Self-assessment of health status is associated with inflammatory activation and predicts long-term outcomes in chronic heart failure

Cost-Effectiveness Analysis of Empagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction in the United States

BACKGROUND

In the EMPEROR-Reduced trial (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure and a Reduced Ejection Fraction), empagliflozin plus standard of care reduced the composite of cardiovascular death or hospitalization for heart failure versus standard of care in adults with heart failure with reduced ejection fraction. This analysis investigated the cost-effectiveness of the 2 regimens from the perspective of US payors.

METHODS AND RESULTS

A Markov cohort model was developed based on Kansas City Cardiomyopathy Questionnaire Clinical Summary Score quartiles and death. Transition probabilities between health states, risk of cardiovascular/all-cause death, hospitalization for heart failure and adverse events, treatment discontinuation, and health utilities were estimated from trial data. Medicare and commercial payment rates were combined for treatment acquisition, acute event management, and disease management. An annual discount rate of 3% was used. Empagliflozin plus standard of care yielded 18% fewer hospitalizations for heart failure and 6% fewer deaths versus standard of care over a lifetime, providing cost-offsets while adding 0.19 life years and 0.19 quality-adjusted life years at an incremental cost of $16 815/patient. The incremental cost-effectiveness ratio was $87 725/quality-adjusted life years gained. Results were consistent across payors, subpopulations, and in deterministic sensitivity analyses. In probabilistic sensitivity analyses, empagliflozin plus standard of care was cost-effective in 3%, 62%, and 80% of iterations at thresholds of $50 000, $100 000, and $150 000/quality-adjusted life years.

CONCLUSIONS

Empagliflozin plus standard of care may prevent hospitalizations for heart failure, extend life, and increase quality-adjusted life years for patients with heart failure with reduced ejection fraction at an acceptable cost for US payors.

Remote Heart Failure Symptoms Assessment After Myocardial Infarction Identifies Patients at Risk for Death

BACKGROUND

Heart failure is a common complication after myocardial infarction (MI) and is associated with increased mortality. Whether remote heart failure symptoms assessment after MI can improve risk stratification is unknown. The authors evaluated the association of the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) with all-cause mortality after MI.

METHODS AND RESULTS

Prospectively collected data from consecutive patients hospitalized for MI at a large tertiary heart center between June 2017 and September 2022 were used. Patients remotely completed the KCCQ 1 month after discharge. A total of 1135 (aged 64±12 years, 26.7% women) of 1721 eligible patients completed the KCCQ. Ranges of KCCQ scores revealed that 30 (2.6%), 114 (10.0%), 274 (24.1%), and 717 (63.2%) had scores <25, 25 to 49, 50 to 74, and ≥75, respectively. During a mean follow-up of 46 months (interquartile range, 29-61), 146 (12.9%) died. In a fully adjusted analysis, KCCQ scores <50 were independently associated with mortality (hazard ratio [HR], 6.05 for KCCQ <25, HR, 2.66 for KCCQ 25-49 versus KCCQ ≥50; both P<0.001). Adding the 30-day KCCQ to clinical risk factors improved risk stratification: change in area under the curve of 2.6 (95% CI, 0.3-5.0), Brier score of -0.6 (95% CI, -1.0 to -0.2), and net reclassification improvement of 0.71 (95% CI, 0.45-1.04). KCCQ items most strongly associated with mortality were walking impairment, leg swelling, and change in symptoms.

CONCLUSIONS

Remote evaluation of heart failure symptoms using the KCCQ among patients recently discharged for MI identifies patients at risk for mortality. Whether closer follow-up and targeted therapy can reduce mortality in high-risk patients warrants further study.

A European multinational cost-effectiveness analysis of empagliflozin in heart failure with reduced ejection fraction

PURPOSE

This research examined the cost-effectiveness of adding empagliflozin to standard of care (SoC) compared with SoC alone for treatment of heart failure with reduced ejection fraction (HFrEF) from the perspective of healthcare payers in the United Kingdom (UK), Spain and France.

METHODS

A lifetime Markov cohort model was developed to simulate patients' progression through health states based on Kansas City Cardiomyopathy Questionnaire Clinical Summary Score. The model predicted risk of death, hospitalisation for worsening heart failure (HHF), treatment-related adverse events, and treatment discontinuation each monthly cycle. Clinical inputs and utilities were derived from EMPEROR-Reduced trial data, supplemented by published literature and national costing databases. Costs (2021 pound sterling/euro) and quality-adjusted life-years (QALYs) were discounted annually for the UK (3.5%), Spain (3.0%) and France (2.5%).

RESULTS

In the UK, Spain and France, empagliflozin plus SoC yielded additional QALYs (0.19, 0.23 and 0.21) at higher cost (£1185, €1770 and €1183 per patient) than SoC alone, yielding incremental cost-effectiveness ratios of £6152/QALY, €7736/QALY and €5511/QALY, respectively. Reduced HHF incidence provided most cost offsets for empagliflozin plus SoC. Similar results were obtained for a range of subgroups and sensitivity analyses. Probabilistic sensitivity results indicated empagliflozin plus SoC remained cost-effective vs. SoC at willingness-to-pay thresholds of £20,000/QALY, €20,000/QALY and €30,000/QALY in 79.6%, 75.5% and 97.3% of model runs for the UK, Spain and France, respectively.

CONCLUSIONS

Empagliflozin added to SoC leads to health benefits for patients with HFrEF and is a cost-effective treatment option for payers in multiple European countries (UK, Spain, France).

Cost-Effectiveness of Empagliflozin in Combination with Standard Care versus Standard Care Only in the Treatment of Heart Failure Patients in Finland

Purpose

Sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin has recently been shown to improve the outcomes of heart failure (HF) patients regardless of patient's left ventricular ejection fraction by reducing the combined risk of cardiovascular death or hospitalization for worsening HF. The aim of this study was to assess the cost-effectiveness of adding empagliflozin to the standard care (SC) in comparison to SC only in the treatment of HF in Finland.

Patients and Methods

The assessment was performed in the cost-utility framework using two Markov cohort state-transition models, one for HF with reduced ejection fraction (HFrEF) and one for HF with preserved ejection fraction (HFpEF). The models have been primarily developed based on the EMPEROR-Reduced and EMPEROR-Preserved trials which informed the modelled patient characteristics, efficacy of treatments in terms of associated risks for heart failure hospitalizations, cardiovascular (CV) and non-CV death, treatment related adverse events (AE), and state- and event-specific health-related quality of life weights (EQ-5D). Direct health care costs were estimated from Finnish published references. Cost-effectiveness was assessed from health care payer perspective based on incremental cost-effectiveness ratio (ICER; cost per quality adjusted life-year [QALY] gained) and probability of cost-effectiveness (at willingness-to-pay [WTP] of 35,000 euros/QALY). The ICER was reported as the weighted (HFrEF, 43.5%; HFpEF, 56.5%) average result of the two models.

Results

Empagliflozin + SC treatment increased the average quality-adjusted life-expectancy, and treatment costs of HF patients by 0.15 QALYs and 1,594 euros, respectively, when compared to SC. An additional QALY with empagliflozin was thus gained at a cost of 10,621 euros. The probability of empagliflozin + SC being cost-effective compared to placebo + SC was 77.6% and 83.5% with WTP of 35,000 and 100,000 euros/QALY, respectively.

