Symptoms, depression, and quality of life in patients with heart failure

Pilot testing of a multicomponent home care intervention for older adults with heart failure: an academic clinical partnership

BACKGROUND

Heart failure (HF) has clinically significant psychological and physical consequences for older persons, and hospitalization for HF is frequent and costly to the Medicare program. As HF is the most common primary Medicare home care diagnosis, there is a critical need to develop home care services that improve heath-related outcomes for this population. The primary aim of this pilot study was to develop, implement, and test the initial feasibility and potential efficacy of the Home-Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities (HEART) trial, a nurse-directed multicomponent home care intervention. Observed outcomes were quality of life (QOL), depressive symptoms, and 90-day hospitalization.

METHODS

Twenty-four patients with a primary diagnosis of HF were assigned to the intervention (n = 12) or control group (n = 12) according to geographical location in a large multibranch Medicare-certified home health agency. Intervention group patients received 8 structured nurse education visits using evidence-based protocols designed in previous trials to teach HF self-management and to prevent/reduce depression, as well as a telemonitoring system. Control group patients received usual care and telemonitoring. Quality of life was assessed using the Minnesota Living With Heart Failure questionnaire. Depressive symptoms were assed using the Patient Health Questionnaire 9 at baseline and 90-day study end point.

RESULTS

Study protocols and instrumentation were found to be feasible and effective. Examination of enrollment data led to a reevaluation of eligibility criteria. Patients participating in the HEART intervention demonstrated significantly improved QOL (F = 8.99, P = .007) and significantly reduced depressive symptoms (F = 35.10, P = .001) in comparison to control group patients at the study end point. There was a trend toward lower hospital readmission rates in the intervention group (16% vs 25%), but this was not statistically significant.

CONCLUSION

This pilot study suggests that a full-scale trial of the HEART intervention is feasible.

End-of-life options for patients with advanced heart failure

Heart failure is a progressive disease with significant morbidity and mortality, but prognostication often is difficult. Many of the evidence-based therapies for heart failure provide symptomatic benefit, but may have intolerable side effects for patients with advanced disease. At the end of life, there is evidence of varying strengths for pharmacologic and nonpharmacologic relief of common symptoms like dyspnea, fatigue, pain, and depression. Patients also may benefit from inotropic therapy, ventricular assist devices, and hospice care. It is important for physicians to encourage patients to formulate advance directives, including decisions about do not resuscitate orders and deactivation of implantable cardioverter-defibrillators and ventricular assist devices.

Symptom presentation in patients hospitalized with acute heart failure

OBJECTIVES

The objectives of this study were to examine the type and frequency of symptoms in patients hospitalized with acute heart failure (HF) as well as the relationship between symptom patterns and patient characteristics, treatment practices, and hospital outcomes in patients hospitalized with decompensated HF.

METHODS

The study sample consisted of 4537 residents of the Worcester, MA metropolitan area hospitalized for decompensated HF at 11 greater Worcester medical centers in 1995 and 2000.

RESULTS

The average age of the study sample was 76 years; the majority (57%) were women, and three-quarters of our patient population had been previously diagnosed with HF. Dyspnea (93%) was the most frequent complaint reported by patients followed by the presence of peripheral edema (70%), cough (51%), orthopnea (37%), and chest pain/discomfort (30%). Patients reporting few cardiac symptoms were less likely to be treated with effective cardiac therapies during hospitalization than patients with multiple cardiac signs and symptoms and experienced higher hospital (9.7% vs. 7.7%) as well as 30-day (17.1% vs. 10.2%) death rates (P < 0.05).

CONCLUSIONS

The results of this study in residents of a large New England community suggest that patients with fewer reported symptoms of decompensated HF were less likely to receive effective cardiac treatments and had worse short-term outcomes. Reasons for these differences in treatment practices and short-term outcomes need to be elucidated and attention directed to these high-risk patients.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

BACKGROUND

Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable.

OBJECTIVE

The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival.

METHODS

A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or chi test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event.

RESULTS

Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37).

CONCLUSION

Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Symptom clusters predict event-free survival in patients with heart failure

BACKGROUND

Physical symptoms are likely to occur in clusters that may be associated with adverse outcome in patients with heart failure (HF). Despite the importance of early recognition of worsening symptoms in HF management, the impact of physical symptoms on adverse outcome has not been explored in the context of symptom clusters.

PURPOSE

The purposes of this study were to explore which physical symptom clusters occur in HF patients and to determine the impact of symptom clusters on event-free survival.

