The Modified Caregiver Strain Index (M-CSI) is a 13-item instrument that measures caregiver strain among various populations. A Danish version is lacking, and the psychometric properties among relatives of out-of-hospital cardiac arrest (OHCA) survivors are unknown. This study aimed to translate, cross-culturally adapt, and evaluate the psychometric properties of the Danish version of the M-CSI in relatives of OHCA survivors. The study used data from the national cross-sectional DANCAS (DANish Cardiac Arrest Survivorship) survey, where relatives of OHCA survivors completed the Danish versions of M-CSI, the Hospital Anxiety and Depression Scale (HADS), and the World Health Organisation's Five Well-being Index (WHO-5). The M-CSI was forward- and back-translated, pre-tested, and culturally adapted. Structural validity was examined with exploratory factor analysis (EFA) and construct validity was investigated using a priori hypothesis testing (known-groups validity) and correlations with the other instruments (convergent validity/overlapping constructs). The internal consistency reliability was assessed using Cronbach's α. In total, 561 relatives responded (response rate 45%), of which 88% were women, the median age was 64, and 24% reported caregiver strain (M-CSI ≥7). The EFA supported a one-factor structure. Based on the a priori hypotheses, it was confirmed that younger caregivers (<55 years) described more caregiver strain (effect size δ = 0.13; small). Correlations between M-CSI, HADS-A, HADS-D, and WHO-5 were moderate. Internal consistency was α = 0.90. The Danish version of the M-CSI demonstrated good structural validity, good internal consistency reliability, and good construct validity in relatives of OHCA survivors.

To describe how telemedicine in cardiac rehabilitation can be optimized through the development of a co-produced, family-focused Cardiac TeleRehabilitation model. A co-production approach was used to collaboratively develop a cardiac telerehabilitation model with eight cardiac patients, three family members, and eight healthcare professionals through three workshops. Data were analysed iteratively after each workshop using an inductive, semantic-level approach inspired by Braun and Clarke's thematic analysis, identifying themes from explicit data content. We first identified the needs, barriers, and facilitators associated with video consultations and home monitoring in cardiac rehabilitation. We gained a deeper understanding of the participants' expectations, preferences, and challenges in adopting video consultations and home monitoring. Six themes emerged from the workshops: (1) Trust and relationship building initiated by the first in-person consultation; (2) Communication and presence in a digital setting; (3) Inclusion of family members; (4) Digital competencies and technical readiness; (5) Informed decision-making and patient autonomy; (6) Practicality, flexibility, and organizational readiness. These themes shaped a cardiac telerehabilitation model, comprising video consultations, home monitoring, manuals, a nurse support tool and a patient decision tool. Through co-productive workshops with patients, family members, and healthcare professionals, a cardiac telerehabilitation model was developed to support the use of video consultations and home monitoring. The model is intended to support the delivery of flexible, accessible rehabilitation tailored to each patient's individual needs. The model requires further evaluation in more diverse settings before broader implementation. Part of ClinicalTrials.gov (NCT06320652).

To describe trajectories of insomnia symptoms over 12 months in patients with heart failure (HF) and to identify characteristics associated with persistent, fluctuating, or low/no insomnia. This secondary analysis used data from the HF-Wii randomized trial, including 400 patients from 10 centers in six countries (Sweden, Italy, Israel, the Netherlands, Germany, USA). Insomnia was assessed at baseline, 3, 6, and 12 months using the Minimal Insomnia Symptom Scale. Patients were grouped into insomnia trajectories (persistent, fluctuating, low/no insomnia). Depression and anxiety were measured with the Hospital Anxiety and Depression Scale, well-being with Cantril's Ladder, quality of life with the Minnesota Living with Heart Failure Questionnaire, comorbidity burden with the Charlson Comorbidity Index, and functional capacity with the 6-minute walk test. Group differences were examined with ANOVA and chi-square tests; variables with p ≤ 0.05 were entered into multivariate logistic regression. Associations were examined with ANOVA, chi-square, and multivariable logistic regression.At baseline, 126 patients (32%) reported insomnia: 51 (40%) had persistent, 48 (38%) fluctuating, and 27 (21%) recovered. Among 274 without baseline insomnia, 25 (9%) developed insomnia at 2-3 follow-ups and 36 (13%) at one time point. Persistent insomnia was independently associated with higher anxiety (OR = 2.73; p < 0.001) and lower functional capacity (OR = 0.50; p < 0.005). A substantial proportion of HF patients experience persistent or fluctuating insomnia. Routine assessment-particularly in those with anxiety or low functional capacity-may aid early detection and guide targeted interventions.

