Using health-related quality of life to predict cardiovascular disease events

Efficacy and Safety of Inclisiran in Patients with Polyvascular Disease: Pooled, Post Hoc Analysis of the ORION-9, ORION-10, and ORION-11 Phase 3 Randomized Controlled Trials

PURPOSE

Patients with polyvascular disease (PVD) are at very high cardiovascular risk and require intensive lipid-lowering therapy. This analysis describes the lipid-lowering efficacy and safety of inclisiran versus placebo in patients with and without PVD.

METHODS

In this post hoc analysis of the ORION-9, ORION-10, and ORION-11 trials, patients were randomized 1:1 to receive 284 mg inclisiran (300 mg inclisiran sodium) or placebo on day 1, day 90, and 6-monthly thereafter. Percentage change in low-density lipoprotein cholesterol (LDL-C) from baseline to day 510 and corresponding time-adjusted change from day 90 and up to day 540 were evaluated per patients' PVD status. Safety was assessed over 540 days.

RESULTS

Of 3454 patients, 470 (13.6%) had PVD, and 2984 (86.4%) did not. Baseline characteristics were generally balanced between the treatment arms in both cohorts. A greater proportion of patients with PVD had comorbidities versus those without. The mean (95% confidence interval [CI]) placebo-corrected LDL-C percentage change from baseline to day 510 was -48.9% (-55.6 to -42.2) in patients with PVD and -51.5% (-53.9 to -49.1) in patients without. Proportions of patients with reported treatment-emergent adverse events (TEAEs) and treatment-emergent serious adverse events were similar between treatment arms, irrespective of PVD status, except for an excess of mild or moderate clinically relevant TEAEs at the injection site with inclisiran.

CONCLUSION

Twice-yearly inclisiran dosing (after the initial and 3-month doses) was well tolerated and provided effective and sustained lipid-lowering in patients, irrespective of PVD status.

Mediational pathways exploring the link between adverse childhood experiences and physical health in a transgender population

BACKGROUND

Adverse childhood experiences (ACEs) consist of instances of abuse, neglect, or household dysfunction occurring before adulthood. Prevalence rates of ACEs are higher among specific populations, including gender minorities. In addition to ACEs, transgender individuals (TG) face many personal, social, and structural factors that have the potential to negatively impact their physical health.

OBJECTIVE

This study examines exploratory mediational pathways between ACEs and two health outcomes (i.e., general health and days physically ill) in TG. Mediators include everyday discrimination, social support, gender non-affirmation, and mental distress.

METHODS

Cross-sectional data from the U.S. Transgender Population Health Survey (TransPop) was used to conduct a serial/parallel mediation analysis. The TransPop survey included a total of 274 TG.

RESULTS

For both outcome variables, the same three indirect pathways were significant. First, ACEs were associated with increased mental distress, which was associated with a decrease in general health and an increase in days physically ill. Second, ACEs were associated with increased discrimination, which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill. Finally, ACEs were associated with discrimination, which was associated with increased gender non-affirmation which was associated with increased mental distress, and this was associated with a decrease in general health and an increase in days physically ill.

CONCLUSION

Interventions focused on reducing discrimination, gender non-affirmation, and poor mental health may be vital to improving the health of TG and to mitigating the indirect role of ACEs on TG health.

Associations of Health-Related Quality of Life and Sleep Disturbance With Cardiovascular Disease Risk in Postmenopausal Breast Cancer Survivors

BACKGROUND

Breast cancer (BC) survivors are at an increased risk of long-term cardiovascular disease (CVD), often attributed to cancer treatment. However, cancer treatment may also negatively impact health-related quality of life (HRQoL), a risk factor of CVD in the general population.

OBJECTIVE

We examined whether sleep disturbance, and physical or mental HRQoL were associated with CVD risk in BC survivors.

METHODS

We conducted a longitudinal analysis in the Women's Health Initiative of postmenopausal women given a diagnosis of invasive BC during follow-up through 2010 with no history of CVD before BC. The primary outcome was incident CVD, defined as physician-adjudicated coronary heart disease or stroke, after BC. Physical and mental HRQoL, measured by the Short-Form 36 Physical and Mental Component Summary scores, and sleep disturbance, measured by the Women's Health Initiative Insomnia Rating Scale, were recorded post BC. Time-dependent Cox proportional hazards models were used starting at BC diagnosis until 2010 or censoring and adjusted for relevant confounders.

RESULTS

In 2884 BC survivors, 157 developed CVD during a median follow-up of 9.5 years. After adjustment, higher Physical Component Summary scores were significantly associated with a lower risk of CVD (hazard ratio, 0.90 [95% confidence interval, 0.81-0.99]; per 5-point increment in Physical Component Summary). No associations with CVD were found for Mental Component Summary or Insomnia Rating Scale.

CONCLUSION

In BC survivors, poor physical HRQoL is a significant predictor of CVD.

IMPLICATIONS FOR PRACTICE

Our findings highlight the importance for nurses to assess and promote physical HRQoL as part of a holistic approach to mitigating the risk of CVD in BC survivors.

Association between healthy lifestyle factors and health-related quality of life among Chinese adolescents: the moderating role of gender

BACKGROUND

To examine the associations of the independent and combined healthy lifestyle factors with health-related quality of life (HRQOL) in adolescents, and to test the moderating role of gender.

METHODS

This cross-sectional study included 5125 adolescents aged between 11 and 20 years. They provided self-reported data on six healthy lifestyle factors, including never smoking, never drinking, good sleep quality, sufficient sleep duration, appropriate Internet use, and adequate physical activity. Adolescents' HRQOL was evaluated using the Pediatric Quality of Life Inventory version 4.0. Linear regression models were conducted to explore the association of individual and combined healthy lifestyle factors with adolescents' HRQOL. We further performed stratified analyses and likelihood ratio test to explore the moderating role of gender in these associations.

