The study aimed to study the influence of musculoskeletal pain on kinesiophobia in patients with heart failure. This cross-sectional study recruited 107 heart failure patients aged 73.18</n>12.68 years (57% men) from an outpatient setting. Participants self-reported pain using the Musculoskeletal System Assessment Inventory and the Cornell Musculoskeletal Discomfort Questionnaire. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia-11. About 62% reported musculoskeletal pain, with knees (16.8%) and lower back (12.%) being the most painful locations. About 31% reported moderate levels and 24% indicated high levels of kinesiophobia. There were positive and significant associations between the indicators of pain and kinesiophobia. Results showed an adequate structural equation model fit to the data with musculoskeletal pain factors explaining 22.09% of the variance in kinesiophobia. Assessment of kinesiophobia in patients with heart failure with musculoskeletal pain is essential to improve self-care and overall quality of life. & COPY; 2023 Elsevier Inc. All rights reserved.

Objectives: Exergaming is promising for patients with heart failure who are less inclined to start or maintain exercise programs involving traditional modes of physical activity. Although no effect on exercise capacity was found for an off-the-shelf exergame, it is important to gain insights into aspects related to costs to develop such interventions further.Materials and Methods: In a randomized controlled trial, the Heart Failure Wii study (HF-Wii study), the intervention group (exergame group) received an introduction to the exergame, the exergame was installed at home and help was offered when needed for 3 months. Patients received telephone follow-ups at 2, 4, 8, and 12 weeks after the installation. The control group (motivational support group) received activity advice and telephone follow-ups at 2, 4, 8, and 12 weeks. We collected data on hospital use and costs, costs of the exergame intervention, patient time-related costs, and willingness to pay.Results: No significant differences were found between the exergame group (n = 300) versus the motivational support group (n = 305) in hospital use or costs (1-year number of hospitalizations: P = 0.60, costs: P = 0.73). The cost of the intervention was 190 Euros, and the patient time-related costs were 98 Euros. Of the total estimated costs for the intervention, 287 Euros, patients were willing to pay, on average, 58%.Conclusion: This study shows that the costs of an intervention using an off-the-shelve exergame are relatively low and that the patients were willing to pay for more than half of the intervention costs. The trial is registered in ClinicalTrials.gov (NCT01785121).

Aims Exercise games (exergames) have been recently proposed as a mode of facilitating physical activity in patients with chronic diseases. Although patients supported with left ventricular assist devices (LVADs) benefit from physical activity, specific LVAD-related issues hinder their ability to exercise properly. The objective of this study was to assess the feasibility and safety of exergaming in LVAD-supported patients. Methods and results Eleven LVAD-supported patients were enrolled in a 4 week exergaming programme using Nintendo Wii console with five sport games. Patients were instructed to play for 30 min a day, 5 days a week. Data on exercise capacity and exergaming were collected by using the 6 min walk test (6MWT) and a daily self-report diary, respectively. Feasibility of using the console and its safety was assessed by a semi-structured patient interview. Quality of life was assessed by the Minnesota Living with Heart failure Questionnaire (MLHFQ) and the Cantrils Ladder of Life. Safety was assessed by patients report in interview and diary. The study group consisted of 10 male patients and 1 female patient, mean age of 67 +/- 7 years, of whom 10 were supported with the HeartMate 3 LVAD for a median of 10 (interquartile range 3, 21) months. Baseline exercise capacity assessed by the 6MWT ranged from 240 to 570 m (mean 448 +/- 112). After 4 weeks of exergaming, 6MWT distance increased from a mean of 448 +/- 112 (evaluated in six patients) to 472 +/- 113 m (P = 0.023). Patients Cantrils Ladder of Life score improved numerically from an average of 6.13 to 7.67, as did their MLHFQ score from 45.9 +/- 27 to 38.7 +/- 18, with higher and lower scores, respectively, reflecting higher quality of life. No specific LVAD-related safety issues regarding exergaming were reported. Conclusions Exergaming was found to be a safe and feasible mode for encouraging physical activity in LVAD-supported patients and carries a potential for improving exercise capacity and quality of life in these patients. Larger scale studies are warranted to further investigate the effect of exergaming in this patient population.

Aims Patients with heart failure (HF) can exhibit kinesiophobia, an excessive, debilitating, and irrational fear of movement. This study aimed to enhance the understanding of kinesiophobia in patients with HF by analysing associations with the following variables: musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability, frailty, sex, and age. Methods and results In this cross-sectional study, 107 participants were included, with ages ranging from 28 to 97 years (57% men, mean age 73.18 +/- 12.68 years). Multiple regression analyses were performed with all variables, including polynomial regressions for variables with a non-linear relationship. Kinesiophobia was significantly correlated (P < 0.01) with musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability, and being at risk of frailty, while age and sex were not statistically significant. Frailty disability and musculoskeletal pain intensity were variables linearly associated with kinesiophobia, while quality of sleep and disability had a non-linear relationship with kinesiophobia. Conclusion Kinesiophobia needs to be evaluated and better understood in patients with HF to improve physical activity and exercise adherence. This study found that musculoskeletal pain intensity, quality of sleep, disability, and frailty risk have a significant association with kinesiophobia in patients with HF. Our results suggest multi-dimensional associations of kinesiophobia in patients with HF, which require further examination and understanding. [Graphics] .

