Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease

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.

Clinical relevance of frailty trajectory post myocardial infarction

BACKGROUND

Frailty describes the heterogeneity of vulnerability in older people and has been shown to predict mortality, disability, and institutionalization. Little is known about the clinical relevance of frailty post myocardial infarction (MI).

DESIGN

The Rockwood frailty index, based on accumulation of deficits, was adapted in a cohort of MI survivors followed up for 20 years, in order to assess trajectory and predictive value for clinical outcomes.

METHODS

Participants were 1521 patients aged ≤65 years admitted to one of eight Israeli hospitals with first acute MI between 1992 and 1993. A frailty index (on a 0-1 continuous scale) was developed comprising 32 variables, including self-rated health, functional limitations, comorbidity, weight loss, and physical activity. Frailty was assessed at baseline and 10-13 years after MI.

RESULTS

Median frailty score increased from 0.08 to 0.19 during follow up. Participants in the frailest group (≥0.25) at baseline had twice the multivariable-adjusted mortality risk of those in the least frail group (<0.10) (hazard ratio, HR, 2.02, 95% CI 1.46-2.79). Frailty index modelled as a time-dependent variable showed a substantially stronger association (HR 3.61, 95% CI 2.82-4.63) and provided incremental value in risk discrimination beyond clinical and socio-demographic variables (p < 0.001 for improvement in c-statistic). The frailest patients were more than twice as likely to be hospitalized during follow up compared to the least frail (adjusted rate ratio 2.14, 95% CI 1.63-2.81).

CONCLUSIONS

Frailty, calculated via an index of deficits, was associated with mortality and hospitalizations following MI. Beyond predictive value, accurate identification of frailty may indicate which individuals will benefit most from preventive interventions.

Targeted intervention improves knowledge but not self-care or readmissions in heart failure patients with mild cognitive impairment

AIMS

Mild cognitive impairment (MCI) is prevalent in heart failure, and can contribute to poor self-care and higher hospital readmissions. Strategies to improve self-care in patients with MCI have not been studied. This randomized controlled trial aimed to test the effect of a targeted intervention on self-care, heart failure knowledge, and 30-day readmissions.

METHODS AND RESULTS

The study included 125 patients hospitalized for exacerbation of heart failure who screened positive for MCI. The treatment group received a targeted self-care teaching intervention using principles of cognitive training. Self-care, heart failure knowledge, depression, and social support were assessed at baseline and 30 days post-discharge. Mean heart failure knowledge scores improved significantly in the intervention group, but decreased in the control group (P < 0.001). When controlling for other variables, patients in the intervention group showed a greater increase in heart failure knowledge than patients in the control group (P = 0.027). Black race was significantly associated with lower heart failure knowledge scores (P = 0.030). Mean change scores for self-care showed greater improvement in the intervention group when compared with the control group; however, this was not statistically significant. There was no difference in readmission rates between the groups.

CONCLUSION

It is feasible to conduct a randomized controlled trial in patients with MCI. Patients in the treatment group had greater heart failure knowledge at 30 days post-discharge; however, this did not impact readmission rates. Further research is needed to describe how MCI affects self-care and knowledge, and how race and other factors may influence outcomes in this population.

Cognitive-behavioral therapy for chronic cardiopulmonary conditions: preliminary outcomes from an open trial

OBJECTIVE

To examine the effectiveness of tailored cognitive-behavioral therapy (CBT) for veterans with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) with comorbid symptoms of depression and/or anxiety.

METHOD

Twenty-three veterans with CHF and/or COPD, identified from electronic medical records at a large Veterans Affairs medical center, with clinically significant symptoms of depression (Beck Depression Inventory-II [BDI-II] score ≥ 14) and/or anxiety (State Trait Anxiety Inventory [STAI] score ≥ 40) were enrolled in an open trial from August 2007 to August 2008. All patients received CBT delivered mostly by advanced psychology trainees that consisted of 6 weekly sessions and 3 telephone booster calls. The intervention expanded traditional CBT techniques in order to address patients' emotional and physical health difficulties using in-person and telephone-based sessions. Outcomes examined depression (BDI-II), anxiety (STAI), and disease-specific quality of life (Chronic Respiratory Questionnaire [CRQ] and Kansas City Cardiomyopathy Questionnaire [KCCQ]) postintervention and at 3-month follow-up.

RESULTS

Symptoms of depression (effect size = 0.97) and anxiety (effect size = 0.57) were improved at 8 weeks and maintained at 3-month follow-up. Physical disease outcomes were also improved for COPD (CRQ mastery effect size = 0.65, CRQ fatigue effect size = 0.75) and CHF (KCCQ overall summary score effect size = 1.19).

CONCLUSIONS

Modifications to traditional CBT approaches have the potential to address the emotional and physical health challenges associated with complex cardiopulmonary patients. The brief duration and use of telephone-based sessions increase the opportunity for CBT interventions to be integrated within primary care settings, but additional trials are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00727155.

Personal characteristics predictive of depressive symptoms in Hispanics with heart failure

Depression is a significant problem in heart failure (HF). The purposes of this study were to assess the prevalence of depressive symptoms in Hispanics with HF and to examine the personal characteristics predicting depressive symptoms at baseline and at 6-months follow-up in a telephone case management intervention. In this secondary data analysis based on 87 subjects, patient characteristics hypothesized to influence depressive symptoms included age, gender, education, living situation, co-morbidity, social support, New York Heart Association (NYHA) class, and acculturation. DSM-IV major depression was present in 39.1% (n = 35) of the participants at baseline and 1.1% (n = 1) at the 6-month follow-up. In regression analysis, factors associated with depressive symptoms at baseline were gender and NYHA class. At 6-month follow-up, acculturation, co-morbidity, and NYHA were significantly related to the presence of depressive symptoms. Depressive symptoms were highly prevalent in Hispanics with HF. Easily identifiable personal characteristics can be useful in designing interventions to reduce depression associated with HF.

Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee

Cardiac resynchronization therapy (CRT) improves survival, symptoms, quality of life, exercise capacity, and cardiac structure and function in patients with New York Heart Association (NYHA) functional class II or ambulatory class IV heart failure (HF) with wide QRS complex. The totality of evidence supports the use of CRT in patients with less severe HF symptoms. CRT is recommended for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block (RBBB) who have severe left ventricular (LV) systolic dysfunction and persistent NYHA functional class II-III symptoms despite optimal medical therapy (strength of evidence A). CRT may be considered for several other patient groups for whom evidence of benefit is clinically significant but less substantial, including patients with a QRS interval of ≥120 to <150 ms and severe LV systolic dysfunction who have persistent mild to severe HF despite optimal medical therapy (strength of evidence B), some patients with atrial fibrillation, and some with ambulatory class IV HF. Several evidence gaps remain that need to be addressed, including the ideal threshold for QRS duration, QRS morphology, lead placement, degree of myocardial scarring, and the modality for evaluating dyssynchrony. Recommendations will evolve over time as additional data emerge from completed and ongoing clinical trials.

Reliability and validity of the Korean version of the Minnesota Living with Heart Failure Questionnaire

OBJECTIVE

The aim of this study was to verify the reliability and validity of the Korean language version of the Minnesota Living with Heart Failure Questionnaire (MLHFQ) before using this version in clinical practice to assess the quality of care in patients with heart failure in a cardiology clinic.

METHODS

The Korean versions of the MLHFQ, 36-Item Short Form Health Survey, and Center for Epidemiologic Studies Depression Scale were administered to evaluate the psychometric properties among 154 patients with heart failure in a major cardiac center in Korea. Cardiac function was assessed by evaluating left ventricular ejection fraction values, N-terminal pro-brain natriuretic peptide levels, and New York Heart Association classifications.

RESULTS

The questionnaire content and construct validity were supported by factor analysis. Three factors explained 70.7% of the variance. Total and subtotal scales had correlations with the mental and physical component scores of the 36-Item Short Form Health Survey and Center for Epidemiologic Studies Depression Scale, supporting the convergent validity of the Korean version of the MLHFQ. We also found that the New York Heart Association classification was associated with the MLHFQ score. The internal consistency of both total and subtotal scales was greater than .80.

CONCLUSION

The Korean version of the MLHFQ demonstrated excellent psychometric properties. These results support the use of the MLHFQ in Korean patients with heart failure. Further studies are recommended to assess the responsiveness to change of the Korean version of the MLHFQ.

Social status, health-related quality of life, and event-free survival in patients with heart failure

BACKGROUND

Social status may impact health-related quality of life (HRQOL), hospitalization, and mortality in patients with heart failure (HF).

PURPOSE

To determine if social status was associated with HRQOL and event-free survival.

HYPOTHESES

Higher social status (quality of perceived support, emotional support, marital status, and economic status) is related to better HRQOL and event-free survival after controlling covariates (New York Heart Association [NYHA] functional class, comorbidity status, and age).

METHODS

Patients (N = 147, 61 ± 11 years old, 70% male, 62% NYHA class III/IV) provided data on HRQOL (measured by the Minnesota Living with Heart Failure questionnaire) and social status. Event-free survival data were collected by medical record reviews and patient or family interviews. Hierarchical regression analysis and survival analysis were used to test the hypothesis.

RESULTS

Better quality of perceived support, better economic status, better functional status, older age, and less comorbidity were related to better HRQOL (R2 = .365, p = <.001). Only economic status predicted event-free survival.

CONCLUSION

Attention should be given to those who have lower social support to improve HRQOL and those who have lower economic status to improve event-free survival.

Capacidade funcional de indivíduos com insuficiência cardíaca avaliada pelo teste de esforço cardiopulmonar e classificação da New York Heart Association

O objetivo deste estudo foi avaliar a capacidade discriminativa da classificação da New York Heart Association (NYHA) em indivíduos com insuficiência cardíaca (IC) classes II e III por meio de variáveis do teste de esforço cardiopulmonar (TECP). Participaram do estudo 17 pessoas com IC classe II (44,47±10,11 anos; fração de ejeção ventricular 32,11±10,37%) e 15 classe III (46,73±8,74 anos; fração de ejeção ventricular 30,46±10,23%) da NYHA que realizaram TECP máximo em esteira ergométrica. De acordo com a distribuição dos dados, houve correlação de Pearson ou Spearman e, para comparação entre classes, utilizou-se o teste t de Student. Foram encontradas correlações significativas (p<0,05) entre consumo de oxigênio (VO2) e pulso de oxigênio (r=0,76), idade (r=0,35) e índice de massa corpórea (r=0,45). Não houve correlação significativa entre fração de ejeção ventricular e as demais variáveis estudadas. Comparando as classes da NYHA, foram encontradas diferenças para VO2 e pulso de oxigênio (p<0,05). Nesta pesquisa, as correlações refletem a complexidade de se analisar e entender o processo de disfunção da IC, considerando que provavelmente há outros fatores influenciando cada uma das variáveis estudadas. A classificação da NYHA foi efetiva na diferenciação dos indivíduos nos diferentes grupos, reforçando sua utilidade na caracterização de grupos de indivíduos com IC para fins de pesquisas científicas, assim como para avaliação de terapêuticas.

New York Heart Association class assessment by cardiologists and outpatients with congenital cardiac disease: a head-to-head comparison of three patient-based versions

BACKGROUND

The objective of this study was to compare three patient-based New York Heart Association assessments with cardiologist assessments in outpatients with congenital cardiac disease.

METHODS

Consecutive adult outpatients completed three questionnaires in a random order: a patient-based translation of the New York Heart Association classes, a self-constructed questionnaire based on the New York Heart Association classes, and the Specific Activity Scale. The treating cardiologist assessed the New York Heart Association class on the same day. Patient-cardiologist agreement was assessed by calculating percent agreement and weighted kappa. We also explored the level of agreement for patients without co-morbidity.

