Predictors of quality of life in women with heart failure. SOLVD Investigators. Studies of Left Ventricular Dysfunction

A State-of-the-Art Review on the Role of Cognitive and Motor Reserve on Quality of Life: A Focus on Cardiovascular Patients in a Lifespan Perspective

Cardiovascular diseases (CVDs) reflect a huge and diversified condition that influences patient quality of life (QoL) both in the physical and mental aspects, especially in older adults who often present comorbidities and may be affected by cognitive decline. The concept of cognitive reserve (CR), which is built through life course experiences, has widely been considered a protective factor against cognitive decline, while the results of QoL in the field of CVDs are still controversial. In particular, there is a lack of evidence that explicitly explores the effects of CR on the QoL in CVD cases since studies have considered only single CR proxies (e.g., education) or specific cardiovascular conditions. Moreover, none of them have considered the motor reserve (MR), another recent concept that considers the amount of physical activity carried out during a lifespan. Its potential role in preventing age-related diseases has been observed, but more clarification is needed given the importance of the physical component in CVDs. The present state-of-the-art review aims to (i) examine how the literature conceives CR and its proxies in CVDs relating to QoL and (ii) integrate the concept of MR in this framework. Implications for clinical practice will also be discussed.

Health-related quality of life and its associated factors among outpatients with heart failure: a cross-sectional study

BACKGROUND

Heart Failure (HF) is a chronic disease associated with life-limiting symptoms that could negatively impact patients' health-related quality of life (HRQOL). This study aimed to evaluate HRQOL and explore the factors associated with poor HRQOL among patients with HF in Jordan.

METHODS

This cross-sectional study used the validated Arabic version of the Minnesota Living with Heart Failure Questionnaire to assess HRQOL in outpatients with HF visiting cardiology clinics at two public hospitals in Jordan. Variables were collected from medical records and custom-designed questionnaires, including socio-demographics, biomedical variables, and disease and medication characteristics. Ordinal regression analysis was used to explore variables associated with poor HRQOL among HF patients.

RESULTS

Ordinal regression analysis showed that the number of HF medications (P < 0.05) and not taking a loop diuretic (P < 0.05) significantly increased HRQOL, while the number of other chronic diseases (P < 0.05), stage III/IV of HF (P < 0.01), low monthly income (P < 0.05), and being unsatisfied with the prescribed medications (P < 0.05) significantly decreased HRQOL of HF patients.

CONCLUSIONS

Although the current study demonstrated low HRQOL among patients with HF in Jordan, HRQOL has a considerable opportunity for improvement in those patients. Variables identified in the present study, including low monthly income, higher New York Heart Association (NYHA) classes, a higher number of comorbidities, and/or taking a loop diuretic, should be considered in future intervention programs, aiming to improve HRQOL in patients with HF.

[Évaluation de la qualité de vie et description des facteurs associés, chez les patients en insuffisance cardiaque chronique vivant dans un pays d'Afrique de l'Ouest à faible revenu]

OBJECTIVE

To assess the quality of life (QOL) and describe associated factors in patients with chronic heart failure (HF) living in a low-income population in West Africa.

METHODS

This is was a cross-sectional study conducted from January 2017 to June 2018, in the department of cardiology of the University Teaching Hospital (CHU-Campus) in Lomé (Togo). Enrolled patients had stable chronic HF and have been hospitalized in the past 6 months; QOL was assessed using the Minnesota Living with Heart Failure questionnaire (MLHFQ).

RESULTS

171 patients were included (women = 40.9%, 33% unschooled, 75% without health insurance; 46.8% in NYHA class II). The prevalence of depression was 62%. The mean total score of MLHFQ was 37.2 ± 22.3. In univariate analysis, there was a positive correlation between the total score and the following factors: age (r= 0.33, p ˂0.0001), NYHA classes (r= 0.67, p ˂0.0001), number of rehospitalizations (r= 0.61, p ˂0.0001), number of comorbidities (r= 0.43, p ˂0.0001), and the depression score (r= 0.67, p ˂0.0001). After adjustments, positive correlation persisted with NYHA classes (p ˂0.0001), number of rehospitalizations (p= 0.02), and depression (p ˂0.0001).

CONCLUSION

The QOL of HF patients was moderately impaired and was comparable to values reported among high-income populations. Factors associated with poor quality of life were advanced NYHA classes, number of rehospitalizations, and depression.

Low educational level increases functional disability risk subsequent to heart failure in Japan: On behalf of the Iwate KENCO study group

Objectives

The risk factors that contribute to future functional disability after heart failure (HF) are poorly understood. The aim of this study was to determine potential risk factors to future functional disability after HF in the general older adult population in Japan.

Methods

The subjects who were community-dwelling older adults aged 65 or older without a history of cardiovascular diseases and functional disability were followed in this prospective study for 11 years. Two case groups were determined from the 4,644 subjects: no long-term care insurance (LTCI) after HF (n = 52) and LTCI after HF (n = 44). We selected the controls by randomly matching each case of HF with three of the remaining 4,548 subjects who were event-free during the period: those with no LTCI and no HF with age +/-1 years and of the same sex, control for the no LTCI after HF group (n = 156), and control for the LTCI after HF group (n = 132). HF was diagnosed according to the Framingham diagnostic criteria. Individuals with a functional disability were those who had been newly certified by the LTCI during the observation period. Objective data including blood samples and several socioeconomic items in the baseline survey were assessed using a self-reported questionnaire.