Introduction Type 2 diabetes is increasing globally and particularly affects vulnerable groups in society, such as migrants. Research shows that type 2 diabetes is a risk factor for severe illness when infected with COVID-19. Diabetes-related complications can be prevented with good glycaemic control. In addition, good glycaemic control has been shown to be an important cornerstone for preventing severe illness in individuals infected with COVID-19. In order to maintain good glycaemic control, self-care is needed. The purpose of this article is to describe self-care maintenance and possible changes in self-care maintenance and to explore factors related to unchanged self-care maintenance in migrant patients with type 2 diabetes during the COVID-19 pandemic. The second aim is to describe well-being, social support, and the need for support from healthcare services during the COVID-19 pandemic in migrant patients with type 2 diabetes. Design/Method A triangulation design with cross-sectional data collection was used. Both quantitative and qualitative data were collected and interpreted together in a triangulation design. Patients were selected by a diabetes nurse from a computer system at a health center in south-eastern Sweden and invited to participate in the study. A questionnaire was translated into the languages most commonly used at the clinic and sent out to 332 migrant patients who had been diagnosed with type 2 diabetes and treated in primary care. This questionnaire assessed self-care maintenance for diabetes (questions inspired by the Self-Care of Diabetes Inventory), with questions added to every item to assess changes during the pandemic. When changes occurred, we asked the participants to elaborate. Open-ended questions asked the participants how they would like to receive information when there are changes in their healthcare. Descriptive statistical analyses were used for the quantitative data and qualitative data was analyzed using a directed approach to content analysis. Results In total, 79 participants answered the questionnaire (mean age 69 +/- 11, 51% male, 47% born in the Middle East). Of these, 76% stated a change in self-care. More than half (58%) stated changes in maintaining an active lifestyle, 40% had changed their physical exercise, and 38% had changed their behavior to avoid getting sick. Participants said that this change was due to staying at home or canceling social activities because they feared meeting people during the pandemic. Others were more physically active than before on a regular basis during the pandemic due to taking walks to get fit, as a precaution related to COVID-19, and having greater awareness about how to avoid getting sick. Approximately one-quarter of the participants experienced a change in contact with healthcare due to poorer access to care, with fewer doctors appointments and care being postponed during the pandemic. More than half (58%) would like to receive information about healthcare changes by a letter in the regular mail. Social support had changed for 35% of the participants, with less support from family and friends due to the risk of being infected with COVID-19. Conclusion The COVID-19 pandemic led to societal restrictions that changed the way of life for many individuals. Migrant patients with type 2 diabetes, who are already a vulnerable group regarding self-care, had difficulties in maintaining good living habits during the pandemic. During crises such as COVID-19, support with self-care, such as closer contact with healthcare providers, is vital. Clinical Relevance Knowledge about how the COVID-19 pandemic has affected migrants with type 2 diabetes can be used to support healthcare providers in identifying individuals who are at high risk of suffering from the consequences of their diabetes associated with the pandemic.

Aims After heart transplantation (HTx), increments in physical activity (PA) are strongly recommended. However, participation rates in exercise-based cardiac rehabilitation and engagement in PA are insufficient in many patients. Hence, this study aimed to explore the central factors and the interconnections among distinct types of motivation to exercise, PA, sedentary time, psychosomatic, diet, and activity limitation characteristics in post-HTx patients. Methods and results This is a cross-sectional study involving 133 post-HTx patients (79 men, mean age 57 +/- 13 years, mean time from transplantation 55 +/- 42 months) recruited from an outpatient clinic in Spain. The patients were asked to fill in questionnaires measuring self-reported PA, motivation to exercise, kinesiophobia, musculoskeletal pain, quality of sleep, depression, functional capacity, frailty, sarcopenia risk, and diet quality. Two network structures were estimated: one network including PA and one network including sedentary time as nodes. The relative importance of each node in the network structures was determined using centrality analyses. According to the strength centrality index, functional capacity and identified regulation (subtypes of motivation to exercise) are the two most central nodes of the network (strength: z-score = 1.35-1.51). Strong and direct connections emerged between frailty and PA and between sarcopenia risk and sedentary time. Conclusion Functional capacity and autonomous motivation to exercise are the most promising targets of interventions to improve PA levels and sedentary time in post-HTx patients. Furthermore, frailty and sarcopenia risk were found to mediate the effects of several other factors on PA and sedentary time.

Background: Reducing cardiovascular risk through lifestyle changes that include a heart-healthy diet and regular exercise is recommended in the rehabilitation of patients with coronary artery disease (CAD). We pilot-tested the effectiveness of a dietary-education and high-intensity interval resistance training (DE-HIIRT) program on healthy food choices and associated anthropometric variables in patients with established CAD. Methods: A total of 22 participants, aged 60.0 +/- 7.2 years, were enrolled in the study. Over 3 months, under the guidance and supervision of a physiotherapist, participants performed the resistance exercises 2x/week in a group setting (cohort of 11). Participants additionally attended three sessions of dietary education led by a dietician. Participants demonstrated their knowledge and understanding of dietary education by picking heart-healthy foods by reading food labels. Outcomes included change in diet (measured using the tricipital skinfold thickness Mediterranean Diet Adherence questionnaire (MEDAS-14) and the Food Consumption Frequency Questionnaire (FCFQ)) and anthropometric measurements (body composition, body circumference, and tricipital skinfold thickness). A paired t-test was performed to analyze the differences between the baseline and post-intervention results. Results: Participants significantly increased their consumption of vegetables (p = 0.04) and lowered their consumption of sweet snacks (p = 0.007), pastries (p = 0.02), and processed food (p = 0.05). Significant improvements in body mass index (p = 0.001), waist circumference (p = 0.0001), hip circumference (p = 0.04), and body fat (p = 0.0001) were also achieved. Conclusion: Making lifestyle changes that include both diet and exercise is essential in the management of CAD. The HIIRT program combined with dietary changes shows promise in achieving weight-loss goals in this population and needs to be further investigated with appropriate study designs.

To improve the practical application of measuring exercise capacity, the purpose of this study was to compare the 6 min walk distance (6MWD) obtained at a 30 m track with the guidance of healthcare professionals vs. the 6MWD obtained by participants themselves using an app. In total, 37 participants performed both tests. The mean of the differences between the 6MWD on the tests was -4 +/- 45 m (95% limits of agreement: 84 to -99 m). The overall agreement between the two 6MWD measures was 97% with an intraclass correlation coefficient of 0.96 (95% confidence interval: 0.91-0.98, P < 0.001). The use of an app is feasible, reliable, and valid to assess the 6MWD.

Self-care is the most important cornerstone of diabetes treatment. As self-care is affected by cultural beliefs, it is important for healthcare professionals to be able to adapt their educational approach and to be culturally competent. The aim of this study was to describe the cultural competence in Swedish healthcare professionals, specialised in diabetes care and to examine related factors for cultural competence. The healthcare professionals perceived level of cultural competence was measured across three domains-Openness and awareness, Workplace support and Interaction skills-in 279 Swedish healthcare professionals from all 21 regions of Sweden, using the Cultural Competence Assessment Instrument (Swedish version-CCAI-S). Descriptive statistics were used to describe cultural competence in healthcare professionals, and linear regression was conducted to examine factors related to cultural competence. Of the healthcare professionals studied, 58% perceived that they had a high level of Openness and awareness, 35% perceived that they had a high level of Interaction skills and 6% perceived that they had a high level of Workplace support. Two factors were found to be related to cultural competence, namely, high percentage of migrant clients at the healthcare clinic and whether the healthcare professionals previously had developed cultural competence through practical experience, education and/or by themselves. In conclusion, most healthcare professionals perceived that they had cultural openness and awareness but need more support from their workplace to improve their interaction skills. Cultural competence-related education could support the healthcare professionals to develop interaction skills.