Conclusion

Empagliflozin is a cost-effective treatment for patients with HF in the Finnish health care setting.

Dietary Antioxidant Insufficiency Is Associated With Increased Inflammatory Markers and Poorer Health-Related Quality of Life in Patients With Heart Failure

BACKGROUND

Antioxidant insufficiency, elevated inflammatory markers, and poor health-related quality of life (HRQOL) are prevalent in patients with heart failure (HF).

OBJECTIVE

The objective of this study was to examine the associations among dietary antioxidant intake, inflammatory markers, and HRQOL in patients with HF.

METHODS

This was a secondary analysis of 265 patients with HF who completed a 4-day food diary. We assessed intake of 10 antioxidants: alpha carotene, beta carotene, beta cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium. Antioxidant insufficiency was reflected by a measured level for each antioxidant that was below the estimate average requirement or lower than median for antioxidants without an estimate average requirement. Inflammatory markers including serum C-reactive protein, cytokines (interleukins 6 and 10), tumor necrosis factor-alpha, and soluble receptors (sTNFR1 and sTNFR2) were assessed with enzyme immunoassay. Health-related quality of life was measured using the Minnesota Living with Heart Failure at 12 months.

RESULTS

Dietary antioxidant insufficiency predicted C-reactive protein (β = 0.135, P = .032) and interleukin 10 (β = -.155, P = .027). Patients with higher antioxidant insufficiency had higher C-reactive protein and lower interleukin 10. Both antioxidant insufficiency (β = 0.13, P = .049) and higher C-reactive protein (β = 0.16, P = .019) were independently associated with poorer HRQOL while adjusting for covariates.

CONCLUSIONS

Dietary antioxidant insufficiency was associated with increased markers of inflammation and poorer HRQOL. Improvement of diet quality among patients with HF may be a fruitful area of research for enhancing HRQOL.

Predictors and outcomes of quality of life in elderly patients with heart failure

Study objective

This study aims to identify predictors of health related quality of life (HRQoL) among patients with heart failure (HF) and assess whether HRQoL was a predictor of rehospitalisation and mortality, and if age influenced the findings.

Design

Observational cohort study.

Setting

Seven hospitals in the Northern Sydney Local Health District, Sydney, Australia.

Participants

Community dwelling patients who completed a Minnesota Living with HF questionnaire (MLHFQ) within 30 days of discharge after a HF hospitalisation.

Main outcome measure

Multivariable linear regression models were used to identify predictors of MLHFQ scores (higher score = worse HRQoL) and adjusted Cox regression models to assess the impact of MLHFQ scores on one-year rehospitalisation and mortality. Separate analyses were conducted for those aged ≤80 or >80 years.

Results

1911 patients of mean age 79 years (57 % aged >80 years) were included in this analysis. Among those aged ≤80 years; younger age, lower haemoglobin and presenting symptoms at hospitalisation of exertional dyspnoea, peripheral oedema and fatigue were predictors of worse post-discharge MLHFQ scores. In patients aged >80 years, living alone, chronic kidney disease, exertional dyspnoea and peripheral oedema were predictors of worse MLHFQ scores. Worse MLHFQ scores predicted one-year HF readmissions in those aged >80 years (HR 1.22, 95 % CI 1.07-1.37) but not those aged ≤80 years (HR 0.90 95 % CI 0.71-1.10).

Conclusions

In-hospital predictors can be identified for worse HRQoL post-discharge for HF. These vary according to age, and should be addressed prior to discharge.

Effects of SGLT-2 inhibitors on health-related quality of life and exercise capacity in heart failure patients with reduced ejection fraction: A systematic review and meta-analysis

OBJECTIVE

Improving health-related quality of life (HRQoL) and exercise capacity is an important goal of treatment in heart failure (HF). However, evidence for the effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on the improvement of HRQoL and exercise capacity seems to be conflicted. We performed a systematic review and meta-analysis to evaluate the effects of SGLT-2 inhibitors on HRQL and exercise capacity in patients with heart failure and reduced ejection fraction (HFrEF).

METHODS

All studies (up to March 20, 2021) evaluating the effects of SGLT-2 inhibitors on HRQoL and exercise capacity in patients with HFrEF were initially searched from four electronic search engines: PubMed, Web of Science, Cochrane Library, and SinoMed. All statistical analyses were performed with RevMan 5.4.

RESULTS

We included 9 articles describing 7 trials with 9428 patients. SGLT-2 inhibitors group exhibited significant improvement in HRQoL assessed by Kansas City Cardiomyopathy Questionnaires (KCCQ) (MD: 2.13, 95% CI: 1.11 to 3.14, p < 0.001) and the rate of KCCQ-overall summary score improvement≥5 points (RR 1.15, 95%CI 1.08 to 1.21, P < 0.001) compared with placebo. No significant difference was observed in exercise capacity assessed by 6-min walk test distance between SGLT-2 inhibitors and placebo (MD 24.45, 95%CI -22.82 to 71.72, P = 0.31).

CONCLUSIONS

Our meta-analysis demonstrates that SGLT-2 inhibitors significantly improve HRQoL, and supports the concept that SGLT-2 inhibitors do not significantly improve exercise capacity in patients with HFrEF. Studies with larger sample sizes and longer follow-up duration are needed to determine whether the treatment with SGLT-2 inhibitors may improve exercise ability.

PROSPERO

CRD42021248346.

Health Status Predicts Short- and Long-Term Risk of Composite Clinical Outcomes in Acute Heart Failure

OBJECTIVES

This study aims to examine the association between the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 score and the 30-day and 1-year rates of composite events of cardiovascular death and heart failure (HF) rehospitalization in patients with acute HF.

BACKGROUND

Few studies reported the prognostic effects of KCCQ in acute HF.

METHODS

This study prospectively enrolled adult patients hospitalized for HF from 52 hospitals in China and collected the KCCQ-12 score within 48 hour of index admission. The study used multivariable Cox regression to examine the association between KCCQ-12 score and 30-day and 1-year composite events and was further stratified by new-onset HF and acutely decompensated chronic heart failure (ADCHF). Subgroup analyses were performed to explore the potential heterogeneity. The study evaluated the incremental prognostic value of KCCQ-12 score over N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and established risk scores by C-statistics, net reclassification improvement, and integrated discrimination improvement.

RESULTS

Among 4,898 patients, 29.4% had new-onset HF. After adjustment, each 10-point decrease in the KCCQ-12 score was associated with a 13% increase in 30-day risk and a 7% increase in 1-year risk. The associations were consistent regardless of new-onset HF or ADCHF, age, sex, left ventricular ejection fraction, New York Heart Association functional class, NT-proBNP level, comorbidities, and renal function. Adding KCCQ-12 score to NT-proBNP and established risk scores significantly improved prognostic capabilities measured by C-statistics, net reclassification improvement, and integrated discrimination improvement.

CONCLUSIONS

In acute HF, a poor KCCQ-12 score predicted short- and long-term risks of cardiovascular death and HF rehospitalization. KCCQ-12 could serve as a convenient tool for rapid initial risk stratification and provide additional prognostic value over NT-proBNP and established risk scores.

