Linkages between anxiety and outcomes in heart failure

Study of the Relationship Between Death Anxiety and Quality of Life in Patients With Heart Failure

This study aimed to investigate the relationship between death anxiety and QoL in a sample of Iranian heart failure (HF) patients. A cross-sectional correlational design was employed to examine this relationship in a sample of 296 HF patients. Participants were recruited using convenience sampling from teaching hospitals in Kermanshah City, western Iran, between October and December 2023. Data were collected using a demographic questionnaire, the Templer Death Anxiety Scale (TDAS), and the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Participants reported moderate to high levels of death anxiety (Mean [SD] = 7.54 [2.35]) on the TDAS and moderate to poor QoL (Mean [SD] = 36.24 [12.26]) on the MLHFQ. The statistical methods used in this study included descriptive statistics, independent t-tests, one-way analysis of variance (ANOVA), Pearson correlation coefficient, multiple linear regression analysis, and the Kolmogorov-Smirnov test. All statistical analyses were performed using SPSS version 26, with a significance level set at 0.05. A significant positive correlation was found between death anxiety and QoL (r = 0.329, p < .001), indicating that higher levels of death anxiety were associated with lower QoL. These results underscore the importance of addressing death anxiety in HF patients to improve their QoL. Interventions targeting the reduction of death anxiety and the enhancement of QoL are essential for optimizing care for this vulnerable population. The study recommends the implementation of psychological interventions, support groups, comprehensive counseling, education, and regular assessments for this purpose.

The Influence of Hybrid Comprehensive Telerehabilitation on Anxiety in Heart Failure Patients: The TELEREH-HF Randomized Clinical Trial

Telerehabilitation for heart failure (HF) patients is beneficial for physical functioning, prognosis, and psychological status. The study aimed at evaluating the influence of hybrid comprehensive telerehabilitation (HCTR) on the level of anxiety in comparison to usual care (UC). The TELEREH-HF study was a multicenter prospective RCT in 850 clinically stable HF participants. Patients underwent clinical examinations, including the assessment of anxiety, at entry and after the 9-week training program (HCTR) or observation (UC). The State-Trait Anxiety Inventory (STAI) was used. 20.3% HCTR and 20.1% UC patients reported high level of anxiety as a state at baseline, with higher STAI results in younger participants (< 63 y.o.) (p = .048 for HCTR; p = .026 for UC). At both stages of the study, patients with lower level of physical capacity (measured by a peak VO2) had shown significantly higher level of anxiety. There were no significant changes in anxiety levels during the 9-week observation for the entire study population, although there were different patterns of change in anxiety (both trait and state) in younger and older groups,with the decrease in younger patients, and the increase-in the older group.Trial registry number NCT02523560 (Clinical Trials.gov), date of registration: August 14, 2015.

Global Prevalence of Anxiety in Adult Cardiology Outpatients: A Systematic Review and Meta-analysis

Anxiety and anxiety disorders are associated with adverse cardiovascular outcomes, and reduced quality of life. Despite this, no comprehensive study on the global prevalence of anxiety symptoms and disorders among adult cardiology outpatients exists. This systematic review and meta-analysis aims to provide cardiologists with a precise estimate of the prevalence of anxiety in their outpatient clinics. PubMed, Embase, Cochrane and PsycINFO databases and Google Scholar were searched from database inception to January 23, 2023. Data characteristics were extracted independently by 2 investigators. Ninety-three studies, n = 36,687 participants across 31 countries, were included. Global prevalence of anxiety symptoms/disorders was 28.9% (95%CI 25.7-32.4; 8927/36, 687; I2 = 97.33; n = 93). The highest rates were found in patients presenting with hypertension, 43.6%. Subgroup analyses revealed higher prevalence estimates when using self-report screening compared to gold-standard diagnostic interview. When using diagnostic interview, the highest rates were reported in outpatients with undifferentiated chest pain/palpitations, 19·0%. Panic disorder was the most frequent diagnosis 15.3%, and rates were significantly higher in patients with undifferentiated chest pain/palpitations compared to ischemic heart disease. Higher rates of anxiety were found in studies of outpatients from developing countries, and female outpatients tended to have higher rates compared to males. Anxiety occurred frequently among cardiology outpatients and at a higher rate than estimated in the general population. Given the impact anxiety has on patient outcomes, it is important that effective identification and management strategies be developed to support cardiologists in identifying and treating these conditions in their clinics.

Anxiety and depression scores in patients subjected to aortic and iliac aneurysm repair procedures

OBJECTIVE

This study examines the changes in anxiety and depression scores of 84 patients subjected to aortic or iliac aneurysm correction with no previous psychiatric history.

METHODS

Patients were referred to the evaluation using the Beck Anxiety and Depression Inventories no more than 3 days before surgery (i.e., preoperative [Pre-Op]), 30 days after revascularization (i.e., Early postoperative [PO]), and at least 6 months after revascularization (i.e., Late PO).

RESULTS

Mean anxiety scores declined from baseline at both the Early (mean difference: 2.75, p<0.001) and Late PO (mean difference: 2.74, p=0.001). The depression levels showed no significant variation in either evaluation (Early PO; mean difference: -0.84, p>0.05, Late PO: 0.87, p=0.05). A more severe degree of anxiety at baseline was related to better anxiety results both in the Early PO (p=0.041) and Late PO (p=0.008). An endovascular technique was related to the improvement in depression symptoms in the Early PO (p=0.01) but the worsening of the symptoms in the Late PO (p=0.033).