Results

Significantly associated risk factors were lower educational levels (odds ratio (OR) [95% confidence interval (CI)]: 3.72 [1.63–8.48]) in the LTCI after HF group and hypertension (2.20 [1.10–4.43]) in no LTCI after HF group. Regular alcohol consumption and unmarried status were marginally significantly associated with LTCI after HF (OR [95% CI]; drinker = 2.69 [0.95–7.66]; P = 0.063; unmarried status = 2.54 [0.91–7.15]; P = 0.076).

Conclusion

Preventive measures must be taken to protect older adults with unfavorable social factors from disability after HF via a multidisciplinary approach.

Personality Traits, Clinical Characteristics, and Health-Related Quality of Life of Patients with Hypertension in a Primary Hospital in Ghana

Background

Hypertension is a major health problem that remains a significant threat to the health and general wellbeing of many people all over the world. In some patients, the etiology and prognosis of hypertension have been linked to psychological factors including personality traits. One primary goal of management is to improve the health-related quality of life (HRQoL) of patients with hypertension. This study aimed to examine the association between personality traits, clinical characteristics, and HRQoL in hypertension.

Methods

A hospital-based cross-sectional quantitative study was conducted in a sample of 331 individuals with hypertension. Data on sociodemographic characteristics, clinical information, personality traits, and HRQoL were obtained from participants using an interviewer administered questionnaire.

Results

The number of participants with a 1-10 years' duration of diagnosis for hypertension was highest (56.8%), with 52.9% having comorbidities such as diabetes (40.2%) and dyslipidaemia (20.9%). The average number of medications taken per patient was 2.14 (SD±0.79) and about 47.1% of the participants reported adequate medication adherence. Significant associations for age, education, monthly income, number of years with hypertension, and HRQoL were observed. While conscientiousness was significantly associated with all HRQoL domains, extraversion and agreeableness were significantly related to only the environmental domain.

Conclusion

This study has demonstrated that clinical characteristics and patients' perception of their personality are relevant to their health-related quality of life outcomes. The findings suggest that when intervention efforts to improve the quality of life of patients with hypertension are being considered, a biopsychosocial approach should be employed. The implication is that treatment of hypertension in Ghana should be broadened to include the expertise of mental health professionals.

Measurement of Health-Related Quality of Life in Chronic Heart Failure, from a Nursing Perspective—a Review of the Literature

BACKGROUND

Living with chronic heart failure (CHF) is distressful and affects daily life. Because of the lack of a cure for CHF, there has been a progressive interest in using health-related quality of life (Hr-QoL) as an outcome measurement of the treatment in patients with CHF.

OBJECTIVE

The aim of this review was to describe the instruments/questionnaires used in different studies in the measurement of Hr-QoL in patients with CHF, and how they were put into operation as seen from a nursing perspective.

METHOD

MEDLINE and CINAHL databases were searched from January 1995 to June 2002, by using the keywords CHF, heart failure, QoL and Hr-QoL. A total of 33 articles were analysed.

RESULTS

Thirty-two different Hr-QoL questionnaires were found. Generic, disease-specific and battery approaches were different ways used to measure Hr-QoL. To assess/describe Hr-QoL, evaluate the impact of interventions and examine relations/predictors were three main objectives. However, different aspects of the concept Hr-QoL, influencing factors, how to implement the questionnaires and a lack of unified CHF criteria existed.

CONCLUSIONS

To create a guideline for the measurement of Hr-QoL in CHF patients is of great importance for nurses and might generate homogeneity in the measurement methods and promote the scientific approach in the nursing care process.

Fatigue and health-related quality of life in elderly patients with and without heart failure in primary healthcare

Background

Patients with heart failure (HF) in primary healthcare are in many respects not comparable to those in specialized care and the knowledge about different patient groups with and without HF is limited.

Aims

To compare fatigue and health-related quality of life (Hr-QoL) when adjusting for age, gender and social provision in patients with confirmed HF ( n=49) to a group of patients with symptoms indicating HF but without HF (NHF, n=59) and to an age-and sex-matched control-group ( n=40).

Method

A questionnaire including the Multidimensional Fatigue Inventory, the SF-36, and the Social Provisions Scale was used.

Results

The average age in all groups was 78 years. Patients in the HF and NHF groups reported worse physical QoL and more general and physical fatigue than the control group. HF patients had worse general health than the NHF group.

Conclusion

Elderly patients in primary healthcare with confirmed heart failure and patients with symptoms similar to heart failure perceived they had a significantly worse physical QoL and more general and physical fatigue than an age- and sex-matched control group. The similarities between the patient groups indicate the importance of the symptom experience for Hr-QoL.

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.

Factors and Interventions Influencing Health-Related Quality of Life in Patients with Heart Failure: A Review of the Literature

INTRODUCTION

Because of the lack of a cure for patients with chronic heart failure (HF), there has been a progressive interest in the use of health-related quality of life (Hr-QoL) as complementary end-point to mortality and morbidity.