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.

Change of Health-Related Quality of Life Over Time and Its Association With Patient Outcomes in Patients With Heart Failure

Background Improving health-related quality of life is an important goal in the management of patients with heart failure (HF). Defining health-related quality of life changes over time in patients with HF with preserved (HFpEF) or reduced ejection fraction and showing their association with other important clinical events could support the use of health-related quality of life as a measure of quantifying HF care. Methods and Results In the Alberta HEART (Heart Failure Aetiology and Analysis Team) cohort (n=621), patients were categorized into 4 subgroups: healthy controls (n=98), at risk (n=163), HFpEF (n=191), and HF with reduced ejection fraction (n=169). The change of the Kansas City Cardiomyopathy Questionnaire (KCCQ), EuroQOL 5 dimensions, and Functional Assessment of Cancer Therapy-Anemia over 12 months, and its association with a composite of death or rehospitalization within 3 years were assessed. At baseline, the KCCQ overall summary score was 73 (interquartile range, 53-86) in HFpEF and 78 (interquartile range, 56-90) in HF with reduced ejection fraction (P=0.22). Overall, 30.5% of patients with HF experienced ≥5-point improvements and 32.4% had ≥5-point worsening in KCCQ overall summary score at 12 months, which did not differ between HFpEF and HF with reduced ejection fraction (P=0.23). Clinical events were higher in patients with HF who had a decline in KCCQ over 12 months as compared with those with stable KCCQ scores (70.2% versus 52.0%, P=0.012). The results were similar for the Functional Assessment of Cancer Therapy-Anemia and EuroQOL 5 dimensions. Conclusions In patients with HF, the KCCQ quantified clinically meaningful changes over time, which were associated with important clinical outcomes in patients with HFpEF. Given the observed variability and prognostication in different patient trajectories, health-related quality of life measures could be valuable for quantifying the quality of care in healthcare systems.

Association of Cardiac Biomarkers With the Kansas City Cardiomyopathy Questionnaire in Patients With Chronic Kidney Disease Without Heart Failure

Background The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a measure of heart failure (HF) health status. Worse KCCQ scores are common in patients with chronic kidney disease (CKD), even without diagnosed heart failure (HF). Elevations in the cardiac biomarkers GDF-15 (growth differentiation factor-15), galectin-3, sST2 (soluble suppression of tumorigenesis-2), hsTnT (high-sensitivity troponin T), and NT-proBNP (N-terminal pro-B-type natriuretic peptide) likely reflect subclinical HF in CKD. Whether cardiac biomarkers are associated with low KCCQ scores is not known. Methods and Results We studied participants with CKD without HF in the multicenter prospective CRIC (Chronic Renal Insufficiency Cohort) Study. Outcomes included (1) low KCCQ score <75 at year 1 and (2) incident decline in KCCQ score to <75. We used multivariable logistic regression and Cox regression models to evaluate the associations between baseline cardiac biomarkers and cross-sectional and longitudinal KCCQ scores. Among 2873 participants, GDF-15 (adjusted odds ratio 1.42 per SD; 99% CI, 1.19-1.68) and galectin-3 (1.28; 1.12-1.48) were significantly associated with KCCQ scores <75, whereas sST2, hsTnT, and NT-proBNP were not significantly associated with KCCQ scores <75 after multivariable adjustment. Of the 2132 participants with KCCQ ≥75 at year 1, GDF-15 (adjusted hazard ratio, 1.36 per SD; 99% CI, 1.12-1.65), hsTnT (1.20; 1.01-1.44), and NT-proBNP (1.30; 1.08-1.56) were associated with incident decline in KCCQ to <75 after multivariable adjustment, whereas galectin-3 and sST2 did not have significant associations with KCCQ decline. Conclusions Among participants with CKD without clinical HF, GDF-15, galectin-3, NT-proBNP, and hsTnT were associated with low KCCQ either at baseline or during follow-up. Our findings show that elevations in cardiac biomarkers reflect early symptomatic changes in HF health status in CKD patients.

Tai Chi exercise and functional electrical stimulation of lower limb muscles for rehabilitation in older adults with chronic systolic heart failure: a non-randomized clinical trial

Exercise-based training decreases hospitalizations in heart failure patients but such patients have exercise intolerance. The objectives of the study were to evaluate the effect of 12 weeks of Tai Chi exercise and lower limb muscles' functional electrical stimulation in older chronic heart failure adults. A total of 1,084 older adults with chronic systolic heart failure were included in a non-randomized clinical trial (n=271 per group). The control group did not receive any kind of intervention, one group received functional electrical stimulation of lower limb muscles (FES group), another group practiced Tai Chi exercise (TCE group), and another received functional electrical stimulation of lower limb muscles and practiced Tai Chi exercise (FES & TCE group). Quality of life and cardiorespiratory functions of all patients were evaluated. Compared to the control group, only FES group had increased Kansas City Cardiomyopathy Questionnaire (KCCQ) score (P<0.0001, q=9.06), only the TCE group had decreased heart rate (P<0.0001, q=5.72), and decreased peak oxygen consumption was reported in the TCE group (P<0.0001, q=9.15) and FES & TCE group (P<0.0001, q=10.69). FES of lower limb muscles and Tai Chi exercise can recover the quality of life and cardiorespiratory functions of older chronic heart failure adults (trial registration: Research Registry 4474, January 1, 2015).

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus

Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure.

Physiological and Psychological Stress in Patients Living With a Left Ventricular Assist Device

Patients with a left ventricular assist device (LVAD) commonly experience psychological distress post-implantation, but physiological stress and differences by implant strategy remain unstudied. This study describes indicators of physiological (salivary cortisol, C-reactive protein, sleep quality) and psychological (perceived stress, depression, and fatigue) stress by implant strategy and examines relationships between stress and outcomes (quality of life [QOL] and functional status). Prospective, cross-sectional data were collected from patients ≥3 months post-LVAD implantation (n = 44), and descriptive statistics and logistic regression were used. The study sample was average age 57.7 ± 13 years, mostly male (73%), married (70.5%), and racially diverse. Median LVAD support was 18.2 months. Most had normal cortisol awakening response and fair sleep quality, with moderate psychological stress. There were no differences in stress by implant strategy. Normal cortisol awakening response was correlated with low depressive symptoms. Sleep quality and psychological stress were associated with QOL, whereas cortisol and C-reactive protein levels were associated with functional status. This is the first report of salivary biomarkers and stress in LVAD outpatients. Future research should examine physiological and psychological stress and consider potential clinical implications for stress measurement for tailored approaches to stress management in this population.

[Research on the cardiovascular function evaluation system based on noninvasive detection indices]

Based on the noninvasive detection indeices and fuzzy mathematics method, this paper studied the noninvasive, convenient and economical cardiovascular health assessment system. The health evaluation index of cardiovascular function was built based on the internationally recognized risk factors of cardiovascular disease and the noninvasive detection index. The weight of 12 indexes was completed by the analytic hierarchy process, and the consistency test was passed. The membership function, evaluation matrix and evaluation model were built by fuzzy mathematics. The introducted methods enhanced the scientificity of the evaluation system. Through the Kappa consistency test, McNemer statistical results ( P = 0.995 > 0.05) and Kappa values (Kappa = 0.616, P < 0.001) suggest that the comprehensive evaluation results of model in this paper are relatively consistent with the clinical, which is of certain scientific significance for the early detection of cardiovascular diseases.

