Relationship of Quality of Life Scores With Baseline Characteristics and Outcomes in the African-American Heart Failure Trial

Association Between Disease-specific Health-related Quality of Life and All-cause Mortality in Patients with Heart Failure: A Meta-analysis

The association between disease-specific health quality of life (QoL) and adverse outcomes remains controversial in patients with heart failure (HF). This meta-analysis aimed to evaluate the association of QoL measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) or Kansas City Cardiomyopathy Questionnaire (KCCQ) with all-cause mortality in patients with HF. PubMed and Embase databases were comprehensively searched until December 30, 2022 to identify studies investigating the utility of QoL measured by the MLHFQ or KCCQ in predicting all-cause mortality patients with HF. Twenty-five studies reported on 24 articles enrolling 42,414 HF patients were identified. A comparison of the top with the bottom MLHFQ score, the pooled adjusted hazard ratios (HR) of all-cause mortality was 1.56 (95% confidence intervals [CI] 1.26-1.94). When analyzed the MLHFQ as continuous variable, each 10-point MLHFQ score increase conferred a 12% (95% CI 6%-18%) higher risk of all-cause mortality, which was consistently significant for physical component (HR 1.19; 95% CI 1.09-1.30) and mental component (HR 1.21; 95% CI 1.05-1.40). A comparison of the bottom with the top KCCQ score, the pooled adjusted HR was 2.34 (95% CI 2.10-2.60) for all-cause mortality. Furthermore, each 10-point KCCQ score decrease was associated with a 12% (95% CI 7%-16%) higher risk of all-cause mortality. Worse health-related QoL defined by the higher MLHFQ or lower KCCQ score was associated with an increased risk of all-cause mortality in patients with HF. Assessment of disease-specific health QoL at baseline may provide important prognostic information in these patients.

Use of patient-reported outcomes in heart failure: from clinical trials to routine practice

Heart failure (HF) is a complex syndrome that affects mortality/morbidity and acts at different levels in the patient's life, resulting in a drastic impairment in multiple aspects of daily activities (e.g. physical, mental/emotional, and social) and leading to a reduction in quality of life. The definition of disease status and symptom severity has been traditionally based on the physician assessment, while the patient's experience of disease has been long overlooked. The active participation of patients in their own care is necessary to better understand the perception of disease and the multiple aspects of life affected, and to improve adherence to treatments. Patient-reported outcomes (PROs) aim to switch traditional care to a more patient-centred approach. Although PROs demonstrated precision in the evaluation of disease status and have a good association with prognosis in several randomized controlled trials, their implementation into clinical practice is limited. This review discusses the modalities of use of PROs in HF, summarizes the most largely adopted PROs in HF care, and provides an overview on the application of PROs in trials and the potential for their transition to clinical practice. By discussing the advantages and the disadvantages of their use, the reasons limiting their application in daily clinical routine, and the strategies that may promote their implementation, this review aims to foster the systematic integration of the patient's standpoint in HF care.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Testing of a health-related quality of life model in patients with heart failure: A cross-sectional, correlational study

Psychological symptoms, physical symptoms, and behavioral factors can affect health-related quality of life (HRQOL) through different pathways, but the relationships have not been fully tested in prior theoretical models. The purpose of this study was to examine direct and indirect relationships of demographic (age), biological/physiological (comorbidity), psychological (depressive symptoms), social (social support), physical (physical symptoms and functional status), and behavioral (dietary sodium adherence) factors to HRQOL. Data from 358 patients with heart failure were analyzed using structural equation modeling. There was a good model fit: Chi-square = 5.488, p = .241, RMSEA = .032, CFI = .998, TLI = .985, and SRMR = .018. Psychological symptoms, physical symptoms, and demographic factors were directly and indirectly associated, while behavioral and biological/physiological factors were indirectly associated with HRQOL through different pathways. Behavioral factors need to be included, and psychological factors and physical factors need to be separated in theoretical models of HRQOL.

Prediction of Heart Failure Symptoms and Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure

BACKGROUND

In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined.

OBJECTIVE

The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL.

METHODS

We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose.

RESULTS

Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL.

CONCLUSION

Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class.