AIM

The aim of this review was from a nursing perspective to describe Hr-QoL and the influencing factors of Hr-QoL, as well as to identify interventions aimed at influencing Hr-QoL in HF patients.

METHOD

Medline, Cinahl and PsycInfo databases were searched from 1995 to 2004. A total of 58 papers were included.

RESULTS

HF symptoms and activity status influence Hr-QoL negatively. However, several individual characteristics such as personality, gender and age must also be taken into consideration because different values might exist regarding what constitutes a good Hr-QoL. Nurse led interventions based on education, support and exercise can influence Hr-QoL positively. There is also a need of more studies about the effects of depression, sleep disturbances, support as well as education on Hr-QoL. There is also a need of exercise studies with larger sample sizes and older patients in higher NYHA classes.

CONCLUSION

Several individual factors impact Hr-QoL, therefore, must nursing interventions are individually adapted to the patient's resources.

The association of co-morbid symptoms of depression and anxiety with all-cause mortality and cardiac rehospitalization in patients with heart failure

BACKGROUND

Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown.

OBJECTIVE

To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF.

METHOD

A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms.

RESULTS

When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio = 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio = 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement.

CONCLUSION

To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

Predictors of change in quality of life in older adults with generalized anxiety disorder

BACKGROUND

Quality of life (QOL) is lower in older adults with generalized anxiety disorder (GAD). QOL generally improves following cognitive-behavioral treatment for GAD. Little is known, however, about additional variables predicting changes in QOL in older adults with GAD. This study examined predictors of change in QOL among older participants in a randomized clinical trial of cognitive behavioral therapy (CBT) for GAD, relative to enhanced usual care (EUC).

METHODS

Hierarchical multilevel mixed-model analyses were used to examine inter-individual and intra-individual factors that predicted QOL over time. Predictors were categorized into treatment, personal and clinical characteristics.

RESULTS

QOL improved over time, and there was significant variability between participants in change in QOL. Controlling for treatment condition, baseline general self-efficacy, baseline social support, within-person variation in worry and depression and average levels of depression across different time points predicted changes in QOL.

CONCLUSIONS

QOL has increasingly been used as an outcome measure in treatment outcome studies to focus on overall improvement in functioning. Attention to improvement in symptoms of depression and worry, along with psychosocial variables, such as social support and self-efficacy, may help improve QOL in older adults with GAD. This study was a secondary study of data from a randomized clinical trial (NCT00308724) registered with clinical.trials.gov.

Correlates of quality of life in rural patients with heart failure

BACKGROUND

There is abundant research indicating poor physical, psychological, and social functioning of patients with chronic heart failure (HF), a reality that can lead to poor health-related quality of life (QoL). Little is known about the experience of rural patients with HF.

METHODS AND RESULTS

This study was part of a randomized clinical trial titled Rural Education to Improve Outcomes in Heart Failure (REMOTE-HF) designed to test an education and counseling intervention to improve self-care in patients with HF. We evaluated 612 rural patients. Multiple validated questionnaires were administered to assess patient perceptions of health and health literacy. Baseline factors were collected and compared with baseline QoL measures only. Patients' health-related QoL was assessed using the Minnesota Living with Heart Failure scale. The data were analyzed using a general linear model to test the association of various patient characteristics with QoL in rural patients with HF. Patients were 65.8 (+12.9) years of age. The majority were men (58.7%), married (56.4%), and had completed a high-school education (80.9%). Factors associated with reduced QoL among this population include geographic location, younger age, male sex, higher New York Heart Association class, worse HF knowledge, poorer perceived control, and symptoms of depression or anxiety. The data provided no evidence of an association between left ventricular ejection fraction and QoL.

CONCLUSIONS

This study of rural patients with HF confirms previously identified factors associated with perceptions of QoL. However, further study is warranted with an urban control group.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00415545.

Patient- and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: a cross-sectional study

Background

Identifying the determinants of health-related quality of life (HRQOL) in patients with systolic heart failure (CHF) is rare in primary care; studies often lack a defined sample, a comprehensive set of variables and clear HRQOL outcomes. Our aim was to explore the impact of such a set of variables on generic and disease-specific HRQOL.

Methods

In a cross-sectional study, we evaluated data from 318 eligible patients. HRQOL measures used were the SF-36 (Physical/Mental Component Summary, PCS/MCS) and four domains of the KCCQ (Functional status, Quality of life, Self efficacy, Social limitation). Potential determinants (instruments) included socio-demographical variables (age, sex, socio-economic status: SES), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, multimorbidity (CIRS-G)), depression (PHQ-9), behavioural (EHFScBs and prescribing) and provider (e.g. list size of and number. of GPs in practice) variables. We performed linear (mixed) regression modelling accounting for clustering.

Results

Patients were predominantly male (71.4%), had a mean age of 69.0 (SD: 10.4) years, 12.9% had major depression, according to PHQ-9. Across the final regression models, eleven determinants explained 27% to 55% of variance (frequency across models, lowest/highest β): Depression (6×, -0.3/-0.7); age (4×, -0.1/-0.2); multimorbidity (4×, 0.1); list size (2×, -0.2); SES (2×, 0.1/0.2); and each of the following once: no. of GPs per practice, NYHA class, COPD, history of CABG surgery, aldosterone antagonist medication and Self-care (0.1/-0.2/-0.2/0.1/-0.1/-0.2).

