Self-rating of quality of life provides additional prognostic information in heart failure. Insights into the EPICAL study

Health-related quality of life and self-care in heart failure patients under telecare-insights from the randomized, prospective, controlled AMULET trial

Introduction

The growing population of heart failure (HF) patients places a burden on the healthcare system. Patient-centered outcomes such as health-related quality of life (HRQoL) and self-care behaviors are key elements of modern HF management programs. Thus, optimized strategies to improve these outcomes are sought.

Purpose

To assess the effects of a new model of medical telecare on HRQoL and self-care in patients with HF (the AMULET study).

Methods

The study was prospective, randomized, open-label, and controlled with two parallel groups: telecare and standard care. In the telecare group, HF nurses performed patient clinical assessments with telemedical support by a cardiologist and provided education focused on the prevention of HF exacerbation. In the standard care group, patients were followed according to standard practices in the existing healthcare system. At the baseline and at 12 months, HRQoL was assessed using the Short Form 36 (SF-36) questionnaire and the Minnesota Living with Heart Failure Questionnaire (MLwHF). The level of self-care was assessed with the 12-item standardized European Heart Failure Self-care Behavior Scale (EHFScBS-12).

Results

In the overall study group, 79% of the subjects were male, the mean age was 67 ± 14 years, and 59% of the subjects were older than 65 years of age. The majority of the subjects (70%) had a left ventricular ejection fraction below 40%. After 12 months, statistically significant increases in physical component of the SF-36 (43.3 vs. 47.4 for telecare vs. 43.4 vs. 46.6 for standard care) and mental component of SF-36 (58.4 vs. 62 for telecare vs. 60.4 vs. 64.2 for standard care) were noted, with no intergroup differences. However, patients receiving telecare showed improvement in specific domains, such as physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health. There was a significant decrease in MLwHF (29 vs. 35.0; lower is better) at follow-up for both groups. Telecare patients had a statistically significant decrease in EHFScBS-12 (lower is better) at 12 months.

Conclusion

AMULET outpatient telecare, which is based on nurse-led non-invasive assessments supported by specialist teleconsultations, improved the HRQoL and self-care of HF patients after an episode of acute HF.

Health-related quality of life and associated factors in heart failure with reduced ejection fraction patients at University of Gondar Hospital, Ethiopia

Introduction

Living with heart failure poses challenges due to its poor prognosis and impact on quality of life, making it crucial to assess how it affects patients for better patient-centered management. This study aimed to assess quality of life and associated factors in heart failure with reduced ejection fraction patients at University of Gondar Comprehensive Specialized Hospital in Ethiopia, 2023.

Methods

An "institution-based" cross-sectional study was conducted at the University of Gondar Comprehensive Specialised Hospital. The data were collected using an interviewer-administered questionnaire. Health-related quality of life was measured using the Minnesota Living with Heart Failure Questionnaire. Sociodemographic, behavioral, clinical, biochemical, and echocardiographic characteristics were included in the questionnaire. The collected data were entered into EpiData version 4.6 and exported into SPSS version 25 for analysis. Multiple linear regression analysis (p < 0.05) was used to measure the degree of association between quality of life and independent variables.

Results

A total of 240 patients with heart failure and reduced ejection fraction participated in the study. The health-related quality of life scores for the physical, emotional, and total were 17.60 ± 10.33, 10.58 ± 6.33 and 46.12 ± 26.06, respectively. Health-related quality of life was significantly associated with age, marital status, occupation, income, heart failure duration, recent hospitalization, New York Heart Association functional class, heart failure etiology, atrial fibrillation comorbidity, systolic blood pressure, heart rate, heart failure medications, severe left ventricular systolic dysfunction, and severe or moderate pulmonary hypertension.

Conclusion

This study found that patients with heart failure and reduced ejection fraction had poor health-related quality of life, influenced by identified factors. These findings aid professionals in assessing and identifying interventions that improve these patients' quality of life.

Metrological performances of the global chronic morbidity indicator of the Minimum European Health Module and implications for chronic disease prevalence and socioeconomic gradient estimations

BACKGROUND

Although the global chronic morbidity indicator (GCMI) of the Minimum European Health Module (MEHM) was not specifically designed to monitor chronic disease in the population, it is increasingly used for this purpose in Europe and elsewhere. However, its metrological characteristics have seldom been examined, with various sensitivity issues being raised. The present study investigated the metrological performances of the GCMI and analyzed its implications in terms of prevalence and demographic and socioeconomic gradients of chronic conditions in the population.

METHODS

We used data from two large French nationwide representative surveys with cross-sectional and longitudinal data conducted between 2010 and 2021. The surveys used MEHM and collected data on numerous chronic conditions and socioeconomic indicators. Criterion and predictive validity of the GCMI regarding chronic conditions and the resultant socioeconomic gradients were compared with indicators based on reports of individual chronic conditions.

RESULTS

GCMI sensitivity to capture chronic conditions varied from <20 to 80% depending on the chronic condition. Number of chronic conditions, gender, age and education were also associated with GCMI endorsement. However, the GCMI was predictive of mortality and activity limitations independently of individual conditions.

CONCLUSION

The varying lack of sensitivity depending on the chronic condition and the respondent's sociodemographic status may bias estimates of demographic and socioeconomic gradients compared with indicators based on reports of individual chronic conditions. Differences between GCMI and list-based approaches should be more cautiously considered when monitoring chronic conditions in the population. These approaches should be viewed as complementary rather than contradictory or interchangeable.

A follow-up program in patients after hospitalization for heart failure: long-term health related quality of life and associated factors

Background

The well-being of individuals with chronic heart failure (HF) is significantly influenced by their health-related quality of life (HRQoL), which serves as a crucial measure indicating how HF affects their daily activities. Monitoring programs aimed at reducing the number of hospitalizations and improving functional conditions are currently being offered to patients with chronic HF.

The objective

To examine the long-term health-related quality of life changes in patients with heart failure enrolled in a follow-up program after hospitalization and to evaluate the factors associated with quality of life of patients with heart failure.

Methods

This prospective study was conducted between 2019 and 2020 at the Department of Cardiology of Lithuanian University of Health Sciences. Patients were divided into two groups: Group I consisted of 71 patients (60.2%) where the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score decreased by more than 10 points at 4th visit if compared to the 1st one; and Group II consisted of 47 patients (39.8%) where the MLHFQ score remained unchanged or increased by less than 10 points at the 4th visit if compared to the 1st visit.

Results

Statistically significant differences were observed between groups. In Group II, a history of myocardial infarction was more frequent (p = 0.038), and there was a significantly higher occurrence of significant coronary artery disease (p = 0.006). Laboratory parameters indicating liver function exhibited statistically significant deterioration among patients in Group II. Specifically, AST (p = 0.050), ALT (p = 0.010), and GGT (p = 0.031) levels significantly increased. Upon analyzing the echocardiographic data, a statistically significant difference was found between the groups in relation to the left ventricular ejection fraction (LVEF) (p = 0.043) and TAPSE (p = 0.031). An analysis of changes in dimensions related to QoL was conducted during the long-term follow-up program, which revealed statistically significant differences between groups in overall changes based on the MLHFQ (p < 0.001). This difference was also observed across all dimensions, including the emotional, physical, and social aspects (p < 0.001).

Conclusion

Patients who had a higher LVEF at baseline, as well as those with an etiology of ischemic heart disease (IHD), better liver function, and fewer manifestations of edema, demonstrated a statistically significant improvement in their quality of life throughout the course of the patient monitoring program.

Changing health related quality of life and outcomes in heart failure by age, sex and subtype

Background

There are calls to integrate serial recordings of health related quality of life (HRQoL) into routine care, clinical trials and prognosis. Little is known about the relationship between change in HRQoL and outcomes in heart failure (HF) patients by age, sex and HF subtype.

Method

From the Swedish Heart Failure Registry (SwedeHF; 2008-2019), patients were categorised by reduced (<40%, HFrEF), mildly-reduced (40-49%, HFmrEF) and preserved (≥50%, HFpEF) ejection fraction. HRQoL was measured using Euro-QoL-5D visual analogue scale (EQ5D-vas), collected at baseline and 1-year. Baseline EQ5D-vas scores were categorised by: "best" (76-100), "good" (51-75), "bad" (26-50), and "worst" (0-25). Change in EQ5D-vas was categorised as 'no significant change' (<5 points increase/decrease); some worsening (5-9 points decrease); considerable worsening (≥10 points decrease); some improvement (5-9 points increase); considerable improvement (≥10 points increase). Associations with admission and death were estimated and interactions with patient sub-groups tested.

Findings

Among 23,553 patients (median age 74 [66-81] years, 8000 [34%] female), baseline EQ5D-vas was worse in older patients, women, and those with HFpEF compared to their respective counterparts. Compared to patients with the "best" EQ5D-vas, the adjusted associations for admission for those with "good", "bad" and "worst" EQ5D-vas were, respectively: HR 1.09 (1.04, 1.14), 1.27 (1.21, 1.33) and 1.39 (1.28, 1.51). Compared to no significant change in EQ5D-vas, the adjusted estimates for admission following some improvement, considerable improvement, some worsening and considerable worsening were, respectively: HR 0.91 (0.82, 1.01), 0.75 (0.70, 0.81), 1.04 (0.92, 1.16) and 1.25 (1.16, 1.35). Results were similar amongst groups and for HF admission and death.