Quality of life of chronic heart failure patients: a systematic review and meta-analysis

Despite various individual studies on the quality of life (QOL) in patients with CHF, a comprehensive study has not yet been conducted; therefore, this study aims to assess the QOL of CHF patients. In the present systematic review and meta-analysis, PubMed, Scopus, and the Web of science databases were searched from January 1, 2000, to December 31, 2018, using QOL and heart failure as keywords. The searches, screenings, quality assessments, and data extractions were conducted separately by two researchers. A total of 70 studies including 25,180 participants entered the final stage. The mean QOL score was 44.1 (95% confidence interval (CI) 40.6, 47.5; I² = 99.3%) using a specific random effects method in 40 studies carried out on 12,520 patients. Moreover, according to the geographical region, heart failure patients in the Americas had higher scores. In 14 studies, in which a general SF-36 survey was implemented, the average physical component score (PCS) and mental component score (MCS) were 33.3 (95% CI 31.9, 34.7; I² = 88.0%) and 50.6 (95% CI 43.8, 57.4; I² = 99.3%), respectively. The general and specific tools used in this study indicated moderate and poor QOL, respectively. Therefore, it is necessary to carry out periodic QOL measurements using appropriate tools as part of the general care of CHF patients.

Pharmacotherapy for heart failure with reduced ejection fraction and health-related quality of life: a systematic review and meta-analysis

AIMS

The aim of this study was to synthesize the evidence on the effect of heart failure with reduced ejection fraction (HFrEF) pharmacotherapy on health-related quality of life (HRQoL).

METHODS AND RESULTS

We searched MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in June 2020. Randomized placebo-controlled trials evaluating contemporary HFrEF pharmacotherapy and reporting HRQoL as an outcome were included. Two reviewers independently assessed studies for eligibility, extracted data, and assessed risk of bias and GRADE certainty of evidence. The primary outcome was HRQoL at last available follow-up analysed using a random-effects model. We included 37 studies from 5770 identified articles. Risk of bias was low in 10 trials and high/unclear in 27 trials. High certainty evidence from meta-analyses demonstrated improved HRQoL over placebo with sodium-glucose co-transporter 2 (SGLT2) inhibitors [standardized mean difference (SMD) 0.16, 95% confidence interval (CI) 0.08-0.23] and intravenous iron (SMD 0.52, 95% CI 0.04-1.00). Furthermore, high certainty evidence from ≥1 landmark trial further supported improved HRQoL with angiotensin receptor blockers (ARBs) (SMD 0.09, 95% CI 0.02-0.17), ivabradine (SMD 0.14, 95% CI 0.04-0.23), hydralazine-nitrate (SMD 0.24, 95% CI 0.04-0.44) vs. placebo, and for angiotensin receptor-neprilysin inhibitor (ARNI) compared with an angiotensin-converting enzyme (ACE) inhibitor (SMD 0.09, 95% CI 0.02-0.17). Findings were inconclusive for ACE inhibitors, beta-blockers, digoxin, and oral iron based on low-to-moderate certainty evidence.

CONCLUSION

ARBs, ARNIs, SGLT2 inhibitors, ivabradine, hydralazine-nitrate, and intravenous iron improved HRQoL in patients with HFrEF. These findings can be incorporated into discussions with patients to enable shared decision-making.

Assessment of chronic disease self-management in patients with chronic heart failure based on the MCID of patient-reported outcomes by the multilevel model

Purpose

The minimal clinically important difference (MCID) of a patient-reported outcome (PRO) represents the threshold value of the change in the score for that PRO. It is deemed to have an important implication in clinical management. This study was performed to evaluate the clinical significance of chronic disease self-management (CDSM) for patients with chronic heart failure based on the MCID of the chronic heart failure—PRO measure (CHF-PROM).

Methods

A multicenter, prospective cohort study of 555 patients with heart failure were enrolled from July 2018. Advice of CDSM was provided in written form at discharge to all patients. Information regarding CHF-PROM and CDSM were collected during follow-up. Multilevel models were applied to dynamically evaluate the effects of CDSM for CHF-PROM scores, as well as its physical and psychological domains. MCID changes of the PRO were introduced and compared with β values of CDSM obtained from the multi-level models to further evaluate the clinical significance. The STROBE checklist is shown in Additional file 1.