RESULTS

Of the included adolescents, the proportions with 0-2, 3, 4, and 5-6 healthy lifestyle factors were 13.6%, 26.4%, 44.3%, and 15.7%, respectively. Compared to adolescents with composite healthy lifestyle scores of 0-2, those with scores of 3, 4, or 5-6 had significantly higher HRQOL scores across all dimensions, summary scales, and total scale in both unadjusted and adjusted models. Specifically, adolescents with 5-6 healthy lifestyle factors had a total scale score that was 19.03 (95%CI: 17.76 to 20.30) points higher than their counterparts who only had 0-2 healthy lifestyle factors. Significant dose-response patterns were also observed in aforementioned associations. Gender was a significant moderator in the associations between composite healthy lifestyle groups and HRQOL scores, except for the social functioning dimension.

CONCLUSIONS

Our results confirmed that combined healthy lifestyle factors were associated with improved HRQOL among adolescents, with a stronger association observed in girls. These findings underscore the necessity for education and healthcare authorities to design health-promoting strategies that encourage multiple healthy lifestyle factors in adolescents, with the objective of enhancing their overall health outcomes.

Positivity and Health Locus of Control: Key Variables to Intervene on Well-Being of Cardiovascular Disease Patients

Psychological well-being is a good predictor of several health outcomes in cardiovascular disease patients (adherence, quality of life, and healthy behaviors). The perception of health control and a positive orientation seem to have a beneficial effect on health and well-being. Therefore, the aim of this study was to investigate the role of the health locus of control and positivity in the psychological well-being and quality of life of cardiovascular patients. A total of 593 cardiac outpatients completed the Multidimensional Health Locus of Control Scale, the Positivity Scale and the Hospital Anxiety and Depression Scale at baseline (January 2017) and 9 m later (follow-up; n = 323). A Spearman rank correlation coefficient and a structural equation modeling approach were determined to explore the relationships between those variables both cross-sectionally and longitudinally. A cross-sectional correlation analysis at baseline revealed that the internal health locus of control and positivity were negatively associated with anxiety (rs = -0.15 and -0.44, ps < 0.01) and depression (rs = -0.22 and -0.55, ps < 0.01) and positively associated with health-related quality of life (rs = 0.16 and 0.46, ps < 0.01). Similar outcomes were found at follow-up and in longitudinal correlations. According to the path analysis, positivity was found to be negatively associated with anxiety and depression level at baseline (β = -0.42 and -0.45, ps < 0.001). Longitudinally, positivity was negatively associated with depression (β = 0.15, p < 0.01) and together with the internal health locus of control, was positively associated with health-related quality of life (β = 0.16 and 0.10, respectively, ps < 0.05). These findings suggest that focusing on the health locus of control and especially positivity may be crucial in enhancing the psychological well-being of patients in the context of cardiac care. The potential impact of these results on future interventions is discussed.

Maternal adverse childhood experiences and health-related quality of life in preschool children: a cross-sectional study

BACKGROUND

The intergenerational association between maternal adverse childhood experiences (ACEs) and their children's health-related quality of life (HRQOL) is underexplored. This study aimed to examine such association in Chinese preschool children and to test the moderation role of children's sex.

METHODS

A cross-sectional study was conducted among 4243 mother-child dyads who attended randomly selected preschools. Mothers self-reported their experience of 12 forms of ACEs, including emotional abuse, physical abuse, emotional neglect, physical neglect, intimate partner violence, substance abuse in the household, incarcerated household member, mental illness in household, parental death, parental separation or divorce, bullying, and community violence. Children's HRQOL was evaluated through mother report of the Pediatric Quality of Life Inventory version 4.0. Linear regression models were established to estimate the associations between maternal ACEs and their children's HRQOL sub-scores and total scores. Stratified analysis and test for interaction were further conducted to evaluate whether the associations were moderated by children's sex.

RESULTS

Of the included mothers, 85.8% (n = 3641) had reported exposure to at least one ACE, and 22.3% (n = 948) were exposed to three or more ACEs. Compared to children of mothers without any ACE exposure, those of mothers with 1, 2, or ≥ 3 ACEs all had significantly lower scores of physical, social, and school functioning, as well as lower psychosocial health summary score and total scale score in both crude and adjusted models. However, only children of mothers with two or more ACEs had significantly poorer emotional functioning when compared to their counterparts whose mothers had no ACE exposure. A significant dose-response pattern was also observed between the number of maternal ACEs and children's HRQOL sub-scores and total scores. Stratified analysis revealed sex-specific pattern between maternal ACEs and their children's HRQOL. Nonetheless, children's sex was not a significant moderator.

CONCLUSIONS

Our study showed that preschool children of mothers who had any experience of ACEs were at risk of poorer HRQOL. Our findings indicated that screening maternal ACEs in young children and promoting targeted interventions might be a feasible way to mitigate or stop the potential negative intergenerational health and wellbeing implications of ACEs.

Sense of vitality is associated with cardiovascular events in type 2 diabetes independently of traditional risk factors and arterial stiffness

AIMS

The aim of this study was to determine if single items in the quality of life questionnaire short form 36 (SF36) were associated with cardiovascular events in patients with type 2 diabetes mellitus (T2DM).

METHODS

In 756 T2DM patients (260 women) from the CARDIPP study, nine questions from the domains vitality and well-being in SF36 were analysed. Patients, 55-66 years, were recruited in 2005-2008 and followed up until 31 December 2018 for the incidence of major adverse cardiovascular events (MACE), that is, myocardial infarction, stroke or cardiovascular death.

