Impact of heart failure and left ventricular systolic dysfunction on quality of life: a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population

Bisoprolol for congestive heart failure

BACKGROUND

beta-Blockers are a cornerstone in the treatment of systolic heart failure treatment, but not all beta-blockers are effective or in this setting.

OBJECTIVE

To define the role of bisoprolol, a highly selective beta(1)-antagonist in congestive heart failure due to systolic dysfunction.

METHODS

Using the keywords 'bisoprolol' and 'heart failure' PubMed and BIOSIS databases were searched for information regarding pharmacology and relevant randomised clinical trials. Supplementary publications were acquired by scrutinising reference lists of relevant papers. Additional information was obtained from the FDA website.

CONCLUSION

Bisoprolol is an effective and well-tolerated first-line beta-blocker for patients with systolic heart failure. The knowledge is primarily based on study patients with moderate-to-severe heart failure from the three CIBIS trials.

Depression is a major determinant of quality of life in patients with chronic systolic heart failure in general practice

BACKGROUND

Quality of life (QoL) is severely restricted in patients with chronic heart failure (CHF). Patients frequently suffer from depressive comorbidity. It is not clear, to what extent sociodemographic variables, heart failure severity, somatic comorbidities and depression determine QoL of patients with CHF in primary care.

METHODS AND RESULTS

In a cross-sectional analysis, 167 patients, 68.2 +/- 10.1 years old, 68.9% male, New York Heart Association (NYHA) functional class II-IV, Left ventricular ejection fraction (LVEF) < or = 40%, were recruited in their general practitioner's practices. Heart failure severity was assessed with echocardiography and N-terminal brain natriuretic peptide (NT-proBNP); multimorbidity was assessed with the Cumulative Illness Rating Scale (CIRS-G). QoL was measured with the Short Form 36 Health Survey (SF-36) and depression with the depression module of the Patient Health Questionnaire (PHQ-9). Significant correlations with all SF-36 subscales were only found for the CIRS-G (r = -0.18 to -0.36; P < .05) and the PHQ-9 (r = -0.26 to -0.75; P < .01). In multivariate forward regression analyses, the PHQ-9 summary score explained the most part of QoL variance in all of the SF-36 subscales (r2 = 0.17-0.56). LVEF and NT-proBNP did not have significant influence on QoL.

CONCLUSIONS

Depression is a major determinant of quality of life in patients with chronic systolic heart failure, whereas somatic measures of heart failure severity such as NT-proBNP and LVEF do not contribute to quality of life. Correct diagnosis and treatment of depressive comorbidity in heart failure patients is essential.

Impact of heart failure on hospital activity and healthcare costs in Belgium

Heart failure (HF) is a serious public health problem worldwide. It has a high prevalence, affects mainly the elderly and causes high mortality or disability with high economic costs. The aim of the present study was to calculate the number of admissions for HF, the total in-hospital stay, the mean length of in-hospital stay and the in-hospital costs due to HF in Belgium. Retrospective analysis of data from the national hospital registration system provided the following results. In 2001, there were 19,398 admissions with HF as a primary diagnosis, with a total in-hospital stay of 286,938 days. The mean in-hospital stay for HF was 14.8 days. The total in-hospital cost of HF as a primary diagnosis was euro 94,113,827, representing 1.8% of the total hospital expenditure. The limitations of this study are its mere focus on admissions and their characteristics in 2001, and the use of a retrospective analysis. Nevertheless, it led to the conclusion that HF was responsible for a significant number of in-hospital days, with a significant impact on healthcare costs in Belgium.

Is health-related quality of life an independent predictor of survival in patients with chronic heart failure?

OBJECTIVE

The aim of this study was to examine whether the physical and mental components of health-related quality of life (HRQoL) are independent predictors of survival in patients with chronic heart failure (CHF).

METHODS

A cohort of 231 outpatients with CHF was followed prospectively for 986 days (median; interquartile range=664-1120). Generic HRQoL was measured with the Short Form-36 Health Survey (SF-36), disease-specific HRQoL was measured with the Kansas City Cardiomyopathy Questionnaire, and depression was measured with the self-reported Patient Health Questionnaire.

RESULTS

Both generic and disease-specific HRQoL were predictive of survival on univariate analyses. After adjustment for prognostic factors such as age, gender, degree of left ventricular dysfunction, and functional status, only the mental health component of SF-36 and the disease-specific HRQoL remained significant. When depression was included, both measures also lost their predictive power.

CONCLUSION

Our data suggest that the prognostic value of patients' HRQoL reflects confounding with the severity of disease and comorbid depression.

Management of end stage cardiac failure

Optimum heart failure medication and an increasing array of interventions have had an enormous effect on morbidity and mortality over the past 10 years. However, patients with end stage disease can still be highly symptomatic. Moreover, such patients are disadvantaged compared with patients with malignant disease. They are less likely to have an understanding of their illness or have access to supportive care. They are also less likely to have the opportunity to plan for care with regard to death and dying. There is increasing demand that the multi-professional clinical team gain good communication and supportive care skills, and that appropriate access to specialist palliative care services is available.

Left atrial enlargement and NT-proBNP as predictors of sudden cardiac death in patients with heart failure

AIMS

The identification of valuable markers of sudden cardiac death (SCD) in patients with established HF remains a challenge. We sought to assess the value of clinical, echocardiographic and biochemical variables to predict SCD in a consecutive cohort of patients with heart failure (HF) due to systolic dysfunction.

METHODS

A cohort of 494 patients with established HF had baseline echocardiographic and NT-proBNP measurements and were followed for 942+/-323 days.

RESULTS

Fifty patients suffered SCD. Independent predictors of SCD were indexed LA size>26 mm/m2 (HR 2.8; 95% CI 1.5-5.0; p=0.0007), NT-proBNP>908 ng/L (HR 3.1; 95% CI 1.5-6.7; p=0.003), history of myocardial infarction (HR 2.3; 95% CI 1.3-4.1; p=0.007), peripheral oedema (HR 2.1; 95% CI 1.1-3.9; p=0.02), and diabetes mellitus (HR 1.9; 95% CI 1.1-3.3; p=0.03). NYHA functional class, left ventricular ejection fraction and glomerular filtration rate were not independent predictors of SCD in this cohort. Notably, the combination of both LA size>26 mm/m2 and NT-proBNP>908 ng/L increased the risk of SCD (HR 4.3; 95% CI 2.5-7.6; p<0.0001). At 36 months, risk of SCD in patients with indexed LA size<or=26 mm/m2 and NT-proBNP<or=908 ng/L was 3%, while in patients with indexed LA size>26 mm/m2 and NT-proBNP>908 ng/L reached 25% (p<0.0001).

CONCLUSIONS

Among HF patients, indexed LA size and NT-proBNP levels are more useful to stratify risk of SCD than other clinical, echocardiographic or biochemical variables. The combination of these two parameters should be considered for predicting SCD in patients with HF.

Determinants of depressive symptoms in hospitalised men and women with heart failure

BACKGROUND

Depressive symptoms are prominent and related to an increased risk on cardiovascular disease outcomes and all cause mortality in HF patients.

AIM

To intervene effectively, factors related to depressive symptoms in men and women should be identified.

METHODS

Depressive symptoms of 921 hospitalised HF patients (61% male; age 71+/-11; LVEF 33%+/-14, NYHA II-IV) were assessed by the Center for Epidemiological Studies-Depression scale (CES-D).

RESULTS

Overall 40% of the patients had depressive symptoms (CES-D >or=16), which were more common in women than in men (47% versus 36%, p<0.001). Multivariable analysis in men revealed that depressive symptoms were related to age (OR 0.84, 95% CI 0.71-0.98, p=0.03, per 10 years), physical health (OR 0.76, 95% CI 0.71-0.83, p<0.001, per 10 units) and HF symptoms. In women depressive symptoms were also related to NYHA II-III versus IV (OR 0.60, 95% CI 0.37-0.95, p<0.03) and COPD (OR 2.33, 95% CI 1.20-4.53, p<0.012).

CONCLUSION

Depressive symptoms are more common in women than in men. In both men and women depressive symptoms are related to age and physical health. For clinical factors: In men only HF symptoms, but in women also NYHA and COPD were related to depressive symptoms.

Quality of life and behavioral compliance in cardiac rehabilitation patients: a longitudinal survey

BACKGROUND

Few data regarding inter-relations between health-related quality of life (HRQoL) and compliance are available. The aim of present study was to assess which aspects of HRQoL might predict patients' behavioral compliance to medical suggestions and whether questionnaires might be useful for patients undergoing cardiac rehabilitation.

METHODS

HRQoL and compliance were measured in 52 consecutive patients undergoing cardiovascular rehabilitation. The measurements were performed at the beginning, at the end of rehabilitation, and after 6 months follow-up. Baseline, demographic and HRQoL characteristics were linked to compliance by multiple regression modelling.

RESULTS

Over time no significant differences between HRQoL and compliance scores were observed. Age (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.08-2.45), number of taken drugs (OR=1.45; 95% CI: 1.02-2.11), anxiety score (OR=0.32; 95% CI: 0.15-1.02), depression score (OR=0.48; 95% CI: 0.06-0.78), and social health score (OR=1.09; 95% CI: 1.01-1.24), appeared to be independent predictors of compliance.

CONCLUSION

Older age, higher number of drugs, high social health score, and low anxiety and depression scores predict better behavioral compliance in cardiac rehabilitation patients.

Symptomatic Relief: Left Ventricular Assist Devices Versus Resynchronization Therapy

In patients who have end-stage heart failure, medical therapy is of limited use, and heart transplantation is frequently not an option because of the shortage of donor hearts. Two new treatment options, left ventricular assist devices (LVADs) and implantable cardiac resynchronization therapy (CRT) devices, can improve survival and quality of life in patients who have heart failure. Both types of devices are easy to implant. However, LVADs carry the risk of infection and mechanical failure, and CRT is ineffective in a substantial proportion of patients who have heart failure. Therefore, methods must be devised to identify patients who have heart failure who are likely to benefit from these devices. Data suggest that early LVAD implantation, before end-stage heart failure develops, is critical to slowing or reversing disease progression. Similarly, in indicated patients who have less advanced disease, CRT may be particularly beneficial.

Using an individualised quality of life measure in older heart failure patients

BACKGROUND

Existing tools purporting to measure quality of life in heart failure do not allow expression of individual needs and preferences. The Patient Generated Index is a recently introduced tool that allows individualised assessment of quality of life.

METHODS

59 patients aged 65 years and over with a clinical diagnosis of chronic heart failure were administered the Patient Generated Index at baseline, 1 week and 12 weeks, along with the Guyatt chronic heart failure questionnaire, Minnesota Living with Heart failure questionnaire and Short Form-12 tool. Changes in questionnaire scores were used to calculate reproducibility and responsiveness to change. Comparison of Patient Generated Index scores with the other questionnaires and with New York Heart Association class was used to determine construct validity.

RESULTS

All four questionnaires were completed by >90% of participants. Intraclass correlation coefficients denoting reproducibility were high for the Guyatt (0.93) and Minnesota questionnaires (0.89), moderate for the Patient Generated Index (0.65) and Short Form-12 (0.59). Responsiveness to change was similar for all questionnaires, but lower than in previous studies. The Patient Generated Index correlated with New York Heart association class and correlated moderately with the other questionnaires. The most important domains nominated on the Patient Generated Index were walking, performing daily activities, feeling tired and climbing stairs.

CONCLUSIONS

The Patient Generated Index can be administered successfully to older heart failure patients; usefulness is limited by suboptimal reproducibility and responsiveness. Impairment of physical function is the factor most cited by older heart failure patients affecting their quality of life.

Quality of Life in Patients With Signs and Symptoms of Heart Failure—Does Systolic Function Matter?

BACKGROUND

The impaired quality of life in patients with systolic heart failure is well described. Less is known about patients with preserved systolic function (PSF) heart failure.

METHODS AND RESULTS

We aimed to compare the quality of life in patients with PSF heart failure with that of those with left ventricular systolic dysfunction (LVSD) using generic and disease-specific quality-of-life questionnaires. Four hundred patients with signs and symptoms of heart failure referred for an echocardiogram to assess left ventricular function were invited to complete quality-of-life questionnaires. A total of 278 of 400 (69.5%) responses were adequate for analysis. The mean age of respondents was 72.5 (10) years; 132 (47%) were male. A total of 189 of 278 (68%) had PSF, and 89 of 278 (32%) had left ventricular systolic dysfunction (LVSD). Both groups were well matched for age, but there were more women in the PSF group (58% vs. 40%). No significant differences were found in the quality of life between PSF and LVSD patients. Women had significantly worse quality of life compared with men in both groups.

CONCLUSION

Patients with PSF are an important subgroup of heart failure patients whose quality of life is as impaired as those with systolic dysfunction. These data suggest these patients warrant more care, perhaps in specialist clinics.

Comparison and validation of three measures of quality of life in patients with pulmonary hypertension

BACKGROUND

Pulmonary hypertension, when advanced, markedly limits exercise capacity, activities of daily living and quality of life (QoL). No measure of QoL has yet been validated for the assessment of pulmonary hypertension. The aim of the study was to compare the validity of the Minnesota Living with Heart Failure (MLwHF) questionnaire, the Short Form-36 (SF-36) questionnaire and the Australian Quality of Life (AQoL) measure for assessing pulmonary hypertension treatment.

METHODS

Eighty-three patients were enrolled in three studies of pulmonary hypertension treatment (treprostinil, bosentan and sildenafil). They were assessed at baseline and 3 months with the MLwHF questionnaire. Treprostinil and bosentan groups also had 6 and 12 months' data. Twenty-one patients in the sildenafil trial completed concurrently, the SF-36 and AQoL measures at baseline and 3 months. QoL scores were correlated with the 6-min walk test distance, New York Heart Association functional class and right heart catheter-derived haemodynamic parameters of the disease for all matching time points and for changes in scores and clinical measurements over time.

RESULTS

The MLwHF and SF-36 scores correlated well with the 6-min walk test distance and New York Heart Association functional class, but did not correlate with haemodynamic measurements. MLwHF and SF-36 scores also correlated with the rate of change of the 6-min walk test distance and New York Heart Association functional class over time.

CONCLUSION

The MLwHF questionnaire and SF-36 are useful tools for the assessment of QoL in pulmonary hypertension and may be useful in the ongoing evaluation of QoL in the treatment and study of pulmonary hypertension.

Heart failure in older adults

Heart failure affects approximately 5 million Americans, half of whom are at least 75 years of age, and is the leading cause of hospital admission among older adults. Additionally, the prevalence of heart failure is increasing, largely owing to the aging of the population. Heart failure in older adults differs in many respects from heart failure that occurs during middle age, including an increased proportion of women, increasing prevalence of heart failure with preserved left ventricular systolic function, and a marked increase in the number of coexisting medical conditions. In light of these factors, this article reviews the epidemiology, pathophysiology, clinical features, and treatment of heart failure in older adults.

CRT improves the exercise capacity and functional reserve of the failing heart through enhancing the cardiac flow- and pressure-generating capacity

BACKGROUND

While information on how cardiac resynchronisation therapy (CRT) affects cardiac performance at rest is readily available, the mechanisms whereby CRT alters cardiac function during maximal exercise are unclear.

AIMS

We examined the medium-term effects of CRT on cardiac and physical functional reserve of patients with severe heart failure (CHF) and prolonged QRS duration.

METHODS

Seventeen consecutive patients with severe CHF (NYHA III-IV) and widened QRS underwent maximal cardiopulmonary exercise testing with non-invasive central haemodynamic measurements before and 6-8 weeks after CRT pacemaker implantation.

RESULTS

After CRT there were significant increases in exercise cardiac output by 19.3% (P=0.0048) from 9.5+/-3.4 l min(-1), peak mean arterial blood pressure by 14.1% (P=0.0001) from 91.3+/-13.6 mm Hg, and peak cardiac power output by 37.2% (P=0.0008) from 1.92+/-0.74 W. There were no significant changes in these variables at rest. Exercise duration (+42.3%, P=0.0002), NYHA functional class (P=0.0001) and SF-36 symptom score (P=0.0006) were also significantly improved. Powerful surrogate indicators of prognosis were also significantly improved with CRT: peak O(2) consumption (+20.9%, P=0.0007), VE/VCO(2) slope (-20.0%, P=0.005) and circulatory power (+42.0%, P=0.0012).

CONCLUSION

In this cohort of patients, post-implant CRT significantly improved the flow-, pressure- and power-generating capacity of the failing hearts. This may be causally related to the improvements observed in exercise capacity, functional class and symptom scores.

Sleep-disordered breathing in a general heart failure population: relationships to neurohumoral activation and subjective symptoms

The aim of this study was to determine the prevalence of sleep-related breathing disorders (SDB) in a UK general heart failure (HF) population, and assess its impact on neurohumoral markers and symptoms of sleepiness and quality of life. Eighty-four ambulatory patients (72 male, mean (SD) age 68.6 (10) yrs) attending UK HF clinics underwent an overnight recording of respiratory impedance, SaO2 and heart rate using a portable monitor (Nexan). Brain natriuretic peptide (BNP) and urinary catecholamines were measured. Subjective sleepiness and the impairment in quality of life were assessed (Epworth Sleepiness Scale (ESS), SF-36 Health Performance Score). SDB was classified using the Apnoea/Hypopnoea Index (AHI). The prevalence of SDB (AHI > 15 events h(-1)) was 24%, increasing from 15% in mild-to-moderate HF to 39% in severe HF. Patients with SDB had significantly higher levels of BNP and noradrenaline than those without SDB (mean (SD) BNP: 187 (119) versus 73 (98) pg mL(-1), P = 0.02; noradrenaline: 309 (183) versus 225 (148) nmol/24 h, P = 0.05). There was no significant difference in reported sleepiness or in any domain of SF-36, between groups with and without SDB (ESS: 7.8 (4.7) versus 7.5 (3.6), P = 0.87). In summary, in a general HF clinic population, the prevalence of SDB increased with the severity of HF. Patients with SDB had higher activation of a neurohumoral marker and more severe HF. Unlike obstructive sleep apnoea, SDB in HF had little discernible effect on sleepiness or quality of life as measured by standard subjective scales.

The DAVES (Disfunzione Asintomatica VEntricolare Sinistra) study by the Italian Society of Cardiovascular Echography: rationale and design

BACKGROUND

Diagnosis of heart failure (HF) is based on clinical signs, instrumental findings and response to treatment. The recent classification of the European Society of Cardiology identifies early stages of ventricular dysfunction not associated with symptoms of HF (Stage A-B). However, only few data are available on the prevalence and prognostic value of asymptomatic left ventricular dysfunction.

METHODS

The SIEC (Società Italiana di Ecografia Cardiovascolare - Italian Society of Cardiovascular Echography) has planned a national multicenter observational study aimed to assess: (1) the prevalence of left ventricular (LV) systolic and diastolic dysfunction in asymptomatic subjects without a history of HF (transversal phase); (2) the relationship between cardiovascular risk factors and LV asymptomatic dysfunction; (3) the relationship between comorbidities and LV asymptomatic dysfunction; and (4) the incidence of cardiac events at follow-up (longitudinal phase). Data from 75 echocardiographic laboratories were recorded, merged, and analyzed using a dedicated software.

CURRENT STATUS

Recruitment started in June 2003 and closed in February 2004. Overall, 16 099 patients (men, 8496; women, 7603; male: female ratio, 1.11) have been screened and 6679 (men, 3504; women, 3175; male: female ratio, 1.10) were enrolled. The follow-up is currently ongoing.

Evidence-based treatment and quality of life in heart failure

OBJECTIVES

To explore whether prescription of evidence-based drug therapy is associated with better quality of life (QoL) in patients with heart failure (HF).

METHODS

Patients (n = 62) were recruited in the outpatient clinic of Groningen University Hospital. Inclusion criteria were previous diagnosis of HF, age 40-80 years; ejection fraction of less than 45%, free from other serious disease (such as cancer) and psychiatric problems in the last year. QoL was assessed with the RAND 36-item health survey questionnaire, on five scales: physical functioning, mental health, social functioning, vitality and general health perception. Medication prescribed for 1 to 6 months before the QoL assessment was classified as either evidence-based treatment or under-treatment, according to the 2001 European guidelines on optimal HF treatment. The study had a cross-sectional design.

RESULTS

QoL did not differ significantly between evidence-based and under-treated patients, unadjusted or after adjustment for significant patient imbalances.

CONCLUSIONS

Conventional step-up medication approach in HF may have a positive impact on survival or morbidity, but it seems not beneficial in relation to QoL. Other interventions should be designed to improve QoL of patients with HF.

Diagnosis of heart failure in primary care

Heart failure is becoming an increasing concern to healthcare worldwide. It is the only cardiovascular disorder that continues to increase in both prevalence and incidence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Guidelines on diagnosis and treatment of heart failure are to be met. Most patients with heart failure will present themselves in general practice. Therefore, the community management of heart failure has become increasingly important and the role of General Practitioners even more crucial. Improving the reliability of diagnosis in primary care is essential since determining the aetiology and stage of heart failure leads to different management choices to improve symptoms, quality of life and disease prognosis. Furthermore, early diagnosis is needed, when there may be no symptoms, since treatment can delay or reverse disease progression. Diagnostic methods may therefore need to encompass screening strategies, as well as symptomatic case identification, in the future. General Practitioners must make correct decisions regarding appropriate further investigation, treatment and referral. A correct diagnosis is the cornerstone leading to effective management. The aim of this paper is to review the role of symptoms and signs and diagnostic tests, such as, chest X-ray, ECG, natriuretic peptides and echocardiography, for diagnosing heart failure in the primary care setting. Improving diagnostic skills remains a continuous challenge for clinicians. Simple and reliable diagnostic procedures are crucial to comply with Guidelines and reduce healthcare utilisation and costs.

Management of elderly patients with congestive heart failure--design of the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF)

BACKGROUND

Little is known about the management of elderly patients with congestive heart failure (CHF) although they represent the majority of the CHF population. Therefore, the TIME-CHF study was set up (1) to evaluate the medical management of very old patients (> or = 75 years) with CHF compared with younger patients (60-74 years), (2) to compare an intensified with a standard treatment approach, and (3) to differentiate between systolic and diastolic dysfunction (ejection fraction < or = 45% vs > 45%).

METHODS

In a prospective single-blinded multicenter trial, 824 symptomatic patients, CHF hospitalization within the last year and elevated NT-BNP, are randomized to an intensified versus a standard medical therapy. Treatment strategies follow the published guidelines with the aim to reduce symptoms to NYHA class < or = II (standard) or, additionally, NT-BNP levels below twice the upper limit of normal (intensified). The primary end points are 18-month hospitalization-free survival and quality of life.

RESULTS

By the end of 2004, 297 patients have been included, 147 randomized to intensified and 150 to standard therapy. Mean age in the older age group was 82 +/- 4 years (n = 174) and 69 +/- 4 years in the younger group (n = 123), respectively. Ejection fraction was > 45% in 26% and 10%, respectively. Significant comorbidities were present in 93% of patients.

CONCLUSION

TIME-CHF will be the first prospective randomized trial to comprehensively study the management of elderly patients with CHF. It will provide unique information comparing two treatment strategies in two age groups irrespective of ejection fraction regarding prognosis, quality of life, as well as resource utilization and costs.

Multicenter randomized phase III study of the cardioprotective effect of dexrazoxane (Cardioxane®) in advanced/metastatic breast cancer patients treated with anthracycline-based chemotherapy

BACKGROUND

Anthracycline-induced cardiotoxicity has led to the adoption of empirical dose limits that may restrict continued use of anthracyclines among patients who might benefit. Dexrazoxane, a cardioprotective agent, has been shown to reduce the risk of anthracycline-associated cardiotoxicity when given from first dose of anthracycline. This study sought to confirm the benefit of dexrazoxane in patients at high risk of cardiotoxicity due to prior anthracycline use.

PATIENTS AND METHODS

A total of 164 female breast cancer patients, previously treated with anthracyclines, received anthracycline-based chemotherapy either with (n = 85) or without (n = 79) dexrazoxane for a maximum of six cycles.

RESULTS

Compared with those receiving anthracycline alone, patients treated with dexrazoxane experienced significantly fewer cardiac events (39% versus 13%, P < 0.001) and a lower and less severe incidence of congestive heart failure (11% versus 1%, P < 0.05). Tumor response rate was unaffected by dexrazoxane therapy. The frequency of adverse events was similar between groups and there were no significant between-group differences in the number of dose modifications/interruptions.

CONCLUSION

Dexrazoxane significantly reduced the occurrence and severity of anthracycline-induced cardiotoxicity in patients at increased risk of cardiac dysfunction due to previous anthracycline treatment without compromising the antitumor efficacy of the chemotherapeutic regimen.

The effect of beta-blocker therapy on quality of life in heart failure patients: a systematic review and meta-analysis

PURPOSE

To assess the impact of beta-blocker therapy on quality of life (QoL) in chronic heart failure (CHF) patients receiving optimal standard medication.

METHODS

Randomised controlled trials (RCT) assessing QoL with a generic or disease specific instrument were identified by searching Medline, Embase, Pascal, Cochrane Controlled Trial database, and the bibliographies of the published articles. Studies published between 1985 and 2002 were included, regardless of language of publication. Cochrane Review Manager 4.2 software was used to analyse the data and standardised mean difference (SMD) was calculated to assess the effect on QoL.

RESULTS

A total of 9 trials involving 1954 patients fit into the inclusion criteria for the analysis. QoL improved more in the beta-blocker group compared to the control arm, but the SMD did not reach statistical significance (SMD, 0.07; 95%CI [-0.16, 0.02]; p = 0.13). Subgroup analysis, per type of beta-blocker and various treatment follow-up showed similar results.

CONCLUSIONS

In this meta-analysis there is evidence that beta-blocker therapy, on top of standard medication, does not impair QoL. Clinicians may add beta-blockers to standard therapy without concerns of impairing QoL in patients with CHF.

Predictors of health status for heart failure patients

Health status is poorly understood for patients with heart failure. The purpose of this study was to determine the relative importance of relevant sociodemographic, clinical, health perception, and emotional variables in predicting health status. In this study of 87 patients, health status was conceptualized as health-related quality of life, physical activity level, and symptom burden. Hierarchical multiple regression was used to determine sociodemographic, clinical health perception, and emotional variables associated with health status. Worse New York Heart Association class, higher anxiety, and higher depression predicted worse health-related quality of life. Better New York Heart Association class and higher anxiety predicted higher levels of physical activity. Worse New York Heart Association class and higher depression predicted greater symptom burden. Traditional demographic and clinical variables were not associated with health status. Although not routinely assessed, emotional variables had a major impact on health status. Interventions to improve health status should target both physical and emotional well-being.

Tei index and neurohormonal activation in patients with incident heart failure: serial changes and prognostic value

BACKGROUND

Natriuretic peptides and Tei index are useful indices for risk stratification in advanced left ventricular dysfunction (LVD). Their role in early stages is less clear.

AIMS

In relation to first diagnosis of LVD to assess the relation of plasma B-type-natriuretic peptide (NT-proBNP) with Tei index, assess serial changes in indices, and to assess the value of indices to predict functional status.

METHODS

Doppler echocardiography and neurohormonal analysis were performed (n=150). NYHA class was registered.

RESULTS

Tei index correlated with p-NT-proBNP (r=0.75, p<0.0001), and changes in indices correlated (r=0.36, p=0.001) in LVD (n=80). No functional improvement (n=47) was related to a median increase in Tei index (-0.2, -0.16; 0.09); an improvement (n=31) to a reduction (0.06; -0.19; 0.35), p=0.02. In the group with functional improvement, more patients had >/=30% reduction in p-NT-proBNP (75% vs. 45%, p<0.01). Addition of NT-proBNP or Tei index to a clinical model, of no functional improvement, improved log-likelihood chi(2) from 9.32 to 20.18 (p=0.001) and 20.67 (p=0.001).

CONCLUSION

Tei index and p-NT-proBNP demonstrated a fair correlation. Unimproved NYHA class was related to progressive LVD and might be identified by monitoring Tei index or p-NT-proBNP. Advanced LVD and high pre-treatment p-NT-proBNP levels indicated a potential of improvement in functional status.

Vulnerabilities of patients recovering from an exacerbation of chronic heart failure

BACKGROUND

Many rehospitalizations for heart failure (HF) are preventable as they are precipitated by modifiable factors. High early readmission rates suggest that patients commonly are discharged from HF hospitalizations with such problems unaddressed. The purpose of this study was to describe the prevalence of multiple risk factors for rehospitalization in patients recently discharged from a hospitalization for decompensated HF.

METHODS AND RESULTS

The following potentially modifiable risk factors for rehospitalization were evaluated in 202 patients: functional status; whether the patient lived alone; presence of anxiety, depression, or poor quality of life; and symptom status and adherence to prescribed medications, low-sodium diet, and symptom monitoring recommendations. Most patients were severely functionally impaired (70% New York Heart Association [NYHA] functional class III/IV). Of the 28% of patients who lived alone, 50% were rated as NYHA functional class III or IV. Fifty percent of patients were anxious, whereas 69% of patients were depressed. Health-related quality of life was substantially impaired. Patients reported substantial symptom burden. Adherence with recommended self-care strategies was poor: 14% weighed themselves daily, 9% of patients reported monitoring for symptoms of worsening HF, 31% could not name any symptom, and only 34% of patients taking all medications as prescribed. A total of 23% of patients had all of the following risk factors: NYHA functional class III or IV, lived alone, > or =1 comorbidities, and were depressed or anxious.

CONCLUSIONS

Patients newly discharged from a hospitalization for HF exhibit many psychosocial and behavioral risk factors for rehospitalization, although they have been judged clinically stable.

Public awareness of heart failure in Europe: first results from SHAPE

AIMS

Appropriate heart failure (HF) care and adequate resourcing require recognition of its clinical, social, and economic importance by the general public besides healthcare authorities and providers. The extent of public awareness in Europe is not known.

METHODS AND RESULTS

A total of 7958 subjects were randomly selected from nine European countries (minimum 100/group per country). Each completed a 32-question survey on HF covering recognition, impact on health, comparative prevalence and severity, treatment, and costs. Although 86% of respondents had heard of HF, only 3% could correctly identify HF from a description of typical symptoms and signs, 31% correctly identified angina, and 51% identified transient ischaemic attack/stroke. Only 29% thought that HF signs and symptoms indicate a 'severe' condition. Most thought that HF patients should reduce all physical activity and 34% believed HF a normal consequence of ageing. Sixty-seven per cent thought that HF patients live longer than cancer patients. Only 9% believed that HF leads to greater healthcare expenditure than cancer, HIV, or diabetes. Overall, responses were comparable between countries.

CONCLUSION

In Europe, community awareness of HF is low. Therefore, the general public is unlikely to demand appropriate measures by healthcare authorities and providers. A better understanding of HF could improve its prevention and management. Strategies to educate the public about HF are needed.

Depression in patients with heart failure

BACKGROUND

Psychologic comorbidities, particularly depression, often accompany heart failure and add to the complexity of clinical management. We conducted a study to describe the prevalence of depression, the differences between patients with minimal versus mild to severe depression, and the correlates of depression in patients with heart failure.

METHODS AND RESULTS

Data were collected from 200 patients with symptoms of heart failure resulting from systolic dysfunction. Psychologic assessment included depression, perceived control, neuroticism, educational needs, and social support/network. Patients were, on average, 57.0 (+/-12.1) years old, male (168, 84.0%), and in New York Heart Association (NYHA) class II or III (n=140, 70.0%) with a mean ejection fraction of 25.5+/-6.4%. They had an average maximal oxygen uptake of 15.8 (+/-4.6) mL x kg x min and 6-minute walk distance of 1345.0 (+/-302.1) feet. Minimal depression was described by 105 (52.5%) patients, mild by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%). The significant differences between patients with minimal depression compared to mild to severe depression were NYHA class (chi2=14.05, P=.003), maximal oxygen uptake (t=2.62, P=.010), 6-minute walk distance (t=4.22, P < .001), beta-blocker therapy (chi2=15.21, P < .001), perceived control (t=7.93, P < .001), and neuroticism (t=-8.85, P < .001).

CONCLUSIONS

More than half the patients studied did not report experiencing significant depression. In those who did, both physical and psychosocial variables accounted for 48.6% of the variance. These findings warrant further research and indicate a need to test interventions aimed at enhancing perceived control, reducing neuroticism, and meeting educational needs to reduce depression in patients with heart failure.

Outcome of exercise training on the long-term burden of hospitalisation in patients with chronic heart failure. A retrospective study

AIMS

Heart failure is a major cause of hospitalisation, particularly in patients more than 65 years of age in the western world. A common endpoint in studies designed to evaluate treatment effects in heart failure is mortality and morbidity, often reported as an event of hospitalisation. It has recently been reported that this endpoint is misleading with respect to the burden of the disease with regard to the patient, the health service and costs. Furthermore, it can be hypothesized that different treatment effects are better evaluated using more sensitive parameters than those traditionally used in clinical studies. Short-term beneficial effects of exercise training in heart failure patients have previously been showed. Therefore, the aim of this study was to evaluate the long-term effects of exercise training in heart failure patients with regard to different outcome parameters. METHOD AND STUDY GROUP: Patients with chronic heart failure, stabilised on pharmacological treatment, who had participated in a physical training program for 8 weeks, were analysed retrospectively after 5 years. The study group was compared to a matched control group which received conventional treatment and was diagnosed during the same period but not participating in a training program.

RESULTS

Exercise training in heart failure patients resulted in significantly less hospitalisation events (2+/-3 vs. 3+/-3, p<0.05) and hospitalisation days (10+/-17 vs. 20+/-27, p<0.05) due to cardiac problems at 5 years after follow-up. Exercise training did not effect mortality.

CONCLUSION

Long-term effects of exercise training on burden of disease in chronic heart failure patients is associated with significantly less events and days of hospitalisation due to worsening of cardiac disease.

NT-ProBNP reduction percentage during admission for acutely decompensated heart failure predicts long-term cardiovascular mortality

BACKGROUND

N-terminal brain natriuretic peptide (NT-proBNP) improves emergency room diagnosis of acutely decompensated heart failure. Less evidence is available on the usefulness of NT-proBNP as a prognostic marker after hospitalization for acute heart failure. The percentage of NT-proBNP reduction during admission and its prognostic significance were studied.

METHODS AND RESULTS

This was a prospective study of 74 patients in the emergency department who were diagnosed with acute heart failure and who had follow-up evaluation for 6 and 12 months after admission. Plasma NT-proBNP concentrations were measured on admission, at 24 hours, at day 7, and at 6 and 12 months. Eighteen patients died during the 12-month follow-up; 12 deaths were from cardiovascular causes. NT-proBNP concentrations were significantly higher in the emergency department and at 24 hours than those concentrations that were found at day 7 and beyond (P < .001). During admission, the NT-proBNP concentration fell a mean of 15% in patients who died of cardiovascular causes during the 1-year follow-up evaluation, in 75% in those patients who died of non-cardiovascular causes, and in 50% in survivors (P = .004). The area under the receiver operator characteristic curve for NT-proBNP reduction percentage to predict cardiovascular death was 0.78 (95% CI, 0.66-0.90; P = .002). A 30% NT-proBNP reduction percentage cutoff value had 75% accuracy for the identification of high-risk patients and was the only variable that was associated with cardiovascular death in multivariate analysis (odds ratio, 4.4; 95% CI, 1.12-17.4; P = .03).

CONCLUSION

NT-proBNP reduction percentage during admission for acutely decompensated heart failure appeared to be the best predictor of cardiovascular death during the follow-up period. A <30% NT-proBNP reduction percentage identified a subgroup of high-risk patients.

The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study

AIMS

To assess the quality of life of patients with heart failure, due to left ventricular dysfunction (NYHA class III or IV), taking optimal medical therapy using baseline quality of life assessments from the CArdiac REsynchronisation in Heart Failure (CARE-HF) trial, and to evaluate the appropriateness of using the EQ-5D in patients with heart failure.

METHODS AND RESULTS

The quality of life of patients enrolled in CARE-HF was evaluated using the EQ-5D and Minnesota Living with Heart Failure Questionnaire. Response rates for the instruments were >90% and statistical modelling revealed an association between EQ-5D and Minnesota Living with Heart Failure scores. Heart failure is shown to have an important impact on all aspects of quality of life, but particularly on patients' mobility and usual activities, and leads to significant reductions in comparison with a representative sample of the UK population.

CONCLUSIONS

The impact of heart failure varies amongst patients but the overall burden of disease appears to be comparable to other chronic conditions such as motor neurone or Parkinson's disease. The EQ-5D appears to be an acceptable valid measure for use in patients with heart failure although further evidence of the responsiveness of this measure in such patients is required.

Survival and Quality of Life After Cardiac Surgery Complicated by Prolonged Intensive Care

AIM

To determine survival, factors determining survival and evaluate quality of life (QOL) after 1 year, in patients who had prolonged intensive care unit (ICU) stay after cardiac surgery.

METHODS

In the year 2001, 804 patients underwent various cardiac procedures utilising cardiopulmonary bypass (CPB). Eighty-nine consecutive patients requiring ICU stay of > or = 5 days constituted the study group, majority of these suffered from multiorgan failure (> 2 organ systems). Survival was determined in the study group after 1 year. Patients with an uncomplicated postoperative course were matched to the survivors in the study group with respect to age, gender, type of surgery, risk scores, and duration of follow-up and constituted the control group. The, Short Form Health Survey was used to assess QOL at the end of 1 year in these patients. QOL was compared between the study group and the control group and to that of general population.

RESULTS

Seventy percent of the patients in the study group suffered from failure of at least three organ systems. Mean ICU stay was 13 +/- 3 days (median nine, maximum 53). At the end of 1 year the mortality in the study group was 34%. The independent predictors of mortality were: preoperative cardiac support, lower ejection fraction, higher Parsonnet score, higher Euroscore, pulmonary complications, renal failure necessitating hemofiltration, CNS complications, and failure of three or more organ systems. The QOL was lower in the study group than the control group in all eight dimensions measured (significant in five p < 0.05): Physical function, Role physical, Vitality, Mental health, General health, and Bodily pain.

CONCLUSION

One year mortality in patients with prolonged ICU stay after cardiac surgery remains high. Identification of risk factors will help to reduce the mortality with help of regular follow up. The QOL remains low in all dimensions especially those measuring physical aspects and pain.

Health status in patients with sub-clinical hypothyroidism

OBJECTIVE

Sub-clinical hypothyroidism (SCH) is a common disorder. People with this condition may have symptoms which could affect their perception of health. Therefore, the perceived health status of people with SCH was assessed and compared with population-matched norms.

DESIGN

A prospective cross-sectional survey.

METHODS

Seventy-one adults with SCH, age range 18-64 years were studied. Perceived health status was measured by the Short Form-36 (SF-36) version 2 questionaire, which has been validated in a UK population setting. The SF-36 has eight scales measuring physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. Their SF-36 scores were compared with UK normative data after matching for age and sex and are reported as z-scores.

RESULTS

Scores of all eight SF-36 scales were significantly lower in people with SCH compared with the normative population. A negative score (compared with zero of the normative population) indicates worse health status. The most significantly impaired aspects of health status were vitality and role limitations due to physical problems (role physical scale) with z-scores (95% confidence intervals) of -1.01 (-0.74 to -1.29) and -0.73 (-0.43 to -1.04) respectively. Thyroid autoimmunity did not influence the results.

CONCLUSION

Perceived health status is significantly impaired in people with SCH when compared with UK normative population scores. This needs to be taken into consideration by clinicians when managing patients with this disease.

Construct validity of activities of daily living scale: a clue to distinguish the disabling effects of COPD and congestive heart failure

STUDY OBJECTIVES

To assess differences, if any, in the pattern of disability measured using basic activities of daily living (BADL) and instrumental activities of daily living (IADL) in COPD and congestive heart failure (CHF), using diabetes mellitus as a reference noncardiorespiratory disabling condition.

DESIGN

Multicenter survey.

SETTING

General medicine or geriatric wards in tertiary hospitals throughout Italy.

PATIENTS

Patients admitted because of CHF (n = 432), COPD (n = 305), and diabetes mellitus (n = 534).

MEASUREMENTS AND RESULTS

Construct validity of self-reported preadmission BADL-IADL was assessed for each group by main component analysis. The three populations had a comparable average degree of dependency in BADL-IADL. In both CHF and diabetes mellitus patients, three components cumulatively explained most of variance in BADL-IADL: the BADL, 10 IADL, and 4 housework-related IADL. In COPD, a four-factor solution was generated, with factor 4 having loading with IADL items assessing mobility and outdoor moving, and factor 3 with selected IADL requiring both physical and mental capabilities such as managing money, taking medicine, and traveling. Correlates of dependency in IADL related to factor 4 in COPD were older age, cognitive impairment, widowhood, and comorbidity. Both factors 3 and 4 were associated with longer stay (factor 3: 13.9 +/- 9.5 days vs 11.5 +/- 7.6 days, p < 0.05; factor 4: 14.2 +/- 8.8 days vs 11.0 +/- 5.5 days, p < 0.05) of COPD patients (mean +/- SD).

CONCLUSION

COPD was associated with a distinctive pattern of disability expressed by loss of selected BADL-IADL but not by the crude number of lost BADL-IADL.

Why is depression bad for the failing heart? A review of the mechanistic relationship between depression and heart failure

BACKGROUND

Depression is 4 to 5 times as common in heart failure (HF) patients as in the general population, might confer a higher risk of developing HF, and negatively affects prognosis in established HF.

METHODS AND RESULTS

A review was undertaken via Medline (1966-2003) and PsycINFO (1872-2003) searches using the subject headings "depressive disorder" and "heart failure, congestive." Our findings suggest that the link between depression and HF may be due to shared pathophysiology. Depression may augment catecholamine release, arrhythmias, elaboration of proinflammatory cytokines, and platelet activation--processes that may influence prognosis in HF. Depression is also associated with a higher risk of noncompliance and lower levels of social support, which have been shown to worsen prognosis in HF. The impact of pharmacologic or behavioral treatment for depression on physiologic parameters or clinical outcomes in HF remains unclear. Inherent difficulties in recognition of depression in the setting of HF may decrease the likelihood that depressed patients receive the treatment they need.

CONCLUSIONS

Depression is common in HF, may contribute to the development of HF in susceptible populations, and is independently predictive of poor clinical outcomes. Pathophysiologic pathways and psychosocial issues that are shared between the 2 conditions might explain these observations and represent potential therapeutic targets. Vigilant attention to the recognition and treatment of depression in HF patients is warranted.