RESULTS

In all, 86 adults--with a median age of 35.8 years--including 46 women participated. An agreement of 75.6% (weighted kappa is 0.43; probability is smaller than 0.01), 70.6% (weighted kappa is 0.44; probability is smaller than 0.01), and 74.4% (weighted kappa is 0.28; probability is smaller than 0.01) was found between the cardiologist assessment and the patient-based translation, self-constructed questionnaire, and the Specific Activity Scale, respectively. The patient-based translation equally over- and underestimated the New York Heart Association class, whereas the self-constructed questionnaire overestimated and the Specific Activity Scale underestimated the New York Heart Association class. Agreement levels for patients without co-morbidity were higher than agreement levels for the total group.

CONCLUSION

The patient-based translation yielded adequate agreement with cardiologist-assessed New York Heart Association class, showed equal over- and underestimation, and was easy to complete. The patient-based translation with the instruction to only consider functional impairments caused by the congenital cardiac defect is recommended in future studies of outpatients with congenital cardiac disease.

Patient-physicians' information exchange in outpatient cardiac care: time for a heart to heart?

OBJECTIVE

Agreement between patients and physicians is an indicator of successful communication. Concordance in domains of communication among patients with heart disease and communication barriers has not been studied.

METHODS

English, Spanish, or Cantonese-speaking patients seen at a public hospital cardiology clinic were assessed with pre-visit questionnaires. Surveys of patients and their physicians immediately after the visit asked each about: (1) cardiac functional status, (2) barriers to self-management, (3) cardiac diagnoses, and (4) treatment. We assessed patient-physician concordance in these domains.

RESULTS

179 patients and 56 physicians completed the study. Patients had low educational attainment, limited literacy and limited English proficiency. Physicians underestimated patients' cardiac functioning status (NYHA Classes 2-4), by 1 class or more in 50% of visits. Physicians were frequently unaware of medication (38/57, 67%) and psychosocial (61/88, 69%) barriers. Patients were unable to describe even 1 matching diagnosis (72/170, 42% concordant) among 5 categories. Physicians' reported medication changes in 106/179 (59%) but patients failed to report these changes in 55% (58/106). Multivariate logistic regression analyses showed no significant association between patient characteristics and concordance.

CONCLUSION

Patients and physicians often fail to communicate effectively and determinants of concordance in CVD care require further investigation.

PRACTICE IMPLICATIONS

Developing strategies to improve communication within the medical encounter are critical to improving ambulatory chronic disease management.

Caregiving for patients with heart failure: impact on patients' families

BACKGROUND

Factors that affect the impact of caregiving on patients' family members who provide care to patients with heart failure have not been adequately addressed. In addition, social support and positive aspects of caregiving have received little attention.

OBJECTIVE

To identify factors associated with the impact of caregiving.

METHODS

Self-report data were collected from 76 dyads of patients with heart failure and their family caregivers. Clinical data were obtained from medical records.

RESULTS

A sense of less family support for caregiving was associated with a higher New York Heart Association class of heart failure, being a nonspousal caregiver, lower caregivers' perceived control, and less social support. More disruption of caregivers' schedules was associated with higher class of heart failure, more care tasks, and less social support. Greater impact of caregiving on caregivers' health was related to more recent patient hospitalization, lower caregivers' perceived control, and less social support. Nonwhite caregivers and caregivers whose family member had fewer emergency department visits felt more positive about caregiving than did other caregivers. Social support had a moderating effect on the relationship between patients' comorbid conditions and positive aspects of caregiving.

CONCLUSIONS

Caregiving has both positive and negative effects on family caregivers of patients with heart failure. The findings suggest the need for interventions to increase caregivers' sense of control and social support. Family caregivers may need additional support immediately after patient hospitalizations to minimize the negative impact of caregiving.

Particle-associated organic compounds and symptoms in myocardial infarction survivors

CONTEXT

The aerosol components responsible for the adverse health effects of the exposure to particulate matter (PM) have not been conclusively identified, and there is especially little information on the role of particulate organic compounds (POC).

OBJECTIVE

This study evaluated the role of PM and POC with regard to daily symptoms.

METHODS

One hundred and fifty-three myocardial infarction survivors from Augsburg, Germany, recorded daily occurrence of different symptoms in winter 2003/2004. Ambient concentrations of PM with a diameter <2.5 μm (PM(2.5)), particle number concentration (PNC), PM(2.5)-bound hopanes, and polycyclic aromatic hydrocarbons (PAH) were quantified. Data were analyzed using generalized estimating equations adjusting for meteorological and other time-variant confounders.

RESULTS

The odds for avoidance of physically demanding activities due to heart problems increased immediately associated with most POC measures (e.g. 5% per 1.08 ng/m(3) increase in benzo[a]pyrene, 95%-confidence interval (CI):1-9%) and tended to a delayed decrease. After a 2-day delayed decrease associated with hopanes, the odds for shortness of breath increased consistently after 3 days with almost all POC measures (e.g. 4% per 0.21 ng/m(3) increase in 17α(H), 21β(H)-hopane, CI: 1-8%). The odds for heart palpitations marginally increased immediately in association with PNC (8% per 8146 cm(-3) increase in PNC, CI: 0-16%).

CONCLUSIONS

The study showed an association between PM, particle-bound POC, and daily symptoms. The organic compounds may be causally related with cardiovascular health or act rather as indicators for traffic- and combustion-related particles.

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.

Indirect calibration between clinical observers - application to the New York Heart Association functional classification system

Background

Previous studies showed an inter-observer agreement for the NYHA classification of approximately 55%. The aim of this study was to calibrate the New York Heart Association (NYHA) classification system between observers, increasing its reliability.

