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Aims: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a key risk factor for ischaemic stroke. Following AF detection, treatment with oral anticoagulation can significantly lower mortality and morbidity rates associated with this risk. The availability of several hand-held devices which can detect AF may enable trained health professionals to adopt AF screening approaches which do not interfere with people's daily routines. This study aims to investigate the effectiveness of a hand-held device (the MyDiagnostick single-lead Electrocardiogram (ECG) sensor) in screening for AF when embedded into the handles of supermarket trolleys., Methods: A mixed methods two-phase approach will be taken. The quantitative first phase will involve the recruitment of 2000 participants from a convenience sample at four large supermarkets with pharmacies. Prospective participants will be asked to conduct their shopping using a trolley embedded with a MyDiagnostick sensor. If the device identifies a participant with AF, the in-store pharmacist will be dispatched to take a manual pulse measurement and a static control sensor reading and offer a cardiologist consultation referral. When the sensor does not detect AF, a researcher will confirm the reading with a manual pulse measurement. ECGs will be compiled, and the sensitivity, specificity and positive and negative predictive values will be determined. A qualitative second phase will consist of semi-structured interviews carried out with those pharmacists and store managers in-store during the running of the trial period. These will explore the perceptions of staff regarding the merits of embedding sensors in the handles of supermarket trolleys to detect AF., Conclusion: This feasibility study will inform a larger future definitive trial.

Concordant assessments of physical activity (PA) and related measures in cardiac rehabilitation (CR) is essential for exercise prescription. This study compared exercise measurement from an in-person walk test; wearable activity tracker; and self-report at CR entry, completion (8-weeks) and follow-up (16-weeks). Forty patients beginning CR completed the Six-Minute Walk Test (6MWT), Physical Activity Scale for the Elderly (PASE), and wore Fitbit-Flex for four consecutive days including two weekend days. The sample mean age was 66 years; 67% were male. Increased exercise capacity at CR completion and follow-up was detected by a 6MWT change in mean distance (39 m and 42 m; p = 0.01, respectively). Increased PA participation at CR completion was detected by Fitbit-Flex mean change in step counts (1794; p = 0.01). Relative changes for Fitbit-Flex step counts and a 6MWT were consistent with previous research, demonstrating Fitbit-Flex's potential as an outcome measure. With four days of data, Fitbit-Flex had acceptable ICC values in measuring step counts and MVPA minutes. Fitbit-Flex steps and 6MWT meters are more responsive to changes in PA patterns following exposure to a cardiac rehabilitation program than Fitbit-Flex or PASE-estimated moderate-vigorous PA (MVPA) minutes. Fitbit-Flex step counts provide a useful additional measure for assessing PA outside of the CR setting and accounts for day-to-day variations. Two weekend days and two weekdays are needed for Fitbit-Flex to estimate PA levels more precisely.

We aim to provide a critical appraisal of basic concepts underlying signal recording and processing technologies applied for (i) atrial fibrillation (AF) mapping to unravel AF mechanisms and/or identifying target sites for AF therapy and (ii) AF detection, to optimize usage of technologies, stimulate research aimed at closing knowledge gaps, and developing ideal AF recording and processing technologies. Recording and processing techniques for assessment of electrical activity during AF essential for diagnosis and guiding ablative therapy including body surface electrocardiograms (ECG) and endo- or epicardial electrograms (EGM) are evaluated. Discussion of (i) differences in uni-, bi-, and multi-polar (omnipolar/Laplacian) recording modes, (ii) impact of recording technologies on EGM morphology, (iii) global or local mapping using various types of EGM involving signal processing techniques including isochronal-, voltage- fractionation-, dipole density-, and rotor mapping, enabling derivation of parameters like atrial rate, entropy, conduction velocity/direction, (iv) value of epicardial and optical mapping, (v) AF detection by cardiac implantable electronic devices containing various detection algorithms applicable to stored EGMs, (vi) contribution of machine learning (ML) to further improvement of signals processing technologies. Recording and processing of EGM (or ECG) are the cornerstones of (body surface) mapping of AF. Currently available AF recording and processing technologies are mainly restricted to specific applications or have technological limitations. Improvements in AF mapping by obtaining highest fidelity source signals (e.g. catheter-electrode combinations) for signal processing (e.g. filtering, digitization, and noise elimination) is of utmost importance. Novel acquisition instruments (multi-polar catheters combined with improved physical modelling and ML techniques) will enable enhanced and automated interpretation of EGM recordings in the near future., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Purpose: This study sought to determine current practice regarding nutrition care within cardiac rehabilitation (CR) programs, including perceived barriers and facilitators to providing nutrition care in this setting., Methods: A cross-sectional survey was conducted in October and November 2019. Potential participants were program coordinators, identified through the Australian Cardiovascular Health and Rehabilitation Association program directory and invited to participate via e-mail., Results: Forty-nine respondents (response rate: 13%) are included in this analysis. Programs provided group (n = 42, 86%) and/or individual (n = 25, 51%) nutrition education, and most were supported by a dietitian (63%). However, the availability of dietitians and nutrition care provided at CR was variable. For example, individual education was consistently provided at 13 programs and usually by health professionals other than dietitians. Eight programs (16%) used a formal behavior change framework for nutrition care. Generally, respondents were positive about the role of nutrition; CR coordinators perceived nutrition as a valuable component of the program, and that they had good nutrition knowledge. An identified barrier was the financial resources available to support the provision of nutrition care., Conclusions: To ensure that patients receive the benefits of evidence-based nutrition care, program staff may require additional support, particularly regarding the use of evidence-based behavior change techniques. Key facilitators that may be leveraged to achieve this include the high value and priority that CR program coordinators place on nutrition care., Competing Interests: L.K. and J.K. are members of the NSW/ACT ACRA board. L.K., J.K., and T.L.S. are members of the NSW/ACT ACRA professional development committee. These relationships did not influence the decision of ACRA to endorse the project. All other authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: Cardiovascular disease burden is increasing globally, pressuring nursing staff to deliver high-quality care across a diverse range of treatment areas. As such, an evaluation of the educational preparation of nurses is needed. To determine the current role, scope of practice, education level, and needs of cardiovascular nurses working across the European Society of Cardiology (ESC)-affiliated countries., Methods and Results: A short survey was distributed in paper (EuroHeartCare 2018) or electronic format to nurses delivering cardiovascular care. A total of 876 cardiovascular nurses from 26 ESC-affiliated countries completed the survey. Most respondents (79%), were educated to at least bachelor level, with 46% having a masters or doctorate, and were highly motivated to continue their educational development. Despite this, a large number (44.3%) of respondents believed they were not fully prepared for their job. The main areas where further education was requested included acute care in cardiovascular disease (CVD) and CVD risk factor management. Face-to-face courses/training were the most requested delivery mode, followed by E-learning-which appears to be underutilized in this population. Awareness of the existing curricula for cardiovascular nurse education was minimal, and therefore these resources require further promotion and implementation., Conclusions: This international sample of cardiovascular nurses was generally educated to degree level and motivated to improve their cardiovascular knowledge. Many believed they were underprepared for their role, highlighting the need for increased investment in education. This should be focused on specific needs and delivered using a face-to-face, E-learning, or blended-learning format. Furthermore, increased signposting of existing resources is required., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Acceptance and commitment therapy (ACT) is an adapted form of cognitive behavioural therapy. ACT focuses on how thinking affects behaviour and promotes psychological flexibility. The prevalence of psychological distress among people living with cardiovascular disease (CVD) and/or type 2 diabetes mellitus (T2DM) is high, and ACT may offer an alternative treatment approach. This scoping review explored the use of ACT as an intervention to support adults living with CVD and/or T2DM. A systematic search of the literature resulted in the inclusion of 15 studies. Studies were reviewed using the Joanna Briggs Institute approach to conducting scoping reviews. Most studies ( n = 13) related to people living with T2DM, and most ( n = 10) used a pre-post design, four studies were randomised controlled trials, and one was a qualitative study. Eight studies reported an improvement in the outcome(s) assessed post-intervention, suggesting that ACT was an acceptable and valid intervention to support people living with CVD or T2DM. However, studies were underpowered and only limited studies involved people living with CVD. ACT was assessed as a valuable approach to improve a range of patient-reported outcomes for those living with CVD or T2DM, and further research involving robust study designs and larger cohorts are warranted.

