Cardiovascular Nursing

Mobile Electrocardiogram Monitoring and Health-Related Quality of Life in Patients With Atrial Fibrillation: Findings From the iPhone Helping Evaluate Atrial Fibrillation Rhythm Through Technology (iHEART) Study Background Atrial fibrillation (AF) is associated with high recurrence rates and poor health-related quality of life (HRQOL) but few effective interventions to improve HRQOL exist. Objective The aim of this study was to examine the impact of the “iPhone Helping Evaluate Atrial Fibrillation Rhythm through Technology” (iHEART) intervention on HRQOL in patients with AF. Methods We randomized English- and Spanish-speaking adult patients with AF to receive either the iHEART intervention or usual care for 6 months. The iHEART intervention used smartphone-based electrocardiogram monitoring and motivational text messages. Three instruments were used to measure HRQOL: the Atrial Fibrillation Effect on Quality of Life (AFEQT), the 36-item Short-Form Health survey, and the EuroQol-5D. We used linear mixed models to compare the effect of the iHEART intervention on HRQOL, quality-adjusted life-years, and AF symptom severity. Results A total of 238 participants were randomized to the iHEART intervention (n = 115) or usual care (n = 123). Of the participants, 77% were men and 76% were white. More than half (55%) had an AF recurrence. Both arms had improved scores from baseline to follow-up for AFEQT and AF symptom severity scores. The global AFEQT score improved 18.5 and 11.2 points in the intervention and control arms, respectively (P < .05). There were no statistically significant differences in HRQOL, quality-adjusted life-years, or AF symptom severity between groups. Conclusions We found clinically meaningful improvements in AF-specific HRQOL and AF symptom severity for both groups. Additional research with longer follow-up should examine the influence of smartphone-based interventions for AF management on HRQOL and address the unique needs of patients diagnosed with different subtypes of AF. Funding: The iHEART was funded by the National Institute of Nursing Research (NINR; R01NR014853). B.A.C. was supported by a training grant from the NINR (T32NR014205). The authors have no conflicts of interest to disclose. Correspondence Billy A. Caceres, PhD, RN, AGPCNP-BC, Columbia University School of Nursing, 560 West 168th St, New York, NY 10032 (bac2134@cumc.columbia.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Effects of Exercise Intervention on Adults With Both Hypertension and Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis Background The positive effect of exercise on blood pressure has been reported in studies that investigated mostly patients with hypertension but without diabetes mellitus. However, the effect of exercise in adults with both hypertension and type 2 diabetes mellitus (T2DM) is unclear, and no systematic review and meta-analysis has been conducted to clarify this effect. Objective This study was a systematic review and meta-analysis designed to investigate the effects of exercise on adults with both hypertension and T2DM. Methods Studies were selected using electronic databases. Data were extracted using a standardized protocol. The risk of bias was assessed using Cochrane Collaboration's tool. To estimate the effect size, a meta-analysis of the studies was conducted. Results Of 3207 publications identified, 8 trials were used to estimate the effect size of exercise. Effect sizes (weighted mean difference [WMD]) were heterogeneous, and random-effects models were used. Exercise was effective for systolic blood pressure (WMD, −5.25 mm Hg; 95% confidence interval [CI], −8.39 to −2.12), diastolic blood pressure (WMD, −3.16 mm Hg; 95% CI, −4.91 to −1.40), body mass index (WMD, −1.47 kg/m2; 95% CI, −2.39 to −0.55), and waist circumference (WMD, −2.91 cm; 95% CI, −5.68 to −0.15). In subgroup analyses, aerobic exercise seemed to be the most effective intervention for lowering systolic (WMD, −9.43 mm Hg; 95% CI, −13.63 to −5.23) and diastolic (WMD, −5.90 mm Hg; 95% CI, −7.69 to −4.11) blood pressure. Conclusions Exercise seemed effective in reducing systolic and diastolic blood pressure, with subgroup analyses indicating that this effect was most profound with aerobic exercise. The authors have no funding or conflicts of interest to disclose. Correspondence Jinhee Kim, PhD, RN, Department of Nursing, Chosun University, 309 Pilmun-daero, Dong-Gu, Gwangju, South Korea 61452 (jinheeara@chosun.ac.kr). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

The Symptom Experience of Patients With Atrial Fibrillation Before Their Initial Diagnosis Background Atrial fibrillation (AF), the most common form of dysrhythmia, steadily increases in prevalence with age. If left untreated, AF significantly increases the risk of stroke, heart failure, and death. Despite the increasing prevalence, there are significant research gaps in the prediagnosis symptom experiences of patients with AF. Objective The purpose of this qualitative descriptive study was to explore the prediagnosis symptom experience of patients with AF. Methods Participants 19 years or older with AF diagnosed in the previous year were recruited (n = 26) from outpatient cardiac rehabilitation and AF clinics. Semistructured interviews, broadly guided by the Symptom Experience Model, explored perceptions, evaluations, and responses to AF symptoms. Thematic analysis used a 2-step approach, deductively coding for participants' symptom