Faculty

Background: Caregiver contribution to heart failure (HF) self-care maintenance and management is important in HF care. Literature remains unclear regarding which practices caregivers perform to contribute to self-care for patients with HF, especially in Southern Europe. Objective: The objective of this study was to describe caregiver contributions to HF self-care maintenance (ie, treatment adherence and symptom monitoring) and management (ie, managing HF symptoms when they occur). Methods: Forty HF caregivers were enrolled from 3 outpatient clinics in Italy for a qualitative descriptive study. Data were collected with a semistructured interview and analyzed using content analysis. Results: Caregivers were 53.6 years old on average and mostly female (63.5%). Caregiver contributions to self-care maintenance included practices related to (1) monitoring medication adherence, (2) educating patients about HF symptom monitoring, (3) motivating patients to perform physical activity, and (4) reinforcing dietary restrictions. However, some of these practices were incorrect (eg, weighing the patient only once a week). Caregiver contributions to self-care management included practices related to (1) symptom recognition and (2) treatment implementation. Caregivers were able to recognize symptoms of HF exacerbation (eg, breathlessness) but lacked confidence regarding treatment implementation (eg, administering an extra diuretic). Conclusions: Although caregivers described contributing to patients' HF self-care maintenance and management, some of their practices were incorrect. Because the caregiver contributions to HF self-care can improve patient outcomes, clinicians should routinely assess caregiver HF self-care practices and provide education and reinforcement regarding evidence-based practices.

Background Patients treated for atrial fibrillation with an ablation can experience decreased mental health. Little is known about the effect of a psychoeducation intervention on this patient group. Objectives The aim of this study was to explore the effect of a psychoeducation intervention on patients' mental health after participating in a cardiac rehabilitation program, with a focus on elaborating on the lack of mental health improvements. Method Sequential explanatory mixed methods including secondary analysis of qualitative and quantitative data collected in a randomized rehabilitation trial was performed. Perceived health was measured by a questionnaire (n = 95), and qualitative interviews were performed (n = 10). Results Patients scoring high on perceived health experienced positive effects of the intervention. Patients scoring low appear to have either low physical capacity and severe atrial fibrillation symptoms, bigger life issues, or lack of social support. Conclusion: A more in-depth understanding of the effect of a psychoeducational intervention included in a cardiac rehabilitation program has been achieved.

Objectives: To understand how patients make decisions regarding a left ventricular assist device (LVAD). Design: A qualitative multiple case study design was used to explore the context and influence of individuals regarding patients’ decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient's decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis. Main outcome measures: Themes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival. Findings: This case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients’ fears, values and preferences. Conclusion: The patients’ decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients’ concerns, an essential component of shared decision-making.

Background: Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care - especially among patients with heart failure (HF). Objective: We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES. Methods: In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated. Results: Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score. Conclusions: Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.

Background: Lifestyle changes and treatment adherence still constitute a challenge to healthcare providers involved in the care of persons with hypertension. The lack of validated instruments measuring the ability of hypertensive patients to manage their disease has slowed research progress in this area. The Self-care of Hypertension Inventory, originally developed in the United States, consists of 23 items divided across 3 scales: Self-care Maintenance, Self-care Management, and Self-care Confidence. These scales measure how well patients with hypertension adhere to treatment and manage elevated blood pressure, as well as their confidence in their ability to perform self-care. A rigorous cross-cultural adaptation and validation process is required before this instrument can be used in other countries. Objective: The aims of this study were to translate the Self-care of Hypertension Inventory into Brazilian Portuguese with cross-cultural adaptation and to evaluate interobserver reliability and temporal stability. Methods: This methodological study involved forward translation, synthesis of forward translations, back-translation, synthesis of back-translations, expert committee review, and pretesting. Interobserver agreement and the temporal stability of the scales were assessed. Results: The expert committee proposed semantic and cultural modifications to some items and the addition of guidance statements to facilitate administration of the scale. Interobserver analysis demonstrated substantial agreement. Analysis of temporal stability showed near-perfect agreement. Conclusions: Cross-cultural adaptation of the Self-care of Hypertension Inventory successfully produced a Portuguese-language version of the instrument for further evaluation of psychometric properties. Once that step is completed, the scale can be used in Brazil.