Conclusions

HRQOL was determined by a variety of established individual variables. Additionally the presence of multimorbidity burden, behavioural (self-care) and provider determinants may influence clinicians in tailoring care to individual patients and highlight future research priorities.

Health-related quality of life is related to cytokine levels at 12 months in patients with chronic heart failure

Chronic heart failure (CHF) is a condition with a high mortality risk. Besides traditional risk factors, poor health-related quality of life (HRQoL) is also associated with poor prognosis in CHF. Immunological functioning might serve as a biological pathway underlying this association, since pro and anti-inflammatory cytokines are independent predictors of prognosis. The aim of this study was to examine the association between HRQoL at inclusion (baseline) and pro and anti-inflammatory cytokine levels both at baseline and 12months, using a prospective study design. CHF outpatients completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Short Form Health Survey 36 (SF-36). Blood samples were drawn at baseline (n=111) and 12months (n=127) to measure pro (IL-6, TNFalpha, sTNFR1, sTNFR2) and anti- (IL1ra, IL-10) inflammatory markers. Linear regression analysis were run for the MLHFQ, the SF-36 mental component summary (MCS) and the physical component summary (PCS), controlling for age, sex, BMI, smoking, co morbidity, NYHA-class and 6min walk test. Baseline MLHFQ was associated with increased levels of baseline sTNFR2, and 12-month sTNFR1 12month sTNFR2. Baseline MCS and change in MCS were related to increased 12-month sTNFR1 levels. All significant findings relate a worse HRQoL at baseline or a deterioration over time to increased sTNFR1/2 levels. These findings suggest that immune activation may be one of the pathways underlying the relationship between poor HRQoL and mortality and morbidity in CHF patients. Future studies are warranted to replicate these findings in larger samples.

Relationship of depressive symptoms to the impact of physical symptoms on functional status in women with heart failure

BACKGROUND

Among patients with heart failure, women have worse functional status than do men, but little research has focused on determining factors that influence functional status in either sex.

OBJECTIVES

To compare factors that influence functional status in men and women with heart failure and to test whether depressive symptoms mediate the relationship between physical symptoms and functional status.

METHODS

A cross-sectional, descriptive study design was used. A total of 231 patients, 133 men and 98 women, were recruited from an inpatient heart failure clinic in South Korea. Functional status (the Korean Activity Scale/Index), physical symptoms (the Symptom Status Questionnaire), depressive symptoms (the Beck Depression Inventory), and situational factors (living status, socioeconomic status) were measured. Hierarchical multiple regression and mediation analysis were used for data analysis.

RESULTS

Women (mean score, 24.5; SD, 17.3) had worse functional status than did men (mean score, 31.9; SD, 20.1; P = .004). Dyspnea on exertion (beta = -0.16), ankle swelling (beta = -0.19), fatigue (beta = -0.20), and depressive symptoms (beta = -0.19) were independently associated with functional status in women, whereas only dyspnea on exertion (beta = -0.30) influenced functional status of men in hierarchical multiple regression analysis. Mediation analysis indicated that depressive symptoms mediated the relationship between physical symptoms and functional status in women with heart failure, but not in men.

CONCLUSIONS

Distinct physical and psychological symptoms influence functional status in women with heart failure. A systematic multidimensional intervention may be required to target depressive symptoms to improve functional status in women with heart failure.

Quality of life in patients with heart failure: ask the patients

BACKGROUND

Heart failure (HF) is a progressive clinical condition that results in substantial impairment of quality of life (QOL). Helping patients maintain optimal QOL is essential. QOL reflects patients' subjective perceptions about the impact of a clinical condition and its treatment on daily life; however, definitions in the literature vary widely and few reflect the patient's perspective.

PURPOSE

The study explored how patients with HF define and perceive QOL.

METHODS

Qualitative data were obtained from 14 men and 6 women with HF (mean age 58 +/- 10 years) using semistructured open-ended interviews. The interviews were analyzed using content analysis.

RESULTS

Patients with HF defined QOL as their ability to 1) perform desired physical and social activities to meet their and their family's needs; 2) maintain happiness; and 3) engage in fulfilling relationships with others. Patients perceived a variety of factors as positively or negatively affecting QOL: physical (symptoms and good or poor physical status), psychologic (mood and positive or negative perspective), economic (financial status), social (social support and ability for social activities), spiritual, and behavioral (self-care). Patients perceived that HF had a serious impact on QOL, but most evaluated their QOL as good nonetheless.

CONCLUSION

Patients' definition of QOL reflected not only the impact of HF on their daily life but also their active pursuit of happiness. Patients' self-evaluation of QOL reflected the negative impact of HF and patients' altered expectations of what constituted good QOL.

A propensity matched study of the association of education and outcomes in chronic heart failure

BACKGROUND

Heart failure (HF) patients' knowledge about their disease may improve short-term outcomes and may be related to their level of education. However, the effects of patients and spousal education on long-term outcomes in ambulatory chronic HF are unknown.

