Predictors of delay in heart failure patients and consequences for outcomes

Psychometric Evaluation of the Heart Failure Somatic Perception Scale in a Middle Eastern Heart Failure Population

BACKGROUND

The Heart Failure Somatic Perception Scale (HFSPS) is an 18-item instrument used to assess how bothersome are common signs and symptoms of heart failure (HF). To date, the psychometric properties of the HFSPS have been tested in American, Italian, and Japanese samples.

OBJECTIVE

The aim of this study was to evaluate the validity and reliability of the HFSPS in a population of Lebanese patients living with HF.

METHODS

A rigorous translation and back-translation process was performed. Cultural appropriateness ratings were assessed by an expert panel. Exploratory factor analysis was conducted to confirm construct validity, whereas an independent t test using the Minnesota Living With HF Questionnaire's scores was conducted to confirm convergent validity. Pearson correlation was performed to confirm discriminant validity using the Self-Care in HF Index Management subscale, whereas predictive validity was evaluated using the Control Attitudes Scale-Revised. Internal consistency reliability was evaluated using Cronbach α .

RESULTS

A total of 109 patients (mean age, 63.66 ± 10.55 years; 69.7% male) were included. A series of exploratory factor analyses was conducted and resulted in a 4-factor model. Cronbach α was 0.869. Convergent (high correlation with total Minnesota Living With HF Questionnaire; r = 0.762, P < .0001), discriminant (no correlation with self-care management; r = 0.180, P = .078), and predictive (significant correlation with the Control Attitudes Scale-Revised; r = -0.523, P < .0001) validity was supported.

CONCLUSION

The reliability and validity of the HFSPS were supportive in this Middle Eastern sample. The HFSPS can be used to assess how bothersome HF symptoms are to improve their management.

Physical Heart Failure Symptom Clusters Predictive of Delay in Seeking Treatment

BACKGROUND

Recent research has focused on the relationship between heart failure (HF) symptom clusters and outcomes, including mortality, hospitalization, functional status, and quality of life. No known studies to date have explored the role of physical HF symptom clusters and delays in seeking treatment.

OBJECTIVES

Describe physical symptom clusters in a population of HF patients and determine if a specific cluster is predictive of delay in seeking treatment for HF symptoms.

METHOD

We analyzed combined data from two studies ( n = 406) collected during acute HF hospitalization. The Heart Failure Somatic Awareness Scale quantified physical HF symptoms. Delay, measured in days, was collected from the medical record and confirmed by interview. Hierarchical agglomerative clustering techniques determined physical HF symptom clusters. Hierarchical multiple regression analysis was computed to explore predictors of delay.

RESULTS

Participants were primarily White, male sex older adults. Three physical HF symptom clusters were identified: discordant, edema-related, and dyspnea-related symptoms. Hierarchical multiple regression analysis revealed in Step 1 that age was a significant predictor of delay.

DISCUSSION

Our findings provide valuable insight into the role of physical symptom clusters on delay in persons with HF. Through agglomerative hierarchical clustering techniques, we found three physical HF symptom clusters that were then used to determine differences in cluster membership by demographic and clinical variables. Significant age differences were noted by cluster membership with youngest older adults in a discordant symptom cluster.

Treatment seeking delay and associated factors in adult heart failure patients admitted to Debre Tabor comprehensive specialized hospital, North West, Ethiopia

Objectives

This study was aimed at assessing the magnitude of treatment-seeking delay in adult heart failure patients and identifying factors that contribute to it.

Design

An institution-based cross-sectional study with a consecutive sampling technique was conducted at Debre Tabor Comprehensive Specialized Hospital from February 1 to November 1, 2021.

Setting

The study was conducted in the medical ward of the hospital.

Participants

A total of 187 patients aged 18 and above admitted with a diagnosis of heart failure, and able to provide information were included.

Results

The median delay time of adult heart failure patients admitted to the hospital was 15 days. The mean length of delay was also calculated to be 25.02 days. Urban residents and those who live at a ten or less-kilometer distance from healthcare facilities were found to be less likely to delay seeking care. Presenting with shortness of breath or paroxysmal nocturnal dyspnea, perceiving the cause to be heart-related, and getting positive responses from significant others were also associated with a relatively short delay time.

Conclusion

Treatment-seeking delay was found to be a major problematic issue in heart failure patients. Therefore, patients, patient families, and the community at large must be taught about the symptoms of heart failure and the need for timely care.

