Investigating the effect of multimedia education in combination with teach-back method on quality of life and cardiac anxiety in patients with heart failure: a randomized clinical trial

Background Education can contribute to promotion of the quality of life and reduction of heart anxiety in patients with heart failure, so it is important to find a suitable educational method for these patients. Therefore, the present study was an attempt to determine the effect of multimedia education using teach-back method on the life quality and cardiac anxiety in patients with heart failure. Methods The present study was a randomized clinical trial. 120 patients with heart failure class I to III and aged less than 60 years old were selected using sequential sampling; then, they were assigned randomly into two intervention groups and one control group. Group A (multimedia education), group B (education using multimedia together with teach-back method), and group C (control). The quality of life and cardiac anxiety were evaluated in the participants of the three groups before, after, 1 month, and 3 months after the intervention. Data were analyzed using descriptive tests, Pearson correlation, Kolmogorov–Smirnov, chi square and ANOVA test in SPSS 22. The significance level was set at P < 0.05. Results No significant differences were found in the mean scores of the quality of life and cardiac anxiety in the control and two intervention groups before the educational intervention. However, immediately after, 1 month and 3 months after the educational intervention, a significant difference was observed between the mean scores of the quality of life and cardiac anxiety in the intervention groups (P < 0.05). Conclusion Multimedia education together with Teach-Back method is effective in promoting the quality of life and reducing cardiac anxiety in patients with heart failure. Therefore, it is recommended that health policymakers should use this educational method in providing treatment programs. Iranian Registry of Clinical Trials 20190917044802N1. Registration date: 5/2/2020.

The Effectiveness of Internet-Based Cognitive Behavioural Therapy with Telephone Support for Non-Cardiac Chest Pain: a Randomized Controlled Trial (Preprint)

BACKGROUND Non-cardiac chest pain (NCCP) is highly prevalent and associated with reduced quality of life, anxiety, avoidance of physical activity and high societal costs. There is a lack of an effective low-cost, easy to distribute intervention to assist NCCP patients. OBJECTIVE This study aimed to investigate the effectiveness of internet-based cognitive behavioural therapy (I-CBT) with telephone support for non-cardiac chest pain (NCCP). METHODS A randomized controlled trial comparing I-CBT to a treatment-as-usual (TAU) control condition with 12-month follow-up was conducted at a cardiac department. A total of 162 participants aged 18-70 with a diagnosis of NCCP were randomized to I-CBT (n=81) or TAU (n=81). The participants in the experimental condition received six weekly sessions of I-CBT. The sessions covered different topics related to coping with NCCP (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to the I-CBT sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence and to provide access to the next session. Participants in the TAU group received standard care for their NCCP without any restrictions. Primary outcomes were cardiac anxiety measured by the Cardiac Anxiety Questionnaire (CAQ) and fear of bodily sensations measured by the Body Sensations Questionnaire (BSQ). Secondary outcomes were depression measured using the Patient Health Questionnaire (PHQ-9), health related quality of life measured using EuroQol Visual Analogue Scale (EQ-VAS) and level of physical activity assessed by an investigator-developed self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 ≥5) was conducted. Linear mixed models were used to evaluate treatment effects. Cohen’s d were used to calculate effect sizes. RESULTS In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the I-CBT group had significant improvements in CAQ (-3.4 points, 95% CI -5.7 to -1.1; P=.004, d=0.38) and a non-significant improvement in BSQ (-2.7 points, 95% CI -5.6 to 0.3; P=.073) compared with TAU. EQ-VAS at the 12-month follow-up improved with statistical and clinical significance in the I-CBT group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with TAU. Physical activity was significantly (P<.001) increased during the intervention period for the I-CBT group. Depression was significantly improved at post-treatment and 3-month follow-up, but not at 12-month follow-up. Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on CAQ (d=0.55) and EQ-VAS (d=0.71) at the 12-month follow-up. In the I-CBT group 84 % (n=68) completed at least five of the six sessions. CONCLUSIONS This study provides evidence that I-CBT with minimal therapist contact and focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with NCCP. CLINICALTRIAL ClinicalTrials.gov ID: NTC03096925

