Tee Joo Yeo

Aims: To evaluate the Integrated-Cardiac Rehabilitation Employing Smartphone Technology (I-CREST) program’s implementation fidelity, impact mechanisms, experiences, and contextual factors influencing its delivery from post-myocardial infarction participants and healthcare professionals. Methods and results: A mixed-methods approach following the Medical Research Council (MRC) guidelines for complex interventions, focusing on implementation, mechanisms of impact, and context. Three quantitative data sources were collected: (ⅰ) records of intervention delivery; (ⅱ) records of intervention delivery time; (ⅲ) content analysis on the frequency of contextual factors from the qualitative interview data. Qualitative data were collected through individual semi-structured interviews with 14 I-CREST participants and healthcare professionals (HCPs). The I-CREST program achieved a high level of intervention delivery fidelity, with an average delivery time of 3.02 h per participant over 6 weeks. Deductive content analysis of participants’ experiences found key mechanisms of impact, including knowledge and belief, self-regulation skills and abilities, and social facilitation. Thematic analysis of participants’ experiences found four main themes: benefits of the I-CREST intervention; a change in mindset; life beyond the 6-weeks intervention; and the potential of I-CREST. Inductive content analysis of both participants’ and HCPs experiences identified implementation-level factors such as recruitment, interoperability and cost, and mechanism/experience-level factors like work commitments and motivation that influenced the I-CREST program’s implementation, mechanisms of impact, participants’ experiences and trial outcomes. Conclusion: The I-CREST program is a promising home-based cardiac telerehabilitation option that was well accepted. However, further revisions are needed if I-CREST is to achieve its full intended benefits and see successful implementation in real-world clinical settings.

Background Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. Methods Between 2020 and 2023, adults hospitalised in the previous 6–24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120–129/70-79 mm Hg) or below target (Results Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76–1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120–129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate Conclusions More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

Type 2 diabetes mellitus (T2DM), hypertension and hyperlipidaemia (collectively DHL) are longstanding cardiometabolic risk factors contributing to premature morbidity and mortality globally.1-3 Despite clear guidelines on early screening, coverage remains suboptimal in many healthcare systems, with disproportionate gaps in lower socioeconomic groups.4-6 Socioeconomic status (SES) is a multifaceted construct that often influences how much access an individual or community has to essentials such as healthcare, housing, transportation and nutritious food, as well as social resources like political influence, social engagement and autonomy.7 In this letter, the authors present key findings from a recent cross-sectional analysis of over 1.1 million residents in western Singapore that highlight missed opportunities for prevention and propose pragmatic implications for clinical practice and health policy.

Aims: Anxiety and depression are associated with poor outcomes in patients with coronary heart disease (CHD), however their association with achieving recommended cardiovascular prevention standards is unclear. We examined this association across all World Health Organization (WHO) regions. Methods and results: Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding 6–24 months with incident or recurrent CHD who underwent a standardized interview and examination (2020–2023) across 14 countries. The main outcome was the INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. A total of 4546 patients (21.1% women) with a mean (SD) age of 60.0 (10.3) were interviewed. Prevalence’s of anxiety and/or depression were greater in women than men, and prevalence of CHD lifestyle and behavioral risk factors increased alongside severity of anxiety and depression symptoms. Compared to those without symptoms, adjusted odds ratios for achieving a suboptimal INTERASPIRE-GTS were: 1.52 (95% CI 1.13–2.04, P = 0.006) for symptoms of depression; 1.57 (95% CI 1.09–2.26, P = 0.015) for “possible” comorbid anxiety and depression; and 2.09 (95% CI 1.22–3.57, P = 0.007) for those with “probable” comorbid anxiety and depression. Conclusion: Increasing severity of depression and anxiety symptoms are associated with reduced potential for achieving guideline standards for CHD secondary prevention. Secondary prevention programs should integrate risk-stratified management of individuals with symptoms of anxiety and/or depression to improve CHD guideline targets. Lay summary: We examined if patients with symptoms of anxiety and/or depression were more or less likely to achieve guideline standards for secondary prevention of coronary heart disease (CHD).Increasing severity of symptoms of anxiety and depression was associated with reduced potential for achieving guideline standards for secondary prevention of CHD.A higher proportion of women with CHD experience more severe levels of anxiety and depression on their own, and combined as a comorbidity.Patients with CHD should be treated holistically, acknowledging the heart and mind connection.

