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Fatigue in Persons With Heart Failure: A Systematic Literature Review and Meta-Synthesis Using the Biopsychosocial Model of Health. J Card Fail 2022; 28:283-315. [PMID: 34329719 PMCID: PMC8795245 DOI: 10.1016/j.cardfail.2021.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/27/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
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.
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Mapelli M, Salvioni E, Bonomi A, Gugliandolo P, De Martino F, Vignati C, Berna G, Agostoni P. How Patients With Heart Failure Perform Daily Life Activities. Circ Heart Fail 2020; 13:e007503. [DOI: 10.1161/circheartfailure.120.007503] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Cardiopulmonary exercise test and 6-minute walking test are frequently used tools to evaluate physical performance in heart failure (HF), but they do neither represent activities of daily living (ADLs) nor fully reproduce patients’ symptoms. We assessed differences in task oxygen uptake, both as absolute value and as percentage of peak oxygen consumption (peakVO
2
), ventilation efficiency (VE/VCO
2
ratio), and dyspnea intensity (Borg scale) in HF and healthy subjects during standard ADLs and other common physical actions.
Methods:
Healthy and HF subjects (ejection fraction <45%, stable conditions) underwent cardiopulmonary exercise test. All of them, carrying a wearable metabolic cart, performed a 6-minute walking test, two 4-minute treadmill exercises (at 2 and 3 km/h), and ADLs: ADL1 (getting dressed), ADL2 (folding 8 towels), ADL3 (putting away 6 bottles), ADL4 (making a bed), ADL5 (sweeping the floor for 4 minutes), ADL6 (climbing 1 flight of stairs carrying a load).
Results:
Sixty patients with HF (age 65.2±12.1 years; ejection fraction 30.4±6.7%, peakVO
2
14.2±4.0 mL/[min·kg]) and 40 healthy volunteers (58.9±8.2 years, peakVO
2
28.1±7.4 mL/[min·kg]) were enrolled. For each exercise, patients showed higher VE/VCO
2
ratio, percentage of peakVO
2
, and Borg scale value than controls, while absolute values of task oxygen uptake and exercise duration were lower and higher, respectively, in all activities, except for treadmill (fixed execution time and intensity). Differently from Borg Scale data, metabolic values and exercise time length changed in parallel with HF severity, except for ADL duration in very short (ADL3) and composite (ADL1) activities. Borg scale values correlated with percentage of peakVO
2
.
Conclusions:
During ADLs, patients self-regulated activities in parallel with HF severity by decreasing intensity (VO
2
) and prolonging the effort.
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Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M.M., C.V., P.A.)
| | - Elisabetta Salvioni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
| | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
| | - Paola Gugliandolo
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
| | - Fabiana De Martino
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M.M., C.V., P.A.)
| | - Giovanni Berna
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milano, Italy (M.M., E.S., A.B., P.G., F.D.M., C.V., G.B., P.A.)
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Italy (M.M., C.V., P.A.)
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Straw S, Byrom R, Gierula J, Paton MF, Koshy A, Cubbon R, Drozd M, Kearney M, Witte KK. Predicting one-year mortality in heart failure using the 'Surprise Question': a prospective pilot study. Eur J Heart Fail 2018; 21:227-234. [PMID: 30548129 DOI: 10.1002/ejhf.1353] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/19/2018] [Accepted: 10/05/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Surprise Question: 'would you be surprised if this patient were to die within the next year?' has been shown to predict mortality in patients with chronic kidney disease and cancer. This prospective study aimed to determine whether the Surprise Question could identify heart failure patients with a prognosis of less than 1 year, and whether the Surprise Question can be used by different healthcare professionals. METHODS AND RESULTS Overall, 129 consecutive patients admitted with decompensated heart failure were included. Doctors and nurses were asked to provide a 'surprised' or 'not surprised' response to the Surprise Question for each patient. Patients were followed up until death or 1 year following study inclusion. The sensitivity, specificity, positive predictive value and negative predictive value of the Surprise Question were assessed. Cox regression was used to determine covariates significantly associated with survival. The Surprise Question showed excellent sensitivity (0.85) and negative predictive value (0.88) but only fair specificity (0.59) and positive predictive value (0.52) when asked of cardiologists. There were similar levels of accuracy between doctors and specialist nurses. The Surprise Question was significantly associated with all-cause mortality in multivariate regression analysis (hazard ratio 2.8, 95% confidence interval 1.0-7.9, P = 0.046). CONCLUSION This study demonstrates that the Surprise Question can identify heart failure patients within the last year of life. Despite over-classification of patients into the 'not surprised' category, the Surprise Question identified nearly all patients who were within the last year of life, whilst also accurately identifying those unlikely to die.