Background: Early heart failure (HF) symptoms are frequently unrecognized for reasons that are unclear. We explored symptom perception in patients with chronic HF. Methods: We enrolled 36 HF out-patients into a longitudinal sequential explanatory mixed methods study. We used objectively measured thoracic fluid accumulation and daily reports of signs and symptoms to evaluate accuracy of detected changes in fluid retention. Patterns of symptom interpretation and response were explored in telephone interviews conducted every 2 weeks for 3-months. Results: In this sample, 44% had a mismatch between objective and subjective fluid retention; younger persons were more likely to have mismatch. In interviews, two patterns were identified: those able to interpret and respond appropriately to symptoms were higher in decision-making skill and the quality of social support received. Conclusion: Many HF patients were poor at interpreting and managing their symptoms. These results suggest a subgroup of patients to target for intervention.

Background Despite the strong literature on the influence of self-care on hypertension (HTN) diagnosis, there is a notable lack of studies that explore self-care among Filipino immigrants in the United States (US) who have HTN. Aim To determine the levels of and relationships between and among acculturation, acculturative stress, HTN self-efficacy, patient activation, and HTN self-care among first generation Filipino immigrants in the US who have HTN. Design A cross-sectional correlational design was used to determine the relationships between and among acculturation, acculturative stress, HTN self-efficacy, patient activation, and HTN self-care using the Transactional Model of Stress and Coping. One hundred and sixty-three community-dwelling first-generation Filipino immigrants participated in the study. Methods Data on HTN self-care, acculturation, acculturative stress, HTN self-efficacy, and patient activation were collected. Results The study results revealed that HTN self-efficacy and patient activation significantly contributed to the regression model that accounted for 29.5% of the variance in HTN self-care for this sample. Further analysis revealed that patient activation had a mediating role between HTN self-efficacy and HTN self-care. Conclusions Findings from this study revealed that HTN self-efficacy and patient activation were associated with self-care behaviors associated with HTN management for this sample. Clinical relevance Findings from this study highlight the importance of addressing HTN self-efficacy and patient activation in improving HTN self-care for this population.

Background: Elevated stress is associated with adverse cardiovascular disease outcomes and accounts in part for the poorer recovery experienced by women compared with men after myocardial infarction (MI). Psychosocial interventions improve outcomes overall but are less effective for women than for men with MI, suggesting the need for different approaches. Mindfulness-based cognitive therapy (MBCT) is an evidence-based intervention that targets key psychosocial vulnerabilities in women including rumination (i.e., repetitive negative thinking) and low social support. This article describes the rationale and design of a multicenter randomized controlled trial to test the effects of telephone-delivered MBCT (MBCT-T) in women with MI. Methods: We plan to randomize 144 women reporting elevated perceived stress at least two months after MI to MBCT-T or enhanced usual care (EUC), which each involve eight weekly telephone sessions. Perceived stress and a set of patient-centered health outcomes and potential mediators will be assessed before and after the 8-week telephone programs and at 6-month follow-up. We will test the hypothesis that MBCT-T will be associated with greater 6-month improvements in perceived stress (primary outcome), disease-specific health status, quality of life, depression and anxiety symptoms, and actigraphy-based sleep quality (secondary outcomes) compared with EUC. Changes in mindfulness, rumination and perceived social support will be evaluated as potential mediators in exploratory analyses. Conclusions: If found to be effective, this innovative, scalable intervention may be a promising secondary prevention strategy for women with MI experiencing elevated perceived stress.

Background/Objectives: Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty. Design: Prospective, cohort study. Setting: Five academic medical centers. Participants: Frail individuals (N = 29; mean age 70.6 ± 5.5, 72.4% male). Measurements: Frailty, defined as having 3 or more of the Fried frailty criteria, was assessed before LVAD implantation and 1, 3, and 6 months after implantation. Other domains assessed included quality of life, using the Kansas City Cardiomyopathy Questionnaire; mood, using the Patient Health Questionnaire; and cognitive function, using the Trail-Making Test Part B. Results: After 6 months, three subjects had died, and one had undergone a heart transplant; of 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9 ± 0.9 at baseline to 2.8 ± 1.4 at 6 months (P =.003). Improvements were observed after 3 to 6 months of LVAD support, although 10 (52.6%) participants still had 3 or more Fried criteria, and all subjects had at least one at 6 months. Changes in frailty were associated with improvement in QOL but not with changes in mood or cognition. Higher estimated glomerular filtration rate at baseline was independently associated with a decrease in frailty. Conclusion: Frailty decreased in approximately half of older adults with advanced heart failure after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.