; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8510 International Registered Report Identifier (IRRID): RR2-10.1007/s12471-020-01508-9 UR - https://www.jmir.org/2022/8/e37728 UR - http://dx.doi.org/10.2196/37728 UR - http://www.ncbi.nlm.nih.gov/pubmed/36018625 ID - info:doi/10.2196/37728 ER - TY - JOUR AU - Hammami, Rania AU - Boudiche, Selim AU - Rami, Tlili AU - Ben Halima, Nejeh AU - Jamel, Ahmed AU - Rekik, Bassem AU - Gribaa, Rym AU - Imtinene, Mrad Ben AU - Charfeddine, Salma AU - Ellouze, Tarek AU - Bahloul, Amine AU - Hédi, Slima Ben AU - Langar, Jamel AU - Ben Ahmed, Habib AU - Ibn Elhadj, Zied AU - Hmam, Mohamed AU - Ben Abdessalem, Aymen Mohamed AU - Maaoui, Sabri AU - Fennira, Sana AU - Lobna, Laroussi AU - Hassine, Majed AU - Ouanes, Sami AU - Mohamed Faouzi, Drissi AU - Mallek, Souad AU - Mahdhaoui, Abdallah AU - Meriem, Dghim AU - Jomaa, Walid AU - Zayed, Sofien AU - Kateb, Tawfik AU - Bouchahda, Nidhal AU - Azaiez, Fares AU - Ben Salem, Helmi AU - Marouen, Morched AU - Noamen, Aymen AU - Abdesselem, Salem AU - Hichem, Denguir AU - Ibn Hadj Amor, Hassen AU - Abdeljelil, Farhati AU - Amara, Amine AU - Bejar, Karim AU - Khaldoun, Hamda Ben AU - Hamza, Chiheb AU - Ben Jamaa, Mohsen AU - Fourati, Sami AU - Elleuch, Faycal AU - Grati, Zeineb AU - Chtourou, Slim AU - Marouene, Sami AU - Sahnoun, Mohamed AU - Hadrich, Morched AU - Mohamed Abdelkader, Maalej AU - Bouraoui, Hatem AU - Kamoun, Kamel AU - Hadrich, Moufid AU - Ben Chedli, Tarek AU - Drissa, Akrem Mohamed AU - Charfeddine, Hanene AU - Saadaoui, Nizar AU - Achraf, Gargouri AU - Ahmed, Siala AU - Ayari, Mokdad AU - Nabil, Marsit AU - Mnif, Sabeur AU - Sahnoun, Maher AU - Kammoun, Helmi AU - Ben Jemaa, Khaled AU - Mostari, Gharbi AU - Hamrouni, Nebil AU - Yamen, Maazoun AU - Ellouz, Yassine AU - Smiri, Zahreddine AU - Hdiji, Amine AU - Bassem, Jerbi AU - Ayadi, Wacef AU - Zouari, Amir AU - Abbassi, Chedly AU - Fatma, Masmoudi Boujelben AU - Battikh, Kais AU - Kharrat, Elyes AU - Gtif, Imen AU - Sami, Milouchi AU - Bezdah, Leila AU - Kachboura, Salem AU - Maatouk, Faouzi Mohamed AU - Kraiem, Sondes AU - Jeridi, Gouider AU - Neffati, Elyes AU - Kammoun, Samir AU - Ben Ameur, Youssef AU - Fehri, Wafa AU - Gamra, Habib AU - Zakhama, Lilia AU - Addad, Faouzi AU - Mohamed Sami, Mourali AU - Abid, Leila PY - 2022/8/5 TI - Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study JO - JMIR Res Protoc SP - e24595 VL - 11 IS - 8 KW - percutaneous coronary intervention KW - 1-year outcome KW - Tunisia KW - national KW - multicentric KW - registry KW - percutaneous KW - coronary KW - artery disease N2 - Background: Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries. Objective: The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia. Methods: We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis. Results: In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022. Conclusions: This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region. Trial Registration: Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761 International Registered Report Identifier (IRRID): RR1-10.2196/24595 UR - https://www.researchprotocols.org/2022/8/e24595 UR - http://dx.doi.org/10.2196/24595 UR - http://www.ncbi.nlm.nih.gov/pubmed/35930353 ID - info:doi/10.2196/24595 ER - TY - JOUR AU - Huang, Yanqun AU - Zheng, Zhimin AU - Ma, Moxuan AU - Xin, Xin AU - Liu, Honglei AU - Fei, Xiaolu AU - Wei, Lan AU - Chen, Hui PY - 2022/8/3 TI - Improving the Performance of Outcome Prediction for Inpatients With Acute Myocardial Infarction Based on Embedding Representation Learned From Electronic Medical Records: Development and Validation Study JO - J Med Internet Res SP - e37486 VL - 24 IS - 8 KW - representation learning KW - skip-gram KW - feature association strengths KW - feature importance KW - mortality risk prediction KW - acute myocardial infarction N2 - Background: The widespread secondary use of electronic medical records (EMRs) promotes health care quality improvement. Representation learning that can automatically extract hidden information from EMR data has gained increasing attention. Objective: We aimed to propose a patient representation with more feature associations and task-specific feature importance to improve the outcome prediction performance for inpatients with acute myocardial infarction (AMI). Methods: Medical concepts, including patients? age, gender, disease diagnoses, laboratory tests, structured radiological features, procedures, and medications, were first embedded into real-value vectors using the improved skip-gram algorithm, where concepts in the context windows were selected by feature association strengths measured by association rule confidence. Then, each patient was represented as the sum of the feature embeddings weighted by the task-specific feature importance, which was applied to facilitate predictive model prediction from global and local perspectives. We finally applied the proposed patient representation into mortality risk prediction for 3010 and 1671 AMI inpatients from a public data set and a private data set, respectively, and compared it with several reference representation methods in terms of the area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), and F1-score. Results: Compared with the reference methods, the proposed embedding-based representation showed consistently superior predictive performance on the 2 data sets, achieving mean AUROCs of 0.878 and 0.973, AUPRCs of 0.220 and 0.505, and F1-scores of 0.376 and 0.674 for the public and private data sets, respectively, while the greatest AUROCs, AUPRCs, and F1-scores among the reference methods were 0.847 and 0.939, 0.196 and 0.283, and 0.344 and 0.361 for the public and private data sets, respectively. Feature importance integrated in patient representation reflected features that were also critical in prediction tasks and clinical practice. Conclusions: The introduction of feature associations and feature importance facilitated an effective patient representation and contributed to prediction performance improvement and model interpretation. UR - https://www.jmir.org/2022/8/e37486 UR - http://dx.doi.org/10.2196/37486 UR - http://www.ncbi.nlm.nih.gov/pubmed/35921141 ID - info:doi/10.2196/37486 ER - TY - JOUR AU - Keessen, Paul AU - van Duijvenbode, CD Ingrid AU - Latour, HM Corine AU - Kraaijenhagen, A. Roderik AU - Janssen, R. Veronica AU - Jørstad, T. Harald AU - Scholte op Reimer, JM Wilma AU - Visser, Bart PY - 2022/5/25 TI - Design of a Remote Coaching Program to Bridge the Gap From Hospital Discharge to Cardiac Rehabilitation: Intervention Mapping Study JO - JMIR Cardio SP - e34974 VL - 6 IS - 1 KW - coronary artery disease KW - intervention mapping approach KW - information needs KW - support needs KW - eHealth KW - cardiac rehabilitation KW - remote coaching KW - e-coaching N2 - Background: Remote coaching might be suited for providing information and support to patients with coronary artery disease (CAD) in the vulnerable phase between hospital discharge and the start of cardiac rehabilitation (CR). Objective: The goal of the research was to explore and summarize information and support needs of patients with CAD and develop an early remote coaching program providing tailored information and support. Methods: We used the intervention mapping approach to develop a remote coaching program. Three steps were completed in this study: (1) identification of information and support needs in patients with CAD, using an exploratory literature study and semistructured interviews, (2) definition of program objectives, and (3) selection of theory-based methods and practical intervention strategies. Results: Our exploratory literature study (n=38) and semistructured interviews (n=17) identified that after hospital discharge, patients with CAD report a need for tailored information and support about CAD itself and the specific treatment procedures, medication and side effects, physical activity, and psychological distress. Based on the preceding steps, we defined the following program objectives: (1) patients gain knowledge on how CAD and revascularization affect their bodies and health, (2) patients gain knowledge about medication and side effects and adhere to their treatment plan, (3) patients know which daily physical activities they can and can?t do safely after hospital discharge and are physically active, and (4) patients know the psychosocial consequences of CAD and know how to discriminate between harmful and harmless body signals. Based on the preceding steps, a remote coaching program was developed with the theory of health behavior change as a theoretical framework with behavioral counseling and video modeling as practical strategies for the program. Conclusions: This study shows that after (acute) cardiac hospitalization, patients are in need of information and support about CAD and revascularization, medication and side effects, physical activity, and psychological distress. In this study, we present the design of an early remote coaching program based on the needs of patients with CAD. The development of this program constitutes a step in the process of bridging the gap from hospital discharge to start of CR. UR - https://cardio.jmir.org/2022/1/e34974 UR - http://dx.doi.org/10.2196/34974 UR - http://www.ncbi.nlm.nih.gov/pubmed/35612879 ID - info:doi/10.2196/34974 ER - TY - JOUR AU - Treskes, Willem Roderick AU - van den Akker-van Marle, Elske M. AU - van Winden, Louise AU - van Keulen, Nicole AU - van der Velde, Tjeerd Enno AU - Beeres, Saskia AU - Atsma, Douwe AU - Schalij, Jan Martin PY - 2022/4/25 TI - The Box?eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis JO - J Med Internet Res SP - e30236 VL - 24 IS - 4 KW - smart technology KW - myocardial infarction KW - cost-utility KW - outpatients KW - cost-effectiveness KW - eHealth KW - remote monitoring KW - cost of care KW - quality of life N2 - Background: Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care. Objective: The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI). Methods: In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated. Results: Mean costs per patient were ?2417±2043 (US $2657±2246) for the intervention and ?2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of ?471 (US $518) per patient. This difference was not statistically significant (95% CI ??275 to ?1217; P=.22, US $?302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference ?0.05, 95% CI ?0.09 to ?0.01; P=.01). Conclusions: eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings. Trial Registration: ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8038 UR - https://www.jmir.org/2022/4/e30236 UR - http://dx.doi.org/10.2196/30236 UR - http://www.ncbi.nlm.nih.gov/pubmed/35468091 ID - info:doi/10.2196/30236 ER - TY - JOUR AU - Dervic, Elma AU - Deischinger, Carola AU - Haug, Nina AU - Leutner, Michael AU - Kautzky-Willer, Alexandra AU - Klimek, Peter PY - 2022/3/25 TI - Authors? Reply to: Using Caution When Interpreting Gender-Based Relative Risk. Comment on ?The Effect of Cardiovascular Comorbidities on Women Compared to Men: Longitudinal Retrospective Analysis? JO - JMIR Cardio SP - e36801 VL - 6 IS - 1 KW - gender gap KW - sex differences KW - cardiovascular diseases KW - acute myocardial infarction KW - chronic ischemic heart disease KW - gender KW - diabetes KW - smoking KW - risk factors KW - comorbidities KW - relative risk KW - interaction UR - https://cardio.jmir.org/2022/1/e36801 UR - http://dx.doi.org/10.2196/36801 UR - http://www.ncbi.nlm.nih.gov/pubmed/35333178 ID - info:doi/10.2196/36801 ER - TY - JOUR AU - Janszky, Imre PY - 2022/3/25 TI - Using Caution When Interpreting Gender-Based Relative Risk. Comment on ?The Effect of Cardiovascular Comorbidities on Women Compared to Men: Longitudinal Retrospective Analysis? JO - JMIR Cardio SP - e34647 VL - 6 IS - 1 KW - gender gap KW - sex differences KW - cardiovascular diseases KW - acute myocardial infarction KW - chronic ischemic heart disease KW - gender KW - diabetes KW - smoking KW - risk factors KW - comorbidities KW - relative risk KW - interaction UR - https://cardio.jmir.org/2022/1/e34647 UR - http://dx.doi.org/10.2196/34647 UR - http://www.ncbi.nlm.nih.gov/pubmed/35333181 ID - info:doi/10.2196/34647 ER - TY - JOUR AU - Ni, Zhao AU - Wu, Bei AU - Yang, Qing AU - Yan, L. Lijing AU - Liu, Changqing AU - Shaw, J. Ryan PY - 2022/3/9 TI - An mHealth Intervention to Improve Medication Adherence and Health Outcomes Among Patients With Coronary Heart Disease: Randomized Controlled Trial JO - J Med Internet Res SP - e27202 VL - 24 IS - 3 KW - mHealth KW - medication adherence KW - coronary disease KW - blood pressure KW - China KW - randomized controlled trial N2 - Background: The treatment of many chronic illnesses involves long-term pharmaceutical therapy, but it is an ongoing challenge to find effective ways to improve medication adherence to promote good health outcomes. Cardioprotective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes, such as uncontrolled high blood pressure and hyperlipidemia, for patients with coronary heart disease. Poor adherence to cardioprotective medications, however, has been reported as a global health concern among patients with coronary heart disease, and it is particularly a concern in China. Objective: This study aimed to evaluate the efficacy of a mobile health (mHealth) intervention using 2 mobile apps to improve medication adherence and health outcomes. Methods: A randomized, placebo-controlled, 2-arm parallel study was conducted in a major university-affiliated medical center located in Chengdu, China. Participants were recruited by flyers and health care provider referrals. Each participant was observed for 90 days, including a 60-day period of mHealth intervention and a 30-day period of nonintervention follow-up. The study coordinator used WeChat and Message Express to send educational materials and reminders to take medication, respectively. Participants used WeChat to receive both the educational materials and reminders. Participants in the control group only received educational materials. This study received ethics approval from the Duke Health Institutional Review Board (Pro00073395) on May 5, 2018, and was approved by West China Hospital (20170331180037). Recruitment began on May 20, 2018. The pilot phase of this study was registered on June 8, 2016, and the current, larger-scale study was retrospectively registered on January 11, 2021 (ClinicalTrials.gov). Results: We recruited 230 patients with coronary heart disease. Of these patients, 196 completed the baseline survey and received the intervention. The majority of participants were married (181/196, 92.4%), male (157/196, 80.1%), and lived in urban China (161/196, 82.1%). Participants? average age was 61 years, and half were retired (103/191, 53.9%). More than half the participants (121/196, 61.7%) were prescribed at least 5 medications. The mean decrease in medication nonadherence score was statistically significant at both 60 days (t179=2.04, P=.04) and 90 days (t155=3.48, P<.001). Systolic blood pressure and diastolic blood pressure decreased in the experimental group but increased in the control group. The mean decrease in diastolic blood pressure was statistically significant at both 60 days (t160=2.07, P=.04) and 90 days (t164=2.21, P=.03). The mean decrease in systolic blood pressure was significantly different in the groups at 90 days (t165=3.12, P=.002). Conclusions: The proposed mHealth intervention can improve medication adherence and health outcomes, including systolic blood pressure and diastolic blood pressure. Trial Registration: ClinicalTrials.gov NCT02793830; https://clinicaltrials.gov/ct2/show/NCT02793830 and ClinicalTrials.gov NCT04703439; https://clinicaltrials.gov/ct2/show/NCT04703439 UR - https://www.jmir.org/2022/3/e27202 UR - http://dx.doi.org/10.2196/27202 UR - http://www.ncbi.nlm.nih.gov/pubmed/35262490 ID - info:doi/10.2196/27202 ER - TY - JOUR AU - Chen, Jinying AU - Wijesundara, G. Jessica AU - Enyim, E. Gabrielle AU - Lombardini, M. Lisa AU - Gerber, S. Ben AU - Houston, K. Thomas AU - Sadasivam, S. Rajani PY - 2022/3/7 TI - Understanding Patients? Intention to Use Digital Health Apps That Support Postdischarge Symptom Monitoring by Providers Among Patients With Acute Coronary Syndrome: Survey Study JO - JMIR Hum Factors SP - e34452 VL - 9 IS - 1 KW - coronary KW - monitor KW - elder KW - health app KW - symptom KW - eHealth KW - mobile health KW - intention KW - barrier KW - facilitator N2 - Background: After hospital discharge, patients with acute coronary syndrome (ACS) often experience symptoms that prompt them to seek acute medical attention. Early evaluation of postdischarge symptoms by health care providers may reduce unnecessary acute care utilization. However, hospital-initiated follow-up encounters are insufficient for timely detection and assessment of symptoms. While digital health tools can help address this issue, little is known about the intention to use such tools in ACS patients. Objective: This study aimed to assess ACS patients? intention to use digital health apps that support postdischarge symptom monitoring by health care providers and identify patient-perceived facilitators and barriers to app use. Methods: Using email invitations or phone calls, we recruited ACS patients discharged from a central Massachusetts health care system between December 2020 and April 2021, to participate in the study. Surveys were delivered online or via phone to individual participants. Demographics and access to technology were assessed. The intention to use a symptom monitoring app was assessed using 5-point Likert-type (from strongly agree to strongly disagree) items, such as ?If this app were available to me, I would use it.? Responses were compared across demographic subgroups and survey delivery methods. Two open-ended questions assessed perceived facilitators and barriers to app use, with responses analyzed using qualitative content analysis. Results: Among 100 respondents (response rate 8.1%), 45 (45%) completed the survey by phone. The respondents were on average 68 years old (SD 13 years), with 90% (90/100) White, 39% (39/100) women, and 88% (88/100) having access to the internet or a mobile phone. Most participants (65/100, 65%) agreed or strongly agreed that they would use the app, among which 53 (82%) would use the app as often as possible. The percentage of participants with the intention to use the app was 75% among those aged 65-74 years and dropped to 44% among those older than 75 years. The intention to use was higher in online survey respondents (vs phone survey respondents; odds ratio 3.07, 95% CI 1.20-7.88) after adjusting for age and access to technology. The analysis of open-ended questions identified the following 4 main facilitators (motivations): (1) easily reaching providers, (2) accessing or providing information, (3) quickly reaching providers, and (4) consulting providers for symptoms, and the following 4 main barriers: (1) privacy/security concerns, (2) uncomfortable using technology, (3) user-unfriendly app interface, and (4) preference for in-person/phone care. Conclusions: There was a strong intention to use a symptom monitoring app postdischarge among ACS patients. However, this intent decreased in patients older than 75 years. The survey identified barriers related to technology use, privacy/security, and the care delivery mode. Further research is warranted to determine if such intent translates into app use, and better symptom management and health care quality. UR - https://humanfactors.jmir.org/2022/1/e34452 UR - http://dx.doi.org/10.2196/34452 UR - http://www.ncbi.nlm.nih.gov/pubmed/35254269 ID - info:doi/10.2196/34452 ER - TY - JOUR AU - Aardoom, J. Jiska AU - Hilt, D. Alexander AU - Woudenberg, Tamar AU - Chavannes, H. Niels AU - Atsma, E. Douwe PY - 2022/2/22 TI - A Preoperative Virtual Reality App for Patients Scheduled for Cardiac Catheterization: Pre?Post Questionnaire Study Examining Feasibility, Usability, and Acceptability JO - JMIR Cardio SP - e29473 VL - 6 IS - 1 KW - virtual reality KW - cardiac catheterization KW - stress inoculation training KW - preoperative anxiety KW - acceptability KW - feasibility KW - presence KW - immersive tendencies KW - patient education KW - mobile phone N2 - Background: Pre- and postoperative anxiety is a common phenomenon associated with negative postoperative outcomes. Symptoms of posttraumatic stress disorder, such as fear, nightmares, and sleep deprivation, are prevalent in approximately 30% to 50% of patients following discharge from intensive care units after cardiac surgery. Preliminary evidence suggests a promising role of virtual reality (VR) in preventing stress-related reactions using stress inoculation training. Such training enables cognitive preparation of individuals for stressful situations, thereby becoming more tolerant and resistant to stress, subsequently reducing the risk of potential