The Dyadic Experience of Managing Heart Failure: A Qualitative Investigation Background: Self-management of heart failure (HF) is often a joint venture between patients and their friends and family (“framily”). However, this joint experience is often overlooked in clinical care. Objectives: The aim of this study was to understand the cognitive, emotional, and relational elements affecting the experience of patient-framily member dyads managing HF. Methods: Participants were patients with HF receiving care at a university hospital and their framily. Dyads participated in 30- to 45-minute semistructured interviews before their clinic visit. Transcribed interviews were analyzed using thematic analyses. Interviews were coded independently and checked for interrater agreement before the final coded data set was developed. Participants were recruited until thematic saturation was attained. Results: A total of 16 patient-framily member dyads and 1 triad (n = 35) participated in the study; 47.1% of patients and 77.8% of framily members were female. Patients were 66 years old (SD, 14 years) and framily members were 59 years old (SD, 12.3 years). Three aspects of the dyadic experience emerged in the themes: (1) health beliefs of dyads were characterized by acceptance and optimism, but also pessimism; (2) negative emotions influenced the dyadic experience; (3) the closeness of their interpersonal relationships influenced their contributions to managing HF. Conclusions: Our study suggests that greater attention to the experience and interpersonal relationships of dyads has the potential for improving HF self-management and facilitating patient-centered care. This study was funded by a grant from the Stanford Presence and Bedside Medicine Program and a National Institutes of Health supplemental award from the Office of Behavioral and Social Science Research awarded to Dr Trivedi. Dr Trivedi was additionally supported by a VA HSR&D Career Development Award. Earlier analyses of this study have been presented at the American Psychosomatic Society Mid Annual Meeting in 2017. The views expressed herein are those of the authors and do not necessarily reflect those of the Department of Veterans' Affairs. The authors have no conflicts of interest to disclose. Correspondence Ranak Trivedi, PhD, 795 Willow Rd 152-MPD, Center for Innovation to Implementation, Bldg 324 B-134, Menlo Park, CA 94025 (ranakt@stanford.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Patient, Caregiver, and Clinician Perceptions of Ventricular Assist Device Self-care Education Inform the Development of a Simulation-based Mastery Learning Curriculum Background Patients who undergo ventricular assist device (VAD) implantation and their caregivers must rapidly learn a significant amount of self-care skills and knowledge. Objective The aim of this study was to explore patient, caregiver, VAD coordinator, and physician perspectives and perceptions of existing VAD self-care training to inform development of a simulation-based mastery learning (SBML) curriculum to teach patients and caregivers VAD self-care skills and knowledge. Methods We conducted semistructured, in-person interviews with patients with a VAD, their caregivers, VAD coordinators, and physicians (cardiac surgeons, an infectious disease physician, and advanced heart failure cardiologists). We used a 2-cycle team-based iterative inductive approach to coding and analysis. Results We interviewed 16 patients, 12 caregivers, 7 VAD coordinators, and 11 physicians. Seven major themes were derived from the interviews including (1) identification of critical curricular content, (2) need for standardization and assessment, (3) training modalities, (4) benefits of repetition, (5) piercing it all together, (6) need for refresher training, and (7) provision of training before implant. Conclusions Findings from this study suggest that SBML is a natural fit for the high-risk tasks needed to save VAD self-care. The 7 unique training-related themes derived from the qualitative data informed the design and development of a VAD SBML self-care curriculum. This work was supported by the National Institutes of Health, National Institute of Nursing Research (grant number 1R21NR016745-01). The authors have no conflicts of interest to disclose. Correspondence Jeffrey H. Barsuk, MD, MS, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Ste 717, Chicago, IL 60611(jbarsuk@nmh.org). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Effects of eHealth Information Technology–Based Interventions on Adherence to Components of Cardiac Rehabilitation: A Systematic Review Objective The aim of this study was to determine the effects of eHealth-based interventions on patient adherence to components of cardiac rehabilitation (CR). Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guided this review. Medline, CINAHL, Embase, and Cochrane Library databases were searched for studies published from January 1996 to December 2017. All studies were included in which eHealth-based components of CR and its effects on patient adherence were measured. Because this review included a heterogeneous group of study designs, the authors qualitatively described the effect of eHealth on adherence into a narrative approach. Results A total of 1520 studies were identified, with 1415 excluded after screening. Of the remaining 105 studies, 90 were excluded after full text assessment, leaving 15 studies for analysis. Most (11) of the 15 studies reported on medication adherence. Other studies focused on adherence to diet, physical activity, vital signs, weight, step counts, smoking, and fluid restriction. The type of eHealth used also varied, ranging from telemonitoring and web-based applications to telephone calls. Of the 15 studies, 7 reported significant improvements with eHealth-based components of CR on adherence. Discussion and Conclusion This review summarizes the effects of eHealth on components of CR and revealed variations in measurement and evaluation methods. The telemonitoring and web-based applications for self-care behaviors were most effective in promoting adherence. The measurement of adherence should be based on an explicit definition of adherence and should be measured with validated scales tested in the CR population. The authors have no funding or conflicts of interest to disclose. Author contributions: AK and MO contributed to the conception and design of the work. AK and MO contributed to the acquisition and analysis of data for the work. AK, MO, and SCL contributed to the interpretation of the data for the work, drafted the manuscript, and critically revised the manuscript. All gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Correspondence Ayda Kebapci, RN, PhD, Koç University, School of Nursing, Health Science Campus, Davutpaşa Cad, No. 4, Topkapi 34010, Istanbul, Turkey (akebapci@ku.edu.tr). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Medication Nonadherence or Self-care? Understanding the Medication Decision-Making Process and Experiences of Older Adults with Heart Failure Background More than half of all patients with heart failure (HF) do not take medications as prescribed, resulting in negative health outcomes. Research has shown that medication adherence may be intentional rather than the ability to follow prescribed regimens, yet very little is known about medication-taking decisions in older patients with HF. Objective The purpose of this qualitative study was to gain insight into the decision-making processes and experiences of older patients with HF by exploring the different aspects in choosing to take or not take medications as prescribed in the community setting. Methods Using a narrative inquiry approach, the personal narratives of 11 adults 65 years or older who took at least 2 daily medications for HF were gathered using in-depth, semistructured interviews. The data in this study were organized and analyzed using Riessman's framework for narrative analysis. Results Participants made intentional decisions to take particular medications differently than prescribed. A worrisome symptom prompted a naturalistic decision-making process. When a medication interfered with attaining a personal goal, participants coped by individualizing their medication regimen. Participants did not consider taking a medication differently than prescribed as nonadherence but a necessary aspect of maintaining a personal level of health, which could be seen as self-care. Conclusions The older patient with HF should be carefully assessed for nonadherence. The development of interventions that are patient specific, target medications with the greatest potential for nonadherence, and use easy-to-access resources may promote decisions for medication adherence. More research is needed to develop interventions that promote decisions for medication adherence. The author has no funding or conflicts of interest to disclose. Correspondence Rebecca Meraz, PhD, MSN, RN, CCRC, CHFN-K, Baylor University Louise Herrington School of Nursing, 333 North Washington Ave, Dallas, TX 75246 (Rebecca_Meraz@baylor.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Thirst in Patients With Heart Failure in Sweden, the Netherlands, and Japan Background: Thirst is a distressing symptom and influences quality of life of patients with heart failure (HF). Knowledge about thirst in HF is insufficient; therefore, the aim of this study was to describe factors related to thirst, self-reported reasons for thirst, and interventions to relieve thirst in 3 different countries. Methods: A cross-sectional study was conducted in Sweden, the Netherlands, and Japan. Patients were recruited at the HF clinic or during HF hospitalization. Thirst was assessed by a visual analog scale (0–100); reasons for thirst and interventions to relieve thirst were assessed by an open-ended questionnaire. Patients were divided into low and high thirst based on the first and third tertiles of the visual analog scale. Results: Two hundred sixty-nine patients participated in the study (age, 72 ± 12 years). Mean thirst intensity was 24 ± 24, with a mean thirst of 53 ± 15 in the highest tertile. No significant differences in thirst among the 3 countries were found. Multivariable logistic regression analysis showed that a higher dose of loop diuretics (odds ratio, 3.47; 95% confidence interval, 1.49–8.06) and fluid restriction (odds ratio, 2.21; 95% confidence interval, 1.08–4.32) were related to thirst. The most reported reasons for thirst were salty/spicy food (20%) and low fluid intake (18%). Most of the patients (56%) drank more in case of thirst; 20% only drank a little bit, probably related to a fluid restriction. Conclusions: Thirst in patients with HF was related to a higher dose of loop diuretics and fluid restriction. Healthcare providers should realize that it is important to assess thirst regularly and reconsider the need of a fluid restriction and the amount of loop diuretics in case of thirst. The authors have no funding or conflicts of interest to disclose. Correspondence Martje H.L. van der Wal, PhD, RN, Department of Cardiology, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands (m.h.l.van.der.wal@umcg.nl). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Implantable Cardioverter Defibrillator Shocks and Psychological Distress: Examining the Mediating Roles of Implantable Cardioverter Defibrillator–Related Concerns and Perceived Control Background: Although the implantable cardioverter defibrillator (ICD) has a survival benefit for the prevention of sudden cardiac death, ICD recipients commonly experience emotional distress as a consequence of ICD shocks. Objective: The aim of this study was to examine whether the association between ICD shocks and psychological distress (anxiety and depressive symptoms) is mediated by ICD-related concerns and perceived control among ICD recipients. Methods: This was a multinational cross-sectional observational study of 334 ICD recipients. Patients reported the number of shocks received since ICD implantation and completed questionnaires to assess anxiety, depressive symptoms, ICD-related concerns, and perceived control. A path analysis was conducted to explore the relationship of receiving ICD shocks with anxiety and depressive symptoms and the mediating effects of