Quality of life and outcomes in heart failure patients with ejection fractions in different ranges

AIMS

Guidelines divide patients with heart failure (HF) into 3 distinct groups based on left ventricular ejection fraction (LVEF) We used the Minnesota Living with Heart Failure Questionnaire (MLHFQ) to quantify the health-related quality of life in patients with HF.

METHODS

Patients were stratified into three cohorts: preserved LVEF (>50%), mid-range LVEF (40-49%) and reduced LVEF (<40%). The MLHFQ scores were evaluated using one-way ANOVA, and differences were observed among the groups. The association of New York Heart Association (NYHA) class with the physical scores was analyzed by Spearman's correlation analysis. The predictive utility of the total MLHFQ scores was assessed with Kaplan-Meier curves for death and HF-related hospitalization. The Cox proportional hazards model was used to identify the risk factors for prognosis. Internal reliability was assessed with Cronbach's α.

RESULTS

There were significant differences in the total MLHFQ scores and the MLHFQ subscale scores among the three groups (p<0.05). MLHFQ domains demonstrated high internal consistency among the three groups (Cronbach's α = 0.92, 0.96 and 0.93). The MLHFQ physical subscale scores were significantly associated with NYHA class in HFrEF (r = 0.59, p<0.001) and HFmrEF patients (r = 0.537, p<0.001). The survival analysis indicated that there was a significant difference among the three groups regarding high MLHFQ scores (p = 0.038). In the groups with low MLHFQ scores, the HFmrEF group exhibited significantly increased rates of death and HF-related hospitalization compared with the HFpEF group (p = 0.035).

CONCLUSIONS

The features and clinical outcomes varied among heart failure patients with different EF values. The MLHFQ appears to be a valid and reliable measurement of health status and offers excellent prognostic ability.

Outcomes of spironolactone treatment in patients in Northeast China suffering from heart failure with mid-range ejection fraction

AIM

The treatment effects of spironolactone on heart failure with reduced (HFrEF LVEF <40%) and preserved (HFpEF LVEF ≥50%) ejection fraction are well characterized. It is not clear whether heart failure patients with mid-range ejection fraction (HFmrEF, LVEF 40-49%) benefit from spironolactone. The present study aims to evaluate the efficacy of spironolactone in HFmrEF patients.

METHOD

This study compared a high dosage of spironolactone (50 mg daily), a low dosage of spironolactone (25 mg daily), and an untreated group for the prevention of major adverse cardiovascular events (MACE) in 279 patients admitted to hospital diagnosed with HFmrEF.

RESULTS

With a mean follow-up duration of 1 year, the death and HF-rehospitalization rate demonstrated significantly lower incidence in those taking spironolactone, compared with the untreated group (21.3% vs 34.5%, p = .014, respectively). Further analysis showed no difference between two spironolactone groups (21.8% vs 20.7%, p = .861). Kaplan-Meier analysis of outcome-free survival illustrated a significant difference in survival rate among three groups (log-rank testing, p = .045). Compared with the baseline level, patients receiving 25 mg spironolactone had a lower physical score (p < .05) at 1-year follow-up. MLHFQ total scores in the two spironolactone groups markedly improved compared with the untreated group (p < .001); similar results were observed in the MLHFQ physical scores (p = .025, .001, respectively) and emotional sub-scale (p = .023, .011, respectively); however, paired comparison between the two spironolactone groups showed no difference.

CONCLUSIONS

In patients with HFmrEF, treatment with spironolactone significantly reduced the incidence of the primary composite outcomes of all-cause death, and rehospitalization for the management of heart failure compared with placebo, and a high dosage of spironolactone did not show trends of reduction in MACE.

The pleiotropic association between IL-10 levels and CVD prognosis: Evidence from a meta-analysis

We examined the precise association between IL-10 levels and cardiovascular disease (CVD) prognosis and explored the pleiotropic role of IL-10 in different cardiac pathologies. We performed a meta-analysis of cross-sectional and longitudinal studies investigating IL-10 levels. Meta-regression analyses were used to determine the cause of the discrepancies. To assess publication bias, funnel plots were constructed, and Egger's tests were performed. Data from the GSE58015 dataset were used to investigate the levels of IL-10 under certain conditions. Because of substantial heterogeneity in the data used to compare the IL-10 levels between patients with CVD and healthy people, we could not determine the differences between the healthy controls and patients with ischemic or nonischemic pathologies (p > 0.05). The analysis of the association between IL-10 levels and CVD prognosis indicated that higher IL-10 levels were significantly associated with a poor prognosis in patients with nonischemic pathologies (HR = 1.10, 95% CI = 1.00-1.20, p = 0.043) but differentially associated with the prognosis of patients with ischemic pathologies based on the sampling time point (before percutaneous coronary intervention (PCI): HR = 4.90, 95% CI = 1.24-19.30, p < 0.001; after PCI: HR = 0.57, 95% CI = 0.43-0.75, p = 0.023). The meta-regression analysis showed that the pooled HR of the IL-10 levels was positively correlated with the IL-10/IL-6 ratio (β = 0.644, p = 0.024). The funnel plots and Egger's tests revealed no statistically significant bias in our meta-analysis (p > 0.1). Furthermore, our data mining analysis supported our findings. Our analysis showed that IL-10 levels may be pleiotropically associated with the CVD prognosis possibly based on the type of pathology, disease stage and levels of other proinflammatory factors, such as IL-6.

Comparison of the Kansas City Cardiomyopathy Questionnaire and Minnesota Living With Heart Failure Questionnaire in Predicting Heart Failure Outcomes

Patient-reported outcome measures (PROMs) are relevant independent outcomes in heart failure (HF) care and are predictive of subsequent hospitalization and death in HF. The Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) are the 2 most widely adopted PROMs specific to HF. We compared their prognostic abilities in a prospective cohort of HF patients. A prospective cohort of subjects from a single-center registry was analyzed with regard to baseline KCCQ and MLHFQ scores and the outcomes of death, transplant, or left ventricular assist device implantation and hospitalization. A total of 516 subjects with reduced left ventricular ejection fraction (HFrEF) and 151 subjects with preserved left ventricular ejection fraction (HFpEF) were included. Discrimination was assessed using c-statistics based on time-to-event analyses and receiver-operator curves. The additive contribution of MLHFQ was assessed through the change in c-statistic, incremental discrimination index, and category-free net reclassification index. Overall, KCCQ was superior to MLHFQ for predicting death/transplant/ventricular assist device (c-statistic 0.702 [0.666 to 0.738] and 0.658 [0.621 to 0.695] respectively, p value for difference <0.001) and hospitalization (c-statistic 0.640 [0.613 to 0.666] and 0.624 [0.597 to 0.651], respectively, p value for difference 0.022). However, this difference was statistically nonsignificant in the HFpEF group alone. When analyzing the additional prognostic information afforded by adding MLHFQ to KCCQ in the overall, HFrEF, and HFpEF groups there was no significant improvement, although adding KCCQ to MLHFQ did significantly improve risk stratification. Scoring based upon the abbreviated KCCQ-12 did not reduce the prognostic accuracy of KCCQ. In conclusion, KCCQ is more prognostic of death/transplant/left ventricular assist device and hospitalization than MLHFQ in a combined cohort of patients with HFrEF and HFpEF, although the effect in HFpEF was less pronounced. KCCQ should be the preferred PROM for patients with HF if prognostication is a desired goal of using the PROMs.