negative psychological consequences. This study investigated a preoperative VR app?Pre-View?aimed at better informing and preparing patients for cardiac catheterization. Objective: This study aims to assess the feasibility, usability, and acceptability of Pre-View in patients undergoing cardiac catheterization. Methods: Eligible participants were adults scheduled for elective cardiac catheterization. Pre-View comprised an interactive virtual representation of the whole care process related to cardiac catheterization, from entering the hospital for admission to postprocedural stay and discharge. These processes were represented through 360° videos and interactive photos. Self-report questionnaires were completed at baseline (ie, before catheterization and after undergoing the VR experience) and after cardiac catheterization. Outcome measures included user experience and satisfaction, VR presence and immersive tendencies, and user friendliness. The perceived effectiveness was assessed exploratively. Results: A total of 8 individuals, with a mean age of 67 (SD 7.5) years, participated in this study. Half of them underwent the VR experience at the hospital and the other half at home. Participants reported high levels of presence in the virtual environment (Presence Questionnaire score: mean 129.1, SD 13.4). The usability of Pre-View was well evaluated (System Usability Scale score: mean 89.1, SD 12.0), and patient satisfaction was high (Client Satisfaction Questionnaire score: mean 27.1, SD 3.2). Usability and satisfaction scores were higher for participants who underwent Pre-View at home versus those who underwent Pre-View at the hospital, although the latter group was significantly older; 72.8 versus 61.3, respectively. All participants reported Pre-View to be effective in terms of feeling better informed about the care process of cardiac catheterization. Most participants (7/8, 88%) reported Pre-View to be effective in terms of feeling better prepared for cardiac catheterization, acknowledging the potential of Pre-View in reducing negative psychological consequences after catheterization. Conclusions: The results provide initial support for the feasibility and acceptability of a preoperative VR app, creating a virtual environment that supports patient education and preparation for upcoming cardiac catheterization. More studies are needed to further investigate the effects of VR as a tool to better prepare patients for medical procedures, its effectiveness in reducing negative patient outcomes (eg, anxiety, stress, and postoperative recovery outcomes), and the generalizability of effects across different settings and patient populations. UR - https://cardio.jmir.org/2022/1/e29473 UR - http://dx.doi.org/10.2196/29473 UR - http://www.ncbi.nlm.nih.gov/pubmed/35191839 ID - info:doi/10.2196/29473 ER - TY - JOUR AU - Li, Yuxi AU - Gong, Yanjun AU - Zheng, Bo AU - Fan, Fangfang AU - Yi, Tieci AU - Zheng, Yimei AU - He, Pengkang AU - Fang, Jin AU - Jia, Jia AU - Zhu, Qin AU - Jiang, Jie AU - Huo, Yong PY - 2022/2/15 TI - Effects on Adherence to a Mobile App?Based Self-management Digital Therapeutics Among Patients With Coronary Heart Disease: Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e32251 VL - 10 IS - 2 KW - coronary heart disease KW - secondary prevention KW - self-management KW - mobile app KW - adherence KW - digital therapeutics KW - mobile phone N2 - Background: The adherence to secondary prevention treatment in patients with coronary heart disease (CHD) is low. Digital therapeutics (DTx) refers to an emerging branch of medicine that delivers medical interventions directly to patients using evidence-based, clinically evaluated, technology-based software algorithms or apps to facilitate disease management, which may be an efficient tool to optimize adherence. Objective: This paper aims to investigate the effect of mobile app?based self-management DTx on long-term use of secondary prevention medications in patients with CHD in China. Methods: This pilot study was a parallel-designed, open-labeled, single-center, randomized controlled trial. Hospitalized patients with CHD admitted to Peking University First Hospital between April 2016 and June 2017 were randomized before discharge on a 1:1 ratio. The intervention group received regular follow-up combined with DTx, which is a self-management mobile app already installed on an Android 5 (Mi Pad 1, Xiaomi Corporation) tablet. Structured data from the hospital informatics system were integrated automatically, and medication, lifestyle intervention plan, follow-up protocol, and patient education materials were also provided according to the diagnosis. Participants could use DTx for self-management at home. The control group was under conventional hospital?based follow-up care. Patients were followed up for 1 year, and the primary end point was the percentage of all guideline-recommended medications at 12 months. The secondary end points included the percentage adhered to standard secondary prevention medications at 6 months, the control rate of lipid profile, and blood pressure at 6 months and 1 year. Results: Among 300 randomized patients with CHD, 290 (96.7%) were included in the final analysis, including 49.3% (143/290) and 50.7% (147/290) of patients from the intervention and control groups, respectively. Baseline characteristics were similar between the 2 groups. There was a statistically significant improvement in the percentage of all guideline-recommended medications at 12 months in the intervention group compared with the control group (relative risk [RR] 1.34, 95% CI 1.12-1.61; P=.001), and there was no interaction with baseline characteristics. The intervention group had a significantly higher proportion of patients achieving blood pressure under control (systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) and low-density lipoprotein cholesterol <1.8 mmol/L (RR 1.45, 95% CI 1.22-1.72; P<.001 and RR 1.40, 95% CI 1.11-1.75; P=.004, respectively) at 12 months. Furthermore, on logistic regression, the intervention group had a lower risk of withdrawing from guideline-recommended medications (odds ratio 0.46, 95% CI 0.27-0.78; P=.004). Conclusions: Among patients with CHD, using a mobile app?based self-management DTx in addition to traditional care resulted in a significant improvement in guideline-recommended medication adherence at 12 months. The results of the trial will be applicable to primary care centers, especially in rural areas with less medical resources. Trial Registration: ClinicalTrials.gov NCT03565978; https://clinicaltrials.gov/ct2/show/NCT03565978 UR - https://mhealth.jmir.org/2022/2/e32251 UR - http://dx.doi.org/10.2196/32251 UR - http://www.ncbi.nlm.nih.gov/pubmed/34906924 ID - info:doi/10.2196/32251 ER - TY - JOUR AU - Chowdhury, Rajiv AU - Noh, Md Mohd Fairulnizal AU - Ismail, Rasheeqa Sophia AU - van Daalen, Robin Kim AU - Kamaruddin, Megat Puteri Sofia Nadira AU - Zulkiply, Hafizah Siti AU - Azizul, Hayati Nur AU - Khalid, Mustafa Norhayati AU - Ali, Azizan AU - Idris, Mohd Izyan AU - Mei, Shih Yong AU - Abdullah, Rifham Shazana AU - Faridus, Norfashihah AU - Yusof, Md Nur Azirah AU - Yusoff, M. Nur Najwa Farahin AU - Jamal, Rahman AU - Rahim, Abdul Aizai Azan AU - Ghapar, Abdul Abdul Kahar AU - Radhakrishnan, Kutty Ammu AU - Fong, Yip Alan Yean AU - Ismail, Omar AU - Krishinan, Saravanan AU - Lee, Yan Chuey AU - Bang, Houng Liew AU - Mageswaren, Eashwary AU - Mahendran, Kauthaman AU - Amin, Mohd Nor Hanim AU - Muthusamy, Gunavathy AU - Jin, Hean Aaron Ong AU - Ramli, Wazi Ahmad AU - Ross, Thomas Noel AU - Ruhani, Irawan Anwar AU - Yahya, Mansor AU - Yusoff, Yusniza AU - Abidin, Zainal Siti Khairani AU - Amado, Laryssa AU - Bolton, Thomas AU - Weston, Sophie AU - Crawte, Jason AU - Ovenden, Niko AU - Michielsen, Ank AU - Monower, Mostafa Md AU - Mahiyuddin, Wan Wan Rozita AU - Wood, Angela AU - Di Angelantonio, Emanuele AU - Sulaiman, Suffia Nur AU - Danesh, John AU - Butterworth, S. Adam PY - 2022/2/10 TI - Investigating Genetic and Other Determinants of First-Onset Myocardial Infarction in Malaysia: Protocol for the Malaysian Acute Vascular Events Risk Study JO - JMIR Res Protoc SP - e31885 VL - 11 IS - 2 KW - myocardial infarction KW - cardiovascular disease KW - case-control study KW - Malaysia N2 - Background: Although the burden of premature myocardial infarction (MI) is high in Malaysia, direct evidence on the determinants of MI in this multi-ethnic population remains sparse. Objective: The Malaysian Acute Vascular Events Risk (MAVERIK) study is a retrospective case-control study established to investigate the genomic, lipid-related, and other determinants of acute MI in Malaysia. In this paper, we report the study protocol and early results. Methods: By June 2019, we had enrolled approximately 2500 patients with their first MI and 2500 controls without cardiovascular disease, who were frequency-matched by age, sex, and ethnicity, from 17 hospitals in Malaysia. For each participant, serum and whole blood have been collected and stored. Clinical, demographic, and behavioral information has been obtained using a 200-item questionnaire. Results: Tobacco consumption, a history of diabetes, hypertension, markers of visceral adiposity, indicators of lower socioeconomic status, and a family history of coronary disease were more prevalent in cases than in controls. Adjusted (age and sex) logistic regression models for traditional risk factors indicated that current smoking (odds ratio [OR] 4.11, 95% CI 3.56-4.75; P<.001), previous smoking (OR 1.34, 95% CI 1.12-1.60; P=.001), a history of high blood pressure (OR 2.13, 95% CI 1.86-2.44; P<.001), a history of diabetes mellitus (OR 2.72, 95% CI 2.34-3.17; P<.001), a family history of coronary heart disease (OR 1.28, 95% CI 1.07-1.55; P=.009), and obesity (BMI >30 kg/m2; OR 1.19, 95% CI 1.05-1.34; P=.009) were associated with MI in age- and sex-adjusted models. Conclusions: The MAVERIK study can serve as a useful platform to investigate genetic and other risk factors for MI in an understudied Southeast Asian population. It should help to hasten the discovery of disease-causing pathways and inform regionally appropriate strategies that optimize public health action. International Registered Report Identifier (IRRID): RR1-10.2196/31885 UR - https://www.researchprotocols.org/2022/2/e31885 UR - http://dx.doi.org/10.2196/31885 UR - http://www.ncbi.nlm.nih.gov/pubmed/35142634 ID - info:doi/10.2196/31885 ER - TY - JOUR AU - Ramachandran, Joann Hadassah AU - Jiang, Ying AU - Teo, Claire Jun Yi AU - Yeo, Joo Tee AU - Wang, Wenru PY - 2022/1/7 TI - Technology Acceptance of Home-Based Cardiac Telerehabilitation Programs in Patients With Coronary Heart Disease: Systematic Scoping Review JO - J Med Internet Res SP - e34657 VL - 24 IS - 1 KW - technology acceptance KW - coronary heart disease KW - home-based KW - telerehabilitation KW - web-based KW - mobile application KW - acceptance KW - heart KW - rehabilitation KW - app KW - review KW - evaluation KW - cardiac KW - cardiology KW - perspective KW - usability KW - acceptability N2 - Background: An understanding of the technology acceptance of home-based cardiac telerehabilitation programs is paramount if they are to be designed and delivered to target the needs and preferences of patients with coronary heart disease; however, the current state of technology acceptance of home-based cardiac telerehabilitation has not been systematically evaluated in the literature. Objective: We aimed to provide a comprehensive summary of home-based cardiac telerehabilitation technology acceptance in terms of (1) the timing and approaches used and (2) patients? perspectives on its usability, utility, acceptability, acceptance, and external variables. Methods: We searched PubMed, CENTRAL, Embase, CINAHL, PsycINFO, and Scopus (inception to July 2021) for English-language papers that reported empirical evidence on the technology acceptance of early-phase home-based cardiac telerehabilitation in patients with coronary heart disease. Content analysis was undertaken. Results: The search identified 1798 studies, of which 18 studies, with 14 unique home-based cardiac telerehabilitation programs, met eligibility criteria. Technology acceptance (of the home-based cardiac telerehabilitation programs) was mostly evaluated at intra- and posttrial stages using questionnaires (n=10) and usage data (n=11). The least used approach was evaluation through qualitative interviews (n=3). Usability, utility, acceptability, and acceptance were generally favored. External variables that influenced home-based cardiac telerehabilitation usage included component quality, system quality, facilitating conditions, and intrinsic factors. Conclusions: Home-based cardiac telerehabilitation usability, utility, acceptability, and acceptance were high; yet, a number of external variables influenced acceptance. Findings and recommendations from this review can provide guidance for developing and evaluating patient-centered home-based cardiac telerehabilitation programs to stakeholders and clinicians. UR - https://www.jmir.org/2022/1/e34657 UR - http://dx.doi.org/10.2196/34657 UR - http://www.ncbi.nlm.nih.gov/pubmed/34994711 ID - info:doi/10.2196/34657 ER - TY - JOUR AU - Rogerson, C. Michelle AU - Jackson, C. Alun AU - Navaratnam, S. Hema AU - Le Grande, R. Michael AU - Higgins, O. Rosemary AU - Clarke, Joanne AU - Murphy, M. Barbara PY - 2021/12/23 TI - Getting ?Back on Track? After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program JO - JMIR Res Protoc SP - e34534 VL - 10 IS - 12 KW - coronary heart disease KW - heart disease KW - coronary KW - cardiovascular KW - prevention KW - RCT KW - randomized control trial KW - secondary prevention KW - self-management KW - online KW - randomised controlled trial KW - health behaviours KW - health behaviour KW - health behavior KW - depression KW - cognitive behaviour therapy KW - motivational interviewing N2 - Background: After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management. Objective: The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone. Methods: People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either ?self-directed? completion of the Back on Track program (without assistance) or ?supported? completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. Results: Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study. Conclusions: The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/34534 UR - https://www.researchprotocols.org/2021/12/e34534 UR - http://dx.doi.org/10.2196/34534 UR - http://www.ncbi.nlm.nih.gov/pubmed/34941550 ID - info:doi/10.2196/34534 ER - TY - JOUR AU - Chen, Yuling AU - Ji, Meihua AU - Wu, Ying AU - Wang, Qingyu AU - Deng, Ying AU - Liu, Yong AU - Wu, Fangqin AU - Liu, Mingxuan AU - Guo, Yiqiang AU - Fu, Ziyuan AU - Zheng, Xiaoying PY - 2021/12/13 TI - An Intelligent Individualized Cardiovascular App for Risk Elimination (iCARE) for Individuals With Coronary Heart Disease: Development and Usability Testing Analysis JO - JMIR Mhealth Uhealth SP - e26439 VL - 9 IS - 12 KW - mobile health KW - health behavior KW - system KW - development KW - usability KW - coronary heart disease N2 - Background: Death and disability from coronary heart disease (CHD) can be largely reduced by improving risk factor management. However, adhering to evidence-based recommendations is challenging and requires interventions at the level of the patient, provider, and health system. Objective: The aim of this study was to develop an Intelligent Individualized Cardiovascular App for Risk Elimination (iCARE) to facilitate adherence to health behaviors and preventive medications, and to test the usability of iCARE. Methods: We developed iCARE based on a user-centered design approach, which included 4 phases: (1) function design, (2) iterative design, (3) expert inspections and walkthroughs of the prototypes, and (4) usability testing with end users. The usability testing of iCARE included 2 stages: stage I, which included a task analysis and a usability evaluation (January to March 2019) of the iCARE patient app using the modified Health Information Technology Usability Survey (Health-ITUES); and stage II (June 2020), which used the Health-ITUES among end users who used the app for 6 months. The end users were individuals with a confirmed diagnosis of CHD from 2 university-affiliated hospitals in Beijing, China. Results: iCARE consists of a patient app, a care provider app, and a cloud platform. It has a set of algorithms that trigger tailored feedback and can send individualized interventions based on data from initial assessment and health monitoring via manual entry or wearable devices. For stage I usability testing, 88 hospitalized patients (72% [63/88] male; mean age 60 [SD 9.9] years) with CHD were included in the study. The mean score of the usability testing was 90.1 (interquartile range 83.3-99.0). Among enrolled participants, 90% (79/88) were satisfied with iCARE; 94% (83/88) and 82% (72/88) reported that iCARE was useful and easy to use, respectively. For stage II usability testing, 61 individuals with CHD (85% [52/61] male; mean age 53 [SD 8.2] years) who were from an intervention arm and used iCARE for at least six months were included. The mean total score on usability testing based on the questionnaire was 89.0 (interquartile distance: 77.0-99.5). Among enrolled participants, 89% (54/61) were satisfied with the use of iCARE, 93% (57/61) perceived it as useful, and 70% (43/61) as easy to use. Conclusions: This study developed an intelligent, individualized, evidence-based, and theory-driven app (iCARE) to improve patients? adherence to health behaviors and medication management. iCARE was identified to be highly acceptable, useful, and easy to use among individuals with a diagnosis of CHD. Trial Registration: Chinese Clinical Trial Registry ChiCTR-INR-16010242; https://tinyurl.com/2p8bkrew UR - https://mhealth.jmir.org/2021/12/e26439 UR - http://dx.doi.org/10.2196/26439 UR - http://www.ncbi.nlm.nih.gov/pubmed/34898449 ID - info:doi/10.2196/26439 ER - TY - JOUR AU - Choi, Yeon Jah AU - Kim, Bak Ji AU - Lee, Sunki AU - Lee, Seo-Joon AU - Shin, Eon Seung AU - Park, Hyun Se AU - Park, Jin Eun AU - Kim, Woohyeun AU - Na, Oh Jin AU - Choi, Ung Cheol AU - Rha, Seung-Woon AU - Park, Gyu Chang AU - Seo, Seog Hong AU - Ahn, Jeonghoon AU - Jeong, Hyun-Ghang AU - Kim, Ju Eung PY - 2021/12/7 TI - A Smartphone App (AnSim) With Various Types and Forms of Messages Using the Transtheoretical Model for Cardiac Rehabilitation in Patients With Coronary Artery Disease: Development and Usability Study JO - JMIR Med Inform SP - e23285 VL - 9 IS - 12 KW - cardiac rehabilitation KW - smartphone app KW - coronary heart disease N2 - Background: Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce. Objective: This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI). Methods: The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed. Results: The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant. Conclusions: We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research. UR - https://medinform.jmir.org/2021/12/e23285 UR - http://dx.doi.org/10.2196/23285 UR - http://www.ncbi.nlm.nih.gov/pubmed/34878987 ID - info:doi/10.2196/23285 ER - TY - JOUR AU - Anttila, Marjo-Riitta AU - Soderlund, Anne AU - Paajanen, Teemu AU - Kivistö, Heikki AU - Kokko, Katja AU - Sjögren, Tuulikki PY - 2021/11/3 TI - Biopsychosocial Profiles of Patients With Cardiac Disease in Remote Rehabilitation Processes: Mixed Methods Grounded Theory Approach JO - JMIR Rehabil Assist Technol SP - e16864 VL - 8 IS - 4 KW - coronary disease KW - experience KW - biopsychosocial model KW - digital cardiac rehabilitation KW - mixed methods grounded theory KW - web-based program KW - physical activity KW - self-efficacy KW - quality of life N2 - Background: Digital development has caused rehabilitation services and rehabilitees to become increasingly interested in using technology as a part of rehabilitation. This study was based on a previously published study that categorized 4 groups of patients with cardiac disease based on different experiences and attitudes toward technology (e-usage groups): feeling outsider, being uninterested, reflecting benefit, and enthusiastic using. Objective: This study identifies differences in the biopsychosocial profiles of patients with cardiac disease in e-usage groups and deepen the understanding of these profiles in cardiac rehabilitation. Methods: Focus group interviews and measurements were conducted with 39 patients with coronary heart disease, and the mean age was 54.8 (SD 9.4, range 34-77) years. Quantitative data were gathered during a 12-month rehabilitation period. First, we used analysis of variance and Tukey honestly significant difference test, a t test, or nonparametric tests?Mann?Whitney and Kruskal?Wallis tests?to compare the 4 e-usage groups?feeling outsider, being uninterested, reflecting benefit, and enthusiastic