Results

Among 1136 community-dwellers in Porto, Portugal, aged ≥ 45 years, 265 reporting breathlessness answered a 4-item questionnaire to characterize symptom severity. The questionnaire was administered by 7 physicians who also classified the subject's functional capacity according to NYHA. Each subject was assessed by one physician. We calibrated NYHA classifications by the concurrent method, using 1-parameter logistic graded response model. Discrepancies between observers were assessed by differences in ability thresholds between NYHA classes I-II and II-III. The ability estimated by the model was used to predict the NYHA classification for each observer.

Estimates of the first and second thresholds for each observer ranged from -1.92 to 0.46 and from 1.42 to 2.30, respectively. The agreement between estimated ability and the observers' NYHA classification was 88% (kappa = 0.61).

Conclusions

The study objectively indicates the main reason why several studies have reported low inter-observer is the existence of discrepant thresholds between observers in the definition of NYHA classes. The concurrent method can be used to minimize the reliability problem of NYHA classification.

Evaluation of a novel index by tissue Doppler imaging in patients with advanced heart failure: relation to functional class and prognosis

BACKGROUND

Despite the ability of tissue Doppler imaging (TDI) to detect left ventricular (LV) systolic and diastolic myocardial functions in patients with heart failure, the added value of TDI to clinical variables and conventional echocardiography in predicting the symptoms and outcome of advanced heart failure has not been clearly defined.

METHODS AND RESULTS

Two hundred and thirty adult patients diagnosed with congestive heart failure were assigned to study groups based on the New York Heart Association functional classes. Pulsed-wave TDI (PWTDI), including average of peak systolic (Sm), early (Em) and late diastolic (Am) velocities from six mitral annular sites was evaluated. PWTDI was also calculated to create a combined index (EAS index) of diastolic and systolic performances. All patients were followed up for cardiac-related death and hospitalisation as a result of heart failure. Patients with functional class III-IV had a significantly higher EAS index (0.21 ± 0.19 vs. 0.13 ± 0.08, p < 0.05) than those with class I-II and the control (0.10 ± 0.04, p < 0.05). Except for Sm and Em, all conventional echocardiographic Doppler parameters and TDI variables significantly correlated with functional class. Moreover, according to multiple stepwise analysis, EAS index and percentage of chronic renal insufficiency (CRF) were the only two independent predictors of functional class (EAS index, p = 0.006; CRF, p = 0.019). During follow-up (median, 30 months), 93 participants had cardiac events. EAS index, LV mass index and CRF were significant predictors of cardiac mortality and hospitalisation [EAS index, hazard ratio (HR) 4.962, p = 0.006; LV mass index, HR 1.007, p = 0.003; CRF, HR 1.616, p = 0.040].

CONCLUSIONS

The EAS index, which reflects systolic and diastolic performances, is a highly effective means of differentiating between patients with functional class I-II and those with III-IV. The index also correlates with cardiac mortality and hospitalisation for worsening heart failure, thus providing additional value to conventional echocardiographic measures.

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.

Severity at entry to specialized heart failure clinics: discrepancies between health-related quality of life and function in men and women

BACKGROUND

We compared severity of heart failure (HF) between men and women at entry to the multidisciplinary HF clinic based on 3 measures: New York Heart Association functional class, norm-referenced 6-minute walk distance, and health-related quality of life.

METHODS

Newly admitted patients to 1 of 6 HF clinics were enrolled. Data were collected from a clinical database, questionnaires were administered to patients, and tests were administered by clinic nurses. We compared men and women with respect to the 3 severity indicators at entry to the clinic.

RESULTS

In adjusted analyses, women had a lower health-related quality of life (P = 0.04) but did not have lower norm-referenced 6-minute walk distance or lower New York Heart Association functional class on entry to the clinic. Having more comorbid conditions, being on medication, and having visited the emergency department or been admitted to hospital in the past 6 months were associated with higher severity at entry according to all 3 indicators.

CONCLUSIONS

Women report a lower health-related quality of life at entry to the clinic, although functional capacity does not seem to differ between women and men. Reasons for these discrepancies will need to be elucidated to better address women's health needs.

Diastolic dysfunction and abnormal exercise ventilation predict adverse outcome in elderly patients with chronic systolic heart failure

BACKGROUND

Heart failure is increasing in the elderly and represents a socioeconomic burden requiring the correct management for which risk stratification is mandatory. Among younger patients, echocardiogram and cardiopulmonary exercise test are useful in prognostic stratification. Few studies have analyzed the utility of these tests in elderly patients.

METHODS

We report on 90 patients over 70 years old, on whom cardiopulmonary tests and echocardiograms were performed between 1998 and 2006 (67 M, 23 F; 75 ± 3 years; ejection fraction (EF) 30 ± 6%; NYHA 2.1 ± 0.8; 60% ischemic; therapy according to international guidelines). Echocardiographic variables were (1) left ventricular ejection fraction (EF); (2) severity of diastolic dysfunction on multiparametric examination of Doppler and TDI parameters; (3) severity of functional mitral regurgitation. Cardiopulmonary variables were (1) peak VO(2); (2) peak O(2) pulse; (3) peak respiratory quotient (RQ); (4) VE/VCO(2) slope. Endpoint considered was mortality of any cause at three-years follow-up.

RESULTS

Mortality was 21%. At univariate analysis, survivors (n = 71) and deceased (n = 19) were similar for age, NYHA class, peakVO(2) and RQ; they differed for EF, severity of mitral regurgitation, severity of diastolic dysfunction, O(2) pulse and VE/VCO(2) slope. At multivariate analysis, only VE/VCO(2) slope and severe diastolic dysfunction (restrictive filling pattern) discriminated between the two groups. In particular, the association of restrictive filling pattern and VE/VCO(2) slope ≥ 45 predicted 3-year mortality with sensitivity of 84% and specificity of 88%.

CONCLUSIONS

Echocardiographic and cardiopulmonary data can identify high-risk elderly patients with systolic heart failure, who may need aggressive clinical management.

