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Background after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. Objective the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. Design single-blind, randomised clinical trial. Setting the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. Subjects cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. Methods the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. Results in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care. Conclusion in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months. Trial registration Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

AimTo evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.DesignA mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.MethodsQuantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.ResultsThe overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.ConclusionAlthough involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.ImpactIn addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Mechanical insufflation-exsufflation (MI-E) is traditionally used in the neuromuscular popula-tion. There is growing interest of MI-E use in invasively ventilated critically ill adults. We aimed to map current evidence on MI-E use in invasively ventilated critically ill adults. Two authors independently searched electronic databases MEDLINE, Embase, and CINAHL via the Ovid platform; PROSPERO; Cochrane Library; ISI Web of Science; and International Clinical Trials Registry Platform between January 1990–April 2021. Inclusion criteria were (1) adult critically ill invasively ventilated subjects, (2) use of MI-E, (3) study design with original data, and (4) published from 1990 onward. Data were extracted by 2 authors independently using a bespoke extraction form. We used Mixed Methods Appraisal Tool to appraise risk of bias. Theoretical Domains Framework was used to interpret qualitative data. Of 3,090 citations identi-fied, 28 citations were taken forward for data extraction. Main indications for MI-E use during invasive ventilation were presence of secretions and mucus plugging (13/28, 46%). Perceived contraindications related to use of high levels of positive pressure (18/28, 68%). Protocolized MI-E settings with a pressure of ±40 cm H2O were most commonly used, with detail on timing, flow, and frequency of prescription infrequently reported. Various outcomes were re-intubation rate, wet sputum weight, and pulmonary mechanics. Only 3 studies reported the occurrence of adverse events. From qualitative data, the main barrier to MI-E use in this subject group was lack of knowledge and skills. We concluded that there is little consistency in how MI-E is used and reported, and therefore, recommendations about best practices are not possible.

(A) BACKGROUND: Home-based cardiac rehabilitation (CR) is an attractive alternative for frail older patients who are unable to participate in hospital-based CR. Yet, the feasibility of home-based CR provided by primary care physiotherapists (PTs) to these patients remains uncertain.(B) OBJECTIVE: To investigate physiotherapists' (PTs) clinical experience with a guideline-centered, home-based CR protocol for frail older patients.(C) METHODS: A qualitative study examined the home-based CR protocol of a randomized controlled trial. Observations and interviews of the CR-trained primary care PTs providing home-based CR were conducted until data saturation. Two researchers separately coded the findings according to the theoretical framework of Gurses.(D) RESULTS: The enrolled PTs (n = 8) had a median age of 45 years (IQR 27-57), and a median work experience of 20 years (IQR 5-33). Three principal themes were identified that influence protocol-adherence by PTs and the feasibility of protocol-implementation: 1) feasibility of exercise testing and the exercise program; 2) patients' motivation and PTs' motivational techniques; and 3) interdisciplinary collaboration with other healthcare providers in monitoring patients' risks.(E) CONCLUSION: Home-based CR for frail patients seems feasible for PTs. Recommendations on the optimal intensity, use of home-based exercise tests and measurement tools, and interventions to optimize self-regulation are needed to facilitate home-based CR.

Background Early identification of older cardiac patients at high risk of readmission or mortality facilitates targeted deployment of preventive interventions. In the Netherlands, the frailty tool of the Dutch Safety Management System (DSMS-tool) consists of (the risk of) delirium, falling, functional impairment, and malnutrition and is currently used in all older hospitalised patients. However, its predictive performance in older cardiac patients is unknown. Aim To estimate the performance of the DSMS-tool alone and combined with other predictors in predicting hospital readmission or mortality within 6 months in acutely hospitalised older cardiac patients. Methods An individual patient data meta-analysis was performed on 529 acutely hospitalised cardiac patients ≥70 years from four prospective cohorts. Missing values for predictor and outcome variables were multiply imputed. We explored discrimination and calibration of: (1) the DSMS-tool alone; (2) the four components of the DSMS-tool and adding easily obtainable clinical predictors; (3) the four components of the DSMS-tool and more difficult to obtain predictors. Predictors in model 2 and 3 were selected using backward selection using a threshold of p = 0.157. We used shrunk c-statistics, calibration plots, regression slopes and Hosmer-Lemeshow p-values (PHL) to describe predictive performance in terms of discrimination and calibration. Results The population mean age was 82 years, 52% were males and 51% were admitted for heart failure. DSMS-tool was positive in 45% for delirium, 41% for falling, 37% for functional impairments and 29% for malnutrition. The incidence of hospital readmission or mortality gradually increased from 37 to 60% with increasing DSMS scores. Overall, the DSMS-tool discriminated limited (c-statistic 0.61, 95% 0.56–0.66). The final model included the DSMS-tool, diagnosis at admission and Charlson Comorbidity Index and had a c-statistic of 0.69 (95% 0.63–0.73; PHL was 0.658). Discussion The DSMS-tool alone has limited capacity to accurately estimate the risk of readmission or mortality in hospitalised older cardiac patients. Adding disease-specific risk factor information to the DSMS-tool resulted in a moderately performing model. To optimise the early identification of older hospitalised cardiac patients at high risk, the combination of geriatric and disease-specific predictors should be further explored.

Introduction: Few data described practicalities of using mechanical insufflation-exsufflation (MI-E) for invasively ventilated ICU patients and evidence for benefit of their use is lacking. Aim and objective: To identify barriers and facilitators to use MI-E devices in invasively ventilated ICU patients, and to explore reasons for their use in various patient indications. Methods: Four focus group discussions; 3 national (Netherlands) and 1 with international representation, each with a purposeful interprofessional sample of a maximum 10 participants with experience in using MI-E in invasively ventilated ICU patients. We developed a semi-structured interview guide informed by the Theoretical Domain Framework. An observer was present in each session. Sessions were audio recorded and transcribed verbatim. Data were analysed using content analysis. Results: Barriers for MI-E use were lack of evidence and lack of expertise in MI-E, as well as lack of device availability within the ICU. Facilitators were experience with MI-E and perceived clinical improvement in patients with MI-E use. Common reasons to start using MI-E were difficult weaning, recurrent atelectasis and pneumonia. Main contraindications were, bullous emphysema, ARDS, high PEEP, hemodynamic instability, recent pneumothorax. There was substantial variability on used technical settings of MI-E in invasively ventilated patients. Conclusions: Key barriers and facilitators to MI-E were lack of evidence, available expertise and perceived clinical improvement. Variability on technical settings likely reflect lack of evidence. Future studies should focus on settings, safety and feasibility of MI-E in invasively ventilated patients before studies on effect can be conducted.

This project studies whether a redesigned baccalaureate nursing curriculum in a University of Applied Sciences in the Netherlands can stimulate positive interest for the field of community care. In many Western countries, healthcare is changing from institutional care delivery to caring for patients in their own homes. Problematic is that most nursing students orientate on a career in the hospital and they do not see community care as an attractive option, due to a limited and often mistaken view of the field. Their career choices lead to increasing shortages in the labour market, which in many Western countries is a societal problem urgently needing attention. Providing students with a curriculum with more elements of community nursing could help them build a more positive perception of the field, leading to more students choosing this area as a career.The curriculum-redesign was based on quantitative and qualitative research about first-year students’ perceptions, placement preferences and underlying assumptions on the field. First, a cross-sectional multicentre survey study (n = 1058) was conducted using the SCOPE (Scale on COmmunity care PErceptions) questionnaire. The findings confirm the hospital’s popularity, with community care being perceived as a ‘low-status-field’ with many elderly patients and few challenges. Students’ perceptions of community care appear to be at odds with things they consider important for their placement (i.e., opportunities for advancement and enjoyable relationships with patients).To better understand the factors underlying the perceptions, a focus group study with first-year students at the start of their programme (n = 16) was performed.This led to formulation of eight redesign themes, namely:(1) variety and diversity,(2) challenges,(3) improving people's health,(4) collaboration,(5) role models,(6) patient- or environment-based perceptions,(7) self-efficacy, and(8) immediate vicinity.First-year students have clear ideas about what they see as important in a placement, but their perceptions do not always appear to be realistic.To remedy these misperceptions, recommendations for curriculum redesign strategies were formulated. Curriculum designers can more prominently highlight the complexity of community nursing in the theory part of the curriculum. As many students strive for challenges, in-depth knowledge about community nursing can be presented about aspects that students lacking experience in the field are not aware of (e.g., working in an interprofessional network). In the courses, patient cases can be presented that do not fit the stereotypical views of community care commonly held. Also, as role models are influential, it is important that students collaborate with mentors in the field with an appropriate level of education, who can act as a source of inspiration, but who also create a structured and supporting learning environment. Finally, it is useful to organise meetings where political developments and labour market issues in healthcare are discussed. This can potentially increase awareness of these topics and contribute to well-informed career decisions. These strategies can potentially foster a more optimistic and realistic career outlook on the community care field.

Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain) Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)

Aims To describe atrial fibrillation (AF) management in member countries of the European Society of Cardiology (ESC) and to verify cardiology practices against guidelines. Methods and results Among 182 hospitals in 35 countries, 5333 ambulant and hospitalized AF patients were enrolled, in 2003 and 2004. AF was primary or secondary diagnosis, and was confirmed on ECG in the preceding 12 months. Clinical type of AF was reported to be first detected in 978, paroxysmal in 1517, persistent in 1167, and permanent in 1547 patients. Concomitant diseases were present in 90% of all patients, causing risk factors for stroke to be also highly prevalent (86%). As many as 69% of patients were symptomatic at the time of the survey; among asymptomatic patients, 54% were previously experienced symptoms. Oral anticoagulation was prescribed in 67 and 49% of eligible and ineligible patients, respectively. A rhythm control strategy was applied in 67% of currently symptomatic patients and in 44% of patients who never experienced symptoms. Conclusion This survey provides a unique snapshot of current AF management in ESC member countries. Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are not substitutes for textbooks. The legal implications of medical guidelines have been discussed previously. A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC web site (http://www.escardio.org/knowledge/guidelines/rules). In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in the tables below. The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report was entirely …

Ongeveer een op de drie Nederlanders sterft aan hart- en vaatziekten. Door vergrijzing van onze bevolking zal dit aantal nog verder gaan toenemen. Preventie van hart- en vaatziekten krijgt dan ook hoge prioriteit van overheid en hulpverleners. De Europese multidisciplinaire richtlijn voor preventie van hart- en vaatziekten is grotendeels gebaseerd op wetenschappelijk bewijs