Symptoms of fatigue in chronic heart failure patients: Clinical and psychological predictors

The Effect of Benson's Relaxation Technique on Fatigue and Quality of Life of Patients Diagnosed With Heart Failure

Patients with heart failure (HF) reported poor quality of life (QOL) due to different reasons among which fatigue is the most important. Improving QOL is a crucial objective for patients with HF and their primary health care providers. Managing fatigue with medication is not enough. Benson's relaxation technique (BRT) is a complementary therapy used to manage fatigue among different populations with limited studies checking its effect among patients diagnosed with HF. The purpose of this quasi-experimental study was to check the effect of BRT on fatigue and QOL among 140 (68 intervention and 72 control) patients diagnosed with HF. Intervention group performed BRT for 20 minutes twice a day for 2 months. Control group received regular care from their health care providers. At baseline, there were no differences between intervention and control groups regarding fatigue, physical component summary, and mental component summary. At follow-up, intervention group had higher scores in physical and mental component summaries than control group (45.48 ± 10.52 vs 37.97 ± 14.78) and (46.22 ± 8.39 vs 41.01 ± 10.36), respectively. Also, intervention group had lower levels of fatigue than control group (2.54 ± 0.87 vs 6.33 ± 0.61). In conclusion, the use of BRT as a complementary therapy for patients with HF might decrease fatigue level and improve QOL.

The DS-14 questionnaire: psychometric characteristics and utility in patients with obstructive sleep apnea

Little is known about type D personality in patients with obstructive sleep apnea (OSA). The DS-14 questionnaire is the standard tool to assess this personality type, but it has not been properly validated in patients with OSA, nor has it been correlated with clinical features in these patients.

PURPOSE

To determine the internal consistency and test-retest reliability of the DS-14 questionnaire, as well as the prevalence of type D personality in the overall OSA sample and subgroups. We assessed the influence of type D on perceived symptoms and its congruence with self-reported measures of personality, depression, fatigue, anxiety, quality of life, and quality of sleep.

METHODS

Patients with OSA completed the DS-14 questionnaire, Big Five Inventory-2 questionnaire, Hospital Anxiety and Depression Scale, SF-36 Health Survey Questionnaire, Epworth Sleepiness Scale and Stanford Sleepiness Scale, Pittsburgh Sleep Quality Index and Insomnia Severity Index, Fatigue Assessment Scale, and Checklist Individual Strength. After 1 month, the DS-14 questionnaire was repeated.

RESULTS

The overall prevalence of type D personality was 32%. Internal consistency (negative affectivity: α = 0.880, social inhibition: α = 0.851) and diagnostic test-retest reliability (kappa value = 0.664) of the DS-14 questionnaire were high. Significantly more symptoms of anxiety, depression, poor sleep quality, fatigue, and a worse health perception were found in OSA with type D. Neither OSA severity nor REM predominance altered these observations.

CONCLUSION

The DS-14 questionnaire showed excellent psychometric properties in patients with OSA. The prevalence of type D personality in patients with OSA was higher than in the general population. The presence of type D personality was associated with higher symptom burden.

Identification of Fatigue Subtypes and Their Correlates in Prevalent Heart Failure: A Secondary Analysis of the Atherosclerosis Risk in Communities Study

BACKGROUND

Among patients with heart failure (HF), fatigue is common and linked to quality of life and functional status. Fatigue is hypothesized to manifest as multiple types, with general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve outcomes. We conducted this study to identify fatigue subtypes in persons with prevalent HF in the ARIC study (Atherosclerosis Risk in Communities) and describe the distribution of characteristics across subtypes.

METHODS

We performed a cross-sectional analysis of 1065 participants with prevalent HF at ARIC visit 5 (2011-2013). We measured exertional fatigue using the Modified Medical Research Council Breathlessness scale and general fatigue using the Patient Reported Outcomes Measurement Information System fatigue scale. We used latent class analysis to identify subtypes of fatigue. Number of classes was determined using model fit statistics, and classes were interpreted and assigned fatigue severity rating based on the conditional probability of endorsing survey items given class. We compared characteristics across classes using multinomial regression.

RESULTS

Overall, participants were 54% female and 38% Black with a mean age of 77. We identified 4 latent classes (fatigue subtypes): (1) high general/high exertional fatigue (18%), (2) high general/low exertional fatigue (27%), (3) moderate general/moderate exertional fatigue (20%), and (4) low/no general and exertional fatigue (35%). Female sex, Black race, lower education level, higher body mass index, increased depressive symptoms, and higher prevalence of diabetes were associated with higher levels of general and exertional fatigue.

CONCLUSIONS

We identified unique subtypes of fatigue in patients with HF who have not been previously described. Within subtype, general and exertional fatigue were mostly concordant in severity, and exertional fatigue only occurred in conjunction with general fatigue, not alone. Further understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication and secondary prevention efforts for persons with HF.