Results

Scores for CHF-PROM improved significantly after discharge. The multilevel models showed that a regular schedule, avoidance of over-eating, a low-sodium diet and exercise increased scores on CHF-PROM. Compared with the MCID, avoidance of over-eating (12.39 vs. 9.75) and maintenance of a regular schedule often (10.98 vs. 9.75), and exercise almost every day (11.36 vs. 9.75) reached clinical significance for the overall summary. Avoidance of over-eating (5.88 vs. 4.79) and a regular schedule almost every day (4.96 vs. 4.79) reached clinical significance for the physical scores. Avoidance of over-eating half of the time (5.26 vs. 4.87) and a regular schedule almost every day (5.84 vs. 4.87) demonstrated clinical significance for the psychological scores.

Conclusions

This study observed an association of avoidance of over-eating and maintenance of a regular schedule with the improvement of CHF-PROM. It provides further evidence for management of heart failure.

Trial Registration: Current Prospective Trials NCT02878811; registered August 25, 2016; https://clinicaltrials.gov/ct2/show/NCT02878811?term=NCT02878811&draw=2&rank=1.

Impact of non-cardiovascular comorbidities on the quality of life of patients with chronic heart failure: a scoping review

PURPOSE

To determine the impact of non-cardiovascular comorbidities on the health-related quality of life (HRQoL) of patients with chronic heart failure (CHF).

METHODS

A scoping review of the scientific literature published between 2009 and 2019 was carried out. Observational studies which assessed the HRQoL of patients with CHF using validated questionnaires and its association with non-cardiovascular comorbidities were included.

RESULTS

The search identified 1904 studies, of which 21 fulfilled the inclusion criteria to be included for analysis. HRQoL was measured through specific, generic, or both types of questionnaires in 72.2%, 16.7%, and 11.1% of the studies, respectively. The most common comorbidities studied were diabetes mellitus (12 studies), mental and behavioral disorders (8 studies), anemia and/or iron deficiency (7 studies), and respiratory diseases (6 studies). Across studies, 93 possible associations between non-cardiovascular comorbidities and HRQoL were tested, of which 21.5% regarded anemia or iron deficiency, 20.4% mental and behavioral disorders, 20.4% diabetes mellitus, and 14.0% respiratory diseases. Despite the large heterogeneity across studies, all 21 showed that the presence of a non-cardiovascular comorbidity had a negative impact on the HRQoL of patients with CHF. A statistically significant impact on worse HRQoL was found in 84.2% of associations between mental and behavioral disorders and HRQoL (patients with depression had up to 200% worse HRQoL than patients without depression); 73.7% of associations between diabetes mellitus and HRQoL (patients with diabetes mellitus had up to 21.8% worse HRQoL than patients without diabetes mellitus); 75% of associations between anemia and/or iron deficiency and HRQoL (patients with anemia and/or iron deficiency had up to 25.6% worse HRQoL than between patients without anemia and/or iron deficiency); and 61.5% of associations between respiratory diseases and HRQoL (patients with a respiratory disease had up to 21.3% worse HRQoL than patients without a respiratory disease).

CONCLUSION

The comprehensive management of patients with CHF should include the management of comorbidities which have been associated with a worse HRQoL, with special emphasis on anemia and iron deficiency, mental and behavioral disorders, diabetes mellitus, and respiratory diseases. An adequate control of these comorbidities may have a positive impact on the HRQoL of patients.

Pharmacological interventions for heart failure in people with chronic kidney disease

BACKGROUND

Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD.

OBJECTIVES

This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence.

MAIN RESULTS

One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies.

AUTHORS' CONCLUSIONS

The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.

Insulin treatment and clinical outcomes in patients with diabetes and heart failure with preserved ejection fraction

Aims

Insulin causes sodium retention and hypoglycaemia and its use is associated with worse outcomes in heart failure (HF) with reduced ejection fraction. We have investigated whether this is also the case in HF with preserved ejection fraction (HFpEF).

Methods and results

We examined the association between diabetes/diabetes treatments and the risk of the primary composite of cardiovascular death or HF hospitalization, as well as other outcomes in adjusted analyses in CHARM‐Preserved (left ventricular ejection fraction ≥ 45%), I‐Preserve and TOPCAT (Americas) pooled. Of 8466 patients, 2653 (31%) had diabetes, including 979 (37%) receiving insulin. Patients receiving insulin were younger, had a higher body mass index, prevalence of ischaemic aetiology, N‐terminal pro‐B‐type natriuretic peptide and use of diuretics, worse New York Heart Association class and signs and symptoms, and worse quality of life and renal function, compared to patients with diabetes not on insulin. Among the 1398 patients with echocardiographic data, insulin use was associated with higher left ventricular end‐diastolic pressure and more diastolic dysfunction than in other participants. The primary outcome occurred at a rate of 6.3 per 100 patient‐years in patients without diabetes, and 10.2 and 17.1 per 100 patient‐years in diabetes patients without and with insulin use, respectively [fully adjusted hazard ratio (aHR) insulin‐treated diabetes vs. other diabetes: 1.41, 95% confidence interval (CI) 1.23–1.63, P < 0.001]. The adjusted HR is 1.67 (95% CI 1.20–2.32, p = 0.002) for sudden death (insulin‐treated diabetes vs. other diabetes).