RESULTS

Median follow-up time: 11.6 years, during which 119 (16%) MACE occurred. The SF36 items: 'seldom full of pep' (HR 1.2, 95% CI: 1.1-1.4, p = 0.006), 'seldom a lot of energy' (HR 1.3, 95%CI: 1.1-1.5, p < 0.001), 'worn out' (HR 1.2, 95%CI: 1.0-1.4, p = 0.020) and 'seldom happy' (HR 1.2, 95%CI: 1.0-1.4, p = 0.012) were independent risk factors for MACE in separate models, as well as male sex, diabetes duration, HbA1c , sagittal abdominal diameter and aortic pulse wave velocity. The variables 'seldom full of pep' and 'seldom a lot of energy' remained associated with MACE when conducting separate analyses for sexes. Only 'seldom a lot of energy' remained associated with MACE when all items from SF-36 were comprised in the same model.

CONCLUSIONS

One single question regarding energy levels from SF36 may be used as an independent risk factor for cardiovascular events in T2DM patients in primary care, for both men and women. This item may be included in future risk assessment for use in clinical practice for cardiovascular risk stratification of T2DM patients.

TRIAL REGISTRATION

The study was registered in clinicaltrial.gov (NCT01049737) in 14 January 2010.

Medical Fuzzy-Expert System for Assessment of the Degree of Anatomical Lesion of Coronary Arteries

BACKGROUND

Today, cardiovascular diseases cause 47% of all deaths among the European population, which is 4 million cases every year. In Ukraine, CAD accounts for 65% of the mortality rate from circulatory system diseases of the able-bodied population and is the main cause of disability. The aim of this study is to develop a medical expert system based on fuzzy sets for assessing the degree of coronary artery lesions in patients with coronary artery disease.

METHODS

The method of using fuzzy sets for the implementation of an information expert system for solving the problems of medical diagnostics, in particular, when assessing the degree of anatomical lesion of the coronary arteries in patients with various forms of coronary artery disease, has been developed.

RESULTS

The paper analyses the main areas of application of mathematical methods in medical diagnostics, and formulates the principles of diagnostics, based on fuzzy logic. The developed models and algorithms of medical diagnostics are based on the ideas and principles of artificial intelligence and knowledge engineering, the theory of experiment planning, the theory of fuzzy sets and linguistic variables. The expert system is tested on real data. Through research and comparison of the results of experts and the created medical expert system, the reliability of supporting the correct decision making of the medical expert system based on fuzzy sets for assessing the degree of anatomical lesion of the coronary arteries in patients with various forms of coronary artery disease with the assessment of experts was 95%, which shows the high efficiency of decision making.

CONCLUSIONS

The practical value of the work lies in the possibility of using the automated expert system for the solution of the problems of medical diagnosis based on fuzzy logic for assessing the degree of anatomical lesion of the coronary arteries in patients with various forms of coronary artery disease. The proposed concept must be further validated for inter-rater consistency and reliability. Thus, it is promising to create expert medical systems based on fuzzy sets for assessing the degree of disease pathology.

Screening for Psychological Distress and Risk of Cardiovascular Disease and Related Mortality: A SYSTEMATIZED REVIEW, META-ANALYSIS, AND CASE FOR PREVENTION

BACKGROUND

Psychological distress-elevated symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), or psychosocial stress-has been associated with risk for cardiovascular disease (CVD). Despite increasing attention to the importance of these factors for CVD prevention, the state of this science requires updated synthesis to enable practice recommendations. Moreover, it is unknown whether psychological distress based on screeners, validated self-report instruments that efficiently identify those who may require mental health services or additional support, is associated with incident CVD.

METHODS

MEDLINE, Embase, and PsycInfo were searched for studies published 2017-2022, including adults without a past psychiatric diagnosis, who were screened at baseline for depression, anxiety, PTSD, stress, or general mental health symptoms, and followed for >6 mo to determine their risk for incident CVD (ie, atrial fibrillation, acute coronary syndrome, coronary heart disease, peripheral vascular disease, heart failure, or a composite). A meta-analysis was used to aggregate results to determine whether clinically significant levels of psychological distress were associated with CVD onset.

RESULTS

The search identified 28 investigations that represented 658 331 participants (58% women). Fifteen studies had adequate data for the primary meta-analysis, which indicated that those reporting high psychological distress showed a 28% greater risk of incident CVD compared with those with low or no distress.

CONCLUSIONS

Rapid screening for psychological distress is a helpful and efficient approach to understanding the CVD risk profile of an individual. Additional investigations are needed to improve prospective evidence concerning psychosocial stress. Conducting analyses by sex may better elucidate the benefits of psychological distress screening for men and women, respectively, and encourage more widespread adoption in CVD prevention.

Health-related quality of life and treatment satisfaction of patients with cardiovascular disease in Ethiopia

Purpose

Cardiovascular disease is the most prevalent health problem associated with poorer health-related quality of life (HRQoL). We aimed to assess HRQoL and treatment satisfaction of cardiovascular disease patients in Ethiopia.

Methods

A cross-sectional survey was conducted among adults attending the outpatient cardiac clinic at Tikur Anbessa Specialized Hospital from July to September 2021. Patients were recruited consecutively during follow-up visits. Treatment Satisfaction Questionnaire for Medication and European Quality of life questionnaires were used to evaluate treatment satisfaction and HRQoL, respectively. Kruskal-Wallis and Mann-Whitney U-tests were used to compare utility weights between patient subgroups. Utility values were computed using disutility weights of the Ethiopian general population derived using a hybrid regression model. Tobit regression modeling was used to explore factors associated with poor HRQoL. Statistical significance was determined at p < 0.05.

Results

A total of 357 patients participated in the study with a mean age of 49.3 ± 17.8 years. The most frequently reported health problems were pain/discomfort (75.4%), followed by mobility (73.4%). The median (interquartile range) European Quality questionnaires five dimensions with five levels utility (EQ-5D-5L) and European Quality of life Visual Analog Scale scores were 0.84 (0.55-0.92) and 70.0 (50.0-85.0), respectively. The highest and lowest mean (standard deviation) treatment satisfaction scores were for the convenience and safety satisfaction dimensions: 87.7 (17.9) and 53.1 (33.5), respectively. Unemployment, older age, previous hospital admission, non-adherence to lifestyle modification, and presence of three or more cardiovascular disease factors were significantly negatively associated with HRQoL.