The impact of heart rate on patients diagnosed with heart failure with mid-range ejection fraction

OBJECTIVE

The relationship between prognosis and heart rate remains unclear among patients diagnosed with heart failure with mid-range ejection fraction (HFmrEF). The aim of the present study was to assess the effect of heart rate in this group of patients.

METHODS

Of the 197 patients diagnosed with HFmrEF, 92 had a heart rate <70 beats/min (bpm), and 105 had a heart rate ≥70 bpm. We analyzed the outcomes including all-cause death and HF-related hospitalization and evaluated the quality of life.

RESULTS

The outcome demonstrated a lower incidence in patients with heart rate <70 bpm. The outcome-free survival illustrated significant difference in survival rate (p=0.045). The Minnesota Living with Heart Failure Questionnaire total scores and physical subscale in the lower heart rate group decreased compared with the heart rate ≥70 bpm group (p=0.048 and p=0.03, respectively). In the following analysis of patients with sinus rhythm, beta blockers showed great positive effects on patients with heart rate <70 bpm (p=0.046), as for the quality of life in patients with beta blocker, heart rate <70 bpm showed lower total and physical scores (p=0.025 and p=0.017, respectively).

CONCLUSION

Our results showed that heart rate is an important prognostic factor in patients with HFmrEF. Patients with heart rate <70 bpm was related with a lower risk of outcomes and better quality of life. Beta blockers reduced the outcome rate in patients with sinus rhythm.

Left Ventricular Diastolic Dysfunction is Associated with Renal Dysfunction, Poor Survival and Low Health Related Quality of Life in Cirrhosis

BACKGROUND

The presence of left ventricular diastolic dysfunction (LVDD) in patients with cirrhosis leads to a restriction of activities and a poor health related quality of life (HRQoL), which should be taken into consideration when treating them for liver and cardiac complications.

AIMS

The prevalence, complications, predictors of HRQoL and survival in cirrhotic patients with LVDD were studied.

METHODS

We report a prospective cohort study of 145 consecutive cirrhotic patients with LVDD who were evaluated for cardiac functional status at enrollment and followed up for hepatic complications, cardiac events, outcome and HRQoL using the Minnesota Living With Heart Failure Questionnaire (MLHFQ) over a period of 2 years.

RESULTS

In total, 145 (mean age 61 years, 59% male) patients were included. Seventeen patients died with 10.5%, 22.5% and 40% mortality rates in patients with Grades 1, 2 and 3 LVDD respectively over 24 months. The parameters that were significant for predicting mortality on bivariate analysis were MELD, MELDNa, hepatic venous pressure gradient, MLHFQ, and left ventricular (LV) diastolic function (e' and E/e' ratio), but only MELD, MELDNa and E/e' remained significant on multivariate analysis. The E/e' ratio (8.7 ± 3.3 in survivors vs. 9.1 ± 2.3 in non-survivors) predicted outcome. On univariate analysis, the predictors of poor HRQoL were the Child-Pugh score ≥9.8 (OR 2.6; 95% confidence intervals (CI) 2.3-9.1, P = 0.041), MELD score ≥ 15.7 (OR 2.48; 95% CI 1.4-3.9, P = 0.029), refractory ascites (OR 1.9; 95% CI 1.1-6.1, P = 0.050), and E/e' ratio ≥7.6 (OR 1.9; 95% CI 1.8-7.1, P = 0.036) The presence of Class II/III (P = 0.046) symptoms of heart failure and MLHFQ≥ 45 (P = 0.042) were predictors of mortality at 24 months.

CONCLUSION

The grade of LVDD correlates with liver function, clinical events, risk of renal dysfunction and HRQoL. Evaluation of novel therapies which target symptomatic improvement in LVDD, should be done with suitable outcome measures, including HRQoL assessment.

CRP genetic variants are associated with mortality and depressive symptoms in chronic heart failure patients

OBJECTIVE

Heart failure (HF) is a complex medical condition with a multitude of genetic and other factors being involved in the pathogenesis. Emerging evidence points to an involvement of inflammatory mechanisms at least in subgroups of patients. The same is true for depression and depressive symptoms, which have a high prevalence in HF patients and are risk factors for the development and outcomes of cardiovascular disease.

METHODS

In 936 patients of the Interdisciplinary Network Heart Failure (INH) program, CRP and IL-6 protein blood levels were measured and genetic variants (single nucleotide polymorphisms) of the CRP and IL6 gene analyzed regarding their influence on mortality.

RESULTS

Less common recessive genotypes of two single nucleotide polymorphisms in the CRP gene (rs1800947 and rs11265263) were associated with significantly higher mortality risk (p < 0.006), higher CRP levels (p = 0.029, p = 0.006) and increased depressive symptoms in the PHQ-9 (p = 0.005, p = 0.003). Variants in the IL-6 gene were not associated with mortality.

CONCLUSION

Our results hint towards an association of less common CRP genetic variants with increased mortality risk, depressive symptoms and peripheral CRP levels in this population of HF patients thereby suggesting a possible role of the inflammatory system as link between poor prognosis in HF and depressive symptoms.

CHF-PROM: validation of a patient-reported outcome measure for patients with chronic heart failure

BACKGROUND

Due to a lack of an appropriate disease-specific patient-reported outcome (PRO) instrument for chronic heart failure including its social support and treatment aspects in China, this study was performed to develop a patient-reported outcome measure (PROM) for patients with chronic heart failure and evaluate its reliability, validity, and feasibility.

METHODS

According to the standard PROM guidelines established by the Food and Drug Administration, an item pool was formed by reviewing a large amount of relevant literature and interviewing patients with chronic heart failure about their main symptoms. Thus, the primary scale was created after adjusting the items and language with the help of patients and experts in the field. Next, 155 patients from 8 hospitals in different districts were recruited for a pilot survey using questionnaires containing these items. The patients' responses were analyzed using the classical test theory and item response theory to select high-quality items and determine the subdomains of the scale. This was followed by a formal investigation in the same eight hospitals. In total, 360 patients and 100 healthy subjects were included to evaluate the reliability, validity, and feasibility of the items. Through this process, the final scale was established.

RESULTS

The final scale comprised 12 subdomains with 57 items related to physical, psychological, social, and therapeutic areas. The data analysis results of the formal investigation showed that the PROM for chronic heart failure had good reliability, validity, and feasibility. Reliability was verified by Cronbach's alpha coefficient, which was 0.913 for the total scale, 0.903 for the physical domain, 0.941 for the psychological domain, 0.827 for the social domain, and 0.839 for the therapeutic domain. The construct validity results met the relative criteria of confirmatory factor analysis. Discriminant validity was represented by score comparisons of nine subdomains. The response rate and the effective rate of return of the CHF-PROM were 98.94% and 98.92%, respectively.