Conclusions

Insulin use is associated with poor outcomes in HFpEF. Although we cannot conclude a causal association, the safety of insulin and alternative glucose‐lowering treatments in HF needs to be evaluated in clinical trials.

Relationship of medication adherence and quality of life among heart failure patients

BACKGROUND

Little is known regarding the relationship between medication adherence and quality of life in heart failure patients. We therefore aimed to examine the nature of relationship between medication adherence and quality of life.

METHODS

A prospective, cross-sectional study of chronic heart failure patients with reduced ejection fraction was performed at a tertiary-care, university hospital in Thailand. Quality of life and medication adherence were assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Morisky Medication Adherence Scale-8 (MMAS-8), respectively. Relationship of MLHFQ and MMAS-8 were examined using Spearman's correlation coefficient and multiple regression analysis for covariates adjustment.

RESULTS

Among 180 patients, 38.3%, 50.0% and 11.7% were found to have high, medium and poor adherence, respectively. For quality of life, the overall median score on the MLHFQ was relatively low. A positive relationship was identified between medication adherence and quality of life. After covariate adjustment, medication adherence was found to have the strongest relationship with quality of life, compared to other covariates.

CONCLUSIONS

Medication adherence has a small and positive relationship with quality of life among heart failure patients.

The prognostic value of health-related quality of life in patients with Chagas heart disease

PURPOSE

To verify the prognostic value of health-related quality of life (HRQoL) and the differences in HRQoL and clinical variables between groups of Chagas heart disease (CHD) patients with and without cardiovascular adverse events.

METHODS

Seventy-five CHD patients were evaluated by echocardiography, maximal exercise testing, and Short-form of Health Survey (SF-36) Questionnaire. Patients were followed during 6 years. In the statistical analysis, uni- and multivariate Cox regression were performed to verify the accuracy of the HRQoL in predicting cardiovascular events.

RESULTS

After the follow-up period (41 ± 12 months), 20 patients (27%) had adverse events. Those with poor outcome had lower left ventricular ejection fraction (LVEF) (p = 0.002), higher left ventricular end-diastolic diameter (LVDd) (p = 0.019), and worse scores in general health perceptions (p = 0.047), social role functioning (p = 0.026), and mental component summary (p = 0.043) of SF-36. Patients with lower LVEF (p = 0.003), higher LVDd (p = 0.022), worse HRQoL in the general heath perceptions domain (p = 0.022), and mental component summary (p = 0.031) were associated with worse prognosis. In the multivariate Cox regression, LVEF (HR 0.94, 95% CI from 0.90 to 0.98, p = 0.007) and mental component summary (HR 0.98, 95% CI from 0.94 to 1.00, p = 0.047) remained as independent predictors of adverse events in CHD patients.

CONCLUSION

The assessment of HRQoL, especially the mental component, should be taken into account to provide an accurate prognosis in addition to other well-established predictors of poor outcomes in CHD patients.

Effects of a supportive educational nursing care programme on fatigue and quality of life in patients with heart failure: a randomised controlled trial

BACKGROUND

Fatigue is a common symptom in patients with heart failure that is easy to ignore. In addition, fatigue may affect patients' physical function and psychosocial conditions that can impair their quality of life. An effective nursing care programme is required to alleviate patients' fatigue and improve their quality of life.

AIM

To investigate the effects of a supportive educational nursing care programme on fatigue and quality of life in patients with heart failure.

METHODS

A randomised controlled trial design was used. Ninety-two patients with heart failure were randomly assigned to an intervention group (n=47) or a control group (n=45). The patients in the intervention group participated in 12 weeks of a supportive educational nursing care programme including fatigue assessment, education, coaching self-care and evaluation. The intervention was conducted by a cardiac nurse during four face-to-face interviews and three follow-up telephone interviews. Fatigue and quality of life were assessed at the baseline and 4 weeks, 8 weeks and 12 weeks after enrollment in both groups.