METHODS

A total of 421 patients (60% male; 62 [SD, 14] years; 72% New York Heart Association class II/III) completed the modified Memorial Symptom Assessment Scale-Heart Failure to measure physical symptoms during an index hospitalization in Seoul, Korea. Times to first event of cardiac rehospitalization and cardiac death were collected for 12 months after discharge and confirmed by review of hospital records. An agglomerative hierarchical clustering approach with Ward's method was used to identify symptom clusters. Hierarchical Cox hazard regression was used to determine the impact of symptom clusters on cardiac rehospitalization and cardiac mortality.

RESULTS

Two distinct symptom clusters, the dyspneic and the weary symptom clusters, occurred in patients with HF. Shortness of breath, difficulty breathing when lying flat, and waking up breathless at night comprised the dyspneic symptom cluster. Lack of energy, lack of appetite, and difficulty sleeping comprised the weary symptom cluster. In hierarchical Cox hazard regression, elevated distress from the weary symptom cluster independently predicted cardiac rehospitalization (hazard ratio, 1.45; 95% confidence interval, 1.09-1.93), and increased distress from the dyspneic symptom cluster independently predicted cardiac mortality (hazard ratio, 2.00; 95% confidence interval, 1.16-3.34).

CONCLUSION

The weary and the dyspneic symptom clusters predicted cardiac rehospitalization and cardiac mortality, respectively. Patient education for self-monitoring of symptoms should focus on symptom clusters rather than single symptom.

Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure

BACKGROUND

Mood is an independent predictor of mortality and quality of life (QoL) for people with heart failure. However, the underlying belief systems involved in mood are unknown.

OBJECTIVE

We sought to identify psychological and clinical variables predicting mood and QoL for people diagnosed with heart failure (HF).

METHODS

One hundred and forty-six HF patients were assessed with standardized measures, to determine their beliefs about HF, coping styles, mood, and QoL.

RESULTS

Patients with more negative beliefs about the consequences of HF and with less perceived control over symptoms showed maladaptive coping styles such as denial and behavioral disengagement, and more severe levels of depression and anxiety. Depression also independently predicted QoL outcomes.

CONCLUSIONS

Anxious and depressed patients have more negative beliefs about HF, leading to negative coping behaviors and poor QoL. Our evidence suggests that changing negative beliefs may improve the psychological well-being and QoL of patients, irrespective of disease severity.

Event-free survival in adults with heart failure who engage in self-care management

BACKGROUND

Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free.

METHODS

A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk.

RESULTS

The sample consisted of older (mean ± standard deviation=61.3 ± 11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364 ± 288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management.

CONCLUSION

Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.

High mortality among heart failure patients treated with antidepressants

BACKGROUND

This study was designed to assess whether pharmacologically treated depression was associated with increased mortality risk in systolic heart failure (SHF) patients.

METHODS

Patients (n=3346) with SHF (left ventricular ejection fraction ≤ 0.45) and primarily New York Heart Association (NYHA) classes II-III (78%) were recruited from a clinical database used in 20 heart failure clinics in Denmark. The association between pharmacologically treated depression identified by at least one prescription of an antidepressant and mortality risk was evaluated.

RESULTS

Follow-up time was 540 days (range: 30-1600 days). 539 patients died. For 243 patients (7%) an antidepressant had been prescribed at least once. In a Cox Proportional Hazard Model, pharmacologically treated depression was associated with a 49% increased mortality risk (Hazard ratio: 1.49, 95% confidence interval: 1.03-2.16) after adjustment for traditional confounders. Three months after the baseline visit in the heart failure clinic, these patients received lower doses of beta-blockers than patients without antidepressant therapy (p=0.006). Female sex (p<0.001) and NYHA classes III-IV (p=0.007) were associated with the prescription of an antidepressant.

CONCLUSIONS

Our analyses suggest that pharmacologically treated depression is associated with a 49% increased mortality risk, and that these high-risk patients receive lower doses of beta-blockers than patients with no antidepressant therapy.

Heart failure: the hidden problem of pain

Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain>or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P<0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P<0.001); interference with relations (P<0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF.

Anxiety and depression in ethnic minorities with chronic heart failure

BACKGROUND

Considerable evidence confirms the high prevalence of anxiety and depression in the patients with heart failure (HF). However, little is known about the relationship of race/ethnicity to psychosocial variables in this population. The purpose of this study was to examine and compare the incidence of anxiety and depression in a cohort of non-Hispanic blacks, Hispanics, and non-Hispanic whites with advanced systolic HF.

METHODS AND RESULTS

Two-hundred forty-one patients (7% non-Hispanic blacks, 22.8% Hispanics, 60.7% non-Hispanic whites) mean age 56.7+/-13.0 years, male (70%), married (81%), retired (75%), New York Heart Association (NYHA) Class III (53.9%), and mean ejection fraction 31.2+/-5.4%) from a single heart transplant facility were asked to complete a series of questionnaires to assess anxiety, depression, perceived control, social support, and financial stability. Non-Hispanic blacks had higher levels of anxiety (P=.048) and depression (P=.026) compared with Hispanics; a similar trend was noted when comparing non-Hispanic blacks and non-Hispanic whites, but these differences were not statistically significant. Perceived control was highest among Hispanics and lowest among non-Hispanic whites (P=.046). In a multivariate model race/ethnicity, perceived control, and social support accounted for 30% of the variance in anxiety while race/ethnicity, NYHA Class, perceived control, and social support accounted for 41% of the variance in depression.

CONCLUSIONS

Our findings reveal that non-Hispanic blacks are more likely to be anxious and depressed than their counterparts. Because patient perceptions of control and social support are related to dysphorias known to influence morbidity and mortality, clinicians should regularly assess patients' concerns and assist in accessing appropriate services and treatments tailored to individual needs. Non-Hispanic blacks warrant increased scrutiny.

Pain and heart failure: unrecognized and untreated

BACKGROUND

Although evidence exists to support the presence of pain in advanced stages of heart failure (HF), the pain experience in the early phases of this progressive disease is poorly documented, and therefore, poorly understood. The current study was conducted to: 1) examine the prevalence of pain in cohort of patients with chronic HF (New York Heart Association class I-IV); and 2) determine the relationship between pain and QOL.

METHODS AND RESULTS

Data were obtained from 300 patients (mean age 54.2+/-12.7 years; 72% male; 65% Caucasians; time since HF diagnosis 4.6+/-4.8 years). Two-thirds of the patients (67%) reported some degree of pain; the prevalence of pain increased as functional class worsened (p<.009). Differences in QOL outcomes for patients experiencing pain vs. no pain were statistically significant for physical and overall QOL. Pain accounted for 20% of the variance in QOL (p<.001) even after adjusting for age, gender, and functional class.

CONCLUSIONS

Our findings suggest pain is present in a majority of patients with HF. Given the potential deleterious effects of untreated pain on QOL in patients with HF, it is important that healthcare providers assess patients for this often-unrecognized symptom.

Quality of life in a diverse population of patients with heart failure: BASELINE FINDINGS FROM THE HEART FAILURE ADHERENCE AND RETENTION TRIAL (HART)

PURPOSE

The exact role of psychosocial status in quality of life (QOL) of patients with heart failure (HF) is not fully clarified. This report investigates the association of depression and social support in 2 subdomains of QOL, overall satisfaction with QOL (S-QOL) and limitations in physical functioning (PF-QOL) in a diverse group of HF patients.

METHODS

Baseline data were used from a behavioral clinical trial, with complete information on 695 HF patients, of whom 33% were black and 24% had diastolic dysfunction. Data were collected via structured questionnaires, medical record review, and a 6-minute walk test. QOL outcomes included the Quality of Life Index (QLI) as a measure of S-QOL and the 36-item Short-Form Health Survey Physical Functioning (SF-36 PF) scale as a measure of PF-QOL.

RESULTS

After adjustment for sociodemographic variables, clinical and functional characteristics of disease status accounted for 19% of the variance in the QLI. Depressive symptoms and social support were significantly associated with QLI scores (P < .001) and accounted for an additional 26% of the variance. Clinical and functional characteristics accounted for 33% of the variance in SF-36 PF scores, whereas depressive symptoms and social support accounted for an additional 1% of the variance.

CONCLUSION

Depression and social support play a substantially greater role in S-QOL than in perceived limitations in basic physical functions. Targeting depression and low social support may be more important to improve overall QOL, whereas medical management of HF symptoms and functional capacity may have a greater impact on reducing basic physical limitations.

Depression and coping in heart failure patients: a review of the literature

PURPOSE

The purpose of this article is to critically evaluate the evidence related to depression and coping in heart failure patients and determine if certain types of coping are more common in heart failure patients with depression.

METHODS

A computer search of the literature from January 1996 through October 2008 was conducted. PubMed was searched using the following key search terms: congestive heart failure, heart failure, coping, and depression. Three independent reviewers met to discuss the studies, interpret findings, compare studies, and discuss recommendations.