CONCLUSIONS

The final scale coincides with the theoretical framework and better reflects the overall quality of life of patients with chronic heart failure. This scale can be used as a valid instrument to evaluate clinical treatment and clinical trials of chronic heart failure.

Targeting BNIP3 in inflammation-mediated heart failure: a novel concept in heart failure therapy

Myocardial injury activates inflammatory mediators and provokes the integration of BCL-2/adenovirus E1B 19KD interacting protein 3 (BNIP3) into mitochondrial membranes. Translocation of BNIP3 to mitochondria inexorably causes mitochondrial fragmentation. Heart failure (HF) epitomizes the life-threatening phase of BNIP3-induced mitochondrial dysfunction and cardiomyocyte death. Available data suggest that inflammatory mediators play a key role in cardiac cell demise and have been implicated in the pathogenesis of HF syndrome. In the present study, we reviewed the changes in BNIP3 protein expression levels during inflammatory response and postulated its role in inflammation-mediated HF. We also identified inflammatory mediators' response such as stimulation of TNF-α and NO as potent inducer of BNIP3. Previous studies suggest that the pro-apoptotic protein has a common regulator with IL-1β and induces IL-6-stimulated cardiac hypertrophy. These findings corroborate our contention that interventions designed to functionally modulate BNIP3 activity during inflammatory-mediated HF may prove beneficial in preventing HF. Such a revelation will open new avenue for further research to unravel a novel therapeutic strategy in HF diseases. Moreover, understanding of the relationship between BNIP3 and inflammatory mediators in HF pathologies will not only contribute to the discovery of drugs that can inhibit inflammation-mediated heart diseases, but also enhance the current knowledge on the key role BNIP3 plays during inflammation.

Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Quality of life (QOL) is impaired in pancreatic cancer patients. Our aim was to investigate the determinants and prognostic value of QOL after diagnosis in a hospital-based cohort of racially/ethnically diverse patients with pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

QOL was prospectively assessed using the Short Form-12 in 2478 PDAC patients. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were categorised into tertiles based on their distribution. Ordered logistic regression was adopted to compare the risk of having lower PCS and MCS by patient sociodemographic and clinical characteristics. The association of PCS and MCS with mortality was assessed by Cox regression.

RESULTS

Compared with non-Hispanic whites, Hispanics were at significantly higher risk of having lower PCS (odds ratio [95% CI], 1.69 [1.26-2.26]; P < 0.001) and lower MCS (1.66 [1.24-2.23]; P < 0.001). Patients diagnosed with stage III (1.80 [1.10-2.94]; P = 0.02) and stage IV (2.32 [1.50-3.59]; P < 0.001) PDAC were more likely to have lower PCS than stage I patients. Other determinants of QOL included sex, age, drinking, smoking, education level, comorbidities and time since diagnosis. The low tertile of PCS (hazard ratio [95% CI], 1.94 [1.72-2.18]; P < 0.001) and MCS (1.42 [1.26-1.59]; P < 0.001) were each related to poor prognosis. Similar results were found for non-Hispanic whites as compared with African-Americans/Hispanics/others.

CONCLUSION

QOL after diagnosis is a significant prognostic indicator for patients with PDAC. Multiple factors determine QOL, suggesting possible means of intervention to improve QOL and outcomes of PDAC patients.

A Personalized and Interactive Web-Based Health Care Innovation to Advance the Quality of Life and Care of Patients With Heart Failure (ACQUIRE-HF): A Mixed Methods Feasibility Study

Background

Heart failure (HF) is a progressive, debilitating, and complex disease, and due to an increasing incidence and prevalence, it represents a global health and economic problem. Hence, there is an urgent need to evaluate alternative care modalities to current practice to safeguard a high level of care for this growing population.

Objective

Our goal was to examine the feasibility of engaging patients to use patient-centered and personalized tools coupled with a Web-based, shared care and interactive platform in order to empower and enable them to live a better life with their disease.

Methods

We used a mixed methods, single-center, pre-post design. Patients with HF and reduced left ventricular ejection fraction (n=26) were recruited from the outpatient HF clinic at Odense University Hospital (Svendborg Hospital), Denmark, between October 2015 and March 2016. Patients were asked to monitor their health status via the platform using the standardized, disease-specific measure, the Kansas City Cardiomyopathy Questionnaire (KCCQ), and to register their weight. A subset of patients and nursing staff were interviewed after 3-month follow-up about their experiences with the platform.

Results

Overall, patients experienced improvement in patient-reported health status but deterioration in self-care behavior between baseline and 3-month follow-up. The mean score reflecting patient expectations toward use prior to start of the study was lower (16 [SD 5]) than their actual experiences with use of the platform (21 [SD 5]) after 3-month follow-up. Of all patients, 19 completed both a baseline and follow-up KCCQ. A total of 9 experienced deterioration in their health status (range from 3-34 points), while 10 experienced an improvement (range from 1-23 points). The qualitative data indicated that the majority of patients found the registration and monitoring on the platform useful. Both nursing staff and patients indicated that such monitoring could be a useful tool to engage and empower patients, in particular when patients are just diagnosed with HF.

Conclusions

The use of patient tracking and monitoring of health status in HF using a standardized and validated measure seems feasible and may lead to insights that will help educate, empower, and engage patients more in their own disease management, although it is not suitable for all patients. Nursing staff found the patient-centered tool beneficial as a communication tool with patients but were more reticent with respect to using it as a replacement for the personal contact in the outpatient clinic.

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.

Predictive value of sICAM-1 and sVCAM-1 as biomarkers of affective temperaments in healthy young adults

BACKGROUND

Affective temperaments are intermediate phenotypes for major affective disorders and are reported to have a neuroimmune etiopathogenesis. Here we investigated the role of soluble intercellular cell adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) in affective temperaments and mood symptoms in healthy adults.

METHODS

Healthy adults (n=94) were screened for psychiatric disorders using the nonpatient version of the Structured Clinical Interview for DSM-IV-I and II. Subjects with medical conditions associated with changes in inflammatory response were excluded, deriving the final sample (n=68). Affective temperaments were evaluated with Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire (TEMPS-A). State mood symptoms were assessed using the Young Mania Rating Scale and Montgomery-Åsberg Depression Rating Scale. Serum sICAM-1 and sVCAM-1 levels were measured using enzyme-linked immunosorbent assay.

RESULTS

After adjusting for confounders (age, gender, BMI, and smoking habits), a high negative correlation between depressive and irritable temperament TEMPS-A scores and sVCAM-1 levels was detected. Although we identified no association between sICAM-1 levels and affective temperament scores, sICAM-1 was related to the state severity of manic symptoms. In a multiple linear regression model, sVCAM-1 remained a significant predictor of depressive but not irritable temperament scores.

LIMITATIONS

The temperaments were estimated on the basis of self-report questionnaire.

CONCLUSIONS

Our findings suggest that sVCAM-1 is related to affective temperaments, and it is a trait marker for liability to mood disorders. This relationship between alterations in cellular adhesion and affective temperament may be important for vulnerability to affective disorders.