Aims: TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck®). We describe the characteristics, inclusion rates, and experiences from participating centres according the TeleCheck-AF infrastructure as well as characteristics and experiences from recruited patients., Methods and Results: Three surveys exploring centre characteristics (n = 25), centre experiences (n = 23), and patient experiences (n = 826) were completed. Self-reported patient characteristics were obtained from the app. Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of the centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs. 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Recruited patients [median age 64 (55-71), 62% male] agreed that the FibriCheck® app was easy to use (94%)., Conclusion: Despite different health care settings and mobile health experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Evidence from longitudinal studies on the influence of area deprivation in cardiac mortality is limited. We aimed to examine the impact of area deprivation on cardiac mortality in a large representative Scottish population. We also examined differences between women and men., Methods and Results: Retrospective analysis was performed by using linked data from Scottish Longitudinal Study from 1991 to 2010. The main exposure variable was socioeconomic status using the Carstairs deprivation scores, a composite score of area-level factors. Cox proportional-hazards models were constructed to evaluate the hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiac mortality and all-cause mortality associated with area-based deprivation. Subgroup analyses were stratified by sex. In a representative population of 217 965 UK adults, a total of 58 770 deaths occurred over a median of 10 years of follow-up period. The risk of cardiac mortality and all-cause mortality showed a consistent graded increased across the deprived groups. Compared to the least deprived group, the adjusted HR of cardiac mortality in the most deprived group was 1.27 (1.15-1.39, P < 0.000). There was strong evidence that women from more deprived areas had significantly higher cardiac death risk than those from the least deprived areas (HR 1.42, 95% CI 1.22-1.65), while this observation was not strong in men with same background., Conclusion: Our study demonstrated area deprivation was the strong predictor of long-term cardiac mortality and all-cause mortality. The inequalities were substantially greater in women from more deprived areas than men from the same background., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great., Competing Interests: Ben Freedman reports prior fees and advisory board honoraria from Bayer Pharma AG, Boehringer Ingelheim, Daiichi-Sankyo, Omron and Pfizer/BMS, loan devices from Alivecor, and grants to the institution for investigator-initiated studies from BMS/Pfizer, unrelated to the current work. Jeff Healey has held research grants and received speaking fees from BMS/Pfizer, Bayer, Servier, Medtronic, Boston Scientific, Abbott, ARCA biopharma, Cipher pharma, and Myokardia. Lis Neubeck has received honoraria from Pfizer BMS and Daiichi Sankyo (<£2000). Renate Schnabel has received lecture fees from BMS/Pfizer outside this work. Jesper Hastrup Svendsen reports grants, personal fees, and other from Medtronic and grants from Gilead. Isabel Arbelo has received speaker fees from Biosense Webster. FD Richard Hobbs has received occasional fees and or travel expenses reimbursed in the past five years for consultancy, speaking, or advisory meetings from BI and Bayer. Janina Stepinska has received research grants from Bayer and Sanofi; consulting or lecture fees from AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Pfizer, Sanofi, and Servier. Antoni Martínez-Rubio has participated in scientific advisory boards or research projects financed by Bayer, Boehringer Ingelheim, Daichii-Sankyo, and Pfizer., (Copyright: © 2021 The Author(s).)

Atrial fibrillation (AF) affects over 1.4 million people in the UK, resulting in a five-fold increased stroke risk and a three to four times greater risk of severe, disabling stroke. Atrial fibrillation, a chronic disease, requires monitoring, medication, and lifestyle measures. A self-management approach supported by mobile health (mHealth) may empower AF self-care. To assess the need to develop new mHealth self-management interventions for those with AF this review aimed to identify commercially available AF self-management apps, analyse, and synthesize (i) characteristics, (ii) functions, (iii) privacy/security, (iv) incorporated behaviour change techniques (BCTs), and (v) quality and usability. We searched app stores for 'atrial fibrillation' and 'anticoagulation', and included apps focused on AF self-management in the review. We examined app functions, privacy statements against best practice recommendations, the inclusion of BCTs using the App Behaviour Change Scale, and app quality/usability using the Mobile App Rating Scale. From an initial search of 555 apps, five apps were included in the review. Common functions were educational content, medication trackers, and communication with healthcare professionals. Apps contained limited BCTs, lacked intuitive functions and were difficult to use. Privacy policies were difficult to read. App quality rated from poor to acceptable and no app had been evaluated in a clinical trial. The review reports a lack of commercially available AF self-management apps of sufficient standard for use in healthcare settings. This highlights the need for clinically validated mHealth interventions incorporating evidence-based BCTs to support AF self-management., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Physical activity referral schemes (PARS) are a popular physical activity (PA) intervention in the UK. Little is known about the type, intensity and duration of PA undertaken during and post PARS. We calculated weekly leisure centre-based moderate/vigorous PA for PARS participants (n = 448) and PARS completers (n = 746) in Northumberland, UK, between March 2019-February 2020 using administrative data. We categorised activity levels (<30 min/week, 30-149 min/week and ≥150 min/week) and used ordinal regression to examine predictors for activity category achieved. PARS participants took part in a median of 57.0 min (IQR 26.0-90.0) and PARS completers a median of 68.0 min (IQR 42.0-100.0) moderate/vigorous leisure centre-based PA per week. Being a PARS completer (OR: 2.14, 95% CI: 1.61-2.82) was a positive predictor of achieving a higher level of physical activity category compared to PARS participants. Female PARS participants were less likely (OR: 0.65, 95% CI: 0.43-0.97) to achieve ≥30 min of moderate/vigorous LCPA per week compared to male PARS participants. PARS participants achieved 38.0% and PARS completers 45.3% of the World Health Organisation recommended ≥150 min of moderate/vigorous weekly PA through leisure centre use. Strategies integrated within PARS to promote PA outside of leisure centre-based activity may help participants achieve PA guidelines.