Associations of multidimensional fatigue with the physical, psychological, and situational factors in outpatients with heart failure: a cross-sectional study

AIMS

Fatigue, a distressing symptom in patients with heart failure (HF), is associated with progress and health outcomes. Fatigue has been identified as having multidimensions, but a few studies have used a multidimensional fatigue scale. Many factors related to HF, including physical, psychological, and situational factors, may impact fatigue. However, there is limited knowledge about how these HF-related factors are associated with multidimensional fatigue in outpatients with HF in Japan. The aim of this study was to identify HF-related factors [physical; clinical characteristics, New York Heart Association (NYHA) functional class and physical function, psychological; depressive symptoms and anxiety, situational; health literacy and perceived control] associated with the five dimensions of fatigue in outpatients with HF.

METHODS AND RESULTS

Outpatients with HF (N = 165, mean age = 69.5 years, 78.8% male) completed the survey and physical assessment of gait speed. Fatigue was assessed using five dimensions of the Multidimensional Fatigue Inventory-20. Multiple linear regression analysis was conducted for each dimension of fatigue. General fatigue was predicted by age, NYHA, and perceived control. Physical fatigue was predicted by NYHA, depressive symptoms, and perceived control. Reduced activity was predicted by NYHA, gait speed, depressive symptoms, communicative health literacy, and critical health literacy. The reduced motivation was predicted by depressive symptoms and perceived control. Mental fatigue was predicted by depressive symptoms.

CONCLUSION

Different factors were significantly associated with each fatigue dimension. Further research is needed to alleviate fatigue in patients with HF.

Exercises in activating lymphatic system on fluid overload symptoms, abnormal weight gains, and physical functions among patients with heart failure: A randomized controlled trial

Background

Fluid overload remains a vexing problem in management of heart failure. The lymphatic system that plays the central role in fluid homeostasis has recently been explored as a potential target to counteract tissue fluid overload. The goal of the study was to evaluate the preliminary effects of exercises in activating lymphatic system on fluid overload symptoms, abnormal weight gains, and physical functions for patients with heart failure.

Methods and results

A pilot, pre- and post-test, randomized clinical trial was conducted to recruit a total of 66 patients who were randomized to receive either a 4-week The-Optimal-Lymph-Flow for Heart Failure (TOLF-HF) program or usual care alone. The primary outcome was the prevalence and burden of the fluid overload symptoms. Findings of the trial showed that the TOLF-HF intervention was effective in reducing the prevalence or burden of the majority of fluid overload symptoms. TOLF-HF intervention also demonstrated significant improvement in the outcomes of abnormal weight gains (MD: -0.82; 95% CI: -1.43 to -0.21; P = 0.010) and physical functions (F = 13.792, P < 0.001).

Conclusions

The TOLF-HF program focusing on activating lymphatic system through the performance of therapeutic lymphatic exercises holds the promise as an adjuvant therapy for patients with heart failure to manage fluid overload symptoms, reduce abnormal weight gains, and improve physical functions. Future larger-scale study with longer duration of follow-up is needed.

Clinical Trial Registration

http://www.chictr.org.cn/index.aspx, identifier ChiCTR2000039121.

[Clinical features of asthenic disorders in chronic heart failure]

OBJECTIVE

The aim of the study is to study the clinical features of asthenic disorders in chronic heart failure (CHF) considering the reaction to the disease.

MATERIAL AND METHODS

62 inpatients with CHF II-IV functional class (FC) according to NYHA were examined. Research methods included somatic, psychopathological and pathopsychological examination using psychometric scales.

RESULTS

According to a pathopsychological study using the Multidimensional Fatigue Inventory (MFI-20), asthenic disorders were discovered in all examined patients, realized mainly by «general fatigue» (75.8%) and «physical fatigue» (72.6%), more rarely «mental fatigue» was observed (32.2%). Correlations of «general fatigue» with the age of patients were revealed (p=0.018). There was a relationship between the severity of asthenic disorders and the severity of CHF, as evidenced by the correlation between «general fatigue» and reduced ejection fraction (EF) of the left ventricle (p=0.005), as well as «physical fatigue» and FC according to NYHA (p=0.022). The negative impact of all components of the dimensions of asthenic disorders on the quality of life was determined (p<0.05). According to the concept of the formation of different perceptions of the manifestations of a somatic disease, two types of reactions to asthenic disorders were identified: 1. Dissociative reactions, manifested by a discrepancy between the severity of CHF and a subjective assessment of the condition with an underestimation of the asthenic symptoms denial of its influence on the usual lifestyle and associated with an unfavorable course of CHF and 2. Adaptive reactions, realized by a harmonious perception of asthenia, awareness of the need to change lifestyle considering the presence of CHF symptoms.

CONCLUSION

In accordance with the results, the described clinical features of asthenic disorders allow to distinguish asthenia in CHF and other pathology, and the identified types of reactions can contribute to the timely verification of asthenia, prevention of further progression of CHF, and the development of appropriate treatment approaches.