Bosentan treatment for Raynauds phenomenon and skin fibrosis in patients with Systemic Sclerosis and pulmonary arterial hypertension: an open-label, observational, retrospective study

Raynaud?s phenomenon (RP) and cutaneous fibrosis are the distinctive manifestations of scleroderma, in which Endothelin-1 plays a fundamental pathogenetic role. Bosentan, an Endothelin-1 receptor antagonist used for the treatment of pulmonary arterial hypertension, retards the beginning of new sclerodermic digital ulcers (DU). This open-label, observational, retrospective study verified the effect of Bosentan on RP and skin fibrosis in sclerodermic outpatients affected by pulmonary arterial hypertension without DU. Fourteen subjects (13 women, 1 man; mean age 60 ± 7.5 years; ten with limited and four with diffuse scleroderma) were observed at baseline (T0) and after four (T1), twelve (T2), twenty-four (T3) and forty-eight (T4) weeks during treatment with Bosentan. They were evaluated for daily quantity and duration of RP attacks and skin thickness (using modified Rodnan total skin score, MRSS). Videocapillaroscopic evaluation was performed at T0 and T4. Bosentan decreased significantly the number and duration of RP attacks, beginning at T2 (p<0.05). Videocapillaroscopy showed significant improvement of microcirculatory patterns at T4 (p<0.05). MRSS decreased throughout the study, reaching the statistical significance at T3 and T4 (p<0.01) in the whole cohort. The present data suggest that Bosentan is effective in stabilizing the microcirculation involvement and in improving skin fibrosis irrespective of scleroderma patterns.

Routine serial echocardiography in systolic heart failure: is it time for the heart failure guidelines to change?

The authors sought to obtain objective evidence for impacting the American College of Cardiology Heart Failure Guidelines for the routine use of serial echocardiography by assessing the reliability of the use of clinician-assessed patient symptoms and New York Heart Association (NYHA) functional classification compared with ejection fraction (EF) measured by echocardiography. A prospective study in 256 patients with systolic heart failure (HF) enrolled into an HF disease management program with EF ≤40% and at least 2 annual echocardiograms were included. Only 86 of 256 (33.5%) patients were correctly classified by NYHA class as showing improvement, no change, or deterioration as compared with echocardiographic assessments. Patients whose NYHA class showed no change between echocardiograms had the lowest survival rate. Quantification in patient's status with NYHA classification is not always a reliable assessment to evaluate prognosis and guide medical therapy for patients with systolic HF.

Comparison of health-related quality of life between American and Taiwanese heart failure patients

Few investigators have compared health-related quality of life (HRQOL) in heart failure (HF) patients from different countries.The purposes of this study were to compare HRQOL between American (n = 87) and Taiwanese (n = 88) HF patients and to determine factors associated with HRQOL in both groups. In this cross-sectional survey, HRQOL was measured using the Minnesota Living with Heart Failure Questionnaire. American patients rated their HRQOL worse than Taiwanese patients did. Sociodemographics, disease severity, and symptom severity were associated with HRQOL, accounting for 42.4% of the variance in HRQOL in Americans and 57.3% in Taiwanese. Symptom severity was the most important predictor of HRQOL in both groups. Interventions targeting symptom severity could improve HF patients' HRQOL.

Predicting heart failure mortality in frail seniors: comparing the NYHA functional classification with the Resident Assessment Instrument (RAI) 2.0

BACKGROUND

Though the NYHA functional classification is recommended in clinical settings, concerns have been raised about its reliability particularly among older patients. The RAI 2.0 is a comprehensive assessment system specifically developed for frail seniors. We hypothesized that a prognostic model for heart failure (HF) developed from the RAI 2.0 would be superior to the NYHA classification. The purpose of this study was to determine whether a HF-specific prognostic model based on the RAI 2.0 is superior to the NYHA functional classification in predicting mortality in frail older HF patients.

METHODS

Secondary analysis of data from a prospective cohort study of a HF education program for care providers in long-term care and retirement homes. Univariate analyses identified RAI 2.0 variables predicting death at 6 months. These and the NYHA classification were used to develop logistic models.

RESULTS

Two RAI 2.0 models were derived. The first includes six items: "weight gain of 5% or more of total body weight over 30 days", "leaving 25% or more food uneaten", "unable to lie flat", "unstable cognitive, ADL, moods, or behavioural patterns", "change in cognitive function" and "needing help to walk in room"; the C statistic was 0.866. The second includes the CHESS health instability scale and the item "requiring help walking in room"; the C statistic was 0.838. The C statistic for the NYHA scale was 0.686.

CONCLUSIONS

These results suggest that data from the RAI 2.0, an instrument for comprehensive assessment of frail seniors, can better predict mortality than the NYHA classification.

Patient-rated health status predicts prognosis following percutaneous coronary intervention with drug-eluting stenting

Purpose

In patients treated with percutaneous coronary intervention (PCI) with the paclitaxel-eluting stent, we examined whether patient-rated health status predicts adverse clinical events.

Methods

Consecutive PCI patients treated with drug-eluting stenting (N = 870; 72.2% men; mean age = 62.6 ± 11.5) completed the EQ-5D post-PCI. The EQ-5D levels were dichotomized into ‘no problems’ (level 1) versus ‘problems’ (levels 2, 3); the visual analogue scale (VAS) was dichotomized using the 25th percentile (cut-off ≤60) indicating poor health status. Patients were followed up for 1-year clinical events (death or non-fatal myocardial infarction (MI)).

Results

There were 53 deaths/MIs at follow-up. The EQ-5D health status dimensions mobility (HR:2.23; 95% CI:1.25–3.97), self-care (HR:3.09; 95% CI:1.54–6.20), and self-reported health status as measured with the EQ-VAS (HR:2.94; 95% CI:1.65–5.25) were independent predictors of death/MI and added to the predictive value of a model comprised of demographic and clinical characteristics. The EQ-5D dimensions usual activities, pain/discomfort, and anxiety/depression were not associated with adverse clinical events in adjusted analysis.