Background Few investigators have explored challenges and facilitators to exergaming, essential factors to exergaming adherence, among patients with heart failure. Objectives In this qualitative study, we explored facilitators and challenges using a home-based exergame platform, the Nintendo Wii Sports, in patients with heart failure. Methods Semistructured face-to-face interviews were conducted in 13 participants given a diagnosis of heart failure (age range, 34-69 years). Participants were asked about their experiences with exergaming. Transcribed interviews were analyzed with content analysis. Results The following 4 facilitators were identified: (1) enjoyment and competition motivated gaming, (2) accessibility at home gave freedom and lowered participants barriers to exercise, (3) physical benefits when decreasing sedentary lifestyle, and (4) psychosocial benefits on stress, mood, and family interactions. Challenges included (1) diminished engagement over time due to boredom playing similar games and (2) frustrations due to game difficulty and lack of improvement. Conclusion Exergaming can increase individuals physical activity because of easy accessibility and the fun and motivating factors the games offer. Participants initially found exergaming enjoyable and challenging. However, engagement diminished over time because of boredom from playing the same games for a period of time. Participants preferences and capacities, participants past experiences, and social support must be considered to avoid boredom and frustrations. Future studies are warranted to determine adherence to exergaming among patients with heart failure and, ultimately, increased overall well-being and healthcare delivery in this patient population.

Objective: Both high-intensity interval training (HIIT) and resistance exercises (R) are used in cardiac rehabilitation in patients with coronary artery disease (CAD). However, the combined effect of an HIIT + R exercise program in older adults with CAD is not well investigated. The studys purpose was to assess the changes in anthropometric parameters, physical activity, functional capacity, physiological parameters, and quality of life (QoL) in this population following a combined HIIT + R program. Design: The study was a 2-group (n = 45 each) randomized controlled single-blinded trial. Setting and Participants: The study was done at a treatment clinic of a tertiary hospital. The mean age of participants was 69.23 +/- 4.9 years. The HIIT + R group performed 8 sessions (1/wk) of HIIT + R training. The 30 minutes of the active exercise phase consisted of ten 3-minute bouts. Each bout comprised of 1 minute of high-intensity treadmill walking at 85% to 90% maximum heart rate (MHR), followed by a low-intensity walking at 60%-70% MHR, followed by low-to moderate-intensity resistance training. The Usual Care group underwent conventional medical treatment. Measures: Anthropometric measurements [weight, body mass index (BMI), waist circumference, body fat percentage, lean body mass], physical activity (International Physical Activity Questionnaire), functional capacity (Incremental Shuttle Walking Test), physiologic measurements (blood pressure, heart rate), and QoL (36-Item Short Form Health Survey) were measured pre- and postintervention. Results: Significant group and time interaction were found for the participants in the HIIT + R Group for BMI (P =.001), body fat percentage (P =.001), waist circumference (P <.001), physical activity (P <.001), functional capacity (P <.001), and QoL (P =.001) compared with the UC Group. Significant improvement in systolic blood pressure (P =.001) was seen in the HIIT + R group. Conclusions and Implications: A combined HIIT thorn R training protocol in older adults with CAD can be useful in producing desired health outcomes. Further evaluation of longer duration exercise programs with more frequent dosing needs to be evaluated for their benefits and sustainability. (C) 2021 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

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Aims Physical activity (PA) is important in patients with heart failure (HF) to improve health outcomes. The adherence to PA is low, and therefore, novel approaches are necessary to increase PA. We aimed to determine the difference in PA in patients with HF who have access to exergaming compared to patients who received motivational support and to explored predictors of a clinically relevant change in non-sedentary time between baseline and 3 months. Methods and results In total, 64 patients (mean age 69 +/- 9 years, 27% female) wore an accelerometer 1 week before and 1 week after the intervention. Data were analysed using logistic regression analysis. Patients spent 9 h and 43 min (+/- 1 h 23 min) during waking hours sedentary. There were no significant differences in PA between patients who received an exergame intervention or motivational support. In total, 30 of 64 patients achieved a clinically relevant increase in non-sedentary time. Having grandchildren [odds ratio (OR) 7.43 P = 0.03], recent diagnosis of HF (OR 0.93 P = 0.02), and higher social motivation (OR 2.31 P = 0.03) were independent predictors of a clinically relevant increase of non-sedentary time. Conclusion Clinicians should encourage their patients to engage in alternative approaches to improve PA and reduce sedentary habits. Future exergaming interventions should target individuals with chronic HF who have low social motivation and a low level of light PA that may benefit most from exergaming. Also (non-familial), intergenerational interaction is important to enabling patients in supporting patients in becoming more active.

Objective To determine whether physical activity enjoyment mediated the association between motivation and physical activity in patients with heart failure. Design and setting A cross-sectional study at the cardiology clinic in the university hospital in Valencia, Spain Subjects A total of 134 patients with heart failure. Main measurements Physical activity was assessed with the International Physical Activity Questionnaire, motivation was assessed with the Exercise Motivation Index and Physical Activity Enjoyment was assessed with the Physical Activity Enjoyment Scale. Analysis Mediation analysis using Hayes PROCESS macro (Model 4) for SPSS. Results The mean age of the sample was 70 +/- 14 years, 47 patients were female (35%), and 87 patients were in New York Heart Association I/II (67%). A positive relationship was found between exercise motivation and physical activity (t = 4.57, p < .01) and physical activity enjoyment (t = 11.52, p < .01). Physical activity enjoyment was found to positively affect physical activity (t = 3.50, p < .01). After controlling for physical activity enjoyment, the effect of exercise motivation on physical activity changed from a significant to non-significant (t = 1.33, p = .89), indicating that enjoyment completely mediated the relationship between motivation and physical activity. Overall, 25% of the variation in physical activity was explained by the mediation model. Conclusions Physical activity enjoyment mediates the relationship between exercise motivation and physical activity in patients with heart failure. This means that even highly motivated heart failure patients may not be physically active if they do not enjoy the physical activity.