ICD-related concerns and perceived control. Results: Of the 334 ICD recipients, 39.2% experienced ICD shocks at least once since implantation. There was no direct effect of ICD shocks on anxiety and depressive symptoms. Experiencing ICD shocks was indirectly associated with an increased likelihood of anxiety and depressive symptoms via the pathways of ICD-related concerns and perceived control (indirect effects on anxiety = 0.060, 0.043; indirect effect on depressive symptoms = 0.025, 0.073). Conclusion: Experiencing defibrillator shocks was associated with psychological distress in ICD recipients; the relationship was fully mediated by ICD-related concerns and perceived control. These results suggest that clinicians should routinely assess ICD-related concerns and perceived control in patients with ICD. Research is needed to develop and test interventions to decrease emotional distress related to the ICD shock experience. Source of funding: the National Research Foundation of Korea grant funded by the Korea government (MEST) (2016R1A2B4008495) and a research grant funded by the Chungnam National University (2015-1794-01) The authors have no conflicts of interest to disclose. Correspondence Kyoung Suk Lee, PhD, RN, MPH, Seoul National University, College of Nursing, 103 Daehak-ro, Jongno-gu, Seoul 03080, South Korea (kyounglee@snu.ac.kr). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Self-management Among Elderly Patients with Hypertension and Its Association With Individual and Social Environmental Factors in China Background: The hypertension control rate in China is much lower than that in developed countries. Self-management among elderly patients with hypertension can improve blood pressure control; thus, it is necessary to explore its association with individual and social environmental factors. Objective: Our objective was to investigate self-management among elderly patients with hypertension in China and its association with individual and social environmental factors based on the social ecological model. Methods: A total of 301 elderly patients with hypertension were recruited to do a questionnaire survey based on the social ecological model, which included the General Demographic Information Questionnaire, Hypertension Patients Self-Management Behavior Rating Scale, World Health Organization Well-Being Index, Family APGAR Index, and Social Support Rating Scale. Results: The lowest level of self-management behaviors was in exercise management, and the highest was in medication management. The results of multiple linear regression analysis showed that well-being, family function, sex, education level, and age were pivotal individual and social environmental factors influencing self-management behaviors among elderly patients with hypertension. Conclusions: There is a need to develop and test interventions that improve self-management in elderly patients with hypertension. Specifically, individualized interventions to promote exercise among elderly persons with hypertension who are single and living alone are needed. Male patients with a lower education level, poor well-being, poor family function, and the lowest self-management levels are a key population to target. X.-N.Z. and C.Q. contributed equally to this study. The research was supported by the National Natural Science Foundation of China (71673199) and the Science & Technology Development Fund of Tianjin Education Commission for Higher Education (2017SK097). The authors have no conflicts of interest to disclose. Correspondence Xiao-Ying Zang, PhD, School of Nursing, Tianjin Medical University, No. 22 Qixiangtai Rd, Heping District, Tianjin 300070, China (xiaoyingzang@163.com); Yue Zhao, PhD, School of Nursing, Tianjin Medical University, No. 22 Qixiangtai Rd, Heping District, Tianjin 300070, China (yuezhao35@hotmail.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Factors Influencing Cardiovascular Risk Factors and Health Perception Among Kentuckians Living in Appalachia Background: Cardiovascular disease (CVD) and risk factors for CVD are prevalent among Appalachians from Kentucky. Appalachian men and women have high rates of engagement in unhealthy behaviors and poor physical health measures that increase their risk for CVD. Objective: In this study, the relationship among gender, CVD risk factors, and health perception in Appalachians from Kentucky was explored. Methods: This cross-sectional secondary analysis is from a randomized controlled trial on CVD health in rural Kentucky. To assess gender differences in smoking history, χ2 was used. Independent t tests compared the mean between participants 50 years or younger and those older than 50 years with differences in body mass index (BMI), waist circumference, systolic and diastolic blood pressure, hemoglobin A1C, total cholesterol, and physical activity. A multivariate linear regression analysis assessed variables predicting the outcome of health perception. Results: Most participants had a mean BMI of 33 kg/m2 and 94.3% of men used smokeless tobacco compared to 5.7% of the women. Differences existed between gender and current, ever, or never smoked (P < .001). Women had higher total cholesterol levels but men had higher waist circumference. Participants older than 50 years had higher engagement in physical activity than did those 50 years or younger. Higher BMI and hemoglobin A1C level were significant predictors of worse health perception (P ≤ .05). For every unit increase in the physical activity scale, there was a 0.2-unit improvement in health perception (P ≤ .001). Conclusion: Appalachians from Kentucky have many CVD risk factors. Minimal engagement in preventative measures against CVD can worsen patient outcomes. The authors have no funding or conflicts of interest to disclose. Correspondence Cilgy M. Abraham, BS, RN, 560 West 168th Street-Mail Code 6, New York, NY 10032 (cma2212@cumc.columbia.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Effect of a Transtheoretical Model–Based Stage-Matched Exercise Intervention on Exercise Behavior and Angina in Patients With Coronary Heart Disease: A Randomized Controlled Trial No abstract available