perceptions, evaluations, and responses and inductively coding within these broader Symptom Experience Model concepts. Results Perception involved awareness of bodily sensations, ranging from imperceptible noticing to commanding attention, heightened by rest and activity. In evaluation, participants used self-derived theories to explain their symptoms, gathered evidence to support/refute their theories, and formulated alternative theories as symptoms changed over time. Responses consisted of nontreatment, self-treatment, and health seeking; most participants needed repeated healthcare visits before diagnosis. Conclusions The current study identified challenges participants experienced in developing awareness of their AF symptoms, the complex cognitive processes associated with evaluation, and barriers that made it difficult to respond to AF symptoms in a timely manner. Understanding the prediagnosis symptom experience from the patient's perspective is essential for the enhancement of current AF screening practices. The authors have no funding or conflicts of interest to disclose. Correspondence: Ryan E. Wilson, PhD, RN, Faculty of Health and Social Development, School of Nursing, The University of British Columbia, Okanagan Campus, 1147 Research Rd, ART 360B, Kelowna, BC V1V 1V7, Canada (Ryan.wilson@ubc.ca). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

A Systematic Review on the Effects of Nonpharmacological Sleep Interventions on Cardiometabolic Risk or Disease Outcomes Background Many authors of epidemiological studies have documented the detrimental effects of insufficient or poor sleep on cardiometabolic health. However, little is known about the effects of sleep interventions on the individuals with cardiometabolic risks/diseases. Objectives This systematic review aimed to evaluate the mediating effects of nonpharmacological sleep interventions, which were defined as interventions not involving the use of medications or invasive methods to alter sleep, on cardiometabolic outcomes among adults with cardiometabolic risks/diseases. Methods A systematic search of randomized controlled trials was conducted in 5 electronic databases from inception to November 2019. The Population, Intervention, Comparison and Outcomes of this review was the effects of nonpharmacological sleep interventions on sleep and cardiometabolic outcomes among the adults with cardiometabolic risks/diseases as compared with any control methods. Two reviewers independently assessed eligibility for inclusion and methodological quality. Narrative analysis was performed when meta-analysis was not appropriate. Results Nine studies met the inclusion criteria. These studies included exercise-based, sleep hygiene, and cognitive behavioral therapy interventions to improve sleep among adults who are overweight or obese and patients with type 2 diabetes and hypertension. All of the exercise-based interventions were effective in improving sleep, but not to an extent that can positively influence cardiometabolic health. The mediating effects on cardiometabolic risks were more apparent for the sleep hygiene and cognitive behavioral therapy interventions, despite the small number of pilot-scale studies in this area. Conclusion The mediating effects of sleep improvement on cardiometabolic risk/disease control were inconclusive. More research to examine the effect of sleep-related risk-factor modification on cardiovascular health is warranted. The authors have no funding or conflicts of interest to disclose. Correspondence Polly W.C. Li, PhD, The School of Nursing, The University of Hong Kong, 4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong (pwcli@hku.hk). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Prediction of Heart Failure Symptoms and Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure Background In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined. Objective The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL. Methods We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose. Results Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R2 = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R2 = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL. Conclusion Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class. Funding sources: Funding for this study came from American Heart Association, Scientific Development grant (0830104N) to Seongkum Heo. The other authors have no funding or conflicts of interest to disclose. Correspondence Seongkum Heo, PhD, RN, Mercer University, Georgia Baptist College of Nursing, 3001 Mercer University Drive, Atlanta, GA 30022 (Heo_s@mercer.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Insight Into Differences in Dietary Sodium Adherence Between Men and Women With Heart Failure Background Men with heart failure are reported to be less adherent to low-sodium diets than women are. One potential reason may be that men consume more food and, consequently, more sodium than women do. Objectives The aims of this study were to compare dietary sodium intake, urine sodium excretion, and sodium density of diet consumed between men and women with heart failure and to determine whether sex moderated the relationship of kilocalories (kcals) consumed with dietary and urine sodium. Methods A total of 223 patients with heart failure (mean age, 62 ± 12 years; 70% men, 46% New York Heart Association class III–IV) completed detailed 4-day food diaries and provided 24-hour urine sodium samples. To account for sodium