Conclusions

Overall, the study found that cardiovascular disease had a profound negative effect on HRQoL and patient treatment satisfaction. We suggest that interventions to enhance HRQoL and treatment satisfactions should focus on modifiable associated factors including lifestyle changes and controlling disease progression.

Cardiovascular Disease and Health-Related Quality of Life Among Asian American, Native Hawaiian and Pacific Islander Older Adults

Objectives: Assess the relationship between cardiovascular disease (CVD) and health-related quality of life (HRQOL) among Asian American, Native Hawaiian, and Pacific Islander (NH/PI) compared to white older adults. Methods: Data were from the 2011-2015 Health Outcomes Survey. HRQOL was assessed using the Veterans RAND 12-Item Survey, composed of physical (PCS) and mental component scores (MCS). Lower scores represent worse health. Multivariate regression was conducted to estimate PCS and MCS mean score differences related to self-reported CVD (coronary artery disease, congestive heart failure, myocardial infarction, other heart conditions, stroke) and race/ethnicity. Results: There were marked differences in PCS and MCS scores by disaggregated Asian American and NH/PI subgroups. After adjustment, Asian American and NH/PI older adults had better PCS but worse MCS than white older adults. Race/ethnicity moderated the relationship between CVD and HRQOL. Discussion: Asian American and NH/PI older adults with CVD had poorer mental health compared to their white counterparts.

Multiple mediating effects of self-efficacy and physical activity on the relationship between frailty and health-related quality of life in adults with CVD

AIMS

Poor health-related quality of life is prevalent among individuals with cardiovascular disease (CVD) and may be associated with frailty as well as low levels of self-efficacy and physical activity. This study aimed to identify the multiple mediating effects of exercise self-efficacy and physical activity on the relationship between frailty and health-related quality of life among community-dwelling adults with CVD.

METHODS AND RESULTS

This cross-sectional study included 489 Korean patients aged >20 years diagnosed with CVD. Data were collected through an online survey conducted in June, 2021. The mediation hypothesis was tested using a serial multiple mediation model and the bootstrapping method. Approximately 39.5% of patients in this study were in a frail state. Our main finding revealed that frailty had an indirect effect on health-related quality of life through all three different pathways: each single mediation of exercise self-efficacy and physical activity, and the serial multiple mediation of exercise self-efficacy and physical activity as the first and second mediators, respectively. The direct effect of frailty on the health-related quality of life was also significant.

CONCLUSION

Frail adults with CVD tended to have lower levels of self-efficacy, physical activity, and poor health-related quality of life. Thus, early identification of frailty and interventions targeting the promotion of self-efficacy and physical activity may improve health-related quality of life in adults with CVD. Longitudinal studies are necessary to further refine our findings across other samples and to address the limitations of the current study.

Cardiovascular risk factors and quality of life among stroke survivors in Korea from 2013 to 2018: a cross-sectional cohort study

Background

Although the cardiovascular health and quality of life (QoL) of stroke survivors have been previously studied, no study has investigated the correlation between cardiovascular health and QoL. This study aimed to investigate whether there would be a difference in the quality of life (QoL) in this population depending on the degree of cardiovascular health.

Methods

Overall, 577 people aged > 40 years who participated in the Korea National Health and Nutrition Examination Survey from 2013 to 2018 were included and were divided into three groups according to the survey period (2013–2014, n = 145; 2015–2016, n = 198; and 2017–2018, n = 234). Participants were further divided into the following groups based on their cardiovascular health score, as defined by the American Heart Association: poor, intermediate, and ideal groups. We examined how the health-related QoL score was expressed through the five-dimensional European Quality of Life Questionnaire (EQ-5D-3L).

Results

The ideal (cardiovascular health scores 11–14) and intermediate (cardiovascular health scores 8–10) groups had the lowest (7.72–8.14%) and highest (46.39–57.70%) number of participants, respectively. The total EQ-5D index score was highest in the ideal group, followed by the intermediate and poor groups across all three periods (2013–2014, p = 0.0015; 2015–2016, p = 0.0040; 2017–2018, p < 0.0001). The dimension-specific analysis revealed that, Findings showed that stroke survivors' mobility significantly varied by cardiovascular health scores (p = 0.0371 in 2015–2016, p =0.0486 in 2017–2018), whereas usual activities (p = 0.0322) and pain/discomfort (p = 0.0420) were significantly different among the three groups in 2015–2016.

Conclusion

QoL in post-stroke survivors, when related to cardiovascular health degree, could be correlated with stroke sequelae.

Acute changes in handgrip strength, lung function and health-related quality of life following cardiac surgery

Background

Handgrip strength (HGS), lung function and health-related quality of life (HRQoL) are relevant indicators of future cardiovascular risk and mortality. The impact of cardiac surgery on these predictive variables has been under-explored. The aim of this study was to determine the acute (within hospital) changes in HGS, lung function and HRQoL, and their relationships, in adults undergoing elective cardiac surgery. Further, the study examined the relationship between these variables and the predictors for lung function and HRQoL in these patients.

Methods

The study was a prospective cohort study that involved 101 patients who completed pre-operative (1–2 days before surgery) and physiotherapy discharge (5–7 days after surgery) assessments. Handgrip strength, lung function and HRQoL were assessed using JAMAR dynamometers, Vitalograph-Alpha or EasyOne spirometer, and Short-Form 36 questionnaire, respectively. Changes in these variables and their relationships were analysed using paired t-test and Pearson correlation coefficients, respectively. Prediction of lung function and HRQoL using HGS and other co-variates was conducted using regression analysis.