Interpretation

Change in HRQoL was an independent indicator of risk of admission and death in people with all HF subtypes, irrespective of age and sex.

Funding

NIHR.

Efficacy and Safety of Sacubitril/Valsartan Compared With ACEI/ARB on Health-Related Quality of Life in Heart Failure Patients: A Meta-Analysis

BACKGROUND

Data on the effects of sacubitril/valsartan compared with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) on health-related quality of life (HRQoL) are limited.

OBJECTIVE

To evaluate the comparative effects between sacubitril/valsartan and ACEI/ARB on HRQoL, a systematic review and meta-analysis were performed.

METHODS

PubMed, EMBASE, Web of Science, and ClinicalTrials.gov were searched from inception to March 2, 2022 for randomized controlled trials that compared the HRQoL scores, including Kansas City Cardiomyopathy Questionnaire (KCCQ), Minnesota Living with Heart Failure Questionnaire (MLHFQ), or Medical Outcomes Study Short-Form Health Survey 12 or 36 (SF-12/36), between sacubitril/valsartan and ACEI/ARB. After screening, studies that met the inclusion criteria were eventually included and analyzed.

RESULTS

A total of 8 studies with 17 390 patients (8693 patients used sacubitril/valsartan, and 8697 patients used ACEI/ARB) were included in this study. Five of these studies used KCCQ, 1 used SF-12/36, 1 used MLHFQ, and 1 used both KCCQ and SF-12/36. The KCCQ overall summary score and its subscales were significantly higher in sacubitril/valsartan compared with ACEI/ARB in heart failure patients with reduced ejection fraction, but were similar in heart failure patients with preserved ejection fraction. Sacubitril/valsartan conferred similar HRQoL scores in MLHFQ and SF-12/36 to ACEI/ARB. The most frequently reported adverse event for sacubitril/valsartan is hypotension and the risk is higher than for ACEI/ARB.

CONCLUSIONS

Sacubitril/valsartan may have the potential to improve HRQoL in heart failure patients with reduced ejection fraction compared with ACEI/ARB. Hypotension is the most common adverse event with sacubitril/valsartan compared with ACEI/ARB. The results of this study may contribute to the rational use of sacubitril/valsartan.

Patient-Reported Status and Heart Failure Outcomes in Asia by Sex, Ethnicity, and Socioeconomic Status

Background

In heart failure (HF), symptoms and health-related quality of life (HRQoL) are known to vary among different HF subgroups, but evidence on the association between changing HRQoL and outcomes has not been evaluated.

Objectives

The authors sought to investigate the relationship between changing symptoms, signs, and HRQoL and outcomes by sex, ethnicity, and socioeconomic status (SES).

Methods

Using the ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) Registry, we investigated associations between the 6-month change in a "global" symptoms and signs score (GSSS), Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS), and visual analogue scale (VAS) and 1-year mortality or HF hospitalization.

Results

In 6,549 patients (mean age: 62 ± 13 years], 29% female, 27% HF with preserved ejection fraction), women and those in low SES groups had higher symptom burden but lower signs and similar KCCQ-OS to their respective counterparts. Malay patients had the highest GSSS (3.9) and lowest KCCQ-OS (58.5), and Thai/Filipino/others (2.6) and Chinese patients (2.7) had the lowest GSSS scores and the highest KCCQ-OS (73.1 and 74.6, respectively). Compared to no change, worsening of GSSS (>1-point increase), KCCQ-OS (≥10-point decrease) and VAS (>1-point decrease) were associated with higher risk of HF admission/death (adjusted HR: 2.95 [95% CI: 2.14-4.06], 1.93 [95% CI: 1.26-2.94], and 2.30 [95% CI: 1.51-3.52], respectively). Conversely, the same degrees of improvement in GSSS, KCCQ-OS, and VAS were associated with reduced rates (HR: 0.35 [95% CI: 0.25-0.49], 0.25 [95% CI: 0.16-0.40], and 0.64 [95% CI: 0.40-1.00], respectively). Results were consistent across all sex, ethnicity, and SES groups (interaction P > 0.05).

Conclusions

Serial measures of patient-reported symptoms and HRQoL are significant and consistent predictors of outcomes among different groups with HF and provide the potential for a patient-centered and pragmatic approach to risk stratification.

Association Between Disease-specific Health-related Quality of Life and All-cause Mortality in Patients with Heart Failure: A Meta-analysis

The association between disease-specific health quality of life (QoL) and adverse outcomes remains controversial in patients with heart failure (HF). This meta-analysis aimed to evaluate the association of QoL measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) or Kansas City Cardiomyopathy Questionnaire (KCCQ) with all-cause mortality in patients with HF. PubMed and Embase databases were comprehensively searched until December 30, 2022 to identify studies investigating the utility of QoL measured by the MLHFQ or KCCQ in predicting all-cause mortality patients with HF. Twenty-five studies reported on 24 articles enrolling 42,414 HF patients were identified. A comparison of the top with the bottom MLHFQ score, the pooled adjusted hazard ratios (HR) of all-cause mortality was 1.56 (95% confidence intervals [CI] 1.26-1.94). When analyzed the MLHFQ as continuous variable, each 10-point MLHFQ score increase conferred a 12% (95% CI 6%-18%) higher risk of all-cause mortality, which was consistently significant for physical component (HR 1.19; 95% CI 1.09-1.30) and mental component (HR 1.21; 95% CI 1.05-1.40). A comparison of the bottom with the top KCCQ score, the pooled adjusted HR was 2.34 (95% CI 2.10-2.60) for all-cause mortality. Furthermore, each 10-point KCCQ score decrease was associated with a 12% (95% CI 7%-16%) higher risk of all-cause mortality. Worse health-related QoL defined by the higher MLHFQ or lower KCCQ score was associated with an increased risk of all-cause mortality in patients with HF. Assessment of disease-specific health QoL at baseline may provide important prognostic information in these patients.

Catheter ablation vs. drug therapy in the treatment of atrial fibrillation patients with heart failure: An update meta-analysis for randomized controlled trials

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist. The treatment of AF in patients with HF has been challenging because of the ongoing debate about the merits of catheter ablation vs. drug therapy.

Methods

The Cochrane Library, PubMed, and www.clinicaltrials.gov were searched until June 14, 2022. Inclusion criteria were catheter ablation compared with drug therapy in adults with AF and HF in randomized controlled trials (RCTs). Primary outcomes consisted of all-cause mortality, re-hospitalization, change in left ventricular ejection fraction (LVEF), and AF recurrence. Secondary outcomes referred to quality of life [QoL; measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ)], six-minute walk distance (6MWD), and adverse events. The PROSPERO registration ID was CRD42022344208.

Findings

In total, nine RCTs with 2,100 patients met the inclusion criteria, with 1,062 for catheter ablation and 1,038 for medication. According to the meta-analysis, catheter ablation significantly reduced all-cause mortality compared with drug therapy [9.2% vs. 14.1%, OR: 0.62, (95% CI: 0.47-0.82), P = 0.0007, I 2   = 0%], improved LVEF [MD: 5.65%, (95% CI: 3.32-7.98), P < 0.00001, I 2   = 86%], reduced AF recurrence [41.6% vs. 61.9%, OR: 0.23, (95% CI: 0.11-0.48), P < 0.0001, I 2   = 82%], decreased the MLHFQ score [MD: -6.38, (95% CI: -11.09 to -1.67), P = 0.008, I2  = 64%] and increased 6MWD [MD: 17.55, (95% CI: 15.77-19.33), P < 0.0001, I 2   = 37%]. Catheter ablation did not increase the re-hospitalization [30.4% vs. 35.5%, OR: 0.68, (95% CI: 0.42-1.10), P = 0.12, I 2   = 73%] and adverse events [31.5% vs. 30.9%, OR: 1.06, (95% CI: 0.83-1.35), P = 0.66, I 2   = 48%].

Interpretation

In AF patients with HF, catheter ablation improves exercise tolerance, QoL, and LVEF and significantly reduced all-cause mortality and AF recurrence. Although the differences were not statistically significant, the study found lower re-hospitalization and approximate adverse events with improved catheter ablation tendency.

PROSPERO registration ID

CRD42022344208.

Exploring Health Literacy Categories in Patients With Heart Failure: A Latent Class Analysis

BACKGROUND

Although a growing number of studies have demonstrated that patients' health literacy is associated with health outcomes, the exact relationship between them is not clear.

AIMS AND OBJECTIVES

The aim of this study was to explore latent classes of health literacy in patients with heart failure and analyze the differences among different groups.

DESIGN AND METHODS

This is a cross-sectional survey. Patients diagnosed with heart failure were selected from 3 tertiary hospitals in Tianjin, China, from March 2019 to November 2019. We measured patients' health literacy using the Health Literacy Scale for Chronic Patients. Latent class analysis was carried out based on the patients' Health Literacy Scale for Chronic Patients scores. Multinomial logistic regression was used to identify the predictive indicators of the latent classes.

RESULTS

The health literacy of patients with heart failure was divided into 3 different latent classes, named "high health literacy group," "low literacy high dependence group," and "moderate literacy high willingness group." There were statistically significant differences in gender, age, smoking history, marital status, education level, household income level, and quality of life among different health literacy classes. Low education level and household income level predicted poor health literacy.

