Older adults' symptoms and their duration before hospitalization for heart failure

End-Of-Life Care for Patients With End-Stage Heart Failure, Comparisons of International Guidelines

Heart failure (HF) is a chronic, debilitating condition associated with significant morbidity, mortality, and socioeconomic burden. Patients with end-stage HF (ESHF) who are not a candidate for advanced therapies will continue to progress despite standard medical therapy. Thus, the focus of care shifts from prolonging life to controlling symptoms and improving quality of life through palliative care (PC). Because the condition and prognosis of HF patients evolve and can rapidly deteriorate, it is imperative to begin the discussion on end-of-life (EOL) issues early during HF management. These include the completion of an advance directive, do-not-resuscitate orders, and policies on device therapy and discontinuation as part of advance care planning (ACP). ESHF patients who do not have indications for advanced therapies or those who wish not to have a left ventricular assist device (LVAD) or heart transplant (HT) often experience high symptom burden despite adequate medical management. The proper identification and assessment of symptoms such as pain, dyspnea, nausea, depression, and anxiety are essential to the management of ESHF and may be underdiagnosed and undertreated. Psychological support and spiritual care are also crucial to improving the quality of life during EOL. Caregivers of ESHF patients must also be provided supportive care to prevent compassion fatigue and improve resilience in patient care. In this narrative review, we compare the international guidelines and provide an overview of end-of-life and palliative care for patients with ESHF.

Spanish version of the Heart Failure Somatic Perception Scale (HFSPS v.3) - psychometric properties

Background

The Heart Failure Somatic Perception Scale (HFSPS) is an instrument that examine the existence and gravity of physical signs and symptoms in patients with heart failure, as well as early and subtle symptoms of HF that have clinical value, we aimed to translate and adapt the HFSPS from English to Spanish and evaluate the psychometric properties.

Method

HFSPS translation and back translation were carried out according to the method established by of Beaton et al. A confirmatory factor analysis (CFA) was performed to test the factor structures. To assess criterion-related validity, HFSPS factor scores were correlated with Kansas City Cardiomyopathy Questionnaire (KCCQ) scores using the Spearman correlation method. The reliability of the internal consistency of the HFSPS was determined by calculating the Cronbach's alpha coefficient and the factor score determination coefficient.

Results

Data from 173 patients with a mean age of 80.7 years (SD 9.1), women (51.1%), were analyzed. The majority (74.7%) were NYHA class II/III. The confirmatory factor analysis of four factors after eliminating one item showed fit indices close to the recommended indices: χ2 = 169.237, p < 0.001, CFI = 0.920, TLI = 0.901, RMSEA = 0.057 and SRMR = 0.061. Regarding the validity related to the criterion, all the scores of the HFSPS dimensions were correlated with all the scores of the KCCQ dimensions and were statistically significant. The reliability of the HFSPS factors of the coefficient of determination obtained scores of 0.73 for the dyspnea factor and early and subtle and lower for edema and chest discomfort with fewer items. Cronbach's alpha was acceptable for three of the scales >0.71 and poor 0.52 for chest discomfort with two items. The internal consistency index based on the model was 0.850.

Conclusion

The Spanish version of the HFSPS is a valid and reliable instrument that that would be feasible to use in clinical and research setting to evaluate in the perception of symptoms in patients with heart failure.

Effect of Daily Activity Record-Based Self-monitoring Intervention on the Perception of Physical Sensations in Patients With Chronic Heart Failure: A Randomized Controlled Trial

BACKGROUND

To prevent rehospitalization for heart failure (HF), patients need to be able to perceive physical changes that occur at the onset of HF exacerbation and seek early help.

OBJECTIVE

The aim of this study was to evaluate the effect of a self-monitoring intervention on patients' perceptions of physical sensations during daily activities in the context of HF via a randomized controlled trial.

METHODS

Participants (N = 70) were randomly assigned to the intervention (received daily activity record-based self-monitoring intervention support; group A) or control (only explained the measured results from the records; group B) group. Group A reflected on and described the physical sensations in their daily activities within 1 month after discharge. Outcome measures were assessed at 1 month after the intervention using the European Heart Failure Self-care Behavior Scale, Evaluation Scale for Self-Monitoring by patients with Heart Failure, clinical events, physical activity, and sleep.

RESULTS

There was no significant difference in the change in the "asking for help" subscale score of the European Heart Failure Self-care Behavior Scale between the groups (+0.7 vs +0.4 points, P = .716). Group A had improved score on the self-monitoring subscale related to "concern about how movements affect body" from baseline (from 12.7 to 14.0 points, P = .026). There was no significant effect of self-monitoring intervention support on the first rehospitalization related to HF and all-cause death (log-rank χ2 = 0.432, P = .511). A significant difference in moderate-intensity physical activity between the groups was observed (+4.6 vs -0.5 minutes, P = .029).

CONCLUSIONS

A focused strategy that enables patients to perceive their physical sensations and promotes early help-seeking behavior is needed.

Predicting emergency department visits and hospitalizations for patients with heart failure in home healthcare using a time series risk model

OBJECTIVES

Little is known about proactive risk assessment concerning emergency department (ED) visits and hospitalizations in patients with heart failure (HF) who receive home healthcare (HHC) services. This study developed a time series risk model for predicting ED visits and hospitalizations in patients with HF using longitudinal electronic health record data. We also explored which data sources yield the best-performing models over various time windows.

MATERIALS AND METHODS

We used data collected from 9362 patients from a large HHC agency. We iteratively developed risk models using both structured (eg, standard assessment tools, vital signs, visit characteristics) and unstructured data (eg, clinical notes). Seven specific sets of variables included: (1) the Outcome and Assessment Information Set, (2) vital signs, (3) visit characteristics, (4) rule-based natural language processing-derived variables, (5) term frequency-inverse document frequency variables, (6) Bio-Clinical Bidirectional Encoder Representations from Transformers variables, and (7) topic modeling. Risk models were developed for 18 time windows (1-15, 30, 45, and 60 days) before an ED visit or hospitalization. Risk prediction performances were compared using recall, precision, accuracy, F1, and area under the receiver operating curve (AUC).