METHODS

Of the 571 patients enrolled in the quality of life sub-study of the Digitalis Investigation Group trial, 159 patients or their spouses reported having higher (>12 years) education. Propensity score for higher education, calculated for each patient using a logistic regression model, was used to match 112 (70% of 159) higher education patients with 215 patients with high school (<or=12 years) education. Matched Cox regression analyses were used to estimate associations of high school education with mortality and hospitalizations.

RESULTS

All-cause hospitalizations occurred in 56% (rate, 3233/10,000 person-years) of higher education and 65% (rate, 4558/10,000 person-years) of high school education patients (hazard ratio {HR} for high school, compared with higher education=1.52; 95% confidence interval {CI}=1.06-2.16; p=0.022). Hospitalizations due to cardiovascular causes occurred in 42% (rate, 2067/10,000 person-years) of higher education and 50% (rate, 4558/10,000 person-years) of high school education patients (HR=1.55; 95% CI, 1.05-2.30; p=0.029). All-cause mortality occurred in 20% (rate, 746/10,000 person-years) of higher education and 30% (rate, 1204/10,000 person-years) of high school education patients (HR=1.52; 95% CI=0.89-2.58; p=0.124).

CONCLUSIONS

Compared with >12 years of education, lower education was associated with increased hospitalizations among ambulatory chronic HF patients. Patient and spousal education levels may be used to risk stratify HF patients at high risk for hospitalizations.

Self-care practices in women with diastolic heart failure

BACKGROUND

For many patients with heart failure (HF), performing self-care is complicated by the complex medication regimen, symptom monitoring, and required decision-making. Women with HF are typically older and more physically debilitated, have more comorbidities, and may be at higher risk for poor self-care practices. Previous studies have largely excluded patients with diastolic heart failure (DHF), however, so little is known about their self-care practices.

OBJECTIVES

The purposes of the study were to describe the (a) performance of self-care behaviors and (b) demographic and clinical characteristics that affected self-care practices in women with DHF.

METHODS

Thirty-two women who were 50 years of age or older and diagnosed with DHF were recruited through cardiologist referral from an outpatient HF clinic in an academic health care setting. Data were collected using a semistructured interview guide. Descriptive statistics were used to analyze participant demographic and clinical characteristics. The responses were tabulated in order of frequency and then coded into categories.

RESULTS

The mean age of the women was 68 +/- 11 years; 81% had annual incomes at or below the poverty level, 41% lived alone, and the majority had three or more comorbidities. Although most perceived their HF knowledge to be fair to good, and 62% had received HF educational information, only six (19%) weighed daily, few followed the recommended sodium restrictions, and 91% were sedentary at the time of the interview. The only self-care behavior that was consistently practiced (72%) was taking prescribed medications. Exertional intolerance often interfered with household chores and was cited most often as the reason for poorer quality of life. Decision-making about self-care activities such as taking diuretics was typically based on daily plans and social outings. Medical attention was sought only when acute or life-threatening symptoms occurred. Few women actively participated in ongoing symptom monitoring, and confusion over symptom recognition was a recurrent problem.

CONCLUSIONS

Lower socioeconomic status and advancing age increase vulnerability for poor self-care and negative clinical outcomes in women with DHF. Recommendations to improve self-care practices among economically disadvantaged women with HF such as prescribing routine activities as exercise, screening for depression, and home visits to increase socialization are discussed along with areas for future research.

Characterization of health-related quality of life in heart failure patients with preserved versus low ejection fraction in CHARM

BACKGROUND

Limited comparative studies assessing the health-related quality of life (HRQL) in heart failure (HF) patients with preserved vs. low ejection fraction (LVEF) have been disparate.

AIMS

The aims of this study were a) to characterize HRQL in a large population of HF patients with preserved and low LVEF and b) to determine the factors associated with worse HRQL.

METHODS

Patients with symptomatic HF (NYHA Class II-IV) enrolled in the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) HRQL study completed the Minnesota Living with Heart Failure questionnaire at randomization. Patients were stratified into 2 HF cohorts: preserved LVEF (>40%) and low LVEF (<or=40%).

RESULTS

In 2709 of the eligible 2744 (98.6%) patients, the summary scores ranged from 0 to 105 (mean 40.9). There were no differences in overall responses of HF patients with preserved vs. low LVEF (41.1 vs. 40.8). Independent factors associated with worse HRQL in both populations included female gender, younger age, higher body mass index, lower systolic blood pressure, greater symptom burden, and worse functional status.

CONCLUSIONS

In symptomatic HF patients, HRQL is equally impaired in both preserved and low LVEF populations. Targeting improvement in symptoms and HRQL is an important treatment objective in all HF patients.

Predictors of the quality of life of older people with heart failure recruited from primary care

BACKGROUND

Current understanding of quality of life in heart failure is largely derived from clinical trials. Older people, women and those with co-morbidities are underrepresented in these. Little is known about factors predictive of quality of life amongst older people with heart failure recruited from community settings.

OBJECTIVE

To identify factors predictive of quality of life amongst older people recruited from community settings.

DESIGN

prospective questionnaire survey.

SETTING

General practice surgeries located in four areas of the UK: Bradford, Barnsley, East Devon and West Hampshire.

SUBJECTS

A total of 542 people aged >60 years with heart failure.