Chronic Fatigue Syndrome in Patients with Deteriorated Iron Metabolism

Fatigue is a common, non-specific symptom that often impairs patients’ quality of life. Even though fatigue may be the first symptom of many serious diseases, it is often underestimated due to its non-specific nature. Iron metabolism disorders are a prominent example of conditions where fatigue is a leading symptom. Whether it is an iron deficiency or overload, tiredness is one of the most common features. Despite significant progress in diagnosing and treating iron pathologies, the approach to chronic fatigue syndrome in such patients is not precisely determined. Our study aims to present the current state of knowledge on fatigue in patients with deteriorated iron metabolism.

Fatigue in Persons With Heart Failure: A Systematic Literature Review and Meta-Synthesis Using the Biopsychosocial Model of Health

BACKGROUND

Fatigue is a common and distressing symptom of heart failure (HF) and has important implications for patient-reported and clinical outcomes. Despite being a common and bothersome symptom, fatigue has been understudied in HF. We sought to synthesize existing literature on fatigue in HF through a systematic literature review guided by the biopsychosocial model of health.

METHODS AND RESULTS

A systematic search of the literature was performed on March 18, 2020, using Pubmed, Embase, and CINAHL. Full-text, primary research articles, written in English, in which fatigue was a primary symptom of interest in adults with a diagnosis of HF, were included. The search yielded 1138 articles; 33 articles that met inclusion criteria were selected for extraction and synthesis. Biological and psychological factors associated with fatigue were New York Heart Association functional class, hemoglobin level, history of stroke, and depression. However, there are limited HF-specific factors linked to fatigue. Social factors related to fatigue included social roles, relationship strain, and loneliness and isolation. Few nonpharmacologic interventions have been tested by show some promise for alleviating fatigue in HF. Studies show conflicting evidence related to the prognostic implications of fatigue.

CONCLUSIONS

Important biological correlates of fatigue were identified; however, psychological and social variables were limited to qualitative description. There is need for expanded models to better understand the complex physiologic nature of fatigue in HF. Additionally, more research is needed to (1) define the relationships between fatigue and both psychological and social factors, (2) better describe the prognostic implications of fatigue, and (3) develop more therapeutic approaches to alleviate fatigue with the goal of improving overall quality of life.

Fatigue in heart failure outpatients: levels, associated factors, and the impact on quality of life

Introduction

Heart failure (HF) patients experience various psychosocial issues and physical symptoms such as fatigue, which adversely affect their quality of life (QoL). The aim of the study was to assess levels of fatigue in HF outpatients and the associated factors, as well as to explore the correlation between fatigue and QoL.

Material and methods

One hundred and thirty patients were enrolled in the study. Data collection was performed by the completion of “Minnesota Living With Heart Failure” questionnaire (MLHFQ) and the Greek version of the Modified Fatigue Impact Scale (MFIS-Greek). Data also included self-reported patients’ characteristics.

Results

Of the 130 HF outpatients, 50% scored above 69 (median) in total fatigue and above 41 and 29 (median) in physical and mental fatigue, respectively. Furthermore, 50% scored above 66 (median) in total QoL and above 32.5 and 13 (median) in the physical and mental state, respectively. These values indicate moderate to high impact of HF on fatigue and on patients’ QoL. Total fatigue was statistically significantly associated with NYHA stage (p = 0.001), confidence to acknowledge health deteriorations (p = 0.004), decrease in appetite (p = 0.001), dyspnoea at night (p = 0.001), oedema in lower limbs (p = 0.023), relation with health professionals (p = 0.031), and whether patients had limited daily activities (p = 0.002), social contacts (p = 0.014), and if they had financial worries (p = 0.003). Finally, as the score of fatigue increased, so the QoL score also increased.

Conclusions

A broader understanding of this distressing symptom in HF may contribute to the development of suitable interventions with the ultimate goal of improving QoL.

The Fatigue Assessment Scale: quality and availability in sarcoidosis and other diseases

PURPOSE OF REVIEW

Fatigue is a problem experienced by many patients suffering from chronic diseases, including sarcoidosis patients. It has a substantial influence on patients' quality of life (QoL). It is, therefore, important to properly assess fatigue with a valid and reliable measure. The Fatigue Assessment Scale (FAS) is the only validated self-reporting instrument classifying fatigue in sarcoidosis. The aim of this review was to examine the psychometric properties of the FAS and the diseases and languages in which it has been used. Studies among sarcoidosis patients were also reviewed in terms of outcomes.

RECENT FINDINGS

Studies were identified by searching the electronic bibliographic database Pubmed. Search terms used were: FAS and fatigue. Articles were included in the review if the FAS had been used to assess fatigue.

RESULTS

Since its introduction, the FAS was used in 26 different diseases or conditions, including stroke, neurologic disorders, rheumatoid arthritis, idiopathic pulmonary fibrosis and sarcoidosis. Its reliability and validity have proved to be good. Unidimensionality has been established. So far, the FAS is available in 20 languages and widely used in sarcoidosis. Digital versions as well as PDFs of various languages are available online (www.wasog.org).

SUMMARY

The FAS has good psychometric qualities for the diseases in which it has been examined, including sarcoidosis, and can be used in clinical practice. Healthcare workers can use the FAS to assess fatigue in the management, follow-up and clinical care programmes for their patients consistently across countries, as well as in clinical research.