Background: Physical activity (PA) levels vary across specific population groups, contributing to health inequalities. Little is known about how local authority leisure centers contribute to population PA and whether this differs by age, sex, or socioeconomic group., Methods: The authors calculated weekly leisure center-based moderate/vigorous PA for 20,904 registered adult users of local authority leisure facilities in Northumberland, United Kingdom, between July 2018 and June 2019, using administrative data. The authors categorized activity levels (<30, 30-149, and ≥150 min/wk) and used ordinal regression to examine predictors for activity category achieved., Results: Registered users were mainly female (58.7%), younger (23.9% of users aged 18-29 y vs 10.1% of those aged 70+ y), and from the 2 most affluent socioeconomic quintiles (53.7%). Median weekly moderate/vigorous leisure center-based activity was 55 minutes per week (interquartile range: 30-99). Being female (odds ratio: 2.09; 95% confidence interval, 1.95-2.35), older (odds ratio: 1.14; 95% confidence interval, 1.11-1.16), and using a large facility (odds ratio: 1.21; 95% confidence interval, 1.03-1.42) were positive predictors of leisure center-based PA., Conclusion: Older adults and females were more likely to be active and achieve the recommended PA levels through usage of the centers. Widespread use of this novel measure of leisure center-based activity would improve the understanding of how local authority leisure centers can address physical inactivity and its associated inequalities.

Physical activity referral schemes (PARS) are implemented internationally to increase physical activity (PA), but evidence of effectiveness for population subgroups is equivocal. We examined gender differences for a Scottish PARS. This mixed-methods, concurrent longitudinal study had equal status quantitative and qualitative components. We conducted 348 telephone interviews across three time points (pre-scheme, 12 and 52 weeks). These included validated self-reported PA and exercise self-efficacy measures and open-ended questions about experiences. We recruited 136 participants, of whom 120 completed 12-week and 92 completed 52-week interviews. PARS uptake was 83.8% (114/136), and 12-week adherence for those who started was 43.0% (49/114). Living in less deprived areas was associated with better uptake ( p = 0.021) and 12-week adherence ( p = 0.020), and with male uptake ( p = 0.024) in gender-stratified analysis. Female adherers significantly increased self-reported PA at 12 weeks ( p = 0.005) but not 52 weeks. Males significantly increased exercise self-efficacy between baseline and 52 weeks ( p = 0.009). Three qualitative themes and eight subthemes developed; gender perspectives, personal factors (health, social circumstances, transport and attendance benefits) and scheme factors (communication, social/staff support, individualisation and age appropriateness). Both genders valued the PARS. To increase uptake, adherence and PA, PARS should ensure timely, personalised communication, individualised, affordable PA and include mechanisms to re-engage those who disengage temporarily.

Commercially available health technologies such as smartphones and smartwatches, activity trackers and eHealth applications, commonly referred to as wearables , are increasingly available and used both in the leisure and healthcare sector for pulse and fitness/activity tracking. The aim of the Position Paper is to identify specific barriers and knowledge gaps for the use of wearables, in particular for heart rate (HR) and activity tracking, in clinical cardiovascular healthcare to support their implementation into clinical care. The widespread use of HR and fitness tracking technologies provides unparalleled opportunities for capturing physiological information from large populations in the community, which has previously only been available in patient populations in the setting of healthcare provision. The availability of low-cost and high-volume physiological data from the community also provides unique challenges. While the number of patients meeting healthcare providers with data from wearables is rapidly growing, there are at present no clinical guidelines on how and when to use data from wearables in primary and secondary prevention. Technical aspects of HR tracking especially during activity need to be further validated. How to analyse, translate, and interpret large datasets of information into clinically applicable recommendations needs further consideration. While the current users of wearable technologies tend to be young, healthy and in the higher sociodemographic strata, wearables could potentially have a greater utility in the elderly and higher-risk population. Wearables may also provide a benefit through increased health awareness, democratization of health data and patient engagement. Use of continuous monitoring may provide opportunities for detection of risk factors and disease development earlier in the causal pathway, which may provide novel applications in both prevention and clinical research. However, wearables may also have potential adverse consequences due to unintended modification of behaviour, uncertain use and interpretation of large physiological data, a possible increase in social inequality due to differential access and technological literacy, challenges with regulatory bodies and privacy issues. In the present position paper, current applications as well as specific barriers and gaps in knowledge are identified and discussed in order to support the implementation of wearable technologies from gadget-ology into clinical cardiology., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Circulatory diseases continue to be the greatest cause of mortality for Australian Aboriginal and Torres Strait Islander people, and a major cause of persistently lower life expectancy compared with non-Aboriginal Australians. The limited information that exists on atrial fibrillation (AF) prevalence in Aboriginal and Torres Strait Islander communities is mostly based on hospital admission data. This shows AF as principal or additional admission diagnosis was 1.4 times higher compared to non-Aboriginal Australians, a higher incidence of AF across the adult life span after age 20 years and a significantly higher prevalence among younger patients. Our study estimates the first national community prevalence and age distribution of AF (including paroxysmal) in Australian Aboriginal people. A handheld single-lead electrocardiograph (ECG) device (iECG), known to be acceptable in this population, was used to record participant ECGs., Methods: This co-designed, descriptive cross-sectional study was conducted in partnership with 16 Aboriginal Community Controlled Health organisations at their facilities and/or with their services delivered elsewhere. The study was also conducted at one state community event. Three (3) Australian jurisdictions were involved: New South Wales, Western Australia and the Northern Territory. Study sites were located in remote, regional and urban areas. Opportunistic recruitment occurred between June 2016 and December 2017. People <45 years of age were excluded., Results: Thirty (30) of 619 Aboriginal people received a 'Possible AF' and 81 an 'Unclassified' result from a hand-held smartphone ECG device. A final diagnosis of AF was made in 29 participants (4.7%; 95%CI 3.0-6.4%), 25 with known AF (five paroxysmal), and four with previously unknown AF. Three (3) of the four with unknown AF were aged between 55-64 years, consistent with a younger age of AF onset in Aboriginal people. Estimated AF prevalence increased with age and was higher in those aged >55 years than the general population (7.2% compared with 5.4%). Slightly more men than women were diagnosed with AF., Conclusions: This study is a significant contribution to the evidence which supports screening for AF in Aboriginal and Torres Strait Islander people commencing at a younger age than as recommended in the Australian guidelines (>65 years). We recommend the age of 55 years. Consideration should be given to the inclusion of AF screening in the Australian Government Department of Health annual 'Aboriginal and Torres Strait Islander Health Assessment'., Clinical Trial Registration: ACTRN12616000459426., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.)