using?in biopsychosocial variables. Second, we compared the results of the 4 e-groups in terms of recommended and reference values. This analysis contained 13 variables related to biomedical, psychological, and social functioning. Finally, we formed biopsychosocial profiles based on the integration of the findings by constant comparative analysis phases through classic grounded theory. Results: The biomedical variables were larger for waistline (mean difference [MD] 14.2; 95% CI 1.0-27.5; P=.03) and lower for physical fitness (MD ?0.72; 95% CI ?1.4 to ?0.06; P=.03) in the being uninterested group than in the enthusiastic using group. The feeling outsider group had lower physical fitness (MD ?55.8; 95% CI ?110.7 to ?0.92; P=.047) than the enthusiastic using group. For psychosocial variables, such as the degree of self-determination in exercise (MD ?7.3; 95% CI ?13.5 to ?1.1; P=.02), the being uninterested group had lower values than the enthusiastic using group. Social variables such as performing guided tasks in the program (P=.03) and communicating via messages (P=.03) were lower in the feeling outsider group than in the enthusiastic using group. The feeling outsider and being uninterested groups had high-risk lifestyle behaviors, and adherence to the web-based program was low. In contrast, members of the being uninterested group were interested in tracking their physical activity. The reflecting benefit and enthusiastic using groups had low-risk lifestyle behavior and good adherence to web-based interventions; however, the enthusiastic using group had low self-efficacy in exercise. These profiles showed how individuals reflected their lifestyle risk factors differently. We renamed the 4 groups as building self-awareness, increasing engagement, maintaining a healthy lifestyle balance, and strengthening self-confidence. Conclusions: The results facilitate more effective and meaningful personalization guidance and inform the remote rehabilitation. Professionals can tailor individual web-based lifestyle risk interventions using these biopsychosocial profiles. UR - https://rehab.jmir.org/2021/4/e16864 UR - http://dx.doi.org/10.2196/16864 UR - http://www.ncbi.nlm.nih.gov/pubmed/34730548 ID - info:doi/10.2196/16864 ER - TY - JOUR AU - Shi, Boqun AU - Liu, Xi AU - Dong, Qiuting AU - Yang, Yuxiu AU - Cai, Zhongxing AU - Wang, Haoyu AU - Yin, Dong AU - Wang, Hongjian AU - Dou, Kefei AU - Song, Weihua PY - 2021/10/27 TI - The Effect of a WeChat-Based Tertiary A-Level Hospital Intervention on Medication Adherence and Risk Factor Control in Patients With Stable Coronary Artery Disease: Multicenter Prospective Study JO - JMIR Mhealth Uhealth SP - e32548 VL - 9 IS - 10 KW - WeChat KW - telemedicine KW - coronary artery disease KW - medication adherence KW - mobile phone N2 - Background: In China, ischemic heart disease is the main cause of mortality. Having cardiac rehabilitation and a secondary prevention program in place is a class IA recommendation for individuals with coronary artery disease. WeChat-based interventions seem to be feasible and efficient for the follow-up and management of chronic diseases. Objective: This study aims to evaluate the effectiveness of a tertiary A-level hospital, WeChat-based telemedicine intervention in comparison with conventional community hospital follow-up on medication adherence and risk factor control in individuals with stable coronary artery disease. Methods: In this multicenter prospective study, 1424 patients with stable coronary artery disease in Beijing, China, were consecutively enrolled between September 2018 and September 2019 from the Fuwai Hospital and 4 community hospitals. At 1-, 3-, 6-, and 12-month follow-up, participants received healthy lifestyle recommendations and medication advice. Subsequently, the control group attended an offline outpatient clinic at 4 separate community hospitals. The intervention group had follow-up visits through WeChat-based telemedicine management. The main end point was medication adherence, which was defined as participant compliance in taking all 4 cardioprotective medications that would improve the patient?s outcome (therapies included antiplatelet therapy, ?-blockers, statins, and angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers). Multivariable generalized estimating equations were used to compare the primary and secondary outcomes between the 2 groups and to calculate the relative risk (RR) at 12 months. Propensity score matching and inverse probability of treatment weighting were performed as sensitivity analyses, and propensity scores were calculated using a multivariable logistic regression model. Results: At 1 year, 88% (565/642) of patients in the intervention group and 91.8% (518/564) of patients in the control group had successful follow-up data. We matched 257 pairs of patients between the intervention and control groups. There was no obvious advantage in medication adherence with the 4 cardioprotective drugs in the intervention group (172/565, 30.4%, vs 142/518, 27.4%; RR 0.99, 95% CI 0.97-1.02; P=.65). The intervention measures improved smoking cessation (44/565, 7.8%, vs 118/518, 22.8%; RR 0.48, 95% CI 0.44-0.53; P<.001) and alcohol restriction (33/565, 5.8%, vs 91/518, 17.6%; RR 0.47, 95% CI 0.42-0.54; P<.001). Conclusions: The tertiary A-level hospital, WeChat-based intervention did not improve adherence to the 4 cardioprotective medications compared with the traditional method. Tertiary A-level hospital, WeChat-based interventions have a positive effect on improving lifestyle, such as quitting drinking and smoking, in patients with stable coronary artery disease and can be tried as a supplement to community hospital follow-up. Trial Registration: ClinicalTrials.gov NCT04795505; https://clinicaltrials.gov/ct2/show/NCT04795505 UR - https://mhealth.jmir.org/2021/10/e32548 UR - http://dx.doi.org/10.2196/32548 UR - http://www.ncbi.nlm.nih.gov/pubmed/34569467 ID - info:doi/10.2196/32548 ER - TY - JOUR AU - Abid, Leila AU - Kammoun, Ikram AU - Ben Halima, Manel AU - Charfeddine, Salma AU - Ben Slima, Hedi AU - Drissa, Meriem AU - Mzoughi, Khadija AU - Mbarek, Dorra AU - Riahi, Leila AU - Antit, Saoussen AU - Ben Halima, Afef AU - Ouechtati, Wejdene AU - Allouche, Emna AU - Mechri, Mehdi AU - Yousfi, Chedi AU - Khorchani, Ali AU - Abid, Omar AU - Sammoud, Kais AU - Ezzaouia, Khaled AU - Gtif, Imen AU - Ouali, Sana AU - Triki, Feten AU - Hamdi, Sonia AU - Boudiche, Selim AU - Chebbi, Marwa AU - Hentati, Mouna AU - Farah, Amani AU - Triki, Habib AU - Ghardallou, Houda AU - Raddaoui, Haythem AU - Zayed, Sofien AU - Azaiez, Fares AU - Omri, Fadwa AU - Zouari, Akram AU - Ben Ali, Zine AU - Najjar, Aymen AU - Thabet, Houssem AU - Chaker, Mouna AU - Mohamed, Samar AU - Chouaieb, Marwa AU - Ben Jemaa, Abdelhamid AU - Tangour, Haythem AU - Kammoun, Yassmine AU - Bouhlel, Mahmoud AU - Azaiez, Seifeddine AU - Letaief, Rim AU - Maskhi, Salah AU - Amri, Aymen AU - Naanaa, Hela AU - Othmani, Raoudha AU - Chahbani, Iheb AU - Zargouni, Houcine AU - Abid, Syrine AU - Ayari, Mokdad AU - ben Ameur, Ines AU - Gasmi, Ali AU - ben Halima, Nejeh AU - Haouala, Habib AU - Boughzela, Essia AU - Zakhama, Lilia AU - ben Youssef, Soraya AU - Nasraoui, Wided AU - Boujnah, Rachid Mohamed AU - Barakett, Nadia AU - Kraiem, Sondes AU - Drissa, Habiba AU - Ben Khalfallah, Ali AU - Gamra, Habib AU - Kachboura, Salem AU - Bezdah, Leila AU - Baccar, Hedi AU - Milouchi, Sami AU - Sdiri, Wissem AU - Ben Omrane, Skander AU - Abdesselem, Salem AU - Kanoun, Alifa AU - Hezbri, Karima AU - Zannad, Faiez AU - Mebazaa, Alexandre AU - Kammoun, Samir AU - Mourali, Sami Mohamed AU - Addad, Faouzi PY - 2021/10/27 TI - Design and Rationale of the National Tunisian Registry of Heart Failure (NATURE-HF): Protocol for a Multicenter Registry Study JO - JMIR Res Protoc SP - e12262 VL - 10 IS - 10 KW - heart failure KW - acute heart failure KW - chronic heart failure KW - diagnosis KW - prognosis KW - treatment N2 - Background: The frequency of heart failure (HF) in Tunisia is on the rise and has now become a public health concern. This is mainly due to an aging Tunisian population (Tunisia has one of the oldest populations in Africa as well as the highest life expectancy in the continent) and an increase in coronary artery disease and hypertension. However, no extensive data are available on demographic characteristics, prognosis, and quality of care of patients with HF in Tunisia (nor in North Africa). Objective: The aim of this study was to analyze, follow, and evaluate patients with HF in a large nation-wide multicenter trial. Methods: A total of 1700 patients with HF diagnosed by the investigator will be included in the National Tunisian Registry of Heart Failure study (NATURE-HF). Patients must visit the cardiology clinic 1, 3, and 12 months after study inclusion. This follow-up is provided by the investigator. All data are collected via the DACIMA Clinical Suite web interface. Results: At the end of the study, we will note the occurrence of cardiovascular death (sudden death, coronary artery disease, refractory HF, stroke), death from any cause (cardiovascular and noncardiovascular), and the occurrence of a rehospitalization episode for an HF relapse during the follow-up period. Based on these data, we will evaluate the demographic characteristics of the study patients, the characteristics of pathological antecedents, and symptomatic and clinical features of HF. In addition, we will report the paraclinical examination findings such as the laboratory standard parameters and brain natriuretic peptides, electrocardiogram or 24-hour Holter monitoring, echocardiography, and coronarography. We will also provide a description of the therapeutic environment and therapeutic changes that occur during the 1-year follow-up of patients, adverse events following medical treatment and intervention during the 3- and 12-month follow-up, the evaluation of left ventricular ejection fraction during the 3- and 12-month follow-up, the overall rate of rehospitalization over the 1-year follow-up for an HF relapse, and the rate of rehospitalization during the first 3 months after inclusion into the study. Conclusions: The NATURE-HF study will fill a significant gap in the dynamic landscape of HF care and research. It will provide unique and necessary data on the management and outcomes of patients with HF. This study will yield the largest contemporary longitudinal cohort of patients with HF in Tunisia. Trial Registration: ClinicalTrials.gov NCT03262675; https://clinicaltrials.gov/ct2/show/NCT03262675 International Registered Report Identifier (IRRID): DERR1-10.2196/12262 UR - https://www.researchprotocols.org/2021/10/e12262 UR - http://dx.doi.org/10.2196/12262 UR - http://www.ncbi.nlm.nih.gov/pubmed/34704958 ID - info:doi/10.2196/12262 ER - TY - JOUR AU - Min, Lingtong AU - Atalag, Koray AU - Tian, Qi AU - Chen, Yani AU - Lu, Xudong PY - 2021/10/19 TI - Verifying the Feasibility of Implementing Semantic Interoperability in Different Countries Based on the OpenEHR Approach: Comparative Study of Acute Coronary Syndrome Registries JO - JMIR Med Inform SP - e31288 VL - 9 IS - 10 KW - semantic interoperability KW - openEHR KW - archetype KW - registry KW - acute coronary syndrome N2 - Background: The semantic interoperability of health care information has been a critical challenge in medical informatics and has influenced the integration, sharing, analysis, and use of medical big data. International standard organizations have developed standards, approaches, and models to improve and implement semantic interoperability. The openEHR approach?one of the standout semantic interoperability approaches?has been implemented worldwide to improve semantic interoperability based on reused archetypes. Objective: This study aimed to verify the feasibility of implementing semantic interoperability in different countries by comparing the openEHR-based information models of 2 acute coronary syndrome (ACS) registries from China and New Zealand. Methods: A semantic archetype comparison method was proposed to determine the semantics reuse degree of reused archetypes in 2 ACS-related clinical registries from 2 countries. This method involved (1) determining the scope of reused archetypes; (2) identifying corresponding data items within corresponding archetypes; (3) comparing the semantics of corresponding data items; and (4) calculating the number of mappings in corresponding data items and analyzing results. Results: Among the related archetypes in the two ACS-related, openEHR-based clinical registries from China and New Zealand, there were 8 pairs of reusable archetypes, which included 89 pairs of corresponding data items and 120 noncorresponding data items. Of the 89 corresponding data item pairs, 87 pairs (98%) were mappable and therefore supported semantic interoperability, and 71 pairs (80%) were labeled as ?direct mapping? data items. Of the 120 noncorresponding data items, 114 (95%) data items were generated via archetype evolution, and 6 (5%) data items were generated via archetype localization. Conclusions: The results of the semantic comparison between the two ACS-related clinical registries prove the feasibility of establishing the semantic interoperability of health care data from different countries based on the openEHR approach. Archetype reuse provides data on the degree to which semantic interoperability exists when using the openEHR approach. Although the openEHR community has effectively promoted archetype reuse and semantic interoperability by providing archetype modeling methods, tools, model repositories, and archetype design patterns, the uncontrolled evolution of archetypes and inconsistent localization have resulted in major challenges for achieving higher levels of semantic interoperability. UR - https://medinform.jmir.org/2021/10/e31288 UR - http://dx.doi.org/10.2196/31288 UR - http://www.ncbi.nlm.nih.gov/pubmed/34665150 ID - info:doi/10.2196/31288 ER - TY - JOUR AU - Dervic, Elma AU - Deischinger, Carola AU - Haug, Nils AU - Leutner, Michael AU - Kautzky-Willer, Alexandra AU - Klimek, Peter PY - 2021/10/4 TI - The Effect of Cardiovascular Comorbidities on Women Compared to Men: Longitudinal Retrospective Analysis JO - JMIR Cardio SP - e28015 VL - 5 IS - 2 KW - gender gap KW - sex differences KW - cardiovascular diseases KW - acute myocardial infarction KW - chronic ischemic heart disease KW - gender KW - diabetes KW - smoking KW - risk factors KW - comorbidities N2 - Background: Although men are more prone to developing cardiovascular disease (CVD) than women, risk factors for CVD, such as nicotine abuse and diabetes mellitus, have been shown to be more detrimental in women than in men. Objective: We developed a method to systematically investigate population-wide electronic health records for all possible associations between risk factors for CVD and other diagnoses. The developed structured approach allows an exploratory and comprehensive screening of all possible comorbidities of CVD, which are more connected to CVD in either men or women. Methods: Based on a population-wide medical claims dataset comprising 44 million records of inpatient stays in Austria from 2003 to 2014, we determined comorbidities of acute myocardial infarction (AMI; International Classification of Diseases, Tenth Revision [ICD-10] code I21) and chronic ischemic heart disease (CHD; ICD-10 code I25) with a significantly different prevalence in men and women. We introduced a measure of sex difference as a measure of differences in logarithmic odds ratios (ORs) between male and female patients in units of pooled standard errors. Results: Except for lipid metabolism disorders (OR for females [ORf]=6.68, 95% confidence interval [CI]=6.57-6.79, OR for males [ORm]=8.31, 95% CI=8.21-8.41), all identified comorbidities were more likely to be associated with AMI and CHD in females than in males: nicotine dependence (ORf=6.16, 95% CI=5.96-6.36, ORm=4.43, 95% CI=4.35-4.5), diabetes mellitus (ORf=3.52, 95% CI=3.45-3.59, ORm=3.13, 95% CI=3.07-3.19), obesity (ORf=3.64, 95% CI=3.56-3.72, ORm=3.33, 95% CI=3.27-3.39), renal disorders (ORf=4.27, 95% CI=4.11-4.44, ORm=3.74, 95% CI=3.67-3.81), asthma (ORf=2.09, 95% CI=1.96-2.23, ORm=1.59, 95% CI=1.5-1.68), and COPD (ORf=2.09, 95% CI 1.96-2.23, ORm=1.59, 95% CI 1.5-1.68). Similar results could be observed for AMI. Conclusions: Although AMI and CHD are more prevalent in men, women appear to be more affected by certain comorbidities of AMI and CHD in their risk for developing CVD. UR - https://cardio.jmir.org/2021/2/e28015 UR - http://dx.doi.org/10.2196/28015 UR - http://www.ncbi.nlm.nih.gov/pubmed/34605767 ID - info:doi/10.2196/28015 ER - TY - JOUR AU - Bae, Jang-Whan AU - Woo, Seoung-Il AU - Lee, Joongyub AU - Park, Sang-Don AU - Kwon, Woo Sung AU - Choi, Huan Seong AU - Yoon, Gwang-Seok AU - Kim, Mi-Sook AU - Hwang, Seung-Sik AU - Lee, Kyung Won PY - 2021/9/24 TI - mHealth Interventions for Lifestyle and Risk Factor Modification in Coronary Heart Disease: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e29928 VL - 9 IS - 9 KW - coronary heart disease KW - prevention KW - lifestyle modification KW - mobile health KW - text message KW - mHealth N2 - Background: Self-management of lifestyle and cardiovascular disease risk factors is challenging in older patients with coronary heart disease (CHD). SMS text messaging could be a potential support tool for self-management and the most affordable and accessible method through a mobile phone. High-quality evidence had been lacking, and previous studies evaluated the effects of SMS text messaging on the subjective measures of short-term outcomes. Recently, a large-sized randomized controlled trial in Australia reported promising findings on the objective measures upon 6-month follow-up. However, an examination of the effectiveness of such interventions in an Asian population with unique demographic characteristics would be worthwhile. Objective: This study examined the effectiveness of a 1-way SMS text messaging program to modify the lifestyle and cardiovascular disease risk factors of patients who underwent the first percutaneous coronary intervention (PCI). Methods: A parallel, single-blinded, 1:1 random allocation clinical trial was conducted with 879 patients treated through PCI. They were recruited during hospital admission from April 2017 to May 2020 at 2 university hospitals in the Republic of Korea. In addition to standard care, the intervention group received access to a supporting website and 4 SMS text messages per week for 6 months regarding a healthy diet, physical activity, smoking cessation, and cardiovascular health. Random allocation upon study enrollment and SMS text messaging after hospital discharge were performed automatically using a computer program. The coprimary outcomes were low-density-lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and BMI. The secondary outcomes were change in lifestyle and adherence to the recommended health behaviors. Results: Of the eligible population, 440 and 439 patients who underwent PCI were assigned to the intervention and control groups, respectively. The 1-way SMS text messaging program significantly enhanced physical activity (P=.02), healthy diet (P<.01), and medication adherence (P<.04) among patients with CHD. Hence, more people were likely to control their cardiovascular disease risk factors per the recommendations. The intervention group was more likely to control all 5 risk factors by 62% (relative risk 1.62, 95% CI 1.05-2.50) per the recommendations. On the other hand, physiological measures of the primary outcomes, including LDL-C levels, SBP, and BMI, were not significant. Most participants found the SMS text messaging program useful and helpful in motivating lifestyle changes. Conclusions: Lifestyle-focused SMS text messages were effective in the self-management of a healthy diet, exercise, and medication adherence, but their influence on the physiological measures was not significant. One-way SMS text messages can be used as an affordable adjuvant method for lifestyle modification to help prevent the recurrence of cardiovascular disease. Trial Registration: Clinical Research Information Service (CRiS) KCT0005087; https://cris.nih.go.kr/cris/search/detailSearch.do/19282 UR - https://mhealth.jmir.org/2021/9/e29928 UR - http://dx.doi.org/10.2196/29928 UR - http://www.ncbi.nlm.nih.gov/pubmed/34559058 ID - info:doi/10.2196/29928 ER - TY - JOUR AU - Tuttle, Katherine AU - Kelemen, Arpad AU - Liang, Yulan PY - 2021/9/17 TI - Use of Smartphone Apps for Improving Physical Function Capacity in Cardiac Patient Rehabilitation: Systematic Review JO - JMIRx Med SP - e21906 VL - 2 IS - 3 KW - cardiac rehabilitation KW - physical capacity KW - exercise KW - smartphone apps N2 - Background: Cardiac rehabilitation (CR) is an evidence-based approach for preventing secondary cardiac events. Smartphone apps are starting to be used in CR to give patients real-time feedback on