Implementation of guidelines for management of heart failure in heart failure clinic: effects beyond pharmacological treatment

BACKGROUND

Patients with heart failure have scarce knowledge of their condition and frequently report poor quality of life. In spite of numerous studies showing improvement of survival and reduction in hospitalizations, several epidemiological studies showed that substantial proportion of patients are not receiving appropriate treatment. Intensive multidisciplinary approach can improve management of the patients with heart failure.

AIM

To assess the efficacy of intensive patient management in heart failure clinic with respect to patient knowledge, pharmacological management, and quality of life.

METHODS

From outpatients, visiting the heart failure clinic in period form March 2002 to March 2003, we prospectively enrolled patients with heart failure due to systolic dysfunction. Patient knowledge about their condition was assessed by a knowledge questionnaire. Data on their clinical characteristics, diagnostic and pharmacological management were analyzed. Quality of life was assessed with Minnesota Living with Heart Failure Questionnaire (MLHFQ). Patients rated their quality of life and heath on a seven-category descriptive scale from 1 (best) to 7 (worst). Data are shown as mean (S.D.).

RESULTS

In this period we treated 50 patients (33 men), aged 67 (12) years. Patient knowledge about their condition improved after two visits to heart failure clinic (4.8 (1.5) vs. 7.3 (1.4), p<0.001). More patients were treated with beta blockers (40% vs. 84%, p<0.001) while there was a positive trend for treatment with angiotensin-converting enzyme inhibitors (94% vs. 98%) and spironolactone (54% vs. 70%). Equivalent mean daily dose of enalapril (11.0 (11.0) mg to 16.7 (8.7) mg, p<0.001) and carvedilol (13.0 (11.5) mg to 32.1 (18.2) mg, p<0.001) increased. Out-patient management was associated with improvement of MLHFQ score (47 (18) vs. 34 (16)), NYHA class (2.9 (0.4) vs. 2.5 (0.7)), quality of life score (5.3 (1.1) vs. 3.7 (1.0)), and health score (5.1 (1.1) vs. 3.7 (1.1)) (p<0.001 for all).

CONCLUSIONS

Intensive management in heart failure clinic can be effective for translation of guidelines into clinical practice. It also improves patient's knowledge and quality of life as well as reduces the hospitalizations in heart failure patients.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.

Torasemide vs. furosemide in primary care patients with chronic heart failure NYHA II to IV--efficacy and quality of life

BACKGROUND

The hypothesis was that torasemide, due to more predictable pharmacokinetics/pharmacodynamics, induces greater improvements in functional and social limitation than furosemide and reduces the frequency of hospitalisations in primary care patients with chronic heart failure (CHF).

PATIENTS AND METHODS

Prospective, randomized, unblinded study in primary care, 237 patients with CHF (NYHA II-IV), all on ACE inhibitors. Randomisation: torasemide (n=122) or furosemide (n=115), treated for 9 months.

ENDPOINTS

Clinical efficacy, quality of life, safety, tolerability, hospitalisations.

RESULTS

Clinical improvement was observed in both groups, but the trend to improve by at least one NYHA class was significant only in torasemide- (P=0.014), but not in furosemide-treated patients. There were no differences with regard to adverse events and hospitalisation due to CHF. Overall, tolerability (P=0.0001) and improvement in daily restrictions (P=0.0002) were significantly higher, number of mictions at 3, 6 and 12 h after diuretic intake (P<0.001 at all time points) and urgency to urinate (P<0.0001) significantly lower in torasemide- vs. furosemide-treated patients.

CONCLUSION

CHF patients treated with torasemide gain a higher benefit in quality of life than furosemide treated patients, due to torasemide's dual effect on both clinical status and social function.

N-terminal probrain natriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patients with dyspnoea and ventricular dysfunction

OBJECTIVE

To evaluate the utility of NT-proBNP in the emergency diagnosis and in-hospital monitoring of patients with acute dyspnoea and ventricular dysfunction.

BACKGROUND

Misdiagnosis of heart failure (HF) is common in the urgent care setting using clinical diagnostic tests. Reports show that BNP is useful to diagnose HF in patients with acute dyspnoea.

METHODS

Prospective study of 100 patients attending the Emergency Department (ED) for acute dyspnoea. Final diagnosis was determined on the basis of ED data sheets, echocardiography and pulmonary function tests. NT-proBNP levels were obtained on admission, at 24 h and at day 7.

RESULTS

Patients with ventricular dysfunction were sub-classified into decompensated HF and masked HF, defined as HF with concomitant signs of pulmonary disease. Decompensated and masked HF patients had significantly higher NT-proBNP values than patients with non-cardiac dyspnoea (normal ventricular function) (920+/-140 and 978+/-363 vs. 50+/-15 pmol/L; P<0.001 and P<0.01, respectively). The mean area under the ROC curve for NT-proBNP was 0.957 (95% CI, 0.918 to 0.996, P<0.001). In multiple logistic-regression analysis NT-proBNP>115 pmol/l was the strongest independent predictor of ventricular dysfunction (odds ratio 45.4; 95% CI: 4.5-452.3). At day 7, a significant and similar reduction in NT-proBNP was observed in the two groups of patients with ventricular dysfunction (P<0.001 vs. admission values), but complete clinical resolution was less frequent in masked HF patients (P<0.05 vs. decompensated HF).

CONCLUSIONS

NT-proBNP is a new candidate marker for the detection and exclusion of ventricular dysfunction in patients attending the ED for acute dyspnoea. NT-proBNP may also serve to monitor outcome during hospitalization.

Health-related quality of life in patients with cardiovascular disease--the effect of upper gastrointestinal symptom treatment

BACKGROUND

Upper gastrointestinal discomfort decreases the already impaired health status of patients with cardiovascular disease.

AIM

To evaluate whether acid suppressive therapy improves health-related quality of life in patients who developed upper gastrointestinal symptoms after starting low-dose acetylsalicylic acid.

METHODS

In a double-blind, placebo-controlled randomized trail, cardiac patients using low-dose (80 mg) acetylsalicylic acid with (n = 142) and without (n = 90) upper gastrointestinal symptoms were included. Patients with symptoms were treated with rabeprazole or placebo for 4 weeks. At baseline and 4 weeks information about gastrointestinal symptoms and health-related quality of life was assessed.

RESULTS

The 73 patients assigned to rabeprazole when compared with 69 patients given placebo reported the same quality of life scores 4 weeks after randomization. The differences in quality of life scores between patients with and without symptoms at baseline remained after 4 weeks. Patients in whom treatment led to complete symptom relief or those who remained symptom-free reported significantly higher scores for Physical Component Summary (P < 0.01) and Mental Component Summary (P < 0.01), when compared to those with persistent symptoms or new onset symptoms.

CONCLUSION

Proton-pump inhibitor therapy did not improve quality of life. Upper gastrointestinal symptom relief in itself considerably increased quality of life.

Heart failure-the importance of ethnicity

Heart failure is a major public health problem in the Western world. Aetiological factors involved in its development include hypertension, diabetes, and ischaemic heart disease--all of which differ in prevalence, and possibly mechanism, between patients of differing ethnicity. Unfortunately, epidemiological and therapeutic trials have involved almost exclusively white populations, and evidence from these trials cannot necessarily be assumed to be generalisable to populations that include high proportions of patients from other ethnic origins. This review will discuss the mechanistic and therapeutic differences that exist in heart failure between those of European origin, and patients from the major ethnic minority groups of the UK.