The aim of this study was to explore the readiness for physical activity (PA) and its related factors in patients with heart failure. This cross-sectional study included 163 patients with heart failure (mean age 66 +/- 16, 50% female). The ability to safely engage in PA was assessed with the PA Readiness Questionnaire (PAR-Q). Psychological readiness was measured using two questionnaires, namely: Exercise Self-efficacy Scale and the Motivation for PA and Exercise/Working Out. A multivariate analysis of covariance was conducted to test the effect of background variables on readiness for PA. 64% (n = 105) of patients reported not being able to safely engage in PA, 80% (n = 129) reported low self-efficacy, and 45% (n = 74) were extrinsically motivated indicating external factors drove their motivation. Factors that positively influenced the PA readiness included lower age (p &lt; 0.01), being male (p &lt; 0.01), being married (p &lt; 0.01), having higher education (p &lt; 0.01), being in NYHA-class I compared with II (p &lt; 0.01), less time since diagnosis (p &lt; 0.01), lower BMI (p = 0.02), and not suffering from COPD (p = 0.02). Prior to recommending exercise, assessment of safety to engage in PA along with self-efficacy and motivation in patients with heart failure is essential.

(1) Background: Assessing preferences in technology-based cardiac physical therapy programs in older adults with coronary artery disease (CAD) is fundamental to promoting adherence to healthy lifestyles and healthy aging. This study aimed at analyzing preferences in technology-based cardiac physical therapy programs in older adults with CAD. Additionally, a comparison by sex was performed. (2) Methods: Cross-sectional study. 70 older adults with CAD (mean age 66.73 +/- 0.77, 80% men) were evaluated. Technology use and preferences in technology-based cardiac physical therapy programs (Technology Usage Questionnaire) were assessed. (3) Results: 97.1% of the sample had Smartphones and 81.4% accessed the Internet every day, mostly with their Smartphones (75.5%). A total of 54.3% were interested in receiving rehabilitation via their Smartphone, and most of the sample considered ideas to manage stress (92.9%), healthy meal ideas and recipes (85.7%), exercise ideas (84.3%), exercise prompts (72.9%), setting goals (67.1%), exercise taught by a virtual therapist (65.7%), ideas to overcome cigarette cravings (62.9%), information on local exercise opportunities (60%), ideas to remember to take medications (57.1%), steps to achieve goals (54.3%) and eating tips for takeaways (51.7%) very useful. Additionally, men considered the technology-based advice about exercise prompts, healthy meal ideas and recipes, and ideas to manage stress more useful than women, and had more frequently a Smartphone, less frequently made phone calls, had more regular access to the Internet, and used the Internet more often. (4) Conclusions: Clinicians should encourage older adults to engage in cardiac technology-based physical therapy programs to provide meaningful exercise counselling, promote healthy lifestyle and healthy aging.

Objective To analyze (1) the effect of an aerobic training program on functional exercise tolerance in decompensated heart failure (DHF) patients; (2) to assess the effects of an aerobic training program on functional independence; and (3) dyspnea during activities of daily living. Design A randomized controlled clinical trial with follow-up at discharge. Settings Eight hospitals. Recruitment took place between 9/ 2017 and 3/2019. Group Assignments Patients with DHF who were admitted to the hospital, were randomly assigned to usual rehabilitation care guideline recommended (control group) or aerobic training program (exercise group). Main outcome Functional exercise tolerance was measured with a 6-min walking test at discharge. Results In total 257 patients with DHF were included, with a mean age of 67 +/- 11 years, 84% (n = 205) had a reduced ejection fraction and the hospital stay was 16 +/- 10 days. At discharge, patients in the intervention group walked further compared to the control group (278 +/- 117m vs 219 +/- 115m, p &lt; 0.01) and this difference stayed significant after correcting for confounders (p &lt; 0.01). A significant difference was found favoring the exercise group in functional independence (96 +/- 7 vs 93 +/- 12, p = 0.02) and dyspnea associated to ADL (13 +/- 5 vs 17 +/- 7, p &lt; 0.01) and these differences persisted after correcting for baseline values and confounders (functional independence p &lt; 0.01; dyspnea associated with ADL p = 0.02). Conclusion The ERIC-HF program is safe, feasible, and effective in increasing functional exercise tolerance and functional independence in hospitalized patients admitted due to DHF.

Gamification is defined as the use of game design elements in contexts other than gaming to increase user engagement and experience. Gamification in cardiovascular care can contribute to positively change health behaviour with possible effects and benefits on physical health and mental well-being. Based on previous literature, in this article we describe: the conceptualization of gamification, the five gamification principles for gamified digital health programmes or applications, the six most common game elements used to impact health behaviour applied in gamified digital health interventions and finally scientifically validated instruments to use for assessment of gamification in terms of self-reported psychological outcomes.

Background: This study aimed to compare well-being and physical activity (PA) before and during COVID-19 confinement in older adults with heart failure (HF), to compare well-being and PA during COVID-19 confinement in octogenarians and non-octogenarians, and to explore well-being, social support, attention to symptoms, and assistance needs during confinement in this population. Methods: A mixed-methods design was performed. Well-being (Cantril Ladder of Life) and PA (International Physical Activity Questionnaire) were assessed. Semi-structured interviews were performed to assess the rest of the variables. Results: 120 participants were evaluated (74.16 +/- 12.90 years; octogenarians = 44.16%, non-octogenarians = 55.83%). Both groups showed lower well-being and performed less PA during confinement than before (p &lt; 0.001). Octogenarians reported lower well-being (p = 0.02), higher sedentary time (p = 0.03), and lower levels of moderate PA (p = 0.04) during confinement. Most individuals in the sample considered their well-being to have decreased during confinement, 30% reported decreased social support, 50% increased their attention to symptoms, and 60% were not satisfied with the assistance received. Octogenarians were more severely impacted during confinement than non-octogenarians in terms of well-being, attention to symptoms, and assistance needs. Conclusions: Well-being and PA decreased during confinement, although octogenarians were more affected than non-octogenarians. Remote monitoring strategies are needed in elders with HF to control health outcomes in critical periods, especially in octogenarians.