density of food, dietary sodium and urine sodium were referenced to sodium per 1000 kcal. Results On an absolute basis, men consumed 23% more kcals and 28% more sodium than women did; 24-hour sodium excretion was 16% higher in men than in women. There were no differences between men and women when dietary sodium and urinary sodium were referenced to 1000 kcal, indicating they consumed foods with similar sodium density. However, both moderation analyses showed that the dietary sodium intake of men and women with lower kcal intake was similar, whereas men with higher kcal intake consumed more sodium-dense foods than women did. Conclusion The results suggest that the men with higher sodium intake than women had 2 reasons for nonadherence. They consumed more food and foods with higher sodium density than women did. Funding: National Institute of Nursing Research (RO1NR009280 and P20NR0106791); American Heart Association, Great Rivers Affiliate Postdoctoral Fellowship; National Center for Research Resource (NIH UL1 RR025008); National Center for Advancing Translational Sciences (NIH UL1TR000117); General Clinical Research Centers NIH: Indiana University (M01RR000750); Atlanta Veterans Administration Medical Center; and Clarian Health Partners (Indiana). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research, National Center for Research Resource, National Institutes of Health, American Heart Association, Clarian Health Partners, and Veterans Administration. The authors have no conflicts of interest to disclose. Correspondence Terry A. Lennie, PhD, RN, University of Kentucky, College of Nursing, 751 Rose St, Lexington, KY 40536-0232 (tlennie@uky.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Psychosocial Factors Related to Adverse Outcomes in Heart Failure Caregivers: A Structural Equation Modeling Analysis Background Heart failure (HF) caregivers experience increased demands and burden. Social support and problem solving may influence the effect of these variables on caregiver outcomes. Objective The aim of this study was to examine whether social support and problem solving mediate relationships among caregiver demands and burden, self-care, depression, and life changes in heart failure caregivers. Methods Using a cross-sectional, exploratory design, heart failure caregivers (n = 530) completed online questionnaires on caregiver demands and burden, social support, problem solving, depression, self-care, and life changes. Path analysis examined a hypothesized mediating role of social support and problem solving in the relationships among caregiver demands and burden and caregiver outcomes. The analysis included (1) a model-development phase (n = 329) to make data-based decisions on measurement indicators and model structure and (2) a confirmatory phase (n = 201) to provide unbiased inference on the model structure resulting from the initial phase. Results Participants were 41.39 (±10.38) years old and primarily white (78.3%) men (50.9%) caring for a spouse (44.9%). Per the magnitudes of the estimated path coefficients, social support mediated the relationship between caregiver burden and depression but did not relevantly mediate the relationship between caregiver burden and self-care or caregiver life changes. In the presence of social support as a parallel mediator, problem solving was not a relevant mediator between caregiver burden and demands and caregiver outcomes. Conclusions Social support mediates the effects of caregiver burden on depression but has little effect on self-care or life changes. In the presence of social support, problem solving does not mediate the effects of caregiver demands and burden on caregiver outcomes. This study was funded by the Florida State University College of Nursing Infrastructure Grant (L.J.G., Primary Investigator) and the Heart Failure Society of America Nursing Mini-Grant (L.J.G., Primary Investigator). The authors have no conflicts of interest to disclose. Correspondence Lucinda J. Graven, PhD, MSN, APRN, FAHA, 401G Duxbury Hall, 98 Varsity Way, Florida State University College of Nursing, Tallahassee, FL (lgraven@fsu.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Sex Differences in Prodromal Symptoms and Individual Responses to Acute Coronary Syndrome Background Although researchers have shown that prodromal symptoms can predict acute coronary events, the ability of patients with acute coronary syndrome (ACS) to identify these symptoms in a timely manner is limited. Objectives We aimed to assess prodromal symptoms in Chinese patients with ACS and their responses to symptoms by sex. Design This cross-sectional, multicenter study involved 5 teaching hospitals in China and included 806 patients admitted for ACS between June 2013 and February 2014. The McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey (Chinese version) was used to gather data. Results Among 806 patients (including 483 women), 688 (85.4%) experienced at least 1 prodromal symptom before ACS onset. Using adjusted logistic regression models, we determined that women were significantly more likely than men to report back pain, between– or under–shoulder blade pain/discomfort, sleep disturbances, anxiousness, or heart racing. The prevalence of generalized chest pain and loss of appetite was higher among men than women. Only 41% of patients attributed their prodromal symptoms to the heart, and women were more likely than men to attribute prodromal symptoms to a heart attack. Conclusions More than two-thirds of patients with ACS reported at least 1 prodromal symptom, with some significant sex differences. Most patients do not attribute their symptoms to an impending ACS event. The authors have no funding or conflicts of interest to disclose. Correspondence: Libin An, MD, PhD, Dalian University, 24 LuXun Rd, Zhongshan District, Dalian, Liaoning 116001, China (anlibin2001@163.com). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