Patients experience of fatigue in advanced heart failure

Aims: Explore the experience of living with fatigue in persons with advanced heart failure. Design: Single-setting, qualitative interview study. Methods: In-depth interviews were conducted from November 2012 - June 2013. Participant responses to open-ended questions were analysed using thematic analysis. Inclusion criteria: 18 years and older, diagnosis of New York Heart Association class III-IV heart failure with reduced ejection fraction and able to participate in interviews in their own language. Exclusion criteria was cognitive deficit Twenty-three participated in the study. Results: Participants (age 72.5 ± 9.5 years, 10/23 female), identified experiencing fatigue daily with 14/23 reporting it as their worst symptom or combined worst symptom with breathlessness. Three key themes were identified: fatigue as a physical barrier, psychological response to fatigue, and living with fatigue as a part of daily life. Conclusion: As heart failure progresses fatigue influences patients' daily life and may negatively affect self-care abilities however patients strive to adapt to these limitations.

Current Trends and Possibilities of Providing Medical Palliative Care in Chronic Heart Failure

Chronic heart failure (CHF) is an important healthcare problem because of high prevalence, morbidity and mortality rates. Treatment resistant symptoms, need for communication and support, unite patients with CHF and oncological diseases but despite that CHF patients rarely receive specialized palliative care (SPC). This review is devoted to the need and possible ways of providing SPC to patients with CHF and their families. We discuss here variants of CHF course in terminal phase, the term end of life appropriate care, various specialists' concepts of SPC delivering to CHF patients in accordance with their preferences.

Assessment of Fatigue in End Stage Renal Disease Patients Undergoing Hemodialysis: Prevalence and Associated Factors

Background:

Fatigue is a common symptom referred by many patients undergoing hemodialysis. Fatigue is associated with poor health-related quality of life (HRQoL) and is an important predictor for survival of hemodialysis patients.

Aim:

To assess the levels of fatigue and demographic factors affecting it among patients with End Stage Renal Disease undergoing hemodialysis.

Methods:

This quantitative study was carried out in two Dialysis Units of Hospitals in Athens Region. Between January 2015 and June 2015, 129 hemodialysis patients completed the Greek Version of the Fatigue Assessment Scale (FAS). Demographic data of patients was recorded. For the statistical analysis IBM SPSS Statistics version 20 was used.

Results:

The mean FAS score was 24.99. 49 patients (38.0%) were non fatigued, 61 patients (47.3%) were fatigued, and 19 patients (13.7%) were extremely fatigued. Higher levels of fatigue were reported among hemodialysis patients residing in urban areas, in those with low educational level and unemployed.

Conclusion:

The findings of this study can be used in the assessment of fatigue and early identification of high-risk patients (especially of the unemployed, those who occupy with domestic works, those with low educational level and of urban citizens). Use of this knowledge by hemodialysis nurses may lead to a better understanding of the factors of fatigue in ESRD, which in turn may lead to a more effective treatment.

The clinical epidemiology of fatigue in newly diagnosed heart failure

BACKGROUND

Fatigue is a common and distressing but poorly understood symptom among patients with heart failure (HF). This study sought to evaluate the prevalence, predictors, and prognostic value of clinically documented fatigue in newly diagnosed HF patients from the community.

METHODS

This retrospective cohort study consisted of 12,285 newly diagnosed HF patients receiving health care services through the Geisinger Health System, with passive data collection through electronic medical records (EMR). Incident HF, fatigue, and other study variables were derived from coded data within EMRs. A collection of 87 candidate predictors were evaluated to ascertain the strongest independent predictors of fatigue using logistic regression. Patients were followed for all-cause mortality for an average of 4.8 years. The associations between fatigue and 6-month, 12-month, and overall mortality were evaluated via Cox proportional hazards regression models.

RESULTS

Clinically documented fatigue was found in 4827 (39%) newly diagnosed HF patients. Depression demonstrated the strongest association with fatigue. Fatigue was often part of a symptom cluster, as other HF symptoms including dyspnea, chest pain, edema, syncope, and palpitations were significant predictors of fatigue. Volume depletion, lower body mass index, and abnormal weight loss were also strong predictors of fatigue. Fatigue was not significantly associated with either 6-month (HR = 1.12, p = 0.16) or overall mortality (HR = 1.00, p = 0.89) in adjusted models.

CONCLUSIONS

Fatigue is a commonly documented symptom among newly diagnosed HF patients, and its origins may lie in both psychologic and physiologic factors. Though fatigue did provide a prognostic signal in the short-term, this was largely explained by physiologic confounders. Proper therapeutic remediation of fatigue in HF relies on identifying underlying factors.