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Affiliation(s)
- Sam Straw
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Aaron Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Morosin M, Farina S, Vignati C, Spadafora E, Sciomer S, Salvioni E, Sinagra G, Agostoni P. Exercise performance, haemodynamics, and respiratory pattern do not identify heart failure patients who end exercise with dyspnoea from those with fatigue. ESC Heart Fail 2017; 5:115-119. [PMID: 29171164 PMCID: PMC5793969 DOI: 10.1002/ehf2.12207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/28/2017] [Accepted: 07/26/2017] [Indexed: 11/10/2022] Open
Abstract
AIMS The two main symptoms referred by chronic heart failure (HF) patients as the causes of exercise termination during maximal cardiopulmonary exercise testing (CPET) are muscular fatigue and dyspnoea. So far, a physiological explanation why some HF patients end exercise because of dyspnoea and others because of fatigue is not available. We assessed whether patients referring dyspnoea or muscular fatigue may be distinguished by different ventilator or haemodynamic behaviours during exercise. METHODS AND RESULTS We analysed exercise data of 170 consecutive HF patients with reduced left ventricular ejection fraction in stable clinical condition. All patients underwent maximal CPET and a second maximal CPET with measurement of cardiac output by inert gas rebreathing at peak exercise. Thirty-eight (age 65.0 ± 11.1 years) and 132 (65.1 ± 11.4 years) patients terminated CPET because of dyspnoea and fatigue, respectively. Haemodynamic and cardiorespiratory parameters were the same in fatigue and dyspnoea patients. VO2 was 10.4 ± 3.2 and 10.5 ± 3.3 mL/min/kg at the anaerobic threshold and 15.5 ± 4.8 and 15.4 ± 4.3 at peak, in fatigue and dyspnoea patients, respectively. In fatigue and dyspnoea patients, peak heart rate was 110 ± 22 and 114 ± 22 beats/min, and VE/VCO2 and VO2 /work relationship slopes were 31.2 ± 6.8 and 30.6 ± 8.2 and 10.6 ± 4.2 and 11.4 ± 5.5 L/min/W, respectively. Peak cardiac output was 6.68 ± 2.51 and 6.21 ± 2.55 L/min (P = NS for all). CONCLUSIONS In chronic HF patients in stable clinical condition, fatigue and dyspnoea as reasons of exercise termination do not highlight different ventilatory or haemodynamic patterns during effort.
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Affiliation(s)
- Marco Morosin
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Cardiovascular Department 'Ospedali Riuniti' Trieste and Postgraduate School Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | | | | | | | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Geriatric, Nephrology and Anesthesiology Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Gianfranco Sinagra
- Cardiovascular Department 'Ospedali Riuniti' Trieste and Postgraduate School Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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Kupzyk KA, Seo Y, Yates B, Pozehl B, Norman J, Lowes B. Use of the Late-Life Function and Disability Instrument for Measuring Physical Functioning in Patients With Heart Failure. J Nurs Meas 2016; 24:323-36. [PMID: 27535318 DOI: 10.1891/1061-3749.24.2.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the psychometric properties of the functioning component of the Late-Life Function and Disability Instrument (LLFDI) in individuals with heart failure (HF). METHODS Factor analyses were used (N = 151) to assess the dimensionality and structure of the basic and advanced lower extremity function subscales. Rasch model scores were compared to the raw means of the items. RESULTS Rasch scores correlated with the raw means of the items at r = .96, indicating raw means are comparable to the more complicated Rasch analysis in estimating physical functioning using the basic and advanced subscales. CONCLUSIONS The lower extremity physical functioning subscales of the LLFDI have potential as a clinical assessment tool to identify HF patients who are at high risk for functional limitations.
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Affiliation(s)
- Kevin A Kupzyk
- College of Nursing, University of Nebraska Medical Center, Omaha
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Gierula J, Witte KKA. Response to (resynchronization) therapy in chronic heart failure: time for a different approach. Eur J Heart Fail 2014; 16:117-8. [DOI: 10.1002/ejhf.53] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/11/2013] [Indexed: 11/10/2022] Open
Affiliation(s)
- John Gierula
- Division of Cardiovascular and Diabetes Research; Leeds Institute of Genetics, Health and Therapeutics Multidisciplinary Cardiovascular Research Centre, University of Leeds; UK
| | - Klaus K. A. Witte
- Division of Cardiovascular and Diabetes Research; Leeds Institute of Genetics, Health and Therapeutics Multidisciplinary Cardiovascular Research Centre, University of Leeds; UK
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Rojas LBA, Gomes MB. Metformin: an old but still the best treatment for type 2 diabetes. Diabetol Metab Syndr 2013; 5:6. [PMID: 23415113 PMCID: PMC3607889 DOI: 10.1186/1758-5996-5-6] [Citation(s) in RCA: 343] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 02/05/2013] [Indexed: 12/13/2022] Open
Abstract
The management of T2DM requires aggressive treatment to achieve glycemic and cardiovascular risk factor goals. In this setting, metformin, an old and widely accepted first line agent, stands out not only for its antihyperglycemic properties but also for its effects beyond glycemic control such as improvements in endothelial dysfunction, hemostasis and oxidative stress, insulin resistance, lipid profiles, and fat redistribution. These properties may have contributed to the decrease of adverse cardiovascular outcomes otherwise not attributable to metformin's mere antihyperglycemic effects. Several other classes of oral antidiabetic agents have been recently launched, introducing the need to evaluate the role of metformin as initial therapy and in combination with these newer drugs. There is increasing evidence from in vivo and in vitro studies supporting its anti-proliferative role in cancer and possibly a neuroprotective effect. Metformin's negligible risk of hypoglycemia in monotherapy and few drug interactions of clinical relevance give this drug a high safety profile. The tolerability of metformin may be improved by using an appropiate dose titration, starting with low doses, so that side-effects can be minimized or by switching to an extended release form. We reviewed the role of metformin in the treatment of patients with type 2 diabetes and describe the additional benefits beyond its glycemic effect. We also discuss its potential role for a variety of insulin resistant and pre-diabetic states, obesity, metabolic abnormalities associated with HIV disease, gestational diabetes, cancer, and neuroprotection.