their health, connect them remotely with their medical team, and allow them to perform their rehabilitation at home. The use of smartphone apps is becoming omnipresent and has real potential in impacting patients in need of CR. Objective: This paper provides critical examinations and summaries of existing research studies with an in-depth analysis of not only the individual studies but also the larger patterns that have emerged with smartphone apps in CR as well as their significance for practice change. Methods: A systematic review was conducted through broad database searches that focused on evaluating randomized controlled trials, in compliance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) expectations. A total of 43 articles were evaluated, and 6 were chosen for this review. The dates of the articles ranged from 2014-2020, and the studies focused on the population of cardiac outpatients who needed CR after suffering a cardiac event, with interventions using a smartphone that incorporated the CR standards of the American Heart Association. The outcomes measured were directed at focusing on improved exercise function capacity, valued at a significance level of P<.05, for improved 6-minute walk test (6MWT) and peak oxygen uptake (PVO2) results. Results: In the evaluated articles, the results were inconsistent for significant positive effects of CR smartphone apps on cardiac patients? physical function capacity in terms of the 6MWT and PVO2 when using a smartphone app to aid in CR. Conclusions: Because evidence in the literature suggests nonhomogeneous results for successful use of smartphone apps in CR, it is crucial to investigate the potential reasons for this inconsistency. An important observation from this systematic review is that smartphone apps used in CR have better clinical outcomes related to physical function capacity if the app automatically records information or provides real-time feedback to participants about their progress, compared to apps that only educate and encourage use while requiring the participant to manually log their CR activities. Additional factors to consider during these studies include the starting health of the patients, the sample sizes, and the specific components of CR that the smartphone apps are using. Overall, more clinical trials are needed that implement smartphone apps with these factors in mind, while placing stronger emphasis on using biosensing capabilities that can automatically log results and send them to providers on a real-time dashboard. UR - https://med.jmirx.org/2021/3/e21906 UR - http://dx.doi.org/10.2196/21906 UR - http://www.ncbi.nlm.nih.gov/pubmed/37725554 ID - info:doi/10.2196/21906 ER - TY - JOUR AU - de Buisonjé, David AU - Van der Geer, Jessica AU - Keesman, Mike AU - Van der Vaart, Roos AU - Reijnders, Thomas AU - Wentzel, Jobke AU - Kemps, Hareld AU - Kraaijenhagen, Roderik AU - Janssen, Veronica AU - Evers, Andrea PY - 2021/8/30 TI - Financial Incentives for Healthy Living for Patients With Cardiac Disease From the Perspective of Health Care Professionals: Interview Study JO - JMIR Cardio SP - e27867 VL - 5 IS - 2 KW - financial incentives KW - material rewards KW - healthy lifestyle KW - cardiovascular disease KW - cardiac rehabilitation KW - CVD N2 - Background: A promising new approach to support lifestyle changes in patients with cardiovascular disease (CVD) is the use of financial incentives. Although financial incentives have proven to be effective, their implementation remains controversial, and ethical objections have been raised. It is unknown whether health care professionals (HCPs) involved in CVD care find it acceptable to provide financial incentives to patients with CVD as support for lifestyle change. Objective: This study aims to investigate HCPs? perspectives on using financial incentives to support healthy living for patients with CVD. More specifically, we aim to provide insight into attitudes toward using financial incentives as well as obstacles and facilitators of implementing financial incentives in current CVD care. Methods: A total of 16 semistructured, in-depth, face-to-face interviews were conducted with Dutch HCPs involved in supporting patients with CVD with lifestyle changes. The topics discussed were attitudes toward an incentive system, obstacles to using an incentive system, and possible solutions to facilitate the use of an incentive system. Results: HCPs perceived an incentive system for healthy living for patients with CVD as possibly effective and showed generally high acceptance. However, there were concerns related to focusing too much on the extrinsic aspects of lifestyle change, disengagement when rewards are insignificant, paternalization and threatening autonomy, and low digital literacy in the target group. According to HCPs, solutions to mitigate these concerns included emphasizing intrinsic aspects of healthy living while giving extrinsic rewards, integrating social aspects to increase engagement, supporting autonomy by allowing freedom of choice in rewards, and aiming for a target group that can work with the necessary technology. Conclusions: This study mapped perspectives of Dutch HCPs and showed that attitudes are predominantly positive, provided that contextual factors, design, and target groups are accurately considered. Concerns about digital literacy in the target group are novel findings that warrant further investigation. Follow-up research is needed to validate these insights among patients with CVD. UR - https://cardio.jmir.org/2021/2/e27867 UR - http://dx.doi.org/10.2196/27867 UR - http://www.ncbi.nlm.nih.gov/pubmed/34459748 ID - info:doi/10.2196/27867 ER - TY - JOUR AU - Maddison, Ralph AU - Jiang, Yannan AU - Stewart, Ralph AU - Scott, Tony AU - Kerr, Andrew AU - Whittaker, Robyn AU - Benatar, Jocelyn AU - Rolleston, Anna AU - Estabrooks, Paul AU - Dale, Leila PY - 2021/6/9 TI - An Intervention to Improve Medication Adherence in People With Heart Disease (Text4HeartII): Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e24952 VL - 9 IS - 6 KW - cardiovascular disease KW - self-management KW - text messaging KW - risk factors N2 - Background: Mobile health technologies have the potential to improve the reach and delivery of interventions for promoting long-term secondary prevention of coronary heart disease. Objective: This study aims to determine the effectiveness of an SMS text messaging intervention (Text4HeartII) for improving adherence to medication and lifestyle changes over and above usual care in people with coronary heart disease at 24 and 52 weeks. Methods: A two-arm, parallel, randomized controlled trial was conducted in New Zealand. Participants with a recent acute coronary syndrome were randomized to receive usual cardiac services alone (control, n=153) or a 24-week SMS text message program for supporting self-management plus usual cardiac services (n=153). The primary outcome was adherence to medication at 24 weeks, defined as a medication possession ratio of 80% or more for aspirin, statin, and antihypertensive therapy. Secondary outcomes included medication possession ratio at 52 weeks, self-reported medication adherence, adherence to healthy lifestyle behaviors, and health-related quality of life at 24 and 52 weeks. Results: Participants were predominantly male (113/306, 80.3%) and European New Zealanders (210/306, 68.6%), with a mean age of 61 years (SD 11 years). Groups were comparable at baseline. National hospitalization and pharmacy dispensing recordswere available for all participants; 92% (282/306, 92.1%) of participants completed a 24-week questionnaire and 95.1% (291/306) of participants completed a 52-week questionnaire. Adherence with 3 medication classes were lower in the intervention group than in the control group (87/153, 56.8% vs 105/153, 68.6%, odds ratio 0.60, 95% CI 0.38-0.96; P=.03) and 52 weeks (104/153, 67.9% vs 83/153, 54.2%; odds ratio 0.56, 95% CI 0.35-0.89; P=.01). Self-reported medication adherence scores showed the same trend at 52 weeks (mean difference 0.3; 95% CI 0.01-0.59; P=.04). Moreover, self-reported adherence to health-related behaviors was similar between groups. Conclusions: Text4HeartII did not improve dispensed medication or adherence to a favorable lifestyle over and above usual care. This finding contrasts with previous studies and highlights that the benefits of text interventions may depend on the context in which they are used. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000422426; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370398. International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-2468-z UR - https://mhealth.jmir.org/2021/6/e24952 UR - http://dx.doi.org/10.2196/24952 UR - http://www.ncbi.nlm.nih.gov/pubmed/34106081 ID - info:doi/10.2196/24952 ER - TY - JOUR AU - Lee, Jen-Kuang AU - Hung, Chi-Sheng AU - Huang, Ching-Chang AU - Chen, Ying-Hsien AU - Wu, Hui-Wen AU - Chuang, Pao-Yu AU - Yu, Jiun-Yu AU - Ho, Yi-Lwun PY - 2021/5/18 TI - The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study JO - J Med Internet Res SP - e24346 VL - 23 IS - 5 KW - peripheral artery disease KW - fourth-generation synchronous telehealth program KW - ischemic stroke KW - hospitalization KW - cardiovascular disease KW - telehealth KW - stroke KW - cost KW - benefit KW - heart N2 - Background: Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown. Objective: The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program. Methods: This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up. Results: The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs. Conclusions: The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings. UR - https://www.jmir.org/2021/5/e24346 UR - http://dx.doi.org/10.2196/24346 UR - http://www.ncbi.nlm.nih.gov/pubmed/34003132 ID - info:doi/10.2196/24346 ER - TY - JOUR AU - Ross, S. Emily AU - Sakakibara, M. Brodie AU - Mackay, H. Martha AU - Whitehurst, T. David G. AU - Singer, Joel AU - Toma, Mustafa AU - Corbett, K. Kitty AU - Van Spall, C. Harriette G. AU - Rutherford, Kimberly AU - Gheorghiu, Bobby AU - Code, Jillianne AU - Lear, A. Scott PY - 2021/5/14 TI - The Use of SMS Text Messaging to Improve the Hospital-to-Community Transition in Patients With Acute Coronary Syndrome (Txt2Prevent): Results From a Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e24530 VL - 9 IS - 5 KW - SMS text messaging KW - mHealth KW - acute coronary syndrome KW - cardiovascular disease N2 - Background: Acute coronary syndrome (ACS) is a leading cause of hospital admission in North America. Many patients with ACS experience challenges after discharge that impact their clinical outcomes and psychosocial well-being. SMS text messaging has the potential to provide support to patients during this postdischarge period. Objective: This study pilot tested a 60-day SMS text messaging intervention (Txt2Prevent) for patients with ACS. The primary objective was to compare self-management domains between usual care and usual care plus Txt2Prevent. The secondary objectives were to compare medication adherence, health-related quality of life, self-efficacy, and health care resource use between groups. The third objective was to assess the feasibility of the study protocol and the acceptability of the intervention. Methods: This was a randomized controlled trial with blinding of outcome assessors. We recruited 76 patients with ACS from St. Paul?s Hospital in Vancouver, Canada, and randomized them to 1 of 2 groups within 7 days of discharge. The Txt2Prevent program included automated 1-way SMS text messages about follow-up care, self-management, and healthy living. Data were collected during the index admission and at 60 days after randomization. The primary outcome was measured with the Health Education Impact Questionnaire (heiQ). Other outcomes included the EQ-5D-5L, EQ-5D-5L Visual Analog Scale, a modified Sullivan Cardiac Self-Efficacy Scale, and Morisky Medication Adherence Scale scores, and self-reported health care resource use. Analyses of covariance were used to test the effect of group assignment on follow-up scores (controlling for baseline) and were considered exploratory in nature. Feasibility was assessed with descriptive characteristics of the study protocol. Acceptability was assessed with 2 survey questions and semistructured interviews. Results: There were no statistically significant differences between the groups for the heiQ domains (adjusted mean difference [Txt2Prevent minus usual care] for each domain?Health-directed activity: ?0.13, 95% CI ?0.39 to 0.13, P=.31; Positive and active engagement in life: 0.03, 95% CI ?0.19 to 0.25, P=.76; Emotional distress: 0.04, 95% CI ?0.22 to 0.29, P=.77; Self-monitoring and insight: ?0.14, 95% CI ?0.33 to 0.05, P=.15; Constructive attitudes and approaches: ?0.10, 95% CI ?0.36 to 0.17, P=.47; Skill technique and acquisition: 0.05, 95% CI ?0.18 to 0.27, P=.69; Social integration and support: ?0.12, 95% CI ?0.34 to 0.10, P=.27; and Health services navigation: ?0.05, 95% CI ?0.29 to 0.19, P=.69). For the secondary outcomes, there were no statistically significant differences in adjusted analyses except in 1 self-efficacy domain (Total plus), where the Txt2Prevent group had lower scores (mean difference ?0.36, 95% CI ?0.66 to ?0.50, P=.03). The study protocol was feasible, but recruitment took longer than expected. Over 90% (29/31 [94%]) of participants reported they were satisfied with the program. Conclusions: The Txt2Prevent study was feasible to implement; however, although exploratory, there were no differences between the 2 groups in adjusted analyses except for 1 self-efficacy domain. As the intervention appeared acceptable, there is potential in using SMS text messages in this context. The design of the intervention may need to be reconsidered to have more impact on outcome measures. Trial Registration: ClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.6968 UR - https://mhealth.jmir.org/2021/5/e24530 UR - http://dx.doi.org/10.2196/24530 UR - http://www.ncbi.nlm.nih.gov/pubmed/33988519 ID - info:doi/10.2196/24530 ER - TY - JOUR AU - Iftikhar, Aleeha AU - Bond, Raymond AU - Mcgilligan, Victoria AU - Leslie, J. Stephen AU - Knoery, Charles AU - Shand, James AU - Ramsewak, Adesh AU - Sharma, Divyesh AU - McShane, Anne AU - Rjoob, Khaled AU - Peace, Aaron PY - 2021/3/2 TI - Human?Computer Agreement of Electrocardiogram Interpretation for Patients Referred to and Declined for Primary Percutaneous Coronary Intervention: Retrospective Data Analysis Study JO - JMIR Med Inform SP - e24188 VL - 9 IS - 3 KW - ECG interpretation KW - agreement between human and computer KW - primary percutaneous coronary intervention service KW - acute myocardial infarction KW - scan KW - electrocardiogram KW - heart KW - intervention KW - infarction KW - human-computer KW - diagnostic N2 - Background: When a patient is suspected of having an acute myocardial infarction, they are accepted or declined for primary percutaneous coronary intervention partly based on clinical assessment of their 12-lead electrocardiogram (ECG) and ST-elevation myocardial infarction criteria. Objective: We retrospectively determined the agreement rate between human (specialists called activator nurses) and computer interpretations of ECGs of patients who were declined for primary percutaneous coronary intervention. Methods: Various features of patients who were referred for primary percutaneous coronary intervention were analyzed. Both the human and computer ECG interpretations were simplified to either ?suggesting? or ?not suggesting? acute myocardial infarction to avoid analysis of complex heterogeneous and synonymous diagnostic terms. Analyses, to measure agreement, and logistic regression, to determine if these ECG interpretations (and other variables such as patient age, chest pain) could predict patient mortality, were carried out. Results: Of a total of 1464 patients referred to and declined for primary percutaneous coronary intervention, 722 (49.3%) computer diagnoses suggested acute myocardial infarction, whereas 634 (43.3%) of the human interpretations suggested acute myocardial infarction (P<.001). The human and computer agreed that there was a possible acute myocardial infarction for 342 out of 1464 (23.3%) patients. However, there was a higher rate of human?computer agreement for patients not having acute myocardial infarctions (450/1464, 30.7%). The overall agreement rate was 54.1% (792/1464). Cohen ? showed poor agreement (?=0.08, P=.001). Only the age (odds ratio [OR] 1.07, 95% CI 1.05-1.09) and chest pain (OR 0.59, 95% CI 0.39-0.89) independent variables were statistically significant (P=.008) in predicting mortality after 30 days and 1 year. The odds for mortality within 1 year of referral were lower in patients with chest pain compared to those patients without chest pain. A referral being out of hours was a trending variable (OR 1.41, 95% CI 0.95-2.11, P=.09) for predicting the odds of 1-year mortality. Conclusions: Mortality in patients who were declined for primary percutaneous coronary intervention was higher than the reported mortality for ST-elevation myocardial infarction patients at 1 year. Agreement between computerized and human ECG interpretation is poor, perhaps leading to a high rate of inappropriate referrals. Work is needed to improve computer and human decision making when reading ECGs to ensure that patients are referred to the correct treatment facility for time-critical therapy. UR - https://medinform.jmir.org/2021/3/e24188 UR - http://dx.doi.org/10.2196/24188 UR - http://www.ncbi.nlm.nih.gov/pubmed/33650984 ID - info:doi/10.2196/24188 ER - TY - JOUR AU - Bashi, Nazli AU - Varnfield, Marlien AU - Karunanithi, Mohanraj PY - 2020/12/18 TI - A Smartphone App for Patients With Acute Coronary Syndrome (MoTER-ACS): User-Centered Design Approach JO - JMIR Form Res SP - e17542 VL - 4 IS - 12 KW - mobile health KW - mHealth KW - mobile health apps KW - smartphone KW - mobile phone KW - self-management KW - patient education KW - cardiovascular disease KW - acute coronary syndrome N2 - Background: Postdischarge interventions are limited for patients with acute coronary syndrome (ACS) due to few scheduled visits to outpatient clinics and the need to travel from remote areas. Smartphones have become viable lifestyle technology to deliver home-based educational and health interventions. Objective: The aim of this study was to develop a smartphone-based intervention for providing postdischarge support to patients with ACS. Methods: The content of Mobile Technology?Enabled Rehabilitation for Patients with ACS (MoTER-ACS) was derived from a series of small studies, termed prestudy surveys, conducted in 2017. The prestudy surveys were conducted in Prince Charles Hospital, Queensland, Australia, and consisted of questionnaires among a convenience sample of patients with ACS (n=30), a focus group discussion with health care professionals (n=10), and an online survey among cardiologists (n=15). Responses from the patient survey identified educational topics of MoTER-ACS. The focus group with health care professionals assisted with identifying educational materials, health monitoring, and self-management interventions. Based on the results of the cardiologists? survey, monitoring of symptoms related to heart failure exacerbation was considered as a weekly diary. Results: The MoTER-ACS app covers multimedia educational materials to adopt a healthy lifestyle and includes user-friendly tools to monitor physiological and health parameters such as blood pressure, weight, and pain, assisting patients in self-managing their condition. A web portal that is linked to the data from the smartphone app is available to clinicians to regularly access patients? data and provide support. Conclusions: The MoTER-ACS platform extends the capabilities of previous mobile health platforms by providing a home-based educational and self-management intervention for patients with ACS following discharge from the hospital. The MoTER-ACS intervention narrows the gap between existing hospital-based programs and home-based interventions by complementing the postdischarge program for patients with ACS. UR - http://formative.jmir.org/2020/12/e17542/ UR - http://dx.doi.org/10.2196/17542 UR - http://www.ncbi.nlm.nih.gov/pubmed/33337339 ID - info:doi/10.2196/17542 ER - TY - JOUR AU - Subedi, Narayan AU - Rawstorn, C. Jonathan AU - Gao, Lan AU - Koorts, Harriet AU - Maddison, Ralph PY - 2020/11/27 TI - Implementation of Telerehabilitation Interventions for the Self-Management of Cardiovascular Disease: Systematic Review JO - JMIR Mhealth Uhealth SP - e17957 VL - 8 IS - 11 KW - heart diseases KW - cardiac rehabilitation KW - telerehabilitation KW - implementation science KW - smartphone KW - systematic review N2 - Background: Coronary heart disease (CHD) is a leading cause of disability and deaths worldwide. Secondary prevention, including cardiac rehabilitation (CR), is crucial to improve risk factors and to reduce disease burden and disability. Accessibility barriers contribute to underutilization of traditional center-based CR programs; therefore, alternative delivery models, including cardiac telerehabilitation (ie, delivery via mobile, smartphone, and/or web-based apps), have been tested. Experimental studies have shown cardiac telerehabilitation to be effective and cost-effective, but there is inadequate evidence about how to translate this research into routine clinical practice. Objective: This systematic review aimed to synthesize research evaluating the effectiveness of implementing cardiac telerehabilitation interventions at scale in routine clinical practice, including factors underlying successful implementation processes, and experimental research evaluating implementation-related outcomes. Methods: MEDLINE, Embase, PsycINFO, and Global Health databases were searched from 1990 through November 9, 2018, for studies evaluating the implementation of telerehabilitation for the self-management of CHD. Reference lists of included studies and relevant systematic reviews were hand searched to identify additional studies. Implementation outcomes of interest included acceptability, appropriateness, adoption, feasibility, fidelity, implementation cost, penetration, and sustainability. A narrative synthesis of results was carried out. Results: No included studies evaluated the implementation of cardiac telerehabilitation in routine clinical practice. A total of 10 studies of 2250 participants evaluated implementation outcomes, including acceptability (8/10, 80%), appropriateness (9/10, 90%), adoption (6/10, 60%), feasibility (6/10, 60%), fidelity (7/10, 70%), and implementation cost (4/10, 40%), predominantly from the participant perspective. Cardiac telerehabilitation interventions had high acceptance among the majority of participants, but technical challenges such as reliable broadband internet connectivity can impact acceptability and feasibility. Many participants considered telerehabilitation to be an appropriate alternative CR delivery model, as it was convenient, flexible, and easy to access. Participants valued interactive intervention components, such as real-time exercise monitoring and feedback as well as individualized support. The penetration and sustainability of cardiac telerehabilitation, as well as the perspectives of CR practitioners and health care organizations, have received little attention in existing cardiac telerehabilitation research. Conclusions: Experimental trials suggest that participants perceive cardiac telerehabilitation to be an acceptable and appropriate approach to improve the reach and utilization of CR, but pragmatic implementation studies are needed to understand how interventions can be sustainably translated from research into clinical practice. Addressing this gap could help realize the potential impact of telerehabilitation on CR accessibility and participation as well as person-centered, health, and economic outcomes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019124254; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=124254 UR - http://mhealth.jmir.org/2020/11/e17957/ UR - http://dx.doi.org/10.2196/17957 UR - http://www.ncbi.nlm.nih.gov/pubmed/33245286 ID - info:doi/10.2196/17957 ER - TY - JOUR AU - Maier, Rebecca AU - Bawamia, Bilal AU - Bennaceur, Karim AU - Dunn, Sarah AU - Marsay, Leanne AU - Amoah, Roland AU - Kasim, Adetayo AU - Filby, Andrew AU - Austin, David AU - Hancock, Helen AU - Spyridopoulos, Ioakim PY - 2020/9/23 TI - Telomerase Activation to Reverse Immunosenescence in Elderly Patients With Acute Coronary Syndrome: Protocol for a Randomized Pilot Trial JO - JMIR Res Protoc SP - e19456 VL - 9 IS - 9 KW - coronary heart disease KW - acute coronary syndrome KW - immunosenescence KW - telomerase activator N2 - Background: Inflammation plays a key role in the pathophysiology of coronary heart disease (CHD) and its acute manifestation, acute coronary syndrome (ACS). Aging is associated with a decline of the immune system, a process known as immunosenescence. This is characterized by an increase in highly proinflammatory T cells that are involved in CHD progression, plaque destabilization, and myocardial ischemia?reperfusion injury. Telomere dysfunction has been implicated in immunosenescence of T lymphocytes. Telomerase is the enzyme responsible for maintaining telomeres during cell divisions. It has a protective effect on cells under oxidative stress and helps regulate flow-mediated dilation in microvasculature. Objective: The TACTIC (Telomerase ACTivator to reverse Immunosenescence in Acute Coronary Syndrome) trial will investigate whether a telomerase activator, TA-65MD, can reduce the proportion of senescent T cells in patients with ACS with confirmed CHD. It will also assess the effect of TA-65MD on decreasing telomere shortening, reducing oxidative stress, and improving endothelial function. Methods: The study was designed as a single-center, randomized, double-blind, parallel-group, placebo-controlled phase II trial. Recruitment started in January 2019. A total of 90 patients, aged 65 years or older, with treated ACS who have had CHD confirmed by angiography will be enrolled. They will be randomized to one of two groups: TA-65MD oral therapy (8 mg twice daily) or placebo taken for 12 months. The primary outcome is the effect on immunosenescence determined by a decrease in the proportion of CD8+ TEMRA (T effector memory cells re-expressing CD45RA [CD45 expressing exon A]) cells at 12 months. Secondary outcomes include leukocyte telomere length, endothelial function, cardiac function as measured by echocardiography and NT-proBNP (N-terminal fragment of the prohormone brain-type natriuretic peptide), systemic inflammation, oxidative stress, and telomerase activity. Results: The study received National Health Service (NHS) ethics approval on August 9, 2018; Medicines and Healthcare products Regulatory Agency approval on October 19, 2018; and NHS Health Research Authority approval on October 22, 2018. The trial began recruiting participants in January 2019 and completed recruitment in March 2020; the trial is due to report results in 2021. Conclusions: This pilot trial in older patients with CHD will explore outcomes not previously investigated outside in vitro or preclinical models. The robust design ensures that bias has been minimized. Should the results indicate reduced frequency of immunosenescent CD8+ T cells as well as improvements in telomere length and endothelial function, we will plan a larger, multicenter trial in patients to determine if TA-65MD is beneficial in the treatment of CHD in elderly patients. Trial Registration: ISRCTN Registry ISRCTN16613292; http://www.isrctn.com/ISRCTN16613292 and European Union Drug Regulating Authorities Clinical Trials Database (EudraCT), European Union Clinical Trials Register 2017-002876-26; https://tinyurl.com/y4m2so8g International Registered Report Identifier (IRRID): DERR1-10.2196/19456 UR - http://www.researchprotocols.org/2020/9/e19456/ UR - http://dx.doi.org/10.2196/19456 UR - http://www.ncbi.nlm.nih.gov/pubmed/32965237 ID - info:doi/10.2196/19456 ER - TY - JOUR AU - Senecal, Conor AU - Gulati, Rajiv AU - Lerman, Amir PY - 2020/8/24 TI - Google Trends Insights Into Reduced Acute Coronary Syndrome Admissions During the COVID-19 Pandemic: Infodemiology Study JO - JMIR Cardio SP - e20426 VL - 4 IS - 1 KW - Google Trends KW - acute coronary syndrome KW - coronary heart disease KW - online search KW - internet KW - trend KW - COVID-19 KW - heart KW - cardiovascular N2 - Background: During the coronavirus disease (COVID-19) pandemic, a reduction in the presentation of acute coronary syndrome (ACS) has been noted in several countries. However, whether these trends reflect a reduction in ACS incidence or a decrease in emergency room visits is unknown. Using Google Trends, queries for chest pain that have previously been shown to closely correlate with coronary heart disease were compared with searches for myocardial infarction and COVID-19 symptoms. Objective: The current study evaluates if search terms (or topics) pertaining to chest pain symptoms correlate with the reported decrease in presentations of ACS. Methods: Google Trends data for search terms ?chest pain,? ?myocardial infarction,? ?cough,? and ?fever? were obtained from June 1, 2019, to May 31, 2020. Related queries were evaluated for a relationship to coronary heart disease. Results: Following the onset of the COVID-19 pandemic, chest pain searches increased in all countries studied by at least 34% (USA P=.003, Spain P=.007, UK P=.001, Italy P=.002), while searches for myocardial infarction dropped or remained unchanged. Rising searches for chest pain included ?coronavirus chest pain,? ?home remedies for chest pain,? and ?natural remedies for chest pain.? Searches on COVID-19 symptoms (eg, cough, fever) rose initially but returned to baseline while chest pain?related searches remained elevated throughout May. Conclusions: Search engine queries for chest pain have risen during the pandemic as have related searches with alternative attribution for chest pain or home care for chest pain, suggesting that recent drops in ACS presentations may be due to patients avoiding the emergency room and potential treatment in the midst of the COVID-19 pandemic. UR - http://cardio.jmir.org/2020/1/e20426/ UR - http://dx.doi.org/10.2196/20426 UR - http://www.ncbi.nlm.nih.gov/pubmed/32831186 ID - info:doi/10.2196/20426 ER - TY - JOUR AU - Brørs, Gunhild AU - Wentzel-Larsen, Tore AU - Dalen, Håvard AU - Hansen, B. Tina AU - Norman, D. Cameron AU - Wahl, Astrid AU - Norekvål, M. Tone AU - PY - 2020/7/28 TI - Psychometric Properties of the Norwegian Version of the Electronic Health Literacy Scale (eHEALS) Among Patients After Percutaneous Coronary Intervention: Cross-Sectional Validation Study JO - J Med Internet Res SP - e17312 VL - 22 IS - 7 KW - eHealth literacy KW - eHEALS KW - health literacy KW - percutaneous coronary intervention KW - psychometric properties KW - validation N2 - Background: Web-based technology has recently become an important source for sharing health information with patients after an acute cardiac event. Therefore, consideration of patients? perceived electronic health (eHealth) literacy skills is crucial for improving the delivery of patient-centered health information. Objective: The aim of this study was to translate and adapt the eHealth Literacy Scale (eHEALS) to conditions in Norway, and to determine its psychometric properties. More specifically, we set out to determine the reliability (internal consistency, test-retest) and construct validity (structural validity, hypotheses testing, and cross-cultural validity) of the eHEALS in self-report format administered to patients after percutaneous coronary intervention. Methods: The original English version of the eHEALS was translated into Norwegian following a widely used cross-cultural adaptation process. Internal consistency was calculated using Cronbach ?. The intraclass correlation coefficient (ICC) was used to assess the test-retest reliability. Confirmatory factor analysis (CFA) was performed for a priori-specified 1-, 2-, and 3-factor models. Demographic, health-related internet use, health literacy, and health status information was collected to examine correlations with eHEALS scores. Results: A total of 1695 patients after percutaneous coronary intervention were included in the validation analysis. The mean age was 66 years, and the majority of patients were men (1313, 77.46%). Cronbach ? for the eHEALS was >.99. The corresponding Cronbach ? for the 2-week retest was .94. The test-retest ICC for eHEALS was 0.605 (95% CI 0.419-0.743, P<.001). The CFA showed a modest model fit for the 1- and 2-factor models (root mean square error of approximation>0.06). After modifications in the 3-factor model, all of the goodness-of-fit indices indicated a good fit. There was a weak correlation with age (r=?0.206). Between-groups analysis of variance showed a difference according to educational groups and the eHEALS score, with a mean difference ranging from 2.24 (P=.002) to 4.61 (P<.001), and a higher eHEALS score was found for patients who were employed compared to those who were retired (mean difference 2.31, P<.001). The eHEALS score was also higher among patients who reported using the internet to find health information (95% CI ?21.40 to ?17.21, P<.001), and there was a moderate correlation with the patients? perceived usefulness (r=0.587) and importance (r=0.574) of using the internet for health information. There were also moderate correlations identified between the eHEALS score and the health literacy domains appraisal of health information (r=0.380) and ability to find good health information (r=0.561). Weak correlations with the mental health composite score (r=0.116) and physical health composite score (r=0.116) were identified. Conclusions: This study provides new information on the psychometric properties of the eHEALS for patients after percutaneous coronary intervention, suggesting a multidimensional rather than unidimensional construct. However, the study also indicated a redundancy of items, indicating the need for further validation studies. Trial Registration: ClinicalTrials.gov NCT03810612; https://clinicaltrials.gov/ct2/show/NCT03810612 UR - https://www.jmir.org/2020/7/e17312 UR - http://dx.doi.org/10.2196/17312 UR - http://www.ncbi.nlm.nih.gov/pubmed/32720900 ID - info:doi/10.2196/17312 ER - TY - JOUR AU - Du, Zhenzhen AU - Yang, Yujie AU - Zheng, Jing AU - Li, Qi AU - Lin, Denan AU - Li, Ye AU - Fan, Jianping AU - Cheng, Wen AU - Chen, Xie-Hui AU - Cai, Yunpeng PY - 2020/7/6 TI - Accurate Prediction of Coronary Heart Disease for Patients With Hypertension From Electronic Health Records With Big Data and Machine-Learning Methods: Model Development and Performance Evaluation JO - JMIR Med Inform SP - e17257 VL - 8 IS - 7 KW - coronary heart disease KW - machine learning KW - electronic health records KW - predictive algorithms KW - hypertension N2 - Background: Predictions of cardiovascular disease risks based on health records have long attracted broad research interests. Despite extensive efforts, the prediction accuracy has remained unsatisfactory. This raises the question as to whether the data insufficiency, statistical and machine-learning methods, or intrinsic noise have hindered the performance of previous approaches, and how these issues can be alleviated. Objective: Based on a large population of patients with hypertension in Shenzhen, China, we aimed to establish a high-precision coronary heart disease (CHD) prediction model through big data and machine-learning Methods: Data from a large cohort of 42,676 patients with hypertension, including 20,156 patients with CHD onset, were investigated from electronic health records (EHRs) 1-3 years prior to CHD onset (for CHD-positive cases) or during a disease-free follow-up period of more than 3 years (for CHD-negative cases). The population was divided evenly into independent training and test datasets. Various machine-learning methods were adopted on the training set to achieve high-accuracy prediction models and the results were compared with traditional statistical methods and well-known risk scales. Comparison analyses were performed to investigate the effects of training sample size, factor sets, and modeling approaches on the prediction performance. Results: An ensemble method, XGBoost, achieved high accuracy in predicting 3-year CHD onset for the independent test dataset with an area under the receiver operating characteristic curve (AUC) value of 0.943. Comparison analysis showed that nonlinear models (K-nearest neighbor AUC 0.908, random forest AUC 0.938) outperform linear models (logistic regression AUC 0.865) on the same datasets, and machine-learning methods significantly surpassed traditional risk scales or fixed models (eg, Framingham cardiovascular disease risk models). Further analyses revealed that using time-dependent features obtained from multiple records, including both statistical variables and changing-trend variables, helped to improve the performance compared to using only static features. Subpopulation analysis showed that the impact of feature design had a more significant effect on model accuracy than the population size. Marginal effect analysis showed that both traditional and EHR factors exhibited highly nonlinear characteristics with respect to the risk scores. Conclusions: We demonstrated that accurate risk prediction of CHD from EHRs is possible given a sufficiently large population of training data. Sophisticated machine-learning methods played an important role in tackling the heterogeneity and nonlinear nature of disease prediction. Moreover, accumulated EHR data over multiple time points provided additional features that were valuable for risk prediction. Our study highlights the importance of accumulating big data from EHRs for accurate disease predictions. UR - https://medinform.jmir.org/2020/7/e17257 UR - http://dx.doi.org/10.2196/17257 UR - http://www.ncbi.nlm.nih.gov/pubmed/32628616 ID - info:doi/10.2196/17257 ER - TY - JOUR AU - Sengupta, Avijit AU - Beckie, Theresa AU - Dutta, Kaushik AU - Dey, Arup AU - Chellappan, Sriram PY - 2020/6/3 TI - A Mobile Health Intervention System for Women With Coronary Heart Disease: Usability Study JO - JMIR Form Res SP - e16420 VL - 4 IS - 6 KW - coronary heart disease KW - mobile health technology KW - behavior change interventions KW - women KW - mobile phone N2 - Background: Coronary heart disease (CHD) is the leading cause of death and disability among American women. The prevalence of CHD is expected to increase by more than 40% by 2035. In 2015, the estimated cost of caring for patients with CHD was US $182 billion in the United States; hospitalizations accounted for more than half of the costs. Compared with men, women with CHD or those who have undergone coronary revascularization have up to 30% more rehospitalizations within 30 days and up to 1 year. Center-based cardiac rehabilitation is the gold standard of care after an acute coronary event, but few women attend these valuable programs. Effective home-based interventions for improving cardiovascular health among women with CHD are vital for addressing this gap in care. Objective: The ubiquity of mobile phones has made mobile health (mHealth) behavioral interventions a viable option to improve healthy behaviors of both women and men with CHD. First, this study aimed to examine the usability of a prototypic mHealth intervention designed specifically for women with CHD (herein referred to as HerBeat). Second, we examined the influence of HerBeat on selected health behaviors (self-efficacy for diet, exercise, and managing chronic illness) and psychological (perceived stress and depressive symptoms) characteristics of the participants. Methods: Using a single-group, pretest, posttest design, 10 women participated in the 12-week usability study. Participants were provided a smartphone and a smartwatch on which the HerBeat app was installed. Using a web portal dashboard, a health coach monitored participants? ecological momentary assessment data, their behavioral data, and their heart rate and step count. Participants then completed a 12-week follow-up assessment. Results: All 10 women (age: mean 64.4 years, SD 6.3 years) completed the study. The usability and acceptability of HerBeat were good, with a mean system usability score of 83.60 (SD 16.3). The participants demonstrated statistically significant improvements in waist circumference (P=.048), weight (P=.02), and BMI (P=.01). Furthermore, depressive symptoms, measured with the Patient Health Questionnaire-9, significantly improved from baseline (P=.04). Conclusions: The mHealth prototype was feasible and usable for women with CHD. Participants provided data that were useful for further development of HerBeat. The mHealth intervention is expected to help women with CHD self-manage their health behaviors. A randomized controlled trial is needed to further verify the findings. UR - https://formative.jmir.org/2020/6/e16420 UR - http://dx.doi.org/10.2196/16420 UR - http://www.ncbi.nlm.nih.gov/pubmed/32348270 ID - info:doi/10.2196/16420 ER - TY - JOUR AU - Bennasar, Mohamed AU - Banks, Duncan AU - Price, A. Blaine AU - Kardos, Attila PY - 2020/5/29 TI - Minimal Patient Clinical Variables to Accurately Predict Stress Echocardiography Outcome: Validation Study Using Machine Learning Techniques JO - JMIR Cardio SP - e16975 VL - 4 IS - 1 KW - stress echocardiography KW - coronary heart disease KW - risk factors KW - machine learning KW - feature selection KW - risk prediction N2 - Background: Stress echocardiography is a well-established diagnostic tool for suspected coronary artery disease (CAD). Cardiovascular risk factors are used in the assessment of the probability of CAD. The link between the outcome of stress