The effect of Internet-delivered cognitive behavioural therapy vs. psychoeducation only on psychological distress in patients with non-cardiac chest pain: a randomized controlled trial (Preprint)

BACKGROUND Patients with recurrent episodes of non-cardiac chest pain (NCCP) suffer from cardiac anxiety, as they misinterpret the pain to be cardiac-related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as Internet-delivered cognitive behavioural therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. OBJECTIVE To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. METHODS Patients with at least two healthcare consultations due to NCCP during the last 6 months, and who were suffering from cardiac anxiety (Cardiac Anxiety Questionnaire (CAQ) score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were 54 (±17) vs 57 (±16) years old and mainly women (59% vs 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of body sensations, depressive symptoms, health-related quality of life (HRQoL), and chest pain frequency. Intention-to-treat analysis was applied, and patients were followed-up for three months. A mixed model analysis was used to determine between-group differences in primary and secondary outcomes. RESULTS No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of interaction effect of time and group over the 3-months follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen’s d=0.31). In the iCBT group, 16 patients (36%) reported a positive reliable change score (≥11 points on the CAQ), and thus an improvement in cardiac anxiety, to be compared with 13 patients (27 %) in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (p=.037), depressive symptoms (p=.007) and of NCCP frequency (p=.005) at 3-months follow-up compared to 5-weeks follow-up in the iCBT group, but not in the psychoeducation group. CONCLUSIONS iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, HRQoL and NCCP frequency than psychoeducation. The effects need to be followed up in order to draw more reliable conclusions. CLINICALTRIAL The study was registered at ClinicalTrials.gov, NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112

Changes in fear of movement in patients attending cardiac rehabilitation: responsiveness of the TSK-NL Heart

Funding Acknowledgements Type of funding sources: None. Background An important factor related to low physical activity in cardiac patients is fear of movement (kinesiophobia). The setting of cardiac rehabilitation (CR) seems suitable for targeting kinesiophobia. Nevertheless, the impact of CR on kinesiophobia is currently unknown, partly due to the absence of information on the responsiveness of instruments to measure kinesiophobia. Purpose To determine the responsiveness of the Dutch version of the Tampa Scale for Kinesiophobia questionnaire (TSK-NL Heart), to asses changes in kinesiophobia during participation in CR and to assess predictors of high levels of kinesiophobia at completion of CR. Methods This study was performed among 109 patients (mean age: 61 years; 76% men) who participated in a 6- till 12-week CR program. Kinesiophobia was measured using the TSK-NL Heart questionnaire. To determine the responsiveness of the TSK-NL Heart, the Cardiac Anxiety Questionnaire (CAQ) and the general anxiety scale of the Hospital Anxiety and Depression Scale (HADS-A) were used as external measures. All questionnaires were completed pre- and post-CR. Internal responsiveness was estimated by calculating the effect size (ES) and standardized response mean (SRM). External responsiveness was determined by calculating the correlation between change scores on the TSK-NL heart and on the external measures. Furthermore, univariate logistic regression analysis was performed with the dichotomized TSK-NL Heart score post-CR as dependent variable (high vs low scores) and baseline characteristics (age, sex, reason for referral and pre-CR scores on the TSK-NL Heart, CAQ and HADS) as predictor variables. Results Prevalence of a high levels of kinesiophobia improved from 40.4% pre-CR to 25.7% at completion of CR (p = 0.05). Both the ES and the SRM of the TSK change score were moderate for patients with an improved CAQ and HADS-A score (respectively ES = 0.52; SRM = 0.57 and ES = 0.54; SRM = 0.60) and small for patients with a stable score (ES = 0; SRM = 0 and ES = 0.26; SRM = 0.36). There was a moderate correlation between the TSK-NL Heart change score and the CAQ (Rs = 0.30, p = 0.023) and a small correlation between the TSK-NL Heart change score and the HADS-A (Rs =0.21, p = 0.107). The odds of having high kinesiophobia levels post-CR were increased by having a high level of kinesiophobia pre-CR (OR= 9.83, 95%CI: 3.52-27.46), a higher baseline score on the CAQ (OR = 1.12, 95%CI: 1.06-1.19), and a higher baseline score on the HADS-A (OR = 1.26, 95% CI: 1.11-1.42). Conclusion The TSK-NL Heart has moderate responsiveness. In addition, this study shows that there are reductions in kinesiophobia during the course of CR. Nevertheless, a large number of patients (26%) still had high levels of kinesiophobia at completion of CR. Interventions targeting kinesiophobia should focus on patients that enter CR with high levels of kinesiophobia, cardiac anxiety and generic anxiety.