Background: Cognitive impairment may limit the uptake of secondary prevention in acute coronary syndrome patients, but is poorly understood, including in cardiac rehabilitation participants., Aim: The aim of this study was to explore cognitive impairment in relation to psychological state in acute coronary syndrome patients over the course of cardiac rehabilitation and follow-up., Methods: Acute coronary syndrome patients without diagnosed dementia were assessed on verbal learning, processing speed, executive function and visual attention, at cardiac rehabilitation entry, completion and follow-up and scores adjusted using normative data. The hospital anxiety and depression scale measured psychological state., Results: Participants (n = 40) had an average age of 66.2 (±8.22) years and were 70% men. Mild cognitive impairment occurred at cardiac rehabilitation entry in single 62.5% and multiple 22.5% domains but was significantly less prevalent by cardiac rehabilitation completion (52.5% and 15.0%) and follow-up (32.5% and 7.0%). Domains most often impaired were verbal learning (52.5%) and processing speed (25.6%), again decreasing significantly with time (verbal learning cardiac rehabilitation completion 42.5%, follow-up 22.5%; processing speed cardiac rehabilitation completion 15.0%, follow-up 15.0%). A small group of patients had persistent multiple domain cognitive impairment. At cardiac rehabilitation entry patients with cognitive impairment in processing speed, a single domain or multiple domains had more depression, and patients with cognitive impairment in executive function had more depression and anxiety., Conclusions: At cardiac rehabilitation entry, mild cognitive impairment is very common in post-acute coronary syndrome patients and worse in patients who have depression or anxiety symptoms. Cognitive impairment decreases significantly by cardiac rehabilitation follow-up. A small proportion of patients has persistent, multiple domain cognitive impairment flagging potential long-term changes and the need for further investigations and cognitive rehabilitation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Objectives: Our objectives were to examine health literacy among first-generation Chinese immigrants living in Australia, identifying health literacy domains associated with emergency department (ED) visits and self-rated health (SRH)., Methods: Chinese immigrants (n = 362, mean age = 59) were recruited from communities across New South Wales and surveyed for health literacy, ED visits in the past 12 months, and SRH using the Health Literacy Questionnaire (simplified Chinese version)., Results: More than 70% of participants experienced health literacy difficulties. Health literacy was significantly lower among the following participants: older, migration at older age, recent immigrants, and those without university level education or proficient English. ED visits were independently associated with the health literacy domains lacking 'social support for health' (OR: 1.80; p = .031) and 'ability to appraise health information' (OR: 2.22; p = .005). Poor SRH was associated with the health literacy domains 'insufficient health information' (OR: 1.81; p = .025), 'inactively managing health' (OR: 1.72; p = .048), and 'lacking ability to appraise health information' (OR: 1.70; p = .048)., Conclusions: Inadequate health literacy was identified in the majority of first-generation Chinese immigrants and it had significantly association with higher prevalence of ED use and poorer SRH., Practice Implications: Early screening and support for health literacy is critical in Chinese immigrants., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Increased exposure to green space has many health benefits. Scottish Green Health Partnerships (GHPs) have established green health referral pathways to enable community-based interventions to contribute to primary prevention and the maintenance of health for those with established disease. This qualitative study included focus groups and semi-structured telephone interviews with a range of professionals involved in strategic planning for and the development and provision of green health interventions ( n = 55). We explored views about establishing GHPs. GHPs worked well, and green health was a good strategic fit with public health priorities. Interventions required embedding into core planning for health, local authority, social care and the third sector to ensure integration into non-medical prescribing models. There were concerns about sustainability and speed of change required for integration due to limited funding. Referral pathways were in the early development stages and intervention provision varied. Participants recognised challenges in addressing equity, developing green health messaging, volunteering capacity and providing evidence of success. Green health interventions have potential to integrate successfully with social prescribing and physical activity referral. Participants recommended GHPs engage political and health champions, embed green health in strategic planning, target mental health, develop simple, positively framed messaging, provide volunteer support and implement robust routine data collection to allow future examination of success.

BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA₂DS₂-VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA₂DS₂-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen detected) versus 74% (preexisting AF)( P =NS), similar to metropolitan and nonrandomized control practices. The incremental cost-effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12618000004268.

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88-1.20] p  = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97-2.03] p  = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p  = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p  = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed., Competing Interests: Competing interestsGeorge Health Enterprises, the social enterprise arm of The George Institute for Global Health is involved in commercialization activities for the SMARThealth suite of products which includes the CONNECT app. None of the authors have a financial interest in these planned products., (© The Author(s) 2020.)

Background: Atrial fibrillation (AF) is a growing epidemic. Current models of care delivery are inadequate in meeting the needs of the population with AF. Furthermore, quality of life is known to be poor in patients with AF and is associated with adverse patient outcomes., Objective: The aim of this study was to determine if nurse-led education and cardiovascular risk factor modification, undertaken using the principles of motivational interviewing, facilitated by an electronic decision support tool to ensure the appropriate use of oral anticoagulation (OAC), could improve health-related quality of life (HRQoL), guideline adherence to OAC, and cardiovascular risk factor profiles in individuals with AF., Methods: This was a multicenter, prospective, randomized controlled feasibility study of 72 individuals with AF. The intervention involved 1 face-to-face nurse-delivered education and risk factor management session with 4 follow-up telephone calls over a 3-month period to monitor progress. The primary outcome measure was HRQoL as assessed by the Short Form-12 survey., Results: A total of 72 participants were randomized, with 36 individuals in each arm completing follow-up. Mean age was 65 ± 11 years and 44% were women. At 3 months follow-up, no significant differences between groups were observed for the physical or mental component summary scores of the Short Form-12, nor any of the subscales. Appropriate use of OAC did not differ between groups at final follow-up., Conclusions: A brief nurse-delivered educational intervention did not significantly impact on HRQoL or risk factor status in individuals with AF. Further research should focus on interventions of greater intensity to improve outcomes in this population., Trial Registration: ACTRN12615000928516.