CONCLUSION

There were 3 latent classes for the health literacy of patients with heart failure. Different health literacy classes exhibited their own distinctive characteristics. Patients in the "moderate literacy high willingness group" had the worst quality of life. Understanding the specific types of health literacy in patients with heart failure facilitates targeted nursing interventions to improve their quality of life.

Assessment of health-related quality of life in patients with heart failure: a cross-sectional study in Saudi Arabia

Background

As a precarious clinical condition and a public health problem, heart failure (HF) is associated with a significant burden of morbidity, mortality, and health care costs. As almost all of the published research has been conducted in Western countries, there is a need for culturally relevant studies in Saudi Arabia. This is the first study to investigate health-related quality of life (HRQoL) and its associated factors among Saudi patients with HF in the Qassim region.

Methods

A cross-sectional study was conducted at the only tertiary care hospital in the Qassim region of Saudi Arabia during the period from November 2020 to July 2021. The participants were interviewed face-to-face by trained interviewers using the standard validated 36-item Short-Form Health Survey (SF-36) questionnaire for HRQoL assessment. The data were analyzed using STATA version 16.

Results

The participants included 246 HF patients whose mean (SD) age was 56.7 (10.9) years. A majority of the respondents (80%, n = 197) were male, and 49% (n = 121) had an education level of less than secondary school. The median scores were high for the domains of social functioning (100 points) and bodily pain (75 points) and low for role-physical functioning (25 points). In general, the median scores for the physical and mental component summaries were 58.1 and 63.7, respectively. Patients with an education level less than secondary school were more likely to have a low physical component summary score (aOR 3.00, 95% CI 1.46–6.17), while female patients were more likely to have a low mental component summary score (aOR 2.67, 95% CI 1.38–5.16).

Conclusions

Health-related quality of life was found to be moderate among these HF patients. Periodic HRQoL assessment is recommended for HF patients to minimize their physical and psychological concerns, particularly for patients with low education levels and female patients.

Quality of life in patients with heart failure and improved ejection fraction: one-year changes and prognosis

AIMS

The criteria for patients with heart failure (HF) and improved ejection fraction (HFimpEF) are a baseline left ventricular ejection fraction (LVEF) ≤40%, a ≥10-point increase from baseline LVEF, and a second LVEF measurement >40%. We aimed to (i) assess patients with HF and reduced LVEF (HFrEF) at baseline and compare quality of life (QoL) changes between those that fulfilled and those that did not fulfil the HFimpEF criteria 1 year later and (ii) assess the prognostic role of QoL in patients with HFimpEF.

METHODS

We reviewed data from a prospective registry of real-world outpatients with HF that were assessed for LVEF and QoL at a first visit to the HF clinic and 1 year later. QoL was evaluated with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). The primary prognostic endpoint was the composite of all-cause death or HF hospitalization.

RESULTS

Baseline and 1-year LVEF and MLWFQ scores were available for 1040 patients with an initial LVEF ≤40% (mean age, 65.2 ± 11.7 years; 75.9% men). The main aetiology was ischaemic heart disease (52.9%), and patients were mostly in New York heart Association Classes II (71.1%) and III (21.6%). At baseline, the mean LVEF was 28.5% ± 7.3, and the mean MLWHFQ score was 30.2 ± 19.5. After 1 year, the mean LVEF increased to 38.0% ± 12.2, and the MLWHFQ scores improved to 17.4 ± 16.0. In 361 patients that fulfilled the HFimpEF criteria (34.7%), significant improvements were observed in both LVEF (from 28.7% ± 6.6 to 50.9% ± 7.6, P < 0.001) and QoL (from 32.9 ± 20.6 to 16.9 ± 16.0, P < 0.001). Patients that did not fulfil the HFimpEF criteria also showed significant improvements in LVEF (from 28.4% ± 7.6 to 31.1% ± 7.9, P < 0.001) and QoL (from 28.7 ± 18.8 to 17.6 ± 15.9, P < 0.001). However, the QoL improvement was significantly higher in the HFimpEF group (-16.0 ± 23.8 vs. -11.1 ± 20.3, P = 0.001), despite the worse mean baseline MLWHFQ score, compared with the non-HFimpEF group (P = 0.001). The 1-year QoL was similar between groups (P = 0.50). The 1-year MLWHFQ score was independently associated with outcomes; the hazard ratio for the composite endpoint was 1.02 (95% CI: 1.01-1.03, P = 0.006). In contrast, the QoL improvement (with a cut-off ≥5 points) was not independently associated with the composite outcome.

CONCLUSIONS

Patients with HFrEF showed improved QoL after 1 year, regardless of whether they met the HFimpEF criteria. The similar 1-year QoL perception between groups suggested that factors other than LVEF influenced QoL perception. The 1-year QoL was superior to the QoL change from baseline for predicting prognosis in patients with HFimpEF.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Stroke risk and its association with quality of life: a cross-sectional study among Chinese urban adults

BACKGROUND

Stroke is a leading cause of mortality and disability worldwide. Most stroke risk studies focused on more established biological and pathophysiological risk factors such as hypertension and smoking, psychosocial factors such as quality of life are often under-investigated and thus less reported. The current study aims to estimate stroke risk and explore the impact of quality of life on stroke risk among a community sample of urban residents in Shanghai.

METHODS

This cross-sectional study was conducted in Fengxian District of Shanghai City from December 2018 to April 2019. 4030 representative participants were recruited through a multistage, stratified, probability proportional to size sampling method and completed the study. Stroke risk was assessed using the Rapid Stroke Risk Screening Chart that included 8 risk factors for stroke. Quality of life was measured using the World Health Organization Quality of Life-brief version (WHOQOL-BREF).

RESULTS

One-third of residents were at risk for stroke, including 14.39% at high risk, and 18.68% at middle risk. The top three most commonly reported risk factors were physical inactivity (37.30%), hypertension (25.38%), and smoking (17.32%). Quality of life and its four domains were all independently and significantly associated with stroke risk. Multinominal logistic regressions showed that a one-unit increase in the quality of life was associated with a decreased relative risk for middle-risk relative to low-risk of stroke by a factor of 0.988 (95% CI:0.979, 0.997, P = 0.007), and a decreased relative risk for high-risk relative to low-risk of stroke by a factor of 0.975 (95% CI:0.966, 0.984, P < 0.001).

CONCLUSIONS

Our findings showed an alarmingly high prevalence of stroke risk among the sample, which may require future intervention programs to focus on improving both biological and behavioral risk factors such as increasing physical activity, early diagnosis and treatment of hypertension, and smoking cessation, as well as improving psychosocial factors such as quality of life.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

BACKGROUND

Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking.

AIM

The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use.

SETTINGS AND PARTICIPANTS

We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died.

RESULTS

Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use.

CONCLUSIONS

Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Health-Related Quality of Life Among Heart Failure Patients Attending an Outpatient Clinic in the University of Gondar Comprehensive Specialized Hospital Northwest, Ethiopia, 2020: Using Structural Equation Modeling Approach

Background

Chronic heart failure is one of the most important public health concerns in the industrialized and developing world having increasing prevalence. Measuring quality of life using rigorous statistical methods may be helpful to provide input for decision-makers and the development of guidelines. This study aimed to assess health-related quality of life and associated factors among heart failure patients attending the University of Gondar Specialized Hospital.

Methods

A cross-sectional study was employed to select 469 heart failure patients who have follow-up at the University of Gondar Specialized Hospital consecutively from March 01 to 30, 2020. Data were entered to Epi Info 7 and exported to STATA version 15 for further statistical analysis. The quality-of-life domains were measured with World Health Organization Quality of Life BREF. Structural equation modeling was employed to estimate the relationships among exogenous, mediating, and endogenous variables simultaneously.

Results

Chronic heart failure patients had a significantly lower mean score in physical health domain (31.70 mean score), environmental health domain (38.35 mean score), and in overall quality of life domain (41.61 mean score) moderate in social relation domain (46.22 mean score), and in psychological health domain (50.21 mean score) of health-related quality of life (p-value <0.0001). Age had a direct positive effect on health-related quality of life. Residency also had a direct negative effect on both physical and environmental health-related quality of life domain. Duration of heart failure had a direct negative effect on psychological health.

Conclusion

The finding of this study indicated that poor health-related quality of life in the physical health domain, moderately poor in overall health-related quality of life, and moderate health-related quality of life in the psychological health domain among Chronic heart failure patients. Age, residence, marital status, income, and duration of HF were significantly associated factors for quality of life among HF patients.

Nutritional interventions for heart failure patients who are malnourished or at risk of malnutrition or cachexia: a systematic review and meta-analysis

Malnutrition is common in heart failure (HF), and it is associated with higher hospital readmission and mortality rates. This review aims to answer the question whether nutritional interventions aiming to increase protein and energy intake are effective at improving outcomes for patients with HF who are malnourished or at risk of malnutrition or cachexia. Systematic searches of four databases (Medline, Embase, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL)) were conducted on 21 June 2019. Randomized controlled trials (RCTs) or other interventional studies using protein or energy supplementation for adult HF patients who are malnourished or at risk of malnutrition or cachexia were included. Two independent reviewers assessed study eligibility and risk of bias. Five studies (four RCTs and one pilot RCT) met the inclusion criteria. The majority of studies were small and of limited quality. The pooled weighted mean difference (WMD) for body weight showed a benefit from the nutritional intervention by 3.83 kg (95% confidence interval (CI) 0.17 to 7.50, P = 0.04) from three trials with no significant benefit for triceps skinfold thickness (WMD = - 2.14 mm, 95% CI - 9.07 to 4.79, P = 0.55) from two trials. The combination of personalized nutrition intervention with conventional treatment led to a decrease in all-cause mortality and hospital readmission in one study. Findings of this review suggest that nutritional interventions could potentially improve outcomes in HF patients who are malnourished or at risk of malnutrition. However, the strength of the evidence is poor, and more robust studies with a larger number of participants are needed.