RESULTS

The best-performing model was built using a combination of all 7 sets of variables and the time window of 4 days before an ED visit or hospitalization (AUC = 0.89 and F1 = 0.69).

DISCUSSION AND CONCLUSION

This prediction model suggests that HHC clinicians can identify patients with HF at risk for visiting the ED or hospitalization within 4 days before the event, allowing for earlier targeted interventions.

Impact of signs and symptoms on the prognosis of patients with HFmrEF

BACKGROUND

Worsening of heart failure (HF) symptoms is the leading cause of medical contact and hospitalization of patients with mildly reduced ejection fraction (HFmrEF). The prognostic value of signs and symptoms for patients with HFmrEF is currently unclear. This study investigated the prognostic impact of signs and symptoms in HFmrEF patients.

METHODS

A Cox proportional risk regression model analyzed the relationship between the number of signs/symptoms and outcomes in 1691 hospitalized HFmrEF patients. Ten significant signs and symptoms were included. Patients were divided into three groups (A: ≤2, B: 3-5, C: ≥6 signs/symptoms). Stratified analysis on male and female patients was performed. The primary endpoint was all-cause mortality, and the secondary outcome was a composite of cardiovascular death and heart failure readmission (CV events) post-discharge.

RESULTS

After a median follow-up of 33 months, all-cause mortality occurred in 457 patients and CV events occurred in 977 patients. Incidence of all-cause mortality was 20.7%, 32.3%* and 49.4%*† in group A, B and C of male patients, (*P < 0.05 vs. A, †P < 0.05 vs. B) and 18.8%, 33.6% and 55.8%* in group A, B and C of female patients. Incidence of CV events was 64.8%, 70.1%* and 87.5%* in group A, B and C of male patients, 61.9%, 75.3%, and 86.1%* in group A, B and C of female patients. Multivariate Cox regression showed older age, renal insufficiency, higher number of signs and symptoms (≥ 3, hazard ratio [HR] 1.317, 95% confidence interval [CI] 1.070-1.621, P = 0.009; ≥6, HR 1.982, 95% CI 1.402-2.801, P < 0.001), myocardial infarction, stroke, faster heart rate on admission, and diabetes were independently associated with all-cause mortality(all P < 0.05). Similarly, higher number of signs and symptoms (≥ 3, HR 1.271, 95% CI 1.119-1.443, P < 0.001; ≥6, HR 1.955, 95% CI 1.524-2.508, P < 0.001), older age, renal insufficiency, atrial fibrillation, and diabetes were independently associated with cardiovascular events (all P < 0.05).

CONCLUSIONS

Higher number of symptoms and signs is associated with increased risk of all-cause mortality and CV events in HFmrEF patients. Our results highlight the prognostic importance of careful inquiry on HF symptoms and related physical examination in HFmrEF patients.

Somatic Changes Perceived by Patients With Heart Failure During Acute Exacerbation: A Qualitative Study Using Text Mining

BACKGROUND

Patients with heart failure (HF) often inadequately perceive their symptoms. This may be because the medical terms do not match the somatic changes experienced by patients. To improve symptom perception, healthcare professionals must understand the somatic changes as perceived by patients.

OBJECTIVE

This study aims to analyze patients' narratives about somatic changes in patients with HF by text mining and to clarify the overall description of somatic changes using patients' expressions.

METHODS

Semistructured interviews were conducted on 21 patients hospitalized for acute exacerbation of HF. Qualitative data obtained from the interviews were analyzed by content analysis through text mining.

RESULTS

Among the 21 patients, 76.2% were men. The mean (SD) age was 71.3 (13.7) years. The most frequently used terms were "breath," "distressed," "feet," and " ha-ha (gasping sound)" (46, 40, 29, and 28 times, respectively). The somatic changes noticed by patients could be categorized into medical jargon such as "dyspnea on exertion," "exercise intolerance," "fatigue," "paroxysmal nocturnal dyspnea," "frequent urination," "increased sputum," "weight gain," "feet and face edema," "abdominal edema," and "ankle edema." However, the expressions of somatic changes used by the patients were diverse.

CONCLUSIONS

The findings of patient-specific expressions of symptoms suggest that there is a need to assess symptoms not only using medical jargon but also by focusing on patient-specific expressions.

Necesidades de cuidado paliativo del paciente con falla cardiaca: un estudio mixto

Highlights: La FC suele estar acompañada de otras patologías crónicas que hacen que la persona presente múltiples síntomas asociados que deben ser abordados por profesionales y equipos de cuidado paliativo. Los profesionales de la salud reconocen la importancia del cuidado paliativo y la falta de preparación para abordar las necesidades espirituales, emocionales, sociales, de pacientes y los cuidadores con FC. La teoría de Lenz permite identificar los síntomas fisiológicos, psicológicos y situacionales durante la FC, permitiendo a los equipos de cuidado paliativo establecer estrategias para mejorar la experiencia del síntoma. El abordaje de cuidados paliativos en FC implica una atención integral, buscando una mejor calidad de vida y mejorar la experiencia del síntoma como lo plantea Lenz, durante toda la trayectoria de la experiencia de la enfermedad hasta la muerte del paciente. Introducción: La presencia de signos y síntomas físicos, psicosociales y espirituales, deben ser identificados y controlados por medio de la atención en cuidados paliativos que proveen los equipos y profesionales de la salud. Objetivo: Identificar las necesidades de cuidado paliativo de las personas con falla cardíaca, sus cuidadores y el equipo multidisciplinario de una unidad de falla cardiaca.  Materiales y Métodos: Estudio mixto, con diseño transformativo secuencial (DITRAS), que inicio con una fase cuantitativa en la que se aplicaron los instrumentos: Edmonton, Facit-Sp-12 y el índice de Barthel. La segunda fase cualitativa se realizó con 3 grupos focales en los que participaron 7 pacientes, 8 cuidadores y 12 profesionales del equipo multidisciplinario. El estudio tomo como guía orientadora la teoría del manejo de síntomas desagradables de Elizabeth Lenz.  Resultados: Se identificaron necesidades de cuidado paliativo desde lo fisiológico:  edema, fatiga y disnea; psicológico: actitud frente a la vida y disfrutar de pasatiempos y factores situacionales: como dependencia del cuidador y redes de apoyo, los cuales permitieron su comprensión a partir de la teoría de Lenz.  Conclusiones: Las necesidades de cuidado paliativo en pacientes con falla cardiaca, se presentan desde un marco de síntomas que son percibidas por pacientes, cuidadores y el equipo de salud.  Se requieren abordajes integrales que mejoren la experiencia del síntoma. Como citar este artículo: Fiscal Idrobo Lucely Marisel, Ospina Muñoz Priscilla, Vargas-Escobar Lina María, Rincon Buenhombre Maria Cilia. Necesidades de cuidado paliativo del paciente con falla cardiaca: un estudio mixto. Revista Cuidarte. 2023;14(1):e2539. http://dx.doi.org/10.15649/cuidarte.2539