These advances in sports cardiology have largely originated from the Western world, with a conspicuous lack of evidence relating to Asian athletes.9 The incidence of SCD in Asian athletes is unknown due to the paucity of structured registries.1 Targeted recommendations for Asian athletes regarding ECG and/or imaging findings are not yet available despite Asia making up almost 60% of the world’s population, as well as having an increasing presence in global competitive sport. At the 2024 Olympics, 19% of athletes competing were from Asia and accounted for 28% of medals awarded, with China, Japan and South Korea among the top 10 bemedalled countries.10 Nonetheless, Asian athletes remain substantially underrepresented in sports cardiology research due to imbalances in access to healthcare resources, …

Background: INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods: Patients 18–80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results: Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76–1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions: INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.

Aims: To quantify international variations in lipid-lowering therapies (LLT) use among patients with coronary heart disease (CHD) and attainment of European guideline-recommended lipid goals. Methods and results: INTERASPIRE is an observational study (2020–23) covering 14 countries from all WHO regions. Patients (18–79 years) hospitalized in the preceding 6–36 months with CHD were invited for standardized interviews and examination, with central laboratory analyses for low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and apolipoprotein B (apoB). Valid lipid data meeting quality control standards were available from 13 countries. Lipid goals followed the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology: LDL-C < 1.4 mmol/L, non-HDL-C < 2.2 mmol/L, and apoB <65 mg/dL. Among 4061 patients (78.8% male, mean age 60.3 years), between index event and interview, 66.3% had no change in treatment intensity. LLT use at interview was largely statin monotherapy: 49.6% high-intensity (inter-country range 5.3%–77.3%) and 24.1% low/moderate-intensity (inter-country range 5.1%–70.1%). Otherwise, 12.2% (inter-country range 0.2%–41.1%) were on combination therapy, and 12.7% on no LLT (inter-country range 3.5%–36.7%). Goal attainment for LDL-C was 17.5%. Corresponding non-HDL-C and apoB goals were achieved by 29.9% and 29.2%, respectively. Higher-income countries (defined by the World Bank’s 2024–25 classification of income levels) did better in goal attainment than lower-middle-income countries. Conclusion: In this international study, contemporary lipid goals were not achieved in most CHD patients, with lower-middle-income countries having the worst goal attainment. Contributory factors include absence of any LLT use, low use of combinations and a failure to up-titrate LLT to achieve guideline targets.

Aims: To evaluate the feasibility and effectiveness of an integrated-cardiac rehabilitation programme employing smartphone technology (I-CREST) for patients post-acute myocardial infarction (AMI) compared with a centre-based cardiac rehabilitation (CBCR) programme. Methods and results: A two-arm parallel pilot randomized controlled trial was conducted with 50 post-AMI patients recruited from a tertiary hospital in Singapore. Participants were randomly allocated to either the I-CREST or the CBCR group. Data were collected at four time points: baseline, post-intervention (6 weeks), at 3 and 6 months. An intention-to-treat approach was adopted for data analysis. Out of 2825 patients screened over 20 months, 171 (6.05%) were eligible, and 50 patients were enrolled. Pre-specified success criteria for feasibility were achieved regarding engagement, with a high rate of participation in weekly telephone calls (95.8%), and intervention safety was confirmed. However, the pre-specified success criteria for feasibility related to recruitment and engagement with weekly educational content were not met. In terms of effectiveness, I-CREST demonstrated significantly higher completion rates (84 vs. 40%; P = 0.001) and better 6-minute walk test results at the 6-week time point (530.8 vs. 480.2 m; P = 0.017) compared with CBCR. Conclusion: This pilot study demonstrated the feasibility of the I-CREST programme, although recruitment methods require refinement. I-CREST showed promise as an effective alternative to CBCR, with fewer resources required. A full-scale study is recommended to confirm these findings statistically. Registration: ClinicalTrials.gov: NCT05270993.

The field of sports cardiology has evolved substantially over the past 2 decades due to improved understanding of the athlete’s heart, causes of sudden cardiac death (SCD) in athletes, as well as differentiation between physiological cardiac remodelling and pathological cardiac conditions in athletic individuals. Application of this knowledge forms the basis of pre-participation screening (PPS)

BACKGROUND: Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography‐guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS: Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12‐lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V ₁ to V ₂ , 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS: Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.