Health-Related Quality of Life Is a Mediator of the Relationship Between Medication Adherence and Cardiac Event-Free Survival in Patients with Heart Failure

BACKGROUND

Health-related quality of life (HRQOL) is an important patient-reported outcome that is related to medication adherence, hospitalization and death. The nature of the relationships among medication adherence, HRQOL, and hospitalization and death is unknown. We sought to determine the relationships among medication adherence, HRQOL, and cardiac event-free survival in patients with heart failure.

METHODS AND RESULTS

We enrolled 218 patients with heart failure. Patients' medication adherence was measured objectively using the Medication Event Monitoring System. HRQOL was assessed using the Minnesota Living with Heart Failure Questionnaire. Patients were followed for up to 3.5 years to collect hospitalization and mortality data. Mediation analysis was used to determine the nature of the relationships among the variables. Patients with better medication adherence had better HRQOL (P = .014). Medication adherence and HRQOL were associated with cardiac event-free survival (both P < .05). Patients with medication nonadherence were 1.86 times more likely to experience a cardiac event than those with better medication adherence (P = .038). Medication adherence was not associated with cardiac event-free survival after entering HRQOL in the model (P = .118), indicating mediation by HRQOL of the relationship between medication adherence and cardiac event-free survival.

CONCLUSIONS

HRQOL mediated the relationship between medication adherence and cardiac event-free survival. It is important to assess medication adherence and HRQOL regularly and develop interventions to improve medication adherence and HRQOL to decrease hospitalization and mortality in patients with heart failure.

Quality of life of chronic heart failure patients: a systematic review and meta-analysis

Despite various individual studies on the quality of life (QOL) in patients with CHF, a comprehensive study has not yet been conducted; therefore, this study aims to assess the QOL of CHF patients. In the present systematic review and meta-analysis, PubMed, Scopus, and the Web of science databases were searched from January 1, 2000, to December 31, 2018, using QOL and heart failure as keywords. The searches, screenings, quality assessments, and data extractions were conducted separately by two researchers. A total of 70 studies including 25,180 participants entered the final stage. The mean QOL score was 44.1 (95% confidence interval (CI) 40.6, 47.5; I² = 99.3%) using a specific random effects method in 40 studies carried out on 12,520 patients. Moreover, according to the geographical region, heart failure patients in the Americas had higher scores. In 14 studies, in which a general SF-36 survey was implemented, the average physical component score (PCS) and mental component score (MCS) were 33.3 (95% CI 31.9, 34.7; I² = 88.0%) and 50.6 (95% CI 43.8, 57.4; I² = 99.3%), respectively. The general and specific tools used in this study indicated moderate and poor QOL, respectively. Therefore, it is necessary to carry out periodic QOL measurements using appropriate tools as part of the general care of CHF patients.

Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study

BACKGROUND

Patients who receive palliative care are less likely to die in hospital.

OBJECTIVE

To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness.

RESEARCH DESIGN

Population-based decedent cohort study using linked health administrative data in Ontario, Canada.

SUBJECTS

A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016.

EXPOSURE

Physician annual rate of referral to palliative care (high, average, low).

MEASURES

Odds of death in hospital versus home, adjusted for patient characteristics.

RESULTS

There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)].

CONCLUSIONS AND RELEVANCE

An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Health-Related Quality of Life and Associated Factors Among Adult Patients with Heart Failure in Wolaita Zone Governmental Hospitals, Southern Ethiopia

Background

Knowing how heart failure affects patients’ quality of life and its associated factors are crucial for a better patient-centred approach and management. Therefore, this study aims to assess health-related quality of life and its associated factors among adult heart failure patients in southern Ethiopia hospitals.

Methods

The facility-based cross-sectional study design was conducted in Wolaita zone governmental hospitals from March to April 2018. The population was all adult heart failure patients in the chronic illness follow-up clinic and inpatient department. All adult heart failure patients on follow-up clinic and inpatient departments who have at least a 6-month follow-up were included in the study. In contrast, patients who had chronic comorbidities were excluded from the study. Minnesota Living with Heart Failure Questionnaire (MLHFQ) tool was used to measure the outcome variable health-related quality of life (HRQoL). Interviews and client medical record reviews also collected socio-demographic, clinical and behavioural characteristics of participants. The data were analyzed using STATA version 14, and multiple linear regression analysis with P-value < 0.05 was used to measure the degree of association between HRQoL and independent variables.

Results

A total of 372 patients participated in the study. The HRQoL score for the physical, emotional, and total were 22.2, 7.7, and 46.37, respectively. HRQoL was significantly associated with gender, age, family size, occupation, residency, and recent admission within the past six months, New York Heart Association (NYHA) functional class, department of treatment, salt intake, and health perception.

Conclusion

Generally, the HRQoL for patients with heart failure was found to be low. Besides the variables age and gender of participants, family size, occupation, residency, admission history, salt intake, and NYHA class were significant factors for the HRQoL of patients with heart failure.

Burden of Heart Failure on Patient Daily Life and Patient-Physician Discordance in Disease Management - Results From a Cross-Sectional Survey in Japan

Background: We investigated the impact of heart failure (HF) on daily life and satisfaction with current HF medication from the patient perspective in a real-world study in Japan. Methods and Results: A cross-sectional survey of 154 HF patients treated by 58 cardiologists was conducted in Japan using patient self-completed questionnaires about their daily life and satisfaction with HF medication, as well as patient record forms completed by their physicians capturing corresponding data. The mean age of patients was 72.7 years. The proportion of patients within New York Heart Association Class I, II, III, and IV was 39%, 44%, 16%, and 1%, respectively. Symptoms reported by patients included dyspnea when active (46%), nocturia (43%), anxiety (18%), and depression (6%). There was a discordance between physician- and patient-reported symptoms, especially for nocturia and inability to sleep. The most frequent lifestyle recommendation from physicians was 'reduce salt/sodium intake', but only 51% of patients receiving this recommendation followed the advice. In all, 44% of patients reported dissatisfaction with their current medication; according to the patients, 27% reported no discussion with their physicians about their prescribed medication, while physicians reported the opposite. Conclusions: HF negatively impacts patient daily life. There is discordance between patients and physicians in symptom reporting, lifestyle modification advice and adherence, and reported medication decision making. Gaps in patient-physician communication exist.

Association of Receipt of Palliative Care Interventions With Health Care Use, Quality of Life, and Symptom Burden Among Adults With Chronic Noncancer Illness: A Systematic Review and Meta-analysis

IMPORTANCE

The evidence for palliative care exists predominantly for patients with cancer. The effect of palliative care on important end-of-life outcomes in patients with noncancer illness is unclear.

OBJECTIVE

To measure the association between palliative care and acute health care use, quality of life (QOL), and symptom burden in adults with chronic noncancer illnesses.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed from inception to April 18, 2020.

STUDY SELECTION

Randomized clinical trials of palliative care interventions in adults with chronic noncancer illness. Studies involving at least 50% of patients with cancer were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all trials. All outcomes were analyzed using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Acute health care use (hospitalizations and emergency department use), disease-generic and disease-specific quality of life (QOL), and symptoms, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (range, 0 [worst] to 184 [best]; minimal clinically important difference, 9 points) and symptoms translated to units of the Edmonton Symptom Assessment Scale global distress score (range, 0 [best] to 90 [worst]; minimal clinically important difference, 5.7 points).

RESULTS

Twenty-eight trials provided data on 13 664 patients (mean age, 74 years; 46% were women). Ten trials were of heart failure (n = 4068 patients), 11 of mixed disease (n = 8119), 4 of dementia (n = 1036), and 3 of chronic obstructive pulmonary disease (n = 441). Palliative care, compared with usual care, was statistically significantly associated with less emergency department use (9 trials [n = 2712]; 20% vs 24%; odds ratio, 0.82 [95% CI, 0.68-1.00]; I2 = 3%), less hospitalization (14 trials [n = 3706]; 38% vs 42%; odds ratio, 0.80 [95% CI, 0.65-0.99]; I2 = 41%), and modestly lower symptom burden (11 trials [n = 2598]; pooled standardized mean difference (SMD), -0.12; [95% CI, -0.20 to -0.03]; I2 = 0%; Edmonton Symptom Assessment Scale score mean difference, -1.6 [95% CI, -2.6 to -0.4]). Palliative care was not significantly associated with disease-generic QOL (6 trials [n = 1334]; SMD, 0.18 [95% CI, -0.24 to 0.61]; I2 = 87%; Functional Assessment of Chronic Illness Therapy-Palliative Care score mean difference, 4.7 [95% CI, -6.3 to 15.9]) or disease-specific measures of QOL (11 trials [n = 2204]; SMD, 0.07 [95% CI, -0.09 to 0.23]; I2 = 68%).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of randomized clinical trials of patients with primarily noncancer illness, palliative care, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. Analyses for some outcomes were based predominantly on studies of patients with heart failure, which may limit generalizability to other chronic illnesses.