The Family Experience of Fatigue in Heart Failure

Fatigue is a symptom experienced almost universally by people living with a chronic illness. People diagnosed with heart failure have described experiencing significant levels of fatigue. The family experience of fatigue, that is, how families perceive, respond to, and manage fatigue, is unknown. Semistructured family group interviews with 22 families ( N = 62 family members) were conducted. Thematic analysis was undertaken to explore the family experience of fatigue. Fatigue was described as a significant symptom that affected physical, emotional, and social functioning at a family level. Fatigue was described as difficult to manage, and while most family members interviewed had developed a shared understanding of fatigue, some family members found acceptance of this invisible symptom more difficult. Spouses were more likely to express concern that fatigue, and especially increased fatigue, represented a decline in health. The study highlighted the importance of a shared understanding of fatigue from a family perspective.

Selecting symptom instruments for cardiovascular populations

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments.

Integrative Medical Care Plus Mindfulness Training for Patients With Congestive Heart Failure

Congestive heart failure (CHF) has a high rate of morbidity and mortality. It is often accompanied by other medical and psychosocial comorbidities that complicate treatment and adherence. We conducted a proof of concept pilot project to determine the feasibility of providing integrative group medical visits plus mindfulness training for patients recently discharged with CHF. Patients were eligible if they had been discharged from an inpatient stay for CHF within the 12 months prior to the new program. The Compassionate Approach to Lifestyle and Mind–Body (CALM) Skills for Patients with CHF consisted of 8 weekly visits focusing on patient education about medications, diet, exercise, sleep, and stress management; group support; and training in mind–body skills such as mindfulness, self-compassion, and loving-kindness. Over two 8-week sessions, 8/11 (73%) patients completed at least 4 visits. The patients had an average age of 57 years. The most common comorbidities were weight gain, sleep problems, and fatigue. After the sessions, 100% of patients planned to make changes to their diet, exercise, and stress management practices. Over half of the patients who met with a pharmacist had a medication-related problem. Improvements were observed in depression, fatigue, and satisfaction with life. Integrative group visits focusing on healthy lifestyle, support, and skill-building are feasible even among CHF patients and should be evaluated in controlled trials as a patient-centered approach to improving outcomes related to improving medication management, depression, fatigue, and quality of life.

The relationship between pain, fatigue, depression and functional performance in stable heart failure

OBJECTIVE

Evaluate the relationship between pain, fatigue, depression, demographic, clinical, and functional variables in stable heart failure (HF).

BACKGROUND

Pain, fatigue and depression are common in HF. Little is known about the relationship between pain, fatigue and depression and functional measures in this population.

METHODS

Secondary data analysis of a cross sectional study of 173 stable HF patients. Associations between clinical and demographic factors, pain (SF-36), depression (CES-D), and fatigue (MAF) to functional performance and capacity (SF-36 role limitations due to physical functioning and 6-Minute Walk Test) were evaluated using hierarchical multiple regressions.

RESULTS

The sample was 65% male with a mean age of 60. Fifty-seven percent (n = 100) had pain, 54% (n = 94) had fatigue, and 46% (n = 79) had depression. Pain, depression and fatigue were negatively associated with functional performance but not functional capacity when controlling for demographic and clinical covariates.

CONCLUSIONS

Pain, fatigue and depression were associated with decreased functional performance in stable HF. Symptom management interventions are needed in HF.

Indoor mobility-related fatigue and muscle strength in nonagenarians: a prospective longitudinal study

BACKGROUND AND AIMS

Mobility-related fatigue is an important indicator of functional decline in old age, however, very little is known about fatigue in the oldest old population segment. The aim of this study was to examine the association between indoor mobility-related fatigue and muscle strength decline in nonagenarians.

METHODS

The study is based on a prospective longitudinal study of all Danes born in 1905 and assessed in 1998, 2000 and 2003, and includes 92- to 93-year-old persons who were independent of help in basic indoor mobility at baseline (n = 1,353). Fatigue was assessed at baseline and defined as a subjective feeling of fatigue when transferring or walking indoors. The outcome measure, maximum grip strength, was measured at each measurement point.

RESULTS

Grip strength declined throughout the study in participants with and without fatigue, but those reporting fatigue had significantly (P < .001) lower muscle strength during the entire study period. Longitudinal analyses indicated slightly slower decline in muscle strength among participants with fatigue compared to those without; however, observed selective dropout of participants with fatigue and poor performance at baseline needs to be considered when interpreting the results. Accordingly, participants without fatigue had significantly higher chances of being alive and having muscle strength above gender-specific median at first (RR 1.32, 95 % CI 1.07-1.58), second (RR 1.51, 1.06-1.96) and third (RR 1.39, 1.01-1.97) measurement points.

CONCLUSIONS

Indoor mobility-related fatigue in advanced later life should not merely be considered as an unpleasant symptom, but rather an indicator of physical impairment, and consequently declined physiological reserve.

Fatigue, inflammation, and projected mortality in heart failure

BACKGROUND

Fatigue is a prominent and poorly understood symptom of heart failure with reduced ejection fraction (HFrEF). The purpose of this study was to determine whether fatigue correlated with immune biomarkers and prognosis.

