SMARTPHONE-BASED TRACKING AND TEXTING INTERVENTIONS FOR PROMOTION OF PHYSICAL ACTIVITY IN CARDIOVASCULAR PREVENTION

Introduction: The recent advent of smartphone-linked wearable accelerometers offers a novel opportunity to promote physical activity using mobile health (mHealth) technology. Methods: mActive was a 5-week, blinded, sequentially-randomized, parallel group, pilot trial that enrolled patients at an academic preventive cardiovascular center in Baltimore, Maryland from 1/17/14-5/20/14. Eligible patients were 18-69 year old smartphone users who reported low leisure-time activity by a standardized questionnaire. After establishing baseline activity during a 1-week blinded run-in, we randomized patients 2:1 to unblinded or blinded tracking in phase I (2 weeks), then randomized unblinded patients 1:1 to receive or not receive smart texts in phase II (2 weeks). Smart texts provided fully-automated, personalized, real-time coaching 3 times/day towards a daily goal of 10,000 steps. The primary outcome was daily step count. Results: Forty-eight patients (22 women, 26 men) enrolled with a mean (SD) age of 58 (8) years, body mass index of 31 (6), and baseline daily step count of 9670 (4350). With 100% uptake of the intervention, the phase I change in activity was non-significantly higher in unblinded patients versus blinded controls by 1024 daily steps (95% CI -580-2628, p=0.21). In phase II, smart text receiving patients increased their daily steps over those not receiving texts by 2534 (1318-3750, p<0.001) and over blinded controls by 3376 (1951-4801, p<0.001). Conclusion: In present-day adult smartphone users receiving preventive cardiovascular care in the United States, a technologically-integrated mHealth strategy combining digital tracking with fully-automated, personalized, real-time text message coaching resulted in a large increase in physical activity

Clinical Characteristics of Patients Classified as Very High Risk and Not Very High Risk Based on the 2018 AHA/ACC Multi-Society Cholesterol Guideline

Background The 2018 AHA/ACC Cholesterol Guideline recommendation to classify ASCVD patients as very high-risk (VHR) vs not-VHR (NVHR) has important implications for ezetimibe and PCSK9 inhibitor eligibility. We aimed to define the clinical characteristics of these two groups within a large multi-state healthcare system in the Western U.S. Methods We performed a retrospective cohort analysis of patients defined as having ASCVD in 2018 using EHR ICD-10 codes. VHR was defined by ≥2 major ASCVD events (ACS ≤12 months, history of MI \u3e12 months, ischemic stroke, or symptomatic PAD) or 1 major ASCVD event and ≥2 high-risk conditions (age ≥65, DM, HTN, smoking, HeFH, CKD, CHF, persistently elevated LDL-C, or prior CABG/PCI). Patients not meeting these criteria were classified as NVHR. Results A total of 180,669 ASCVD patients were identified: 104,123 (58%) were VHR and 76,546 (42%) were NVHR. Mean age and gender was 70.1±13.4 years, 54% male and 73.1±11.9 years, 55% male for the NVHR and VHR groups, respectively. Among patients with a history of MI or recent ACS, 99% and 96% were classified as VHR, respectively (Table). Age ≥65, HTN and DM were the most prevalent high-risk conditions. Conclusion Criteria used to predict future CV risk largely divide ASCVD patients into groups of similar prevalence. Nearly all ACS/MI patients were VHR. With growing emphasis on individualized risk assessment and intense LDL-C reduction, opportunity exists to further refine risk prediction within these two at-risk groups