echocardiography and patients? variables including risk factors, current medication, and anthropometric variables has not been widely investigated. Objective: This study aimed to use machine learning to predict significant CAD defined by positive stress echocardiography results in patients with chest pain based on anthropometrics, cardiovascular risk factors, and medication as variables. This could allow clinical prioritization of patients with likely prediction of CAD, thus saving clinician time and improving outcomes. Methods: A machine learning framework was proposed to automate the prediction of stress echocardiography results. The framework consisted of four stages: feature extraction, preprocessing, feature selection, and classification stage. A mutual information?based feature selection method was used to investigate the amount of information that each feature carried to define the positive outcome of stress echocardiography. Two classification algorithms, support vector machine (SVM) and random forest classifiers, have been deployed. Data from 529 patients were used to train and validate the framework. Patient mean age was 61 (SD 12) years. The data consists of anthropological data and cardiovascular risk factors such as gender, age, weight, family history, diabetes, smoking history, hypertension, hypercholesterolemia, prior diagnosis of CAD, and prescribed medications at the time of the test. There were 82 positive (abnormal) and 447 negative (normal) stress echocardiography results. The framework was evaluated using the whole dataset including cases with prior diagnosis of CAD. Five-fold cross-validation was used to validate the performance of the framework. We also investigated the model in the subset of patients with no prior CAD. Results: The feature selection methods showed that prior diagnosis of CAD, sex, and prescribed medications such as angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were the features that shared the most information about the outcome of stress echocardiography. SVM classifiers showed the best trade-off between sensitivity and specificity and was achieved with three features. Using only these three features, we achieved an accuracy of 67.63% with sensitivity and specificity 72.87% and 66.67% respectively. However, for patients with no prior diagnosis of CAD, only two features (sex and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use) were needed to achieve accuracy of 70.32% with sensitivity and specificity at 70.24%. Conclusions: This study shows that machine learning can predict the outcome of stress echocardiography based on only a few features: patient prior cardiac history, gender, and prescribed medication. Further research recruiting higher number of patients who underwent stress echocardiography could further improve the performance of the proposed algorithm with the potential of facilitating patient selection for early treatment/intervention avoiding unnecessary downstream testing. UR - http://cardio.jmir.org/2020/1/e16975/ UR - http://dx.doi.org/10.2196/16975 UR - http://www.ncbi.nlm.nih.gov/pubmed/32469316 ID - info:doi/10.2196/16975 ER - TY - JOUR AU - Fortunato, Michael AU - Adusumalli, Srinath AU - Chokshi, Neel AU - Harrison, Joseph AU - Rareshide, Charles AU - Patel, Mitesh PY - 2020/4/7 TI - Usability of Wearable Devices to Remotely Monitor Sleep Patterns Among Patients With Ischemic Heart Disease: Observational Study JO - JMIR Form Res SP - e14508 VL - 4 IS - 4 KW - sleep KW - wearable devices KW - ischemic heart disease N2 - Background: There is growing interest in using wearable devices to remotely monitor patient behaviors. However, there has been little evaluation of how often these technologies are used to monitor sleep patterns over longer term periods, particularly among more high-risk patients. Objective: The goal of the research was to evaluate the proportion of time that patients with ischemic heart disease used wearable devices to monitor their sleep and identify differences in characteristics of patients with higher versus lower use. Methods: We evaluated wearable device data from a previously conducted clinical trial testing the use of wearable devices with personalized goal-setting and financial incentives. Patients with ischemic heart disease established a sleep baseline and were then followed for 24 weeks. The proportion of days that sleep data was collected was compared over the 24 weeks and by study arm. Characteristics of patients were compared to groups with high, low, or no sleep data. Results: The sample comprised 99 patients with ischemic heart disease, among which 79% (78/99) used the wearable device to track their sleep. During the 6-month trial, sleep data were collected on 60% (10,024/16,632) of patient-days. These rates declined over time from 77% (4292/5544) in months 1 and 2 to 58% (3188/5544) in months 3 and 4 to 46% (2544/5544) in months 5 and 6. Sleep data were collected at higher rates among the intervention group compared with control (67% vs 55%, P<.001). In the main intervention period (months 3 and 4), patients with higher rates of sleep data were on average older (P=.03), had a history of smoking (P=.007), and had higher rates of commercial health insurance (P=.03). Conclusions: Among patients with ischemic heart disease in a physical activity trial, a high proportion used wearable devices to track their sleep; however, rates declined over time. Future research should consider larger evaluations coupled with behavioral interventions. Trial Registration: ClinicalTrials.gov NCT02531022; https://clinicaltrials.gov/ct2/show/NCT02531022 UR - https://formative.jmir.org/2020/4/e14508 UR - http://dx.doi.org/10.2196/14508 UR - http://www.ncbi.nlm.nih.gov/pubmed/32254044 ID - info:doi/10.2196/14508 ER - TY - JOUR AU - Herkert, Cyrille AU - Kraal, Johannes Jos AU - van Loon, Agnes Eline Maria AU - van Hooff, Martijn AU - Kemps, Clemens Hareld Marijn PY - 2019/12/19 TI - Usefulness of Modern Activity Trackers for Monitoring Exercise Behavior in Chronic Cardiac Patients: Validation Study JO - JMIR Mhealth Uhealth SP - e15045 VL - 7 IS - 12 KW - cardiac diseases KW - activity trackers KW - energy metabolism KW - physical activity KW - validation studies N2 - Background: Improving physical activity (PA) is a core component of secondary prevention and cardiac (tele)rehabilitation. Commercially available activity trackers are frequently used to monitor and promote PA in cardiac patients. However, studies on the validity of these devices in cardiac patients are scarce. As cardiac patients are being advised and treated based on PA parameters measured by these devices, it is highly important to evaluate the accuracy of these parameters in this specific population. Objective: The aim of this study was to determine the accuracy and responsiveness of 2 wrist-worn activity trackers, Fitbit Charge 2 (FC2) and Mio Slice (MS), for the assessment of energy expenditure (EE) in cardiac patients. Methods: EE assessed by the activity trackers was compared with indirect calorimetry (Oxycon Mobile [OM]) during a laboratory activity protocol. Two groups were assessed: patients with stable coronary artery disease (CAD) with preserved left ventricular ejection fraction (LVEF) and patients with heart failure with reduced ejection fraction (HFrEF). Results: A total of 38 patients were included: 19 with CAD and 19 with HFrEF (LVEF 31.8%, SD 7.6%). The CAD group showed no significant difference in total EE between FC2 and OM (47.5 kcal, SD 112 kcal; P=.09), in contrast to a significant difference between MS and OM (88 kcal, SD 108 kcal; P=.003). The HFrEF group showed significant differences in EE between FC2 and OM (38 kcal, SD 57 kcal; P=.01), as well as between MS and OM (106 kcal, SD 167 kcal; P=.02). Agreement of the activity trackers was low in both groups (CAD: intraclass correlation coefficient [ICC] FC2=0.10, ICC MS=0.12; HFrEF: ICC FC2=0.42, ICC MS=0.11). The responsiveness of FC2 was poor, whereas MS was able to detect changes in cycling loads only. Conclusions: Both activity trackers demonstrated low accuracy in estimating EE in cardiac patients and poor performance to detect within-patient changes in the low-to-moderate exercise intensity domain. Although the use of activity trackers in cardiac patients is promising and could enhance daily exercise behavior, these findings highlight the need for population-specific devices and algorithms. UR - http://mhealth.jmir.org/2019/12/e15045/ UR - http://dx.doi.org/10.2196/15045 UR - http://www.ncbi.nlm.nih.gov/pubmed/31855191 ID - info:doi/10.2196/15045 ER - TY - JOUR AU - Lima, Paula Ana AU - Nascimento, Oliveira Isabella AU - Oliveira, A. Anne Caroline AU - Martins, S. Thiago Henrique AU - Pereira, Gomes Danielle A. AU - Britto, Rodrigues Raquel PY - 2019/11/7 TI - Home-Based Cardiac Rehabilitation in Brazil?s Public Health Care: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e13901 VL - 8 IS - 11 KW - cardiac rehabilitation KW - coronary disease KW - exercise N2 - Background: Coronary artery disease (CAD) is among the main causes of hospitalization and death worldwide, therefore, the implementation of programs to reduce its impact is necessary. Supervised cardiac rehabilitation has been shown to have positive effects on CAD control. However, there are barriers to patient participation in the traditional, face-to-face cardiac rehabilitation programs, mainly in low-resource environments. Objective: This study aimed to verify patient compliance to a home-based cardiac rehabilitation program, which includes unsupervised health education and physical exercises, guided by telephone. Moreover, we compare this new method to the traditional supervised cardiac rehabilitation offered in most hospital centers. Methods: We present here a two-arm, single-blinded, and randomized controlled design protocol, which compares the traditional cardiac rehabilitation (CenterRehab) with the home-based cardiac rehabilitation (Home-Based) in 72 patients affected by CAD. The primary outcome is the compliance to the cardiac rehabilitation sessions. The secondary outcomes (to evaluate effectiveness) include measurable variables such as functional capacity, CAD risk factors (blood pressure, waist circumference, glycemic, cholesterol levels, depressive symptoms, and the level of physical activity), the patient?s quality of life, the disease knowledge, and the morbidity rate. Parameters such as the program cost and the usability will also be evaluated. The programs will last 12 weeks, with a total of 60 rehabilitation and 6 educational sessions. Patients of the CenterRehab program will participate in 24 supervised sessions and 36 home sessions, while the patients of the Home-Based program will participate in 2 supervised sessions and 58 home sessions, guided by telephone. After the 12-week period all participants will be recommended to continue practicing physical exercises at home or at a community center, and they will be invited for re-evaluation after 3 months. The outcomes will be evaluated at baseline, and after 3 and 6 months. Results: Participants are currently being recruited for the trial. Data collection is anticipated to be completed by October 2019. Conclusions: This is the first study in Brazil comparing the traditional cardiac rehabilitation approach with a novel, home-based protocol that uses an accessible and low-cost technology. If positive results are obtained, the study will contribute to establish a new and viable model of cardiac rehabilitation. Trial Registration: ClinicalTrials.gov NCT03605992; https://clinicaltrials.gov/ct2/show/NCT03605992 International Registered Report Identifier (IRRID): DERR1-10.2196/13901 UR - https://www.researchprotocols.org/2019/11/e13901 UR - http://dx.doi.org/10.2196/13901 UR - http://www.ncbi.nlm.nih.gov/pubmed/31697246 ID - info:doi/10.2196/13901 ER - TY - JOUR AU - Kentgen, Markus AU - Varghese, Julian AU - Samol, Alexander AU - Waltenberger, Johannes AU - Dugas, Martin PY - 2019/08/23 TI - Common Data Elements for Acute Coronary Syndrome: Analysis Based on the Unified Medical Language System JO - JMIR Med Inform SP - e14107 VL - 7 IS - 3 KW - common data elements KW - acute coronary syndrome KW - documentation KW - standardization N2 - Background: Standardization in clinical documentation can increase efficiency and can save time and resources. Objective: The objectives of this work are to compare documentation forms for acute coronary syndrome (ACS), check for standardization, and generate a list of the most common data elements using semantic form annotation with the Unified Medical Language System (UMLS). Methods: Forms from registries, studies, risk scores, quality assurance, official guidelines, and routine documentation from four hospitals in Germany were semantically annotated using UMLS. This allowed for automatic comparison of concept frequencies and the generation of a list of the most common concepts. Results: A total of 3710 forms items from 86 sources were semantically annotated using 842 unique UMLS concepts. Half of all medical concept occurrences were covered by 60 unique concepts, which suggests the existence of a core dataset of relevant concepts. Overlap percentages between forms were relatively low, hinting at inconsistent documentation structures and lack of standardization. Conclusions: This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the European Society for Cardiology have not yet been fully implemented. Utilizing a standardized and annotated core dataset of the most important data concepts could make export and automatic reuse of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach. UR - http://medinform.jmir.org/2019/3/e14107/ UR - http://dx.doi.org/10.2196/14107 UR - http://www.ncbi.nlm.nih.gov/pubmed/31444871 ID - info:doi/10.2196/14107 ER - TY - JOUR AU - Sankaran, Supraja AU - Dendale, Paul AU - Coninx, Karin PY - 2019/04/04 TI - Evaluating the Impact of the HeartHab App on Motivation, Physical Activity, Quality of Life, and Risk Factors of Coronary Artery Disease Patients: Multidisciplinary Crossover Study JO - JMIR Mhealth Uhealth SP - e10874 VL - 7 IS - 4 KW - heart diseases KW - cardiac rehabilitation KW - human factors engineering KW - evaluation studies KW - telerehabilitation KW - mobile app KW - multidisciplinary research N2 - Background: Telerehabilitation approaches have been successful in supporting coronary artery disease (CAD) patients to rehabilitate at home after hospital-based rehabilitation. However, on completing a telerehabilitation program, the effects are not sustained beyond the intervention period because of the lack of lifestyle adaptations. Furthermore, decline in patients? motivation lead to recurrence of disease and increased rehospitalization rates. We developed HeartHab, using persuasive design principles and personalization, to enable sustenance of rehabilitation effects beyond the intervention period. HeartHab promotes patients? understanding, motivates them to reach personalized rehabilitation goals, and helps to maintain positive lifestyle adaptations during telerehabilitation. Objective: This study aimed to investigate the impact of the HeartHab app on patients? overall motivation, increasing physical activities, reaching exercise targets, quality of life, and modifiable risk factors in patients with CAD during telerehabilitation. The study also investigated carryover effects to determine the maintenance of effects after the conclusion of the intervention. Methods: A total of 32 CAD patients were randomized on a 1:1 ratio to telerehabilitation or usual care. We conducted a 4-month crossover study with a crossover point at 2 months using a mixed-methods approach for evaluation. We collected qualitative data on users? motivation, user experience, and quality of life using questionnaires, semistructured interviews and context-based sentiment analysis. Quantitative data on health parameters, exercise capacity, and risk factors were gathered from blood tests and ergo-spirometry tests. Data procured during the app usage phase were compared against baseline values to assess the impact of the app on parameters such as motivation, physical activity, quality of life, and risk factors. Carryover effects were used to gather insights on the maintenance of effects. Results: The qualitative data showed that 75% (21/28) of patients found the HeartHab app motivating and felt encouraged to achieve their rehabilitation targets. 84% (21/25) of patients either reached or exceeded their prescribed physical activity targets. We found positive significant effects on glycated hemoglobin (P=.01; d=1.03; 95% CI 0.24-1.82) with a mean decrease of 1.5 mg/dL and high-density lipoprotein (HDL) cholesterol (P=.04; d=0.78; 95% CI 0.02-1.55) with a mean increase of 0.61 mg/dL after patients used the HeartHab app. We observed significant carryover effects on weight, HDL cholesterol, and maximal oxygen consumption (VO2 max), indicating the maintenance of effects. Conclusions: Persuasive design techniques integrated in HeartHab and tailoring of exercise targets were effective in motivating patients to reach their telerehabilitation targets. This study demonstrated significant effects on glucose and HDL cholesterol and positive carryover effects on weight, HDL cholesterol, and VO2 max. There was also a perceived improvement in quality of life. A longer-term evaluation with more patients could possibly reveal effectiveness on other risk factors and maintenance of the positive health behavior change. Trial Registration: ClinicalTrials.gov NCT03102671; https://clinicaltrials.gov/ct2/show/NCT03102671 (Archived by WebCite at http://www.webcitation.org/76gzI9Pvd) UR - https://mhealth.jmir.org/2019/4/e10874/ UR - http://dx.doi.org/10.2196/10874 UR - http://www.ncbi.nlm.nih.gov/pubmed/30946021 ID - info:doi/10.2196/10874 ER - TY - JOUR AU - Fitze, P. Daniel AU - Franchi, Martino AU - Popp, L. Werner AU - Ruoss, Severin AU - Catuogno, Silvio AU - Camenisch, Karin AU - Lehmann, Debora AU - Schmied, M. Christian AU - Niederseer, David AU - Frey, O. Walter AU - Flück, Martin PY - 2019/03/27 TI - Concentric and Eccentric Pedaling-Type Interval Exercise on a Soft Robot for Stable Coronary Artery Disease Patients: Toward a Personalized Protocol JO - JMIR Res Protoc SP - e10970 VL - 8 IS - 3 KW - cardiovascular rehabilitation KW - concentric and eccentric exercise KW - high-intensity interval training KW - muscle oxygen saturation KW - near-infrared spectroscopy KW - peak oxygen uptake KW - ramp test KW - skeletal muscle power KW - soft robot N2 - Background: Cardiovascular diseases are the leading causes of death worldwide, and coronary artery disease (CAD) is one of the most common causes of death in Europe. Leading cardiac societies recommend exercise as an integral part of cardiovascular rehabilitation because it reduces the morbidity and mortality of patients with CAD. Continuous low-intensity exercise using shortening muscle actions (concentric, CON) is a common training modality during cardiovascular rehabilitation. However, a growing clinical interest has been recently developed in high-intensity interval training (HIIT) for stable patients with CAD. Exercise performed with lengthening muscle actions (eccentric, ECC) could be tolerated better by patients with CAD as they can be performed with higher loads and lower metabolic cost than CON exercise. Objective: We developed a clinical protocol on a soft robot to compare cardiovascular and muscle effects of repeated and work-matched CON versus ECC pedaling-type interval exercise between patients with CAD during cardiovascular rehabilitation. This study aims to ascertain whether the developed training protocols affect peak oxygen uptake (VO2peak), peak aerobic power output (Ppeak), and parameters of muscle oxygen saturation (SmO2) during exercise, and anaerobic muscle power. Methods: We will randomize 20-30 subjects to either the CON or ECC group. Both groups will perform a ramp test to exhaustion before and after the training period to measure cardiovascular parameters and SmO2. Moreover, the aerobic skeletal muscle power (Ppeak) is measured weekly during the 8-week training period using a simulated squat jump and a counter movement jump on the soft robot and used to adjust the training load. The pedaling-type interval exercise on the soft robot is performed involving either CON or ECC muscle actions. The soft robotic device being used is a closed kinetic chain, force-controlled interactive training, and testing device for the lower extremities, which consists of two independent pedals and free footplates that are operated by pneumatic artificial muscles. Results: The first patients with CAD, who completed the training, showed protocol-specific improvements, reflecting, in part, the lower aerobic training status of the patient completing the CON protocol. Rehabilitation under the CON protocol, more than under the ECC protocol, improved cardiovascular parameters, that is, VO2peak (+26% vs ?6%), and Ppeak (+20% vs 0%), and exaggerated muscle deoxygenation during the ramp test (248% vs 49%). Conversely, markers of metabolic stress and recovery from the exhaustive ramp test improved more after the ECC than the CON protocol, that is, peak blood lactate (?9% vs +20%) and peak SmO2 (+7% vs ?7%). Anaerobic muscle power only improved after the CON protocol (+18% vs ?15%). Conclusions: This study indicates the potential of the implemented CON and ECC protocols of pedaling-type interval exercise to improve oxygen metabolism of exercised muscle groups while maintaining or even increasing the Ppeak. The ECC training protocol seemingly provided a lower cardiovascular stimulus in patients with CAD while specifically enhancing the reoxygenation and blood lactate clearance in recruited muscle groups during recovery from exercise. Trial Registration: ClinicalTrials.gov NCT02845063; https://clinicaltrials.gov/ct2/show/NCT02845063 UR - https://www.researchprotocols.org/2019/3/e10970/ UR - http://dx.doi.org/10.2196/10970 UR - http://www.ncbi.nlm.nih.gov/pubmed/30916659 ID - info:doi/10.2196/10970 ER - TY - JOUR AU - Duan, Ping Yan AU - Liang, Wei AU - Guo, Lan AU - Wienert, Julian AU - Si, Yan Gang AU - Lippke, Sonia PY - 2018/11/19 TI - Evaluation of a Web-Based Intervention for Multiple Health Behavior Changes in Patients With Coronary Heart Disease in Home-Based Rehabilitation: Pilot Randomized Controlled Trial JO - J Med Internet Res SP - e12052 VL - 20 IS - 11 KW - eHealth KW - physical activity KW - diet KW - cardiac rehabilitation KW - health resources N2 - Background: Web-based and theory-based interventions for multiple health behaviors appears to be a promising approach with respect to the adoption and maintenance of a healthy lifestyle in cardiac patients who have been discharged from the hospital. Until now, no randomized controlled trials have tested this assumption among Chinese rehabilitation patients with coronary heart disease using a Web-based intervention. Objective: The study aim was to evaluate the effect of an 8-week Web-based intervention in terms of physical activity (PA), fruit and vegetable consumption (FVC), lifestyle changes, social-cognitive outcomes, and health outcomes compared with a waiting control group in Chinese cardiac patients. The intervention content was theory-based on the health action process approach. Self-reported data were evaluated, including PA, FVC, healthy lifestyle (the synthesis of PA and FVC), internal resources (combination of intention, self-efficacy, and planning), and an external resource (social support) of PA and FVC behaviors, as well as perceived health outcomes (body mass index, quality of life, and depression). Methods: In a randomized controlled trial, 136 outpatients with coronary heart disease from the cardiac rehabilitation center of a hospital in China were recruited. After randomization and exclusion of unsuitable participants, 114 patients were assigned to 1 of the 2 groups: (1) the intervention group: first 4 weeks on PA and subsequent 4 weeks on FVC and (2) the waiting control group. A total of 2 Web-based assessments were conducted, including 1 at the beginning of the intervention (T1, N=114), and 1 at the end of the 8-week intervention (T2, N=83). The enrollment and follow-up took place from December 2015 to May 2016. Results: The Web-based intervention outperformed the control condition for PA, FVC, internal resources of PA and FVC, and an external resource of FVC, with an eta-squared effect size ranging from 0.06 to 0.43. Furthermore, the intervention effect was seen in the improvement of quality of life (F1,79=16.36, P<.001, ?2=.17). When predicting a healthy lifestyle at follow-up, baseline lifestyle (odds ratio, OR 145.60, 95% CI 11.24-1886; P<.001) and the intervention (OR 21.32, 95% CI 2.40-189.20; P=.006) were found to be significant predictors. Internal resources for FVC mediated the effect of the intervention on the adoption of a healthy lifestyle (R2adj=.29; P=.001), indicating that if the intervention increased the internal resource of behavior, the adoption of a healthy lifestyle was more likely. Conclusions: Patients? psychological resources such as motivation, self-efficacy, planning, and social support as well as lifestyle can be improved by a Web-based intervention that focuses on both PA and FVC. Such an intervention enriches extended rehabilitation approaches for cardiac patients to be active and remain healthy in daily life after hospital discharge. Trial Registration: ClinicalTrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/6pHV1A0G1) UR - http://www.jmir.org/2018/11/e12052/ UR - http://dx.doi.org/10.2196/12052 UR - http://www.ncbi.nlm.nih.gov/pubmed/30455167 ID - info:doi/10.2196/12052 ER - TY - JOUR AU - Bashi, Nazli AU - Hassanzadeh, Hamed AU - Varnfield, Marlien AU - Wee, Yong AU - Walters, Darren AU - Karunanithi, Mohanraj PY - 2018/10/31 TI - Multidisciplinary Smartphone-Based Interventions to Empower Patients With Acute Coronary Syndromes: Qualitative Study on Health Care Providers? Perspectives JO - JMIR Cardio SP - e10183 VL - 2 IS - 2 KW - acute coronary syndrome KW - focus group KW - health care professionals KW - mobile phone KW - multidisciplinary KW - thematic analysis N2 - Background: Postdischarge interventions are limited in patients with acute coronary syndrome (ACS) due to few scheduled visits to outpatient clinics and travel from remote areas. Smartphones have become a viable lifestyle technology to deliver educational and health interventions following discharge from hospital. Objective: The purpose of this study was to identify the requirements for the delivery of a mobile health intervention for the postdischarge management of patients with ACS via a multidisciplinary focus group. Methods: We conducted a focus group among health care professionals (n=10) from a large metropolitan hospital in May 2017. These participants from a multidisciplinary team contributed to a 1-hour discussion by responding to 8 questions relating to the applicability of smartphone-based educational and health interventions. Descriptive statistics of the focus group data were analyzed using SPSS. The qualitative data were analyzed according to relevant themes extracted from the focus group transcription, using a qualitative description software program (NVivo 11) and an ontology-based concept mapping approach. Results: The mean age of the participants was 47 (SD 8) years: 3 cardiologists; 2 nurse practitioners; 2 clinical nurses; 2 research scientists; and 1 physiotherapist. Of these participants, 70% (7/10) had experience using electronic health intervention during their professional practice. A total of 7 major themes and their subthemes emerged from the qualitative analysis. Health care providers indicated that comprehensive education on diet, particularly providing daily meal plans, is critical for patients with ACS. In terms of ACS symptoms, a strong recommendation was to focus on educating patients instead of daily monitoring of chest pain and shortness of breathing due to subjectivity and insufficient information for clinicians. Participants pointed that monitoring health measures such as blood pressure and body weight may result in increased awareness of patient physical health, yet may not be sufficient to support patients with ACS via the smartphone-based intervention. Therefore, monitoring pain and emotional status along with other health measures was recommended. Real-time support via FaceTime or video conferencing was indicated as motivational and supportive for patient engagement and self-monitoring. The general demographics of patients with ACS being older, having a low educational level, and a lack of computer skills were identified as potential barriers for engagement with the smartphone-based intervention. Conclusions: A smartphone-based program that incorporates the identified educational materials and health interventions would motivate patients with ACS to engage in the multidisciplinary intervention and improve their health outcomes following discharge from hospital. UR - http://cardio.jmir.org/2018/2/e10183/ UR - http://dx.doi.org/10.2196/10183 UR - http://www.ncbi.nlm.nih.gov/pubmed/31758781 ID - info:doi/10.2196/10183 ER - TY - JOUR AU - Avila, Andrea AU - Claes, Jomme AU - Goetschalckx, Kaatje AU - Buys, Roselien AU - Azzawi, May AU - Vanhees, Luc AU - Cornelissen, Véronique PY - 2018/06/22 TI - Home-Based Rehabilitation With Telemonitoring Guidance for Patients With Coronary Artery Disease (Short-Term Results of the TRiCH Study): Randomized Controlled Trial JO - J Med Internet Res SP - e225 VL - 20 IS - 6 KW - cardiac rehabilitation KW - telemonitoring KW - exercise KW - coronary artery disease N2 - Background: Cardiac rehabilitation (CR) is an essential part of contemporary coronary heart disease management. However, patients exiting a center-based CR program have difficulty retaining its benefits. Objective: We aimed to evaluate the added benefit of a home-based CR program with telemonitoring guidance on physical fitness in patients with coronary artery disease (CAD) completing a phase II ambulatory CR program and to compare the effectiveness of this program in a prolonged center-based CR intervention by means of a randomized controlled trial. Methods: Between February 2014 and August 2016, 90 CAD patients (unblinded, mean age 61.2 years, SD 7.6; 80/90, 89.0% males; mean height 1.73 m, SD 0.7; mean weight 82.9 kg, SD 13; mean body mass index 27.5 kg/m2, SD 3.4) who successfully completed a 3-month ambulatory CR program were randomly allocated to one of three groups: home-based (30), center-based (30), or control group (30) on a 1:1:1 basis. Home-based patients received a home-based exercise intervention with telemonitoring guidance consisting of weekly emails or phone calls; center-based patients continued the standard in-hospital CR, and control group patients received the usual care including the advice to remain physically active. All the patients underwent cardiopulmonary exercise testing for assessment of their peak oxygen uptake (VO2 P) at baseline and after a 12-week intervention period. Secondary outcomes included physical activity behavior, anthropometric characteristics, traditional cardiovascular risk factors, and quality of life. Results: Following 12 weeks of intervention, the increase in VO2 P was larger in the center-based (P=.03) and home-based (P=.04) groups than in the control group. In addition, oxygen uptake at the first (P-interaction=.03) and second (P-interaction=.03) ventilatory thresholds increased significantly more in the home-based group than in the center-based group. No significant changes were observed in the secondary outcomes. Conclusions: Adding a home-based exercise program with telemonitoring guidance following completion of a phase II ambulatory CR program results in further improvement of physical fitness and is equally as effective as prolonging a center-based CR in patients with CAD. Trial Registration: ClinicalTrials.gov NCT02047942; https://clinicaltrials.gov/ct2/show/NCT02047942 (Archived by WebCite at http://www.webcitation.org/70CBkSURj) UR - http://www.jmir.org/2018/6/e225/ UR - http://dx.doi.org/10.2196/jmir.9943 UR - http://www.ncbi.nlm.nih.gov/pubmed/29934286 ID - info:doi/10.2196/jmir.9943 ER - TY - JOUR AU - Östbring, Johansson Malin AU - Eriksson, Tommy AU - Petersson, Göran AU - Hellström, Lina PY - 2018/02/20 TI - Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Protocol for a Randomized Controlled Trial Investigating Effects on Clinical Outcomes, Adherence, and Quality of Life JO - JMIR Res Protoc SP - e57 VL - 7 IS - 2 KW - medication adherence KW - medication therapy management KW - pharmacist KW - coronary artery disease KW - randomized controlled trial N2 - Background: Preventive treatment goals for blood pressure and cholesterol levels continue to be unmet for many coronary patients. The effect of drug treatment depends on both its appropriateness and the patients? adherence to the treatment regimen. There is a need for adherence interventions that have a measurable effect on clinical outcomes. Objective: This study aims to evaluate the effects on treatment goals of an intervention designed to improve patient adherence and treatment quality in secondary prevention of coronary heart disease. A protocol for the prespecified process evaluation of the trial is published separately. Methods: The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a prospective, randomized, outcomes-blinded trial designed to compare individualized follow-up by a clinical pharmacist using motivational interviewing (MI) and medication review with standard follow-up. Patients were randomized to 2 groups after stratification according to their beliefs about medicines. After standard follow-up at the cardiology clinic, patients in the intervention group are seen individually by a clinical pharmacist 2 to 5 times as required over 7 months, at the clinic. The pharmacist reviews each patient?s medication and uses MI to manage any problems with prescribing and adherence. The primary study outcome is the proportion of patients who have reached the treatment goal for low-density lipoprotein cholesterol by 12 months after discharge. Secondary outcomes are the effects on patient adherence, systolic blood pressure, disease-specific quality of life, and health care use. Results: The protocol for this study was approved by the Regional Ethics Committee, Linköping, in 2013. Enrollment started in October 2013 and ended in December 2016 when 417 patients had been included. Follow-up data collection will conclude in March 2018. Publication of the primary and secondary outcome results from the MIMeRiC trial is anticipated in 2019. Conclusions: The MIMeRiC trial will assess the effectiveness of an intervention involving medication reviews and individualized support. The results will inform the continued development of support for this large group of patients who use preventive medicines for lifelong treatment. The design of this adherence intervention is based on a theoretical framework and is the first trial of an intervention that uses beliefs about medicines to individualize the intervention protocol. Trial Registration: ClinicalTrials.gov NCT02102503; https://clinicaltrials.gov/ct2/show/NCT02102503 (Archived by WebCite at http://www.webcitation.org/6x7iUDohy) UR - http://www.researchprotocols.org/2018/2/e57/ UR - http://dx.doi.org/10.2196/resprot.8659 UR - http://www.ncbi.nlm.nih.gov/pubmed/29463490 ID - info:doi/10.2196/resprot.8659 ER - TY - JOUR AU - Östbring, Johansson Malin AU - Eriksson, Tommy AU - Petersson, Göran AU - Hellström, Lina PY - 2018/01/30 TI - Motivational Interviewing and Medication Review in Coronary Heart Disease (MIMeRiC): Intervention Development and Protocol for the Process Evaluation JO - JMIR Res Protoc SP - e21 VL - 7 IS - 1 KW - medication adherence KW - medication therapy management KW - pharmacist KW - coronary artery disease, quality of health care N2 - Background: Trials of complex interventions are often criticized for being difficult to interpret because the effects of apparently similar interventions vary across studies dependent on context, targeted groups, and the delivery of the intervention. The Motivational Interviewing and Medication Review in Coronary heart disease (MIMeRiC) trial is a randomized controlled trial (RCT) of an intervention aimed at improving pharmacological secondary prevention. Guidelines for the development and evaluation of complex interventions have recently highlighted the need for better reporting of the development of interventions, including descriptions of how the intervention is assumed to work, how this theory informed the process evaluation, and how the process evaluation relates to the outcome evaluation. Objective: This paper aims to describe how the intervention was designed and developed. The aim of the process evaluation is to better understand how and why the intervention in the MIMeRiC trial was effective or not effective. Methods: The research questions for evaluating the process are based on the conceptual model of change processes assumed in the intervention and will be analyzed by qualitative and quantitative methods. Quantitative data are used to evaluate the medication review in terms of drug-related problems, to describe how patients? beliefs about medicines are affected by the intervention, and to evaluate the quality of motivational interviewing. Qualitative data will be used to analyze whether patients experienced the intervention as intended, how cardiologists experienced the collaboration and intervention, and how the intervention affected patients? overall experience of care after coronary heart disease. Results: The development and piloting of the intervention are described in relation to the theoretical framework. Data for the process evaluation will be collected until March 2018. Some process evaluation questions will be analyzed before, and others will be analyzed after the outcomes of the MIMeRiC RCT are known. Conclusions: This paper describes the framework for the design of the intervention tested in the MIMeRiC trial, development of the intervention from the pilot stage to the complete trial intervention, and the framework and methods for the process evaluation. Providing the protocol of the process evaluation allows prespecification of the processes that will be evaluated, because we hypothesize that they will determine the outcomes of the MIMeRiC trial. This protocol also constitutes a contribution to the new field of process evaluations as made explicit in health services research and clinical trials of complex interventions. UR - http://www.researchprotocols.org/2018/1/e21/ UR - http://dx.doi.org/10.2196/resprot.8660 UR - http://www.ncbi.nlm.nih.gov/pubmed/29382630 ID - info:doi/10.2196/resprot.8660 ER - TY - JOUR AU - Chen, Shu AU - Gong, Enying AU - Kazi, S. Dhruv AU - Gates, B. Ann AU - Bai, Rong AU - Fu, Hua AU - Peng, Weixia AU - De La Cruz, Ginny AU - Chen, Lei AU - Liu, Xianxia AU - Su, Qingjie AU - Girerd, Nicolas AU - Karaye, M. Kamilu AU - Alhabib, F. Khalid AU - Yan, L. Lijing AU - Schwalm, JD PY - 2018/01/25 TI - Using Mobile Health Intervention to Improve Secondary Prevention of Coronary Heart Diseases in China: Mixed-Methods Feasibility Study JO - JMIR Mhealth Uhealth SP - e9 VL - 6 IS - 1 KW - coronary heart disease KW - secondary prevention KW - medication adherence KW - mobile applications KW - text messaging N2 - Background: Coronary heart disease (CHD) is the leading cause of cardiovascular mortality worldwide, yet implementation of evidence-based strategies for secondary prevention remains suboptimal. Objective: This study aimed to evaluate the feasibility, specifically the usability and acceptability, and estimate the preliminary effectiveness of a mobile health (mHealth) intervention targeting both physicians and patients to improve adherence to evidence-based medications and lifestyle modifications. Methods: We conducted a 12-week pre-post interventional pilot study at two sites in Shanghai and Hainan, China. Physicians used the app designed in this study to prescribe evidence-based medicines and record patient information. Eligible and consenting patients received automatic text messages or voice calls 4 to 5 times per week for 12 weeks on medication adherence and healthy behaviors. Interviews were conducted among 10 physicians and 24 patients at the two sites for their thoughts on medication adherence and feedback on the usability and acceptability. Questions on usability and acceptability were also asked in a patient follow-up survey. With regard to estimating effectiveness, the primary outcome was medication adherence (as estimated by the Morisky Green Levine Scale) at 12 weeks. Secondary outcomes included physical activity, smoking status, fruits and vegetables consumption, and facility visit frequency. Results: Interview findings and patient survey showed the good usability and acceptability of the intervention. Among 190 patients who completed the intervention, there was a significant increase in medication adherence (odds ratio [OR] 1.80, 95% CI 1.14-2.85). The study also showed decrease of smokers? percentage (?5%, P=.05), increase of daily vegetables consumption frequency (+0.3/day, P=.01), and community health care center visit frequency (+3 in 3 months, P=.04). The following site-specific differences were noted: medication adherence appeared to increase in Hainan (OR 14.68, 95% CI 5.20-41.45) but not in Shanghai (OR 0.61, 95% CI 0.33-1.12). Conclusions: Our study demonstrated that the intervention was feasible in both a tertiary care center and an urban community health center in China. Preliminary results from pre-post comparison suggest the possibility that provider and patient-linked mHealth interventions may improve medication adherence and lifestyle modifications among CHD patients, especially in resource-scarce settings. Randomized controlled trials are needed to verify the findings. UR - http://mhealth.jmir.org/2018/1/e9/ UR - http://dx.doi.org/10.2196/mhealth.7849 UR - http://www.ncbi.nlm.nih.gov/pubmed/29371178 ID - info:doi/10.2196/mhealth.7849 ER - TY - JOUR AU - Partridge, R. Stephanie AU - Gallagher, Patrick AU - Freeman, Becky AU - Gallagher, Robyn PY - 2018/01/17 TI - Facebook Groups for the Management of Chronic Diseases JO - J Med Internet Res SP - e21 VL - 20 IS - 1 KW - social media, prevention, intervention, Facebook UR - http://www.jmir.org/2018/1/e21/ UR - http://dx.doi.org/10.2196/jmir.7558 UR - http://www.ncbi.nlm.nih.gov/pubmed/29343460 ID - info:doi/10.2196/jmir.7558 ER - TY - JOUR AU - Marcolino, Soriano Milena AU - Oliveira, Queiroz João Antonio AU - D'Agostino, Marcelo AU - Ribeiro, Luiz Antonio AU - Alkmim, Moreira Maria Beatriz AU - Novillo-Ortiz, David PY - 2018/01/17 TI - The Impact of mHealth Interventions: Systematic Review of Systematic Reviews JO - JMIR Mhealth Uhealth SP - e23 VL - 6 IS - 1 KW - telemedicine KW - medical informatics KW - mobile phones N2 - Background: Mobile phone usage has been rapidly increasing worldwide. mHealth could efficiently deliver high-quality health care, but the evidence supporting its current effectiveness is still mixed. Objective: We performed a systematic review of systematic reviews to assess the impact or effectiveness of mobile health (mHealth) interventions in different health conditions and in the processes of health care service delivery. Methods: We used a common search strategy of five major scientific databases, restricting the search by publication date, language, and parameters in methodology and content. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Results: The searches resulted in a total of 10,689 articles. Of these, 23 systematic reviews (371 studies; more than 79,665 patients) were included. Seventeen reviews included studies performed in low- and middle-income countries. The studies used diverse mHealth interventions, most frequently text messaging (short message service, SMS) applied to different purposes (reminder, alert, education, motivation, prevention). Ten reviews were rated as low quality (AMSTAR score 0-4), seven were rated as moderate quality (AMSTAR score 5-8), and six were categorized as high quality (AMSTAR score 9-11). A beneficial impact of mHealth was observed in chronic disease management, showing improvement in symptoms and peak flow variability in asthma patients, reducing hospitalizations and improving forced expiratory volume in 1 second; improving chronic pulmonary diseases symptoms; improving heart failure symptoms, reducing deaths and hospitalization; improving glycemic control in diabetes patients; improving blood pressure in hypertensive patients; and reducing weight in overweight and obese patients. Studies also showed a positive impact of SMS reminders in improving attendance rates, with a similar impact to phone call reminders at reduced cost, and improved adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decrease of viral load. Conclusions: Although mHealth is growing in popularity, the evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist. Exceptions include the moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. Most studies were performed in high-income countries, implying that mHealth is still at an early stage of development in low-income countries. UR - http://mhealth.jmir.org/2018/1/e23/ UR - http://dx.doi.org/10.2196/mhealth.8873 UR - http://www.ncbi.nlm.nih.gov/pubmed/29343463 ID - info:doi/10.2196/mhealth.8873 ER - TY - JOUR AU - Birkeland, Kade AU - Khandwalla, M. Raj AU - Kedan, Ilan AU - Shufelt, L. Chrisandra AU - Mehta, K. Puja AU - Minissian, B. Margo AU - Wei, Janet AU - Handberg, M. Eileen AU - Thomson, EJ Louise AU - Berman, S. Daniel AU - Petersen, W. John AU - Anderson, David R. AU - Cook-Wiens, Galen AU - Pepine, J. Carl AU - Bairey Merz, Noel C. PY - 2017/12/20 TI - Daily Activity Measured With Wearable Technology as a Novel Measurement of Treatment Effect in Patients With Coronary Microvascular Dysfunction: Substudy of a Randomized Controlled Crossover Trial JO - JMIR Res Protoc SP - e255 VL - 6 IS - 12 KW - angina KW - coronary microvascular dysfunction KW - physical activity N2 - Background: Digital wearable devices provide a ?real-world? assessment of physical activity and quantify intervention-related changes in clinical trials. However, the value of digital wearable device-recorded physical activity as a clinical trial outcome is unknown. Objective: Because late sodium channel inhibition (ranolazine) improves stress laboratory exercise duration among angina patients, we proposed that this benefit could be quantified and translated during daily life by measuring digital wearable device-determined step count in a clinical trial. Methods: We conducted a substudy in a randomized, double-blinded, placebo-controlled, crossover trial of participants with angina and coronary microvascular dysfunction (CMD) with no obstructive coronary artery disease to evaluate the value of digital wearable device monitoring. Ranolazine or placebo were administered (500-1000 mg twice a day) for 2 weeks with a subsequent 2-week washout followed by crossover to ranolazine or placebo (500-1000 mg twice a day) for an additional 2 weeks. The outcome of interest was within-subject difference in Fitbit Flex daily step count during week 2 of ranolazine versus placebo during each treatment period. Secondary outcomes included within-subject differences in angina, quality of life, myocardial perfusion reserve, and diastolic function. Results: A total of 43 participants were enrolled in the substudy and 30 successfully completed the substudy for analysis. Overall, late sodium channel inhibition reduced within-subject daily step count versus placebo (mean 5757 [SD 3076] vs mean 6593 [SD 339], P=.01) but did not improve angina (Seattle Angina Questionnaire-7 [SAQ-7]) (P=.83). Among the subgroup with improved angina (SAQ-7), a direct correlation with increased step count (r=.42, P=.02) was observed. Conclusions: We report one of the first studies to use digital wearable device-determined step count as an outcome variable in a placebo-controlled crossover trial of late sodium channel inhibition in participants with CMD. Our substudy demonstrates that late sodium channel inhibition was associated with a decreased step count overall, although the subgroup with angina improvement had a step count increase. Our findings suggest digital wearable device technology may provide new insights in clinical trial research. Trial Registration: Clinicaltrials.gov NCT01342029; https://clinicaltrials.gov/ct2/show/NCT01342029 (Archived by WebCite at http://www.webcitation.org/6uyd6B2PO) UR - http://www.researchprotocols.org/2017/12/e255/ UR - http://dx.doi.org/10.2196/resprot.8057 UR - http://www.ncbi.nlm.nih.gov/pubmed/29263019 ID - info:doi/10.2196/resprot.8057 ER - TY - JOUR AU - Alonzo, A. Angelo PY - 2017/10/13 TI - Studying Acute Coronary Syndrome Through the World Wide Web: Experiences and Lessons JO - JMIR Res Protoc SP - e182 VL - 6 IS - 10 KW - acute coronary syndrome KW - care-seeking KW - Internet study KW - Internet recruitment UR - http://www.researchprotocols.org/2017/10/e182/ UR - http://dx.doi.org/10.2196/resprot.6788 UR - http://www.ncbi.nlm.nih.gov/pubmed/29030328 ID - info:doi/10.2196/resprot.6788 ER - TY - JOUR AU - Brokmann, C. Jörg AU - Conrad, Clemens AU - Rossaint, Rolf AU - Bergrath, Sebastian AU - Beckers, K. Stefan AU - Tamm, Miriam AU - Czaplik, Michael AU - Hirsch, Frederik PY - 2016/12/01 TI - Treatment of Acute Coronary Syndrome by Telemedically Supported Paramedics Compared With Physician-Based Treatment: A Prospective, Interventional, Multicenter Trial JO - J Med Internet Res SP - e314 VL - 18 IS - 12 KW - acute coronary syndrome KW - prehospital emergency care KW - telemedicine KW - telehealth KW - myocardial infarction N2 - Background: Prehospital treatment of acute coronary syndrome (ACS) in German emergency medical services (EMSs) is reserved for EMS physicians due to legal issues. Objective: The objective of this prospective, interventional, multicenter trial was to evaluate the quality of telemedically-delegated therapy and the possible complications in patients with ACS. Methods: After approval by the ethics committee and trial registration, a one-year study phase was started in August 2012 with 5 ambulances, telemedically equipped and staffed with paramedics, in 4 German EMS districts. The paramedics could contact an EMS-physician?staffed telemedicine center. After initiation of an audio connection, real-time data transmission was automatically established. If required, 12-lead electrocardiogram (ECG) and still pictures could be sent. Video was streamed from inside each ambulance. All drugs, including opioids, were delegated to the paramedics based on standardized, predefined algorithms. To compare telemedically-delegated medication and treatment in ACS cases with regular EMS missions, a matched pair analysis with historical controls was performed. Results: Teleconsultation was performed on 150 patients having a cardiovascular emergency. In 39 cases, teleconsultation was started due to suspected ACS. No case had a medical complication. Correct handling of 12-lead ECG was performed equally between the groups (study group, n=38 vs control group, n=39, P>.99). There were no differences in correct handling of intravenous administration of acetylsalicylic acid, heparin, or morphine between both the groups (study group vs control group): acetylsalicylic acid, n=31 vs n=33, P=.73; unfractionated heparin, n=34 vs n=33, P>.99; morphine, n=29 vs n=27, P=.50. The correct handling of oxygen administration was significantly higher in the study group (n=29 vs n=18, P=.007). Conclusions: Telemedical delegation of guideline conform medication and therapy by paramedics in patients with ACS and was found to be feasible and safe. The quality of guideline-adherent therapy was not significantly different in both the groups except for the correct administration of oxygen, which was significantly higher in the study group. Trial Registration: Clinicaltrials.gov NCT01644006; http://clinicaltrials.gov/ct2/show/NCT01644006 (Archived by WebCite at http://www.webcitation.org/6mPam3eDy). UR - http://www.jmir.org/2016/12/e314/ UR - http://dx.doi.org/10.2196/jmir.6358 UR - http://www.ncbi.nlm.nih.gov/pubmed/27908843 ID - info:doi/10.2196/jmir.6358 ER - TY - JOUR AU - Farias-Itao, Souza Daniela AU - Pasqualucci, Augusto Carlos AU - Nishizawa, Aline AU - Silva, Ferraz Luiz Fernando AU - Campos, Marinho Fernanda AU - Silva, da Karen Cristina Souza AU - Leite, Paraizo Renata Elaine AU - Grinberg, Tenenholz Lea AU - Ferretti-Rebustini, Lucena Renata Eloah AU - Jacob Filho, Wilson AU - Suemoto, Kimie Claudia PY - 2016/11/18 TI - Perivascular Adipose Tissue Inflammation and Coronary Artery Disease: An Autopsy Study Protocol JO - JMIR Res Protoc SP - e211 VL - 5 IS - 4 KW - coronary artery disease KW - atherosclerosis KW - inflammation KW - adipose tissue KW - macrophages KW - B lymphocytes KW - T lymphocytes N2 - Background: Perivascular adipose tissue (PAT) inflammation may have a role in coronary artery disease (CAD) pathophysiology. However, most evidence has come from samples obtained during surgical procedures that may imply in some limitations. Moreover, the role of B lymphocytes and inflammation in PAT that is adjacent to unstable atheroma plaques has not been investigated in humans using morphometric measurements. Objective: The objective of this study is to investigate the inflammation in PAT, subcutaneous, and perirenal adipose tissues (SAT and PrAT) among chronic CAD, acute CAD, and control groups in an autopsy study. Methods: Heart, SAT, and PrAT samples are collected from autopsied subjects in a general autopsy service, with the written informed consent of the next-of-kin (NOK). Sociodemographic and clinical data are obtained from a semistructure interview with the NOK. Coronary arteries are dissected and PAT are removed. Sections with the greatest arterial obstruction or unstable plaques, and the local with absence of atherosclerosis in all coronary arteries are sampled. PAT are represented adjacent to these fragments. Adipose tissues are fixed in 4% buffered paraformaldehyde solution and analyzed immunohistochemically for macrophages (CD68), macrophage polarization (CD11c for proinflammatory and CD206 for anti-inflammatory), B lymphocytes (CD20), and T lymphocytes (CD3). Slides will be scanned, and inflammatory cells will be quantified in 20 random fields. Participants will be categorized in CAD groups, after morphometric measurement of arterial obstruction and plaque composition analysis in accordance with American Heart Association classification. Three study groups will be investigated: acute CAD (at least one unstable plaque); chronic CAD (?50% arterial obstruction); and controls (<50% arterial obstruction). Inflammatory cells in PAT, SAT, and PrAT will be counted and compared between groups using multivariate linear regression, adjusted for age, body mass index, hypertension, diabetes, alcohol use, and smoking. Results: We present the methods of our study that was developed from 2 pilots. Currently, data collection and tissue processing are ongoing. Data collection, histology and immunochemistry procedures, and quantification of all inflammatory cells are expected to be concluded within 1 year. Conclusions: This study will contribute for the understanding of the mechanisms of CAD pathophysiology because it will help to clarify the role of inflammation both in chronic and acute CAD. UR - http://www.researchprotocols.org/2016/4/e211/ UR - http://dx.doi.org/10.2196/resprot.6340 UR - http://www.ncbi.nlm.nih.gov/pubmed/27864166 ID - info:doi/10.2196/resprot.6340 ER - TY - JOUR AU - Pfaeffli Dale, Leila AU - Whittaker, Robyn AU - Jiang, Yannan AU - Stewart, Ralph AU - Rolleston, Anna AU - Maddison, Ralph PY - 2015/10/21 TI - Text Message and Internet Support for Coronary Heart Disease Self-Management: Results From the Text4Heart Randomized Controlled Trial JO - J Med Internet Res SP - e237 VL - 17 IS - 10 KW - text messaging KW - mHealth KW - cellular phone KW - cardiovascular diseases KW - intervention KW - lifestyle change KW - behavior N2 - Background: Mobile technology has the potential to deliver behavior change interventions (mHealth) to reduce coronary heart disease (CHD) at modest cost. Previous studies have focused on single behaviors; however, cardiac rehabilitation (CR), a component of CHD self-management, needs to address multiple risk factors. Objective: The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program (Text4Heart) to improve adherence to recommended lifestyle behaviors (smoking cessation, physical activity, healthy diet, and nonharmful alcohol use) in addition to usual care (traditional CR). Methods: A 2-arm, parallel, randomized controlled trial was conducted in New Zealand adults diagnosed with CHD. Participants were recruited in-hospital and were encouraged to attend center-based CR (usual care control). In addition, the intervention group received a personalized 24-week mHealth program, framed in social cognitive theory, sent by fully automated daily short message service (SMS) text messages and a supporting website. The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score (?3) at 3 and 6 months. Secondary outcomes included clinical outcomes, medication adherence score, self-efficacy, illness perceptions, and anxiety and/or depression at 6 months. Baseline and 6-month follow-up assessments (unblinded) were conducted in person. Results: Eligible patients (N=123) recruited from 2 large metropolitan hospitals were randomized to the intervention (n=61) or the control (n=62) group. Participants were predominantly male (100/123, 81.3%), New Zealand European (73/123, 59.3%), with a mean age of 59.5 (SD 11.1) years. A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months (AOR 2.55, 95% CI 1.12-5.84; P=.03), but not at 6 months (AOR 1.93, 95% CI 0.83-4.53; P=.13). The intervention group reported significantly greater medication adherence score (mean difference: 0.58, 95% CI 0.19-0.97; P=.004). The majority of intervention participants reported reading all their text messages (52/61, 85%). The number of visits to the website per person ranged from zero to 100 (median 3) over the 6-month intervention period. Conclusions: A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zealand adults with CHD compared to usual care alone. The effect was not sustained to the end of the 6-month intervention. A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events. Trial Registration: ACTRN 12613000901707; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364758&isReview=true (Archived by WebCite at http://www.webcitation.org/6c4qhcHKt) UR - http://www.jmir.org/2015/10/e237/ UR - http://dx.doi.org/10.2196/jmir.4944 UR - http://www.ncbi.nlm.nih.gov/pubmed/26490012 ID - info:doi/10.2196/jmir.4944 ER - TY - JOUR AU - Schweier, Rebecca AU - Romppel, Matthias AU - Richter, Cynthia AU - Hoberg, Eike AU - Hahmann, Harry AU - Scherwinski, Inge AU - Kosmützky, Gregor AU - Grande, Gesine PY - 2014/07/23 TI - A Web-Based Peer-Modeling Intervention Aimed at Lifestyle Changes in Patients With Coronary Heart Disease and Chronic Back Pain: Sequential Controlled Trial JO - J Med Internet Res SP - e177 VL - 16 IS - 7 KW - coronary artery disease KW - lifestyle KW - health behavior KW - back pain KW - personal narratives as topic KW - Internet KW - diet KW - exercise KW - Web-based intervention N2 - Background: Traditional secondary prevention programs often fail to produce sustainable behavioral changes in everyday life. Peer-modeling interventions and integration of peer experiences in health education are a promising way to improve long-term effects in behavior modification. However, effects of peer support modeling on behavioral change have not been evaluated yet. Therefore, we implemented and evaluated a website featuring patient narratives about successful lifestyle changes. Objective: Our aim is to examine the effects of using Web-based patient narratives about successful lifestyle change on improvements in physical activity and eating behavior for patients with coronary heart disease and chronic back pain 3 months after participation in a rehabilitation program. Methods: The lebensstil-aendern (?lifestyle-change?) website is a nonrestricted, no-cost, German language website that provides more than 1000 video, audio, and text clips from interviews with people with coronary heart disease and chronic back pain. To test efficacy, we conducted a sequential controlled trial and recruited patients with coronary heart disease and chronic back pain from 7 inpatient rehabilitation centers in Germany. The intervention group attended a presentation on the website; the control group did not. Physical activity and eating behavior were assessed by questionnaire during the rehabilitation program and 12 weeks later. Analyses were conducted based on an intention-to-treat and an as-treated protocol. Results: A total of 699 patients were enrolled and 571 cases were included in the analyses (control: n=313, intervention: n=258; female: 51.1%, 292/571; age: mean 53.2, SD 8.6 years; chronic back pain: 62.5%, 357/571). Website usage in the intervention group was 46.1% (119/258). In total, 141 trial participants used the website. Independent t tests based on the intention-to-treat protocol only demonstrated nonsignificant trends in behavioral change related to physical activity and eating behavior. Multivariate regression analyses confirmed belonging to the intervention group was an independent predictor of self-reported improvements in physical activity regularity (?=.09, P=.03) and using less fat for cooking (?=.09, P=.04). In independent t tests based on the as-treated protocol, website use was associated with higher self-reported improvements in integrating physical activity into daily routine (d=0.22, P=.02), in physical activity regularity (d=0.23, P=.02), and in using less fat for cooking (d=0.21, P=.03). Multivariate regression analyses revealed that using the website at least 3 times was the only factor associated with improved lifestyle behaviors. Conclusions: Usage of the lebensstil-aendern website corresponds to more positive lifestyle changes. However, as-treated analyses do not allow for differentiating between causal effects and selection bias. Despite these limitations, the trial indicates that more than occasional website usage is necessary to reach dose-response efficacy. Therefore, future studies should concentrate on strategies to improve adherence to Web-based interventions and to encourage more frequent usage of these programs. UR - http://www.jmir.org/2014/7/e177/ UR - http://dx.doi.org/10.2196/jmir.3434 UR - http://www.ncbi.nlm.nih.gov/pubmed/25057119 ID - info:doi/10.2196/jmir.3434 ER -