RESULTS

The participants in the intervention group exhibited a significant decrease in the level of fatigue after 12 weeks, whereas those in the control group exhibited no significant changes. Compared with the control group, the intervention group exhibited a significantly greater decrease in the level of fatigue and significantly greater improvement in quality of life after 12 weeks of intervention.

CONCLUSIONS

The supportive educational nursing care programme was recommended to alleviate fatigue and improve quality of life in patients with heart failure.

Non-cardiovascular comorbidity, severity and prognosis in non-selected heart failure populations: A systematic review and meta-analysis

Background

Non-cardiovascular comorbidities are recognised as independent prognostic factors in selected heart failure (HF) populations, but the evidence on non-selected HF and how comorbid disease severity and change impacts on outcomes has not been synthesised. We identified primary HF comorbidity follow-up studies to compare the impact of non-cardiovascular comorbidity, severity and change on the outcomes of quality of life, all-cause hospital admissions and all-cause mortality.

Methods

Literature databases (Jan 1990–May 2013) were screened using validated strategies and quality appraisal (QUIPS tool). Adjusted hazard ratios for the main HF outcomes were combined using random effects meta-analysis and inclusion of comorbidity in prognostic models was described.

Results

There were 68 primary HF studies covering nine non-cardiovascular comorbidities. Most were on diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and renal dysfunction (RD) for the outcome of mortality (93%) and hospital admissions (16%), median follow-up of 4 years. The adjusted associations between HF comorbidity and mortality were DM (HR 1.34; 95% CI 1.2, 1.5), COPD (1.39; 1.2, 1.6) and RD (1.52; 1.3, 1.7). Comorbidity severity increased mortality from moderate to severe disease by an estimated 78%, 42% and 80% respectively. The risk of hospital admissions increased up to 50% for each disease. Few studies or prognostic models included comorbidity change.

Conclusions

Non-cardiovascular comorbidity and severity significantly increases the prognostic risk of poor outcomes in non-selected HF populations but there is a major gap in investigating change in comorbid status over time. The evidence supports a step-change for the inclusion of comorbidity severity in new HF interventions to improve prognostic outcomes.

•

We synthesise the prognosis evidence on non-CVD comorbidity and severity in non-selected HF

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Most studies focused on three comorbid diseases for mortality and admissions and none for QoL

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COPD, diabetes and CKD increased mortality and admission risk in non-selected HF

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Severity studies were few but where available, risk increased with disease severity

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Comorbidity severity is important but has yet to be included in HF prognostic models

Transitions of care in heart failure: a scientific statement from the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Use of isosorbide dinitrate and hydralazine in African-Americans with heart failure 9 years after the African-American Heart Failure Trial

The 2013 American College of Cardiology Foundation/American Heart Association guidelines recommend combined isosorbide dinitrate (ISDN) and hydralazine to reduce mortality and morbidity for African-Americans with symptomatic heart failure (HF) and reduced ejection fraction, currently receiving optimal medical therapy (class I, level A). Nitrates can alleviate HF symptoms, but continuous use is limited by tolerance. Hydralazine may mitigate nitrate tolerance, and the ISDN-hydralazine combination in the Vasodilators in Heart Failure Trial (V-HeFT) I improved survival and exercise tolerance in men with dilated cardiomyopathy or HF with reduced ejection fraction, most notably in self-identified black participants. In the subsequent V-HeFT II, survival was greater with enalapril than with ISDN-hydralazine in the overall cohort, but mortality rate was similar in the enalapril and ISDN-hydralazine groups in the self-identified black patients. Consequently, in the African-American Heart Failure Trial (A-HeFT) in self-identified black patients with symptomatic HF, adding a fixed-dose combination ISDN-hydralazine to modern guideline-based care improved outcomes versus placebo, including all-cause mortality, and led to early trial termination. Hypertension underlies HF, especially in African-Americans; the A-HeFT and its substudies demonstrated not only improvements in echocardiographic parameters, morbidity, and mortality but also a decrease in hospitalizations, potentially affecting burgeoning HF health-care costs. Genetic characteristics may, therefore, determine response to ISDN-hydralazine, and the Genetic Risk Assessment in Heart Failure substudy demonstrated important hypothesis-generating pharmacogenetic data.