Early Detection of Worsening Heart Failure in Patients at Home Using a New Telemonitoring System of Respiratory Stability

BACKGROUND

Early detection of worsening heart failure (HF) with a telemonitoring system crucially depends on monitoring parameters. The present study aimed to examine whether a serial follow up of all-night respiratory stability time (RST) built into a telemonitoring system could faithfully reflect ongoing deterioration in HF patients at home and detect early signs of worsening HF in a multicenter, prospective study.Methods and Results:Seventeen subjects with New York Heart Association class II or III were followed up for a mean of 9 months using a newly developed telemonitoring system equipped with non-attached sensor technologies and automatic RST analysis. Signals from the home sensor were transferred to a cloud server, where all-night RSTs were calculated every morning and traced by the monitoring center. During the follow up, 9 episodes of admission due to worsening HF and 1 episode of sudden death were preceded by progressive declines of RST. The receiver operating characteristic curve demonstrated that the progressive or sustained reduction of RST below 20 s during 28 days before hospital admission achieved the highest sensitivity of 90.0% and specificity of 81.7% to subsequent hospitalization, with an area under the curve of 0.85.

CONCLUSIONS

RST could serve as a sensitive and specific indicator of worsening HF and allow the detection of an early sign of clinical deterioration in the telemedical management of HF.

Older and younger patients' perceptions, evaluations, and responses to worsening heart failure symptoms

BACKGROUND

Whether recognition and prompt response to worsening symptoms are worse in older compared with younger patients with heart failure (HF) is unclear.

OBJECTIVES

The aims of this study were to compare older and younger patients (1) perceptions, evaluations, and responses to worsening HF symptoms, and (2) responses once worsening symptoms were perceived.

METHODS

A mixed-methods study was conducted and to compare data between older (≥ 65) and younger (< 65) in 185 patients hospitalized with HF.

RESULTS

There were few differences attributed to age. In response to higher perceived symptom distress, patients in both groups did nothing and hoped their symptoms would go away (p = 0.004), ignored symptoms and continued doing what they were doing (p = 0.002), or laid down to relax (p < 0.001).

CONCLUSIONS

The majority of patients, regardless of age, did not recognize, interpret, and respond appropriately to HF symptoms. Interventions should be tested that target better symptom appraisal and promote appropriate symptom responses in patients with HF across all ages.

Association of the induction of a self-care management system with 1-year outcomes in patients hospitalized for heart failure

BACKGROUND

To perform self-care in patients with heart failure (HF), we developed and implemented a new HF point self-care system, which was characterized by 1) the way weight and HF symptoms were scored ("Heart Failure Points") and 2) the timing of consultations defined for both patients and health care providers. We examined the association between the induction of the new system and 1-year outcomes in patients hospitalized for HF.

METHODS

We retrospectively enrolled 569 consecutive patients into our study who were admitted for HF treatment at our hospital: 275 patients between November 2011 and October 2013 (before the induction of the self-management system) and 294 patients between November 2015 and October 2017 (after the induction). We sought to compare the clinical outcomes between patients using the self-management system and those not using the system after propensity-score (PS) matching. The primary outcome measure was a composite of all-cause death or HF rehospitalization.

RESULTS

The cumulative 1-year incidence of the primary outcome measure in the use group (n = 153) was significantly lower than that in the non-use group (n = 153) (24.5% vs. 34.9%, respectively; p = 0.031; hazard ratio: 0.62; 95% confidence interval: 0.40-0.96), mainly due to a reduction in HF hospitalization.

CONCLUSIONS

The induction of the new self-care system was associated with better 1-year outcomes in patients hospitalized for HF. This system may help patients with HF to achieve more efficient self-care.

Perceived Control Predicts Symptom Status in Patients With Heart Failure

BACKGROUND

Symptom status is an important indicator of disease progression in patients with heart failure (HF). Perceived control is a target of most self-care interventions and is associated with better outcomes in HF; however, little is known about the relationship between perceived control and symptom status in patients with HF.

OBJECTIVE

The aims of this study were to (1) determine the relationship of perceived control to HF symptom status and (2) examine the associations of perceived control to self-care and of self-care to symptom status.

METHODS

A total of 115 patients with HF were included. Data on symptom status (Memorial Symptom Assessment Scale-HF), perceived control (Control Attitudes Scale-Revised), and self-care (Self-Care of Heart Failure Index) were collected. Other covariates included were age, gender, New York Heart Association class, comorbidity burden, and depressive symptoms. Multiple regression analyses were performed to analyze the data.

