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Background: Alcohol use is an important cardiovascular risk factor and a major contributor to morbidity and mortality. Successful implementation of alcohol interventions in cardiology depends on patient acceptability.

Objective: To understand patient perspectives on the feasibility of implementing alcohol interventions in cardiology services.

Methods: Multi-site qualitative study. We conducted semi-structured interviews with a heterogenous-purposive sample of 15 adult cardiology patients with hazardous alcohol use. Participants were recruited from three geographically diverse regions in Sweden (Dalarna, Gävleborg, Stockholm) and were varied in terms of sociodemographic characteristics, cardiovascular diagnosis, risk factor profile, and level of alcohol use. We applied the Capability, Opportunity, Motivation and Behaviour (COM-B) system during coding and conducted a reflexive thematic analysis.

Results: We identified 56 feasibility factors: 15 related to capability, 10 to opportunity, and 31 to motivation. Four themes emerged: 1. Alcohol use as relevant to cardiology, where participants recognized cardiovascular risk factors, expressed motivation for change, and identified a need to address alcohol use sensitively; 2. Aligning interventions with expectations and goals, where participants linked acceptability of alcohol interventions to personal goals and social norms; 3. Morbidity and shifting priorities, where participants prioritized quality of life and respect for autonomy; 4. Addressing barriers to alcohol dependence treatments, where participants saw a need to improve access to care.

Conclusions: Findings suggest that alcohol interventions are acceptable to cardiology patients with hazardous alcohol use. Implementation strategies that prioritize quality of life, respect autonomy, and align with individual expectations and goals may be among the most acceptable. We also identified an opportunity to improve access to treatments for alcohol dependence within multidisciplinary heart teams or hospital-based addiction care services.

Background: Alcohol screening and brief interventions (SBI) are effective strategies to reduce hazardous alcohol use in healthcare settings but are implemented inconsistently in cardiology practice. There is a need to understand factors associated with alcohol prevention practices in clinical cardiology to bridge this evidence-practice gap. The aim of this study was to investigate factors associated with SBI practices in cardiology.

Methods: Multi-centre cross-sectional study. We surveyed clinicians at cardiology services in 12 regions across Sweden. The outcome was participants' tendency to initiate SBI. Predictor variables included perceived importance of alcohol screening, level of comfort discussing alcohol habits with patients, perceived reliability of self-reported alcohol habits, and perceived competence for screening and brief interventions. Analyses included Wilcoxon signed-rank tests and ordinal logistic regression models.

Results: In total, 692 clinicians participated in the survey (nurses = 55%; doctors = 19%; assistant nurses = 22%). Perceived importance of screening was not significantly associated with initiating SBI (OR = 1.55, 95%CI = 0.75–3.20). However, greater comfort when discussing alcohol habits was strongly associated with participants' tendency to initiate SBI (OR = 4.06, 95%CI = 2.62–6.30) in maximally-adjusted models. Competence with screening (OR = 1.65, 95%CI = 1.06–2.56) and brief interventions (OR = 1.93, 95%CI = 1.30–2.85), and perceived reliability of self-reported alcohol habits (OR = 1.54, 95%CI = 1.12–2.13) were also positively associated with initiating SBI. While most (> 95%) participants considered it important that cardiology patients are asked about their alcohol habits, just 27% indicated that they often or always initiate SBI (z = 21.88, p <.001).

Conclusions: Many cardiology clinicians in Sweden view alcohol screening as important, but these views are frequently not aligned with self-reported clinical practice. Findings highlight a need to empower clinicians to initiate conversations about alcohol use with their patients and for improved training to support SBI implementation. Promising strategies may include creating workflows that normalize discussions around alcohol use and clinician training that focuses on challenging stereotypes associated with alcohol use disorder.

Aims: This study aimed to explore clinicians' perspectives on the feasibility of implementing alcohol screening and brief interventions (SBI) in cardiology services.