Background: Reduction of cardiovascular disease (CVD) is a worldwide health priority and innovative uses of technology-based interventions may assist patients with improving prevention behaviours. Targeting these interventions to recipients most likely to benefit requires understanding how contexts of use influence responsiveness to the intervention, and how this interaction favours or discourages health behaviour. Using a realist evaluation approach, the aim of this study was to examine the contextual factors influencing behaviour change within a multi-feature eHealth intervention with personalised data integration from the primary care electronic health record (EHR)., Methods: Realist evaluation of qualitative data from the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) randomised trial (N = 934). Thirty-six participants from the intervention group (N = 486) who had completed 12 months of study follow-up were interviewed. Coding of transcripts was structured around configurations of contexts, mechanisms, and outcomes of intervention use. Contextual narratives were derived from thematic analysis of the interviews., Results: Mechanisms favouring positive health behaviour occurred when participants responded to four interactive features of the intervention. Facilitating mechanisms included greater cognitive engagement whereby participants perceived value and benefit, and felt motivated, confident and incentivised. Participants moved from being unconcerned (or unaware) to more task-oriented engagement with personal CVD risk profile and prevention. Increased personalisation occurred when modifiable CVD risk factors became relatable to lifestyle behaviour; and experiences of feeling greater agency/self-efficacy emerged. Use and non-use of the intervention were influenced by four overarching narratives within the individual's micro-level and meso-level environments: illness experiences; receptiveness to risk and prevention information; history of the doctor-patient relationship; and relationship with technology., Conclusions: Intervention-context interactions are central to understanding how change mechanisms activate within complex interventions to exert their impact on recipients. Intervention use and non-use were context-dependent, underscoring the need for further research to target eHealth innovations to those most likely to benefit.

Non-vitamin K antagonist oral anticoagulants (NOACs) represent a paradigm shift in the treatment of non-valvular atrial fibrillation (AF) with major practice guidelines around the world recommending NOACs over vitamin K antagonist oral anticoagulants for initial treatment of AF for stroke prevention. Here we describe the evidence collated and the process followed for the successful inclusion of NOACs into the 21st WHO Model List of Essential Medicines (EML). Individual NOACs have been reported to be non-inferior or superior to warfarin in preventing stroke and systemic embolism in eligible AF patients with a reduction in the risk of stroke and systemic embolism and a lower risk of major bleeding in patients with non-valvular AF compared with warfarin in both RCTs and real-world data. The successful inclusion of NOACs in the WHO EML is an important step forward in the global fight against cardiovascular morbidity and mortality, especially in low- and middle-income countries, where the burden of disease is high and limited access to diagnosis and treatment translates into a higher burden of morbidity, mortality, and economic costs., Competing Interests: MDH has received support from the American Heart Association, Verily, and AstraZeneca for work unrelated to this research. MDH has received salary support from the American Medical Association for his role as an associate editor for JAMA Cardiology. The George Institute for Global Health has a patent and license and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. LN received speakers fees from Daiichi Sankyo unrelated to this research. EJZ received speakers fees from Novartis, Pfizer and Bayer unrelated to this research. The author alone is responsible for the views expressed in this article, which do not necessarily represent the views, decisions or policies of the institution., (Copyright: © 2020 The Author(s).)

Background: Although attention is focused on addressing the acute situation created by the COVID-19 illness, it is imperative to continue our efforts to prevent cardiovascular morbidity and mortality, particularly during a period of prolonged social isolation which may limit physical activity, adversely affect mental health and reduce access to usual care. One option may be to deliver healthcare interventions remotely through digital healthcare solutions. Therefore, the aim of this paper is to bring together the evidence for remote healthcare during a quarantine situation period to support people living with cardiovascular disease during COVID-19 isolation., Methods: The PubMed, CINAHL and Google Scholar were searched using telehealth OR digital health OR mHealth OR eHealth OR mobile apps AND COVID-19 OR quarantine search terms. We also searched for literature relating to cardiovascular disease AND quarantine., Results: The literature search identified 45 potentially relevant publications, out of which nine articles were included. Three overarching themes emerged from this review: (1) preparing the workforce and ensuring reimbursement for remote healthcare, (2) supporting mental and physical health and (3) supporting usual care., Conclusion: To support people living with cardiovascular disease during COVID-19 isolation and to mitigate the effects of quarantine and adverse effect on mental and physical well-being, we should offer remote healthcare and provide access to their usual care.

Background: Non-adherence to medications is common in patients with atrial fibrillation (AF), increasing the risk of stroke, co-morbidities, and AF symptoms. Understanding factors influencing medication adherence is important in providing holistic care to patients with AF. This study aimed to explore medication adherence in patients with AF, and explore associations with health literacy, cognition, or AF knowledge., Methods: A single-centre pilot study, using survey questionnaires and open questions. Patients with a primary cardiac diagnosis, with AF as primary or secondary diagnosis, were eligible for recruitment. During hospitalisation, adherence to cardiac medications was assessed using the Basel Assessment of Adherence to Immunosuppressive Medication Scale (BAASIS). Health literacy, cognition, and AF knowledge were assessed through validated questionnaires. Facilitators and barriers for medication adherence were obtained through open-ended question and coded using a content analysis approach., Results: Fifty-four (54) patients were recruited (61% male, mean age 71±11). Twenty-two (22) participants (41%) were classified as non-adherent using the BAASIS; with a corresponding self-reported adherence of 87.7% in non-adherent participants compared to 97.8% in adherent participants. No associations were identified between medication adherence and cognition, health literacy, or AF knowledge. Facilitators for adherence included external assistance, routines, and medication knowledge, and these were reported by both adherent and non-adherent participants. Non-adherent participants reported more barriers including medication concerns, forgetfulness, and lifestyle factors., Conclusions: Large numbers of AF patients are likely to be non-adherent to medications. Medication adherence is influenced by multiple factors, individual to each patient. Diverse strategies are required to ensure adherence to cardiac medications., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Introduction: Health disparities among immigrants exist across socioecological domains. While Chinese immigrants face increased risk for coronary heart disease (CHD) after migration, the reasons are not well understood. Method: This descriptive qualitative study collected 18 semistructured interviews with Chinese immigrants with CHD and family carers from two Australian hospitals. Analysis was guided by the social-ecological model. Results: Poor knowledge and limited English proficiency increased CHD risk and difficulty navigating health care systems/resources. Interpersonal and family factors positively influenced health-seeking behaviors, acceptance of cardiac procedures, adoption of secondary preventive behaviors and information acquisition through social networks. A lack of culturally specific health information and programs in Chinese languages was described. Ethnic concordance between Chinese doctors and patients improved health literacy and engendered trust. Discussion: Culturally specific interventions could include health promotion materials in Chinese, inclusion of family in educational programs, and Chinese-focused public health campaigns about warning signs of heart attack.