Virtual healthcare solutions in heart failure: a literature review

The widespread adoption of mobile technologies offers an opportunity for a new approach to post-discharge care for patients with heart failure (HF). By enabling non-invasive remote monitoring and two-way, real-time communication between the clinic and home-based patients, as well as a host of other capabilities, mobile technologies have a potential to significantly improve remote patient care. This literature review summarizes clinical evidence related to virtual healthcare (VHC), defined as a care team + connected devices + a digital solution in post-release care of patients with HF. Searches were conducted on Embase (06/12/2020). A total of 171 studies were included for data extraction and evidence synthesis: 96 studies related to VHC efficacy, and 75 studies related to AI in HF. In addition, 15 publications were included from the search on studies scaling up VHC solutions in HF within the real-world setting. The most successful VHC interventions, as measured by the number of reported significant results, were those targeting reduction in rehospitalization rates. In terms of relative success rate, the two most effective interventions targeted patient self-care and all-cause hospital visits in their primary endpoint. Among the three categories of VHC identified in this review (telemonitoring, remote patient management, and patient self-empowerment) the integrated approach in remote patient management solutions performs the best in decreasing HF patients' re-admission rates and overall hospital visits. Given the increased amount of data generated by VHC technologies, artificial intelligence (AI) is being investigated as a tool to aid decision making in the context of primary diagnostics, identifying disease phenotypes, and predicting treatment outcomes. Currently, most AI algorithms are developed using data gathered in clinic and only a few studies deploy AI in the context of VHC. Most successes have been reported in predicting HF outcomes. Since the field of VHC in HF is relatively new and still in flux, this is not a typical systematic review capturing all published studies within this domain. Although the standard methodology for this type of reviews was followed, the nature of this review is qualitative. The main objective was to summarize the most promising results and identify potential research directions

SMARTPHONE-BASED TRACKING AND TEXTING INTERVENTIONS FOR PROMOTION OF PHYSICAL ACTIVITY IN CARDIOVASCULAR PREVENTION

Introduction: The recent advent of smartphone-linked wearable accelerometers offers a novel opportunity to promote physical activity using mobile health (mHealth) technology. Methods: mActive was a 5-week, blinded, sequentially-randomized, parallel group, pilot trial that enrolled patients at an academic preventive cardiovascular center in Baltimore, Maryland from 1/17/14-5/20/14. Eligible patients were 18-69 year old smartphone users who reported low leisure-time activity by a standardized questionnaire. After establishing baseline activity during a 1-week blinded run-in, we randomized patients 2:1 to unblinded or blinded tracking in phase I (2 weeks), then randomized unblinded patients 1:1 to receive or not receive smart texts in phase II (2 weeks). Smart texts provided fully-automated, personalized, real-time coaching 3 times/day towards a daily goal of 10,000 steps. The primary outcome was daily step count. Results: Forty-eight patients (22 women, 26 men) enrolled with a mean (SD) age of 58 (8) years, body mass index of 31 (6), and baseline daily step count of 9670 (4350). With 100% uptake of the intervention, the phase I change in activity was non-significantly higher in unblinded patients versus blinded controls by 1024 daily steps (95% CI -580-2628, p=0.21). In phase II, smart text receiving patients increased their daily steps over those not receiving texts by 2534 (1318-3750, p<0.001) and over blinded controls by 3376 (1951-4801, p<0.001). Conclusion: In present-day adult smartphone users receiving preventive cardiovascular care in the United States, a technologically-integrated mHealth strategy combining digital tracking with fully-automated, personalized, real-time text message coaching resulted in a large increase in physical activity

Associations of emotional social support, depressive symptoms, chronic stress, and anxiety with hard cardiovascular disease events in the United States: the multi-ethnic study of atherosclerosis (MESA)

Abstract Background Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality around the globe and psychosocial factors are not sufficiently understood. Aim In the current study, we aimed to evaluate the role of different psychosocial factors including depressive symptoms, chronic stress, anxiety, and emotional social support (ESS) on the incidence of hard CVD (HCVD). Methods We examined the association of psychosocial factors and HCVD incidence amongst 6,779 participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Using physician reviewers’ adjudication of CVD events incident, depressive symptoms, chronic stress, anxiety, emotional social support scores were measured by validated scales. We used Cox proportional Hazards (PH) models with psychosocial factors in several of the following approaches: (1) Continuous; (2) categorical; and (3) spline approach. No violation of the PH was found. The model with the lowest AIC value was chosen. Results Over an 8.46-year median follow-up period, 370 participants experienced HCVD. There was not a statistically significant association between anxiety and HCVD (95%CI) for the highest versus the lowest category [HR = 1.51 (0.80–2.86)]. Each one point higher score for chronic stress (HR, 1.18; 95% CI, 1.08–1.29) and depressive symptoms (HR, 1.02; 95% CI, 1.01–1.03) was associated with a higher risk of HCVD in separate models. In contrary, emotional social support (HR, 0.98; 95% CI, 0.96–0.99) was linked with a lower risk of HCVD. Conclusions Higher levels of chronic stress is associated with greater risk of incident HCVD whereas ESS has a protective association

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates