Identifying heart failure patients at high risk for near-term cardiovascular events with serial health status assessments

Baseline distribution of participants with depression and impaired quality of life in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial

BACKGROUND

Previous studies have demonstrated the psychosocial effect of heart failure in patients with reduced ejection fraction. However, the effects on patients with preserved ejection fraction have not yet been elucidated. This study aimed to determine the baseline characteristics of participants with heart failure with preserved ejection fraction as it relates to impaired quality of life (QOL) and depression, identify predictors of poor QOL and depression, and determine the correlation between QOL and depression.

METHODS AND RESULTS

Among patients enrolled in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial (TOPCAT), 3400 patients completed the Kansas City Cardiomyopathy Questionnaire, 3395 patients completed European QOL 5D Visual Analog Scale, and 1431 patients in United States and Canada completed the Patient Health Questionnaire-9. The mean summary score on the Kansas City Cardiomyopathy Questionnaire was 54.8, and on European QOL 5D Visual Analog Scale, it was 60.3; 27% of patients had moderate to severe depression. Factors associated with better Kansas City Cardiomyopathy Questionnaire and European QOL 5D Visual Analog Scale via multiple logistic regression analysis were American region, older age, no history of angina pectoris or asthma, no use of hypoglycemic agent, more activity level, and lower New York Heart Association class. Factors associated with depression via multiple logistic regression analysis included younger age, female sex, comorbid angina, chronic obstructive pulmonary disease, use of a hypoglycemic agent, lower activity level, higher New York Heart Association class, and selective serotonin reuptake inhibitor use. There were significant correlations between each of the QOL scores and depression.

CONCLUSIONS

Patients with heart failure with preserved ejection fraction, who were younger had higher New York Heart Association class or comorbid angina pectoris, had lower activity levels, lived in Eastern Europe or were taking hypoglycemic agents, were more likely to have impaired QOL and depression.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.

Transitions of care in heart failure: a scientific statement from the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Neuroticism personality trait is associated with Quality of Life in patients with Chronic Heart Failure

AIM: To evaluate Quality of life (QoL) in chronic heart failure (CHF) in relation to Neuroticism personality trait and CHF severity.

METHODS: Thirty six consecutive, outpatients with Chronic Heart Failure (6 females and 30 males, mean age: 54 ± 12 years), with a left ventricular ejection fraction ≤ 45% at optimal medical treatment at the time of inclusion, were asked to answer the Kansas City Cardiomyopathy Questionnaire (KCCQ) for Quality of Life assessment and the NEO Five-Factor Personality Inventory for personality assessment. All patients underwent a symptom limited cardiopulmonary exercise testing on a cycle-ergometer, in order to access CHF severity. A multivariate linear regression analysis using simultaneous entry of predictors was performed to examine which of the CHF variables and of the personality variables were correlated independently to QoL scores in the two summary scales of the KCCQ, namely the Overall Summary Scale and the Clinical Summary Scale.

RESULTS: The Neuroticism personality trait score had a significant inverse correlation with the Clinical Summary Score and Overall Summary Score of the KCCQ (r = -0.621, P < 0.05 and r = -0.543, P < 0.001, respectively). KCCQ summary scales did not show significant correlations with the personality traits of Extraversion, Openness, Conscientiousness and Agreeableness. Multivariate linear regression analysis using simultaneous entry of predictors was also conducted to determine the best linear combination of statistically significant univariate predictors such as Neuroticism, VE/VCO₂ slope and VO₂ peak, for predicting KCCQ Clinical Summary Score. The results show Neuroticism (β = -0.37, P < 0.05), VE/VCO₂ slope (β = -0.31, P < 0.05) and VO₂ peak (β = 0.37, P < 0.05) to be independent predictors of QoL. In multivariate regression analysis Neuroticism (b = -0.37, P < 0.05), the slope of ventilatory equivalent for carbon dioxide output during exercise, (VE/VCO₂ slope) (b = -0.31, P < 0.05) and peak oxygen uptake (VO₂ peak), (b = 0.37, P < 0.05) were independent predictors of QoL (adjusted R2 = 0.64; F = 18.89, P < 0.001).

CONCLUSION: Neuroticism is independently associated with QoL in CHF. QoL in CHF is not only determined by disease severity but also by the Neuroticism personality trait.

Trajectories of heart failure self-care management and changes in quality of life

INTRODUCTION

Heart failure patients vary considerably in their self-care management behaviors (i.e. recognizing and responding to symptoms). The goal of this study was to identify unique patterns of change in heart failure self-care management and quantify associations between self-care management and quality of life (HRQOL) over time.

METHODS

A prospective cohort study among adults with symptomatic heart failure was designed to measure changes in self-care management (Self-care of Heart Failure Index) and HRQOL (Kansas City Cardiomyopathy Questionnaire) over six months. Growth mixture modeling was used to identify unique trajectories of change in self-care management.

RESULTS

The mean age (n=146) was 57 years, 70% were male, and 41% had class II heart failure. Two trajectories of self-care management were identified (entropy = 0.88). The larger trajectory (73.3%) was characterized by a significant decline in self-care management over time and no change in HRQOL. The smaller trajectory (26.7%) was characterized by marked improvements in self-care management and HRQOL. Changes in heart failure self-care management occurred in the absence of change in routine self-care maintenance behaviors, functional classification, and physical and psychological symptoms. Patients with greater physical symptoms at enrollment (odds ratio (OR) =1.04, p=0.037), larger left ventricles (OR=1.50, p=0.044), and ischemic heart failure (OR=3.84, p=0.014) were more likely to have the declining trajectory of self-care management. Higher levels of depression at enrollment were associated with reduced odds of having a decline in self-care management over time (OR=0.85, p<0.001).

CONCLUSIONS

There are unique and clinically-relevant trajectories of change in heart failure self-care management that are associated with differences in HRQOL.

Family caregivers of patients with heart failure: a longitudinal study

BACKGROUND

The family caregivers of patients with heart failure (HF) report burden and poor quality of life, but little is known about changes in their perceptions over time.

OBJECTIVES

The aims of this study were (1) to evaluate changes in caregiver burden (perceived time spent and difficulty with caregiving tasks), perceived control, depressive symptoms, anxiety, perceived life changes, and physical and emotional health-related quality of life; (2) to determine differences in perceptions between caregivers of patients with low HF symptoms (New York Heart Association class I and II) and caregivers of patients with high HF symptoms (New York Heart Association class III and IV); and (3) to the estimate time spent performing caregiving tasks.

METHODS

Sixty-three HF patients and 63 family caregivers were enrolled; 53 caregivers completed the longitudinal study. Data were collected from medical records and interviews conducted by advanced practice nurses at baseline and 4 and 8 months later.

RESULTS

Caregivers who completed the study had significant improvements in perceived time spent on and difficulty of caregiving tasks from baseline to 4 and 8 months, and depressive symptoms decreased from baseline to 8 months. Perceived life changes resulting from caregiving became more positive from baseline to 4 and 8 months. Perceived control, anxiety, and health-related quality of life did not change. Compared with caregivers of patients with low symptoms, caregivers of patients with high symptoms perceived that they spent more time on tasks and that tasks were more difficult, had higher anxiety, and had poorer physical health-related quality of life. Estimated time in hours spent providing care was high.

CONCLUSIONS

In this sample, perceptions of the caregiving experience improved over 8 months. Health-related quality of life was moderately poor over the 8 months. Caregivers of patients with more severe HF symptoms may be particularly in need of interventions to reduce time and difficulty of caregiving tasks and improve physical health-related quality of life.

Discrepancy between echocardiographic and patient-reported health status response to cardiac resynchronization therapy: results of the PSYHEART-CRT study

AIMS

The current study examined the degree of agreement between echocardiographic and patient-reported health status response to CRT 6 months after implantation, and evaluated the differences in pre-implantation characteristics of patients with concordant and discordant echocardiographic and health status responses.

METHODS AND RESULTS

Consecutively implanted CRT-defibrillator patients (n = 109, mean age = 65.4 ± 10.1 years, 74 men) were recruited from the University Medical Center Utrecht, The Netherlands. Prior to implantation and 6 months post-implantation, all patients underwent echocardiography and completed the Kansas City Cardiomyopathy Questionnaire (KCCQ). Echocardiographic response was defined as a relative reduction of ≥15% in LV end-systolic volume; an improvement of ≥10 points in KCCQ score indicated a health status response. In the 54 patients with discordant responses, 25 (22.9%) had an echocardiographic response but no health status response and 29 (26.6%) had a health status response but no echocardiographic response. Patients with concordant and discordant responses differed on various pre-implantation characteristics, including sex, employment status, LV volumes, and pre-implantation KCCQ score. In multivariable analysis, pre-implantation KCCQ score [odds ratio (OR) = 0.91, 95% confidence interval (CI) = 0.88-0.95, P < 0.001] and QRS duration (OR = 1.03, 95% CI = 1.01-1.06, P = 0.009) were the only characteristics associated with health status response to CRT.

CONCLUSIONS

Our results show a large discrepancy between echocardiographic and patient-reported health status response to CRT. The most important predictor of health status response was the pre-implantation health status score. These results emphasize that disease-specific health status measures may have additional value over 'objective' measures of CRT response and should be incorporated in clinical practice.

Comparable performance of the Kansas City Cardiomyopathy Questionnaire in patients with heart failure with preserved and reduced ejection fraction

BACKGROUND

Despite the growing epidemic of heart failure with preserved ejection fraction (HFpEF), no valid measure of patients' health status (symptoms, function, and quality of life) exists. We evaluated the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated measure of HF with reduced EF, in patients with HFpEF.

METHODS AND RESULTS

Using a prospective HF registry, we dichotomized patients into HF with reduced EF (EF≤ 40) and HFpEF (EF≥50). The associations between New York Heart Association class, a commonly used criterion standard, and KCCQ Overall Summary and Total Symptom domains were evaluated using Spearman correlations and 2-way ANOVA with differences between patients with HF with reduced EF and HFpEF tested with interaction terms. Predictive validity of the KCCQ Overall Summary scores was assessed with Kaplan-Meier curves for death and all-cause hospitalization. Covariate adjustment was made using Cox proportional hazards models. Internal reliability was assessed with Cronbach's α. Among 849 patients, 200 (24%) had HFpEF. KCCQ summary scores were strongly associated with New York Heart Association class in both patients with HFpEF (r=-0.62; P<0.001) and HF with reduced EF (r=-0.55; P=0.27 for interaction). One-year event-free rates by KCCQ category among patients with HFpEF were 0 to 25=13.8%, 26 to 50=59.1%, 51 to 75=73.8%, and 76 to 100=77.8% (log rank P<0.001), with no significant interaction by EF (P=0.37). The KCCQ domains demonstrated high internal consistency among patients with HFpEF (Cronbach's α=0.96 for overall summary and ≥0.69 in all subdomains).

CONCLUSIONS

Among patients with HFpEF, the KCCQ seems to be a valid and reliable measure of health status and offers excellent prognostic ability. Future studies should extend and replicate our findings, including the establishment of its responsiveness to clinical change.

Pre-operative health status and outcomes after continuous-flow left ventricular assist device implantation

BACKGROUND

Health status predicts adverse outcomes in heart failure and cardiac surgery patients, but its prognostic value in left ventricular assist device (LVAD) placement is unknown.

METHODS

We examined the association of pre-operative health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), with survival and hospitalization after LVAD using the KCCQ score as a continuous variable and stratified by KCCQ score quartile plus missing KCCQ in 1,125 clinical trial participants who received the HeartMate II (Thoratec Corp, Pleasanton, CA) as destination therapy (n = 635) or bridge to transplantation (n = 490).

RESULTS

The mean pre-operative KCCQ score was 29.4 ± 18.7 among survivors (n = 719), and 27.1 ± 18.3 (n = 406) in those who died. In time-to-event analysis for all available follow-up using health status as a continuous variable, the pre-operative KCCQ score did not correlate with overall mortality after LVAD implantation (p = 0.178). Small absolute differences were seen between the pre-operative KCCQ quartile and 30-day survival (Q4 95% vs. Q1 89% vs. missing 87%; p = 0.0009 for trend), 180-day survival (Q4 83% vs. Q1 76% vs missing 79%; p = 0.060 for trend), and days hospitalized at 180 days (Q4 29.8 ± 25.6 vs. Q1 34.1 ± 27.1 vs. missing 36.5 ± 29.9 days; p = 0.009 for trend).

CONCLUSION

Our findings suggest that pre-operative health status has limited association with outcomes after LVAD implantation. Although these data require further study in a diverse population, mechanical circulatory support may represent a relatively unique clinical situation, distinct from heart failure and other cardiac surgeries, in which heart failure-specific health status measures may be largely reversed.

Effect of psychosocial interventions on quality of life in patients with chronic heart failure: a meta-analysis of randomized controlled trials

BACKGROUND

Patients with chronic heart failure (CHF) usually experience poor quality of life (QoL). Psychosocial interventions tend to affect QoL in CHF. The aim of this study was to explore: 1) the effectiveness of psychosocial interventions on patients' QoL; 2) the magnitude of this effect; and 3) factors that appear to moderate the reported effect on QoL.

METHODS AND RESULTS

Meta-analysis of the data of 1,074 intervention patients and 1,106 control patients from 16 randomized controlled trials (RCTs) that reported QoL measures in treatment and control groups before and after a psychosocial intervention. Subgroup analyses were conducted between: 1) face-to-face versus telephone interventions; 2) interventions that included only patients versus those that included patients and their caregivers; and 3) interventions conducted by a physician and a nurse only, versus those conducted by a multidisciplinary team. Psychosocial interventions improved QoL of CHF patients (standardized mean difference 0.46, confidence interval [CI] 0.19-0.72; P < .001). Face-to-face interventions showed greater QoL improvement compared with telephone interventions (χ(2) = 5.73; df = 1; P < .02). Interventions that included caregivers did not appear to be significantly more effective (χ(2) = 1.12; df = 1; P > .29). A trend was found for multidisciplinary team approaches being more effective compared with nonmultidisciplinary approaches (χ(2) = 1.96; df = 1; P = .16).

CONCLUSIONS

A significant overall QoL improvement emerged after conducting psychosocial interventions with CHF patients. Interventions based on a face-to-face approach showed greater benefit for patients' QoL compared with telephone-based approaches. No significant advantage was found for interventions conducted by a multidisciplinary team compared with a physician and nurse approach, or for psychosocial interventions which included patients' caregivers compared with patient-only approaches.

End points for comparative effectiveness research in heart failure

CER for heart failure continues to evolve, including its assessment of end points. Reliance on surrogate end points is unacceptable as a means of definitively establishing comparisons of clinical effectiveness. CER needs to focus on measures that clearly reflect clinical effectiveness and safety, not just survival but also standardized assessments of health status and detailed resource utilization, and it must do so in a standardized way to allow for comparison. This strategy almost certainly requires increased reliance on prospective studies with proactive end-point capture, preferably in the setting of randomized allocation of the interventions being compared.

Patient-reported selective adherence to heart failure self-care recommendations: a prospective cohort study: the Atlanta Cardiomyopathy Consortium

Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described. Patient-reported adherence to 8 recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0="never" to 5="always," maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence. The mean follow-up was 2.0±1.0 years, and adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs 107.6; P=.018; HF 29.6 vs 43.8; P=.007) and hospitalized days (all-cause 422 vs 465; P=.015; HF 228 vs 282; P<.001) per 100-person-years and better health status (KCCQ overall score 70.1±24.6 vs 63.8±22.8; P=.011). Adherence was not associated with clinical events or functional capacity. Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.

End-point selection for acute heart failure trials

The appropriate selection of response variables for clinical trials of new therapies for acute heart failure (AHF) is a complex process with major trade-offs. For one therapeutic approach to be considered superior to another, it must produce clinically significant improvements in making patients live longer, making patients feel better, or saving resources without adversely affecting these two goals. This review outlines factors that complicate AHF end-point selection, discusses a variety of end points used in recently completed and ongoing AHF studies, and suggests directions for future design and standardization of end points across AHF trials.

Identifying patients hospitalized with heart failure at risk for unfavorable future quality of life

BACKGROUND

Communicating prognosis to enable shared decision-making is strongly endorsed by heart failure (HF) guidelines. Patients are concerned with both their quantity and quality of life (QoL). To facilitate the recognition of patients at high risk for unfavorable future QoL or death, we created a simple prognostic tool to estimate this combined outcome.

METHODS AND RESULTS

We identified factors associated with 6-month mortality or persistently unfavorable QoL, defined by Kansas City Cardiomyopathy Questionnaire (KCCQ) scores <45 at 1 and 24 weeks after hospital discharge, among 1458 patients from the Efficacy of Vasopressin Antagonism in HF Outcome Study with Tolvaptan (EVEREST). Within 24 weeks of discharge, 478 (32.8%) patients had died and 192 (13.2%) patients had serial KCCQ scores <45. After adjusting for 23 predischarge covariates, independent predictors of the combined end point included low admission KCCQ score, high B-type natriuretic peptide, hyponatremia, tachycardia, hypotension, absence of β-blocker therapy, and history of diabetes mellitus and arrhythmia. A simplified predischarge HF score for subsequent death or unfavorable QoL had moderate discrimination (c-statistic 0.72). Predischarge clinical covariates were substantially different in predicting the QoL end point as compared with traditional death or rehospitalization end points.

CONCLUSIONS

At the time of hospital discharge, readily available clinical characteristics are associated with HF patients at high risk for persistently unfavorable QoL or death over the next 6 months. Such information can target patients for whom aggressive treatment options (eg, devices or transplantation) and/or end-of-life discussions should be strongly considered before hospital discharge.

Outcomes associated with anemia in patients with heart failure

Over the past decade, a growing body of literature has led to a greater understanding of the relationship between anemia and the outcomes in patients with heart failure. This article reviews the current literature on the association between anemia and a broad range of clinical outcomes, including mortality, hospitalization, health status, and cost.

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Echocardiographic dyssynchrony and health status outcomes from cardiac resynchronization therapy: insights from the PROSPECT trial

OBJECTIVES

This study sought to assess the prognostic utility of echocardiographic dyssynchrony for health status improvement after cardiac resynchronization therapy (CRT).

BACKGROUND

Echocardiographic measures of dyssynchrony have been proposed for patient selection for CRT, but prospective validation studies are lacking.

METHODS

A prospective cohort of 324 patients from 53 centers with moderate to severe heart failure, left ventricular dysfunction, QRS > or =130 ms, and available echocardiographic and health status information were identified from the PROSPECT (Predictors of Response to Cardiac Re-Synchronization Therapy) trial, which evaluated the prognostic utility of dyssynchrony measures in CRT recipients. The association of 12 echocardiographic dyssynchrony parameters with 6-month improvement in health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), was assessed both as a continuous variable and by responder status (DeltaKCCQ > or =+10 points reflecting moderate to large improvement).

RESULTS

Of 12 pre-defined dyssynchrony parameters, only 3 were consistently reported: interventricular mechanical delay (IVMD), left ventricular filling time relative to the cardiac cycle (LVFT), and left ventricular pre-ejection interval. After multivariable adjustment, IVMD (+5.18, 95% confidence interval [CI]: +0.76 to +9.60; p = 0.02) and LVFT (+5.19, 95% CI: +0.45 to +0.94; p = 0.03) were independently associated with 6-month improvements in KCCQ. Patients with 6-month improvements in KCCQ had lower subsequent mortality (adjusted hazard ratio [HR] for each 5-point improvement: 0.83; 95% CI: 0.72 to 0.93; p = 0.03). Additionally, IVMD was associated with CRT responder status (for DeltaKCCQ > or =+10 points: odds ratio [OR]: 1.85; 95% CI: 1.12 to 3.05; p = 0.03), whereas LVFT was not (OR: 1.63; 95% CI: 0.85 to 3.11; p = 0.14). Patients classified as health status responders had a 76% lower subsequent risk of all-cause mortality (adjusted HR: 0.24; 95% CI: 0.07 to 0.84; p = 0.03).

CONCLUSIONS

The presence of pre-implantation IVMD and LVFT was associated with 6-month health status improvement, and IVMD was associated with a significant CRT response. These echocardiographic factors may help clinicians counsel patients regarding their likelihood of symptomatic improvement with CRT. (

PROSPECT

Predictors of Response to Cardiac Re-Synchronization Therapy; NCT00253357).

Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction

BACKGROUND

The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF).

METHODS

A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality.

RESULTS

There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive.

CONCLUSIONS

As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Health-related quality of life and long-term mortality in patients treated with percutaneous coronary intervention

BACKGROUND

Health status has become increasingly important as an outcome measure in patients with cardiovascular disease. Poor patient-rated health status has been shown to predict mortality in patients with coronary artery disease and heart failure. In patients treated with percutaneous coronary intervention (PCI), we examined whether poor health status predicts 6-year mortality and whether a decline in health status is associated with adverse clinical outcome.

METHODS

Consecutive patients (N = 872) treated with PCI as part of the RESEARCH registry, completed the 36-item Short-Form Health Survey (SF-36) at 1 and 12 months post-PCI.

RESULTS

The SF-36 domains physical functioning (hazard ratio [HR] 2.59, 95% CI 1.61-4.16), social functioning (HR 2.76, 95% CI 1.74-4.37), role limitations due to physical functioning (HR 2.45, CI 1.52-3.92), mental health (HR 2.12, 95% CI 1.35-3.31), vitality (HR 1.73, 95% CI 1.09-2.74), bodily pain (HR 2.25, 95% CI 1.43-3.54), and general health (HR 2.46, 95% CI 1.57-3.87) were associated with 6-year mortality. A decline in health status was not related with higher 6-year mortality.

CONCLUSIONS

Health status domains as measured with the SF-36 predicted death at 6-year follow-up in PCI patients treated with drug-eluting stenting, independent of demographic and clinical characteristics. In contrast, a decline in health status between 1 and 12 months post index procedure, as measured with the SF-36, was not associated with 6-year mortality in PCI patients treated with drug-eluting stenting.

Outcomes, health policy, and managed care: relationships between patient-reported outcome measures and clinical measures in outpatients with heart failure

BACKGROUND

Patient-reported outcomes are increasingly used to assess the efficacy of new treatments. Understanding relationships between these and clinical measures can facilitate their interpretation. We examined associations between patient-reported measures of health-related quality of life and clinical indicators of disease severity in a large, heterogeneous sample of patients with heart failure.

METHODS

Patient-reported measures, including the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQol Visual Analog Scale (VAS), and clinical measures, including peak VO(2), 6-minute walk distance, and New York Heart Association (NYHA) class, were assessed at baseline in 2331 patients with heart failure. We used general linear models to regress patient-reported measures on each clinical measure. Final models included for significant sociodemographic variables and 2-way interactions.

RESULTS

The KCCQ was correlated with peak VO(2) (r = .21) and 6-minute walk distance (r = .27). The VAS was correlated with peak VO(2) (r = .09) and 6-minute walk distance (r = .11). Using the KCCQ as the response variable, a 1-SD difference in peak Vo(2) (4.7 mL/kg/min) was associated with a 2.86-point difference in the VAS (95% CI, 1.98-3.74) and a 4.75-point difference in the KCCQ (95% CI, 3.78-5.72). A 1-SD difference in 6-minute walk distance (105 m) was associated with a 2.78-point difference in the VAS (95% CI, 1.92-3.64) and a 5.92-point difference in the KCCQ (95% CI, 4.98-6.87); NYHA class III was associated with an 8.26-point lower VAS (95% CI, 6.59-9.93) and a 12.73-point lower KCCQ (95% CI, 10.92-14.53) than NYHA class II.

CONCLUSIONS

These data may inform deliberations about how to best measure benefits of heart failure interventions, and they generally support the practice of considering a 5-point difference on the KCCQ and a 3-point difference on the VAS to be clinically meaningful.

Percutaneous mitral annuloplasty for functional mitral regurgitation: results of the CARILLON Mitral Annuloplasty Device European Union Study

BACKGROUND

Functional mitral regurgitation (FMR), a well-recognized component of left ventricular remodeling, is associated with increased morbidity and mortality in heart failure patients. Percutaneous mitral annuloplasty has the potential to serve as a therapeutic adjunct to standard medical care.

METHODS AND RESULTS

Patients with dilated cardiomyopathy, moderate to severe FMR, an ejection fraction <40%, and a 6-minute walk distance between 150 and 450 m were enrolled in the CARILLON Mitral Annuloplasty Device European Union Study (AMADEUS). Percutaneous mitral annuloplasty was achieved through the coronary sinus with the CARILLON Mitral Contour System. Echocardiographic FMR grade, exercise tolerance, New York Heart Association class, and quality of life were assessed at baseline and 1 and 6 months. Of the 48 patients enrolled in the trial, 30 received the CARILLON device. Eighteen patients did not receive a device because of access issues, insufficient acute FMR reduction, or coronary artery compromise. The major adverse event rate was 13% at 30 days. At 6 months, the degree of FMR reduction among 5 different quantitative echocardiographic measures ranged from 22% to 32%. Six-minute walk distance improved from 307+/-87 m at baseline to 403+/-137 m at 6 months (P<0.001). Quality of life, measured by the Kansas City Cardiomyopathy Questionnaire, improved from 47+/-16 points at baseline to 69+/-15 points at 6 months (P<0.001).

CONCLUSIONS

Percutaneous reduction in FMR with a novel coronary sinus-based mitral annuloplasty device is feasible in patients with heart failure, is associated with a low rate of major adverse events, and is associated with improvement in quality of life and exercise tolerance.

The relationship between self-care and health status domains in Thai patients with heart failure

BACKGROUND

Little is known about the relationship between self-care in heart failure (HF) and outcomes like health status. The purpose of this study was to describe the relationship between HF self-care and Short Form-36 (SF-36) health status domains.

METHODS AND RESULTS

A secondary analysis of cross-sectional data collected on 400 HF patients living in southern Thailand was completed using bivariate comparisons and hierarchical multiple regression modeling. Thai population norm-based SF-36 scores and Self-Care of Heart Failure Index (SCHFI) scores were used in the analysis. The sample was in older adulthood (65.7 +/- 13.8 years), a slight majority of subjects were male (52%); the majority of subjects (62%) had class III or IV HF. Each health domain was low in this sample compared to the general population. SCHFI maintenance and confidence scores were correlated significantly with each health status domain. SCHFI scores explained a significant amount of variance all domains, both in bivariate and multivariate models, except social functioning. In multivariate models, higher levels of self-care were associated with better health in certain domains, but only when both SCFHI management and confidence were high.

CONCLUSION

Improving HF self-care may be a mechanism through which future interventions can improve health in this population.

Self-assessment of health status is associated with inflammatory activation and predicts long-term outcomes in chronic heart failure

AIMS

Clinicians lack a generally accepted means for health status assessment in chronic heart failure (CHF). We investigated the correlation between health status and inflammation burden as well as its long-term prognostic value in CHF outpatients.

METHODS AND RESULTS

Kansas City Cardiomyopathy Questionnaires (KCCQ) were completed by 137 CHF outpatients (aged 64+/-12 years, mean ejection fraction 27+/-7%). Inflammatory markers [interleukin (IL)-6, IL-10, TNF-alpha, soluble Fas, Fas ligand, ICAM-1, VCAM-1], plasma B-type natriuretic peptide (BNP), 6 min walk test (6MWT), Zung self-rating depression scale, and Beck Depression Inventory were also assessed. Patients were followed for major cardiovascular events (death or hospitalization for disease progression) for up to 250 days. Patients with worse KCCQ-summary (KCCQ-s<50) score had lower 6MWT (P<0.05), and higher BNP (P<0.05) and pro-inflammatory markers (P<0.05) than those with KCCQ-s>or=50. Worse health status was also associated with shorter event-free survival (115+/-12 days for KCCQ-s<50 vs. 214+/-15 days for KCCQ-s>or=50, P=0.0179). Separating patients according KCCQ-functional score (KCCQ-f, cut-off 50) showed similar results. In multivariate Cox regression analysis, only LVEF (HR=0.637, 95% CI 0.450-0.900, P=0.011) and KCCQ-f (HR=0.035, 95% CI 0.002-0.824, P=0.037) were independent predictors of event-free survival at 250 days.

CONCLUSION

KCCQ-s reflects neurohormonal and inflammatory burden in CHF. Among studied questionnaires, only KCCQ-f is an independent predictor of long-term event-free survival in CHF.

Health status as a risk factor in cardiovascular disease: a systematic review of current evidence

BACKGROUND

Patient-perceived health status is receiving increased recognition as a patient-centered outcome in chronic heart failure (CHF) and coronary artery disease (CAD), but poor health status is also associated with adverse prognosis. In this systematic review, we examined current evidence on the influence of health status on prognosis in CHF and CAD.

METHODS

We conducted a search of PubMed using a set of a priori-defined search terms, the Web of Science for newly cited articles, and the reference lists of eligible articles, resulting in 34 articles.

RESULTS

Poor physical health status was a significant predictor for adverse health outcomes in patients with CHF and CAD. In CHF, poor physical health status seemed to be a stronger predictor of hospitalization than mortality. Little evidence was found that poor mental health status is associated with adverse prognosis in CHF and CAD. A disease-specific measure was a better predictor in CHF, but not in CAD. The majority of studies adjusted for an objective measure of disease severity. Neither the index event nor time to follow-up appeared to influence the predictive value of health status.

CONCLUSIONS

Poor physical health status is associated with adverse CAD and CHF prognosis. Heterogeneity across studies makes definitive conclusions difficult as to which components of health status may be detrimental to patients' health, and how health status as a potential risk factor should be assessed, monitored, and intervened upon in clinical practice.

Evolving applications for patient-centered health status measures

Patient-centered health status measures-assessments of patients' symptoms, function, and quality of life-have matured substantially over the past 2 decades. Currently, valid, reliable, and sensitive disease-specific measures are available for quantifying the health status of patients with cardiovascular disease. This article briefly reviews the concept of health status measures, with a focus on their interpretation. It then discusses both the rationale and potential applications of health status measures in clinical care. Health status measures are not surrogate measures of outcome but rather highly meaningful outcomes of care. As such, they have important emerging roles as outcomes in clinical trials, as tools for monitoring patients in routine clinical care, as a mechanism for operationalizing and evaluating disease management programs, and as tools for quality assessment/improvement. Over time, it is expected that health status measures will also have an increasingly important role in patient-centered medical decision making. By becoming aware of the evolving roles of health status measures, clinicians can help to accelerate the realization of the Institute of Medicine's vision for a more transparent, evidence-based, patient-centered healthcare system.

Health-related quality of life in unselected outpatients with heart failure across Spain in two different health care levels. Magnitude and determinants of impairment: the INCA study

AIMS

To assess health-related quality of life (HRQL) in Spanish outpatients with chronic heart failure (CHF).

METHODS

Cross-sectional study carried out in a sample of CHF patients (echocardiography was performed in all of them) followed either in Primary Care (PC) centres or Cardiology outpatient clinics throughout Spain. HRQL was evaluated using the EuroQol 5D (EQ-5D) and Minnesota Living with Heart Failure (MLWHF) Questionnaire.

RESULTS

The study subjects were 2161 CHF patients (1412 PC; 749 Cardiology). Patients were older and had more severe disease in PC than in Cardiology settings. Their HRQL scores were likewise worse. After adjusting for clinical variables, the differences in global and physical MLWHF disappeared, but persisted to a smaller degree in EQ-5D and mental MLWHF. HRQL was worse than in a representative sample of the Spanish population and in other chronic conditions such as rheumatoid arthritis or type 2 diabetes, being only comparable to severe chronic obstructive pulmonary disease (COPD).

CONCLUSION

All domains of HRQL were significantly impaired in CHF patients. Differences found in HRQL between PC and Cardiology should possibly be attributed to a large extent to the different clinical characteristics of the patients attended. In spite of the differences between EQ-5D and MLWHF, our results suggest that both questionnaires adequately reflect the severity of the disease.

Physician attitudes toward end-stage heart failure: a national survey

BACKGROUND

Despite recent improvements in medical therapies, heart failure remains a prevalent condition that places significant burdens on providers, patients, and families. However, there is a paucity of data published describing physician beliefs about heart failure management, especially in its advanced stages.

METHODS

In order to better understand physician decision-making in end-stage heart failure, we used a stratified random sampling of physicians obtained from the Master File of the American Medical Association to survey cardiologists (n=600), geriatricians (n=250), and internists/family practitioners (n=600).

RESULTS

Response rate was 59.6% (highest among geriatricians). The vast majority (>90%) of respondents cited similarities between the clinical trajectory of end-stage heart failure and lung cancer or chronic obstructive pulmonary disease; however, only 15.7% stated that they could predict death at 6 months "most of the time" or "always." Inpatient volume was a predictor of confidence in predicting mortality (odds ratio=1.38, 95% confidence interval, 1.36-1.40). Less than one quarter of respondents formally measure quality of life. The experience with deactivation of implantable cardioverter defibrillators was limited: 59.8% of cardiologists, 88.0% of geriatricians, and 95.1% of internal medicine/family practice physicians have had 2 or fewer conversations with patients and families about this option.

CONCLUSIONS

Significant gaps in knowledge about and experience with end-stage heart failure exist among a large proportion of physicians. The growing prevalence and highly symptomatic nature of heart failure highlight the need to further evaluate and improve the way in which care is delivered to patients dying from the disease.

Validity, reliability, and responsiveness of the Kansas City Cardiomyopathy Questionnaire in anemic heart failure patients

BACKGROUND

While generic health status measures quantify the impact of all patients' diseases on their health-related quality of life, disease specific measures focus on only one of the many conditions that a patient may have. If a patient has two diseases with similar clinical manifestations, they may respond differently to a disease-specific instrument if one of their conditions improves while the other worsens or remains stable, thus undermining the instruments in that patient population. We sought empirical evidence of the reliability and validity (including responsiveness) of the Kansas City Cardiomyopathy Questionnaire (KCCQ), a disease-specific measure for heart failure (HF), among HF patients with and without anemia, a condition that has similar symptoms to HF.

METHODS

This work used a prospective cohort study of 811 HF outpatients from 58 U.S. centers with a baseline assessment of anemia of whom 698 were followed for 3 months with serial health status measures.

RESULTS

Among participants, 268 (33%) were anemic. The construct validity of the KCCQ was supported by showing similar correlations with the New York Heart Association (NYHA) classification in patients with and without anemia (P value for interaction = 0.38). The internal consistency (Cronbach's alpha = 0.92 and 0.93 for anemic and non-anemic patients, respectively) and test-retest reliability (mean 3-month change scores in stable patients = -2.8 [SD = 1.4] and -0.5 [SD = 0.8], P = 0.14) were similar. Estimates of responsiveness were also similar.

CONCLUSION

This study provides empirical evidence that the psychometric properties of the KCCQ are similar in patients with or without anemia, a potentially confounding clinical condition in patients with heart failure.