Conclusions

Patient-rated health status predicted adverse clinical events at 1-year follow-up in PCI patients treated with drug-eluting stenting, with the risk being more than 2-fold independent of disease severity and other demographic and clinical characteristics. It may be timely to adopt standard assessment of health status in clinical practice.

Validation of the Spanish version of the Kansas city cardiomyopathy questionnaire

INTRODUCTION AND OBJECTIVES

The Kansas City Cardiomyopathy Questionnaire (KCCQ) is specifically designed to evaluate quality of life in patients with chronic heart failure (CHF). The purpose of this study was to assess the reliability, validity, and responsiveness to change of the Spanish version of the KCCQ.

METHODS

The multicenter study involved 315 patients with CHF. Patients were evaluated at baseline and at weeks 24 and 26. The KCCQ, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and the Short Form-36 (SF-36) were administered. Reliability was assessed in stable patients (n=163) by examining test-retest and internal consistency measures between weeks 24 and 26. Validity was evaluated at baseline (n=315) by determining how KCCQ scores varied with New York Heart Association functional class and by comparing scores with those on similar domains of the MLHFQ and SF-36. Responsiveness to change was assessed in patients who experienced significant clinical improvement between baseline and week 24 (n=31) by determining the effect size.

RESULTS

Reliability coefficients ranged between 0.70 and 0.96 for the different domains. Mean KCCQ scores varied significantly with New York Heart Association functional class (P<.001). Correlations with comparable domains on the other questionnaires were acceptable (e.g. for physical limitation, they were between 0.77 and 0.81). The changes observed at 24 weeks in the majority of KCCQ scores in the subsample that improved corresponded to a moderate effect size (i.e. 0.4-0.6).

CONCLUSIONS

The Spanish version of the KCCQ has good metric properties (i.e. validity, reliability and responsiveness), which make it suitable for use in evaluating quality of life in Spanish CHF patients.

The effects of adding torasemide to standard therapy on peak oxygen consumption, natriuretic peptides, and quality of life in patients with compensated left ventricular systolic dysfunction

AIMS

Diuretics, when used to treat congestion in patients with chronic heart failure, improve symptoms and, perhaps, prognosis but little information is available to guide their use in patients with left ventricular systolic dysfunction (LVSD) who are not congested. Chronic diuretic therapy causes persistent and potentially harmful neuroendocrine activation. Alternatively, in patients in whom neuroendocrine activation is blocked with angiotensin-converting enzyme (ACE)-inhibitors and beta-blockers, diuretics may be beneficial by decreasing preload and afterload and preventing congestion. We aimed to assess the effect of the loop diuretic, torasemide on quality of life, and surrogate markers of prognosis when given to patients with LVSD who were not clinically congested and who were optimally treated with ACE-inhibitors (or angiotensin receptor antagonists) and beta-blockers.

METHODS AND RESULTS

Thirty patients with stable LVSD who had no clinically detectable fluid overload were randomized to receive either torasemide 5 mg daily or placebo for 3 months (Phase A), and after a washout phase of 2 months, cross-over was performed for 3 months (Phase B). Diuretic therapy did not cause significant change in peak VO(2), mean N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) levels, or measures of quality of life compared with placebo. Diuretic therapy did however lead to significant fall in systolic and diastolic blood pressures and increase in plasma renin levels compared with placebo.

CONCLUSION

Diuretic therapy with torasemide is not superior to placebo in improving peak VO(2) or reducing NT-proBNP levels in patients with left ventricular dysfunction who are not clinically congested.

Cognitive deficits and health-related quality of life in chronic heart failure

BACKGROUND

Patients with chronic heart failure (HF) have cognitive deficits in memory, psychomotor speed, and executive function and poor health-related quality of life (HRQL), but the association between cognitive deficits and HRQL is unknown.

OBJECTIVES

The objectives of this study were to (1) evaluate the relationship between HF severity, age, comorbidities, and cognitive deficits and HRQL among patients with chronic HF and (2) examine whether cognitive deficits mediated the relationship between HF severity and HRQL.

DESIGN AND SAMPLE

This study was part of a larger explanatory study; 249 patients with HF completed face-to-face interviews.

METHODS

Measures of HF severity, comorbidity (multiple comorbid conditions, hypertension, and depressive symptoms), cognitive function (domains of language, working memory, memory, psychomotor speed, and executive function), and HRQL were obtained. Clinical variables were abstracted from patients' records. Statistical analyses were conducted using descriptive statistics, Pearson correlation coefficients, and multiple linear regression analyses.

RESULTS

Overall, the HRQL of patients was moderately poor. Heart failure severity, age, depressive symptoms, and total recall memory explained 55% of the variance in HRQL, but the contribution of memory was minimal (1%). Patients with more severe HF, younger age, and more depressive symptoms had poorer HRQL. Other cognitive function variables, multiple comorbidity, and hypertension were not significant explanatory variables for HRQL. Cognitive deficits did not mediate the relationship between HF severity and HRQL.

CONCLUSIONS

Novel interventions targeted at improving HRQL continue to be urgently needed, particularly among younger patients and patients with depressive symptoms. Measures of HRQL are not sufficient as outcomes when investigating cognitive deficits in HF. Investigators need to include outcome measures of patients' actual abilities to perform daily activities and HF self-care.

A Phase 1 study of imatinib mesylate in combination with cytarabine and daunorubicin for c-kit positive relapsed acute myeloid leukemia

The c-kit receptor is expressed in 95% of relapsed acute myeloid leukemias (AMLs) and mediates leukemic proliferation. We conducted a Phase 1 study of the c-kit inhibitor, imatinib mesylate (IM), in combination with cytarabine and daunorubicin (7+3) in c-kit+ relapsed AML. IM was dose escalated using a 3 by 3 design. Phosphorylated STAT5 was absent to minimally present in residual blasts on day 14 bone marrows. The maximum tolerated dose of IM was 300 mg. The dose-limiting toxicity was Grade 3-4 hepatic toxicity. The CR/CRp rate was 57%. Cytotoxic therapy that includes IM for relapsed AML is well-tolerated and effective.