METHODS/RESULTS

In patients with HFrEF (N = 59) and healthy controls (N = 25), we prospectively measured fatigue (Profile of Mood States), depressive symptoms (Patient Health Questionnaire-8), sleep quality (Pittsburgh Sleep Quality Index), and immune biomarkers (plasma C-reactive protein [CRP], tumor necrosis factor-α [TNFα], and interleukins [IL-6 and IL-10]). Seattle Heart Failure Model (SHFM) mortality risk scores were determined. Patients with HFrEF had significantly greater fatigue and depressive symptoms and poorer sleep quality compared to control subjects. When controlling for depressive symptoms, however, fatigue did not differ significantly between patients with HFrEF and controls. Patients with HFrEF had significantly lower levels of IL-10 compared to controls. Cytokines did not correlate significantly with fatigue, but fatigue was significantly associated with higher SHFM scores.

CONCLUSIONS

Depressive symptoms were an important covariate of fatigue in patients with HFrEF. Our study findings were the first to show a positive association between fatigue and the SHFM score, indicating that fatigue was associated with poorer prognosis.

Type D (distressed) personality and its assessment with the DS14 in Lithuanian patients with coronary artery disease

We examined Type D personality (combination of negative affectivity with social inhibition) and its assessment with the DS14 in 543 Lithuanian coronary patients. Psychometric analyses confirmed the two-factor structure, internal consistency (α = 0.84/α = 0.75), and test-retest reliability (r = 0.69/0.81) of the DS14 negative affectivity and inhibition components. Negative affectivity correlated (r = -0.58) with emotional stability and social inhibition (r = -0.46) with extraversion; correlations with other Big-Five traits ranged between r = -0.11 and -0.19. Type D patients (34%) had a ninefold increased odds of depression (95% confidence interval = 5.01-17.36) and a fivefold increased odds of anxiety (95% confidence interval = 3.47-7.97). These findings support the validity of the Type D construct in Lithuania.

Neurocognitive function and CNS integrity in adult survivors of childhood hodgkin lymphoma

PURPOSE

Long-term survivors of childhood Hodgkin lymphoma (HL) are at risk for cardiopulmonary complications and CNS stroke, although neurocognitive function has not been previously examined. The aim of this study was to examine neurocognitive and brain imaging outcomes in adult survivors of childhood HL.

PATIENTS AND METHODS

In all, 62 adult survivors (mean age, 42.2 years; standard deviation [SD], 4.77; mean age at diagnosis, 15.1 years; SD, 3.30) were identified by stratified random selection from a large cohort treated with either high-dose (≥ 30 Gy) thoracic radiation (n = 38) or lower-dose (< 30 Gy) thoracic radiation combined with anthracycline (n = 24). Patients underwent neurocognitive evaluations, brain magnetic resonance imaging (MRI), echocardiograms, pulmonary function tests, and physical examinations.

RESULTS

Compared with national age-adjusted norms, HL survivors demonstrated lower performance on sustained attention (P = .004), short-term memory (P = .001), long-term memory (P = .006), working memory (P < .001), naming speed (P < .001), and cognitive fluency (P = .007). MRI revealed leukoencephalopathy in 53% of survivors, and 37% had evidence of cerebrovascular injury. Higher thoracic radiation dose was associated with impaired cardiac diastolic function (E/E'; ratio of peak mitral flow velocity of early rapid filling [E] to early diastolic velocity of the mitral annulus [E']; P = .003), impaired pulmonary function (diffusing capacity of lungs for carbon monoxide [DL(co)(corr); P = .04), and leukoencephalopathy (P = .02). Survivors with leukoencephalopathy demonstrated reduced cognitive fluency (P = .001). Working memory impairment was associated with E/E', although impaired sustained attention and naming speed were associated with DL(co)(corr). Neurocognitive performance was associated with academic and vocational functioning.

CONCLUSION

These results suggest that adult long-term survivors of childhood HL are at risk for neurocognitive impairment, which is associated with radiologic indices suggestive of reduced brain integrity and which occurs in the presence of symptoms of cardiopulmonary dysfunction.

Somatic depression predicts mortality in chronic heart failure: can this be explained by covarying symptoms of fatigue?

OBJECTIVE

Somatic symptoms of depression predict mortality in chronic heart failure (CHF), but symptoms of fatigue that are common to both conditions may confound this association. We therefore examined the contribution of fatigue to the association between somatic depression and increased risk of mortality in patients with CHF.

METHODS

At baseline, 380 consecutive patients with CHF were assessed for symptoms of depression, exertion fatigue, and general fatigue. Demographic and clinical data were obtained from the patients' medical records or the treating cardiologist. The primary end point was mortality after a median follow-up of 2.3 years (range = 0.15-4.76 years).

RESULTS

At follow-up, 63 patients (16.6%) had died. Exertion fatigue (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.01-1.06, p = .003), not general fatigue, was associated with an increased risk of mortality in CHF. Multivariate Cox regression analysis revealed that somatic symptoms of depression (HR = 1.41, 95% CI = 1.05-1.88, p = .02) were independently associated with increased mortality risk and that this association could not be explained by exertion fatigue (HR = 1.02, 95% CI = 0.97-1.05, p = .31).