INSPIRATORY MUSCLE TRAINING REDUCES HEART ANXIETY IN PATIENTS SUBMITTED TO CORONARY ARTERY BYPASS GRAFTING: CONTROLLED RANDOMIZED CLINICAL TRIAL

Introduction:Cardiac anxiety(CA) is a common finding in patients in the pre- and postoperative period of coronary artery bypass graft(CABG) surgery. Ventilatory restriction generated by pain and reduced muscle strength is associated with increased CA level. Inspiratory muscle training(IMT) for generating increased muscle strength can cause a decrease in CA in the postoperative period. Objective:To evaluate the impact of IMT on inspiratory muscle strength and its relationship with cardiac anxiety in patients undergoing CABG. Methodology:This is a randomized controlled clinical trial. In the preoperative moment, all patients answered a cardiac anxiety questionnaire, composed of two domains: fear and vigilance and avoidance. In addition, their maximum inspiratory pressure(MIP) was assessed. After the surgical procedure, the patients were divided into a control group(CG) that received routine hospital care and a training group(TG) who underwent an IMT protocol until the moment of hospital discharge. Results:80 patients were evaluated,40 in each group. The IMT group showed a 17% decrease in MIP while the CG decreased 43%(p <0.01). The fear and vigilance domain had a decrease of -16±3 in the CG while in the TG the reduction was -8±3(p <0.01). The avoidance domain reduced -17±4 in the CG vs -10±4 in the TG(p <0.01). In addition, there was a strong correlation between the MIP of the TG with the domains of fear/vigilance(r -0.77) and avoidance(r -0.72). Conclusion:IMT is associated with a reduction in the loss of inspiratory muscle strength, resulting in a reduced level of cardiac anxiety in patients undergoing CABG.

Anxiety, depression and cardiac anxiety in patients with implantable cardioverter-defibrillator according to gender and age

Objective: to investigate the relationship between gender and age with symptoms of anxiety, depression and cardiac anxiety in patients with implantable cardioverter-defibrillator. Methods: cross-sectional study, with 76 patients with device attended in a university hospital. For data collection, a sociodemographic/clinical form and two validated scales were used in Brazil. In the analysis, the chi-square tests, exact Fischer and Mann-Whitney, with a significance level of 5% were adopted. Results: it was observed that the groups were homogeneous in terms of gender and age. Women presented higher medians in both anxiety and depression symptoms, with statistical significance. They also presented higher medians in symptoms of cardiac anxiety, but without statistical significance. Regarding age, no significant differences were found for the symptoms investigated. Conclusion: women presented more symptoms of anxiety and depression; however there was no relationship between the age of the patients and their symptoms.

Anxiety-Driven Cardiopulmonary Complaints during COVID-19 Pandemic Outbreak

Background We intend to examine whether the COVID-19 outbreak influences medical decision-making (MDM) among Non-COVID patients. Method We recruit 287 patients who admit to ER department due to cardiovascular complaints. Anxiety level was measured using three questionnaires (GAD-7, Beck Inventory, and the cardiac anxiety questionnaire). A fourth survey was designed to assess MDM considerations. Results 64% of patients were male (median age 54). Almost half of the patients were found to have moderate to severe levels of anxiety.79.3% of patients reported that the outbreak influenced their MDM. 44.5% of patients sought medical care 2-3 from the onset of symptoms. Coronary artery disease was found in only 26 patients (9.1%). Almost half of the patients stated that they would have gone earlier if not for the current pandemic. Conclusion Non-COVID patients seeking medical care had a high anxiety level that directly affected decision-making and put them at unnecessary risk.