Self-rated health predicts healthcare utilization in heart failure

Background

Heart failure (HF) patients experience impaired functional status, diminished quality of life, high utilization of healthcare resources, and poor survival. Yet, the identification of patient‐centered factors that influence prognosis is lacking.

Methods and Results

We determined the association of 2 measures of self‐rated health with healthcare utilization and skilled nursing facility (SNF) admission in a community cohort of 417 HF patients prospectively enrolled between October 2007 and December 2010 from Olmsted County, MN. Patients completed a 12‐item Short Form Health Survey (SF‐12). Low self‐reported physical functioning was defined as a score ≤25 on the SF‐12 physical component. The first question of the SF‐12 was used as a measure of self‐rated general health. After 2 years, 1033 hospitalizations, 1407 emergency department (ED) visits, and 19,780 outpatient office visits were observed; 87 patients were admitted to a SNF. After adjustment for confounding factors, an increased risk of hospitalizations (1.52 [1.17 to 1.99]) and ED visits (1.48 [1.04 to 2.11]) was observed for those with low versus moderate‐high self‐reported physical functioning. Patients with poor and fair self‐rated general health also experienced an increased risk of hospitalizations (poor: 1.73 [1.29 to 2.32]; fair: 1.46 [1.14 to 1.87]) and ED visits (poor: 1.73 [1.16 to 2.56]; fair: 1.48 [1.13 to 1.93]) compared with good‐excellent self‐rated general health. No association between self‐reported physical functioning or self‐rated general health with outpatient visits and SNF admission was observed.

Conclusion

In community HF patients, self‐reported measures of physical functioning predict hospitalizations and ED visits, indicating that these patient‐reported measures may be useful in risk stratification and management in HF.

Physical health status measures predict all-cause mortality in patients with heart failure

BACKGROUND

Physical health status measures have been shown to predict death in heart failure (HF); however, few studies found significant associations after adjustment for confounders, and most were not representative of all HF patients.

METHODS AND RESULTS

HF patients from southeastern MN were prospectively enrolled between 10/2007 and 12/2010, completed a 12-item Short Form Health Survey (SF-12) and a 6-minute walk, and were followed through 2011 for death from any cause. Scores ≤ 25 on the SF-12 physical component indicated low self-reported physical functioning, and the first question of the SF-12 measured self-rated general health. Low functional exercise capacity was defined as ≤ 300 m walked during a 6-minute walk. Over a mean follow-up of 2.3 years, 86 deaths occurred among the 352 participants. A 1.6-fold (95% confidence interval, 1.0-2.7) and 1.8-fold (95% confidence interval, 1.1-2.9) increased risk of death was observed among patients with low self-reported physical functioning and low functional exercise capacity, respectively. Poor self-rated general health corresponded to a 2.7-fold (95% confidence interval, 1.5-4.9) increased risk of death compared with good to excellent general health. All measures equally discriminated between who would die and who would survive (C-statistics: 0.729, 0.750, and 0.740 for self-reported physical functioning, self-rated general health, and functional exercise capacity, respectively).

CONCLUSIONS

Three physical health status measures, captured by the SF-12 and a 6-minute walk, equally predict death among community HF patients. Therefore, the first question of the SF-12, which is the least burdensome to administer, may be sufficient to identify HF patients at greatest risk of death.

Development and Validation of the First Iranian Questionnaire to Assess Quality of Life in Patients With Heart Failure: IHF-QoL

BACKGROUND

In its Constitution of 1948, WHO defined health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity" . In 1994, the Agency for Health Care Policy and Research published clinical practice guidelines recommending providers to routinely evaluate patients' HRQoL (Health Related Quality of Life) and use their assessment to modify and guide patient care.

OBJECTIVES

to create a valid, sensitive, disease-specific Persian health status quality of life questionnaire for patients with chronic heart failure in Iran.

MATERIALS AND METHODS

Considering the existing relevant inventories and scientific literature, the authors designed the first draft of questionnaire which was modified and validated, using expert opinions and finalized in a session of expert panel. The questionnaire was processed among 130 patients with heart failure. Construct validity evaluated by principle component factor analysis, and promax method was used for factor rotation. MacNew quality of life questionnaire was selected to assess convergence validity, and the agreements were measured in 60 patients. Discriminant validity was also assessed. Thirty patients were followed for 3 months and responsiveness of questionnaire was measured. Cronbach's alpha, item analysis, and Intra-class correlation coefficients (ICCs) were used to investigate reliability of questionnaire. SPSS 15 for Windows was applied for statistical analysis.

