Optimizing patient experience during cardiac stress testing

Cardiovascular disease is one of the main causes of death worldwide (Khan,
2020). One of the precursors of serious heart problems such as a heart attack
is myocardial ischemia which occurs when blood flow to the heart is reduced,
preventing enough oxygen supply to the heart muscle. Myocardial ischemia is
often caused by partial or complete blockage of the coronary arteries (coronary
artery disease: CAD). Resulting persistent cardiac symptoms, such as chest
pain, are a substantial burden to patients and society. Optimal and efficient
diagnosis of myocardial ischemia is therefore paramount. The present study
focusses on the effects of testing environment on emotion and mood states,
cardiac symptoms and patient satisfaction during cardiac stress testing in
patients that are referred to the Verbeeten Institute for SPECT MPI.

Primary objective: To determine whether adding information and coaching
support to the standard diagnostic testing environment for the inducibility of
myocardial ischemia improves patient psychological wellbeing.
The role of the testing environment on psychological measures will be assessed
by comparing four approaches during the diagnostic project: care-as-usual
(CAU), providing information support using video clips, providing supportive
coaching by a coach, and a combination of information support and supportive
coaching. It is hypothesized that both interventions will additively improve
psychological wellbeing during the diagnostic process (i.e., emotional states
and mood).

Secondary Objectives
2.1. To determine whether adding information and coaching support to the
standard diagnostic testing environment for the inducibility of myocardial
ischemia reduces cardiac and other physical symptoms during the testing
procedure.
Previous studies have already shown a relation between negative emotions such
as anxiety with cardiac and other physical symptoms. It is therefore
hypothesized that both information and supportive coaching interventions will
additively reduce cardiac and other physical symptoms during the diagnostic
testing procedure.

2.2. To determine whether adding information and coaching support to the
standard diagnostic testing environment for the inducibility of myocardial
ischemia will improve patient satisfaction with the clinic visit.
It is hypothesized that information support and supportive coaching improves
patient satisfaction by improving psychological wellbeing (i.e., reducing
anxiety, uncertainty and distress) and reducing cardiac and other physical
symptoms during the diagnostic testing procedure.

2.3 To establish the association between patient wellbeing experiences during
the diagnostic testing procedure for inducibility of myocardial ischemia with
autonomic nervous system activity.
It is hypothesized that higher levels of psychological wellbeing are
associated with a shift towards reduced sympathetic and increased
parasympathetic autonomic nervous system activity as indexed by lower heart
rate and blood pressure responses during cardiac testing and higher levels of
heart rate variability during ambulatory ECG monitoring.

Experimental 2x2 factorial design with four groups: CAU, CAU + Information, CAU
+ Coach, CAU + Information + Coach. Outcome measures: psychological wellbeing
(primary outcome: emotional states self-report and FaceReader assessments), and
symptoms during the diagnostic testing procedure, patient satisfaction and
autonomic nervous system activity (secondary outcome measures).

To improve the patient experiences during cardiac stress testing and MPI, we
will compare four approaches while patients visit the Institute Verbeeten: Care
as usual, information support, emotional support by a coach and a combination
of information and emotional support. This type of intervention is intended as
quality of care evaluation. As per study protocol, participating patients will
be randomly assigned into four groups before their first clinic visit at
Institute Verbeeten.
Group 1: Care as usual (CAU) = Patients in this group will not receive any
additional information materials or support on top of care as usual, but
information videos will be made available after completion of the MPI
procedures.
Group 2: CAU + Information support = patients in this group will primarily
receive additional information on the diagnostic process that they will go
through with the use of video materials as well as answers to questions.
Emotional support by additional coaching will not be provided in this group.
Group 3: CAU + Supportive coaching = Patients in this group will receive
emotional support throughout their clinic visit. The coach is available for
questions as well as specific support for each patient. Additional information
using video materials will not be supplied to the patients during the
diagnostic process, but will be made available after completion of the MPI
procedures.
Group 4: CAU + Information + Coaching = Patients in this group will receive
both additional information as well as supportive coaching during their visit
of the clinic.

- Filling out one questionnaire on psychological factors, which takes
approximately 25 minutes.
- Filling out a second questionnaire on demographic and psychosocial factors in
a take-home questionnaire, and returning them by postal mail. Estimated time 25
minutes.
- Receiving two short (<5 min each) information video clips or interacting with
a coach who provides emotional support (<10 minutes total)
- Filling out a third brief questionnaire on patient experience and
satisfaction using an online questionnaire taking approximately 25 minutes.
- Use of a Holter monitor over the 24 hours after the hospital visit.
- Consent to have video recordings taken of the patient during the bicycle or
adenosine myocardial perfusion stress task. These recordings will be used to
detect facial expressions using specialized software (FaceReader) at Tilburg
University. See protocol for details. Reporting (cardiac) symptoms during the
second day of cardiac stress testing; which is part of routine clinical
practice, expanded by a scale to measure intensity of the symptoms for the
present study
- Consent to collect additional collection of data from hospital records at the
Verbeeten Institute (including blood pressure and heart rate monitoring) and
the Elisabeth-Tweesteden hospital cardiology unit.