METHODS

Participants completed a postal questionnaire, which included a disease-specific measure (Kansas City Cardiomyopathy Questionnaire), a generic quality-of-life measure (SF-36) and sociodemographic information.

RESULTS

A multiple linear regression analysis identified the following factors as predictive of decreased quality of life: being female, being in New York Heart Association (NYHA) functional class III or IV, showing evidence of depression, being in socioeconomic groups III-V and experiencing two or more co-morbidities. Older age was associated with decreased quality of life, as measured by a generic health-related quality-of-life tool (the SF-36 mental and physical health functioning scales) but not by a disease-specific tool (the Kansas City Cardiomyopathy Questionnaire).

CONCLUSION

Findings from the study suggest that quality of life for older people with heart failure can be described as challenging and difficult, particularly for women, those in a high NYHA class, patients showing evidence of depression, patients in socioeconomic groups III-V, those experiencing two or more co-morbidities and the 'oldest old'. Such information can help clinicians working with older people identify those at risk of reduced quality of life and target interventions appropriately.

Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure

BACKGROUND

Heart failure is an escalating health problem around the world. Despite significant scientific advances, heart failure patients experience multiple physical and psychological symptoms that can impact the quality of life.

AIMS

To determine the (1) symptom prevalence, severity, distress and symptom burden in patients with heart failure; (2) impact of age and gender on symptom prevalence, severity, distress and symptom burden; and (3) impact of symptom prevalence and symptom burden on health-related quality of life (HRQOL) in patients with heart failure.

METHODS

A convenience sample of 53 heart failure patients participated in this descriptive, cross-sectional design. Symptoms and HRQOL were measured using the Memorial Symptom Assessment Scale-Heart Failure and the Minnesota Living with Heart Failure Questionnaire.

RESULTS

Patients experienced a mean of 15.1+/-8.0 symptoms. Shortness of breath and lack of energy were the most prevalent. Difficulty sleeping was the most burdensome symptom. Lower age, worse functional status, total symptom prevalence and total symptom burden predicted 67% of the variance in HRQOL.

CONCLUSION

Patients with heart failure experience a high level of symptoms and symptom burden. Nurses should target interventions to decrease frequency, severity, distress and overall symptom burden and improve HRQOL.

The effect of physical training in chronic heart failure

BACKGROUND

Supervised cardiac rehabilitation programs have been offered to patients following myocardial infarct (MI), coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) for many years. However, limited information is available on the usefulness of rehabilitation programs in chronic heart failure (CHF). The aim of our study was to evaluate the outcome of supervised physical training on CHF patients by measuring both central and peripheral factors.

METHODS

This was a prospective randomized study, including 43 patients with CHF, New York Heart Association (NYHA) class II or III, mean age 68 years. After initial measurements of VO2 peak, 6 min walk distance, muscle strength, plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), echocardiogram, measurements of pulmonary function and quality of life questionnaire, patients were randomized to either a training group (n = 21) or a control group (n = 22). The training group had supervised aerobic and resistance training program twice a week for five months. After the training program was completed, all measurements were repeated in both groups.

RESULTS

No training related adverse events were reported. Significant improvement was found between groups in the six minute walk test (+37.1 m vs. +5.3 m, p = 0.01), work load on the bicycle exercise test (+6.1 W vs. +2.1 W, p = 0.03), time on the bicycle exercise test (+41 s vs. +0 s, p = 0.02) and quadriceps muscle strength test (+2.8 kg. vs. +0.2 kg., p = 0.003). Quality of life factors that reflect exercise tolerance and general health, improved significantly in the training group compared to the control group. No other significant changes were found between the two groups.

CONCLUSION

Supervised physical training as used in this study appears safe for CHF patients in NYHA class II or III. The improvement in functional capacity observed in the training group seems to be related to peripheral factors rather than in central cardiovascular performance.

Patients with heart failure who die in hospice

BACKGROUND

Patients with end-stage heart failure experience disability, dyspnea, pain, and suffering at the end of life despite progress in treatment approaches. Little is known about the patients with heart failure in hospice and the impact of hospice care on health-related outcomes.

METHODS AND RESULTS

The purposes of this retrospective, descriptive chart review were to (1) describe the characteristics of patients who receive hospice care, (2) identify symptoms most commonly reported by patients with heart failure in hospice during the last 7 days of life, and (3) identify interventions used by hospice nurses to manage the symptoms. The majority of the patients were women, widowed, and white. Median length of stay was 10 days. Nearly 37% of the patients were admitted to hospice during the last week of life. Primary symptoms at admission for hospice care included dyspnea, confusion at least some of the time, and poor appetite. There was no statistically significant difference in symptoms between the day of admission for hospice care and the day of death. Symptom management strategies included oxygen, family reassurance or education, skin care, and patient education. Medications commonly used to relieve symptoms included antianxiety medications, morphine, and/or other narcotics. Although mainstay heart failure drugs had been prescribed for some patients, prescription rates were low and not in line with current guideline recommendations, nor were those medications recorded as being used for symptom management.

CONCLUSION

Further research including prospective study is needed to clearly articulate the impact of hospice care on patients and families affected by heart failure.