RESULTS

Lower perceived control predicted worse symptom status after controlling for covariates (P = .009). Other covariates predictive of worse symptom status were younger age, New York Heart Association class III/IV, and higher levels of depressive symptoms. Higher levels of perceived control were associated with better self-care (P = .044). Better self-care was associated with better symptom status (P = .038).

CONCLUSIONS

Lower levels of perceived control were independently associated with worse symptom status in patients with HF. Intervention strategies targeting perceived control should be tested to determine whether they could improve symptom status.

Vascular Parameters for Ambulatory Monitoring of Congestive Heart Failure Patients: Proof of Concept

PURPOSE

Prompt detection of congestion is an essential target in order to prevent heart failure (HF) related hospitalization, being ambulatory monitoring a promising strategy to do so. A successful non-invasive ambulatory monitoring system requires automatic devices for physiological data recording; these data must give information about HF deterioration early enough to predict HF-related adverse events. This work aims to evaluate seven vascular parameters for the ambulatory monitoring of congestive heart failure patients.

METHODS

Seven vascular parameters are proposed as indicators of HF deterioration. These parameters are obtained using venous occlusion plethysmography; a technique that uses hardware able of being miniaturized and easily integrated into wearables for ambulatory monitoring. The ability of the proposed vascular parameters to detect congestion is evaluated in eight healthy volunteers and ten congestive heart failure patients with different congestion levels-mild, moderate and severe.

RESULTS

Most parameters distinguish between healthy volunteers and heart failure patients, and some of them present significant differences between volunteers and low levels of congestion-mild or moderate.

CONCLUSION

Home monitoring of some of the proposed parameters could detect HF deterioration on its onset and alert to health personnel.

Multicenter, Prospective Study on Respiratory Stability During Recovery From Deterioration of Chronic Heart Failure

BACKGROUND

The respiratory instability frequently observed in advanced heart failure (HF) is likely to mirror the clinical status of worsening HF. The present multicenter study was conducted to examine whether the noble respiratory stability index (RSI), a quantitative measure of respiratory instability, reflects the recovery process from HF decompensation. Methods and Results: Thirty-six of 44 patients hospitalized for worsening HF completed all-night measurements of RSI both at deterioration and recovery phases. Based on the signs, symptoms, and laboratory data during hospitalization, the Central Adjudication Committee identified 22 convalescent patients and 14 patients with less extent of recovery in a blinded manner without any information on RSI or other respiratory variables. The all-night RSI in the convalescent patients was increased from 27.8±18.4 to 34.6±15.8 (P<0.05). There was no significant improvement of RSI, however, in the remaining patients with little clinical improvement. Of the clinical and laboratory variables, on stepwise linear regression modeling, body weight, peripheral edema, and lung congestion were closely related to the RSI of recovered patients and accounted for 56% of the changes in RSI (coefficient of determination, R²=0.56).

CONCLUSIONS

All-night RSI, a quantitative measure of respiratory instability, could faithfully reflect congestive signs and clinical status of HF during the recovery process from acute decompensation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Direction of the Relationship Between Acceptance of Illness and Health-Related Quality of Life in Chronic Heart Failure Patients

BACKGROUND

This study provides an in-depth insight into the relationships between illness acceptance and health-related quality of life (HRQoL) of chronic heart failure (CHF) patients. Although HRQoL is a well-established endpoint in CHF, little is known on illness acceptance in this group.

AIMS

The aim of this study is to critically reconsider the direction of a relationship between HRQoL and illness acceptance in CHF patients.

METHODS

The study included 204 patients (160 men and 44 women; mean age, 63 ± 11 years) with at least 6-month clinical evidence of CHF corresponding to New York heart Association (NYHA) classes I to IV. All the patients were examined with the Minnesota Living With Heart Failure Questionnaire (MLHFQ) and Acceptance of Illness Scale (AIS).

RESULTS

Univariate analysis showed that the level of illness acceptance correlated inversely with patient age, and the level of HRQoL decreased with the severity of CHF (NYHA class). A relationship between illness acceptance and HRQoL was analyzed by structural equation modeling. Model 1 was based on the assumption that HRQoL is modulated by illness acceptance, and model 2 tested the opposite relationship. Both models included patient age and NYHA class as extrinsic determinants of AIS and MLHFQ scores, respectively. Model 2 proved to be well fitted (χ [df = 2] = 3.22, P = .20, root-mean-square error of approximation = 0.055). Scores on the AIS correlated inversely with age (bage->AIS = -0.15, SE = 0.05, P = .002) and HRQoL (bQoL->AIS = -0.15, SE = 0.02, P < .001), and an increase in NYHA class was reflected by an increase in HRQoL scores (bNYHA->QoL = 5.75, SE = 1.97, P = .004).

CONCLUSION

Patients with CHF may not accept their disease due to deteriorated HRQoL. As a result, they may be uninvolved in the therapeutic process, which leads to exacerbation of CHF, further deterioration of HRQoL, and inability to accept the illness.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Psychometric Analysis of the Heart Failure Somatic Perception Scale as a Measure of Patient Symptom Perception

BACKGROUND

Symptoms are known to predict survival among patients with heart failure (HF), but discrepancies exist between patients' and health providers' perceptions of HF symptom burden.

OBJECTIVE

The purpose of this study is to quantify the internal consistency, validity, and prognostic value of patient perception of a broad range of HF symptoms using an HF-specific physical symptom measure, the 18-item HF Somatic Perception Scale v. 3.

METHODS

Factor analysis of the HF Somatic Perception Scale was conducted in a convenience sample of 378 patients with chronic HF. Convergent validity was examined using the Physical Limitation subscale of the Kansas City Cardiomyopathy Questionnaire. Divergent validity was examined using the Self-care of HF Index self-care management score. One-year survival based on HF Somatic Perception Scale scores was quantified using Cox regression controlling for Seattle HF Model scores to account for clinical status, therapeutics, and lab values.

RESULTS

The sample was 63% male, 85% white, 67% functionally compromised (New York Heart Association class III-IV) with a mean (SD) age of 63 (12.8) years. Internal consistency of the HF Somatic Perception Scale was α = .90. Convergent (r = -0.54, P < .0001) and divergent (r = 0.18, P > .05) validities were supported. Controlling for Seattle HF scores, HF Somatic Perception Scale was a significant predictor of 1-year survival, with those most symptomatic having worse survival (hazard ratio, 1.012; 95% confidence interval, 1.001-1.024; P = .038).

CONCLUSIONS

Perception of HF symptom burden as measured by the HF Somatic Perception Scale is a significant predictor of survival, contributing additional prognostic value over and above objective Seattle HF Risk Model scores. This analysis suggests that assessment of a broad range of HF symptoms, or those related to dyspnea or early and subtle symptoms, may be useful in evaluating therapeutic outcomes and predicting event-free survival.

Symptom Diary Use and Improved Survival for Patients With Heart Failure

BACKGROUND

Attention to symptoms of weight gain and dyspnea are central tenets of patient education in heart failure (HF). However, it is not known whether diary use improves patient outcomes. The aims of this study were to compare mortality among rural patients with HF who completed versus did not complete a daily diary of weight and symptom self-assessment and to identify predictors of diary use.

METHODS AND RESULTS

This is a secondary analysis of a 3-arm randomized controlled trial on HF education of self-care with 2 intervention groups versus control who were given diaries for 24 months to track daily weight, HF symptoms, and response to symptom changes. Mean age was 66±13, 58% were men, and 67% completed diaries (n=393). We formed 5 groups (no use, low, medium, high, and very high) based on the first 3 months of diary use and then analyzed time to event (cardiac mortality, all-cause mortality, and HF-related readmission) starting at 3 months. Compared with patients with no diary use, high and very high diary users were less likely to experience all-cause mortality (P=0.02 and P=0.01, respectively). Self-reported sedentary lifestyle was associated with less diary use in an adjusted model (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P=0.03). Depression and sex were not significant predictors of diary use in the adjusted model.

CONCLUSIONS

In this study of 393 rural patients with HF, we found that greater diary use was associated with longer survival. These findings suggest that greater engagement in self-care behaviors is associated with better HF outcomes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00415545.

Daily Variability in Dyspnea, Edema and Body Weight in Heart Failure Patients

BACKGROUND

Heart failure (HF) and heart failure exacerbations are associated with distressing physical signs and symptoms that include dyspnea, peripheral edema and weight gain. There are no prior investigations that describe the daily fluctuations of these.

PURPOSE

The purpose of this investigation was to characterize daily dyspnea, edema and body weight in patients with HF for 1 month.

METHODS

This analysis used a descriptive correlational design. Data were collected daily for 30 days from a cohort of heart failure subjects (n=48). Daily mean values and associations between self-reported dyspnea, edema and body weight were determined.

RESULTS

The sample included 48 participants with a mean age of 48+/-15 years. Slightly more than half were male (54%) and a majority were married (54%). On average, subjects with HF reported moderate daily levels of self-reported dyspnea and perceived edema. The average daily association between self-reported dyspnea and edema was a positive, significant relationship (p<0.001). There were fewer significant positive associations between self-reported dyspnea and body weight and self-reported edema and body weight.

CONCLUSIONS

In this cohort, heart failure patients were able to monitor symptoms daily, detect fluctuations and may be able to modify self-care activities and therapeutic regimen based on these ratings.

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Quality of life assessment in heart failure interventions: a 10-year (1996–2005) review

The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996–2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure. Eur J Cardiovasc Prev Rehabil 14:589-607 © 2007 The European Society of Cardiology

Improving Outcomes for African Americans with Chronic Heart Failure: A Comparison of Two Home Care Management Delivery Methods

Available data indicate disparity in heart failure (HF) morbidity and mortality among African Americans. African Americans are diagnosed with HF at a younger age, have a more rapid clinical progression, and have higher hospitalization rates related to HF than Whites. Lack of inclusion of African Americans in research studies has been suggested as a possible contributing factor to this disparity. This study presents a secondary analysis from a randomized trial comparing biopsychosocial outcomes for only the African Americans whose HF home management was provided by one of two home care delivery methods—nurse telemanagement (NTM) or nurse home visits. Results indicate significantly higher self-efficacy, home care satisfaction, and quality of life, with significantly lower symptom distress, HF rehospitalization, and intervention charges for African Americans whose HF home management was delivered by the NTM method. These data suggest, independent of race, that NTM may be more efficient and effective as a delivery method for HF home management.

Impact of Chronic Heart Failure on Elderly Persons' Daily Life: A Validation Study

BACKGROUND

Knowledge about how elderly persons perceive the impact of chronic heart failure (CHF) on daily life is important when planning nursing care. For this purpose, disease specific instruments are needed. However, few instruments have been developed or tested specifically on elderly persons.

AIM

To validate a Swedish version of the Minnesota Living with Heart Failure Questionnaire (LHFQ) on elderly persons with CHF, and use it to describe the impact of CHF on daily life in the same population.

METHODS

The sample comprised of 357 persons, aged between 65 and 99, diagnosed with CHF. A questionnaire including background data, the LHFQ and the SF-12 was used.

RESULTS

A factor analysis resulted in four dimensions: physical, emotional, treatment and pleasure. LHFQ showed convergent validity and ability to discriminate between known groups. Cronbach's alpha for the total scale was 0.94. Impairments in the physical dimension were most common, especially fatigue (88%) and shortness of breath (87%).

CONCLUSIONS

The LHFQ showed satisfying psychometric properties in an elderly Swedish population with CHF and can, with minor alterations, be recommended for research and clinical use. The impact of chronic heart failure on daily life was mostly physical, but other impairments were also common.

Gender Makes a Difference in the Description of Dyspnoea in Patients with Chronic Heart Failure

Background: Dyspnoea is a common symptom of chronic heart failure (CHF). In the community setting, patients with CHF are most often women.