Results

At the time of physiotherapy discharge, lung function, HGS and the physical component of HRQoL were significantly (<0.001) reduced compared to their pre-operative values. Significant (<0.001) and moderate correlations were identified between HGS and lung function at pre-operation and physiotherapy discharge. Handgrip strength was a significant predictor of lung function pre-operatively but not at physiotherapy discharge. Pre-operative lung function and HRQoL, as well as other variables, were significant predictors of lung function and HRQoL during physiotherapy discharge.

Conclusions

Undergoing cardiac surgery acutely and significantly reduced lung function, HGS and physical component of HRQoL in adults with cardiac disease. Assessment of HGS at physiotherapy discharge may be a poor indicator of operative changes in lung function and HRQoL. Clinicians may consider HGS as an inadequate tool in predicting lung function and HRQoL following cardiac surgery.

Trajectories of physical health-related quality of life and the risk of incident cardiovascular disease events and all-cause mortality in older people

Study objective

The aim of this study was to identify whether physical component score (PCS) of health-related quality of life trajectories over 4.7-years predicted subsequent risk of incident fatal and non-fatal CVD events, and all-cause mortality.

Methods

This study included 16,871 community-dwelling people aged ≥65 years enrolled in the ASPREE (ASPirin in Reducing Events in the Elderly) trial. PCS was assessed annually using the SF-12 (version-2) over a median 4.7-years (i.e. from baseline (2010-2014) till June 2017). Incident CVD events and all-cause mortality occurring after June 2017 until the second-year after the end of the trial were considered. Growth mixture and logistic regression modelling were used.

Results

Four PCS trajectories were identified: high (66.5%), intermediate (13.3%), decline (13.8%), and low (6.5%), and there was subsequently a total of 406 (2.50%) incident CVD events, 197 (1.17%) fatal CVD, and 751 (4.45%) deaths. The declining PCS trajectory group had the highest risk of incident CVD (adjusted OR, 1.51; 95% CI 1.14, 1.99), while the low PCS trajectory group had the greatest risk of fatal CVD (adjusted OR, 1.74; 95%CI 1.06, 2.85) and all-cause mortality (adjusted OR, 1.83; 95%CI 1.40, 2.40). After further adjustment for the baseline PCS score, only the association between declining PCS trajectory and incident CVD (adjusted OR, 1.51; 95%CI 1.11, 2.07) remained.

Conclusion

Our study strengthens the importance of PCS as a predictive measure of CVD and all-cause mortality in older people and also highlights that a declining PCS trajectory could be considered an early predictor of future CVD events.

What really matters: a patient-centered instrument to evaluate health-related quality of life in cardiovascular disease

Aims

Patient-reported outcome measures (PROMs) to assess health-related quality of life (HRQoL) are increasingly used to guide decision-making in cardiovascular care. However, many of the existing PROMs are developed with limited patient involvement and overlook personal health preferences. We aim to develop a cardiovascular disease (CVD)-specific patient-centred preference-based PROM to assess and monitor HRQoL in CVD patients.

Methods and results

A mixed-methods study consisting of several phases was conducted to identify important health items: (i) a scoping literature review, (ii) first- and second-round expert group meetings, (iii) interviews with CVD patients, and (iv) an online survey asking CVD patients to indicate from a large set those health items that are considered the most important. The literature review, expert group meetings, and patient interviews resulted in a list of 55 items potentially important to CVD patients. In total, 666 CVD patients responded to the survey. The following nine items were considered the most important by CVD patients: mobility, activities, self-reliance, fatigue, shortness of breath, chest pain, palpitations, anxiety/worrying, and sexual limitations. An electronic preference-based PROM consisting of these nine items was developed within a cloud-based environment for clinical implementation.

Conclusion

Nine items considered the most important for health by CVD patients were identified and included in a new preference-based patient-centred PROM. This new CVD-specific PROM can be easily implemented using the electronic application and has the potential to improve quality of care for CVD patients.

Assessment of Quality of Life in Patients With Cardiovascular Disease Using the SF-36, MacNew, and EQ-5D-5L Questionnaires

Background Cardiovascular disease (CVD) is responsible for 18 million annual deaths worldwide. CVD affects patients' Quality of Life (QoL) mainly in physical, emotional and social dimension. Aim To assess the QoL of patients with CVD in Northern Greece, using three different instruments. Methods The study was conducted in one large hospital located in a major Greek city. A convenience sample of 80 patients participated. A questionnaire including Short Form-36 Health Survey (SF-36), EuroQoL 5-dimensions 5-levels (EQ-5D-5L), MacNew, demographic, and clinical characteristics was used to collect data. Results The mean age of the patients was 63.31±14.07. Analysis revealed statistically significant main effects of age on the physical limitations, emotional limitations, social functioning, and pain. Also, the analysis showed significant main effects of education on the MacNew Physical, MacNew Social, and the EQ-5D-5L index (p< 0.05). Participants who had graduated primary school had significantly lower quality of life scores than higher education graduates in the MacNew physical (p< 0.02). Furthermore, in the SF-36 pain subscale, the heart failure group had a significantly lower quality of life than the other heart diseases (p= 0.03). Conclusion Quality of life is affected by factors such as age, type of heart disease, therapy, and comorbidities. Health care providers should be knowledgeable of the factors that affect the quality of life sectors (physical, emotional, and social life) of patients with CVD in order to meet their needs and have the most suitable treatment.

Association of Health-Related Quality of Life with Atherosclerotic Cardiovascular Disease: Lifetime Risk Pooling Project

Objective

The Pooled Cohort Equations (PCE) serve as the platform for quantitative risk assessment for atherosclerotic cardiovascular disease (ASCVD). Data are sparse regarding the benefit of adding health-related quality of life (HRQoL) measures to the PCE. We sought to estimate the association of HRQoL with ASCVD events and evaluate the potential utility of adding HRQoL to the PCE in refining quantitative risk assessment for primary prevention decisions.