CONCLUSIONS

Patients subjected to aortoiliac aneurysm corrections have a higher incidence of anxiety and depressive symptoms. Anxiety symptoms, but not the depressive ones, improved considerably following the successful treatment. The formal psychiatric evaluation may be beneficial for patients with less improvement in the symptom.

Is heart failure an obstacle to air travel?

Rapid increasing trend in air travel brings necessity of urgent approach to health situations such as heart failure (HF). The prevalence of HF was projected to be more than 8 million patients ≥18 years of age in 2030; Main factors that contribute to physiological changes to cardiovascular system during a flight are changes in cabin pressure, humidity, stress, prolonged mobility. Identifying patients at risk of pre/post and during air travel along with adequate care by physicians and crew would help in better outcomes and comfortable travel for patients with HF.

Psychosocial Syndemics and Multimorbidity in Patients with Heart Failure †

Heart failure (HF) is a common cause of hospitalization and mortality in older adults. HF is almost always embedded within a larger pattern of multimorbidity, yet many studies exclude patients with complex psychiatric and medical comorbidities or cognitive impairment. This has left significant gaps in research on the problems and treatment of patients with HF. In addition, HF is only one of multiple challenges facing patients with multimorbidity, stressful socioeconomic circumstances, and psychosocial problems. The purpose of this study is to identify combinations of comorbidities and health disparities that may affect HF outcomes and require different mixtures of medical, psychological, and social services to address. The syndemics framework has yielded important insights into other disorders such as HIV/AIDS, but it has not been applied to the complex psychosocial problems of patients with HF. The multimorbidity framework is an alternative approach for investigating the effects of multiple comorbidities on health outcomes. The specific aims are: (1) to determine the coprevalence of psychiatric and medical comorbidities in patients with HF (n = 535); (2) to determine whether coprevalent comorbidities have synergistic effects on readmissions, mortality, self-care, and global health; (3) to identify vulnerable subpopulations of patients with HF who have high coprevalences of syndemic comorbidities; (4) to determine the extent to which syndemic comorbidities explain adverse HF outcomes in vulnerable subgroups of patients with HF; and (5) to determine the effects of multimorbidity on readmissions, mortality, self-care, and global health.

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Type D Personality and Myocardial Infarction: A Case-Control Study

BACKGROUND

Coronary heart disease (CHD) is an impending global pandemic in developed countries as well as developing countries and economies in transition, such as India. A significant increase in the incidence of myocardial infarction (MI), one of the most common types of CHD, is being reported in India, and the incidence and severity of the disease are more among the youth in Kerala. Studies assessing the association between psychological factors and MI are few in India.

METHODS

We adopted a case-control study design. A total of 150 cases (with MI) and 150 controls (without MI and matched for age and gender) from a tertiary care hospital in Trivandrum, Kerala, India, were selected using convenient sampling method, between September 2016 and August 2017.

RESULTS

As compared to 33.3% of the controls, 50.7% of patients with MI had type D personality characteristics. Multivariate logistic regression analysis after adjusting for the confounders indicated a positive and statistically significant association between type D personality and MI: OR = 4.14, 95% CI = 2.19-8.85, P = 0.003.

CONCLUSION

Type D personality is associated with MI.

Patient-reported outcomes and medication adherence in patients with heart failure

AIMS

Patient-reported outcome measures (PROMs) may predict poor clinical outcome in patients with heart failure (HF). It remains unclear whether PROMs are associated with subsequent adherence to HF medication. We aimed to determine whether health-related quality of life, anxiety, and depression were associated with long-term medication adherence in these patients.

METHODS AND RESULTS

A national cohort study of Danish patients with HF with 3-year follow-up (n = 1464). PROMs included the EuroQol five-dimensional, five-level questionnaire (EQ-5D-5L), the HeartQoL and the Hospital Anxiety and Depression Scale (HADS). Patient-reported outcomes (PRO) data were linked to demographic and clinical data at baseline, and data on all redeemed prescriptions for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor neprilysin inhibitors (ACEI/ARB/ARNI), β-blockers, and mineralocorticoid receptor antagonists during follow-up. Medication non-adherence was defined as <80% of proportion of days covered. In adjusted regression analyses, lower health-related quality of life (EQ-5D and HeartQoL) and symptoms of depression (HADS-D) at discharge were associated with non-adherence. After 3 years of follow-up, lower health-related quality of life (EQ-5D) was associated with non-adherence for ACEI/ARB/ARNI [adjusted OR 2.78, 95% confidence interval (CI): 1.19-6.49], β-blockers (adjusted OR 2.35, 95% CI: 1.04-5.29), whereas HADS-D was associated with non-adherence for ACEI/ARB/ARNI (adjusted OR 1.07, 95% CI: 1.03-1.11) and β-blockers (adjusted OR 1.06, 95% CI: 1.02-1.10).

CONCLUSION

Lower health-related quality of life and symptoms of depression were associated with non-adherence across HF medications at 1 and 3 years of follow-up. Person-centred care using PROMs may carry a potential for identifying patients at increased risk of future medication non-adherence.

Prognostic impact of self-reported health on clinical outcomes in patients with heart failure

AIMS

An in-depth understanding of the prognostic value of patient-reported outcomes (PRO) is essential to facilitate person-centred care in heart failure (HF). This study aimed to clarify the prognostic role of subjective mental and physical health status in patients with HF.