RESULTS

Principle component factor analysis revealed 4 main components. Sub-group analysis suggested that IHF-QoL questionnaire demonstrated an acceptable discriminant validity. High conformity between this inventory and MacNew questionnaire revealed an appropriate convergence validity. Cronbach's alpha (α) for the overall questionnaire was equal to 0.922. Intra-class correlation coefficients (ICCs) for all components were significant (from. 708 to. 883; all P values < 0.001). Patients fallow-up revealed an acceptable responsiveness of our questionnaire.

CONCLUSIONS

IHF-QoL questionnaire is a valid and reliable inventory. It can be applied in daily clinical practice and in the clinical research context.

Inorganic phosphate and FGF-23 predict outcome in stable systolic heart failure

BACKGROUND

Recent studies show associations between inorganic phosphate and risk of heart failure in the general population as well as between fibroblast growth factor 23 (FGF-23) and outcome in coronary heart disease. This study was carried out to assess whether circulating levels of inorganic phosphate and FGF-23, a new central hormone in mineral bone metabolism, predict outcome in systolic heart failure.

MATERIALS AND METHODS

Ninety-nine consecutive outpatients with systolic heart failure were enrolled. Mean (SD) age was 61 years (11), mean left ventricular ejection fraction (LVEF) was 33% (10), 82 patients were men, median estimated creatinine clearance was 83 mL/min (Q(1) -Q(3) 58-106), median NTproBNP level was 803 pg/mL (Q(1) -Q(3) 404-2757), median inorganic phosphate was 1·12 mM (Q(1) -Q(3) 1·02-1·22), median FGF-23 was 39·02 pg/mL (Q(1) -Q(3) 32·45-55·86) and median follow-up was 35 months. Associations between inorganic phosphate, FGF-23 and endpoints were assessed using Cox regression analyses.

RESULTS

Inorganic phosphate and FGF-23 levels were significantly higher (P < 0·001 and P = 0·009) in patients reaching the combined endpoint of cardiac hospitalization or death. FGF-23 (ln) predicted all-cause mortality (hazard ratio (HR) 5·042, P = 0·032) in a model adjusted for age, gender, estimated creatinine clearance, LVEF, New York Heart Association (NYHA) stage and NTproBNP level. Inorganic phosphate predicted heart failure hospitalization (HR 26·944, P = 0·021), cardiac hospitalization (HR 16·016, P = 0·017) and the combined endpoint (HR 13·294, P = 0·015) in models adjusted for the same co-variables.

CONCLUSION

The results of this study demonstrate the independent prognostic value of inorganic phosphate and FGF-23 in heart failure even in the context of established risk markers.

Hemoglobin A1c improvements and better diabetes-specific quality of life among participants completing diabetes self-management programs: a nested cohort study

BACKGROUND

Numerous primary care innovations emphasize patient-centered processes of care. Within the context of these innovations, greater understanding is needed of the relationship between improvements in clinical endpoints and patient-centered outcomes. To address this gap, we evaluated the association between glycosylated hemoglobin (HbA1c) and diabetes-specific quality of life among patients completing diabetes self-management programs.

METHODS

We conducted a retrospective cohort study nested within a randomized comparative effectiveness trial of diabetes self-management interventions in 75 diabetic patients. Multiple linear regression models were developed to examine the relationship between change in HbA1c from baseline to one-year follow-up and Diabetes-39 (a diabetes-specific quality of life measure) at one year.

RESULTS

HbA1c levels improved for the overall cohort from baseline to one-year follow-up (t (74) = 3.09, p = .0029). One-year follow up HbA1c was correlated with worse overall quality of life (r = 0.33, p = 0.004). Improvements in HbA1c from baseline to one-year follow-up were associated with greater D-39 diabetes control (β = 0.23, p = .04) and D-39 sexual functioning (β = 0.25, p = .03) quality of life subscales.

CONCLUSIONS

Improvements in HbA1c among participants completing a diabetes self-management program were associated with better diabetes-specific quality of life. Innovations in primary care that engage patients in self-management and improve clinical biomarkers, such as HbA1c, may also be associated with better quality of life, a key outcome from the patient perspective.