To study whether chronic physiological stress may play a role in the onset of Takotsubo Syndrome (TS) and whether it is associated with worse psychological distress in patients recovering from a recent TS episode. We compared hair cortisol concentration (HCC), a validated biomarker of chronic stress, between a group of patients recently admitted with a new diagnosis of TS (Mayo criteria) and a cohort of clinically stable historical controls. HCC, demographics, perceived stress, depression, anxiety, PTSD symptoms, and trigger history were assessed approximately 4 weeks after discharge. Descriptive statistics and linear regression models were used to assess associations. Participants (n=59) had a mean age of 64.5 years and were mostly non-Hispanic White (94.9%) and female (96.6%). A large proportion of participants had a history of psychiatric disorders (62.7%), including anxiety disorders (40.7%) and mood disorders (39.0%). The HCC in the TS sample was twice as high as that of clinically stable controls (geometric mean: 7.3 pg/mg (SD 2.9) vs. 3.5 pg/mg (SD 3.7), p < .01). We found that patients with higher HCC did not report a history of triggers prior to TS onset or greater psychological distress post-discharge. Patients with a recent TS episode had significantly higher HCC compared to clinically stable controls, suggesting that chronic physiological stress may play a role in the onset of TS. These preliminary findings support further investigation into the effects of stress-reduction approaches for the prevention of recurrent TS and related morbidity. ClinicalTrials.gov NCT04325321.

Pregnancy-related cardiometabolic complications such as gestational diabetes mellitus, hypertensive disorders, and preterm birth significantly increase the risk of future cardiovascular diseases (CVD). Many postpartum women remain unaware of this risk, highlighting the need for targeted educational interventions. Validated tools to assess knowledge gaps in this population are lacking. Therefore, this study aimed to develop and preliminarily validate the Coronary Artery Disease Education Questionnaire for Postpartum Women (CADE-Q-PP) to ensure content validity and relevance. The CADE-Q was systematically revised to identify items specific to postpartum women's knowledge concerning pregnancy-related cardiometabolic complications and CVD risk. A modified Delphi process was conducted with a panel of 28 international experts to refine the items, using a five-point Likert scale for consensus (mean score ≥4). Items were further simplified into plain language and a clarity assessment was completed with 20 postpartum women. A total of 61 items were drafted across four key knowledge areas: cardiovascular risk, physical activity, mental health, and nutrition. Through iterative discussion, consensus was achieved on 22 questionnaire items. Clarity assessment revealed a high degree of understanding among postpartum women (total mean 4.3 ± 0.9), with 20/22 items scoring above 4.0. Items that scored lower concerned long-term risks and specific interventions. Suggestions included sentence structure and providing context for terms like 'hidden sugar' and 'extra vitamins'. The CADE-Q-PP was developed as an accessible tool for clinicians to assess knowledge gaps regarding cardiovascular risk and health promotion in postpartum women. Future work will include testing of psychometric properties to confirm validity.