METHODS AND RESULTS

Patients with HF were identified from the DenHeart Survey (n = 1499) and PRO data were obtained at hospital discharge, including the EuroQol five-dimensional questionnaire (EQ-5D), the HeartQoL, and the Hospital Anxiety and Depression Scale (HADS). Clinical baseline data were obtained from medical records and linked to nationwide registries with patient-level data on sociodemographics and healthcare contacts. Outcomes were all-cause and cardiovascular (CV) mortality, CV events, and HF hospitalization with 1- and 3-year follow-up. Analysing the PRO data on a continuous scale, a worse score in the following were associated with risk of all-cause and CV mortality after 1 year: the HeartQoL (adjusted hazard ratios (HRs) 1.91, 95% confidence interval (CI) 1.42-2.57 and 2.17, 95% CI 1.50-3.15, respectively), the EQ-5D (adjusted HRs 1.26, 95% CI 1.15-1.38 and 1.27, 95% CI 1.13-1.42, respectively), the HADS depression subscale (adjusted HRs 1.12, 95% CI 1.07-1.17 and 1.11, 95% CI 1.05-1.17, respectively), and the HADS anxiety subscale (adjusted HRs 1.08, 95% CI 1.03-1.13 and 1.09, 95% CI 1.04-1.15, respectively). Three-year results were overall in concordance with the 1-year results. A similar pattern was also observed for non-fatal outcomes.

CONCLUSION

Health-related quality of life and symptoms of anxiety and depression at discharge were associated with all-cause and CV mortality at 1- and 3-year follow-up.

Changes in cardiac anxiety and self-care practices in heart failure patients following implantation of wireless hemodynamic monitoring sensors

Background:

Wireless implantable hemodynamic monitors assist cardiac care providers in tailoring medication regimens to reduce chronic heart failure hospital admissions and to improve patient quality of life. Previous research exists to support wireless implantable hemodynamic monitors favorable impact on medical endpoints but, however, their psychological and behavioral effects have not yet been established. The purpose of this pilot study was to investigate patient psychological and behavioral changes after receiving the wireless implantable hemodynamic monitor.

Methods:

Patients with heart failure ( n=26) who were implanted with wireless implantable hemodynamic monitor sensors completed the Cardiac Anxiety Questionnaire and Self-Care of Heart Failure Index version 6.2 at pre-implant and at one-month post-implant, as well as an initial demographic questionnaire.

Results:

Heart failure patients who received a wireless implantable hemodynamic monitor experienced a significant reduction in cardiac anxiety, t(25)=2.93, p=0.007, z=−0.46, d=0.58, driven by a reduction in fear of their condition, t(25)=2.26, p=0.03, z=−0.42, d=0.44. Increases in self-care behaviors fell short of significance t(25)=1.67, p=0.11, but showed a medium effect size, d=0.33.

Conclusion:

Heart failure patients who received a wireless implantable hemodynamic monitor reported significantly reduced cardiac fear, indicating that wireless implantable hemodynamic monitor technology may produce a collateral benefit in psychological effects. Patient self-care may also benefit but the current study was under-powered to reach statistical significance. Patient education about psychological and behavioral aspects of the wireless implantable hemodynamic monitor implant may yield increased patient engagement and broader health benefits if these results are confirmed in a larger study.

Evaluating emotional distress and health-related quality of life in patients with heart failure and their family caregivers: Testing dyadic dynamics using the Actor-Partner Interdependence Model

PURPOSE

1) To compare levels of emotional symptoms and health-related quality of life between patients with heart failure and their family caregivers; and 2) to examine whether patients' and caregivers' emotional symptoms were associated with their own, as well as their partner's health-related quality of life.

METHOD

In this cross-sectional study, 41 patients-caregiver dyads (78% male patients, aged 68.6 years; and 83% female caregivers, aged 65.8 years) completed all nine dimensions of the Brief Symptom Inventory and the Minnesota Living with Heart failure Questionnaire. Dyadic data were analysed for 6 sub-scales of the Brief Symptom Inventory, using the Actor-Partner Interdependence Model.

RESULTS

There were no statistically significant differences in emotional symptoms and health-related quality of life between patients with heart failure and their caregivers. Patients' and caregivers' emotional symptoms were associated with their own health-related quality of life. Caregivers' anxiety, phobic anxiety, obsession-compulsion, depression and hostility negatively influenced their partner's (i.e. the patient's) health-related quality of life. There were no partner effects of patients' emotional symptoms on the health-related quality of life of caregivers.

CONCLUSIONS

The results of this study suggest that patients may be particularly vulnerable to the emotional distress, i.e. thoughts, impulses and actions of their caregivers. It may be possible to improve patients' health-related quality of life by targeting specific detrimental emotional symptoms of caregivers.

Assessment of Heart Failure Patients' Interest in Mobile Health Apps for Self-Care: Survey Study

BACKGROUND

Heart failure is a serious public health concern that afflicts millions of individuals in the United States. Development of behaviors that promote heart failure self-care may be imperative to reduce complications and avoid hospital re-admissions. Mobile health solutions, such as activity trackers and smartphone apps, could potentially help to promote self-care through remote tracking and issuing reminders.

OBJECTIVE

The objective of this study was to ascertain heart failure patients' interest in a smartphone app to assist them in managing their treatment and symptoms and to determine factors that influence their interest in such an app.

METHODS

In the clinic waiting room on the day of their outpatient clinic appointments, 50 heart failure patients participated in a self-administered survey. The survey comprised 139 questions from previously published, institutional review board-approved questionnaires. The survey measured patients' interest in and experience using technology as well as their function, heart failure symptoms, and heart failure self-care behaviors. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was among the 11 questionnaires and was used to measure the heart failure patients' health-related quality of life through patient-reported outcomes.