Methods

Three multi-ethnic longitudinal cohorts were included in the study. HRQoL was measured using the SF-12 physical component summary (PCS) and mental component summary (MCS); higher PCS or MCS scores indicate better HRQoL. We constructed a four-level HRQoL status variable: MCS <50 and PCS <50; MCS <50 and PCS ≥50; MCS ≥50 and PCS <50; MCS ≥50 and PCS ≥50. Harrell's C statistics and net reclassification improvement (NRI) analyses were used to assess the added predictive ability of HRQoL for incident ASCVD.

Results

A total of 9,904 individuals were included in the analysis, of whom 4,743 were in the low risk subgroup (<5% predicted 10-year risk). HRQoL status, PCS and its subscale scores were independent predictors of ASCVD events. HRQoL improved both discrimination (delta C: 0.004, p = 0.05) and reclassification (cNRI: 0.15, p<0.01) modestly when added to PCE; 3% and 6% of individuals with events were correctly reclassified to higher risk in the overall sample and low risk subgroup, respectively.

Conclusion

HRQoL is an independent predictor of ASCVD events, and improves ASCVD risk prediction significantly, though modestly, overall and in low-risk individuals. HRQoL may be a cost-effective risk-enhancing factor for refining quantitative risk assessment for primary prevention decisions.

Health-related quality of life and incident cardiovascular disease events in community-dwelling older people: A prospective cohort study

BACKGROUND

Lower health-related quality of life (HRQoL) has been shown to predict a higher risk of hospital readmission and mortality in patients with cardiovascular disease (CVD). Few studies have explored the associations between HRQoL and incident CVD. We explored the associations between baseline HRQoL and incident and fatal CVD in community-dwelling older people in Australia and the United States.

METHODS

Longitudinal study using ASPirin in Reducing Events in the Elderly (ASPREE) trial data. This includes 19,106 individuals aged 65-98 years, initially free of CVD, dementia, or disability, and followed between March 2010 and June 2017. The physical (PCS) and mental component scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Incident major adverse CVD events included fatal CVD (death due to atherothrombotic CVD), hospitalizations for heart failure, myocardial infarction or stroke. Analyses were performed using Cox proportional-hazard regression.

RESULTS

Over a median 4.7 follow-up years, there were 922 incident CVD events, 203 fatal CVD events, 171 hospitalizations for heart failure, 355 fatal or nonfatal myocardial infarction and 403 fatal or nonfatal strokes. After adjustment for sociodemographic, health-related behaviours and clinical measures, a 10-unit higher PCS, but not MCS, was associated with a 14% lower risk of incident CVD, 28% lower risk of hospitalization for heart failure and 15% lower risk of myocardial infarction. Neither PCS nor MCS was associated with fatal CVD events or stroke.

CONCLUSION

Physical HRQoL can be used in combination with clinical data to identify the incident CVD risk among older individuals.

The Utility of Assessing Health-Related Quality of Life to Predict Cognitive Decline and Dementia

BACKGROUND

Health-related quality of life (HRQoL) has been shown to predict adverse health outcome in the general population.

OBJECTIVE

We examined the cross-sectional association between HRQoL and cognitive performance at baseline. Next, we explored whether baseline HRQoL predicted 5-year incident cognitive decline and dementia and whether there were gender differences.

METHODS

19,106 community-dwelling participants from the ASPirin in Reducing Events in the Elderly (ASPREE) trial, aged 65-98 years, free of major cognitive impairments, and completed the HRQoL 12-item short-form (SF-12) at baseline (2010-2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were calculated. The cognitive tests were assessed at baseline, year 1, 3, 5, and 7 or close-out visit. Cognitive decline was defined as > 1.5 SD drop from baseline on any of the cognitive tests. Dementia was adjudicated according to DSM-IV criteria. Linear and Cox proportional-hazards regressions were used to examine the cross-sectional and longitudinal associations respectively.

RESULTS

At baseline, higher PCS and MCS were associated with better cognition. Over a median 4.7-year follow-up, higher MCS was associated with a reduced risk of cognitive decline and dementia (12% and 15% respectively, per 10-unit increase) and a 10-unit higher PCS was associated with a 6% decreased risk of cognitive decline. PCS did not predict dementia incidence. Findings were not different by gender.

CONCLUSION

Our study found that higher HRQoL, in particular MCS, predicted a reduced risk of cognitive decline and dementia over time in community-dwelling older people.

Volunteering and self-reported health outcomes among older people living in the community: the Yilan study, Taiwan

PURPOSE

This study aimed to explore associations between volunteering and various self-reported health outcomes among older people, including subjective physical and mental health, self-rated health, and self-rated happiness.

METHODS

This questionnaire survey was conducted in Yilan, Taiwan. By convenient sampling, a total of 3692 older people living in the community were recruited from 2012 to 2016. Participants' engagement in community volunteer activities in the past month was recorded. Subjective physical and mental health were evaluated using the Short Form-12 version2 Health Survey physical and mental component summary scores. Self-rated health and happiness were each evaluated by a single question. Participants' demographic information and comorbidities were also recorded. We conducted multiple linear regression analyses adjusted for age, sex, marital status, body mass index, educational level, living status, comorbidities, smoking status, and status of alcohol drinking.

RESULTSS

After adjusting for covariates, volunteering was significantly associated with better subjective physical health, self-rated health, and self-rated happiness scores (B = 2.41, 95% confidence interval [CI] (1.56, 3.26); B = 3.46, 95% CI (2.66, 4.66), and B = 4.62, 95% CI (3.18, 6.05), respectively). The strength of the relationships between volunteering and various self-reported health outcomes differed.