Aim: To examine the impact of gender on the description of dyspnoea and to explore which clinical variables support a diagnosis of CHF.

Methods: From four primary health care centres, 158 patients with CHF were included. Patients were examined with echocardiography and a cardiologist assessed the diagnosis of CHF. The patients filled in a questionnaire containing 11 descriptors of dyspnoea.

Results: A diagnosis of CHF was confirmed in 87 (55%) patients (47 males and 40 females). One descriptor, I feel that I am suffocating, was significantly scored higher in CHF patients ( p=0.014) as compared to non-CHF patients. Three descriptors, My breath does not go in all the way ( p=0.006), I feel that I am suffocating ( p=0.040), and I cannot get enough air ( p=0.0327) were significantly scored higher among men with CHF, compared to no descriptor among women with CHF. Being male (OR=2.7; CI: 1.3–5.6, p=0.008), having diabetes (OR=5.6; CI: 1.7–18.2, p=0.004), IHD (OR=3.3; CI: 1.3–8.5, p=0.014), and a borderline significance for age (OR=1.04; CI: 0.99–1.08, p=0.058) predicted a confirmed diagnosis of CHF.

Conclusion: Three descriptors of dyspnoea were associated with CHF among men, whereas no such association was found among women. Our results suggest that gender is an important factor and should—together with age, underlying heart disease, and diabetes—be taken into account when symptoms are evaluated in the diagnosis of CHF in primary care.

Predictors of delay in heart failure patients and consequences for outcomes

Persons with heart failure (HF) symptoms delay up to 7 days before seeking treatment. Delay can result in worse symptoms and potentially impact outcomes. The purpose of this review was to describe predictors and outcomes of delay in HF patients. Demographic factors, increased symptom number, social factors, greater HF knowledge, lower anxiety, and depression predicted increased delay. HF patients had difficulty recognizing and interpreting symptoms of HF. Results are conflicting related to symptom pattern, time of care seeking, and history of HF as predictors of delay. The only outcome predicted by delay was length of stay with those delaying longer reporting longer lengths of stay. Future research related to delay should include theoretical frameworks and larger, more ethnically diverse samples from multiple sites and link delay to outcomes. Valid and reliable instruments are needed to measure delay and related factors. HF education should include supportive others.

Long-term monitoring of respiratory rate in patients with heart failure: the Multiparametric Heart Failure Evaluation in Implantable Cardioverter-Defibrillator Patients (MULTITUDE-HF) study

BACKGROUND

Monitoring respiratory rate (RR) is recommended at the time of hospital presentation for acute decompensation in heart failure (HF). Device-based continuous monitoring of RR may be helpful for diagnostic and prognostic stratification after implantable cardioverter-defibrillator (ICD) implantation. This study was undertaken to analyze short- and long-term changes in ICD-measured RR and to relate RR with the patient's clinical status and the occurrence of HF events.

METHODS

One hundred twenty-four consecutive HF patients who received ICD endowed with this diagnostic capability (Boston Scientific Inc., Natick, MA, USA) were prospectively enrolled. Patients were followed up for 12 months.

RESULTS

At the baseline, the proportion of New York Heart Association (NYHA) class III-IV was higher among patients with daily maximum RR >27 breaths/min (third tertile) than those with <24 breaths/min (first tertile) (43 vs. 23%, p < 0.05). Moreover, the ejection fraction was lower (27 ± 7 vs. 34 ± 8%, p < 0.05). In patients with HF hospitalizations (33 events) and urgent visits for HF (15 events), the weekly average of RR calculated over the 7 days preceding hospital accesses did not differ from values recorded at the baseline and before scheduled follow-up visits. However, the weekly variation in RR (i.e., the difference between maximum and minimum values collected over the week) was significantly higher prior to hospitalization (p < 0.05). A weekly variation >3 breaths/min in maximum RR predicted an impending hospital admission for HF with sensitivity of 73 % and specificity of 57%.

CONCLUSIONS

In this study, elevated values of ICD-monitored RR identified patients with worse functional status and lower systolic function. The weekly variation in RR increased before HF exacerbation. This monitoring technology may represent a useful tool in the clinical management of patients with HF.

Factors predictive of airflow obstruction among veterans with presumed empirical diagnosis and treatment of COPD

BACKGROUND

Despite guideline recommendations, patients suspected of having COPD often are treated empirically instead of undergoing spirometry to confirm airflow obstruction (AFO). Accurate diagnosis and treatment are essential to provide high-quality, value-oriented care. We sought to identify predictors associated with AFO among patients with and treated for COPD prior to performance of confirmatory spirometry.

METHODS

We identified a cohort of veterans with spirometry performed at Pacific Northwest Department of Veterans Affairs medical centers between 2003 and 2007. We included only patients with empirically diagnosed COPD in the 2 years prior to spirometry who were also taking inhaled medication to treat COPD in the 1 year prior to spirometry. We used relative risk regression analysis to identify predictors of AFO.

RESULTS

Among patients empirically treated for COPD (N = 3,209), 62% had AFO. Risk factors such as older age, prior smoking status, and underweight status were associated with AFO on spirometry. In contrast, comorbidities often associated with somatic symptoms were associated with absence of AFO and included congestive heart failure, depression, diabetes, obesity, and sleep apnea.

CONCLUSIONS

Comorbidities associated with somatic complaints of dyspnea were associated with a lower risk of having airflow limitations, suggesting that empirical diagnosis and treatment of COPD may lead to inappropriate treatment of individuals who do not have AFO.

A comprehensive symptom diary intervention to improve outcomes in patients with HF: a pilot study

BACKGROUND

Patients with heart failure must monitor for and recognize escalating symptoms to take action to relieve symptoms and decrease hospitalizations. However, symptom monitoring is not commonly performed. One way to promote patients' engagement in symptom monitoring is by providing a symptom diary.