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Affiliation(s)
- Lilian Beatriz Aguayo Rojas
- Department of Medicine, Diabetes Unit, State University of Rio de Janeiro, Av 28 setembro 77, Rio de Janeiro CEP20555-030, Brazil
| | - Marilia Brito Gomes
- Department of Medicine, Diabetes Unit, State University of Rio de Janeiro, Av 28 setembro 77, Rio de Janeiro CEP20555-030, Brazil
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Witte KK, Clark AL. NYHA class I heart failure is not 'mild'. Int J Cardiol 2011; 146:128-9. [PMID: 20970201 DOI: 10.1016/j.ijcard.2010.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 10/02/2010] [Indexed: 10/18/2022]
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Bailey CD, Wagland R, Dabbour R, Caress A, Smith J, Molassiotis A. An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses. BMC Pulm Med 2010; 10:63. [PMID: 21143887 PMCID: PMC3016307 DOI: 10.1186/1471-2466-10-63] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 12/09/2010] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation. METHODS Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms. RESULTS In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication. CONCLUSIONS More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.
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Affiliation(s)
- Chris D Bailey
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Richard Wagland
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Rasha Dabbour
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Ann Caress
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Jaclyn Smith
- Department of Translational Medicine, University of Manchester, Manchester, UK & Johns Hopkins Asthma and Allergy Center, Boston, USA
| | - Alex Molassiotis
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
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Sun XG, Hansen JE, Beshai JF, Wasserman K. Oscillatory breathing and exercise gas exchange abnormalities prognosticate early mortality and morbidity in heart failure. J Am Coll Cardiol 2010; 55:1814-23. [PMID: 20413031 DOI: 10.1016/j.jacc.2009.10.075] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 10/19/2009] [Accepted: 10/20/2009] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The goal of this study was to identify better predictors of early death in patients with chronic left ventricular heart failure (CHF). Potential predictors, derived from cardiopulmonary exercise testing, were compared with other commonly used cardiovascular measurements. BACKGROUND The prediction of early death in patients with CHF remains challenging. METHODS Five hundred eight patients with CHF due to systolic dysfunction underwent resting cardiovascular measurements, 6-min walking tests, and cardiopulmonary exercise testing. The peak oxygen uptake (.VO(2)), peak oxygen pulse, anaerobic threshold, ratio of ventilation to carbon dioxide output (.VE/.VCO(2)), slope of .VE versus .VCO(2), and presence or absence of a distinctive oscillatory breathing pattern (OB) were ascertained. Outcomes were 6-month mortality and morbidity, the latter a sum of cardiac hospitalizations and deaths. RESULTS The single best predictor of mortality was an elevated lowest .VE/.VCO(2) (> or =155% predicted). Adding OB on the basis of stepwise regression (optimal 2-predictor model), the odds ratio for mortality increased from 9.4 to 38.9 (p < 0.001). The slope of .VE versus .VCO(2) slope, peak .VO(2), peak oxygen pulse, and anaerobic threshold combined with OB were also strong predictors. OB also increased the odds ratio 2- to 3-fold for each of these (p < 0.01). Kaplan-Meier survival curves and area under the receiver-operating characteristic curve confirmed that lowest .VE/.VCO(2) and OB were superior. For morbidity, elevated lowest .VE/.VCO(2) or lower peak .VO(2) with OB were the best predictors. No nonexercise measurements discriminated mortality and morbidity. CONCLUSIONS Cardiopulmonary exercise testing parameters are powerful prognosticators of early mortality and morbidity in patients with CHF, especially the optimal 2-predictor model of a combination of elevated lowest .VE/.VCO(2) and OB.
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Affiliation(s)
- Xing-Guo Sun
- Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502, USA.
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