Atrial fibrillation (AF) accounts for up to one third of strokes, one of the lead mortality causes worldwide. The European Society of Cardiology guidelines recommend opportunistic screening as a means to increase the odds of early detection and institution of appropriate treatment according to risk factors identified. However, in most countries there are various barriers to effective uptake of screening, including low awareness. The Atrial Fibrillation Association is a patient association engaged with raising awareness of AF. Establishing a partnership with the International Pharmacists for Anticoagulation Care Taskforce, we set as goals to test a model for raising awareness of AF involving pharmacists globally; and to identify barriers and enablers to its implementation. A cross-sectional study was conducted during the Arrhythmia Alliance World Heart Rhythm Week. Pharmacists from 10 countries invited individuals (≥ 40 years; without anticoagulation therapy of AF) to participate in the awareness campaign. Participants agreeing were engaged in the early detection of AF (EDAF) using pulse palpation. Individuals with rhythm discrepancies were referred and prospectively assessed to have information on the proportion of confirmed diagnosis, leading to estimate the detection rate. Interviews with country coordinators explored barriers and enablers to implementation. The study involved 4193 participants in the awareness campaign and 2762 in the EDAF event (mean age 65.3 ± 13.0), of whom 46.2% individuals were asymptomatic, recruited across 120 sites. Most common CHA 2 DS 2 -VASc risk factor was hypertension. Among 161 patients referred to physician, feedback was obtained for 32 cases, of whom 12 new arrhythmia diagnoses were confirmed (5 for AF, 2 for atrial flutter), all among elders (≥ 65 years). Qualitative evaluation suggested a local champion to enable pharmacists' success; technology enhanced engagement amongst patients and increased pharmacists' confidence in referring to physicians; interprofessional relationship was crucial in success. This study suggests pharmacists can contribute to greater outreach of awareness campaigns. Effective communication pathways for inter-professional collaboration were suggested enablers to gain full benefits of EDAF.

Background: Widespread availability of mobile technologies offers the opportunity to support secondary prevention of coronary heart disease (CHD) via mobile apps, however, the target audience and their app preferences are unknown. This study aims to identify the potential audience for an Australian CHD specific app and their recommendations and preferences., Methods: A two-phase mixed methods study: Phase 1: CHD patients (n=282) were surveyed on mobile app engagement. Phase 2: Four focus groups with regular app users (n=12) identified preferences and recommendations generated after using a CHD-specific publicly available app (MyHeartMyLife) for 2 weeks. Data were thematically analysed., Results: Survey participants were aged ≥56 years (238/282, 84.4%) and male (204/282, 72.3%). More than one third (108/282, 38.3%) were regular app users, of whom 83/108, (76.9%) used health apps. Regular app users were more likely to be <56 years (versus ≥70 years; OR 4.70, 95% CI 1.92, 11.51), employed (OR 3.07, 95% CI 1.63, 5.77) and had completed high school education (OR 2.37, 95% CI 1.30, 4.34). Focus group participants using the CHD-specific app were aged 41-79 years (mean 62.2 SD 5.3 years) and 10/12 were male. Coronary heart disease specific app preferences generated included: immediate access to relevant and practical health information and records; behaviour change motivation; more experienced app users located and used app features readily and provided support for less experienced users. In addition, ensuring ease of reading and interpreting data, adding physical activity tracking, the ability to integrate and synchronise with other apps and devices, and capacity to store additional personal medical records were also recommended., Conclusions: The target audience for CHD-specific apps is aged <56 years, employed, has completed high school and is an experienced app user. User preferences and recommendations identified features present in publicly available apps, but many features need development., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objective: Health literacy measurement can identify healthcare consumers' needs and help inform healthcare service delivery. The objective of this review is to identify and evaluate tools to measure health literacy among Chinese speakers., Methods: A systematic literature search was undertaken in nine databases, both English and Chinese, on articles published from the databases' inception to May 2018, addressing health literacy among Chinese speakers., Results: Ten health literacy instruments in the Chinese language were reported in 17 studies, of which ten were published in English and seven in Chinese. Of the 17 studies, six reported on a new instrument, while the remainder reported on derivative instruments. All, except for one, are self-administered. These studies applied various implicit or explicit conceptual or operational health literacy definitions. The psychometric strength varied across the instruments., Conclusions: A number of instruments are available for assessing health literacy among Chinese speakers. Careful selection is recommended, given the variation in components and psychometric properties assessed., Practice Implications: This review can be used by healthcare providers and researchers to select effective health literacy tools to examine patients' ability to understand and apply health information so that services can be more appropriately tailored to Chinese speaking patients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Clinical registries are effective for monitoring clinical practice, yet manual data collection can limit their implementation and sustainability. The objective of this study was to assess the feasibility of using a data capture tool to collect cardiac rehabilitation (CR) minimum variables from electronic hospital administration databases to populate a new CR registry in Australia., Methods: Two CR facilities located in Melbourne, Australia participated, providing data on 42 variables including: patient socio-demographics, risk factors and co-morbidities, CR program information (e.g. number of CR sessions), process indicators (e.g. wait time) and patient outcomes (e.g. change in exercise capacity). A pre-programmed, automated data capture tool (GeneRic Health Network Information for the Enterprise [20]: https://www.grhanite.com/) (GRHANITE™) was installed at the sites to extract data available in an electronic format from hospital sites. Additionally, clinicians entered data on CR patients into a purpose-built web-based tool (Research Electronic Data Capture: https://www.project-redcap.org/) (REDCap). Formative evaluation including staff feedback was collected., Results: The GRHANITE™ tool was successfully installed at the two CR sites and data from 176 patients (median age = 67 years, 76% male) were securely extracted between September-December 2017. Data pulled electronically from hospital databases was limited to seven of the 42 requested variables. This is due to CR sites only capturing basic patient information (e.g. socio-demographics, CR appointment bookings) in hospital administrative databases. The remaining clinical information required for the CR registry was collected in formats (e.g. paper-based, scanned or Excel spreadsheet) deemed unusable for electronic data capture. Manually entered data into the web-tool enabled data collection on all remaining variables. Compared to historical methods of data collection, CR staff reported that the REDCap tool reduced data entry time., Conclusions: The key benefits of a scalable, automated data capture tool like GRHANITE™ cannot be fully realised in settings with under-developed electronic health infrastructure. While this approach remains promising for creating and maintaining a registry that monitors the quality of CR provided to patients, further investment is required in the digital platforms underpinning this approach., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Exercise-based cardiac rehabilitation is recognised internationally as an effective therapy to improve quality of life and reduce the risk of hospital readmission for individuals diagnosed with acute coronary syndrome. Despite this, half of eligible individuals choose not to engage and the main reason is lack of interest. Furthermore, prior to attending, 40% of eligible individuals report meeting physical activity guidelines. It is unclear whether this influences decisions about engagement., Aims: The aim of this review is to examine systematically qualitative evidence describing patients' perceptions and experiences, and synthesise what is known about how a previous experience of physical activity in adults diagnosed with acute coronary syndrome influences engagement with physical activity during cardiac rehabilitation., Methods: A systematic review and thematic synthesis was conducted of primary qualitative studies to examine peer-reviewed literature published between1990 and 2017, accessed from database searches of MEDLINE, CINHAL, PsycINFO and Embase., Results: The initial search produced 486 studies, and of these 12 relevant studies were included in this review. Studies included 388 participants from six countries. For previously active individuals, communication factors, self-perceptions of an exercise identity and experience of cardiac rehabilitation influence engagement in physical activity during cardiac rehabilitation., Conclusion: In adults diagnosed with acute coronary syndrome, communication post event and during cardiac rehabilitation is a source of self-appraisal and creates expectations of cardiac rehabilitation. In addition, perceptions of an exercise identity and experience of exercise-based cardiac rehabilitation influence decisions about engagement. To improve uptake and adherence, health professionals should consider previous physical activity levels and tailor information to optimise physical activity post event.