Quality of Life Is Improved 1 Year After Cardiac Surgery

BACKGROUND

Quality of life (QoL) is increasingly important in the era of patient-centered outcomes and value-based reimbursement. However most follow-up is limited to 30 days, and long-term data on QoL improvement associated with symptom relief are lacking. Therefore we sought to analyze QoL after cardiac surgery in a nonemergent, all-comers population.

METHODS

Four hundred two patients undergoing routine cardiac surgery at 2 large urban hospitals in the Dallas, Texas area were enrolled. Follow-up was complete for 364 patients. Data were collected from August 2013 to January 2017. The Kansas City Cardiomyopathy Questionnaire was administered at baseline, 1 month, and 1 year after surgery. Repeated-measures analysis was used for each domain of the questionnaire for all procedures and stratified by procedure. If time was found to be a significant factor, pairwise analysis was performed with P values adjusted using the Tukey-Kramer method.

RESULTS

There was a significant increase across all domains of Kansas City Cardiomyopathy Questionnaire scores for all procedures and for most domains when stratifying by procedure. This increase in QoL was most marked after 1 month. All domain scores increased through 1 year except symptom stability, which peaked at 1 month postsurgery and then regressed at 1 year, suggesting an overall improvement and stabilization of symptoms. The occurrence of complications did not alter this trajectory.

CONCLUSIONS

QoL and other patient-centered outcomes are improved at 1 month and continue to improve throughout the year. Knowledge of these data is important for patient selection, fully informed consent, and shared decision-making.

Impact of hospitalisation on health-related quality of life in patients with chronic heart failure

BACKGROUND

Empirical identification of the direct impact of hospitalisation in the change in utility could provide an interpretation for some of the unexplained variance in quality of life responses in clinical practice and clinical trials and provide assistance to researchers in assessing the impact of a hospitalisation in the context of economic evaluations. This study had the goal of determining the impact of nonfatal hospitalisations on the quality of life of a cohort of patients previously diagnosed with heart failure by using their quality of life measurements before and after hospitalisation.

METHODS

The impact of hospitalisation on health-related quality of life was estimated by calculating the difference in utility measured using the EQ-5D-3L in patients that were hospitalised and had records of utility before and after hospitalisation. The variation in differences between the utilities pre and post hospitalisation was explained through two multiple linear regression models using (1) the individual patient characteristics and (2) the hospitalisation characteristics as explanatory variables.

RESULTS

The mean difference between health-related quality of life measurement pre and post hospitalisation was found to be 0.020 [95% CI: - 0.020, 0.059] when measured with the EQ-5D index, while there was a mean decrease of - 0.012 [95% CI: - 0.043, 0.020] in the utility measured with the visual analogue scale. Differences in utility variation according to the primary cause for hospitalisation were found. Regression models showed a statistically significant impact of body mass index and serum creatinine in the index utility differences and of serum creatinine for utilities measured with the visual analogue scale.

CONCLUSIONS

Knowing the impact of hospitalisation on health-related quality of life is particularly relevant for informing cost-effectiveness studies designed to assess health technologies aimed at reducing hospital admissions. Through using patient-level data it was possible to estimate the variation in utilities before and after the average hospitalisation and for hospitalisations due to the most common causes for hospital admission. These estimates for (dis) utility could be used in the calculations of effectiveness on economic evaluations, especially when discrete event simulations are the employed modelling technique.

Global mapping of interventions to improve the quality of life of patients with cardiovascular diseases during 1990-2018

BACKGROUND

Cardiovascular diseases (CVDs) have been the global health problems that cause a substantial burden for the patients and the society. Assessing the Quality of Life (QOL) of CVD patients is critical in the effectiveness evaluation of CVD treatments as well as in determining potential areas for enhancing health outcomes. Through the adoption of a combination of bibliometric approach and content analysis, publications trend and the common topics regarding interventions to improve QOL of CVD patients were searched and characterized to inform priority setting and policy development.

METHODS

Bibliographic data of publications published from 1990 to 2018 on interventions to improve QOL of CVD patients were retrieved from Web of Science. Network graphs illustrating the terms co-occurrence clusters were created by VOSviewer software. Latent Dirichlet Allocation approach was adopted to classify papers into major research topics.

RESULTS

A total of 6457 papers was analyzed. We found a substantial increase in the number of publications, citations, and the number of download times of papers in the last 5 years. There has been a rise in the number of papers related to intervention to increase quality of life among patients with CVD during 1990-2018. Conventional therapies (surgery and medication), and psychological, behavioral interventions were common research topics. Meanwhile, the number of papers evaluating economic effectiveness has not been as high as that of other topics.

CONCLUSIONS

The research areas among the scientific studies emphasized the importance of interdisciplinary and inter-sectoral approaches in both evaluation and intervention. Future research should be a focus on economic evaluation of intervention as well as interventions to reduce mental issues among people with CVD.

Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study

OBJECTIVE

To measure the associations between newly initiated palliative care in the last six months of life, healthcare use, and location of death in adults dying from non-cancer illness, and to compare these associations with those in adults who die from cancer at a population level.

DESIGN

Population based matched cohort study.

SETTING

Ontario, Canada between 2010 and 2015.

PARTICIPANTS

113 540 adults dying from cancer and non-cancer illness who were given newly initiated physician delivered palliative care in the last six months of life administered across all healthcare settings. Linked health administrative data were used to directly match patients on cause of death, hospital frailty risk score, presence of metastatic cancer, residential location (according to 1 of 14 local health integration networks that organise all healthcare services in Ontario), and a propensity score to receive palliative care that was derived by using age and sex.

MAIN OUTCOME MEASURES

Rates of emergency department visits, admissions to hospital, and admissions to the intensive care unit, and odds of death at home versus in hospital after first palliative care visit, adjusted for patient characteristics (such as age, sex, and comorbidities).

RESULTS

In patients dying from non-cancer illness related to chronic organ failure (such as heart failure, cirrhosis, and stroke), palliative care was associated with reduced rates of emergency department visits (crude rate 1.9 (standard deviation 6.2) v 2.9 (8.7) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.85 to 0.91), admissions to hospital (crude rate 6.1 (standard deviation 10.2) v 8.7 (12.6) per person year; adjusted rate ratio 0.88, 95% confidence interval 0.86 to 0.91), and admissions to the intensive care unit (crude rate 1.4 (standard deviation 5.9) v 2.9 (8.7) per person year; adjusted rate ratio 0.59, 95% confidence interval 0.56 to 0.62) compared with those who did not receive palliative care. Additionally increased odds of dying at home or in a nursing home compared with dying in hospital were found in these patients (n=6936 (49.5%) v n=9526 (39.6%); adjusted odds ratio 1.67, 95% confidence interval 1.60 to 1.74). Overall, in patients dying from dementia, palliative care was associated with increased rates of emergency department visits (crude rate 1.2 (standard deviation 4.9) v 1.3 (5.5) per person year; adjusted rate ratio 1.06, 95% confidence interval 1.01 to 1.12) and admissions to hospital (crude rate 3.6 (standard deviation 8.2) v 2.8 (7.8) per person year; adjusted rate ratio 1.33, 95% confidence interval 1.27 to 1.39), and reduced odds of dying at home or in a nursing home (n=6667 (72.1%) v n=13 384 (83.5%); adjusted odds ratio 0.68, 95% confidence interval 0.64 to 0.73). However, these rates differed depending on whether patients dying with dementia lived in the community or in a nursing home. No association was found between healthcare use and palliative care for patients dying from dementia who lived in the community, and these patients had increased odds of dying at home.

CONCLUSIONS

These findings highlight the potential benefits of palliative care in some non-cancer illnesses. Increasing access to palliative care through sustained investment in physician training and current models of collaborative palliative care could improve end-of-life care, which might have important implications for health policy.

Left Ventricular Flow Analysis

BACKGROUND

Cardiac remodeling, after a myocardial insult, often causes progression to heart failure. The relationship between alterations in left ventricular blood flow, including kinetic energy (KE), and remodeling is uncertain. We hypothesized that increasing derangements in left ventricular blood flow would relate to (1) conventional cardiac remodeling markers, (2) increased levels of biochemical remodeling markers, (3) altered cardiac energetics, and (4) worsening patient symptoms and functional capacity. Methods Thirty-four dilated cardiomyopathy patients, 30 ischemic cardiomyopathy patients, and 36 controls underwent magnetic resonance including 4-dimensional flow, BNP (brain-type natriuretic peptide) measurement, functional capacity assessment (6-minute walk test), and symptom quantification. A subgroup of dilated cardiomyopathy and control subjects underwent cardiac energetic assessment. Left ventricular flow was separated into 4 components: direct flow, retained inflow, delayed ejection flow, and residual volume. Average KE throughout the cardiac cycle was calculated.

RESULTS

Patients had reduced direct flow proportion and direct-flow average KE compared with controls ( P<0.0001). The residual volume proportion and residual volume average KE were increased in patients ( P<0.0001). Importantly, in a multiple linear regression model to predict the patient's 6-minute walk test, the independent predictors were age (β=-0.3015; P=0.019) and direct-flow average KE (β=0.280, P=0.035; R² model, 0.466, P=0.002). In contrast, neither ejection fraction nor left ventricular volumes were independently predictive.