Sleep Difficulties, Daytime Sleepiness, and Health-related Quality of Life in Patients With Chronic Heart Failure

BACKGROUND

Normal sleep changes with age in duration, fragmentation, and depth. The prevalence of insomnia is high in the elderly general population. In patients with chronic heart failure (HF) objective sleep assessments have shown disturbances such as a shorter total duration of sleep, frequent arousals, and sleep stage changes.

OBJECTIVE

To describe self-assessed sleep difficulties, daytime sleepiness, and their relation to health-related quality of life (HRQOL) in men and women with HF, as well as to make a comparison to data from a norm population.

METHODS

Cross-sectional design including 223 patients with HF, New York Heart Association classification II-IV, assessed using the Uppsala Sleep Inventory-Chronic Heart Failure, the Epworth Sleepiness Scale, Medical Outcomes Study 36-Item Short Form Health Survey, and Minnesota Living With Heart Failure Questionnaire.

RESULTS

The most commonly reported sleep difficulties were initiating and maintaining sleep. The ratio of habitual sleep to the amount of estimated need for sleep was significantly shorter for women (P < .05), and the number of awakenings per night was significantly increased for men (P < .001). A total of 21% suffered from daytime sleepiness. Patients suffering from difficulties maintaining sleep, initiating sleep, and early morning awakenings reported significantly lower HRQOL in almost all dimensions of the SF-36 (P < .05-P < .001) compared to patients without sleeping difficulties, as well as to the normal population. The disease-specific Minnesota Living With Heart Failure Questionnaire showed significantly reduced (P < .05-P < .001) HRQOL as measured by the total and subscale scores for patients suffering from sleeping difficulties compared to patients without sleeping difficulties.

CONCLUSION

Patients with HF have a reduced HRQOL especially if difficulties maintaining sleep, initiating sleep, and early morning awakenings are involved.

Hospice as an alternative model of care for older patients with end-stage heart failure

The end of life for patients with end-stage heart failure is often characterized by pain, shortness of breath, and diminished quality of life, indicating a lack of adequate care necessary for patients to experience a good death. The vast majority of those who die from heart failure are 65 or older and potentially eligible for the Medicare Hospice Benefit. Yet, only about 10% of patients with end-stage heart failure actually enroll in hospice programs. Lack of enrollment into hospice has been attributed to a variety of factors including a lack of understanding of the availability of hospice as an option for those with heart failure. While improving models of care for patients with heart failure has been of great interest during the last two decades, little is known about the benefits of hospice as a model for care in patients with end-stage heart failure. Nursing must participate in research that explores options of either improving current models of care or developing new and improved models of care for patients with heart failure.

Relationship of Age and Sex to Health-Related Quality of Life in Patients With Heart Failure

• Background Although health-related quality of life is diminished among patients with chronic heart failure, few investigators have examined interactions of age and sex with health-related quality of life longitudinally.

• Objectives To examine differences in health-related quality of life among 4 groups of patients with heart failure on the basis of age (&lt;65 years and &gt;65 years) and sex and to evaluate relationships of age and sex to changes in health-related quality of life during 6 months.

• Methods Patients from 2 outpatient clinics in an urban county hospital were interviewed at baseline and 26 weeks later. Health-related quality of life was measured by using the Minnesota Living With Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire.

• Results A total of 165 patients (52% women; mean age, 57.6 years) completed interviews at baseline and 26 weeks later. At baseline, patients younger than 65 years had poorer health-related quality of life scores on total scales and some subscales than did older patients. Women had poorer scores than did men on some scales, particularly the emotional subscales. At 26 weeks, patients younger than 65 had poorer total health-related quality of life on 1 scale than did patients 65 and older, and women had poorer scores than did men on 1 total scale. With demographic and clinical factors controlled for, women younger than 65 had improvements in health-related quality of life on some scales.

• Conclusions Women younger than 65 years had relatively poorer initial health-related quality of life that improved after 26 weeks.

Transitions in Health Status in Older Patients with Heart Failure

BACKGROUND

We aimed to determine transitions in health perception and functional status in older Medicare patients with heart failure.

METHODS

We used 1991 to 1994 data from the Medicare Current Beneficiary Survey, a database that combines Medicare claims with yearly longitudinal surveys. We identified 872 patients 65 years or older in 1991 with a diagnostic code of heart failure.

RESULTS

At baseline, 58% of the patients rated their general health perception as "fair" or "poor." Over 1 year, 18% of the patients died. Transition matrices revealed that health perception, activities of daily living, and instrumental activities of daily living were strong correlates of mortality; that dramatic changes in health status were relatively uncommon over 1 year among survivors; and that decline was common in patients with "excellent" or "very good" health perception. The prior year's health status and comorbidity were powerful predictors of the subsequent year's health status.

CONCLUSION

Many older patients with heart failure have worsening health status over time. Measures of prior health status can help predict chances of functional recovery.

Living with heart failure: depression and quality of life in patients and spouses

BACKGROUND

Although spouses are a key support for patients with heart failure, and help them remain in the community, no one has studied patient-spouse pairs to determine the nature of their experience. Therefore, we conducted a study of patients and spouses to compare their levels of depression and health-related quality of life (HRQOL), and to identify factors that contribute to depression and HRQOL in patient-spouse pairs.