Predicting quality of life in veterans with heart failure: the role of disease severity, depression, and comorbid anxiety

This study focused on the relative contribution of heart failure (HF) disease severity, depression, and comorbid anxiety to quality of life for 96 ambulatory HF veterans (48 with and 48 without depressive symptoms). Primary analyses sought to predict HF quality of life using constructs including depression symptoms, comorbid anxiety symptoms, HF severity, medical-illness burden, and demographic factors. Multiple regression procedures found 3 significant predictors of better quality of life, including HF severity (beta = -13.33, p < .001), depressive symptoms (beta = -2.34, p = .003), and age (beta = 0.76, p < .01). These results suggest that disease severity and depression, but not necessarily comorbid anxiety, significantly affect quality of life for HF patients. As HF is a progressive, deteriorating condition, mental health interventions, especially those that target depression, might offer opportunities for improved quality of life for HF patients.

Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?

Object

Intracranial pressure (ICP) monitoring is increasingly used in the treatment of patients with malignant middle cerebral artery (MCA) infarction. However, neurological deterioration may exist independent from intracranial hypertension. This study aimed to present the findings of continuous ICP monitoring in a cohort of patients with malignant MCA infarction and to correlate these findings with clinical and radiological features.

Methods

The authors studied a prospective cohort of 25 patients with malignant MCA infarction consecutively admitted to the neurotrauma intensive care unit of the Vall d'Hebron University Hospital between March 2002 and September 2006. The patients were treated using a combined protocol of initial moderate hypothermia and hemicraniectomy. The latter was performed when patients showed a midline shift (MLS) ≥ 5 mm or ICP > 20 mm Hg. Six patients had an MLS ≥ 5 mm on the first CT scan and underwent surgery without prior ICP monitoring. This study focuses on the subgroup of 19 patients who underwent intraparenchymatous ICP monitoring before surgery.

Results

Intracranial pressure readings were evaluated and correlated with pupillary abnormalities, MLS, and ischemic tissue volume. In 12 of the 19 patients, ICP values were always ≤ 20 mm Hg, despite a mean (± SD) MLS of 6.7 ± 2 mm and a mean ischemic tissue volume of 241.3 ± 83 cm3. In 2 patients with anisocoria, ICP values were also normal.

Conclusions

In patients with a malignant MCA infarction, pupillary abnormalities and severe brainstem compression may be present despite normal ICP values. Therefore, continuous ICP monitoring cannot substitute for close clinical and radiological follow-up in the management of these patients.

Cognitive deficits in chronic heart failure

BACKGROUND

Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF.

OBJECTIVES

: The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits.

METHODS

A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF.

RESULTS

Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample.

DISCUSSION

HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.

Family caregiving for patients with heart failure: types of care provided and gender differences

BACKGROUND

Knowledge about the potential burden for family caregivers related to the care of patients with heart failure (HF) is limited. The aims of the study were to compare the kind and amount of care provided by partners of HF patients and partners of healthy individuals and to examine the associations between gender and the performance of caregiving tasks.

METHODS AND RESULTS

Caregiving tasks performed by 338 partners of HF patients were compared with those performed by 1202 partners of healthy individuals. Partners (age 70 +/- 9, 76% female) of HF patients were more likely to provide personal care compared with partners (age 65 +/- 7, 66% female) of healthy individuals after controlling for their age. However, the magnitude of the odds ratios (OR) differed by gender of partners (OR for male 6.7; 95% confidence interval [CI] 3.9-11.4; OR for female 3.7; 95% CI 2.7-5.1). Partners of HF patients were more likely to provide emotional care than partners of healthy individuals, controlling for age and gender (OR 2.4; 95% CI 1.5-3.6). Male partners of HF patients were more likely to provide personal care compared to female partners of HF patients (OR 1.9; 95% CI 1.1-3.2).

CONCLUSIONS

The care performed by partners of HF patients is above and beyond normal spousal assistance. The study underscores the crucial role of family caregivers in the care of HF patients and encourages health care providers to address the needs of both HF patients and their caregivers.

Erythropoiesis-stimulating agents for anaemia in chronic heart failure patients

BACKGROUND

Chronic heart failure (CHF) is a leading cause of morbidity and mortality worldwide. Anaemia is a common (12-55%) co-morbid condition and is associated with worsening symptoms and increased mortality. Anaemia is treatable and can be targeted in the treatment of patients with CHF. Erythropoiesis-stimulating agents (ESA), supplemented by iron therapy, are used to treat anaemia in chronic kidney disease and cancer, however safety concerns have been raised in these patients. The clinical benefit and safety of these agents in CHF remains unclear.

OBJECTIVES

To assess the benefits and risks of ESA for CHF patients with anaemia.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to October 2008), EMBASE (1980 to October 2008) and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of any ESA, with or without iron therapy, in CHF patients were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed study quality and extracted data. Original authors were contacted for additional information. The outcomes of interest were: exercise tolerance, haemoglobin level, New York Heart Association (NYHA) functional class, quality of life, left-ventricular ejection fraction, B-type natriuretic peptide, CHF-related hospitalisations, all-cause mortality and adverse effects. Risk ratios (RR) were calculated for dichotomous data and weighted mean difference (WMD) for continuous data.

MAIN RESULTS

Eleven studies (794 participants) were included. Overall quality of studies was moderate with nine studies being placebo-controlled but only five double-blinded. Compared to control, ESA treatment significantly improved exercise duration by 96.8 seconds (95% CI 5.2 to 188.4, p=0.04) and 6-minute walk distance by 69.3 metres (95% CI 17.0 to 121.7, p=0.009). Benefit was also noted in terms of peak VO2 (+2.29 mL/kg/min, p=0.007), NYHA class (-0.73, p<0.001), ejection fraction (+5.8%, p<0.001), B-type natriuretic peptide (-226.99 pg/mL, p<0.001) and quality-of-life indicators, with a mean increase in haemoglobin of 1.98 g/dL (p<0.0001). There was also a significantly lower rate of heart failure related hospitalisations (RR 0.62, 95% CI 0.44 to 0.87) and lower all-cause mortality (RR 0.61, 95% CI 0.37 to 0.99). No increase in adverse events with ESA therapy was observed, however studies were of small sample sizes and limited duration.