RESULTS

Participants were aged 64.5 years on average, 32% (16/50) of the participants were women, and 91% (41/45) of the participants were determined to be New York Heart Association Class II or higher. More than 60% (30/50) of the survey participants expressed interest in several potential features of a smartphone app designed for heart failure patients. Participant age correlated negatively with interest in tracking, tips, and reminders in multivariate regression analysis (P<.05). In contrast, MLHFQ scores (worse health status) produced positive correlations with these interests (P<.05).

CONCLUSIONS

The majority of heart failure patients showed interest in activity tracking, heart failure symptom management tips, and reminder features of a smartphone app. Desirable features and an understanding of factors that influence patient interest in a smartphone app for heart failure self-care may allow researchers to address common concerns and to develop apps that demonstrate the potential benefits of mobile technology.

Atrial fibrillation: a leading cause of heart failure-related hospitalizations; a dual epidemic

BACKGROUND

Atrial fibrillation (AF), and heart failure (HF) are a major cardiovascular epidemic over the last decade. The prevalence and rehospitalization of heart failure are on rising edge, and many factors are responsible for these re-exacerbations of heart failure. In this study, we sought to determine an association of a risk factor for frequent rehospitalization of heart failure at our institute. We aimed to find the re-admission rate, heart rate, and rhythm of heart failure exacerbation.

METHODS

We performed a single-center retrospective study at the Abington Hospital - Jefferson health and 418 patients having a history of heart failure, and AF were selected. The heart failure readmission rate (days), heart rate, and rhythm were analyzed.

RESULTS

The mean age of the included population was 82.8 years SD ± 9.2. About 53% had AF with a mean heart rate 90 SD ± 21 bpm, and 47% had normal sinus rhythm (NSR) with a mean heart rate of 78 ± 16 bpm on re-admission. This difference was statistically significant (p=0.02). The mean re-admission rate for atrial fibrillation was 27.49 days SD ± 18.97, compared to 32.68 SD ± 20.26 days for NSR, statistically significant (p=0.007) and the Pearson Chi-square was also significant P = 0.006.

CONCLUSION

There is a significantly increased rate of re-admission in heart failure patients with atrial fibrillation with a rapid ventricular rate. Efforts should be taken to keep the patient in NSR or controlled AF to minimize the rehospitalization rate, and this, in turn, reduces the financial burden on patients and institutes.

Prognostic Value of Anxiety Between Heart Failure With Reduced Ejection Fraction and Heart Failure With Preserved Ejection Fraction

Background

Evidence suggests differences in clinical characteristics, causes, and prognoses between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Most studies have failed to support the prognostic relevance of anxiety in HFrEF or unclassified HF with mean left ventricular ejection fraction <40%. Meanwhile, the association between anxiety and prognoses in HFpEF remains unexamined. This study compared the prognostic value of anxiety between HFrEF and HFpEF.

Methods and Results

A total of 158 patients with HFrEF (left ventricular ejection fraction=28.51±7.53%) and 108 patients with HFpEF (left ventricular ejection fraction=64.53±9.67%) were recruited between May 2012 and December 2014. Demographic and clinical characteristics, Spielberger State‐Trait Anxiety Inventory, Beck Depression Inventory‐II scale, and 18‐month follow‐up outcomes were recorded during the hospital stay. There were significant differences in age, sex, comorbidities, laboratory biomarkers, discharge medications, and unhealthy behaviors, which supported the contention that HFrEF and HFpEF represent 2 distinct phenotypes, although there were no significant differences in anxiety and 18‐month outcomes. Multiple logistic regression yielded no significant associations between anxiety and 18‐month outcomes in HFrEF. By contrast, trait anxiety could predict 18‐month all‐cause mortality (odds ratio, 1.429; 95% CI, 1.020–2.000; P=0.038), all‐cause readmission or death (odds ratio, 1.147; 95% CI, 1.036–1.271; P=0.008), and cardiac readmission or death (odds ratio, 1.133; 95% CI, 1.031–1.245; P=0.010) in HFpEF after adjusting for possible confounders.

Conclusions

Trait anxiety was independently associated with 18‐month all‐cause mortality, all‐cause readmission or death, and cardiac readmission or death in HFpEF, but not in HFrEF.

Assessment of quality of life and anxiety in heart failure outpatients

Introduction

Heart failure (HF) is a chronic disease associated with increased morbidity and mortality. HF prevalence is expected to expand enormously, largely due to population ageing, rising incidence of HF risk factors and increased survival after cardiovascular events. The aim of the study was to assess levels of quality of life (QOL) and anxiety in HF outpatients and the associated factors as well as to explore the impact of anxiety on QOL.

Material and methods

One hundred HF outpatients were enrolled in the study. Data collection was performed by completion of the Minnesota Living with Heart Failure Questionnaire (MLHFQ), the Self-rating Anxiety Scale (SAS) and a questionnaire including patients’ characteristics.

Results

Of the 100 HF outpatients, 64% were men and 66% above 70 years old. Regarding QOL, at least 50% of patients scored above 68 (median) in the total score of MLHFQ and in terms of anxiety, 50% scored above 46 (median) in the SAS. These values indicate a large impact of HF on QOL and a moderate impact of HF on anxiety. Furthermore, a statistically significant correlation was observed between QOL and anxiety in HF outpatients (rho > 0.6, p < 0.001). An increase in anxiety score by one unit implies a statistically significant increase in QOL by 1.22 points (95% CI: 0.91–1.52, p < 0.001), after adjustment for potential confounders.

Conclusions

The present findings emphasize the importance of alleviating the emotional burden of anxiety, thus improving patients’ QOL.

Emotion Regulation and Perceptions of Illness Coherence and Controllability on Regimen Adherence and Negative Cardiac Health Events in African American Women With Heart Failure

BACKGROUND

African American women with heart failure (HF) have stressors that negatively impact HF self-management adherence and heighten the occurrence of negative cardiac health events. Perceptions of illness coherence and controllability and emotion regulation are known to facilitate self-management in the face of stressors.

