{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T01:36:19Z","timestamp":1787016979940,"version":"build-2736575974"},"reference-count":44,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2023,8,19]],"date-time":"2023-08-19T00:00:00Z","timestamp":1692403200000},"content-version":"unspecified","delay-in-days":18,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100014467","name":"Western Sydney Local Health District","doi-asserted-by":"publisher","award":["Research and Education Network Kickstarter Grant"],"award-info":[{"award-number":["Research and Education Network Kickstarter Grant"]}],"id":[{"id":"10.13039\/100014467","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000925","name":"NHMRC","doi-asserted-by":"crossref","award":["GNT1143538"],"award-info":[{"award-number":["GNT1143538"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100000925","name":"NHMRC","doi-asserted-by":"crossref","award":["GNT1182301"],"award-info":[{"award-number":["GNT1182301"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100001030","name":"National Heart Foundation of Australia","doi-asserted-by":"publisher","award":["102990"],"award-info":[{"award-number":["102990"]}],"id":[{"id":"10.13039\/501100001030","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,8,8]]},"published-print":{"date-parts":[[2023,8]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Many hospital presentations for acute coronary syndrome (ACS) occur in people previously hospitalised with coronary heart disease (CHD), leading to increased costs and health burden. Secondary prevention education including a prehospital discharge plan is recommended for all individuals to reduce the risk of recurrence. However, many clinicians lack the time or support to provide education, and patients\u2019 uptake of secondary prevention programmes is limited. An avatar-based education app is a novel and engaging way to provide self-delivered, evidence-based secondary prevention information during the hospital admission and remains accessible after discharge. This protocol aims to evaluate the effect of an avatar-based education app on individuals with ACS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>This protocol describes a prospective, randomised controlled trial with 3-month follow-up and blinded assessment of 72 participants. Intervention group participants will download the app onto their own device during the hospital admission and independently complete six interactive education modules based on the National Heart Foundation\u2019s six steps to cardiac recovery. All participants will receive a text message reminder of the study after 3\u2009weeks. Both groups will receive usual care consisting of bedside education and a pamphlet about cardiac rehabilitation. The primary outcome is knowledge of CHD, assessed using the Coronary Artery Disease Education Questionnaire II. Secondary outcomes include quality of life, response to heart attack symptoms, cardiac-related readmissions and mortality and modifiable cardiac risk factors. Engagement with the app will be evaluated objectively. Intention-to-treat analysis will be conducted, with between-group comparisons and 95% CIs of the primary outcome analysed using analysis of covariance, adjusting for baseline values.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>This study protocol has been approved by the Western Sydney Local Health District Human Research Ethics Committee. The results of this study will be disseminated via a peer-reviewed journal and research thesis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>Australian New Zealand Clinical Trials Registry (ACTRN12622001436763).<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-073621","type":"journal-article","created":{"date-parts":[[2023,8,21]],"date-time":"2023-08-21T12:45:26Z","timestamp":1692621926000},"page":"e073621","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Effect of an avatar-based discharge education application on knowledge and behaviour in people after acute coronary syndrome: protocol for a pragmatic prospective randomised controlled trial"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5815-7893","authenticated-orcid":false,"given":"Tiffany","family":"Ellis","sequence":"first","affiliation":[{"name":"Department of Physiotherapy, Westmead Hospital, Sydney, New South Wales, Australia"},{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sonia","family":"Cheng","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Zecchin","sequence":"additional","affiliation":[{"name":"Cardiac Rehabilitation Services, Western Sydney Local Health District, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clara","family":"Zwack","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karice","family":"Hyun","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ling","family":"Zhang","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robyn","family":"Gallagher","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robyn","family":"Clark","sequence":"additional","affiliation":[{"name":"Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8707-5563","authenticated-orcid":false,"given":"Julie","family":"Redfern","sequence":"additional","affiliation":[{"name":"Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2023,8,21]]},"reference":[{"key":"2025120519482511000_13.8.e073621.1","doi-asserted-by":"publisher","DOI":"10.5694\/mja16.00368"},{"key":"2025120519482511000_13.8.e073621.2","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1177\/2047487319893035","article-title":"Update on cardiovascular prevention in clinical practice: A position paper of the European Association of preventive cardiology of the European society of cardiology","volume":"27","author":"Piepoli","year":"2020","journal-title":"Eur J Prev Cardiolog"},{"key":"2025120519482511000_13.8.e073621.3","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehs215"},{"key":"2025120519482511000_13.8.e073621.4","unstructured":"ACCF\/AHA focused update incorporated into the ACC\/AHA 2007 guidelines for the management of patients with unstable angina\/non\u2013ST-elevation myocardial infarction: a report of the American college of cardiology foundation\/American heart Association task force on practice guidelines. Circulation 2011:e426\u2013579."},{"key":"2025120519482511000_13.8.e073621.5","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2013-305296"},{"key":"2025120519482511000_13.8.e073621.6","doi-asserted-by":"crossref","DOI":"10.1016\/j.hlc.2019.06.558","article-title":"SNAPSHOT ACS cohort follow-up \u2013 what happens to Australian patients in the 3 years after hospital discharge: A national data linkage study","volume":"28","author":"Redfern","year":"2019","journal-title":"Heart, Lung and Circulation"},{"key":"2025120519482511000_13.8.e073621.7","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.aucc.2016.07.001","article-title":"Cardiac rehabilitation in the acute care setting: integrative review","volume":"30","author":"Hall","year":"2017","journal-title":"Aust Crit Care"},{"key":"2025120519482511000_13.8.e073621.8","doi-asserted-by":"publisher","DOI":"10.1038\/nrcardio.2015.34"},{"key":"2025120519482511000_13.8.e073621.9","doi-asserted-by":"crossref","DOI":"10.5334\/gh.1141","article-title":"World heart Federation roadmap for Digital health in cardiology","volume":"17","author":"Tromp","year":"2022","journal-title":"Glob Heart"},{"key":"2025120519482511000_13.8.e073621.10","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1177\/2047487317750913","article-title":"Effectiveness, acceptability and usefulness of mobile applications for cardiovascular disease self-management: systematic review with meta-synthesis of quantitative and qualitative data","volume":"25","author":"Coorey","year":"2018","journal-title":"Eur J Prev Cardiolog"},{"key":"2025120519482511000_13.8.e073621.11","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph20031723","article-title":"Information needs and communication strategies for people with coronary heart disease: A Scoping review","volume":"20","author":"Zwack","year":"2023","journal-title":"Int J Environ Res Public Health"},{"key":"2025120519482511000_13.8.e073621.12","doi-asserted-by":"publisher","DOI":"10.1007\/s12265-015-9629-1"},{"key":"2025120519482511000_13.8.e073621.13","doi-asserted-by":"crossref","DOI":"10.2196\/jmir.2895","article-title":"Animated randomness, avatars, movement, and Personalization in risk Graphics","volume":"16","author":"Witteman","year":"2014","journal-title":"J Med Internet Res"},{"key":"2025120519482511000_13.8.e073621.14","first-page":"341","article-title":"The communication of global cardiovascular risk by avatars","volume":"220","author":"Ruiz","year":"2016","journal-title":"Stud Health Technol Inform"},{"key":"2025120519482511000_13.8.e073621.15","first-page":"1768","article-title":"Feasibility of using the Metaverse as Telecardiology platform: remote follow-up of a patient with Vasospastic angina","volume":"38","author":"Skalidis","year":"2022","journal-title":"Can J Cardiol"},{"key":"2025120519482511000_13.8.e073621.16","first-page":"1101","article-title":"Effectiveness of Avatar-based technology in patient education for improving chronic disease knowledge and self-care behavior: a systematic review","volume":"17","author":"Wonggom","year":"2019","journal-title":"JBI Evidence Synthesis"},{"key":"2025120519482511000_13.8.e073621.17","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1111\/jan.14210","article-title":"Effectiveness of an Avatar application for teaching heart attack recognition and response: A pragmatic randomized control trial","volume":"76","author":"Tongpeth","year":"2020","journal-title":"J Adv Nurs"},{"key":"2025120519482511000_13.8.e073621.18","doi-asserted-by":"crossref","first-page":"S45","DOI":"10.1016\/j.hlc.2022.06.017","article-title":"A Co-designed, self-delivered, Avatar-based patient discharge education application improves acute coronary syndrome patient knowledge","volume":"31","author":"Zhang","year":"2022","journal-title":"Heart, Lung and Circulation"},{"key":"2025120519482511000_13.8.e073621.19","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-158-3-201302050-00583"},{"key":"2025120519482511000_13.8.e073621.20","unstructured":"National Heart Foundation Australia . The heart foundation six steps to cardiac recovery. n.d. Available: https:\/\/sixstepstocardiacrecovery.com.au\/moodle"},{"key":"2025120519482511000_13.8.e073621.21","doi-asserted-by":"publisher","DOI":"10.1037\/0278-6133.27.3.379"},{"key":"2025120519482511000_13.8.e073621.22","doi-asserted-by":"crossref","first-page":"2401","DOI":"10.1111\/jan.14414","article-title":"Effectiveness of an Avatar educational application for improving heart failure patients\u2019 knowledge and Self\u2010Care behaviors: A pragmatic randomized controlled trial","volume":"76","author":"Wonggom","year":"2020","journal-title":"J Adv Nurs"},{"key":"2025120519482511000_13.8.e073621.23","doi-asserted-by":"crossref","DOI":"10.2196\/jmir.8.4.e27","article-title":"eHEALS: the Ehealth literacy scale","volume":"8","author":"Norman","year":"2016","journal-title":"J Med Internet Res"},{"key":"2025120519482511000_13.8.e073621.24","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1016\/j.pec.2014.11.019","article-title":"Development and Psychometric validation of the second version of the coronary artery disease education questionnaire (CADE-Q II)","volume":"98","author":"Ghisi","year":"2015","journal-title":"Patient Educ Couns"},{"key":"2025120519482511000_13.8.e073621.25","doi-asserted-by":"crossref","first-page":"21","DOI":"10.5694\/j.1326-5377.2007.tb00783.x","article-title":"High Risk\u2010Factor level and low Risk\u2010Factor knowledge in patients not Accessing cardiac rehabilitation after acute coronary syndrome","volume":"186","author":"Redfern","year":"2007","journal-title":"Med J Aust"},{"key":"2025120519482511000_13.8.e073621.26","doi-asserted-by":"publisher","DOI":"10.1002\/nur.20213"},{"key":"2025120519482511000_13.8.e073621.27","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.pec.2014.05.022","article-title":"Improving knowledge, attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: a randomized controlled trial","volume":"96","author":"O\u2019Brien","year":"2014","journal-title":"Patient Educ Couns"},{"key":"2025120519482511000_13.8.e073621.28","unstructured":"EuroQol Research Foundation . EQ-5D-5L user guide. 2019. Available: https:\/\/euroqol.org\/publications\/user-guides"},{"key":"2025120519482511000_13.8.e073621.29","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-004-0614-4"},{"key":"2025120519482511000_13.8.e073621.30","unstructured":"National Heart Foundation Australia . Warning signs action plan Australia. 2019. Available: https:\/\/www.heartfoundation.org.au\/getmedia\/0bd3d10-c464-4227-bd7b-59264f57c6eb\/Heart_Attack_Action_Plan.pdf"},{"key":"2025120519482511000_13.8.e073621.31","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehaa575"},{"key":"2025120519482511000_13.8.e073621.32","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehx393"},{"key":"2025120519482511000_13.8.e073621.33","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2017-017540","article-title":"Medication reminder Apps to improve medication adherence in coronary heart disease (Medapp-CHD) study: a randomised controlled trial protocol","volume":"7","author":"Santo","year":"2017","journal-title":"BMJ Open"},{"key":"2025120519482511000_13.8.e073621.34","doi-asserted-by":"crossref","first-page":"2280","DOI":"10.1093\/ntr\/ntaa141","article-title":"Changing the language of how we measure and report smoking status: implications for reducing stigma, restoring dignity, and improving the precision of scientific communication","volume":"22","author":"Williamson","year":"2020","journal-title":"Nicotine Tob Res"},{"key":"2025120519482511000_13.8.e073621.35","doi-asserted-by":"publisher","DOI":"10.1249\/01.MSS.0000078924.61453.FB"},{"key":"2025120519482511000_13.8.e073621.36","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph19063617","article-title":"Active lifestyle post first myocardial infarction: A comparison between participants and non-participants of a structured cardiac rehabilitation program","volume":"19","author":"Shlomo","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"2025120519482511000_13.8.e073621.37","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph19127289","article-title":"Expression of the Endothelin-1 gene and its type a receptor including physical activity among patients with acute myocardial infarction","volume":"19","author":"D\u0105bek","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"2025120519482511000_13.8.e073621.38","doi-asserted-by":"crossref","unstructured":"Singleton AC , Raeside R , Partridge SR , et al . Supporting women\u2019s health outcomes after breast cancer treatment comparing a text message intervention to usual care: the EMPOWER-SMS randomised clinical trial. J Cancer Surviv 2022. doi:10.1007\/s11764-022-01209-9","DOI":"10.1007\/s11764-022-01209-9"},{"key":"2025120519482511000_13.8.e073621.39","doi-asserted-by":"crossref","DOI":"10.1093\/eurheartj\/ehy565.1109","article-title":"Medication reminder Apps to improve medication adherence in coronary heart disease patients (Medapp-CHD): a randomised clinical trial","volume":"39","author":"Santo","year":"2018","journal-title":"Eur Heart J"},{"key":"2025120519482511000_13.8.e073621.40","unstructured":"Chow S-CS , Wang H . Sample size calculations in clinical research, 2nd edn. Boca Raton: Chapman & Hall\/CRC, 2008."},{"key":"2025120519482511000_13.8.e073621.41","unstructured":"Hulley SC , Browner WS , Grady D , et al . 4th Designing clinical research: an epidemiologic approach, 4th edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2013."},{"key":"2025120519482511000_13.8.e073621.42","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1097\/HCR.0000000000000512","article-title":"Comprehensive cardiac rehabilitation effectiveness in a middle-income setting: A RANDOMIZED CONTROLLED TRIAL","volume":"40","author":"Ghisi","year":"2020","journal-title":"J Cardiopulm Rehabil Prev"},{"key":"2025120519482511000_13.8.e073621.43","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2015.10945"},{"key":"2025120519482511000_13.8.e073621.44","doi-asserted-by":"crossref","DOI":"10.2196\/humanfactors.6217","article-title":"eHealth literacy: predictors in a population with moderate-to-high cardiovascular risk","volume":"4","author":"Richtering","year":"2017","journal-title":"JMIR Hum Factors"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2023-073621","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,6]],"date-time":"2025-12-06T03:48:41Z","timestamp":1764992921000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2023-073621"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8]]},"references-count":44,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2023,8,21]]},"published-print":{"date-parts":[[2023,8]]}},"alternative-id":["10.1136\/bmjopen-2023-073621"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2023-073621","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8]]}}}