Methods and results: We conducted a multi-site, exploratory-sequential mixed methods study. Themes from qualitative interviews were integrated with the Capability, Opportunity, Motivation (COM-B) framework during the design and analysis of a cross-sectional survey of cardiology clinicians across Sweden. We assessed perceived capability, opportunities, motivation, and overall perceived feasibility for SBI, and explored associations using ordinal logistic regression. Among 638 participants (mean age = 43 years, 75% women), median perceived feasibility was 66.7%; motivation for SBI was the highest (68.8%), followed by perceived opportunities (66.6%) and capability (62.5%). Perceived feasibility was higher among doctors [OR = 2.67, 95% confidence interval (CI) = 1.38-5.13] compared to assistant nurses and among outpatient clinicians (OR = 1.75, 95% CI = 1.14-2.70) compared to inpatient staff. Participants with specialist experience in arrhythmia (OR = 1.82, 95% CI = 1.01-3.28) and heart failure (OR = 1.95, 95% CI = 1.14-3.33) perceived SBI as particularly feasible. Integrated analysis indicated that clinicians perceive universal alcohol screening as important and that opportunities for SBI exist in cardiology. Implementation barriers may include low competence with brief interventions and doubts about the reliability of self-reported alcohol use.

Conclusion: Findings suggest that the perceived feasibility of SBI varies according to clinicians' professional backgrounds and the clinical context. Doctors, outpatient staff, and those with specialist experience tended to perceive SBI as feasible and may be important stakeholders for implementation in cardiology. Effective strategies may include task sharing with assistant nurses and adapting training to clinical competencies and professional independence.

Registration: OSF (osf.io/x62be)

Background: Alcohol use is understudied in cardiology settings. We investigated the prevalence of hazardous alcohol use and probable dependence among cardiology patients.

Methods: Cross-sectional study in three regions of Sweden. Alcohol use was assessed using the AUDIT-10 questionnaire. We defined hazardous alcohol use as: AUDIT-10 >= 6 for women or >= 8 for men (primary definition) and probable dependence as AUDIT-10 >= 13 for women or >= 15 for men. We examined associations using logistic regression.

Results: We included 1107 participants (median age = 73 years; range = 18-102; 66% men). The prevalence of hazardous alcohol use was 7.8% (95%CI = 6.2-9.3, primary definition) and 0.9% (95%CI = 0.3-1.5) had probable alcohol dependence. We found increased odds of hazardous alcohol use in: age groups 18-39 years (OR = 4.90, 95%CI = 1.41-17.08) and 40-64 years (OR = 4.02, 95%CI = 1.69-9.67) compared to >= 80 years; a city compared to a small town (OR = 2.44, 95%CI = 1.02-5.84); participants with unhealthy diets (OR = 2.37, 95%CI = 1.36-4.13), and overweight participants (OR = 2.25, 95%CI = 1.23-4.12).

Conclusions: Hazardous alcohol use affected about one in 12 cardiology patients. However, less than 1 in 100 had probable alcohol dependence. Findings suggest that many cardiology patients with hazardous alcohol use are appropriate for brief interventions, and may not require more intensive alcohol dependence treatments.

Aims: To investigate rates of alcohol screening and brief interventions (SBI) in cardiology, and to examine associations between patient characteristics and the implementation of screening and brief interventions (BIs).

Methods: Cross-sectional survey of cardiology patients (aged ≥18 years) in three towns/cities in Sweden (Falun, Gävle, Stockholm). Self-reported study outcomes included: (a) being screened for alcohol use and (b) receiving a BI. Covariates included sociodemographic characteristics and clinical factors. We examined associations between covariates and study outcomes using logistic regression models.

Results: From a total of 1051 participants (median age = 73 years, 66% men), 54% were screened for alcohol use, mostly by doctors (48%) and nurses (40%). Odds ratios (ORs) for being screened were lower among participants aged ≥80 years (OR = 0.57, 95% confidence intervals (CI) = 0.41–0.79), relative to those aged 65–79 years, and higher among participants with overweight (OR = 1.84, 95%CI = 1.38–2.44). Of those screened, 12% received BIs. Odds ratios for receiving BIs were higher among: men (OR = 3.04, 95%CI = 1.41–6.56), current smokers (OR = 10.88, 95%CI = 3.86–30.69), and participants with hazardous drinking (OR = 5.66, 95%CI = 2.59–12.36).

Conclusions: Just over half cardiology patients were screened for alcohol use. Almost two-thirds of those identified with hazardous drinking did not receive BIs. Screening and BI practices varied according to individual participant characteristics, and there was a shortfall in screening among the elderly. Findings indicate inconsistent implementation of European cardiology guidelines, which recommend universal screening, and highlight a need for improved implementation strategies.