PURPOSE

The aim of this study was to test the effect of a comprehensive daily symptom diary intervention on event-free survival and health-related quality of life (HRQOL).

METHODS

Patients were randomized into either intervention (n = 23) or usual-care groups (n = 21). The intervention group received a symptom diary with self-care education and counseling at baseline with 5 follow-up calls for 3 months. All patients were interviewed to obtain survival data at 1 month and 3 months. HRQOL was measured at baseline, 1 month, and 3 months. Kaplan-Meier curves with the log-rank test were used to compare group differences in time to first event. Linear mixed models were conducted to examine the relationship between groups and changes in HRQOL over 3 months.

RESULTS

The intervention group had longer event-free survival than the usual-care group (P = .03). There were no differences in changes in HRQOL scores between the groups over 3 months.

CONCLUSIONS

Positive effects of the intervention on survival were found. However, there was no significant difference in changes in HRQOL.

Identification of symptom clusters among patients with heart failure: an international observational study

BACKGROUND

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.

OBJECTIVES

To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.

DESIGN

Cross-sectional, observational study.

SETTINGS

In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.

PARTICIPANTS

A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.

METHODS

Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.

RESULTS

There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.

CONCLUSION

Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: testing dyadic dynamics using the actor-partner interdependence model

Emotions are contagious in couples. The purpose of this study was to analyze the manner in which adults with chronic heart failure (HF) and their informal caregivers influence each other's self-care behavior and quality of life (QOL). A sample of 138 HF patients and spouses was enrolled from ambulatory centers across Italy. The Actor-Partner Interdependence Model (APIM) was used to analyze dyadic data obtained with the Self-Care of Heart Failure Index (SCHFI), the Caregivers Contribution to the SCHFI, and the Short Form 12. Both actor and partner effects were found. Higher self-care was related to lower physical QOL in patients and caregivers. Higher self-care maintenance in patients was associated with better mental QOL in caregivers. In caregivers, confidence in the ability to support patients in self-care was associated with improved caregivers' mental QOL, but worsened physical QOL in patients. Interventions that build the caregivers' confidence are needed.

Patterns of symptom recognition, interpretation, and response in heart failure patients: an integrative review

BACKGROUND

Heart failure (HF) is a chronic illness affecting more than 5 million Americans, and it continues to lead healthcare-related expenditures in the United States. Hospitalization rates remain high and are caused by many factors, including poor self-care behaviors. Self-care research is growing, and a situation-specific theory for the HF population is now published. Self-care management, which is part of self-care, includes a series of responses and actions that the individual living with HF assumes in response to a change in baseline health. A critical aspect of enacting a self-care management plan is the ability to recognize changes in baseline health as being related to HF.

PURPOSE

This integrative review examined research to date on self-reported patterns of symptom recognition, an antecedent to self-care management, and treatment-seeking behaviors in HF patients.

CONCLUSIONS

Descriptive research strategies were predominantly used to examine symptom recognition, interpretation, and response in HF patients. Seven studies used retrospective approaches, such as chart review or patient recall, to collect data, and 7 studies collected data from the patient prospectively. The quantitative portion of 2 mixed-methods study was also analyzed. Dyspnea was the most frequently reported symptom across all studies reviewed. Dyspnea was characterized in terms of duration and was defined inconsistently across studies. In some studies, duration of dyspnea was associated with treatment-seeking delays. Elderly patients and newly diagnosed HF patients are more likely to delay treatment seeking for onset of symptoms.

CLINICAL IMPLICATIONS

Research is limited on symptom recognition and treatment-seeking behaviors in HF patients. Evidence suggests that symptom recognition may be impaired in the elderly population. Research studies to date on symptom recognition have largely been descriptive; no studies in this review followed patients' ability to recognize and respond to symptoms prospectively in their home environment. Symptoms may vary and their pattern may influence patients' recognition and/or response patterns.

Heart failure symptom monitoring and response training

OBJECTIVE

The purpose of this study was to test the efficacy of a heart failure (HF) training program on patients' ability to recognize and respond to changes in HF symptoms. The primary aim was to compare event-free survival at 90 days.

METHODS

A total of 99 HF patients randomized to the HF symptom training intervention or usual care completed instruments about self-care (Self-Care of HF Index) and at baseline and 3 months. Demographic, clinical, and comorbidity data were collected by interview and chart review. Time to first event (death or a HF-related hospitalization) was tracked by electronic records and patient interview.

RESULTS

The sample was predominately male (67.7%), elderly (67.7 yrs ± 12.1) and Caucasian (88.9%). The intervention group reported more events but the difference was not significantly different (χ(2) = 1.18, p = 0.26). There was no difference in survival time between groups (χ(2) = 1.53, p = 0.216). In paired t-tests, the intervention group had significantly improved self-care maintenance, management and confidence scores (all p < 0.01). The usual care group had significantly improved self-care maintenance and management (both p < 0.01). Improvements in self-care maintenance and confidence were higher in the intervention group compared with usual care (18.0 vs. 12.9 points).

CONCLUSIONS

HF symptom awareness training appeared to have an early but not sustained benefit resulting in no difference in 90-day event-free survival. However, larger improvement in self-care maintenance and confidence scores in the intervention group compared to usual care is promising. Embedding meaningful symptom monitoring strategies in self-care maintenance interventions requires further investigation.

Delayed hospital presentation in acute decompensated heart failure: clinical and patient reported factors

BACKGROUND

Patients with acute decompensated heart failure (ADHF) often wait a considerable amount of time before going to the hospital. Prior studies have examined the reasons why such delays may occur, but additional studies are needed to identify modifiable factors contributing to these delays.

PURPOSE

To describe care-seeking delay times, factors associated with prolonged delay, and patient's thoughts and actions in adult men and women hospitalized with ADHF.

METHODS

We surveyed 1271 patients hospitalized with ADHF at 8 urban medical centers between 2007 and 2010.