Effect of drug therapy for heart failure on quality of life

Symptomatic heart failure interferes with a patient's quality of life (QOL) by limiting his or her ability to perform physical tasks and daily activities and by lowering his or her sense of psychological well-being. Therefore, in addition to decreasing mortality and morbidity, improving QOL should be an important goal when selecting pharmacotherapy. QOL questionnaires, both generic and disease specific, are used widely, but in randomized controlled trials of heart failure treatments, QOL has not been a routine study end point. Beta blockers and angiotensin-converting enzyme inhibitors, medications widely used in the management of heart failure and hypertension--one of the most common causes of heart failure--have been associated with negative, neutral, and modestly positive QOL effects. Angiotensin receptor blockers, combined with other therapy, including angiotensin-converting enzyme inhibitors (usually with a diuretic) and/or b blockers in heart failure, have produced improvements in QOL. Patients with hypertension whose blood pressure has been lowered have also experienced an improvement in QOL scores. With current heart failure regimens prolonging life, improving QOL becomes an even more essential end point in assessing the effectiveness of new medications, whether used alone or in combination with standard therapy.

Therapeutic exercise for individuals with heart failure: special attention to older women with heart failure

BACKGROUND

A cardinal feature of heart failure (HF) is the reduced peak aerobic power (VO(2peak)) secondary to alterations in cardiovascular and musculoskeletal function. Methods and results During the last decade, a number of randomized trials have examined the role that exercise training plays in attenuating the HF-mediated decline in VO(2peak) and muscle strength. The major finding of these investigations was that aerobic or strength training was an effective intervention to increase VO(2peak), muscular strength, distance walked in 6 minutes, and quality of life without negatively altering left ventricular systolic function. Despite these benefits, a limitation of these investigations was the primary focus on males <60 years with impaired left ventricular systolic function. Thus the role that exercise training may play in attenuating the HF-mediated decline in VO(2peak) in women > or =65 years of age remains unknown.

CONCLUSION

Older women with HF have a VO(2peak) that is below the minimal threshold level required for independent living. Moreover, older women with HF have greater disability then men and are less likely to be referred to an exercise rehabilitation program. Accordingly, future exercise intervention trials are required to examine the role that exercise training may play in attenuating the HF-mediated decline in cardiorespiratory and musculoskeletal fitness and disability in older women with HF.

Effect of rate or rhythm control on quality of life in persistent atrial fibrillation

OBJECTIVES

We studied the influence of rate control or rhythm control in patients with persistent atrial fibrillation (AF) on quality of life (QoL).

BACKGROUND

Atrial fibrillation may cause symptoms like fatigue and dyspnea. This can impair QoL. Treatment of AF with either rate or rhythm control may influence QoL.

METHOD

Quality of life was assessed in patients included in the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) study (rate vs. rhythm control in persistent AF). Rate control patients (n = 175) were given negative chronotropic drugs and oral anticoagulation. Rhythm control patients (n = 177) received serial electrocardioversion, antiarrhythmic drugs, and oral anticoagulation, as needed. Quality of life was studied using the Short Form (SF)-36 health survey questionnaire at baseline, one year, and the end of the study (after 2 to 3 years of follow-up). At baseline, QoL was compared with that of healthy control subjects. Patient characteristics related to QoL changes were determined.

RESULTS

Mean follow-up was 2.3 years. At baseline, QoL was lower in patients than in age-matched healthy controls. At study end, under rate control, three subscales of the SF-36 improved. Under rhythm control, no significant changes occurred compared with baseline. At study end, QoL was comparable between both groups. The presence of complaints of AF at baseline, a short duration of AF, and the presence of sinus rhythm (SR) at the end of follow-up, rather than the assigned strategy, were associated with QoL improvement.

CONCLUSIONS

Quality of life is impaired in patients with AF compared with healthy controls. Treatment strategy does not affect QoL. Patients with complaints related to AF, however, may benefit from rhythm control if SR can be maintained.

Congestive heart failure patients' perceptions of quality of life: the integration of physical and psychosocial factors

Congestive heart failure (CHF) lowers survival and worsens the quality of life (QOL) of over four million older Americans. Both clinicians and standardized instruments used to assess the QOL of patients with CHF focus primarily on physical symptoms rather than capturing the full range of psychosocial concerns. The purpose of this study was to gather descriptions of the components of QOL as understood by patients living with CHF. Focus groups were conducted with patients with known CHF, New York Heart Association (NYHA) class I-IV, and left ventricular fraction of <40%. Focus groups were audiotaped, transcribed, and reviewed for common and recurrent themes using the methods of constant comparisons. We conducted three focus groups (n = 15) stratified by NYHA stage with male patients ranging in age from 47-82 years of age. Five patients were classified with NYHA stage III/IV and ten with NYHA stage I/II. Thirty attributes of QOL were identified which fell into five broad domains: symptoms, role loss, affective response, coping, and social support. Expectedly, patients reported the importance of physical symptoms; however, participants also identified concern for family, the uncertainty of prognosis, and cognitive function as dimensions of QOL. Changes in patients' lives attributed to CHF were not always considered deficiencies; rather, methods of coping with CHF were identified as important attributes representing possible opportunities for personal growth. Clinicians must understand the full range of concerns affecting the QOL of their older patients with CHF. The findings suggest that psychosocial aspects and patient uncertainty about their prognosis are important components of QOL among CHF patients.

Epidemiology and clinical aspects of congestive heart failure

Congestive heart failure (CHF) is an increasing problem for healthcare systems in all developed countries. The prevalence is increasing partly due to ageing of the population, but also due to improved survival from acute cardiac disease such as myocardial infarction. Advances in diagnostic techniques and better understanding of the pathophysiology offer many opportunities for substantial improvement in the management of CHF. This article reviews the current epidemiology of CHF and the related diagnostic issues.

[Quality of life in patients with vasovagal syncope. Clinical parameters influence]

BACKGROUND AND OBJECTIVE

The prevalence and morbidity of the vaso-vagal syncope are well-known. With the intention of measuring the Quality of Life (QoL) of patients with vaso-vagal syncope, as well as age and gender influence, we have used the Spanish version of Short form 36 (SF-36) questionnaire in those patients and have compared it with the general population and with patients with heart failure.

PATIENTS AND METHOD

All consecutive patients with vaso-vagal syncope submitted for head-up tilt test performance from January 2001 to December 2002 were included. SF-36 was self-administered prior to the head-up tilt test.

RESULTS

Two hundred and seventy one patients were included (50.5% females). In these patients, QoL scores were lower than those of the Spanish general population and similar to those in patients with heart failure. Women's scores were lower in eight dimensions, and only four were lower in men's. Women QoL was worst than men's (p < 0.05). Age had a negative influence on the eight dimensions of SF-36, especially in women. The number of syncopes was the most influential clinic parameter on the QoL of such patients.

CONCLUSIONS

In our series, patients suffering from vaso-vagal syncope had a poor QoL when compared with heart failure or control populations. Women had lower QoL than men, and there was an age-related worsening in both men and women. Our data show that the number of syncopes is the clinic parameter having the best correlation with QoL.