Objective: To investigate clinicians’ preferences for alcohol screening and brief interventions in clinical cardiology settings.

Results: A total of 664 cardiology clinicians responded to a cross-sectional survey (30.9% response rate), including 55.1% nurses, 21.4% assistant nurses, 18.8% doctors, and 4.7% other clinical staff. Among these participants, 87.5% indicated that patients should be screened for alcohol use on cardiology wards, 79.8% in outpatient clinics, 49.1% in emergency departments, and 45.9% on coronary care units. Doctors and nurses were the preferred professions to be responsible for screening across all clinical contexts, while fewer respondents indicated that assistant nurses or physiotherapists should be responsible for screening (p <.001). Most participants (85.2%) indicated that patients should be screened in more than one clinical context and 84.6% indicated that more than one profession should be responsible for alcohol screening. Clinicians’ preferred modality for assessing alcohol use was verbal screening (92% of participants), followed by questionnaires (53.5%), digital tools (28.5%), and alcohol biomarkers (22.1%, p <.001). Just over half of participants (58%) indicated that they would like to attend training on brief interventions. Findings suggest that task sharing, teamwork, and training may be effective strategies for implementation of alcohol screening and brief interventions in clinical cardiology.

Aims: This study aimed to identify barriers and facilitators to implementing alcohol screening and brief interventions (SBI) in cardiology services.

Methods and results: This was a qualitative study. Individual, semi-structured interviews were conducted with 24 clinical cardiology staff (doctors, nurses, and assistant nurses) of varying experience levels and from various clinical settings (high-dependency unit, ward, and outpatient clinic), in three regions of Sweden. Reflexive thematic analysis was used, with deductive coding applying the Capability, Opportunity, Motivation (COM-B) theoretical framework. A total of 41 barriers and facilitators were identified, including 12 related to capability, 9 to opportunity, and 20 to motivation. Four themes were developed: (i) uncharted territory, where clinicians expressed a need to address alcohol use but lacked knowledge and a roadmap for implementing SBI; (ii) cardiology as a cardiovascular specialty, where tasks were prioritized according to established roles; (iii) alcohol stigma, where alcohol was reported to be a sensitive topic that staff avoid discussing with patients; and (iv) window of opportunity, where staff expressed potential for implementing SBI in routine cardiology care.

Conclusion: Findings suggest that opportunities exist for early identification and follow-up of hazardous alcohol use within routine cardiology care. Several barriers, including low knowledge, stigma, a lack of ownership, and a greater focus on other risk factors, must be addressed prior to the implementation of SBI in cardiology. To meet current clinical guidelines, there is a need to increase awareness and to improve pathways to addiction care. In addition, there may be a need for clinicians dedicated to alcohol interventions within cardiology services.

Registratio:n OSF (osf.io/hx3ts). 

Background: Hazardous alcohol use is a leading risk factor for disability and death, yet observational studies have also reported reduced cardiovascular disease mortality among regular, low-level drinkers. Such findings are refuted by more recent research, yet have received significant media coverage. We aimed to explore: (1) how patients with cardiovascular diseases access health information about moderate drinking and cardiovascular health; (2) the perceived messages these sources convey, and (3) associations with own level of alcohol use.

Methods: We conducted a cross-sectional survey of patients in cardiology services at three hospitals in Sweden. The study outcome was hazardous alcohol use, assessed using the AUDIT-C questionnaire and defined as ≥ 3 in women and ≥ 4 in men. The exposure was accessing information sources suggesting that moderate alcohol consumption can be good for the heart, as opposed to accessing information that alcohol is bad for the heart. Health information sources were described using descriptive statistics. Gender, age and education were adjusted for in multiple logistic regression analyses.

Results: A total of 330 (66.3%) of 498 patients (mean age 70.5 years, 65% males) who had heard that drinking moderately can affect the heart described being exposed to reports that moderate alcohol use can be good for the heart, and 108 (21.7%) met criteria for hazardous alcohol use. Health information sources included newspapers (32.9%), television (29.2%), healthcare staff (13.4%), friends/family (11.8%), social media (8.9%) and websites (3.7%). Participants indicated that most reports (77.9%) conveyed mixed messages about the cardiovascular effects of moderate drinking. Exposure to reports of healthy heart effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use (OR = 1.67, 95%CI = 1.02–2.74).