OBJECTIVE

The aim of this study was to determine whether difficulties with emotion regulation and negative perceptions of illness coherence and controllability are detrimental to adherence and increase negative cardiac health events in this patient population.

METHODS

African American women (n = 54) with HF, aged 49 to 84 years, participated in this longitudinal descriptive correlational study. Using convenience sampling, we recruited patients from hospitals and HF clinics. They completed interviews at intake and 30 days, and their medical records were reviewed at 90 days. Linear and logistic regression models were used to assess predictors of general adherence and negative cardiac health events.

RESULTS

Of 54 patients who participated in the study, 28 experienced a negative health event during 90 days, and 57% of these events were cardiac related. The only clear predictor of these events was greater New York Heart Association functional classification (β = 1.47, P = .027). No associations were found between predictors (emotion regulation, controllability, coherence, age, education) and general adherence.

CONCLUSIONS

Emotion regulation showed a possible greater impact on negative cardiac health events than on general adherence. Perceived illness coherence showed less impact on negative cardiac health events than on general adherence.

African American Race Is Associated With Poorer Outcomes in Heart Failure Patients

Health care disparities associated with African American race may influence event-free survival in patients with heart failure (HF). A secondary data analysis included 863 outpatients enrolled in a multicenter HF registry. Cox regression was used to determine whether African American race was associated with shorter HF event-free survival after controlling for covariates. The multivariable-adjusted hazard ratios (95% confidence intervals [CI]) of older age (1.03, 95% CI = [1.01, 1.04]), New York Heart Association (NYHA) functional class (1.73, 95% CI = [1.29, 2.31]), depressive symptoms (1.05, 95% CI = [1.02, 1.07]), and African American race (1.64, 95% CI = [1.01, 2.68]) were predictors of shorter event-free survival (all ps < .05). Comparisons showed that NYHA functional class was predictive of shorter event-free survival in Caucasians (1.81, 95% CI = [1.33, 2.46]) but not in African Americans (1.24, 95% CI = [.40, 3.81]). African Americans with HF experienced a disparate risk of shorter event-free survival not explained by a variety of risk factors.

Symptom-Hemodynamic Mismatch and Heart Failure Event Risk

BACKGROUND

Heart failure (HF) is a heterogeneous condition of both symptoms and hemodynamics.

OBJECTIVE

The goals of this study were to identify distinct profiles among integrated data on physical and psychological symptoms and hemodynamics and quantify differences in 180-day event risk among observed profiles.

METHODS

A secondary analysis of data collected during 2 prospective cohort studies by a single group of investigators was performed. Latent class mixture modeling was used to identify distinct symptom-hemodynamic profiles. Cox proportional hazards modeling was used to quantify difference in event risk (HF emergency visit, hospitalization, or death) among profiles.

RESULTS

The mean age (n = 291) was 57 ± 13 years, 38% were female, and 61% had class III/IV HF. Three distinct symptom-hemodynamic profiles were identified: 17.9% of patients had concordant symptoms and hemodynamics (ie, moderate physical and psychological symptoms matched the comparatively good hemodynamic profile), 17.9% had severe symptoms and average hemodynamics, and 64.2% had poor hemodynamics and mild symptoms. Compared with those in the concordant profile, both profiles of symptom-hemodynamic mismatch were associated with a markedly increased event risk (severe symptoms hazards ratio, 3.38; P = .033; poor hemodynamics hazards ratio, 3.48; P = .016).

CONCLUSIONS

A minority of adults with HF have concordant symptoms and hemodynamics. Either profile of symptom-hemodynamic mismatch in HF is associated with a greater risk of healthcare utilization for HF or death.

Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis

OBJECTIVE

Psychological distress has been associated with poor outcomes in patients with chronic heart failure (HF), which is assumed to be partly due to poor HF self-care behavior. This systematic review and meta-analysis describes the current evidence concerning psychological determinants of self-care in patients with chronic HF.

METHODS

Eligible studies were systematically identified by searching electronic databases PubMed, PsycINFO, and the Conference Proceedings Citation Index (Web of Science) for relevant literature (1980-October 17, 2014). Study quality was assessed according to the level of risk of bias. Quantitative data were pooled using random-effects models.

RESULTS

Sixty-five studies were identified for inclusion that varied considerably with respect to sample and study characteristics. Risk of bias was high in the reviewed studies and most problematic with regard to selection bias (67%). Depression (r = -0.19, p < .001), self-efficacy (r = 0.37, p < .001), and mental well-being (r = 0.14, p = .030) were significantly associated with self-reported self-care. Anxiety was not significantly associated with either self-reported (r = -0.18, p = .24) or objective self-care (r = -0.04, p = .79), neither was depression associated with objectively measured medication adherence (r = -0.05, p = .44).

CONCLUSIONS

Psychological factors (depression, self-efficacy, and mental well-being) were associated with specific self-care facets in patients with chronic HF. These associations were predominantly observed with self-reported indices of self-care and not objective indices. Methodological heterogeneity and limitations preclude definite conclusions about the association between psychological factors and self-care and should be addressed in future research.

Do Self-Management Interventions Work in Patients With Heart Failure? An Individual Patient Data Meta-Analysis

BACKGROUND

Self-management interventions are widely implemented in the care for patients with heart failure (HF). However, trials show inconsistent results, and whether specific patient groups respond differently is unknown. This individual patient data meta-analysis assessed the effectiveness of self-management interventions in patients with HF and whether subgroups of patients respond differently.