CONCLUSIONS

Volunteering has positive associations on subjective physical health, self-rated health, and happiness for older people living in the community in Yilan, Taiwan. Further follow-up studies are needed to examine the mechanisms of associations between volunteering and various self-reported health outcomes, and clarify the differences in the strength of their associations.

Participation in exercise-based cardiac rehabilitation is related to reduced total mortality in both men and women: results from the SWEDEHEART registry

AIMS

Participation in exercise-based cardiac rehabilitation (exCR) increases aerobic capacity and improves outcomes in patients following myocardial infarction (MI) and is therefore universally recommended. While meta-analyses consistently report that participation in exCR reduces cardiovascular mortality, there are conflicting results regarding effects on total mortality. Presently, many eligible patients do not receive exCR in clinical practice. We aimed to investigate the relation between participation in exCR post-MI and total mortality in men and women in a nationwide real-world cohort from the SWEDEHEART registry.

DESIGN

Longitudinal, observational cohort study.

METHODS AND RESULTS

In total, 20 895 patients from the SWEDEHEART registry were included. Mortality data were obtained from the Swedish National Population Registry. During a mean of 4.55 (±2.33) years of follow-up, 1000 patients died. Using Cox regression for proportional odds and taking a wide range of potential confounders into consideration, participation in exCR was related to significantly lower total mortality [hazard ratio (HR) 0.72, 95% confidence interval 0.62-0.83]. Excluding patients with shorter follow-up than 2 years did not alter the results. Exercise-based CR participation was related to lowered total mortality in most of the investigated subgroups. The risk reduction was more pronounced in women than in men (HR 0.54 vs. 0.81, respectively).

CONCLUSION

Participation in exCR was associated with reduced total mortality, and more pronounced in women, compared with men. Our results further support the recommendations to participate in exCR, and hence we argue that exCR should be a mandatory part of comprehensive CR programmes, offered to all patients post-MI.

Positive psychological profiles based on perceived health clustering in patients with cardiovascular disease: a longitudinal study

OBJECTIVES

Psychological well-being and sociodemographic factors have been associated with cardiovascular health. Positive psychological well-being research is limited in the literature; as such, this study aimed to investigate how patients with cardiovascular disease could be classified according to their perceived mental and physical health, and to identify positive psychological profiles based on this classification and test their stability over time.

DESIGN AND SETTING

Longitudinal study with patients from a public hospital located in Córdoba (Spain).

PARTICIPANTS

This study comprised 379 cardiovascular patients (87.3% men) tested at three measurement points.

OUTCOME MEASURES

Participants reported their sociodemographic variables (age, sex, educational level, employment and socioeconomic status) at phase 1, while their perceived health and variables relating to positive psychological well-being were tested at this and two subsequent time points (average interval time: 9 months).

RESULTS

The two-step cluster analysis classified participants into three groups according to their mental and physical health levels, p<0.001: high (n=76), moderate (n=113) and low (n=189) perceived health clusters. Low perceived health was the largest cluster, comprising almost half of patients. Clusters significantly differed according to sex, p=0.002, and socioeconomic level, p=0.004. The profile analysis indicated that participants in the high perceived health cluster showed high positive affect, positivity, life satisfaction, and self-efficacy in emotion regulation, and less negative affect and use of passive strategies over the three measurement points (95% CI, all ps<0.01). Moreover, psychological profile stability for each cluster was generally found over an 18-month period, all ps<0.05.

CONCLUSION

Cardiovascular patients may differ in terms of their perceived health and, accordingly, in terms of other relevant variables. Perceived health clusters generated varying and generally stable psychological profiles based on positive psychological well-being variables. Psychological interventions should be adapted to patients' requirements.

Implications of response shift for micro-, meso-, and macro-level healthcare decision-making using results of patient-reported outcome measures

PURPOSE

Results of patient-reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Research has shown that response shift can impact PROM results. As part of an international collaboration, our goal is to provide a framework regarding the implications of response shift at the level of patient care (micro), healthcare institute (meso), and healthcare policy (macro).

METHODS

Empirical evidence of response shift that can influence patients' self-reported health and preferences provided the foundation for development of the framework. Measurement validity theory, hermeneutic philosophy, and micro-, meso-, and macro-level healthcare decision-making informed our theoretical analysis.

RESULTS

At the micro-level, patients' self-reported health needs to be interpreted via dialogue with the clinician to avoid misinterpretation of PROM data due to response shift. It is also important to consider the potential impact of response shift on study results, when these are used to support decisions. At the meso-level, individual-level data should be examined for response shift before aggregating PROM data for decision-making related to quality improvement, performance monitoring, and accreditation. At the macro-level, critical reflection on the conceptualization of health is required to know whether response shift needs to be controlled for when PROM data are used to inform healthcare coverage.

CONCLUSION

Given empirical evidence of response shift, there is a critical need for guidelines and knowledge translation to avoid potential misinterpretations of PROM results and consequential biases in decision-making. Our framework with guiding questions provides a structure for developing strategies to address potential impacts of response shift at micro-, meso-, and macro-levels.

Number of Social Determinants of Health and Fatal and Nonfatal Incident Coronary Heart Disease in the REGARDS Study

BACKGROUND

Social determinants of health (SDH) are individually associated with incident coronary heart disease (CHD) events. Indices reflecting social deprivation have been developed for population management, but are difficult to operationalize during clinical care. We examined whether a simple count of SDH is associated with fatal incident CHD and nonfatal myocardial infarction (MI).

METHODS

We used data from the prospective longitudinal REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke), a national population-based sample of community-dwelling Black and White adults age ≥45 years recruited from 2003 to 2007. Seven SDH from the 5 Healthy People 2020 domains included social context (Black race, social isolation); education (educational attainment); economic stability (annual household income); neighborhood (living in a zip code with high poverty); and health care (lacking health insurance, living in 1 of the 9 US states with the least public health infrastructure). Outcomes were expert adjudicated fatal incident CHD and nonfatal MI.