AUTHORS' CONCLUSIONS

Meta-analysis of small RCTs suggests that ESA treatment in patients with symptomatic CHF and mild anaemia (haemoglobin more than 10g/dL) can improve anaemia and exercise tolerance, reduce symptoms and have benefits on clinical outcomes. Confirmation requires well-designed studies with careful attention to dose, haemoglobin treatment target and associated iron therapy.

Factors related to time to admission to specialized multidisciplinary clinics in patients with congestive heart failure

BACKGROUND

Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF.

OBJECTIVES

To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics.

METHODS

Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients.

RESULTS

A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF.

CONCLUSION

There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.

Impact of home-based, supervised exercise on congestive heart failure

AIMS

Comparison of supervised home-based exercise program as adjunctive therapy, with comprehensive disease management alone, on symptoms and quality of life in congestive heart failure patients.

METHODS

8 women and 11 men were enrolled in a randomized trial. The mean subject age was 69 (±4.44) in the controls and 70 (±4.05) in the intervention group. Baseline and 3, 6, and 12-month evaluations consisted of the Chronic Heart Failure Questionnaire (CHFQ), measuring perceived functional capacity (perceived symptoms of dyspnea, fatigue, and emotional function) and the Yale Physical Activity Survey (YPAS). A stress test was given at baseline and 12 months.

RESULTS AND CONCLUSIONS

The home-based exercise intervention caused a significant change in perceived fatigue between study groups (p=0.015), after 6 months of study participation, with the control group feeling less fatigued than the intervention group. After 12 months of participation, there were no significant differences in perceived functional capacity. Home-based exercise was well tolerated and favorably evaluated. This pilot study demonstrates the feasibility of studying home-based exercise in patients with moderate congestive heart failure. Larger and longer studies will be required to determine treatment effects.

Patients' self-assessed functional status in heart failure by New York Heart Association class: a prognostic predictor of hospitalizations, quality of life and death

Background

Clinician-assigned New York Heart Association (NYHA) class is an established predictor of outcomes in heart failure. This study aims to test whether patients' self-assessment of functional status by NYHA class predicts hospital admissions, quality of life, and mortality.

Methods and Results

This was an observational study within a randomized controlled trial. A total of 293 adult patients diagnosed with heart failure were recruited after an emergency admission at 3 acute hospitals in Norfolk, UK. Outcome measures included number of emergency admissions over 6 months, self-assessed quality of life measured with the Minnesota Living with Heart Failure questionnaire (MLHFQ) and EQ-5D at 6 months, and deaths up to 20 months' follow-up. Patients were grouped into 3 NYHA groups (I/II, III, and IV) based on patients' self-assigned NYHA class (SA-NYHA). A Poisson model indicated an increased readmission rate associated with higher SA-NYHA class (adjusted rate ratio 1.21; 95% CI 1.04–1.41; P = .02). Higher SA-NYHA class at baseline predicted worse quality of life at 6 months' follow-up (P = .002 for MLHFQ; P = .047 for EQ-5D), and was associated with higher mortality rate (adjusted hazard ratio 1.84; 95% CI 1.10–3.06; P = .02).

Conclusions

SA-NYHA class is predictive of hospitalization, quality of life, and mortality among patients with heart failure.

Validity and reliability of the chronic heart failure questionnaire mastery subscale in patients with defibrillators

Reliable, valid measures are needed to assess one's sense of mastery, which has the potential for decreasing anxiety and depressive symptoms among patients with implantable cardioverter-defibrillators (ICDs). This study evaluates the reliability and validity of a measure of mastery, the Chronic Heart Failure Questionnaire (CHQ) mastery subscale. One hundred twenty-two (75% men, mean age 65 years) and 100 patients complete baseline and 12-month face-to-face interviews, respectively. The CHQ mastery subscale is found to have internal consistency reliability (Cronbach's alphas = .79, .84), and its validity is supported. Factor analysis yields a single robust factor. Differences in the CHQ mastery subscale scores by the New York Heart Association (NYHA) classes are found: Patients with NYHA Class III or IV have lower mastery than those with Class I or II. Baseline younger age and less frequent ICD shocks and lower mastery are significant predictors of respectively 12-month anxiety (R( 2) = .37) and depressive symptoms (R(2) = .45).The CHQ mastery subscale has demonstrated satisfactory reliability and validity in this sample.

Response to cardiac resynchronization therapy: is it time to expand the criteria?

BACKGROUND

Cardiac resynchronization therapy (CRT) is a promising treatment for a subgroup of patients with advanced congestive heart failure and a prolonged QRS interval. Despite the majority of patients benefiting from CRT, 10-40% of patients do not respond to this treatment and are labeled as nonresponders. Given that there is a lack of consensus on how to define response to CRT, the purpose of this viewpoint is to discuss currently used definitions and their shortcomings, and to provide recommendations as to how an expansion of the criteria for CRT response may be useful to clinicians.

METHODS AND RESULTS

Analysis of the literature and case reports indicates that the majority of established measures of CRT response, including New York Heart Association functional class and echocardiographic, hemodynamic, and neurohormonal parameters, are poor associates of patient-reported symptoms and quality of life. Moreover, the potential moderating role of psychological factors in determining health outcomes after CRT has largely been neglected.

CONCLUSIONS

It is recommended to routinely assess health status after CRT with a disease-specific questionnaire in standard clinical practice and to examine its determinants, including psychological factors such as personality traits and depression. This may lead to improved (secondary) treatment and prognosis in CHF patients treated with CRT.