Background: Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016-June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice., Methods: A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory., Results: GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP 'screening champion' had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated., Conclusions: Introducing an AF screening program is likely to be successful in contexts where there is a senior GP 'screening champion', a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke., Trial Registrations: AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry). AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Screening asymptomatic people with a resting electrocardiogram (ECG) has been theorized to detect latent cardiovascular disease. However, resting ECG screening is not recommended for numerous populations, such as asymptomatic middle-aged (sedentary) people, as it is not sufficiently sensitive to detect coronary artery disease. While the issues raised in this article are largely common to all screening programs, this review focuses on 2 distinct programs: (1) screening elite athletes for conditions associated with sudden cardiac death (SCD); and (2) screening people aged ≥65 years for atrial fibrillation (AF). These 2 settings have recently gained attention for their promise and concerns regarding prevention of SCD and stroke, respectively. If screening is to be done, it must be done well. Organizations conducting screening must consider a range of legal, ethical, and logistical responsibilities that arise from the beginning to the end of the process. This includes consideration of who to screen, timing of screening, whether screening is mandatory, consent issues, and auditing systems to ensure quality control. Good infrastructure for interpretation of ECG results according to expert guidelines and follow-up testing for abnormal screening results, including a pathway to treatment, are essential. Finally, there may be significant implications for those diagnosed with cardiac disease, including insurance, employment, the ability to play sport, and mental health issues. There are several legal risks, and the best protective measures are good communication systems, thorough clinical record-keeping, careful handling of eligibility questions for those diagnosed, and reference to expert guidelines as the standard of care., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata., Methods and Findings: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60-64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples., Conclusions: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: GYHL reports consultancy and speaker fees from Bayer, Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo outside the submitted work. No fees were received personally. YC reports grants from Bayer during the conduct of the study. DDM reports grants from National Institutes of Health, grants and other research support from Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, grants, personal fees and other from Bristol Myers Squibb and Pfizer, other research support from Apple, Samsung Electronics, grants from National Science Foundation during the conduct of the study; other from Mobile Sense Technologies and grants from Philips outside the submitted work. MP reports consultancy activity for Boehringer Ingelheim. JJO reports grants from Pfizer, nonfinancial support from Alivecor, outside the submitted work. JW reports grants from Bayer during the conduct of the study. GHM reports grants from Belgian Heart Rhythm Association during the conduct of the study; personal fees from Boehringer Ingelheim, Bayer, Daiichi Sankyo, BMS/Pfizer, St Jude Medical outside the submitted work. RBS reports personal fees from Bristol-Myers Squibb/Pfizer Pharma outside the submitted work. JSH reports grants from Medtronic, grants from Bristol-Meyers-Squibb/Pfizer outside the submitted work. FDRH reports personal fees from BMS/Pfizer, BI, and Bayer outside the submitted work. FRQ reports personal fees from Bayer, personal fees from Servier, grants from Bayer, grants from Boehringer Ingelheim, personal fees from BMS outside the submitted work. BF reports grants, personal fees and nonfinancial support from Bayer, grants, personal fees and nonfinancial support from BMS-Pfizer, personal fees and non-financial support from Daiichi-Sankyo outside the submitted work. PSW reports grants and personal fees from Boehringer Ingelheim, grants from Philips Medical Systems, grants and personal fees from Sanofi-Aventis, grants and personal fees from Bayer Vital, grants from Daiichi Sankyo Europe, personal fees from Bayer HealthCare, personal fees from Astra Zeneca, personal fees and nonfinancial support from DiaSorin, nonfinancial support from I.E.M., grants from Evonik, outside the submitted work. FK reports grants from Boehringer Ingelheim outside the submitted work. RT reports grants and personal fees from Boehringer Ingelheim during the conduct of the study. In addition, RT has a patent as a co-inventor of the MyDiagnostick with royalties paid. The following authors have declared that no competing interests exist: VWL, AD, JH, NL, JO, LAPDT, AKR, RKS, SAC, TFC, JN, EMR, WK, JM, JM, LN, JWM, BPY, TM, JJGD, AS, BS, JSL, and DAF.

Background: Health practitioners' values, attitudes and beliefs largely determine their referrals to cardiac rehabilitation (CR)., Objective: To develop and test the Recommending Cardiac Rehabilitation scale (ReCaRe), designed to assess health professionals attitudes, values and beliefs to CR referral., Methods: ReCaRe was appraised for: content validity (Delphi method, expert panel); interpretability and face validity (interview, health professionals); factor structure and internal consistency (survey, health professionals); and test-retest reliability (survey, health professionals). Normative scores were collated., Results: ReCaRe initially comprised 75 items. Initially, a Content Validity Index (CVI) was calculated for ratings of item relevance (CVI range; 0.27-1.0), which resulted in the removal of 19 items. After preliminary validation and psychometric testing, 34 items were factor-analysed (n = 24) providing a 17-item, four-factor scale: perceived severity and susceptibility (α = 0.93, κ = 0.37); perceived service accessibility (α = 0.91, κ = 0.67); perceived benefit (α = 0.97, κ = 0.47); perceived barriers and attitudes (α = 0.82, κ = 0.49). ReCaRe normative scores (n = 75) are reported., Conclusions: This psychometric analysis found ReCaRe to demonstrate good face validity, internal consistency and fair to substantial test-retest reliability. The next step is to validate these initial findings on a larger sample size to confirm whether ReCaRe can enable identification of factors impacting CR referral., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region., Methods: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models., Findings: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05)., Interpretation: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes., Competing Interests: Dr. Derman reports some financial activities that were outside the submitted work (i.e., grants from International Olympic and Paralympic Committees, as well as personal fees from 2 advisory boards). All other authors declare no financial or personal interests related to the work.

Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density., Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed., Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35-1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04-1.06), and significantly lower with private (OR = .92, 95%CI = .91-.93) or public (OR = .83, 95%CI = .82-84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150-390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally., Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation., Competing Interests: Dr. Derman reports some financial activities that were outside the submitted work (i.e., grants from International Olympic and Paralympic Committees, as well as personal fees from 2 advisory boards). All other authors declare no financial or personal interests.