CONCLUSIONS

This study demonstrates an independent predictive relationship between the direct-flow average KE and a prognostic measure of functional capacity. Intracardiac 4-dimensional flow parameters are novel biomarkers in heart failure and may provide additive value in monitoring new therapies and predicting prognosis.

Correlation between medication regimen complexity and quality of life in patients with heart failure

PURPOSE

To determine if a correlation exists between the medication regimen complexity index (MRCI) and quality of life (QoL) in patients with heart failure (HF) assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).

METHODS

Retrospective chart review from July 2012 through June 2018 identified patients for inclusion who completed an MLHFQ. Baseline and, if available, follow-up MLHFQ scores were collected. The medication list documented on the date of the MLHFQ was used to calculate the MRCI.

RESULTS

Patients with a documented MLHFQ score were included (n = 72) in the primary analysis. No correlation existed between baseline MRCI and MLHFQ (r = 0.07; p = 0.55). A secondary analysis of correlation between change in MRCI and MLHFQ was conducted for patients (n = 30) with a follow-up MLHFQ score. A moderate, negative correlation (r = -0.47; p = 0.009) existed between change in MRCI and MLHFQ from baseline to follow-up.

CONCLUSION

No significant correlation between MRCI and MLHFQ scores were found at baseline. Patients with follow-up MLHFQ scores demonstrated improvements in QoL, despite increasingly complex medication regimens. Medication regimen complexity alone is likely an insufficient marker for predicting QoL in patients with HF.

Pregnancy Outcomes in Women With Transposition of the Great Arteries After an Arterial Switch Operation

Importance

A growing number of women are approaching childbearing age after arterial switch surgery for transposition of the great arteries. Prepregnancy counseling requires updated knowledge of the additional cardiovascular risks pregnancy poses for this cohort of women and the potential effect on their offspring; however, to our knowledge, this information is currently unknown.

Objective

To determine the pregnancy outcomes of women with transposition of the great arteries after an arterial switch operation, as well as the outcomes of their offspring.

Design, Setting, and Participants

This cohort study assessed women who had had arterial switch surgery from 1985 to the present and who were 16 years or older as of January 2018. All women with a previous arterial switch surgery for transposition of the great arteries with completed or ongoing pregnancy were included. Data were collected in a level 1 congenital cardiology center and joint obstetrics-cardiology clinic in Birmingham, United Kingdom.

Exposures

Patients were assessed before, during, and after pregnancy.

Main Outcomes and Measures

Adverse maternal cardiac events (arrhythmia, heart failure, aortic dissection, or acute coronary syndrome) and aortic root dilatation, aortic regurgitation, and left ventricular function before and after pregnancy were the main outcomes. Mode of delivery and fetal outcomes were considered secondary outcomes.

Results

A total of 25 pregnancies were identified in 15 women; 8 women had had 1 pregnancy, while 7 were multiparous. There were no adverse maternal cardiac events. Before pregnancy, 8 women (53%) had no aortic regurgitation, 1 (7%) had a trivial degree of regurgitation, 4 (26%) had mild regurgitation, and 2 (14%) had moderate regurgitation. After pregnancies, 1 woman (7%) had minor progression of aortic regurgitation. Five women (36%) had mild neoaortic root dilatation prepregnancy, but none developed progressive dilatation in the first year post-partum. A total of 24 pregnancies were completed by the end of the study, with all infants born alive and well. Nineteen modes of delivery were known; there were 7 cesarean deliveries (37%), of which 2 (11%) were recommended for aortic dilatation and 5 (26%) for obstetric indications or maternal choice.

Conclusions and Relevance

Pregnancy is well tolerated after arterial switch operation; no adverse maternal cardiac events or early progression of neoaortic root dilatation or aortic regurgitation were observed in this study. These results provide evidence to allow reassurance of women with previous arterial switch surgery who are planning pregnancies.

Effects of tailored telemonitoring on functional status and health-related quality of life in patients with heart failure

Background

Functional status and health-related quality of life (HRQoL) are important in patients with heart failure (HF). Little is known about the effect of telemonitoring on functional status and HRQoL in that population.

Methods and results

A total of 382 patients with HF (New York Heart Association class 2–4) were included in a randomised controlled trial to investigate the effect of tailored telemonitoring on improving HRQoL and functional status in HF patients. Randomisation was computer-generated with stratification per centre. At baseline and after 12 months, patients’ functional status was determined by metabolic equivalent scores (METS). HRQoL was measured with the EuroQol five dimensions questionnaire (EQ-5D), visual analogue scale (VAS) and Borg rating of perceived exertion scale (Borg). Additional outcome data included number of HF-related outpatient clinic visits and mortality. Telemonitoring was statistically significantly related to an increase in METS after 1 year (regression coefficient 0.318; p = 0.01). Telemonitoring did not improve Borg, EQ-5D or VAS scores after 1 year. EQ-5D [hazard ratio (HR) 0.20, 95% confidence interval (CI) 0.07–0.54], VAS (HR 0.98, 95% CI 0.96–0.99), Borg (HR 1.21, 95% CI 1.11–1.31) and METS (HR 0.73, 95% CI 0.58–0.93) at baseline were significantly associated with survival after 12 months.

Conclusions

Tailored telemonitoring stabilised the functional status of HF patients but did not improve HRQoL. Therefore, telemonitoring may help to prevent deterioration of exercise capacity in patients with HF. However, because our study is a reanalysis of a randomised controlled trial (RCT), this is considered hypothesis-generating and should be confirmed by adequately powered RCTs.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-01323-x) contains supplementary material, which is available to authorized users.

Prognostic value of health-related quality of life in elderly patients hospitalized with heart failure

Purpose: Previous research has shown that poor health-related quality of life (HRQOL) is associated with adverse long-term prognosis in patients with heart failure (HF); however, there have been inconsistencies among studies and not all of them confirmed the prognostic value of HRQOL. In addition, few studies involved elderly patients and most focused on all-cause mortality and HF-related hospitalization as outcomes. The aim of our study was to determine whether HRQOL is a predictor and an independent predictor of long-term cardiac mortality, all-cause mortality, and HF-related rehospitalization in elderly patients hospitalized with HF.

Patients and methods: This prospective observational study included 200 elderly patients hospitalized with HF in Serbia. HRQOL was measured using the Minnesota Living with Heart Failure questionnaire (MLHFQ). The median follow-up period was 28 months. The primary outcome was cardiac mortality, and all-cause mortality and HF-related rehospitalization were secondary outcomes. Survival analysis was conducted using the Kaplan–Meier method and Cox-proportional hazards regression.

Results: Subjects with poor HRQOL (higher than the median MLHFQ score) had a higher probability of cardiac mortality (P=0.029) and HF-related rehospitalization (P=0.001) during long-term follow-up. Poor HRQOL was an independent predictor of cardiac mortality (HR: 2.051, 95% CI: 1.260–3.339, P=0.004), all-cause mortality (HR: 1.620, 95% CI: 1.076–2.438, P=0.021), and HF-related rehospitalization (HR: 2.040, 95% CI: 1.290–3.227, P=0.002).

Conclusion: HRQOL is an independent predictor of long-term cardiac mortality in elderly patients hospitalized with HF. It also independently predicts all-cause mortality and HF-related rehospitalization. HRQOL could be used as a complementary clinical predictive tool in this patient population.

Left atrial compliance index predicts exercise capacity in patients with heart failure and preserved ejection fraction irrespective of right ventricular dysfunction

BACKGROUND AND AIM

Predictors of exercise capacity in heart failure (HF) with preserved ejection fraction (HFpEF) remain of difficult determination. The aim of this study was to identify predictors of exercise capacity in a group of patients with HFpEF and right ventricle (RV) dysfunction METHODS: In 143 consecutive patients with HFpEF (age 62 ± 9 years, LV EF ≥45) and 41 controls, a complete echocardiographic study was performed. In addition to conventional measurements, LA compliance was calculated using the formula: [LAV max - LAV min/LAV min × 100]. Exercise capacity was assessed using the six-minute walking test (6-MWT). Tricuspid annular plane systolic excursion (TAPSE) < 1.7 cm was utilized to categorize patients with RV dysfunction (n = 40) from those with maintained RV function (n = 103).

RESULTS

Patients with RV dysfunction were older (P = 0.002), had higher NYHA class (P = 0.001), higher LV mass index (P = 0.01), reduced septal and lateral MAPSE (all P < 0.001), enlarged LA (P = 0.001) impaired LA compliance index (P < 0.001) and exhibited a more compromised 6-MWT (P = 0.001). LA compliance index correlated more closely with 6-MWT (r = 0.51, P < 0.001) compared with the other LA indices (AP diameter, transverse diameter and volume indexed; r = -0.30, r = -0.35 and r = -0.38, respectively). In multivariate analysis, LA compliance index <60% was 88% sensitive and 61% specific (AUC 0.80, CI = 0.67-0.92 P = 0.001) in predicting exercise capacity.

CONCLUSION

An impairment in LA compliance was profound in patients with HFpEF and RV dysfunction and seems to be most powerful independent predictor of limited exercise capacity.