METHODS AND RESULTS

A systematic literature search identified randomized trials of self-management interventions. Data from 20 studies, representing 5624 patients, were included and analyzed with the use of mixed-effects models and Cox proportional-hazard models, including interaction terms. Self-management interventions reduced the risk of time to the combined end point of HF-related hospitalization or all-cause death (hazard ratio, 0.80; 95% confidence interval [CI], 0.71-0.89), time to HF-related hospitalization (hazard ratio, 0.80; 95% CI, 0.69-0.92), and improved 12-month HF-related quality of life (standardized mean difference, 0.15; 95% CI, 0.00-0.30). Subgroup analysis revealed a protective effect of self-management on the number of HF-related hospital days in patients <65 years of age (mean, 0.70 versus 5.35 days; interaction P=0.03). Patients without depression did not show an effect of self-management on survival (hazard ratio for all-cause mortality, 0.86; 95% CI, 0.69-1.06), whereas in patients with moderate/severe depression, self-management reduced survival (hazard ratio, 1.39; 95% CI, 1.06-1.83, interaction P=0.01).

CONCLUSIONS

This study shows that self-management interventions had a beneficial effect on time to HF-related hospitalization or all-cause death and HF-related hospitalization alone and elicited a small increase in HF-related quality of life. The findings do not endorse limiting self-management interventions to subgroups of patients with HF, but increased mortality in depressed patients warrants caution in applying self-management strategies in these patients.

Psychological distress and mortality in patients with acute dyspnea: data from the Akershus Cardiac Examination (ACE) 2 Study

OBJECTIVE

To test the hypotheses that anxiety and depression are associated with etiology, disease severity and mortality in patients hospitalized with acute dyspnea.

METHODS

The Hospital Anxiety and Depression Scale was completed within 48h of admission in 185 patients. A subscale score of ≥8 was regarded as clinically significant. The etiology and severity of dyspnea on admission and all-cause mortality during follow-up (median, 2.3years) were recorded.

RESULTS

Anxiety and depression were more prevalent in patients with chronic obstructive pulmonary disease (COPD) (n=53; 42% and 31%) and heart failure (HF) (n=80; 33% and 23%) than in other causes of acute dyspnea (15% and 11%). Psychological distress was not associated with clinical status or cardiac biomarkers. Anxiety, but not depression, was associated with increased mortality, also when adjusting for cardiac biomarkers in multivariate Cox analysis. In contrast, anxiety was not associated with mortality after adjustment for body mass index, history of COPD and disease severity (hazard ratio, 1.67; 95% confidence interval, 0.92-3.00).

CONCLUSION

Psychological distress was associated with COPD and HF as etiology of acute dyspnea, but not with disease severity. Anxious patients had a higher mortality rate, but this association was related to the presence and severity of COPD.

The synergistic effects of anxiety and cerebral hypoperfusion on cognitive dysfunction in older adults with cardiovascular disease

OBJECTIVES

Anxiety is a risk factor for cardiovascular disease (CVD) and is associated with neurocognitive outcomes. The effect of anxiety on brain perfusion in a CVD population has yet to be examined, and no study has investigated the interactive effects of anxiety and cerebral perfusion on cognition.

METHODS

A total of 55 older adults with CVD completed the Beck Anxiety Inventory (BAI) and underwent arterial spin labeling to quantify cortical perfusion and thickness. Participants were administered the Mini-Mental State Examination (MMSE) and the Repeatable Battery for the Assessment of Neuropsychological Status.

RESULTS

Reduced perfusion predicted poorer cognition and decreased cortical thickness. Higher anxiety score predicted worse memory performance and decreased frontal perfusion. Frontal lobe hypoperfusion combined with increased BAI scores exacerbated poorer MMSE performance.

CONCLUSIONS

Higher anxiety may exacerbate the effects of cerebral hypoperfusion on cognitive impairment. Longitudinal studies are needed to confirm our findings and determine whether anxiety treatment improves neurocognitive outcomes in CVD.

Physical and psychological symptom profiling and event-free survival in adults with moderate to advanced heart failure

: Heart failure (HF) is a heterogeneous symptomatic disorder. The goal of this study was to identify and link common profiles of physical and psychological symptoms to 1-year event-free survival in adults with moderate to advanced HF.

METHODS

Multiple valid, reliable, and domain-specific measures were used to assess physical and psychological symptoms. Latent class mixture modeling was used to identify distinct symptom profiles. Associations between observed symptom profiles and 1-year event-free survival were quantified using Cox proportional hazards modeling.

RESULTS

The mean age of the participants (n = 202) was 57 ± 13 years, 50% were men, and 60% had class III/IV HF. Three distinct profiles, mild (41.7%), moderate (30.2%), and severe (28.1%), that captured a gradient of both physical and psychological symptom burden were identified (P < .001 for all comparisons). Controlling for the Seattle HF Score, adults with the moderate symptom profile were 82% more likely (hazard ratio, 1.82; 95% confidence interval, 1.07-3.11; P = .028) and adults with the severe symptom profile were more than twice as likely (hazard ratio, 2.06; 95% confidence interval, 1.21-3.52; P = .001) to have a clinical event within 1 year than patients with the mild symptom profile.

CONCLUSIONS

Profiling patterns among physical and psychological symptoms identifies HF patient subgroups with significantly worse 1-year event-free survival independent of prognostication based on objective clinical HF data.