Background: As patients are increasingly searching for information about their medical condition on the internet, there is a need for health professionals to be able to guide patients toward reliable and suitable information sources on the internet.

Objective: The aim of the study was to develop a clinical tool for health care professionals to assess the usability and quality of the content of websites containing medical information that could be recommended to patients.

Methods: A 3-round modified electronic Delphi (eDelphi) study was conducted with 20 health care professionals.

Results: In round one of the eDelphi study, of the 68 items initially created, 41 items (29 on usability and 12 on content) were rated as important or very important by more than half of the panel and thus selected for further evaluation in round two. In round two, of the 41 items chosen from round 1, 19 were selected (9 on usability and 10 on content) as important or very important by more than half of the panel for further evaluation. As a result of round three, 2 items were combined as a single item, leaving the instrument with 18 items in total (8 on usability and 10 on content). The tool is freely accessible online.

Conclusions: The CUE-tool can be used to (1) evaluate the usability and reliability of the content of websites before recommending them to patients as a good information source; (2) identify websites that do not have reliable content or may be difficult for patients to use; (3) develop quality websites by using the criteria in the CUE-tool; and (4) identify different qualities between different websites.

Aims Although physical activity (PA) and exercise are essential for patients with heart failure (HF), adherence to the recommended guidelines is low. Not much is known about the mediating effect of HF patients mental state with their readiness for PA and reported activity levels. The purpose of this study is to investigate the mediatory effect of depression on PA readiness (physical limitation and psychological readiness) and self-reported PA in patients with HF. Methods and results In this cross-sectional study, 163 New York Heart Association Class I and II HF patients, during their clinic visit, reported on their physical limitation (PAR-Q) and psychological readiness [self-efficacy (ESES) and motivation (RM 4-FM)] for PA, depression (HADS-D), and PA (s-IPAQ). Mediation analysis was performed to test the mediating effect of depression on PA readiness (physical limitation and psychological readiness) and self-reported PA following the steps described by Baron and Kenny (1986). Hierarchical regression models were tested for their effects. The Self-Efficacy Theory and Self-Determination theory provided the theoretical platform for the study. Depression completely mediated the effect of physical limitation (beta(dep) = 268.57; P &lt; 0.0001) and partially mediated the effect of self-efficacy on PA (beta(dep) = 344.16; P &lt; 0.0001). Both intrinsic (P &lt; .0001) and extrinsic motivation (P &lt; .0001) for PA had an independent and significant effect on PA, not mediated by depression. Conclusions Patients with HF should be screened for depression throughout the trajectory of the disease as it can impact their physical and psychological readiness to perform PA.

Aims Exergaming is a new tool to increase physical activity. This study aimed to determine the effects of access to a home-based exergame (Nintendo Wii) in patients with heart failure (HF) on exercise capacity, self-reported physical activity and patient-reported outcome measures. Methods and results We enrolled 605 HF patients in New York Heart Association functional class I-IV, independent of ejection fraction, in an international multicentre randomized controlled trial. Patients were randomized to exergame (intervention) or motivational support (control). The primary endpoint was change in submaximal aerobic exercise capacity as measured by the distance walked in 6 min (6MWT) between baseline and 3 months. Secondary endpoints included long-term submaximal aerobic exercise capacity, muscle function, self-reported physical activity, exercise motivation, exercise self-efficacy at 3, 6 and 12months. At baseline, patients on average walked 403142m on the 6MWT. Patients in the exergame group walked further compared to controls at 3 months (454123 vs. 420 +/- 127m, P = 0.005), at 6 months (452 +/- 123 vs. 426 +/- 133m, P = 0.015) and 12months (456 +/- 122 vs. 420 +/- 135m, P = 0.004). However, correcting for baseline 6MWT values by means of a linear mixed-effects model revealed no main effect for the intervention on 6MWT. Small significant effects on muscle function were found. Statistically significant treatment effects were found for muscle function but after correction for baseline and confounders, only the treatment effect for the heel-rise left at 6 months was significant (P&lt;0.05). No treatment effect was found for exercise motivation, exercise self-efficacy, or self-reported physical activity. ConclusionExergaming was safe and feasible in patients with HF with different profiles in different health care systems, cultures and climates. However, it was not effective in improving outcomes on submaximal aerobic exercise capacity. Subgroup analysis did not identify specific subgroups benefiting from the intervention. Clinical Trial Registration: Identifier: NCT01785121.

Purpose: To examine profiles in patients with heart failure (HF) regarding their exercise motivation and self-efficacy. Patients & Methods: The baseline data of patients with HF participating in the HFWii study were analysed. In total, 517 patients were divided into four groups based on their exercise motivation (exercise motivation index) and self-efficacy (exercise self efficacy scale). To describe the differences in demographic and clinical variables between the groups, chi-square cross-tabulations and ANOVAs were conducted. Results: The four groups were labelled as insecure avoiders (25%), laid-back strugglers (10%), conscientious self-doubters (42%) and determined achievers (22%). Patients profiles differ according to their motivations and self-efficacy towards exercise. Most patients were conscientious self-doubters (high motivation and low self efficacy), and these patients had more comorbidities and lower exercise capacity compared to the other groups, which could decrease their confidence in exercising. However, only half of the patients who were determined achievers (high motivation and high self-efficacy) reached the recommended amount of physical activity per week. This indicates that motivation and self-efficacy are crucial determinants, but more factors are important for becoming more physically active. Conclusion: Understanding patients motivations and self-efficacy are necessary in order to provide meaningful physical activity counselling and promotion.

Objective: To describe the experience of physical activity in patients with heart failure who were randomized to a control group in which they received exercise advice and motivational support. Design: A qualitative descriptive interview study, using qualitative content analysis. Patients: Fifteen patients with heart failure. Methods: Interviews with members of the control group in a physical activity trial (Heart Failure-Wii study), who received exercise advice and telephone follow-ups. Results: The experience of physical activity was described by 4 categories: (1) affected by study participation; (ii) impact of having heart failure; (iii) mixed feelings when physically active; and (iv) influence of the social and physical environment. Study participation made patients feel encouraged or obliged, or they gained a sense of security in connection with becoming more physically active. Symptoms, side-effects and barriers could hamper their physical activity. They changed their type and level of physical activity, or used resources or equipment to become physically active. Patients experienced physical and emotional improvements and developed routines and structures, and their environment and caregivers were able to influence their physical activity. Conclusion: The role of study participation, having heart failure, and psychological and environmental factors describe the experiences of physical activity in patients with heart failure who were randomized to a control group, and are important in evaluating and motivating patients physical activity.