Association Between Illness Perception and Care-Seeking Intention in Patients With Chronic Heart Failure

This study aimed to investigate the association between illness perception and care-seeking intention in Japanese patients with chronic heart failure (CHF). A cross-sectional study was conducted on 160 CHF outpatients with reference to the framework of the Common-Sense Model. Illness perception was measured using the Brief Illness Perception Questionnaire (B-IPQ). Care-seeking intention was assessed based on the intent to consult medical care at the onset of varying symptoms. Association between illness perception and the care-seeking intention was analyzed by logistic regression analysis after univariate analysis. In the univariate analysis, illness perception was only associated with care-seeking intention at the onset of dyspnea at rest. Treatment control, which means the expected effectiveness of treatment in B-IPQ, was associated with care-seeking intention at the onset of dyspnea at rest (OR: 1.261, 95% CI [1.025-1.550]). It may be necessary to assess the patients' perceptions of their treatment and explain its effects.

Effectiveness and Cost-effectiveness of an Empowerment-Based Self-care Education Program on Health Outcomes Among Patients With Heart Failure: A Randomized Clinical Trial

Importance

Strategies that enhance self-care of patients with heart failure reduce mortality and health care use.

Objective

To examine whether an empowerment-based self-care education program was more effective and cost-effective to improve self-care, health status, and hospital service use than a didactic education program in patients with heart failure.

Design, Setting, and Participants

In this double-blind randomized clinical trial, a consecutive sample of 988 patients with heart failure from the cardiac clinics of 2 regional hospitals underwent eligibility screening from February 1, 2017, to May 31, 2019, using the criteria of age of 55 years or older, heart failure diagnosed 6 months before screening, and New York Heart Association class II to IV. A total of 236 participants were randomized to the empowerment (n = 118) or education (n = 118) group.

Interventions

The 12-week, group-based, empowerment-based education program included self-care assessment, goal-orientated actions in symptom recognition and response, fluid and dietary modification, and lifestyle management. Didactic education covered the same topics without empowerment strategies.

Main Outcomes and Measures

The primary outcome was self-care measured by the Self-care Heart Failure Index (SCHFI) maintenance, management, and symptom perception subscales at posttest and 3-month end points. Secondary outcomes included measures of knowledge, confidence, health-related quality of life, and health service use. Direct, indirect, and social costs of the 2 programs were collected for cost-effectiveness analysis.

Results

A total of 236 Chinese patients (mean [SD] age, 70 [8.0] years; 149 [63.1%] men) were included in the study. The empowerment group reported significantly greater improvement in SCHFI management scores (mean difference, 13.76; 95% CI, 5.89-21.62; Cohen d = 0.46 at posttest and Cohen d = 0.35 at 3 months) and symptom perception scores (mean difference, 20.36; 95% CI, 13.98-26.75; Cohen d = 0.84 at posttest and Cohen d = 0.61 at 3 months). The empowerment group had lower risks of emergency department attendance (incidence rate ratio, 0.55; 95% CI, 0.31-0.95; P = .03) and hospital admission (incidence rate ratio, 0.38; 95% CI, 0.21-0.68; P = .001) and better improved self-care knowledge (change in score [empowerment minus education], 1.29; 95% CI, 0.48-2.09) and confidence (change in score [empowerment minus education], 7.98; 95% CI, 1.91-14.05). Empowerment was cost-saving and cost-effective at T2 compared with the education group for quality-adjusted life-years, with an incremental cost-effectiveness ratio of -114 485.

Conclusion and Relevance

In this randomized clinical trial, an empowerment approach led to clinically relevant improvement in symptom perception and self-care management among patients with heart failure. Its cost-effectiveness in improving these prognostic factors also benefits the patient-reported outcome.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR-IOR-16008254.

Navigating Symptom Management in Heart Failure: The Crucial Role of the Critical Care Nurse

High-acuity, progressive care, and critical care nurses often provide care for patients with heart failure during an exacerbation of acute disease or at the end of life. Identifying and managing heart failure symptoms is complex and requires early recognition and early intervention. Because symptoms of heart failure are not disease specific, patients may not respond to them appropriately, resulting in treatment delays. This article reviews the complexities and issues surrounding the patient's ability to recognize heart failure symptoms and the critical care nurse's role in facilitating early intervention. It outlines the many barriers to symptom recognition and response, including multimorbidities, age, symptom intensity, symptom escalation, and health literacy. The influence of self-care on heart failure management is also described. The critical care nurse plays a crucial role in teaching heart failure patients to identify and respond appropriately to their symptoms, thus promoting early intervention.