The bidirectional relation between psychiatric disorders with selected cardiovascular and endocrinal diseases: an Egyptian perspective

Cardiovascular and endocrine diseases may act as burdens for individuals suffering from one of these medical illnesses, and whether through the ensuing psychological distress, or some biological mechanisms, these medical diseases can eventually lead to the development of psychiatric morbidities. Moreover, psychiatric morbidities negatively affect the prognosis of both cardiovascular and endocrine diseases. Despite transcultural differences, Egyptian patients with ischemic heart diseases (ISHD), heart failure (HF), diabetes mellitus (DM), or thyroid diseases (TD) endure the same psychological distress as their Western counterparts. Psychiatric assessment and evaluation should be regularly repeated among patients with cardiovascular and endocrinal diseases, and patients who are at risk should be closely followed up.

End-of-life care in patients with heart failure

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

Examination of the potential association of stress with morbidity and mortality outcomes in patient with heart failure

Objectives:

The high mortality and morbidity rates associated with heart failure are still not well explained. A few psychosocial factors have been studied and explain some of this risk, but other factors, like stress, remain largely unexplored in heart failure. This study aimed to (1) examine the association of stress with 6-month cardiac event-free survival, (2) examine the relationship of stress with salivary cortisol, and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival.

Method:

A total of 81 heart failure patients participated. Stress was measured using the brief Perceived Stress Scale. Cortisol was measured from unstimulated whole expectorated saliva. Cox regression analyses were used to determine whether stress predicted event-free survival, and if salivary cortisol predicted event-free survival. Linear and multiple regressions were used to determine the association of stress with salivary cortisol.

Results:

Stress was not a significant predictor of event-free survival in heart failure (heart rate = 1.06; 95% confidence interval = 0.95–1.81; p = 0.32). Salivary cortisol was a significant predictor of event-free survival in the unadjusted model (heart rate = 2.30; 95% confidence interval = 0.99–5.927; p = 0.05), but not in the adjusted model. Stress (β 1.06; 95% confidence interval = 0.95–1.18; p = 0.32) was not a significant predictor of salivary cortisol level.

Conclusion:

Stress is a complex phenomenon, and our measure of stress may not have captured it well. Alternatively, the physical stressors acting in heart failure produce levels of neurohormonal activation that mask the effects of psychosocial stressors or an indirect association of stress with outcomes that is mediated through another construct. Future studies are needed to investigate stress in patients with heart failure to provide definitive answers.

The journey of the frail older adult with heart failure: implications for management and health care systems

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Positive psychological states and health behaviors in acute coronary syndrome patients: A qualitative study

Positive psychological states are linked to superior cardiac outcomes, possibly mediated through increased participation in health behaviors. Trained study staff conducted in-depth semi-structured interviews in the hospital and 3 months later for 34 patients diagnosed with an acute coronary syndrome. These interviews focused on positive psychological states, cardiac health behaviors, and their connection; the interviews were transcribed and independently coded using directed content analysis. Both optimism and positive affect were associated with completion of physical activity and healthy eating in a bidirectional manner. In contrast, gratitude, while common, was infrequently linked to completion of health behaviors.

Air travel considerations for the patients with heart failure

Context:

Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them are limited.

Evidence Acquisition:

We evaluated the conditions that may be encountered in a HF patient and provide the recommendations to prevent the exacerbation of cardiac failure during air travel. For this review article, a comprehensive search was undertaken for the studies that evaluated the complications and considerations of HF patients during flight. Data bases searched were: MEDLINE, EMBASE, Science Direct, and Google Scholar.

Results:

HF patients are more prone to experience respiratory distress, anxiety, stress, cardiac decompensation, and venous thromboembolism (VTE) during air travel. Although stable HF patients can tolerate air travel, but those with acute heart failure syndrome should not fly until complete improvement is achieved.

Conclusions:

Thus, identifying the HF patients before the flight and providing them proper education about the events that may occur during flight is necessary.

Pathophysiological Relationships Between Heart Failure and Depression and Anxiety

Depression and anxiety are common comorbid conditions in patients with heart failure. Patients with heart failure and depression have increased mortality. The association of anxiety with increased mortality in patients with heart failure is not established. The purpose of this article is to illustrate the similarities of the underlying pathophysiology of heart failure, depression, and anxiety by using the Biopsychosocial Holistic Model of Cardiovascular Health. Depression and anxiety affect biological processes of cardiovascular function in patients with heart failure by altering neurohormonal function via activation of the hypothalamic-pituitary-adrenal axis, autonomic dysregulation, and activation of cytokine cascades and platelets. Patients with heart failure and depression or anxiety may exhibit a continued cycle of heart failure progression, increased depression, and increased anxiety. Understanding the underlying pathophysiological relationships in patients with heart failure who experience comorbid depression and/or anxiety is critical in order to implement appropriate treatments, educate patients and caregivers, and educate other health professionals.

Profiles of self-care management versus consulting behaviors in adults with heart failure

INTRODUCTION

Patients with heart failure (HF) vary in their ability to respond to symptoms when they occur. The goal of this study was to classify common patterns of symptom response behaviors among adults with HF and identify biobehavioral determinants thereof.

METHODS

Consulting behaviors (i.e. contacting a provider for guidance) were measured using the European Heart Failure Self-care Behavior Scale consulting behaviors subscale, and self-care management (i.e. recognizing and engaging in self-initiated treatment of symptoms) was measured with the Self-Care of HF Index self-care management scale in a prospective cohort study. Latent class mixture modeling was used to identify distinct profiles of consulting and of self-care management behaviors.