Aims This study aimed to explore factors related to non-adherence to exergaming in patients with heart failure. Methods and results Data from patients in the exergame group in the HF-Wii trial were used. Adherence to exergaming was defined as playing 80% or more of the recommended time. Data on adherence and reasons for not exergaming at all were collected during phone calls after 2, 4, 8, and 12 weeks. Logistic regression was performed between patients who were adherent and patients who were non-adherent. Secondly, a logistic regression was performed between patients who not exergamed at all and patients who were adherent to exergaming. Finally, we analysed the reasons for not exergaming at all with manifest content analysis. Almost half of the patients were adherent to exergaming. Patients who were adherent had lower social motivation [odds ratio (OR) 0.072; 95% confidence interval (CI) 0.054-0.095], fewer sleeping problems (OR 0.84; 95% CI 0.76-0.092), and higher exercise capacity (OR 1.003; 95% CI 1.001-1.005) compared with patients who were non-adherent. Patients who not exergamed at all had lower cognition (OR 1.18; 95% CI 1.06-1.31) and more often suffered from peripheral vascular disease (OR 3.74; 95% CI 1.01-13.83) compared with patients who were adherent to exergaming. Patients most often cited disease-specific barriers as a reason for not exergaming at all. Conclusions A thorough baseline assessment of physical function and cognition is needed before beginning an exergame intervention. It is important to offer the possibility to exergame with others, to be able to adapt the intensity of physical activity.

Aims Improvement in exercise capacity is the primary goal of physical activity programmes for patients with heart failure (HF). Although activity programmes are effective for some patients, others do not benefit. Identifying factors related to a lack of improvement in submaximal exercise capacity may help us interpret findings and design new interventions. The aim of this study is to identify factors contributing to a lack of improvement in submaximal exercise capacity 3 months after physical activity advice or an exergame intervention in patients with HF. Additionally, we aimed to assess differences in lack of improvement in submaximal exercise capacity of patients whose baseline exercise capacity predicted a worse compared with better prognosis of HF. Methods and results This secondary analysis of the HF-Wii study analysed baseline and 3 month data of the 6 min walk test (6MWT) from 480 patients (mean age 67 years, 72% male). Data were analysed separately in patients with a pre-defined 6 min walking distance at baseline of &lt;300 m (n = 79) and &gt;= 300 m (n = 401). Among patients with a baseline 6MWT of &gt;= 300 m, 18% had deteriorated submaximal exercise capacity. In the multiple logistic regression analysis, lower baseline levels of self-reported physical activity [odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.97], lower baseline levels of cognitive function (OR = 0.87, 95%CI = 0.79-0.96) were significantly associated with lack of improvement in exercise capacity at 3 months. Not randomized to exergaming (OR = 0.63, 95%CI = 0.37-1.09) was likely (P = 0.097) to be associated with lack of improvement in exercise capacity at 3 months. Among the 79 patients with baseline 6MWT of &lt;300 m, 41% (n = 32) did not improve 6MWT distance at 3 months. Independent predictors for the lack of improvement for 6MWT were New York Heart Association class III/IV (OR = 4.68, 95%CI = 1.08-20.35), higher levels of serum creatinine (OR = 1.02, 95%CI = 1.003-1.03), lower cognitive function (OR = 0.86, 95%CI = 0.75-0.99), and fewer anxiety symptoms (OR = 0.84, 95%CI = 0.72-0.98). Conclusions Lower self-reported physical activity and cognitive impairment predict lack of improvement in submaximal exercise capacity in HF patients. Patients who have a worse prognosis (score &lt;300 m at the 6MWT) are often frail and gain less in exercise capacity. These patients may need a more comprehensive approach to have an effect on exercise capacity, including an individually tailored exercise programme with aerobic exercise (if tolerated) and strength exercises.

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Background: For people with long-term illness, debilitated by severe symptoms, it can be difficult to attend regular yoga classes. We have therefore developed a tele-health format of yoga that can be delivered in the home. The tele-yoga was co-designed with members of a patient-organisation, yoga-instructor, and IT-technician. It includes live-streamed group-yoga sessions twice a week and an app with instructions on how to self-perform yoga. Aim: To describe a study protocol for a randomised controlled trial (RCT) including a process evaluation and report on a pilot study evaluating method- and intervention-related components including feasibility, safety, and efficacy. Methods: Ten participants with heart failure aged between 41-76 years were randomised to tele-yoga (n = 5) or to the control group (n = 5). In the pilot study recruitment, enrolment, randomisation, and data collection of all outcomes including primary, secondary and process evaluation measures were tested according to the study protocol. Fidelity, adherence and acceptability to the tele-yoga group training and app use was determined. Safety was assessed by adverse events. Results: The pilot revealed that the methodological aspect of the protocol worked sufficiently in all aspects except for missing data in the physical test of two participants and one participant in the control-group that dropped out of the study at three months follow-up. The tele-yoga training did not lead to any adverse events or injuries, adherence of tele-yoga was sufficient according to preset limits. The tele-yoga intervention also showed some favourable trends of improvements in the composite-end point compared to the active control group. However, since data only was presented descriptively due to the small sample size, the impact of these trends should be interpreted carefully. Conclusion: Our pilot study showed promising results in feasibility, safety, and acceptability of the tele-yoga intervention. Some changes in the protocol have been made to decrease the risk of missing data in the measures of physical function and in the full-scale RCT now ongoing the results of the sample size calculation for 300 participants have included the estimated level of drop outs and missing data.