Kansas City Cardiomyopathy Questionnaire Administered to Hospitalized Patients With Heart Failure

BACKGROUND AND PURPOSE

The psychometric properties of the Kansas City Cardiomyopathy Questionnaire (KCCQ) have been examined primarily in community-dwelling patients with heart failure (HF). The objective of this research was to examine the properties of the KCCQ administered to patients hospitalized with HF (N = 233).

METHODS

Confirmatory factor analysis, Cronbach's alphas, and correlations were performed to examine the scale's dimensions, reliability, and validity.

RESULTS

Confirmatory factor analysis indicated a 5-factor solution (63.6% of the variance). The Cronbach's alpha levels were greater than .70, except for the self-efficacy dimension (.60). Convergent validity was not verified between the KCCQ and several illness severity measures.

CONCLUSIONS

The psychometric properties of the KCCQ may be different based on the population in which the KCCQ is administered, which may have clinical implications.

Depressive symptoms in heart failure: Independent prognostic factor or marker of functional status?

OBJECTIVE

The prognostic potential of depressive symptoms independent of somatic features of heart failure severity has repeatedly been demonstrated. However, patient-reported functional status has rarely been accounted for in these studies. Thus, it has remained unclear to what extent the predictive power of depressive symptoms may mirror functional status. We therefore aimed to evaluate the prognostic value of depressive symptoms adjusting for patient-reported functional status in a large, well-characterized sample of patients with systolic heart failure.

METHODS

Eight hundred sixty-three patients, 67±12 years old, 72% men, and 42% with New York Heart Association functional classes III/IV, who participated in the extended Interdisciplinary Network Heart Failure (INH) study were investigated. We assessed depressive symptoms using the Patient Health Questionnaire (PHQ-9) and patient-reported functional status with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Data on survival was obtained after a follow-up of 18 months (100% complete).

RESULTS

Depressive symptoms predicted mortality risk (HR per PHQ-9 scale point=1.07, 95% CI 1.04-1.09, p<.001), even after adjustment for heart failure severity and co-morbidities (HR=1.04, 95% CI 1.01-1.07, p=.017). However, they were no longer significant predictors (HR=1.01, 95% CI 0.98-1.05, p=0.46) after additional adjustment for patient-reported functional status, which proved predictive of mortality risk (HR=0.90, 95% CI 0.82-0.99, p=.025).

CONCLUSION

Our results suggest that the association of depressive symptoms with functional status may at least partly explain the prognostic potential of depressive symptoms.

Kansas City Cardiomyopathy Questionnaire Score Is Associated With Incident Heart Failure Hospitalization in Patients With Chronic Kidney Disease Without Previously Diagnosed Heart Failure: Chronic Renal Insufficiency Cohort Study

BACKGROUND

Chronic kidney disease is a risk factor for heart failure (HF). Patients with chronic kidney disease without diagnosed HF have an increased burden of symptoms characteristic of HF. It is not known whether these symptoms are associated with occurrence of new onset HF.

METHODS AND RESULTS

We studied the association of a modified Kansas City Cardiomyopathy Questionnaire with newly identified cases of hospitalized HF among 3093 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study who did not report HF at baseline. The annually updated Kansas City Cardiomyopathy Questionnaire score was categorized into quartiles (Q1-4) with the lower scores representing the worse symptoms. Multivariable-adjusted repeated measure logistic regression models were adjusted for demographic characteristics, clinical risk factors for HF, N-terminal probrain natriuretic peptide level and left ventricular hypertrophy, left ventricular systolic and diastolic dysfunction. Over a mean (±SD) follow-up period of 4.3±1.6 years, there were 211 new cases of HF hospitalizations. The risk of HF hospitalization increased with increasing symptom quartiles; 2.62, 1.85, 1.14, and 0.74 events per 100 person-years, respectively. The median number of annual Kansas City Cardiomyopathy Questionnaire assessments per participant was 5 (interquartile range, 3-6). The annually updated Kansas City Cardiomyopathy Questionnaire score was independently associated with higher risk of incident HF hospitalization in multivariable-adjusted models (odds ratio, 3.30 [1.66-6.52]; P=0.001 for Q1 compared with Q4).

CONCLUSIONS

Symptoms characteristic of HF are common in patients with chronic kidney disease and are associated with higher short-term risk for new hospitalization for HF, independent of level of kidney function, and other known HF risk factors.

The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations

End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.

Depressive symptoms, health-related quality of life, and cardiac event-free survival in patients with heart failure: a mediation analysis

PURPOSE

Health-related quality of life (HRQOL) and depressive symptoms both are associated with an adverse prognosis in heart failure (HF), although their associations with outcomes have been examined only in isolation. Therefore, it is unknown how HRQOL and depressive symptoms might interact in their associations with outcomes. The present study was conducted to determine whether the association between HRQOL and cardiac event-free survival is mediated by depressive symptoms in HF patients given that depressive symptoms are associated strongly with HRQOL.

METHODS

A total of 209 HF patients (61 ± 11 years, 24 % female, 49 % NYHA III/IV) participated. The Minnesota Living with HF Questionnaire and the Patient Health Questionnaire-9 were used to measure HRQOL and depressive symptoms, respectively. Patients were followed for a median of 357 days to determine cardiac event-free survival.

RESULTS

In Cox regression analysis, HRQOL [hazard ratio (HR) 1.013; 95 % confidence interval (CI) 1.001-1.026] and depressive symptoms (HR 1.075; 95 % CI 1.025-1.127) predicted cardiac event-free survival separately, controlling for demographic and clinical variables. HRQOL independently explained 38.7 % of the variance in depressive symptoms (p < 0.05; standardized β = 0.695) in a multiple regression. When HRQOL and depressive symptoms were entered in the model simultaneously, only depressive symptoms independently predicted cardiac event-free survival (HR 1.068; 95 % CI 1.001-1.139), demonstrating a mediation effect of depressive symptoms.

CONCLUSIONS

Depressive symptoms mediated the relationship between HRQOL and cardiac event-free survival. Interventions targeting HRQOL to enhance patient outcomes must also address patient depressive symptoms to be fully efficacious.

Comparable performance of the Kansas City Cardiomyopathy Questionnaire in patients with heart failure with preserved and reduced ejection fraction

BACKGROUND

Despite the growing epidemic of heart failure with preserved ejection fraction (HFpEF), no valid measure of patients' health status (symptoms, function, and quality of life) exists. We evaluated the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated measure of HF with reduced EF, in patients with HFpEF.

METHODS AND RESULTS

Using a prospective HF registry, we dichotomized patients into HF with reduced EF (EF≤ 40) and HFpEF (EF≥50). The associations between New York Heart Association class, a commonly used criterion standard, and KCCQ Overall Summary and Total Symptom domains were evaluated using Spearman correlations and 2-way ANOVA with differences between patients with HF with reduced EF and HFpEF tested with interaction terms. Predictive validity of the KCCQ Overall Summary scores was assessed with Kaplan-Meier curves for death and all-cause hospitalization. Covariate adjustment was made using Cox proportional hazards models. Internal reliability was assessed with Cronbach's α. Among 849 patients, 200 (24%) had HFpEF. KCCQ summary scores were strongly associated with New York Heart Association class in both patients with HFpEF (r=-0.62; P<0.001) and HF with reduced EF (r=-0.55; P=0.27 for interaction). One-year event-free rates by KCCQ category among patients with HFpEF were 0 to 25=13.8%, 26 to 50=59.1%, 51 to 75=73.8%, and 76 to 100=77.8% (log rank P<0.001), with no significant interaction by EF (P=0.37). The KCCQ domains demonstrated high internal consistency among patients with HFpEF (Cronbach's α=0.96 for overall summary and ≥0.69 in all subdomains).