RESULTS

The mean age (n=146) was 57±13 years, 30% were female, and 59% had class III/IV HF. Two distinct profiles of consulting behaviors (novice and expert) and three distinct profiles of self-care management (novice, inconsistent and expert) were identified. There was a weak association between profiles of consulting behaviors and self-care management (Kendall's tau-b=0.211). Higher levels of anxiety were associated with worse consulting behaviors (β=1.67±0.60) and worse self-care management (β= -5.82±3.12) and lower odds of exhibiting expert level consulting behaviors (odds ratio (OR)=0.50; 95% confidence interval (CI)=0.26-0.95) and self-care management (OR=0.47; 95% CI=0.24-0.92) (all p<0.05). Higher levels of physical symptoms were associated with better self-care management (β=0.50±0.12; OR =1.02, 95% CI=1.00-1.05; both p<0.05).

CONCLUSIONS

Expertise in consulting behaviors does not necessarily confer expertise in symptom self-care management and vice versa. Physical and psychological symptoms are strong determinants of symptom response behaviors.

Nutrition intervention to decrease symptoms in patients with advanced heart failure

For a majority of patients with advanced heart failure, there is a need for complementary, non-pharmacologic interventions that could be easily implemented by health care providers to provide palliative care. Three major pathologic pathways underlying heart failure symptoms have been identified: fluid overload, inflammation, and oxidative stress. Prior research has demonstrated that three nutrients-sodium, omega-3 fatty acids, and lycopene-can alter these pathologic pathways. Therefore, the purposes of this study are to test the effects of a 6-month nutrition intervention of dietary sodium reduction combined with supplementation of lycopene and omega-3 fatty acids on heart failure symptoms, health-related quality of life, and time to heart failure rehospitalization or all-cause death. The aims of this double blind-placebo controlled study are (1) to determine the effects of a 6-month nutrition intervention on symptom burden (edema, shortness of air, and fatigue) and health-related quality of life at 3 and 6 months, and time to heart failure rehospitalization or all-cause death over 12 months from baseline; (2) compare dietary sodium intake, inflammation, and markers of oxidative stress between the nutrition intervention group and a placebo group at 3 and 6 months; and (3) compare body weight, serum lycopene, and erythrocyte omega-3 index between the nutrition intervention group and a placebo group at 3 and 6 months. A total of 175 patients with advanced heart failure will be randomized to either the nutrition intervention or placebo group.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

BACKGROUND

Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure.

AIMS

To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure.

METHODS

A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS).

RESULTS

Cronbach's alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22-.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman's rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t(318) = -5.05, p < .001) supported construct validity.

CONCLUSION

The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

Care dependency independently predicts two-year survival in outpatients with advanced chronic organ failure

OBJECTIVE

Previous studies suggest that care dependency may predict survival in hospitalized patients, but the prognostic value of care dependency in clinically stable outpatients with advanced chronic organ failure remains unknown. The objective of this study was to assess whether and to what extent care dependency predicts 2-year survival in patients with advanced chronic organ failure.

DESIGN

Longitudinal observational study.

SETTING

Patients were recruited at the outpatient clinic of one academic and six general hospitals in The Netherlands.

PARTICIPANTS

A total of 265 clinically stable outpatients with advanced chronic obstructive pulmonary disease (n = 105), chronic heart failure (n = 80), and chronic renal failure (n = 80) were included at baseline.

MEASUREMENTS

Care dependency was assessed using the Care Dependency Scale (CDS), a 15-item self-administered questionnaire. In addition, patients performed a Timed Up and Go test to assess mobility. Finally, demographics, clinical characteristics, and 2-year survival were recorded.

RESULTS

At baseline, 116 patients (43.8%) reported a CDS score ≤ 68 points and were considered as care dependent. In total, 66 patients (24.9%) died within 2 years. The Cox regression model showed that a higher CDS score (lower level of care dependency) was associated with a lower probability of dying within 2 years (hazard ratio, 0.95; 95% CI: 0.90-0.97), whereas older age was associated with a greater probability of dying within 2 years (hazard ratio, 1.06; 95% CI, 1.03-1.09).

CONCLUSION

The level of care dependency independently predicts 2-year survival among clinically stable outpatients with advanced chronic organ failure. Therefore, regular assessment of the level of care dependency should be included in clinical care for patients with advanced chronic organ failure.

Cognitive function and treatment adherence in older adults with heart failure

OBJECTIVE

Treatment recommendation and guidelines for patients with heart failure (HF) can be complex, and past work has shown that patients with HF demonstrate low rates of adherence to recommended health behaviors. Although previous work has identified several medical, demographic, and psychosocial predictors of the capacity to adhere to treatment recommendations of persons with HF, little is known about the contribution of cognitive impairment to reported treatment adherence in this population.

METHODS

A total of 149 persons with HF (mean [standard deviation] = 68.08 [10.74] years) completed a brief fitness assessment and neuropsychological testing. Treatment adherence was assessed using the Heart Failure Compliance Questionnaire, a brief measure that asks participants to report their adherence to a variety of recommended health behaviors (i.e., medication management, diet, and exercise, among others).

RESULTS

The percentage of participants who reported poor overall adherence was 16.1%, with particularly high rates of nonadherence to dietary and exercise recommendations. Hierarchical regression analyses adjusting for possible confounds revealed that reduced performance on attention (β = .26, p = .01), executive function (β = .18, p = .04), and language (β = .22, p = .01) was associated with poorer overall adherence. Follow-up analyses showed that these cognitive domains were associated with behaviors such as keeping doctor appointments, medication management, and dietary recommendations (p < .05 for all).

CONCLUSIONS

The current findings demonstrate that cognitive function is an independent contributor to adherence in older adults with HF. Prospective studies that objectively measure treatment adherence are needed to clarify these findings and identify possible strategies to improve outcomes in this population.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00871897.