Cardiovascular disease is one of the main causes of morbidity and mortality worldwide. Despite the availability of highly effective treatments, the contemporary burden of disease remains huge. Digital health interventions hold promise to improve further the quality and experience of cardiovascular care. This position paper provides a brief overview of currently existing digital health applications in different cardiovascular disease settings. It provides the reader with the most relevant challenges for their large-scale deployment in Europe. The potential role of different stakeholders and related challenges are identified, and the key points suggestions on how to proceed are given. This position paper was developed by the European Society of Cardiology (ESC) e-Cardiology working group, in close collaboration with the ESC Digital Health Committee, the European Association of Preventive Cardiology, the European Heart Rhythm Association, the Heart Failure Association, the European Association of Cardiovascular Imaging, the Acute Cardiovascular Care Association, the European Association of Percutaneous Cardiovascular Interventions, the Association of Cardiovascular Nursing and Allied Professions and the Council on Hypertension. It relates to the ESC's action plan and mission to play a pro-active role in all aspects of the e-health agenda in support of cardiovascular health in Europe and aims to be used as guiding document for cardiologists and other relevant stakeholders in the field of digital health.

Introduction: eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records., Methods: Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes., Results: Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security., Conclusion: Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals., Competing Interests: The authors have declared that no competing interests exist.

Background: Wearable trackers as research or clinical tools are increasingly used to support the care of older adults, due to their practicality in self-monitoring and potential to promote healthy lifestyle behaviours. However, there is limited understanding of appropriate data collection and analysis methods in different contexts., Aim: To summarise evidence on wearable data generation and management in older adults, focusing on physical activity (PA), electrocardiogram (ECG), and vital signs monitoring. In addition to examine the accuracy and utility of wearable trackers in the care of older people., Methods: A systematic search of CINAHL, MEDLINE, PubMed and a manual search were conducted. Twenty studies on the use of wearable trackers by older adults met the inclusion criteria., Results: Methodological designs for data collection and analysis were heterogeneous, with diverse definitions of wear and no-wear time, the number and type of valid days, and proprietary algorithms. Wearable trackers had adequate accuracy for measuring step counts, moderate to vigorous physical activity (MVPA), ECG and heart rate (HR), but not for respiratory rate. Participants reported ease of use and had high-level adherence over daily long-term use. Moreover, wearable trackers encouraged users to increase their daily level of physical activity and decrease waist circumference, facilitating atrial fibrillation (AF) diagnoses and predicting length of stay., Conclusion: Wearable trackers are multi-dimensional technologies offering a viable and promising approach for sustained and scaled monitoring of older people's health. Frameworks and/or guidelines, including standards for the design, data management and application of use specifically for older adults, are required to enhance validity and reliability., (Copyright © 2019. Published by Elsevier B.V.)

Introduction: Recurrence of cardiac events is common after a first event, leading to hospitalisations and increased health burden. Patients have difficulties achieving the lifestyle changes required for secondary prevention and access to secondary prevention programs is limited. This study aims to evaluate the impact of a game-based mobile app, MyHeartMate, which is designed to motivate engagement in secondary prevention behaviours for cardiovascular risk factors., Methods and Analysis: The MyHeartMate study is a randomised controlled trial with 6-month follow-up and blinded assessment of the primary outcome. Participants (n=394) with coronary heart disease will be recruited from hospitals in metropolitan Sydney and randomly allocated to standard care or the MyHeartMate app intervention. The intervention group will receive the app, which uses game techniques to promote engagement and lifestyle behaviour change for secondary prevention. The primary outcome is difference between the groups in physical activity (metabolic equivalent of task minutes/week) at 6 months. Secondary outcomes include change in low-density lipoprotein cholesterol, systolic blood pressure, medication adherence, body mass index, waist circumference, mood and dietary changes at 6 months. Data on app engagement, and patient perspectives of usability and acceptability, will also be analysed., Ethics and Dissemination: The study has received ethics approval from Northern Sydney Local Health District Human Research Ethics Committee. The study findings will be disseminated via peer-reviewed publications and presentation at international scientific meetings/conferences., Trial Registration Number: ACTRN12617000869370; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This systematic review describes tools which could be considered for use for holistic needs assessment (HNA) in brain cancer. MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO were searched. Studies were included which met the following criteria; primary research published in English which reported the development, psychometric testing or clinical utility testing of patient-reported outcome measures (PROMs) for the assessment of adult brain cancer patients' needs, problems or concerns or generic cancer needs assessment tools developed specifically on a brain cancer or brain tumour population. Nine articles describing four tools were identified. The tools were first assessed using the COSMIN protocol for systematic reviews of measurement properties and then assessed for their quality and usefulness as a holistic needs assessment tool. None of the four tools had strong psychometric properties; however, the two symptom questionnaires had better psychometric properties but would need adapted to holistically assess the multiple domains of need. The two HNA tools had only minimal psychometric testing. The lack of a tool, which adequately meets all requirements for HNA, supports the need to further development of tools to optimise this intervention., (© 2018 John Wiley & Sons Ltd.)

Background: Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD., Methods: Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months' follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.)., Results: In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= -0.26 mmol/l, 95% CI= -0.4 to -0.11, p <0.001), low-density lipoprotein (WMD= -0.28, 95% CI = -0.50 to -0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04]., Conclusions: Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.

Background This eH ealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation ( AF ) screening using electronic screening prompts and improve treatment using electronic decision support ( EDS ) software. Methods and Results An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline-based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA 2 DS 2 - VAS c, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1-448 patients per general practitioner). The proportion of patients with AF who had CHA 2 DS 2 - VAS c ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen-detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study ( P<0.001). The EDS was accessed 111 times for patients with AF and for 4 of 19 screen-detected patients. Conclusions The eH ealth tools showed promise. Adherence to guideline-based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice. Clinical Trial Registration URL : www.anzctr.org.au . Unique identifier: ACTRN 12616000850471.

Background: Globally, attendance at cardiac rehabilitation (CR) is between 15 and 30%. Alternative models of individualised care are recommended to promote participation in CR, however there has been no prospective testing of different durations of such models. We aimed to replicate the previously proven Choice of Health Options In prevention of Cardiovascular Events (CHOICE) intervention, and to determine if an extended version (CHOICEplus) would confer additional benefits., Methods: Acute coronary syndrome (ACS) survivors not accessing centre-based CR (n=203) were randomised to CHOICE for 3 months (n=100) or CHOICEplus for 24 months (n=103) at four urban hospitals. The program comprised telephone-based tailored risk-factor reduction., Results: CHOICE and CHOICEplus were equivalent demographically and in risk profile at baseline. At 24 months, lipid profiles improved significantly and fewer patients had ≥3 risk factors above target compared to baseline in both groups. There were no significant differences between groups., Conclusions: The 24-month CHOICEplus program did not confer additional benefit above the brief 3-month CHOICE intervention. However, participation in either CHOICE and CHOICEplus significantly improved cardiovascular risk profile in ACS survivors. Importantly, the study was feasible, and the intervention translated readily across four hospitals. Overall, this study adds to the existing evidence for brief individualised approaches to CR., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)