METHODS

Forty-eight couples, in which all patients were men with heart failure, were recruited from a university-affiliated, outpatient heart failure clinic. Data were collected using the Beck Depression Inventory, the 12-item Short Form (that measures physical and mental components of QOL), and the 6-minute walk test.

RESULTS

Patients with heart failure were significantly more depressed and had poorer physical quality of life compared with spouses. Patients' depression was correlated with their own functional status and mental quality of life, with the combination of 6-minute walk distance and mental QOL contributing 51% of the variance in patient depression. Spouse depression and HRQOL did not significantly influence patient depression. In contrast, spouses' depression was related to their husbands' functional status and employment, as well as their own mental QOL. The mental component of spouse QOL and the age of the patient accounted for 33% of the adjusted variance in spousal depression.

CONCLUSIONS

Patients with heart failure and their spouses experience significantly different levels of depression and physical QOL. In developing interventions, it may be important to take these differences into account and focus on their unique needs as well as those issues that affect the couple together. Interventions that improve patient functional status may result in decreased depression and improved HRQOL on the part of both patients and spouses.

Heart failure and its impact on older women's lives

AIM OF THE STUDY

This phenomenological study sought to examine and describe the experience of living with heart failure (HF) from the perspective of five women who live with Stage II HF.

BACKGROUND

Research has shown that women are affected by HF differently than men, having different risk factors, a higher increase in mortality per decade, and longer survival after diagnosis. Women have also been greatly under-represented in studies of HF. A search of the literature revealed only one Swedish study examining the overall impact of HF on women's conceptions of their own lives.

RESEARCH METHODS

Four 1-hour semi-structured interviews were held with each participant. Colaizzi's steps were used to analyse the verbatim transcripts of the interviews, drawing meanings from the participants' words.

FINDINGS

Four main themes emerged from the data: 'Acknowledging Losses in Their Lives', 'Accepting the Losses', 'Changing Their Lives' and 'Deepening Relationships'. Additionally, each theme contained several subthemes.

CONCLUSION

Findings from this study indicate that no aspect of women's lives escapes the impact of HF. It causes immense losses in many areas of life, and requires tremendous changes in many aspects of daily living. Yet, drawing on inner resources of great strength and courage, these women learn to find contentment in their lives. They discover ways to create productive lives and deeply meaningful relationships, within the boundaries imposed by HF.

Heart failure in older adults: keys to successful management

Recent American Heart Association statistics indicate that approximately 5 million people experience heart failure, and that an estimated 400,000 to 700,000 new cases are expected annually. Improved efforts in the emergency care of myocardial infarction and the increased life expectancy of the population in general are credited for the rapidly increasing number of elderly adults with such chronic cardiac diseases as heart failure. New drug therapies are tested daily to improve the treatment of heart failure. However, drugs alone cannot improve the lives of elderly men and women with this disorder. Skillful delivery of expert care is necessary if advanced practice nurses are to reduce the burden of heart failure and improve the lives of the individuals who must live with this devastating disease.

Self-report quality of life as a predictor of hospitalization for patients with LV dysfunction: a life course approach

For this secondary data analysis of a large clinical drug study, researchers investigated the independent prognostic utility of self-report quality-of-life measures versus clinical measures for assessing patient risk for heart-failure-related hospitalization. The experience of heart failure varies over the life course; hence, four age groups were investigated. Quality-of-life measures, specifically health-related quality-of-life and psychosocial quality-of-life measures, were found to be independent and significant predictors of heart-failure-related hospitalizations, as compared to traditional clinical indicators. In addition, the psychosocial quality-of-life measure varied by age group in its importance as a predictor of hospitalization, suggesting differential relevance over the life course. Specifically, psychosocial quality of life was most strongly predictive of hospitalization for those ages 21-44, was less predictive for those ages 45-54, and was nonsignificant for those 55-64 years of age and those 65 and over. Including self-report quality-of-life measures provides a more complete picture of the factors associated with risk of hospitalization at different points in the life course for individuals with heart failure. These findings suggest that researchers and practitioners could use self-report quality-of-life measures as additional prognostic indicators of a patient's condition and risk for heart-failure-related hospitalization, especially for younger patients.

Quality of life in patients with heart failure: do gender differences exist?

OBJECTIVE

The purpose of this study was to evaluate gender differences in quality of life (QOL) in a large sample of age-matched and ejection fraction (EF)-matched patients with heart failure.

DESIGN

Matched comparisons of secondary data were used.

SETTING

The setting consisted of multicenter Studies of Left Ventricular Dysfunction trials.

SAMPLE

The sample included 1382 patients (691 men and 691 women) who were age-matched and EF-matched.

OUTCOME MEASURES

Global QOL and the QOL dimensions of physical function, emotional distress, social health, and general health were measured using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the beta-Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

RESULTS

Women had significantly worse general life satisfaction, physical function, and social and general health scores than men. There were no significant differences found between gender groups for current life situation or emotional distress. After controlling for New York Heart Association classification, women still had significantly worse ratings for intermediate activities of daily living (a sub-dimension of physical functioning) and social activity.

CONCLUSIONS

Despite controlling for age, EF, and New York Heart Association classification, women had worse QOL ratings than did men for intermediate activities of daily living and social activity. Research should focus on identifying why differences exist and developing measures to improve QOL, particularly physical functioning, in women with heart failure.