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Aims Cognitive impairment (CI) in heart failure (HF) patients has mostly been studied in single countries in specific health care settings. Sociodemographic and clinical predictors of the global CI and CI dimensions are still unclear. We described CI in a diverse HF population recruited in several countries and in different health care settings and investigated sociodemographic and clinical factors associated with the global and specific CI dimensions in HF patients. Methods and results A secondary analysis from the baseline data of the Wii-HF trial. Patients (n = 605) were enrolled in Sweden, Italy, Israel, The Netherlands, Germany, and the United States. We used the Montreal Cognitive Assessment to evaluate CI and the 6 minute walk test (6MWT) to measure exercise capacity. Patients were on average 67 years old (SD, 12), and 86% were in New York Heart Association Class II and III. The mean Montreal Cognitive Assessment score was 24 (SD, 4), and 67% of patients had at least a mild CI. The item evaluating short-term memory had a considerable proportion of low scoring patients (28.1%). Worse CI was associated with patients older age, lower education, and lower 6MWT scores (R-2 = 0.27). CI dimension scores were differently associated with specific clinical and demographic variables, but the 6MWT scores were associated with five out of seven CI dimension scores. Conclusions CI is an important problem in HF patients, with specific challenges in regard to memory. Exercise capacity is a modifiable factor that could be improved in HF patients with the potential to improve cognition and other outcomes in this population.

Background Although attention is focused on addressing the acute situation created by the COVID-19 illness, it is imperative to continue our efforts to prevent cardiovascular morbidity and mortality, particularly during a period of prolonged social isolation which may limit physical activity, adversely affect mental health and reduce access to usual care. One option may be to deliver healthcare interventions remotely through digital healthcare solutions. Therefore, the aim of this paper is to bring together the evidence for remote healthcare during a quarantine situation period to support people living with cardiovascular disease during COVID-19 isolation. Methods The PubMed, CINAHL and Google Scholar were searched using telehealth OR digital health OR mHealth OR eHealth OR mobile apps AND COVID-19 OR quarantine search terms. We also searched for literature relating to cardiovascular disease AND quarantine. Results The literature search identified 45 potentially relevant publications, out of which nine articles were included. Three overarching themes emerged from this review: (1) preparing the workforce and ensuring reimbursement for remote healthcare, (2) supporting mental and physical health and (3) supporting usual care. Conclusion To support people living with cardiovascular disease during COVID-19 isolation and to mitigate the effects of quarantine and adverse effect on mental and physical well-being, we should offer remote healthcare and provide access to their usual care.

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Background: The use of digital technologies is increasing in health care. However, studies evaluating digital health technologies can be characterized by selective nonparticipation of older people, although older people represent one of the main user groups of health care. Objective: We examined whether and how participation in an exergame intervention study was associated with age, gender, and heart failure (HF) symptom severity. Methods: A subset of data from the HF-Wii study was used. The data came from patients with HF in institutional settings in Germany, Italy, the Netherlands, and Sweden. Selective nonparticipation was examined as resulting from two processes: (non)recruitment and self-selection. Baseline information on age, gender, and New York Heart Association Functional Classification of 1632 patients with HF were the predictor variables. These patients were screened for HF-Wii study participation. Reasons for nonparticipation were evaluated. Results: Of the 1632 screened patients, 71% did not participate. The nonrecmitment rate was 21%, and based on the eligible sample, the refusal rate was 61%. Higher age was associated with lower probability of participation; it increased both the probabilities of not being recruited and declining to participate. More severe symptoms increased the likelihood of nonrecruitment. Gender had no effect. The most common reasons for nonrecruitment and self-selection were related to physical limitations and lack of time, respectively. Conclusions: Results indicate that selective nonparticipation takes place in digital health research and that it is associated with age and symptom severity. Gender effects cannot be proven. Such systematic selection can lead to biased research results that inappropriately inform research, policy, and practice.

BACKGROUND: The assessment of self-care behaviour is important for tailoring care to patients and evaluating the effectiveness of heart failure (HF) disease-management programmes. The European HF Self-care Behaviour (EHFScB) scale is a validated instrument used worldwide.

AIM: The purpose of the study was to evaluate psychometric properties of the Hebrew version of the nine-item EHFScB scale in Israeli patients with HF.

METHOD: To develop the Hebrew version of the EHFScB scale, forward and back translation was performed. The psychometric evaluation was based on data from 102 patients with HF (mean age 61±12 yr, male 75%, New York Heart Association [NYHA] class II 42% and NYHA class III 51%) included in two cross-sectional studies performed in 2007 and 2015-2017 in an Israeli hospital. Content validity, construct validity, known-groups validity, and discriminant validity were assessed. Reliability was evaluated with internal consistency.

RESULTS: Content validity and useability were confirmed by HF experts and patients with HF. Construct validity was tested using factor analysis and two factors were extracted (factor 1: consulting behaviour; factor 2: adherence to the regimen). Known-groups validity testing revealed a significant difference before and after an educational intervention in the total score (n=40 [41.6±23.8] vs [67.6±21.8]; p<0.01). A weak correlation between the self-care score and health-related quality of life (r= -0.299, p<0.01) was observed, showing that these concepts were related but not overlapping. Cronbach's alpha was 0.78 for the total scale, 0.76 for factor 1, and 0.68 for factor 2, suggesting that the internal consistency of this scale was acceptable.

CONCLUSIONS: Our study provides support for the useability, validity, and reliability of the nine-item Hebrew version of the EHFScB scale.

Aim The purpose of this study was to explore the utility of two single-item self-report (SR) questions to assess physical inactivity in patients with heart failure (HF). Methods and results This is a cross-sectional study using data from 106 patients with HF equipped with accelerometers for 1 week each. Two SR items relating to physical activity were also collected. Correlations between accelerometer activity counts and the SR items were analysed. Patients were classified as physically active or inactive on the basis of accelerometer counts, and the SR items were used to try to predict that classification. Finally, patients were classified as having high self-reported physical activity or low self-reported physical activity, on the basis of the SR items, and the resulting groups were analysed for differences in actual physical activity. There were significant but weak correlations between the SR items and accelerometer counts: rho = 0.24, P = 0.016 for SR1 and rho = 0.21, P = 0.033 for SR2. Using SR items to predict whether a patient was physically active or inactive produced an area under the curve of 0.62 for SR1, with a specificity of 92% and a sensitivity of 30%. When dividing patients into groups on the basis of SR1, there was a significant difference of 1583 steps per day, or 49% more steps in the high self-reported physical activity group (P &lt; 0.001). Conclusions There might be utility in the single SR question for high-specificity screening of large populations to identify physically inactive patients in order to assign therapeutic interventions efficiently where resources are limited.