CONCLUSIONS

The adverse effect of somatic depression on prognosis in CHF was not confounded by exertion fatigue. Behavioral interventions should focus not only on fatigue but also on other somatic manifestations of depression in patients with CHF.

Construct and criterion validity of the DUFS and DEFS⁴ in Lithuanian patients with coronary artery disease

BACKGROUND

Fatigue has become an important symptom in clinical diagnosis and clinical trials among subjects with cardiovascular diseases and disease-specific fatigue scales were developed in a Dutch and English version.

OBJECTIVE

Various questionnaires for measuring fatigue have been developed, but currently no validated questionnaire targeted at subjects with cardiovascular disease and heart failure exists in the Lithuanian language.

METHODS

Despite the rigor of the exploratory factor analysis and analyses of the psychometric properties of the disease-specific Dutch Fatigue Scale and the Dutch Exertion Fatigue Scale (DUFS-DEFS) we adopted a confirmatory approach considered as the gold standard method for the evaluation of construct validity in psychometric inventories. To test the criterion validity of the DUFS and DEFS structural equation modelling was employed with the widely used and validated Multidimensional Fatigue Inventory (MFI).

RESULTS

The a priori specification of a hypothesized five-factor model of the MFI-20 and a two-factor model of the DUFS and DEFS appeared to have a good fit to the data in Lithuanian patients. The hypothesized model of the criterion validity of the DUFS and DEFS had a good fit and classes of disease severity showed statistically significant and clinically relevant differences on fatigue scores.

CONCLUSION

The construct validity and criterion validity of the DUFS and DEFS were confirmed in a Lithuanian sample of cardiac patients. The construct validity of the MFI was also supported and this fatigue measure can be used in Lithuanian settings of clinical practice and research.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Signs and symptoms of heart failure: are you asking the right questions?

BACKGROUND

Patients may not verbalize common and atypical signs and symptoms of heart failure and may not understand their association with worsening disease and treatments.

OBJECTIVES

To examine prevalence of signs and symptoms relative to demographics, care setting, and functional class.

METHODS

A convenience sample of 276 patients (164 ambulatory, 112 hospitalized) with systolic heart failure completed a 1-page checklist of signs and symptoms experienced in the preceding 7 days (ambulatory) or in the 7 days before hospitalization. Demographic and medical history data were collected.

RESULTS

Mean age was 61.6 (SD, 14.8) years, 65% were male, 58% were white, and 45% had ischemic cardiomyopathy. Hospitalized patients reported more sudden weight gain, weight loss, severe cough, low/orthostatic blood pressure, profound fatigue, decreased exercise, restlessness/confusion, irregular pulse, and palpitations (all P < .05). Patients in functional class IV reported more atypical signs and symptoms of heart failure (severe cough, nausea/vomiting, diarrhea or loss of appetite, and restlessness, confusion, or fainting, all P <or= .001). Sudden weight gain increased from 5% in functional class I to 37.5% in functional class IV (P < .001). Dyspnea occurred in all functional classes (98%-100%) and both settings (92%-100%). Profound fatigue was associated with worsening functional class (P < .001) and hospital setting (P = .001); paroxysmal nocturnal dyspnea was associated with functional class IV (P = .02) and hospital setting (P < .001).

CONCLUSION

Profound fatigue is more reliable than dyspnea as an indicator of functional class. Nurses must recognize atypical signs and symptoms of worsening functional class to determine clinical status and facilitate patient care decisions.

Distinct trajectories of fatigue in chronic heart failure and their association with prognosis

AIMS

To identify distinct trajectories of fatigue over a 12-month period and to examine their impact on mortality in chronic heart failure (CHF).

METHODS AND RESULTS

Consecutive CHF patients (n = 310) were assessed at baseline and at 2- and 12-month follow-up for symptoms of exertion and general fatigue. Latent growth mixture modelling was used to examine the course of fatigue over time. The endpoint was mortality following the 12-month assessment of fatigue. Over the initial 12-month follow-up, six distinct trajectories for exertion fatigue and four distinct trajectories for general fatigue were identified. Beyond the 12-month follow-up (mean follow-up period, 693 days), 50 patients (17%) had died. After controlling for standard risk factors and disease severity, both severe exertion fatigue [hazards ratio (HR) = 2.59, 95% confidence interval (CI): 1.09-6.16, P = 0.03] and severe general fatigue (HR = 3.20, 95% CI: 1.62-6.31, P = 0.001) trajectories predicted an increased mortality rate (29 vs. 19% and 28 vs. 14%, respectively). The low exertion fatigue trajectory was associated with a decreased mortality risk (3 vs. 19%, HR = 0.12, 95% CI: 0.02-0.93, P = 0.04).

CONCLUSION

Fatigue trajectories varied across CHF patients and had a differential effect on mortality. Persistent severe fatigue was a predictor of poor prognosis. These results may help identify distinct groups of CHF patients with potentially differential risks of adverse health outcomes.