RESULTS

Of 22 152 participants free of CHD at baseline, 58.8% were women and 42.0% were Black; 20.6% had no SDH, 30.6% had 1, 23.0% had 2, and 25.8% had ≥3. There were 463 fatal incident CHD events and 932 nonfatal MIs over a median of 10.7 years (interquartile range, 6.6 to 12.7). Fewer SDHs were associated with nonfatal MI than with fatal incident CHD. The age-adjusted incidence per 1000 person-years increased with the number of SDH for both fatal incident CHD (0 SDH, 1.30; 1 SDH, 1.44; 2 SDH, 2.05; ≥3 SDH, 2.86) and nonfatal MI (0 SDH, 3.91; 1 SDH, 4.33; ≥2 SDH, 5.44). Compared with those without SDH, crude and fully adjusted hazard ratios for fatal incident CHD among those with ≥3 SDH were 3.00 (95% CI, 2.17 to 4.15) and 1.67 (95% CI, 1.18 to 2.37), respectively; hazard ratios for nonfatal MI among those with ≥2 SDH were 1.57 (95% CI, 1.30 to 1.90) and 1.14 (95% CI, 0.93 to 1.41), respectively.

CONCLUSIONS

A greater burden of SDH was associated with a graded increase in risk of incident CHD, with greater magnitude and independent associations for fatal incident CHD. Counting the number of SDHs may be a promising approach that could be incorporated into clinical care to identify individuals at high risk of CHD.

Impaired breathing, sleeping, vitality, and depression, and negative impact of L-T4 treatment characterize health-related quality of life in older people with stable CVD

BACKGROUND

Cardiovascular disease (CVD) and thyroid dysfunction are common in older people, but little is known about how they affect health-related quality of life (HRQoL).

METHODS

We assessed HRQoL with the 15D instrument in 329 home-dwelling patients aged ≥ 75 years with stable CVD and compared the results to those of an age- and gender-matched general population (n = 103). We also studied the impact of age, BMI, number of medications, thyroid-stimulating hormone (TSH) concentration, levothyroxine (L-T4) substitution and Mini-Mental State Examination (MMSE) on HRQoL.

RESULTS

Overall HRQoL was impaired in older people with stable CVD (mean 15D score 0.777 vs 0.801, p = 0.001), and also on single dimensions of breathing, sleeping, discomfort and symptoms, distress, vitality (all p < 0.001), and depression (p = 0.016) compared to the age- and gender-matched general population. Furthermore, in the patients, L-T4 substitution associated with impaired sleeping (p = 0.018) and sexual activity (p = 0.030). Moreover, MMSE points, number of medications used, age (all p < 0.001) and BMI (p = 0.009) predicted impaired HRQoL.

CONCLUSIONS

Older people with stable CVD are characterized by impaired HRQoL compared to age- and gender-matched controls. We demonstrate that this is the consequence of impaired breathing, sleeping, discomfort and symptoms, distress, vitality, and depression. L-T4 substitution has a negative impact on HRQoL in old patients with stable CVD. MMSE score, number of medications, age and BMI predict worse HRQoL.

The Role of Emotional Regulation and Affective Balance on Health Perception in Cardiovascular Disease Patients According to Sex Differences

One of the challenges of aging is the increase of people with chronic diseases, such as cardiovascular disease (CVD). Men and women experience the disease differently. Therefore, it has an impact on how CVD is treated and its outcomes. This research analyzed the relationship between psychosocial variables and health promotion among cardiovascular patients, paying special attention to sex differences. A longitudinal study with cardiovascular patients (747 in phase 1 (122 women) and 586 in phase 2 (83 women)) was carried out. Participants were evaluated based on their sociodemographic characteristics, affective balance, regulatory negative affect self-efficacy, stress and anxiety regulation strategies, and perceived global health. Results showed that men presented significantly higher scores in positive affect, affective balance, and self-efficacy to regulate negative emotions, while women presented significantly higher scores in negative affect and the use of passive strategies to cope with stressful situations. Regression analyses showed that all psychological variables studied in phase 1 were significant predictors of health perception in phase 2. According to the results, it is necessary to include strategies to improve cardiovascular health through education and emotional regulation, with a gender focus.

Association of cardiovascular health through early adulthood and health-related quality of life in middle age: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Previous studies have linked cardiovascular health (CVH) and health-related quality of life (HRQoL), but only in cross-sectional analyses where temporality cannot be established. The aim of this study was to determine trajectories of CVH from early adulthood to middle age, and examine their association with HRQoL in middle age. This analysis, conducted in 2018, included 3275 participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study who completed a year 30 follow-up exam in 2015/2016. Group-based trajectory modeling was used to create CVH trajectories, according to American Heart Association definitions, from baseline through follow-up year 20. HRQoL was assessed by the Medical Outcomes Study 12-Item Short Form Health Survey at year 30, which included the physical component summary score (PCS), the mental component summary score (MCS), and overall self-rated health (SRH). The mean (SD) age of the sample was 55.1 (3.6) years, 1868 (57%) were women, and 1541 (47%) were black. Five CVH trajectories were identified, 31% of CARDIA participants maintained ideal CVH during follow-up. Maintaining ideal CVH was associated with higher PCS and MCS, and lower odds of fair/poor SRH as compared to the other trajectory groups. Compared to the consistently low CVH group, those who maintained ideal CVH had on average a 5.9 point higher PCS (95% CI, 4.2-7.7), a 2.5-point higher MCS (95% CI, 0.5-4.4), and 84% lower odds of fair/poor SRH (95% CI, 0.09, 0.31). Our findings suggest that maintaining ideal CVH from early adulthood results in higher health-related quality of life in middle age.