BackgroundThe prevalence of multimorbidity is increasing worldwide, and older people with multimorbidity are frequent users of health care services. Since multimorbidity has a significant negative impact on Health-related Quality of Life (HrQoL) and is more common in older age it would be expected that factors related to HrQoL in this group might have been thoroughly researched, but this is not the case. Furthermore, it is important to look at old people living at home, considering the shift from residential to home-based care. Therefore, we aim to investigate factors that are related to HrQoL in older people with multimorbidity and high health care consumption, living at home.MethodsThis is a secondary analysis of a RCT study conducted in a municipality in south-eastern Sweden. The study had a longitudinal design with a two-year follow-up period assessing HrQoL, symptom burden, activities of daily living, physical activity and depression.ResultsIn total, 238 older people with multimorbidity and high health care consumption, living at home were included (mean age 82, 52% female). A multiple linear regression model including symptom burden, activities of daily living and depression as independent variables explained 64% of the HrQoL. Higher symptom burden, lower ability in activities of daily living and a higher degree of depression were negatively related to HrQoL. Depression at baseline and a change in symptom burden over a two-year period explained 28% of the change in HrQoL over a two-year period variability. A higher degree of depression at baseline and negative change in higher symptom burden were related to a decrease in HrQoL over a two-year period.ConclusionIn order to facilitate better delivery of appropriate health care to older people with high health care consumption living at home it is important to assess HrQoL, and HrQoL over time. Symptom burden, activities of daily living, depression and change in symptom burden over time are important indicators for HrQoL.Trial registrationClinicaltrials.gov identifier: NCT01446757, the trial was registered prospectively with the date of trial registration October 5(th), 2011.

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Objectives: To describe the relationships among 3 measures of physical fitness (exercise capacity, muscle function and functional capacity) in patients with heart failure, and to determine whether these measures are influenced by impairment of movement. Methods: Secondary analysis of baseline data from the Italian subsample (n= 96) of patients with heart failure enrolled in a randomized controlled trial, the HF-Wii study. Exercise capacity was measured with the 6-min walk test, muscle function was measured with the unilateral isotonic heel-lift, bilateral isometric shoulder abduction and unilateral isotonic shoulder flexion, and functional capacity was measured with the Duke Activity Status Index. Principal component analysis was used to detect covariance of the data. Results: Exercise capacity correlated with all of the tests related to muscle function (r=0.691-0.423, pamp;lt; 0.001) and functional capacity (r = 0.531). Moreover, functional capacity correlated with muscle function (r=0.482-0.393). Principal component analysis revealed the bidimensional structure of these 3 measures, thus accounting for 58% of the total variance in the variables measured. Conclusion: Despite the correlations among exercise capacity, muscle function and functional capacity, these measures loaded on 2 different factors. The use of a wider range of tests will help clinicians to perform a more tailored assessment of physical fitness, especially in those patients with heart failure who have impairment of movement.

Background and objectives: Physical activity is important for all heart failure (HF) patients to improve quality of life and physical function. Since adherence to physical activity is low and could differ between seasons, it is essential to explore factors related to change that may depend on seasonal changes. The purpose of this study was to describe the seasonal differences in physical activity and assess factors that influence these differences in a country with markedly different winter-to-summer weather conditions (in temperature, hours of daylight and snow fall). Methods: The study had a cross-sectional survey design. Outpatients with HF completed a questionnaire on physical activity, motivation and self-efficacy to exercise and I-IF symptom severity in the summer and the winter in a northern hemisphere country. We used analysis of variance to evaluate seasonal differences in physical activity, motivation, self-efficacy and HF symptom severity. Results: Eighty-seven patients with HF (29% women, mean age 70 +/- 9 years) were included and 35% performed less physical activity (METs) in the winter, compared to the summer. Increased symptom severity during the winter was associated with lower activity levels. Conclusion: One-third of the patients performed less physical activity during the winter compared to the summer, and this was associated with symptom severity. Decreased physical activity was not related with motivation and self-efficacy. This study emphasises the need for personalised physical activity programmes that also assess symptom severity and change in symptom severity depending between seasons. (C) 2019 The Authors. Published by Elsevier Inc.

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Background: Regular physical activity in patients with heart failure (HF) improves physical capacity and quality of life, and may reduce health care utilization. One low-cost effective physical activity intervention to increase exercise capacity is exergaming. Exploring patients’ willingness to pay (WTP) for treatments/interventions is a way to obtain a monetary value for the health consequences of an intervention. This can further be used in economic evaluations.

Aim: The aim of this study was to describe patients´ WTP for an exergame intervention and to determine factors influencing the WTP.

Methods: This is a substudy of the Swedish cohort of the HF-Wii study (evaluating the effect of exergaming on exercise capacity in patients with HF; clinicaltrial.gov NCT01785121) including 34 patients who finished the 1-year follow-up. Structured telephone interviews were conducted focusing on WTP for the exergame intervention they received during the study including an exergame platform, an introduction lesson, installation of the exergame computer, and telephone follow-ups, and with an estimated cost of ∼€440 per patient. The WTP methodology used was adjusted for this specific study.

Patients were also asked to rate their level of satisfaction with the intervention on a Numeric Rating Scale (NRS) from 0-10. In addition, information on background variables and income was collected during the interview, while data on six minute walk test (6MWT) and quality of life was retrieved from previous data collection in the main study.

Results: In total, 29 patients with HF participated in this substudy, mean age 68±9 years, 69% males, and with a mean household disposable income/month of ∼€2700 (±1360). Ten patients (34.5%) had a clinically significant effect of the exergaming and improved more than 30 meters on the 6MWT.

The average WTP for the exergame intervention was ∼€160 (range €0-580). Most patients were satisfied with the exergame intervention and the median score was 8 on the NRS. The satisfaction level was significantly related to WTP (r_s=0.468, p=0.012). Patients with higher satisfaction levels were willing to pay more (€210±165) for the exergame intervention than those with lower satisfaction levels (€60±70), p=0.015. Income, changes in 6MWT, and quality of life showed no significant relationship to WTP.

Conclusions: The WTP for an exergame intervention varied largely in patients with HF despite high satisfaction level with the intervention. The satisfaction level was the only factor influencing patients´ WTP. On average, patients were willing to pay about one-third of the cost of the exergame intervention. Future studies should focus on the cost-effectiveness of this intervention.

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Background: Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity. Objectives: The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients. Methods: This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment. Results: The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT. Conclusions: The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients. (C) 2018 Elsevier Inc. All rights reserved.