Despite its proven effectiveness, traditional exercise-based cardiac rehabilitation (exCR) suffers from low participation rates. However, telemedicine-based exCR can overcome access barriers to traditional rehabilitation while providing personalized, structured exercise training and remote monitoring. The aim of this review is to ascertain the efficacy of personalized, structured, telemedicine-based exCR in improving health outcomes in patients with coronary heart disease (CHD). A systematic search was conducted in databases including Cochrane Library, PubMed, Web of Science, Embase, CINAHL, Scopus, Medline, China National Knowledge Infrastructure, Wanfang, VIP, and SINOMED from inception to March 2024 to identify randomized controlled trials (RCTs). The final analysis included 19 RCTs comprising 2219 participants. Among patients with CHD, telemedicine-based exCR demonstrated comparable effects to centre-based exCR across multiple outcomes, including exercise capacity, physical activity levels, cardiovascular risk factors, and quality of life (all P > 0.05). Notably, when compared with usual care, telemedicine-based exCR showed significant improvements in exercise capacity [standardized mean difference (SMD) = 0.23, 95% CI: (0.12, 0.35), I2 = 34%, P < 0.0001], physical activity level [SMD = 0.32, 95% CI: (0.09, 0.54), I2 = 53%, P = 0.006], diastolic blood pressure [mean difference (MD) = -1.54, 95% CI: (-2.89, -0.20), I2 =8%, P = 0.02], body mass index [MD = -0.54, 95% CI: (-1.94, -0.14), I2 = 4%, P = 0.008], and depression [SMD = -0.27, 95% CI: (-0.42, -0.13), I2 = 33%, P = 0.0002]. Telemedicine-based exCR is equally effective as centre-based exCR in improving key health outcomes for patients with CHD, including exercise capacity, physical activity levels, cardiovascular risk factors, and quality of life. Furthermore, telemedicine-based exCR shows superior effectiveness to usual care, with statistically significant improvements in exercise capacity, physical activity, diastolic blood pressure, and depressive symptoms. PROSPERO: CRD42024521465.

Cardiovascular disease (CVD) and stroke disproportionately affect people from culturally and linguistically diverse (CALD) backgrounds, with disparities driven by cultural, social, and systemic barriers. Despite these disparities, people of CALD backgrounds remain underrepresented throughout CVD research. The Transcultural Nursing theoretical framework provides a structure for culturally appropriate research by integrating patients' beliefs, values, and preferences. This discussion paper examines the Transcultural Nursing theoretical framework and its relevance in CVD and stroke research, and demonstrates its application through exemplars. Despite critiques concerning complexity and potential stereotyping, the Transcultural Nursing theoretical framework remains a valuable framework for culturally responsive research.

Administrative health data provide valuable insights into healthcare, but missing data remains a major barrier to ensuring the veracity of findings. This paper presents a structured approach to addressing missingness in administrative datasets, focusing on data assessment and statistical methods. Using causal diagrams and understanding the types of missing data to guide appropriate analytical strategies aligned with the Treatment And Reporting of Missing data in Observational Studies (TARMOS) framework. A real-world example demonstrates multiple imputations in large-scale health research. By promoting transparent and rigorous methods, this methods paper enhances the reliability and policy relevance of administrative data-based healthcare research.

This study examined the associations between spirituality, caregiver burden, disability, and health-related quality of life (HRQoL) within stroke survivor-caregiver dyads using a dyadic structural equation modeling (SEM) approach. The aim was to explore spirituality as a shared dyadic resource in post-stroke adaptation. A cross-sectional analysis was conducted with 217 stroke survivor-caregiver dyads recruited at discharge from rehabilitation hospitals. Spirituality, caregiver burden, disability, and HRQoL were assessed using validated instruments. Dyadic SEM estimated within-person and cross-dyadic associations. Missing data were minimal and not systematic. Survivors' spirituality showed significant within-person associations with better physical (β = 0.304, p < 0.001), cognitive (β = 0.449, p < 0.001), emotional (β = 0.455, p < 0.001), and social HRQoL (β = 0.343, p < 0.001). Cross-dyadic associations were observed: higher survivor spirituality was associated with lower caregiver time-dependent (β = -0.275, p < 0.001), developmental (β = -0.208, p < 0.001), and physical burden (β = -0.183, p = 0.030). Caregivers' spirituality showed a non-significant trend toward lower survivor cognitive disability (β = -0.117, p = 0.052). After adjustment for caregiver gender and survivors' activities of daily living, caregiver spirituality was associated with lower developmental burden (β = -0.227, p = 0.023). Spirituality was associated with multiple dimensions of post-stroke adaptation through distinct within- and cross-dyadic pathways. These findings support the relevance of dyadic SEM in stroke rehabilitation and highlight spirituality as a relational psychosocial resource within survivor-caregiver dyads.