[Cardiac implantable electronic devices and health-related quality of life]

Patients, scientists and healthcare providers are increasingly interested in identifying interventions that not only reduce mortality but also improve symptoms, function and health-related quality of life. Health-related quality of life is a strong, independent predictor of mortality, cardiovascular events, hospitalization and treatment costs in patients with cardiac diseases. Remote monitoring of pacemakers has a positive effect on health-related quality of life and functional capacity and is equivalent to monitoring these patients in hospitals. Implantation of an implantable cardioverter defibrillator has a major impact on mental health, with the majority of patients experiencing the fear of ICD shocks as particularly detrimental to the quality of life. Variables, such as age, gender and duration of implantation should be considered in the assessment and planning of strategies for improving the quality of life of patients with electronic implantable cardiac devices.

Validation of heart failure quality of life tool and usage to predict all-cause mortality in acute heart failure in Uganda: the Mbarara heart failure registry (MAHFER)

BACKGROUND

The health-related quality of life (HRQoL) is an important treatment goal that could serve as low-cost prognostication tool in resource poor settings. We sought to validate the Kansas City Cardiomyopathy Questionnaire (KCCQ) and evaluate its use as a predictor of 3 months all-cause mortality among heart failure participants in rural Uganda.

METHODS

The Mbarara Heart Failure Registry Cohort study observes heart failure patients during hospital stay and in the community in rural Uganda. Participants completed health failure evaluations and HRQoL questionnaires at enrollment, 1 and 3 months of follow-up. We used Cronbach's alpha coefficients to define internal consistency, intraclass correlation coefficients as a reliability coefficient, and Cox proportional hazard models to predict the risk of 3 months all-cause mortality.

RESULTS

Among the 195 participants who completed HRQoL questionnaires, the mean age was 52 (standard deviation (SD) 21.4) years, 68% were women and 29% reported history of hypertension. The KCCQ had excellent internal consistency (87% Cronbach alpha) but poor reliability. Independent predictors of all-cause mortality within 3 months included: worse overall KCCQ score (Adjusted Hazard ratio (AHR) 2.9, 95% confidence interval (CI) 1.1, 8.1), highest asset ownership (AHR 3.6, 95% CI 1.2, 10.8), alcoholic drinks per sitting (AHR per 1 drink 1.4, 95% CI 1.0, 1.9), New York Heart Association (NYHA) functional class IV heart failure (AHR 2.6, 95% CI 1.3, 5.4), estimated glomerular filtration rate (eGFR) 30 to 59 ml/min/1.73 m2 (AHR 3.4, 95% CI 1.1, 10.8), and eGFR less than 15 ml/min/1.73 m2 (AHR 2.7, 95% CI 1.0, 7.1), each 1 pg/mL increase in Brain Natriuretic Peptide (BNP) (AHR, 1.0, 95% CI 1.0, 1.0), and each 1 ng/mL increase in Creatine-Kinase MB isomer (CKMB) (AHR 1.0, 95% CI 1.0, 1.1).

CONCLUSION

The KCCQ showed excellent internal consistency. Worse overall KCCQ score, highest asset ownership, increasing alcoholic drink per sitting, NYHA class IV, decreased estimated glomerular filtration rate, BNP, and CKMB predicted all-cause mortality at 3 months. The KCCQ could be an additional low-cost tool to aid in the prognostication of acute heart failure patients.

Relationship of medication adherence and quality of life among heart failure patients

BACKGROUND

Little is known regarding the relationship between medication adherence and quality of life in heart failure patients. We therefore aimed to examine the nature of relationship between medication adherence and quality of life.

METHODS

A prospective, cross-sectional study of chronic heart failure patients with reduced ejection fraction was performed at a tertiary-care, university hospital in Thailand. Quality of life and medication adherence were assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Morisky Medication Adherence Scale-8 (MMAS-8), respectively. Relationship of MLHFQ and MMAS-8 were examined using Spearman's correlation coefficient and multiple regression analysis for covariates adjustment.

RESULTS

Among 180 patients, 38.3%, 50.0% and 11.7% were found to have high, medium and poor adherence, respectively. For quality of life, the overall median score on the MLHFQ was relatively low. A positive relationship was identified between medication adherence and quality of life. After covariate adjustment, medication adherence was found to have the strongest relationship with quality of life, compared to other covariates.

CONCLUSIONS

Medication adherence has a small and positive relationship with quality of life among heart failure patients.

Cognitive Function Does Not Impact Self-reported Health-Related Quality of Life in Heart Failure Patients

BACKGROUND

Adults with heart failure (HF) often demonstrate impairment across multiple domains of cognitive functioning and report poor health-related quality of life (HRQoL). Previous researchers have found that cognitive deficits were generally not associated with HRQoL in a carefully evaluated sample. The exception was memory, which was only weakly associated with HRQoL. However, cognitive deficits interfere with self-care and disease self-management, which could be expected to affect HRQoL.

OBJECTIVE

We sought to verify this counterintuitive finding in a large well-characterized sample of HF patients using a well-validated neuropsychological battery.

METHODS

Participants were 302 adults (63% male) predominately white (72.5%) HF patients (68.7 ± 9.6 years) recruited from 2 medical centers. Self-reported HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire. Participants completed a neuropsychological battery examining attention, executive function, memory, and visuospatial functioning. Hierarchical multiple linear regression was used for analyses.

RESULTS

Mild global cognitive impairment was observed in 29.5% of the sample (Modified Mini-Mental State [3MS] Examination score <90). Controlling for gender, depression, HF severity, premorbid IQ, comorbidities, and education, only executive function predicted HRQoL, β = .17, P < .05. However, executive function accounted for only 0.6% of the variance in HRQoL.

CONCLUSION

Cognitive function generally did not predict HRQoL in HF patients. The correlates of HRQoL in HF do not appear to include mild cognitive impairment. Other factors may play a bigger role such as disease severity, age, and depressive symptoms. Future studies should investigate modifiable determinants of HRQoL in HF patients, toward the goal of finding interventions that preserve HRQoL during this chronic illness.

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.

Impact of a Telehealth Program With Voice Recognition Technology in Patients With Chronic Heart Failure: Feasibility Study

Background

Despite the advances in the diagnosis and treatment of heart failure (HF), the current hospital-oriented framework for HF management does not appear to be sufficient to maintain the stability of HF patients in the long term. The importance of self-care management is increasingly being emphasized as a promising long-term treatment strategy for patients with chronic HF.

Objective

The objective of this study was to evaluate whether a new information communication technology (ICT)–based telehealth program with voice recognition technology could improve clinical or laboratory outcomes in HF patients.

Methods

In this prospective single-arm pilot study, we recruited 31 consecutive patients with chronic HF who were referred to our institute. An ICT-based telehealth program with voice recognition technology was developed and used by patients with HF for 12 weeks. Patients were educated on the use of this program via mobile phone, landline, or the Internet for the purpose of improving communication and data collection. Using these systems, we collected comprehensive data elements related to the risk of HF self-care management such as weight, diet, exercise, medication adherence, overall symptom change, and home blood pressure. The study endpoints were the changes observed in urine sodium concentration (uNa), Minnesota Living with Heart Failure (MLHFQ) scores, 6-min walk test, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as surrogate markers for appropriate HF management.

Results

Among the 31 enrolled patients, 27 (87%) patients completed the study, and 10 (10/27, 37%) showed good adherence to ICT-based telehealth program with voice recognition technology, which was defined as the use of the program for 100 times or more during the study period. Nearly three-fourths of the patients had been hospitalized at least once because of HF before the enrollment (20/27, 74%); 14 patients had 1, 2 patients had 2, and 4 patients had 3 or more previous HF hospitalizations. In the total study population, there was no significant interval change in laboratory and functional outcome variables after 12 weeks of ICT-based telehealth program. In patients with good adherence to ICT-based telehealth program, there was a significant improvement in the mean uNa (103.1 to 78.1; P=.01) but not in those without (85.4 to 96.9; P=.49). Similarly, a marginal improvement in MLHFQ scores was only observed in patients with good adherence (27.5 to 21.4; P=.08) but not in their counterparts (19.0 to 19.7; P=.73). The mean 6-min walk distance and NT-proBNP were not significantly increased in patients regardless of their adherence.

Conclusions

Short-term application of ICT-based telehealth program with voice recognition technology showed the potential to improve uNa values and MLHFQ scores in HF patients, suggesting that better control of sodium intake and greater quality of life can be achieved by this program.

Baseline Quality of Life and Risk of Stroke in the ALLHAT Study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial)

BACKGROUND AND PURPOSE

The visual analogue scale is a self-reported, validated tool to measure quality of life (QoL). Our purpose was to determine whether baseline QoL predicted strokes in the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) and evaluate determinants of poststroke change in QoL. In the ALLHAT study, among the 33 357 patients randomized to treatment arms, 1525 experienced strokes; 1202 (79%) strokes were nonfatal. This study cohort includes 32 318 (97%) subjects who completed the baseline visual analogue scale QoL estimate.

METHODS

QoL was measured on a visual analogue scale and adjusted using a Torrance transformation (transformed QoL [TQoL]). Kaplan-Meier curves and adjusted proportional hazards analyses were used to estimate the effect of TQoL on the risk of stroke, on a continuous scale (0-1) and by quartiles (≤0.81, >0.81≤0.89, >0.89≤0.95, >0.95). We analyzed the change from baseline to first poststroke TQoL using adjusted linear regression.

