“If it’s necessary, it has to be done. And that’s for the physician to decide, not me.” Imaging techniques in monitoring routines in coronary heart disease and post-stroke patients: A qualitative interview study from the patients’ perspective

Laura Rink; Julia Heisig; Ciara Elisa Fink; Carolin Gonschorek; Veronika van der Wardt; Annika Viniol; Thomas Kühlein; Susann Hueber

doi:10.1371/journal.pone.0338431

Peer Review History

Original SubmissionJune 17, 2025
3 Sep 2025 Decision Letter - Jennifer Tucker, Editor Dear Dr. Rink, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible. 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We acknowledge financial support by Deutsche Forschungsgemeinschaft and Friedrich-Alexander-Universität Erlangen-Nürnberg within the funding programme “Open Access Publication Funding”.-->--> -->-->We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. -->-->Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. 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Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.-->--> -->-->5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. ?> [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Introduction - please include a sentence or two about how CHD and stroke patients share characteristics. Please explain that CHD can be a risk factor for stroke, so interviewing both cohorts could help with longitudinal monitoring to predict changes before stroke, in the case of patients with CHD only. Please include information about the differences between stroke and TIA, since TIA patients were included in this analysis. TIA is also a risk factor for stroke, so it should be considered the way CHD is - a potential diagnosis to monitor to prevent a stroke. Did your patients with TIA also participate in regular echocardiography and carotid duplex sonography monitoring? What does "regular monitoring" intervals mean, i.e. how frequent? Were these procedures performed in a clinical setting or at home? Methods - please provide a paragraph explaining the rationale for why reflexive thematic analysis by Braun and Clarke is best suited for this project. Define this analysis approach for the study. Participants and recruitment - how were diagnoses defined? Did you obtain diagnosis from electronic medical records or Patient self-reporting? Data analysis - Could you start this section with the sentence so readers know which tool was used: "The analysis was conducted using MAXQDA (2020) software." ? Results - could you create a participant enrollment diagram that shows how many patients you contacted, the 29 who replied (and how they dropped out), the 14 who completed the study, and then 2 separate boxes showing the number of study completion participants by diagnosis (CHD diagnosis vs stroke diagnosis)? Could you give the average/mean for this: "lasted between 20 and 51 minutes."? Is there any information about participant education levels? Do you have ethnicity information? Line 222 is missing a leading " for the quote. Discussion - after line 281, you mention "The results of our study suggest that similar principles could be applied to monitoring routines, particularly". It would be beneficial to include a few sentences about the state of monitoring routines in real-world settings, perhaps by citing a review involving ischemic heart disease and CHD as well as a novel TIA/stroke mood monitoring study (below). The range of remote monitoring digital tools should be discussed here. #1 - Indraratna P, Tardo D, Yu J, Delbaere K, Brodie M, Lovell N, Ooi SY Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis JMIR Mhealth Uhealth 2020;8(7):e16695 doi: 10.2196/16695 #2 - Zawada S, Acosta J, Collins C, Dumitrascu O, Harahsheh E, Hagen C, et al. Real- World Smartphone Data Predicts Mood After Ischemic Stroke and Transient Ischemic Attack Symptoms and May Constitute Digital Endpoints: A Proof-of-Concept Study. Mayo Clinic 598 Proceedings: Digital Health. 2025;3(3) Strengths and limitations - were all interviews conducted in patients' homes? ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0338431.r001
Revision 1
22 Oct 2025 Author Response Reviewer #1: Introduction - please include a sentence or two about how CHD and stroke patients share characteristics. Please explain that CHD can be a risk factor for stroke, so interviewing both cohorts could help with longitudinal monitoring to predict changes before stroke, in the case of patients with CHD only. Please include information about the differences between stroke and TIA, since TIA patients were included in this analysis. TIA is also a risk factor for stroke, so it should be considered the way CHD is - a potential diagnosis to monitor to prevent a stroke. Response: Thank you for your thoughts on this. Both conditions have been chosen as examples for monitoring routines. In this context, it was considered whether the conditions are relevant to primary care and whether the monitoring routines can be reflected in billing data for another part of the project. From our perspective, there was no thematic connection between the two conditions. Therefore, although you were absolutely right to describe these connections, we would not include them in the introduction, as they were not part of the study question and methodology. Did your patients with TIA also participate in regular echocardiography and carotid duplex sonography monitoring? What does "regular monitoring" intervals mean, i.e. how frequent? Were these procedures performed in a clinical setting or at home? Response: Yes, all patients included in our study had undergone at least three echocardiography or carotid duplex sonography examinations within the last three years. That was one of the recruitment criteria. Monitoring intervals ranged between every three months and every eighteen months (see RESULTS – Theme 3). All examinations were performed in outpatient clinical settings by cardiologists or neurologists. Changes in manuscript: • METHODS “Participants included adult patients diagnosed with CHD, stroke or TIA who had undergone echocardiography or carotid duplex sonography monitoring at least three times within the past three years.” • RESULTS “The participants reported that echocardiography or carotid duplex sonography monitoring is carried out exclusively by cardiologists and neurologists in an outpatient clinical setting, not in GP practices.” Methods - please provide a paragraph explaining the rationale for why reflexive thematic analysis by Braun and Clarke is best suited for this project. Define this analysis approach for the study. Response: A paragraph defining and justifying the use of reflexive thematic analysis has been added to the Data Analysis section. This addition clarifies the flexibility and reflexivity of this method and its alignment with our research aims. Changes in manuscript: “The qualitative data analysis followed the thematic framework by Braun and Clarke (18, 19), as it is a flexible analytic approach that allows researchers to identify, analyse, and interpret patterns of meaning across qualitative data. It emphasises researcher reflexivity and the active role of interpretation. This method was particularly suited to our study because it enabled both inductive and deductive exploration of participants’ experiences and perceptions of monitoring without being bound to a predefined theoretical framework, by following a systematic process of data immersion, coding and theme development.” Participants and recruitment - how were diagnoses defined? Did you obtain diagnosis from electronic medical records or Patient self-reporting? Response: Diagnoses were based on patient self-reporting during recruitment. As the study focused on patients’ experiences rather than clinical validation, self-reported diagnoses of CHD, stroke, or TIA were considered appropriate. Changes in manuscript: “Diagnoses of CHD, stroke, or TIA were based on patient self-reporting during recruitment.” Data analysis - Could you start this section with the sentence so readers know which tool was used: "The analysis was conducted using MAXQDA (2020) software."? Response: We agree and have moved this sentence to the beginning of the data analysis section. Results - could you create a participant enrollment diagram that shows how many patients you contacted, the 29 who replied (and how they dropped out), the 14 who completed the study, and then 2 separate boxes showing the number of study completion participants by diagnosis (CHD diagnosis vs stroke diagnosis)? Response: We appreciate this suggestion. However, it was not possible to determine the total number of individuals reached by our recruitment efforts, as participants were recruited a public press calls and several general practices. Therefore, we could not create an enrollment flowchart. We clarified in the Results section how participants were selected and why some were not included, describing the screening criteria and selection process in more detail. Changes in manuscript: “Of these, 14 interviews were scheduled and conducted, comprising individuals with diverse backgrounds in terms of age, gender, disease duration and time of response. Individuals who had not yet undergone, or had completed only one monitoring examination, were excluded during screening, as the study focused on patients with regular monitoring”. Could you give the average/mean for this: "lasted between 20 and 51 minutes."? Response: Thank you for the suggestion. We added the mean interview duration to the Results section. Changes in manuscript: “The interviews took place between November 2023 and March 2024 and lasted on average 32 minutes (range 20-51 minutes).” Is there any information about participant education levels? Do you have ethnicity information? Response: As the study focused on patients’ experiences rather than sociodemographic differences, education and ethnicity data were not collected. Line 222 is missing a leading " for the quote. Response: Thank you for catching this. The missing quotation mark in line 222 has been added. Discussion - after line 281, you mention "The results of our study suggest that similar principles could be applied to monitoring routines, particularly". It would be beneficial to include a few sentences about the state of monitoring routines in real-world settings, perhaps by citing a review involving ischemic heart disease and CHD as well as a novel TIA/stroke mood monitoring study (below). The range of remote monitoring digital tools should be discussed here. #1 - Indraratna P, Tardo D, Yu J, Delbaere K, Brodie M, Lovell N, Ooi SY Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis JMIR Mhealth Uhealth 2020;8(7):e16695 doi: 10.2196/16695 #2 - Zawada S, Acosta J, Collins C, Dumitrascu O, Harahsheh E, Hagen C, et al. Real-World Smartphone Data Predicts Mood After Ischemic Stroke and Transient Ischemic Attack Symptoms and May Constitute Digital Endpoints: A Proof-of-Concept Study. Mayo Clinic 598 Proceedings: Digital Health. 2025;3(3) Response: We thank you for this thoughtful suggestion. However, our study specifically focused on physician-led, imaging-based monitoring in outpatient care. The integration of remote monitoring technologies lies outside the scope of our research. To maintain conceptual and methodological focus, we therefore decided not to expand the discussion in this direction. Strengths and limitations - were all interviews conducted in patients' homes? Response: We clarified the settings of the interviews in the strengths and limitations section. Changes in manuscript: “Interviews were conducted either in participants’ homes, at one of the study centres, via online Zoom call, or via telephone, depending on participant preference and health status. This flexibility ensured accessibility and comfort for all participants.” Attachments Attachment Submitted filename: Response to Reviewers.pdf https://doi.org/10.1371/journal.pone.0338431.r002
23 Nov 2025 Decision Letter - Redoy Ranjan, Editor "If it's necessary, it has to be done. And that's for the physician to decide, not me." Imaging techniques in monitoring routines in coronary heart disease and post-stroke patients: A qualitative interview study from the patients' perspective PONE-D-25-31747R1 Dear Dr. Rink, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Redoy Ranjan, MBBS, MRCSEd, Ch.M., MS (CV&TS), FACS Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: N/A ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Author reply satisfactory. Recommendation to accept paper. Research revisions meet each request outlined in review round 1 ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0338431.r003
Formally Accepted
Acceptance Letter - Redoy Ranjan, Editor PONE-D-25-31747R1 PLOS ONE Dear Dr. Rink, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Redoy Ranjan Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0338431.r004

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