Conclusions: This study suggests that many patients in cardiology care access health information about alcohol from media sources, which convey mixed messages about the cardiovascular effects of alcohol. Exposure to reports that moderate drinking has protective cardiovascular effects, or mixed messages about the cardiovascular effects of alcohol, was associated with increased odds of hazardous alcohol use. Findings highlight a need for clear and consistent messages about the health effects of alcohol.

Low-molecular-weight heparin (LMWH) is often recommended as a bridging therapy during temporary interruptions in warfarin treatment, despite lack of evidence. The aim of this study was to see whether we could find benefit from LMWH bridging. We studied all planned interruptions of warfarin within the Swedish anticoagulation register Auricula during 2006 to 2011. Low-molecular-weight heparin bridging was compared to nonbridging (control) after propensity score matching. Complications were identified in national clinical registers for 30 days following warfarin cessation, and defined as all-cause mortality, bleeding (intracranial, gastrointestinal, or other), or thrombosis (ischemic stroke or systemic embolism, venous thromboembolism, or myocardial infarction) that was fatal or required hospital care. Of the 14 556 identified warfarin interruptions, 12 659 with a known medical background had a mean age of 69 years, 61% were males, mean CHADS2 (1 point for each of congestive heart failure, hypertension, age >/=75 years, diabetes, and 2 points for stroke or transient ischemic attack) score was 1.7, and CHA2DS2-VASc score was 3.4. The total number of LMWH bridgings was 7021. Major indications for anticoagulation were mechanical heart valve prostheses 4331, atrial fibrillation 1097, and venous thromboembolism 1331. Bridging patients had a higher rate of thrombotic events overall. Total risk of any complication did not differ significantly between bridging (1.5%) and nonbridging (1.2%). Regardless of indication for warfarin treatment, we found no benefit from bridging. The type of procedure prompting bridging was not known, and the likely reason for the observed higher risk of thrombosis with LMWH bridging is that low-risk procedures more often meant no bridging. Results from randomized trials are needed, especially for patients with mechanical heart valves.

OBJECTIVES: To study the impact of time in therapeutic range (TTR) and international normalised ratio (INR) variability on the risk of thromboembolic events, major bleeding complications and death after mechanical heart valve (MHV) implantation. Additionally, the importance of different target INR levels was elucidated.

METHODS: A retrospective, non-randomised multicentre cohort study including all patients with mechanical heart valve (MVH) prosthesis registered in the Swedish National Quality Registry Auricula from 2006 to 2011. Data were merged with the Swedish National Patient Registry, SWEDEHEART and Cause of Death Registry.

RESULTS: In total 4687 ordination periods, corresponding to 18 022 patient-years on warfarin, were included. High INR variability (above mean ≥0.40) or lower TTR (≤70%) was associated with a higher risk of bleeding (rate per 100 years 4.33 (95% CI 3.87 to 4.82) vs 2.08 (1.78 to 2.41); HR 2.15 (1.75 to 2.61) and 5.13 (4.51 to 5.82) vs 2.30 (2.03 to 2.60); HR 2.43 (2.02 to 2.89)), respectively. High variability and low TTR combined was associated with an even higher risk of bleedings (rate per 100 years 4.12 (95% CI 3.68 to 4.51) vs 2.02 (1.71 to 2.30); HR 2.16 (1.71 to 2.58) and 4.99 (4.38 to 5.52) vs 2.36 (2.06 to 2.60); HR 2.38 (2.05 to 2.85)) compared with the best group.Higher treatment intensity (mean INR 2.8-3.2 vs 2.2-2.7) was associated with higher rate of bleedings (2.92 (2.39 to 3.47) vs 2.48 (2.21 to 2.77); HR 1.29 (1.06 to 1.58)), death (3.36 (2.79 to 4.02) vs 1.89 (1.64 to 2.17), HR 1.65 (1.31 to 2.06)) and complications in total (6.61 (5.74 to 7.46) vs 5.65 (5.20 to 6.06); HR 1.24 (1.06 to 1.41)) after adjustment for MHV position, age and comorbidity.

CONCLUSIONS: A high warfarin treatment quality improves outcome after MHV implantation, both measured with TTR and INR variability. No benefit was found with higher treatment intensity (mean INR 2.8-3.2 vs 2.2-2.7).