RESULTS

After adjusting for multiple stroke risk factors, the hazard ratio for stroke events for baseline TQoL was 0.93 (95% confidence interval, 0.89-0.98) per 0.1 U increase. The lowest baseline TQoL quartile had a 20% increased stroke risk (hazard ratio=1.20 [95% confidence interval, 1.00-1.44]) compared with the reference highest quartile TQoL. Poststroke TQoL change was significant within all treatment groups (P≤0.001). Multivariate regression analysis revealed that baseline TQoL was the strongest predictor of poststroke TQoL with similar results for the untransformed QoL.

CONCLUSIONS

The lowest baseline TQoL quartile had a 20% higher stroke risk than the highest quartile. Baseline TQoL was the only factor that predicted poststroke change in TQoL.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Health-Related Quality of Life, Functional Status, and Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Health-related quality of life (HRQOL), functional status, and cardiac event-free survival are outcomes used to assess the effectiveness of interventions in patients with heart failure (HF). However, the nature of the relationships among HRQOL, functional status, and cardiac event-free survival remains unclear.

OBJECTIVE

The purpose of this study is to examine the nature of the relationships among HRQOL, functional status, and cardiac event-free survival in patients with HF.

METHODS

This was a prospective, observational study of 313 patients with HF that was a secondary analysis from a registry. At baseline, patient demographic and clinical data were collected. Health-related quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire and functional status was measured using the Duke Activity Status Index. Cardiac event-free survival data were obtained by patient interview, hospital database, and death certificate review. Multiple linear and Cox regressions were used to explore the relationships among HRQOL, functional status, and cardiac event-free survival while adjusting for demographic and clinical factors.

RESULTS

Participants (n = 313) were men (69%), white (79%), and aged 62 ± 11 years. Mean left ventricular ejection fraction was 35% ± 14%. The mean HRQOL score of 32.3 ± 20.6 indicated poor HRQOL. The mean Duke Activity Status Index score of 16.2 ± 12.9 indicated poor functional status. Cardiac event-free survival was significantly worse in patients who had worse HRQOL or poorer functional status. Patients who had better functional status had better HRQOL (P < .001). Health-related quality of life was not a significant predictor of cardiac event-free survival after entering functional status in the model (P = .54), demonstrating that it was a mediator of the relationship between HRQOL and outcome.

CONCLUSION

Functional status was a mediator between HRQOL and cardiac event-free survival. These data suggest that intervention studies to improve functional status are needed.

Health-related Quality of Life and Survival in Pulmonary Arterial Hypertension

RATIONALE

Pulmonary arterial hypertension is a progressive disease with high morbidity and mortality despite advances in medical therapy. The relationship between patient-related outcomes, such as health-related quality of life (HRQOL), and survival is not well described.

OBJECTIVE

To assess the relationship between HRQOL and outcomes in patients with pulmonary arterial hypertension.

METHODS

Consecutive patients with right heart catheterization-proven pulmonary arterial hypertension who completed the Medical Outcomes Survey Short Form-36 survey (SF-36) were included. Demographic, clinical, physiological, and hemodynamic data were collected at baseline. Survival was assessed from the time of diagnosis of pulmonary arterial hypertension. Cox proportional hazard models were constructed to assess the relationship between HRQOL and transplant-free survival.

MEASUREMENTS AND MAIN RESULTS

Eighty-seven patients with pulmonary arterial hypertension were enrolled and followed prospectively for a median of 3.8 years. At baseline, HRQOL was significantly worse than U.S. normal values for six of eight domains of the SF-36. Several domains demonstrated moderate correlation (r value ≥ 0.40) with 6-minute-walk distance and World Health Organization functional class; there were no significant associations with hemodynamics. In univariable Cox proportional hazard models, six of eight domains and both summary scores were significantly associated with survival. In multivariable models, adjusted for age, disease type, and cardiac function, these relationships largely persisted.

CONCLUSIONS

In this cohort of patients with pulmonary arterial hypertension, HRQOL, as assessed by the SF-36, was strongly associated with transplant-free survival. These relationships persisted when controlling for potential confounders such as disease type and disease severity. These findings suggest that HRQOL may be an important predictor of outcomes in pulmonary arterial hypertension and therefore a target for future therapeutic interventions.

[Assessment of subjective physical well-being in heart failure : Validation of the FEW16 questionnaire]

INTRODUCTION

Improvement in the quality of life (QoL) is a major goal of therapy for heart failure (HF) patients. Physical well-being as an important component of QoL has not yet been sufficiently covered by disease-specific assessment instruments. The aim of the study was to validate the questionnaire for assessing subjective physical well-being (FEW16) in HF patients with preserved ejection fraction (HFpEF) from the exercise training in diastolic heart failure (Ex-DHF‑P) trial.

METHOD

A total of 64 HFpEF patients (65 years, 56 % female) were randomized to usual routine treatment with (n = 44) or without training (n = 20). At baseline and 3 months, patients were clinically evaluated and assessed using appropriate questionnaires on the QoL (SF36), physical well-being (FEW16) and depression (PHQ-D).

RESULTS

The FEW16 showed good values for Cronbachs' alpha coefficients (0.85-0.93). The cross-validity with SF36 and PHQ-D was highly significant but more so for psychological aspects. At baseline, the FEW16 score correlated with age, the subscale resilience with age and the 6 min walking distance test. At follow-up, the total and resilience scores had improved in the training group. In contrast to the SF36, the FEW16 did not detect differences between the groups in Ex-DHF‑P.

DISCUSSION

The FEW16 questionnaire showed good internal consistency and correlation with SF36, its total score and resilience had improved after training; however, it did not reflect different changes between the study groups. The FEW16 is therefore more suited to assess general/mental well-being than the subjective physical well-being.

Patient-Reported Outcomes in Chronic Heart Failure: Applicability for Regulatory Approval

OBJECTIVES

The study sought to review the characteristics of existing patient-reported outcome (PRO) instruments used with chronic heart failure (HF) patients and evaluate their potential to support an approved U.S. Food and Drug Administration (FDA) product label claim.

BACKGROUND

PROs, including symptoms and their associated functional limitations, contribute substantially to HF patient morbidity. PRO measurements capture the patient perspective and can be systematically assessed with structured questionnaires, however rigorous recommendations have been set by the FDA regarding the acceptability of PRO measures as a basis for product label claims.

METHODS

Extensive searches of databases and specialty guidelines identified PRO instruments used in patients with chronic HF. Information on critical properties recommended by the FDA guidance were systematically extracted and used to evaluate the selected PRO instruments.

RESULTS

Nineteen PRO instruments used with chronic HF patients were identified. The Kansas City Cardiomyopathy Questionnaire and Minnesota Living with Heart Failure Questionnaire were the most extensively evaluated and validated in studies of this population. However, judged by criteria listed in the FDA PRO guidance, no existing PRO measure met all of the criteria to support a product label claim in the United States.

CONCLUSIONS

Currently available chronic HF PRO measures do not fulfill all the recommendations provided in the FDA PRO guidance and therefore may not support an FDA-approved product label claim. Future investigations are merited to develop a PRO measure for use in patients with chronic HF in accordance with the FDA guidance.

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.

Gender Differences in the Effects of Physical and Emotional Symptoms on Health-Related Quality of Life in Patients with Heart Failure

BACKGROUND

Physical and emotional symptoms are common in heart failure. These symptoms are theorized to affect health-related quality of life (HRQOL), but their impact is likely mediated by variables not yet explored. Moreover, gender may affect these relationships.

AIM

To determine gender differences in the effects of physical and emotional symptom status on HRQOL.

METHODS AND RESULTS

Data from 51 men and 47 women with heart failure were analyzed using regression analyses. There were no gender differences in physical or emotional symptom status, or HRQOL, but there were differences in the dynamic relationships among the variables. In bivariate analyses, physical and emotional symptom status was related to HRQOL in both men and women. However, in women, physical symptom status was related to HRQOL, while in men depression affected HRQOL in multivariate analyses (p<.001, r(2)=.27; p<.001, r(2)=.40, respectively). Functional status measured by the New York Heart Association functional class mediated the effects of anxiety and depression on HRQOL only in women.

CONCLUSION

There were gender differences in the dynamic relationships among variables related to HRQOL. These results demonstrate the need for individualized, comprehensive evaluation of patient's HRQOL and symptom status in order to appropriately target interventions.

The Minnesota living with heart failure questionnaire: comparison of different factor structures

Background

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is one of the most widely used health-related quality of life questionnaires for patients with heart failure (HF). It provides scores for two dimensions, physical and emotional, and a total score. However, there are some concerns about its factor structure and alternatives have been proposed, some including a third factor representing a social dimension. The objectives of the present study were to analyze the internal structure of the MLHFQ and the unidimensionality of the total score, and to compare the different factor structures proposed.

Methods

The MLHFQ was given to 2565 patients with HF. The structural validity of the questionnaire was assessed by confirmatory factor analysis (CFA), and Rasch analysis. These two approaches were also applied to the alternative structures proposed.

Results

The CFA results for the hypothesized model of two latent factors and the Rasch analysis confirmed the adequacy of the physical and emotional scales. Rasch analysis for the total score showed only two problematic items. The results of the CFA for other two-factor structures proposed were not better than the results for the original structure. The Rasch analyses applied to the different social factors yielded the best results for Munyombwe’s social dimension, composed of six items.

Conclusions

Our results support the validity of using the MLHFQ physical, emotional and total scores in patients with HF, for clinical practice and research. In addition, they confirmed the existence of a third factor, and we recommend the use of Munyombwe’s social factor.