Heart failure survival score in patients with Chagas disease: correlation with functional variables

INTRODUCTION AND OBJECTIVES

Chagas disease is a prevalent cause of heart failure in Latin America, and its prognosis is worse than other etiologies. The Heart Failure Survival Score has been used to assess prognosis in patients with heart failure; however, this score has not yet been studied in patients with Chagas cardiopathy.

METHODS

The Heart Failure Survival Score was calculated in 55 patients with severe left ventricular systolic dysfunction due to Chagas disease. Correlations were assessed between the Heart Failure Survival Score and variables obtained from, cardiopulmonary exercise tests, quality-of-life measures, and 6-minute walking tests.

RESULTS

Patients were distributed among New York Heart Association classes II-IV; 89% were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, 62% were taking beta-blockers, 86% were taking diuretics, and 74% were taking aldosterone receptor blockers. The mean Heart Failure Survival Score was 8.75 (0.80). The score correlated well with cardiopulmonary test variables such as peak oxygen uptake (0.662; P<.01), oxygen uptake at the anaerobic threshold (0.644; P<.01), ventilation carbon dioxide efficiency slope (-0.417; P<.01), oxygen pulse (0.375; P<.01), oxygen uptake efficiency slope (0.626; P<.01), 6-minute walking test (0.370; P<.01), left ventricle ejection fraction (0.650; P=.01), and left atrium diameter (-0.377; P<.01). There was also a borderline significant correlation between the Heart Failure Survival Score and quality of life (-0.283; P<.05).

CONCLUSIONS

In heart failure patients with Chagas disease, the Heart Failure Survival Score correlated well with the main prognostic functional test variables.

Assessment of long-term effects of irbesartan on heart failure with preserved ejection fraction as measured by the minnesota living with heart failure questionnaire in the irbesartan in heart failure with preserved systolic function (I-PRESERVE) trial

BACKGROUND

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used in a large, multinational, randomized, placebo-controlled trial to measure adverse effects of heart failure with preserved ejection fraction (HF-PEF) on patients' lives and the effects of irbesartan.

METHODS AND RESULTS

Patients with symptomatic HF-PEF were randomly assigned to irbesartan (up to 300 mg daily) or placebo. The MLHFQ was administered at baseline (n=3605), month 6 (n=3137), month 14 (n=2904), and the end of study (median, 56 months, n=2205). Baseline MLHFQ scores of 43±21 indicated that HF-PEF had a substantial adverse effects. Estimated retest reliability was 0.80. Baseline MLHFQ scores were associated with other measures of the severity of heart failure including symptoms, signs of congestion, cardiac structure, and time to hospitalizations or deaths attributed to heart failure. Slight improvement in shortness of breath or fatigue was associated with significant improvement in MLHFQ scores (-5.9 and -5.0, P<0.0001). Compared with placebo, further improvement in MLHFQ scores was not observed with irbesartan after 6 months (mean adjusted difference, 0.4; 95% confidence interval, -0.8 to 1.7), 14 months (0.5; 95% confidence interval, -0.9 to 1.8), or the end of study (2.0; 95% confidence interval, -4.1 to 0.01).

CONCLUSIONS

The MLHFQ scores are a reliable, valid, and sensitive measure of the adverse impact of HF-PEF on patients' lives. Irbesartan did not substantially improve MLHFQ scores during a long period of follow-up. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00095238.

Current concepts underlying benefits of exercise training in congestive heart failure patients

The pathophysiology of several conditions including heart failure is partly attributable to a failure of the cell energy metabolism. Studies have shown that exercise training (ET) improves quality of life (QOL) and is beneficial in terms of reduction of symptoms, mortality and duration of hospitalization. Increasingly, ET is now achieving acceptance as complimentary therapy in addition to routine clinical practice in patients with chronic heart failure (CHF). However, the mechanisms underlying the beneficial effects of ET are far less understood and need further evaluation. Evidence suggests that while CHF induces generalized metabolic energy depletion, ET largely enhances the overall function of the heart muscle. Hence, research efforts are now aiming to uncover why ET is beneficial as a complimentary treatment of CHF in the context of improving endothelial function and coronary perfusion, decreasing peripheral resistance, induction of cardiac and skeletal muscle cells remodeling, increasing oxygen uptake, substrate oxidation, and resistance to fatigue. Here we discuss the current evidence that suggest that there are beneficial effects of ET on cardiac and skeletal muscle cells oxidative metabolism and intracellular energy transfer in patients with CHF.