Measurement, consequences and determinants of time to diagnosis in children with new-onset heart failure: A population-based retrospective study (DIACARD study)

BACKGROUND

Time from first symptoms to diagnosis, called time to diagnosis, is related to prognosis in several diseases. The aim of this study was to assess time to diagnosis in children with new-onset heart failure (HF) and assess its consequences and determinants.

METHODS

A retrospective population-based observational study was conducted between 2007 and 2016 in a French tertiary care center. We included all children under 16 years old with no known heart disease, and HF confirmed by echocardiography. With logistic regression used for outcomes and a Cox proportional-hazards model for determinants, analyses were stratified by HF etiology: congenital heart diseases (CHD) and cardiomyopathies/myocarditis (CM).

RESULTS

A total of 117 children were included (median age [interquartile range (IQR)] 25 days (6-146), 50.4% were male, 60 had CHD and 57 had CM). Overall median (IQR) time to diagnosis was 3.3 days (1.0-21.2). The frequency of 1-year mortality was 17% and 1-year neuromotor sequel 18%. Death at 1 year was associated with low birth weight for all patients (adjusted odds ratio 0.24, 95% confidence interval [CI] 0.08-0.68) and time to diagnosis below the median with CM (0.09, 0.01-0.87) but not time to diagnosis above the median for all patients (0.59, 0.13-2.66). Short time to diagnosis was associated with clinical severity on the first day of symptoms for all patients (adjusted hazard ratio 3.39, 95% CI 2.01-5.72), and young age with CM (0.09, 0.02-0.41).

CONCLUSIONS

In children with new-onset HF presenting in our region, median time to diagnosis was short. Long time to diagnosis was not associated with poor outcome.

A Structural Equation Model of Gratitude, Self-efficacy, and Medication Adherence in Patients With Stage B Heart Failure

BACKGROUND

Consistent self-care slows the progression of heart failure (HF). Gratitude, the practice of appreciating the positive aspects of life, may influence self-efficacy, which in turn is known to improve self-care. However, little is known about the relationships among gratitude, self-efficacy, and medication adherence in HF.

OBJECTIVE

The aim of this study was to test a model to determine if self-efficacy mediates the relationship between gratitude and medication adherence in asymptomatic patients with HF.

METHOD

This is a secondary analysis of data from a prospective observational study. Data were analyzed using a structural equation model to examine associations between gratitude, cardiac-specific self-efficacy, and medication adherence in 153 patients with HF. Gratitude, self-efficacy, and medication adherence were assessed using the Gratitude Questionnaire-6, Cardiac Self-efficacy Scale-Maintain Function Subscale, and the Morisky Medication Adherence Scale, respectively.

RESULTS

Patient mean (SD) age was 66 (11) years, and 95% of the participants were men. Patients were primarily white (79%), black (12%), or Asian (6%). Gratitude exerted an indirect effect on medication adherence through self-efficacy (b = 0.16; P < .05). Gratitude was positively related to self-efficacy (b = 0.50; P < .05), and self-efficacy was positively related to medication adherence (b = 0.31; P < .05). The model fit was acceptable (comparative fit index = 0.92, Tucker-Lewis index = 0.90, root-mean-square error of approximation = 0.08).

CONCLUSION

In this study, we found evidence that self-efficacy was a mechanism through which gratitude was associated with medication adherence in asymptomatic patients with HF, suggesting a way to improve self-care nonpharmacologically. Future work will examine whether gratitude intervention results in improved self-care.

Dissection of mechanisms of Chinese medicinal formula Si-Miao-Yong-an decoction protects against cardiac hypertrophy and fibrosis in isoprenaline-induced heart failure

ETHNOPHARMACOLOGICAL RELEVANCE

Si-Miao-Yong-An decoction (SMYAD) is a traditional Chinese herbal formulation. SMYAD first appeared in the Eastern Han Dynasty according to the "Shen Yi Mi Zhuan". Then the formula was recorded in the "Yan Fang Xin Bian" edited by medical scientist Bao Xiangao in the Qing Dynasty. This well-known prescription has been traditionally used for gangrene and vascular vasculitis. It is mainly used for cardiovascular and endocrine diseases in current clinical applications and research.

AIM OF STUDY

In this study, the potential mechanisms of SMYAD against cardiac fibrosis and hypertrophy in the β-adrenoceptor agonist isoprenaline induced heart failure model were investigated.