Propriedades psicométricas da Dutch Fatigue Scale e Dutch Exertion Fatigue Scale: versão brasileira

Fadiga é uma resposta humana em diversas situações agudas e crônicas e também na população geral. Este artigo relata estudo realizado para estimar confiabilidade e validade da Dutch Fatigue Scale (DUFS) e da Dutch Exertion Fatigue Scale (DEFS) adaptadas para o Brasil. Trezentos pacientes ambulatoriais com insuficiência cardíaca e 64 voluntários responderam a DUFS e a DEFS vertidas para o português. Análise fatorial sobre o conjunto de itens das duas escalas produziu solução com um fator para cada escala (variância explicada = 53,9%) e boas estimativas de confiabilidade pelo alfa de Chronbach (DUFS=0,85 e DEFS=0,92) foram obtidas. Na amostra de pacientes, os escores nas escalas foram positivamente associados com a classe funcional da insuficiência cardíaca (DUFS e DEFS p=0,000), com os escores de depressão (DUFS r s=0,63; p=0,00 e DEFS r s=0,55; p=0,00) e com distúrbio de sono (DUFS e DEFS p=0,000). As versões brasileiras mostraram propriedades semelhantes as das escalas originais.

Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients

The combination of negative affectivity (NA) and social inhibition (SI) - the Type D Personality - is associated with poor outcomes in coronary artery disease (CAD) patients. A Norwegian translation of the standard instrument measuring Type D (DS14) was tested on 432 CAD patients receiving coronary revascularization treatment. Factor analysis produced two factors with high inter-item reliability, indicating that the Norwegian DS14 has acceptable psychometric properties. Eighteen percent were classified as Type D, lower than has been reported elsewhere. Type D was associated with anxiety, depression, and passive coping. NA correlated positively with depression, anxiety, and passive coping. SI correlated positively with depression and anxiety, and negatively with active coping. The prevalence of Type D was higher among women, and negatively correlated with time since treatment. The variation in Type D prevalence among studies needs further elucidation as does the predictive power of continuous scoring of the Type D trait.

Fatigue with systolic heart failure

BACKGROUND AND RESEARCH OBJECTIVE

Fatigue is one of the most prevalent symptoms in persons with systolic heart failure (HF). There remains insufficient information about the physiological and psychosocial underpinnings of fatigue in HF. The specific aims of this study were to (1) determine the psychometric properties of 2 fatigue questionnaires in patients with HF, (2) compare fatigue in patients with HF to published scores of healthy adults and patients with cancer undergoing treatment, and (3) identify the physiological (eg, hemoglobin, B-type natriuretic peptide, body mass index, and ejection fraction) and psychosocial (eg, depressed mood) correlates of fatigue in HF.

SUBJECTS AND METHODS

A convenience sample of 87 HF outpatients was recruited from 2 urban medical centers. Patients completed the Fatigue Symptom Inventory, Profile of Mood States, and Short Form-36 Health Survey.

RESULTS AND CONCLUSIONS

Patients with HF and patients with cancer reported similar levels of fatigue, and both patient groups reported significantly more fatigue than did healthy adults. Physical functioning and hemoglobin categories explained 30% of the variance in Fatigue Symptom Inventory-Interference Scale scores, whereas depressed mood and physical functioning explained 47% of the variance in Profile of Mood States Fatigue subscale scores. Patients with HF experienced substantial fatigue that is comparable with cancer-related fatigue. Low physical functioning, depressed mood, and low hemoglobin level were associated with HF-related fatigue.

Characteristics of fatigue in heart failure patients: a literature review

This is a literature review report to describe characteristics (frequency, intensity and correlates) of fatigue in cases of heart failure. MedLine and LILACS were the examined databases. Out of 89 articles identified, 27 were selected for data extraction. Fatigue frequency ranged from 69% to 88% and fatigue intensities are incomparable due to differences in measurement scales. Quality of life, illness progression, physical activity, social and demographic variables, comorbidity, treatment and who assessed the fatigue were variables studied in relation to fatigue. The diversity of fatigue assessment methods causes difficulties to integrate results on fatigue frequency, characteristics and related factors. No study was found on fatigue characteristics in samples of Brazilian heart failure patients.

Clinical assessment of heart failure: utility of symptoms, signs, and daily weights

Heart failure is a clinical syndrome defined by the presence of characteristic signs and symptoms. History taking and physical examination have particular utility in assessing patients who have heart failure. In recent years the validity of conventional signs and symptoms of heart failure has been tested in large population studies and in clinical trials, providing an evidence basis for their utility in the clinical assessment of the patient who has known or suspected heart failure. There also has been progress in characterizing the process of acute decompensation from a previously chronic stable state. This article addresses the usefulness of signs and symptoms and daily weights in the assessment and management of patients who have heart failure.

Assessment of fatigue in adults with disabilities

Fatigue is prevalent and can produce major public health consequences. Assessment of fatigue by the PM&R physician begins with a careful history and physical examination, complemented by pertinent rating scales and laboratory studies. In adults with disabilities, a wide variety of etiologies may lead to fatigue. Educating and providing resources about fatigue to patients can help open the discussion about this highly debilitating symptom.