RESULTS

Coping strategies were found to be associated with depression in patients with heart failure. Adaptive coping such as active coping, acceptance, and planning tended to be used by more patients and were associated with less depression. Those who used more maladaptive methods of coping such as denial and disengagement had higher levels of depression.

CONCLUSIONS

Further longitudinal research on depression and coping strategies and best treatment options for coping and depression in patients with heart failure are needed.

Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients

BACKGROUND

A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.

OBJECTIVE

We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.

DESIGN

This was a cross-sectional study.

PARTICIPANTS

Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.

MEASUREMENTS

Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale).

MAIN RESULTS

Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction < or =30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.

CONCLUSIONS

Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Relation of depression to severity of illness in heart failure (from Heart Failure And a Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION])

Depression is common in patients with heart failure (HF), prognostic for adverse outcomes and purportedly related to disease severity. Psychological and physiologic factors relevant to HF were assessed in HF-ACTION, a large randomized study of aerobic exercise training in patients with systolic HF. The relation of objective and subjective parameters was compared with scores on the Beck Depression Inventory (BDI) to examine the hypothesis that depressive symptoms are better associated with perception of disease severity than with objective markers of HF severity. At baseline, 2,322 of 2,331 subjects entered into HF-ACTION completed questionnaires to assess depression (BDI) and quality of life (Kansas City Cardiomyopathy Questionnaire [KCCQ]). Objective markers of HF severity included ejection fraction, B-type natriuretic peptide, and peak oxygen consumption (using cardiopulmonary exercise testing, with evaluation of duration and respiratory exchange ratio also performed). Measures more likely to be affected by perceived functional status included New York Heart Association (NYHA) classification and the 6-minute walk test. Objective assessments of disease severity were slightly related (peak oxygen consumption) or not related (B-type natriuretic peptide and ejection fraction) to BDI scores. Using multivariate analysis (KCCQ not included), only age, gender, cardiopulmonary exercise testing duration, NYHA class, 6-minute walk distance, and peak respiratory exchange ratio independently correlated with BDI scores. In conclusion, depression was minimally related to objective assessments of severity of disease in patients with HF, but was associated with patient (and clinician) perceptions of disease severity. Addressing depression might improve symptoms in patients with HF.

A comparative study of pain in heart failure and non-heart failure veterans

BACKGROUND

Progress has been made in addressing pain in specific diseases such as cancer, but less attention has focused on understanding pain in nonmalignant states, including heart failure (HF).

METHODS AND RESULTS

From March 2006 to June 2007, 672 veterans were surveyed and scores for the Brief Pain Inventory, pain distress, clinically significant pain levels (moderate to severe pain), and pain locations were compared using univariate and multivariate models. Fifteen percent of the final sample had HF (95/634). In our study, the HF patients were older (P < .000), reported lower levels of general health (P = .018), had more co-morbidities (P < .000), were more likely to have a history of cancer (P = .035), and suffered more chest pain and fewer headaches (P = .026, P = .03, respectively) than their non-HF cohorts. When controlling for age, co-morbidity and cancer disorders, HF and non-HF patients did not differ in pain severity, interference, distress or locations. Of the patients currently experiencing pain, 67.3% of HF patients and 68.4% of non-HF patients rated their pain as moderate or severe (pain >or=4 on a 0 to 10 scale).

CONCLUSIONS

Although HF has not been identified as a painful condition, this study suggests the burden of pain is significant for both HF and non-HF ambulatory care patients.

A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: the relevance of the placebo effect and psychological symptoms

BACKGROUND

Little is known about the treatment of depression in older patients with heart failure. This study was developed to investigate the effectiveness of antidepressant treatment for major depressive disorder (MDD) in the elderly with heart failure.

METHODS

We enrolled 72 older outpatients with ejection fraction <50 and diagnosed with MDD by the structured clinical interview for DSM-IV. Thirty-seven patients, 19 on citalopram and 18 on placebo, initiated an 8-week double-blind treatment phase. Measurements were performed with the 31-item Hamilton Rating Scale for Depression (Ham-D-31), the Montgomery-Asberg rating scale (MADRS) and the Systematic Assessment for Treatment Emergent Effects (SAFTEE). A psychiatrist followed up the patients weekly, performing a consultation for about 20 min to field complaints after the measurements.

RESULTS

A trend toward superiority of citalopram over placebo in reducing depression was observed in MADRS scores (15.05+9.74 vs 9.44+9.25, P=.082) but not on HAM-D scores. The depressive symptomatology significantly decreased in both groups (P < .001). The high rate of placebo response during the double-blind phase (56.3%) led us to conclude the study at the interim analysis with 37 patients.