The Association Between Patient Outcomes and the Initial Emergency Severity Index Triage Score in Patients With Suspected Acute Coronary Syndrome Background The Emergency Severity Index (ESI) is a widely used tool to triage patients in emergency departments. The ESI tool is used to assess all complaints and has significant limitation for accurately triaging patients with suspected acute coronary syndrome (ACS). Objective We evaluated the accuracy of ESI in predicting serious outcomes in suspected ACS and aimed to assess the incremental reclassification performance if ESI is supplemented with a clinically validated tool used to risk-stratify suspected ACS. Methods We used existing data from an observational cohort study of patients with chest pain. We extracted ESI scores documented by triage nurses during routine medical care. Two independent reviewers adjudicated the primary outcome, incidence of 30-day major adverse cardiac events. We compared ESI with the well-established modified HEAR/T (patient History, Electrocardiogram, Age, Risk factors, but without Troponin) score. Results Our sample included 750 patients (age, 59 ± 17 years; 43% female; 40% black). A total of 145 patients (19%) experienced major adverse cardiac event. The area under the receiver operating characteristic curve for ESI score for predicting major adverse cardiac event was 0.656, compared with 0.796 for the modified HEAR/T score. Using the modified HEAR/T score, 181 of the 391 false positives (46%) and 16 of the 19 false negatives (84%) assigned by ESI could be reclassified correctly. Conclusion The ESI score is poorly associated with serious outcomes in patients with suspected ACS. Supplementing the ESI tool with input from other validated clinical tools can greatly improve the accuracy of triage in patients with suspected ACS. This study is supported by grant no. R01 HL 137761 from the National Institutes of Health, United States. S.O.F. received support from the National Institute of Nursing Research of the National Institutes of Health, United States, under award T32NR008857; the Robert Wood Johnson Foundation Future of Nursing Scholar program; and the Newmeyer-Thompson doctoral award from the University of Pittsburgh School of Nursing. The authors have no conflicts of interest to disclose. Correspondence Salah S. Al-Zaiti, PhD, RN, ANP-BC, FAHA, Departments of Acute & Tertiary Care Nursing and Emergency Medicine, University of Pittsburgh School of Nursing, 3500 Victoria St, Pittsburgh, PA 15261 (ssa33@pitt.edu). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Effectiveness of Enhanced External Counterpulsation Treatment on Symptom Burden, Medication Profile, Physical Capacity, Cardiac Anxiety, and Health-Related Quality of Life in Patients With Refractory Angina Pectoris Background Patients with refractory angina pectoris experience recurrent symptoms that limit their functional capacity, including psychological distress and impaired health-related quality of life (HRQoL), despite optimized medical therapy. Enhanced external counterpulsation (EECP) is an evidence-based alternative noninvasive treatment. Although physical well-being and mental well-being are equally important components of health, few studies have investigated the psychological effects of EECP in patients with refractory angina pectoris. Objective The aim of this study was to evaluate the effects of EECP treatment in patients with refractory angina pectoris regarding medication profile, physical capacity, cardiac anxiety, and HRQoL. Methods This quasi-experimental study with 1-group pretest-posttest design includes a 6-month follow-up of 50 patients (men, n = 37; mean age, 65.8 years) who had undergone 1 EECP course. The following pretreatment and posttreatment data were collected: medication use, 6-minute walk test results, functional class according to the Canadian Cardiovascular Society, and self-reported (ie, questionnaire data) cardiac anxiety and HRQoL. In addition, the questionnaires were also completed at a 6-month follow-up. Results After EECP treatment, patients used significantly less nitrates (P < .001), walking distance increased on average by 46 m (P < .001), and Canadian Cardiovascular Society class improved (P < .001). In addition, all but 1 subscale of cardiac anxiety and all HRQoL components improved significantly (P < .05). The positive effects for cardiac anxiety and HRQoL were maintained at the 6-month follow-up. Conclusions Enhanced external counterpulsation treatment resulted in reduced symptom burden, improved physical capacity, and less cardiac anxiety, leading to increased physical activity and enhanced life satisfaction for patients with refractory angina pectoris. Enhanced external counterpulsation treatment should be considered to improve the life situation for these patients. The authors have no funding or conflicts of interest to disclose. Correspondence Eline Wu, MNSc, RN, Heart and Vascular Theme, Karolinska University Hospital, 141 86 Stockholm, Sweden (eline.wu@sll.se). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved