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doi: 10.1097/JCN.0000000000000551
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New: Digital Stroke Prevention Guide

The Preventive Cardiovascular Nurses Association is excited to announce the release of a new digital resource for busy clinicians in search of national guideline recommendations for stroke prevention. The National Guidelines and Tools for Stroke Prevention: A Guide for Nurses includes all the stroke-related guidelines in 1 easy-to-use guide and is available for use on phone, tablet, or computer.

Just search the table of contents for the specific recommendation you are looking for, and 1 click will take you there. Sections include the following:

  • Modifiable risk factors
  • Stroke prevention in nonvalvular atrial fibrillation
  • Stroke prevention in other cardiac conditions
  • Stroke prevention in noncardiac conditions
  • Stroke prevention in women
  • Antiplatelet agents and aspirin in stroke prevention
  • Secondary prevention of stroke

The tool is free for members, and nonmembers can gain access for $25. Learn more at

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Exercise and Mental Health: What Is Optimal?

As the winter months ensue, health behaviors are at risk for taking a negative turn by changes in eating patterns, with more exposure to calorie-dense holiday foods, increased sedentary time, reduced overall activity, and altered sleep patterns. In addition, reduced exposure to natural light as people tend to stay indoors because of inclement weather may contribute to altered mood, “feeling blue,” and increased depressive symptoms. Cardiovascular nurses have long appreciated the importance of physical activity, especially during winter months, for its effects on reducing risk factors, weight management during this time of potential weight gain, and reducing the risk of cardiovascular disease and stroke. However, associations between exercise and mental health have not been as clearly defined, with past studies reporting conflicting results likely because of variations in how exercise was defined and small sample sizes. An interesting study reported in 2018 sheds some important light on this topic by examining the associations between mental health and exercise type, frequency, duration, and intensity.1

The researchers accessed a large data set from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. This survey is conducted each year, asking a variety of questions of respondents about their health and behavior. The sample of adults older than 18 years in age was large (N = 1°237°194) and diverse. Information on type, duration, frequency, and intensity of exercise was used to divide the sample into those who exercised and those who did not. The groups were well balanced (matched) on a variety of physical and sociodemographic variables, including age, race, gender, marital status, income, education, body mass index, self-reported physical health, and prior diagnosis of depression. The exercise and nonexercise groups were compared on the number of bad mental health days experienced in the last month, reported in response to a standardized Behavioral Risk Factor Surveillance System question: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”1 The regression analysis was adjusted for the covariates noted above.

Respondents reported a mean of 3.36 poor mental health days, and findings revealed that people who exercised had 43.2% fewer days of poor mental health than those who did not. Although the exercising group reported only a mean of 1.49 fewer days, it is important to note that all types of exercise were associated with better mental health when compared with not exercising. Team sports, cycling, and aerobic and gym activity accounted for 22.3%, 21.6%, and 20.1% lower mental health burden, respectively. The authors suggested that there may be a social component of these activities that was additive.1 An exploratory analysis revealed that even “mindful” types of exercise such as yoga or Tai Chi were better than not exercising.

Several nonlinear associations were found indicating U-shaped patterns—less relationship at the lower and higher ends of the data. This was seen in dose of exercise and response, with the greater association between 30 and 60 minutes (most optimal around 45 minutes) for all types of exercise. However, an exercise episode duration of 90 minutes to 3 hours was associated with worse mental health. Optimal frequency was 3 to 5 times a week, with lower mental health in those exercising less frequently and in those exercising more than 5 times a week. The worst outcomes were for those who exercised greater than 23 days per month or for durations of greater than 90 minutes.1 If a previous diagnosis of depression was reported, the positive influence of exercise was even greater. The associations of exercise and mental health held across all age, gender, racial, and household income groups.

Although this study was cross-sectional, and interpretation of 1-way cause-effect is cautioned, the strengths of the large and diverse sample as well as the robust analysis provide confidence in the associations of exercise and mental health or reduction in self-reported poor mental health days in the context of exercise. Important evidence is provided for cardiovascular nurses who can incorporate these findings in their patient education and counseling, especially by encouraging patients and those at risk to engage in exercise to reduce low mental health days. Specific recommendations could include types of exercise most beneficial, such as team sports and cycling when appropriate, and individualized counseling regarding the type, frequency, and duration of exercise according to what the person might be able to do in the winter months. Most importantly, cardiovascular nurses can encourage and motivate patients by explaining that any exercise is helpful for their mental health over none at all.


  1. Chekroud SR, Gueorguieva R, Zheutlin AB, Paulus M, Krumholz HM, Krystal JH, Chekroud AM. Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study. Lancet Psychiatry 2018; 5:739–746.
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Climate Change and Health

Climate change threatens human health and well-being in the United States. The US Global Change Research Program conducted a Climate and Health Assessment to enhance understanding and inform decisions surrounding this growing threat. The executive summary states that as the climate continues to change, the risks to human health will grow, increasing existing health threats and creating new public health challenges. Every American is vulnerable to the health impacts associated with climate change. Increased exposure to multiple health threats, along with decreased ability to adapt to those threats, increases a person's vulnerability to climate-related health effects. Some populations, however, are more vulnerable, including those with low income, some communities of color, immigrant groups, indigenous peoples, children, pregnant women, older adults, persons with disabilities, and persons with preexisting or chronic medical conditions such as cardiovascular disease.1

With climate change, the frequency, severity, duration, and location of weather and climate phenomena, like rising temperatures, heavy rains, and droughts, are increasing. As a result, areas experiencing health-threatening weather such as severe heat or hurricanes are likely to experience worsening impacts, such as higher temperatures, increased storm intensity and rainfall, and greater storm surge. Some locations will experience new climate-related health threats. For example, areas with cooler water temperatures may see an increase in toxic algae blooms or waterborne diseases as the water temperature increases.1

For those with cardiovascular disease, temperature extremes can be problematic. Prolonged exposure to high temperatures is associated with increased rates of hospital admissions. Likewise, changes in air quality can negatively impact the cardiovascular system. Climate change is projected to increase the number and severity of naturally occurring wildfires in parts of the United States. The rising incidence of wildfires and decreasing precipitation will lead to increases in ozone and particulate matter, which increases the risks of cardiovascular illnesses and death. Changes in temperature, precipitation patterns, and higher frequency of extreme weather events can also influence vector-borne diseases, which are transmitted by ticks and mosquitoes. Such diseases generally bear more risks for those with cardiovascular disorders.1

Climate change impacts can be widespread. Food safety, nutrition, and distribution could be affected by disruptions in food availability and decreased access to food. Physical health can also be impacted by changes in fitness and activity levels. Stress, anxiety, depression, grief, and a sense of loss, along with strained social relationships and posttraumatic stress disorder, are mental health problems that can occur. Vulnerable groups of people, such as those with cardiovascular disease, can experience disproportionate and complex risks to their health and well-being in response to climate change.1

Climate change harms our water supply, air quality, food supply, and mental health and increases the occurrence of vector-borne diseases and extreme weather events. Addressing these concerns should be every nurse's responsibility. Nurses are the most trusted profession and we have a unique opportunity to engage and educate the public on health issues. There are many ways nurses can be influential, and, as nurses focused on prevention, we should call for and work toward climate solutions that will protect and promote health in our communities.2 The Preventive Cardiovascular Nurses Association has joined the Nursing Collaborative on Climate Change and Health to elevate climate change as a visible health priority.


  1. The U.S. Global Change Research Program Climate and Health Assessment. Accessed September 28, 2018.
  2. Alliance of Nurses for Healthy Environments. Accessed September 28, 2018.
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Beating the Weather During Season Changes: Maintaining a Routine of Physical Activity

Many common health problems such as heart disease, diabetes, hypertension, and stroke have been linked to poor lifestyle choices.1 One of the simplest forms of disease prevention that many Americans fail to implement in their daily lives is sufficient moderate to brisk physical activity. Approximately 35% of American adults are physically inactive, a fundamental component to a healthy lifestyle that carries significant physical and mental health.2 However, season change, specifically winter, has been associated with decreased activity levels, increase in appetite, and an increase in depression.3 A study from Switzerland of more than 300 fitness club members showed that outdoor activity was more pleasurable than indoor activity.2 The study confirmed that physical activity would be more sustained if it is considered to be enjoyable by the participant. The study also indicated that adverse weather conditions could directly inhibit the decision to endure preplanned exercise activity. Factors such as season change, length of daylight, weather, temperature, wind, and precipitation all affect participation in outdoor physical activity. Ice or snow in the winter and rain in the summer are the primary weather conditions that changed attitudes about outdoor activity. Another study consisting of more than 1800 individuals in Australia showed that there was a perceived barrier to physical activity relative to the season.4 This study also established that inclement weather negatively impacts outdoor physical activity. In addition, an individual's perception of outdoor activity is often influenced by one's view of safety, exercise comfort level, and appropriateness of the neighborhood.2 From this, authors concluded that healthcare providers should pursue and contest the negative perceptions associated with physical activity and seasonal weather.2

The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week to improve overall cardiovascular health.5 Forty minutes of moderate to vigorous aerobic activity 3 to 4 times per week lowers blood pressure and cholesterol. To ensure that physical activity remains consistent and people stay motivated from season to season, new goals should be set and exercise planned around inclement weather.6 For example, during the winter months, options such as walking in the local mall, joining a gym, or working out at home with a DVD or personal equipment could be alternative options. Winter sports such as cross-country skiing or ice skating are great outdoor activities to stay active during the colder months.7 Connecting with a partner or making social connections can create an atmosphere of accountability and help to maintain focus on one's goals.6 Communities can work to ensure affordable indoor activities as well as provide neighborhoods or recreation areas that do not limit the ability to exercise.2 The best medicine for the winter blues is exercise. A consistent exercise routine that fits one's lifestyle, time, and budget will improve overall mental and physical health.1

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1. Harvard School of Public Health. Staying active. 2018. Accessed September 28, 2018.
2. Wagner A, Keusch F, Yan T, Clark P. The impact of weather on summer and winter exercise behaviors. J Sport Health Sci. 2017.
3. Mental Health America. Seasonal depression. 2018. Accessed September 28, 2018.
4. Badland H, Christian H, Giles-Corti B, Knuiman M. Seasonality in physical activity: should this be a concern in all settings? Health Place. 2011;1084–1089.
5. American Heart Association. 2018. Recommendations for physical activity in adults. Accessed September 28, 2018.
6. Go Red for Women. New season, new exercise routine ideas. 2018. Accessed September 28, 2018.
7. Soares C (2016). Avoid Being a Cold Weather Couch Potato. Medic ALert Foundation. Accessed September 28, 2018.
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