MATERIALS AND METHODS

The heart failure animal model was established via injected isoprenaline in rats. Echocardiography was used to detect the structure and function of the heart. HE staining and Masson's trichrome staining was performed to assess myocardial tissue morphology. The serum biochemical indexes were detected by dedicated biochemical kit. BNP was tested by ELISA kit. The levels of mRNA were detected by RT-qPCR. Cardiomyocyte morphology was assessed by immunofluorescence. Phosphorylated and total p38, Akt were analyzed by Western blot. The production of reactive oxygen species (ROS) was tested by CM-H2DCFDA probe. Formula identification of chemical constituents of SMYAD in plasma was disclosed through ultra-performance liquid chromatography coupled to quadrupole time-of-flight mass spectrometry (UPLC-Q/TOF-MS).

RESULTS

SMYAD was able to improve the heart function in ISO induced heart failure rat model via protecting rat from developing cardiac hypertrophy and fibrosis. SMYAD also decreased plasma expression of these biochemical indexes. It was found that SMYAD could regulate cardiac hypertrophy and fibrosis makers' mRNA levels in vitro and vivo. In addition, SMYAD inhibited the phosphorylation of p38 and Akt, which are key mediators in the pathological process of ISO-induced cardiac hypertrophy and myocardial fibrosis. It also showed that the components of SMYAD in rat plasma exerted myocardial cell protective activity.

CONCLUSION

In summary, SMYAD may comprise more than one active ingredient to the pursuit of combination therapies instead of specifically target a single disease-causing molecule. These experimental results suggest that SMYAD may be a potential drug candidate in diseases of cardiac hypertrophy and myocardial fibrosis caused by β-adrenoceptor abnormalities.

Symptom perception in heart failure - Interventions and outcomes: A scoping review

BACKGROUND

Symptom perception in heart failure has recently been described as essential in the self-care process bridging self-care maintenance and self-care management. Accordingly, symptom perception appears to be critical for improving patient outcomes such as decreased hospital readmission and increased survival.

OBJECTIVES

To explore what interventions have been reported on heart failure symptom perception and to describe outcomes responsive to symptom perception.

DESIGN

We conducted a scoping review using PRISMA Extension for Scoping Reviews.

DATA SOURCES

Structured searches of Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, Joanna Briggs Institute and Grey literature databases.

REVIEW METHODS

Two authors independently screened references for eligibility. Eligible articles were written in English, French, German, Swedish, Italian or Spanish and concerned symptom perception in adults with heart failure. Data were extracted and charted in tables by three reviewers. Results were narratively summarized.

RESULTS

We identified 99 eligible studies from 3055 references. Seven interventional studies targeted symptom perception as the single intervention component. Mixed results have been found: while some reported decreased symptom frequency, intensity and distress, enhanced health-related quality of life, improved heart failure self-care maintenance and management as well as a greater ability to mention heart failure symptoms, others found more contacts with healthcare providers or no impact on anxiety, heart failure self-care nor a number of diary reported symptoms. Additional interventional studies included symptom perception as one component of a multi-faceted intervention. Outcomes responsive to symptom perception were improved general and physical health, decreased mortality, heart failure decompensation, as hospital/emergency visits, shorter delays in seeking care, more consistent weight monitoring, improved symptom recognition as well as self-care management, decreased hospital length of stay and decreased costs.

CONCLUSIONS

While many studies allowed to map a comprehensive overview of interventions supporting symptom perception in heart failure as well as responsiveness to outcomes, only a few single component intervention studies targeting symptom perception have been reported and study designs preclude assessing intervention effectiveness. With regard to multiple component interventions, the specific impact of symptom perception interventions on outcomes remains uncertain to date. Well-designed studies are needed to test the effectiveness of symptom perception interventions and to elucidate relationships with outcomes.

Symptom perception in heart failure: a scoping review on definition, factors and instruments

Background:

Symptom perception in heart failure has been identified as crucial for effective self-care that is a modifiable factor related to decreased hospital readmission and improved survival.

Aims:

To review systematically the heart failure symptom perception literature and synthesise knowledge on definition, description, factors and instruments.

Methods:

We conducted a scoping review including studies reporting patient-reported symptom perception in adults with heart failure. Structured searches were conducted in Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, JBI and grey literature. Two authors independently reviewed references for eligibility. Data were charted in tables and results narratively summarised.

Results:

The search yielded 3057 references, of which 106 were included. The definition of heart failure symptom perception comprised body listening, monitoring signs, recognising, interpreting and labelling symptoms, and furthermore awareness of and assigning meaning to the change. Symptom monitoring, recognition and interpretation were identified as challenging. Symptom perception facilitators include prior heart failure hospitalisation, heart failure self-care maintenance, symptom perception confidence, illness uncertainty and social support. Barriers include knowledge deficits, symptom clusters and lack of tools/materials. Factors with inconsistent impact on symptom perception include age, sex, education, experiences of living with heart failure, comorbidities, cognitive impairment, depression and symptom progression. One instrument measuring all dimensions of heart failure symptom perception was identified.