CONCLUSION

Citalopram treatment of MDD in older patients with heart failure is well-tolerated with low rates of side effects, but was not significantly more effective than placebo in the treatment of depression. Weekly psychiatric follow-up including counseling may contribute to the improvement of depression in this population. Scales weighted on psychological symptoms such as the MADRS are possibly better suited to measure depression severity and improvement in patients with heart failure.

Cancer, comorbidities, and health-related quality of life of older adults

This study examined the physical and mental health of 126,685 males and females age 65 or over, with and without cancer that completed a Medicare Health Outcomes Survey (MHOS) between 1998-2002. Cancer information was ascertained through the National Cancer Institute's (NCI's) Surveillance, Epidemiology and End Results (SEER) program and linked to MHOS data. Results indicated that across most cancer types, cancer patients reported significantly more comorbid conditions and poorer physical and mental health compared with patients without cancer. Negative associations were most pronounced in those with two or more comorbidities and in those diagnosed with cancer within the past year.

Pain and quality of life in hospitalized patients with heart failure

The pain experience of patients with heart failure (HF) and its impact on their quality of life (QOL) has not been described in sufficient detail. This study sampled patients hospitalized with HF to describe the prevalence and severity of bodily pain; evaluate differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effect of selected demographic, disease-specific characteristics, bodily pain, and mental health on QOL. Two items from the Medical Outcomes Study--Short Form (SF-36) were used to measure pain, and one subscale of the SF-36 was used to evaluate mental health. The Minnesota Living With Heart Failure Questionnaire was used to measure QOL. Patients with HF (n=93) had a mean age of 75 years, were predominantly male (65%), and lived alone (47.3%). Lung diseases and diabetes were the most common comorbidities; 58% were categorized as New York Heart Association (NYHA) Class III, whereas 58% of the sample was diagnosed with HF in the past four years. Of note, 85% of the patients reported pain and 42.5% said that it was in the severe or very severe range. No demographic variables were associated with pain, whereas a higher number of chronic conditions were associated with pain. SF-36 mental health and pain scores, as well as NYHA class, explained 34.1% of the variance in QOL in patients with HF. These data suggest that pain is highly prevalent and has a significant impact on the QOL of patients with HF. However, additional research is warranted to determine the specific causes and characteristics of pain in these patients.

Use of specific serotonin reuptake inhibitors (SSRIs) (Sertraline or Citalopram) in the treatment of depression reduces the cardiovascular risk in the elderly: evidence from a Sicilian population >80 years recovered in the assisted sanitary residences (RSA)

The correlation between depression and cardiovascular pathologies was studied in geriatric age. As a matter of fact, the high comorbidity of depression with the sudden cardiac deaths or other cardiovascular events requires a careful evaluation of these causalities. A total of 110 patients were analyzed, recovered in assisted sanitary residence (from the widely used Italian name: "residenza sanitaria assistita" abbreviated as RSA) during the last 12 months. All patients were above the age of 80 years at the admission (mean age was 83.2+/-2.8 years), and all of them have had a diagnosis of depression according to the DSM IV. All patients were treated with the antidepressive specific serotonin reuptake inhibitor (SSRI) (Citalopram, 20-40mg/day, or Sertraline 50-100mg/day). The patients were divided on the basis of their therapeutic response in two groups: Group A (responders) and Group B (non-responders). After 4, 6 and 12 months of treatment, we observed a reduction of the cardiovascular events (-75%, -83% and -60%, respectively). These findings confirm the existence of a correlation between the level of affectivity and the cardiac functions.

Defining the role of palliative care in older adults with heart failure

While palliative care is often thought of as only being applicable to dying patients, its focus on symptom alleviation, patient function, and quality of life has much to offer older adults with chronic heart failure. Heart failure worsens patients' health status through patients' symptom burden, functional limitations, and reduced health-related quality of life. Moreover, older adults with heart failure have multiple other comorbidities and polypharmacy that further contribute to poor health status. Comorbid depression is a particularly important issue. In this patient population, prognosis is limited and often uncertain. Spouses and caregivers of patients report significant distress and depression. Through symptom management, depression and psychosocial care, assistance with defining goals of care and planning for the future, and caregiver support, palliative care has the potential to improve patient health status and reduce costs and hospitalizations. This care is complementary to contemporary heart failure care and can be provided concurrently at any point during the illness based on patient and caregiver needs.