RESULTS

The average age of our study population was 73 years, 47% were female, and 72% had prior heart failure. The median duration of pre-hospital delay prior to hospital presentation was 5.3 h. Patients who delayed longer than the median were older, more likely to have diabetes, peripheral edema, to have symptoms that began in the afternoon, and to have contacted their medical provider(s) about their symptoms. Prolonged care seekers were less likely to have attributed their symptoms to ADHF, less likely to want to have bothered their doctor or family, and were more likely to be concerned about missing work due to their illness (all p values < 0.05).

CONCLUSIONS

Care-seeking delays are common among patients with ADHF. A variety of factors contribute to these delays, which in some cases may represent efforts to manage ADHF symptoms at home. More research is needed to better understand the detrimental effects of these delays and how best to encourage timely care-seeking behavior in the setting of ADHF.

Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia

IMPORTANCE

To better guide strategies intended to reduce high rates of 30-day readmission after hospitalization for heart failure (HF), acute myocardial infarction (MI), or pneumonia, further information is needed about readmission diagnoses, readmission timing, and the relationship of both to patient age, sex, and race.

OBJECTIVE

To examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, acute MI, or pneumonia.

DESIGN, SETTING, AND PATIENTS

We analyzed 2007-2009 Medicare fee-for-service claims data to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for HF, acute MI, or pneumonia. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare & Medicaid Services' Condition Categories. Readmission timing was determined by day after discharge.

MAIN OUTCOME MEASURES

We examined the percentage of 30-day readmissions occurring on each day (0-30) after discharge; the most common readmission diagnoses occurring during cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods (days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics and readmission diagnoses and timing.

RESULTS

From 2007 through 2009, we identified 329,308 30-day readmissions after 1,330,157 HF hospitalizations (24.8% readmitted), 108,992 30-day readmissions after 548,834 acute MI hospitalizations (19.9% readmitted), and 214,239 30-day readmissions after 1,168,624 pneumonia hospitalizations (18.3% readmitted). The proportion of patients readmitted for the same condition was 35.2% after the index HF hospitalization, 10.0% after the index acute MI hospitalization, and 22.4% after the index pneumonia hospitalization. Of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The diverse spectrum of readmission diagnoses was largely similar in both cumulative and consecutive periods after discharge. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for patients initially hospitalized for acute MI, and 12 days for patients initially hospitalized for pneumonia and was comparable across common readmission diagnoses. Neither readmission diagnoses nor timing substantively varied by age, sex, or race.

CONCLUSION AND RELEVANCE

Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge.

Symptoms in heart failure correlate poorly with objective haemodynamic parameters

INTRODUCTION

Even though heart failure (HF) is a very common condition, surprisingly little is known regarding association between patient's symptoms and objective data. The purpose of this study was to evaluate for any correlations between haemodynamic, echocardiographic and laboratory data of presenting symptoms in HF patients.

METHODS

This study is a retrospective analysis of the limited access dataset from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial provided by the National Heart, Lung and Blood Institute. Symptoms including dyspnoea, orthopnoea, fatigue and gastrointestinal (GI) discomfort were graded by their severity from minimal (0) to maximal (3) on admission, at discharge, at 3 months and at 6 months from the admission. Results of Minnesota Living with Heart Failure (MLHF) score and assigned New York Heart Association (NYHA) functional class were available at the same time points.

RESULTS

A total of 433 patients with decompensated HF and decreased systolic function (ejection fraction < 30%) were included in this trial. Orthopnoea, dyspnoea and fatigue had weak correlation with invasive pulmonary artery systolic and diastolic pressure and negative correlation with serum creatinine, albumin, sodium, total bilirubin, haemoglobin and haematocrit; fatigue showed positive correlation to pulmonary artery pressures. Abdominal discomfort had no correlation to symptoms. There was no correlation of symptoms, NYHA class, or MLHF scores with age, gender, peak VO(2) on cardiopulmonary stress test, body mass index, either right or left ventricular systolic function, B-type natriuretic peptide, cardiac output or cardiac index, troponin level, velocity of tricuspid regurgitation and multiple other factors predicting morbidity and mortality in HF.

CONCLUSION

Overall, the correlation between symptoms and objective parameters was weak. Because of low magnitude of relationship between symptoms to objective parameters, it was concluded that there are likely other factors determining the perception of symptoms in HF patients.

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.

Understanding help-seeking decisions in people with heart failure: a qualitative systematic review

OBJECTIVE

To understand the process of help-seeking among heart failure patients from the perspectives of patients, caregivers and health professionals.

DESIGN

Systematic review using qualitative meta-synthesis.

METHODS

A systematic search (20th May 2011) was conducted to identify studies published in English as full papers ≥1995 reporting primary qualitative data with extractable heart failure-specific data or themes related to help-seeking in patients, caregivers or health professionals. Databases searched were: CINAHL, Medline, PsycInfo, Social Science Citation Index, Embase, Social policy/Practice, SocIndex, Ageline, Health Source Nursing, Scopus; additionally, we consulted with experts and manually searched references.

RESULTS

58 studies (990 patients; 274 female, 527 male, 189 sex not described; 229 caregivers, 79 health professionals) were included. Heart failure help-seeking was embedded in daily experiences of heart failure but ongoing symptoms were confusing, ambiguous and disruptive; little support was available from professionals to interpret the presence and significance of fluctuations in symptoms for help-seeking. Other significant barriers to help-seeking were: avoidance-based coping, fear of hospitals and misplaced reluctance to be burdensome. Help-seeking was facilitated by good involvement and frank communication between patients, caregivers and health professionals and the presence of a sense of elevated personal risk.

CONCLUSION

Health services should harness primary care providers and support patients and caregivers to prioritize development of objective symptom monitoring skills, recognize and personally assimilate the elevated risks of heart failure and help-seeking delays and discourage avoidance-based coping and unwarranted concerns that downplay the significance of heart failure and urgency to address symptoms.