Conclusion:

Heart failure symptom perception definition and description have been elucidated. Several factors facilitating or hampering symptom perception are known. Further research is needed to determine a risk profile for poor symptom perception – which can then be taken into consideration when supporting heart failure self-care.

Heart Failure Rehospitalization and Delayed Decision Making: The Impact of Self-care and Depression

BACKGROUND

Rehospitalization soon after discharge can be distressing for persons with heart failure (HF) and places a heavy burden on the healthcare system.

OBJECTIVE

We investigated and explored the association of self-care decision making variables with (1) rehospitalization within 30 days of discharge and (2) delay in seeking medical assistance (delayed decision making).

METHODS

A cross-sectional, explanatory sequential mixed methods design (quan > qual) was used to survey 127 hospitalized HF patients and interview 15 of these participants to explain their survey responses. The survey assessed rehospitalization within 30 days of discharge, delayed decision making, HF self-care, and psychosocial factors influencing self-care.

RESULTS

The likelihood of delaying the decision to be hospitalized was more than 5 times higher among those with high depressive symptoms (odds ratio, 5.33; 95% confidence interval, 2.14-13.28). Those who delayed going to the hospital were uncertain about their prognosis and did not feel their symptoms were urgent. The likelihood of being rehospitalized within 30 days was more than doubled among those with high depressive symptoms (OR, 2.31; 95% confidence interval, 1.01-5.31). Those who were rehospitalized within 30 days were less likely to consult healthcare professionals in their decision making and wanted immediate relief from their symptoms.

CONCLUSIONS

We recommend a patient-centered approach to help HF patients identify and adequately self-manage symptoms. The strong association between high depressive symptoms and rehospitalization within 30 days as well as delayed decision making highlights the critical need for clinicians to carefully assess and address depression among HF patients.

Medication Adherence Mediates the Relationship Between Heart Failure Symptoms and Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Heart failure (HF) symptoms such as dyspnea are common and may precipitate hospitalization. Medication nonadherence is presumed to be associated with symptom exacerbations, yet how HF symptoms, medication adherence, and hospitalization/death are related remains unclear.

OBJECTIVE

The aim of this study was to explore the relationships among HF symptoms, medication adherence, and cardiac event-free survival in patients with HF.

METHODS

At baseline, patient demographics, clinical data, and HF symptoms were collected in 219 patients with HF. Medication adherence was monitored using the Medication Event Monitoring System. Patients were followed for up to 3.5 years to collect hospitalization and survival data. Logistic regression and survival analyses were used for the analyses.

RESULTS

Patients reporting dyspnea or ankle swelling were more likely to have poor medication adherence (P = .05). Poor medication adherence was associated with worse cardiac event-free survival (P = .006). In Cox regression, patients with HF symptoms had 2 times greater risk for a cardiac event than patients without HF symptoms (P = .042). Heart failure symptoms were not a significant predictor of cardiac event-free survival after entering medication adherence in the model (P = .091), indicating mediation.

CONCLUSIONS

Medication adherence was associated with fewer HF symptoms and lower rates of hospitalization and death. It is important to develop interventions to improve medication adherence that may reduce HF symptoms and high hospitalization and mortality in patients with HF.

Fostering self-care behaviours through symptom diary use? An exploratory, cross-sectional study about the use of and attitude towards a symptom diary of patients with heart failure

Using health diaries is associated with improved outcomes in patients with heart failure. However, heart failure patients’ attitudes towards using a diary have not been investigated so far. The aim of this study was to investigate heart failure patients’ attitudes towards and the factors influencing diary use. Patients who took part in an educational session to foster self-care behaviours, during which they were given a diary, were asked to participate in this explorative, cross-sectional survey study. The survey took place at least six months after the educational session. Over half of the 53 participants (52.8%) were still using the diary. Reasons for not using it were no perceived need to use it, stable vital signs, and being able to recognise symptoms of exacerbation without the diary. Users and non-users did not differ in their general attitudes towards diary use except regarding the statements ‘Keeping a diary makes no sense’ and ‘Keeping a diary helps to control the disease and the occurrence of symptoms’. Therefore, diary users may be prone to better self-care activities. Age and living situation are influencing diary use. To improve diary adherence, health care providers should stress the advantage of using a diary and the importance of diary adherence.