CONCLUSIONS

Among patients with HFpEF, the KCCQ seems to be a valid and reliable measure of health status and offers excellent prognostic ability. Future studies should extend and replicate our findings, including the establishment of its responsiveness to clinical change.

Pre-operative health status and outcomes after continuous-flow left ventricular assist device implantation

BACKGROUND

Health status predicts adverse outcomes in heart failure and cardiac surgery patients, but its prognostic value in left ventricular assist device (LVAD) placement is unknown.

METHODS

We examined the association of pre-operative health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), with survival and hospitalization after LVAD using the KCCQ score as a continuous variable and stratified by KCCQ score quartile plus missing KCCQ in 1,125 clinical trial participants who received the HeartMate II (Thoratec Corp, Pleasanton, CA) as destination therapy (n = 635) or bridge to transplantation (n = 490).

RESULTS

The mean pre-operative KCCQ score was 29.4 ± 18.7 among survivors (n = 719), and 27.1 ± 18.3 (n = 406) in those who died. In time-to-event analysis for all available follow-up using health status as a continuous variable, the pre-operative KCCQ score did not correlate with overall mortality after LVAD implantation (p = 0.178). Small absolute differences were seen between the pre-operative KCCQ quartile and 30-day survival (Q4 95% vs. Q1 89% vs. missing 87%; p = 0.0009 for trend), 180-day survival (Q4 83% vs. Q1 76% vs missing 79%; p = 0.060 for trend), and days hospitalized at 180 days (Q4 29.8 ± 25.6 vs. Q1 34.1 ± 27.1 vs. missing 36.5 ± 29.9 days; p = 0.009 for trend).

CONCLUSION

Our findings suggest that pre-operative health status has limited association with outcomes after LVAD implantation. Although these data require further study in a diverse population, mechanical circulatory support may represent a relatively unique clinical situation, distinct from heart failure and other cardiac surgeries, in which heart failure-specific health status measures may be largely reversed.

Correlation between changes in diastolic dysfunction and health-related quality of life after cardiac rehabilitation program in dilated cardiomyopathy

Chronic heart failure (CHF) is a complex syndrome characterized by progressive decline in left ventricular function, low exercise tolerance and raised mortality and morbidity. Left ventricular diastolic dysfunction plays a major role in CHF and progression of most cardiac diseases. The current recommended goals can theoretically be accomplished via exercise and pharmacological therapy so the aim of the present study was to evaluate the impact of cardiac rehabilitation program on diastolic dysfunction and health related quality of life and to determine the correlation between changes in left ventricular diastolic dysfunction and domains of health-related quality of life (HRQoL). Forty patients with chronic heart failure were diagnosed as having dilated cardiomyopathy (DCM) with systolic and diastolic dysfunction. The patients were equally and randomly divided into training and control groups. Only 30 of them completed the study duration. The training group participated in rehabilitation program in the form of circuit-interval aerobic training adjusted according to 55-80% of heart rate reserve for a period of 7 months. Circuit training improved both diastolic and systolic dysfunction in the training group. On the other hand, only a significant correlation was found between improvement in diastolic dysfunction and health related quality of life measured by Kansas City Cardiomyopathy Questionnaire. It was concluded that improvement in diastolic dysfunction as a result of rehabilitation program is one of the important underlying mechanisms responsible for improvement in health-related quality of life in DCM patients.

Type D personality and course of health status over 18 months in outpatients with heart failure: multiple mediating inflammatory biomarkers

BACKGROUND

The distressed (Type D) personality is associated with poor health status (HS) and increased inflammatory activation in heart failure (HF). We tested whether multiple inflammatory biomarkers mediated the association between Type D personality and the course of self-reported HS over 18 months.

METHODS

HF outpatients (n=228, 80% male, mean age 67.0±8.7 years), filled out the Type D questionnaire (DS14) at inclusion and the Short Form-12 (SF12) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) at 0, 6, 12, and 18 months. Blood samples at inclusion were analyzed for high sensitive C-reactive protein (hsCRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, and its soluble receptors (sTNFr1, sTNFr2). A multiple mediation latent growth model was tested using structural equation modeling.

RESULTS

Type D personality (prevalence=21%) was associated with poorer HS (all scales p<0.001), deterioration of mental HS (p<0.001), and higher TNF-α and sTNFr2 levels in the full mediation model. A higher inflammatory burden was associated with a poorer baseline level and a deterioration of generic physical, mental and disease-specific HS. No mediating effects were found for the multiple inflammatory biomarkers on the association between Type D and baseline self-reported HS, whereas change in physical HS was significantly mediated by the group of five inflammatory biomarkers (p=0.026).

CONCLUSIONS

Only the association between Type D personality and change in self-reported physical health status was significantly mediated by inflammatory biomarkers. Future research should investigate whether the association between Type D personality and poor health status may be explained by other biological or behavioral factors.

Additive prognostic value of subjective assessment with respect to clinical cardiological data in patients with chronic heart failure

BACKGROUND

Health-related quality of life tools that better reflect the unique subjective perception of heart failure (HF) are needed for patients with this disorder. The aim of this study was to explore whether subjective satisfaction of HF patients about daily life may provide additional prognostic information with respect to clinical cardiological data.

METHODS

One hundred and seventy-eight patients (age 51 ± 9 years) with moderate to severe HF [New York Heart Association (NYHA) class 2.0 ± 0.7; left ventricular ejection fraction (LVEF) 29 ± 8%] in stable clinical condition underwent a standard clinical evaluation and compiled the Satisfaction Profile (SAT-P) questionnaire focusing on subjective satisfaction with daily life. Cox regression analysis was used to assess whether SAT-P factors (psychological functioning, physical functioning, work, sleep/eating/leisure, social functioning) had any prognostic value.

RESULTS

Forty-six cardiac deaths occurred during a median of 30 months. Patients who died had higher NYHA class, more depressed left ventricular function, reduced systolic blood pressure (SBP), increased heart rate (HR), and worse biochemistry (all p < 0.05). Among the SAT-P factors, only physical functioning (PF) was significantly reduced in the patients who died (p = 0.003). Using the best subset selection procedure, resistance to physical fatigue (RPF) was selected from among the items of the PF factor. RPF showed independent predictive value when entered into a prognostic model including NYHA class, LVEF, SBP, and HR with an adjusted hazard ratio of 0.86 per 10 units increase (95% CI 0.75-0.98, p = 0.02).

CONCLUSIONS

Patients' dissatisfaction with physical functioning is associated with reduced long-term survival, after adjustment for known risk factors in HF. Given its user-friendly structure, simplicity, and significant prognostic value, the RPF score may represent a useful instrument in clinical practice.

Metabolomic differences in heart failure patients with and without major depression

Metabolomics is an emerging technology that allows researchers to characterize hundreds of small molecules that comprise the metabolome. We sought to determine metabolic differences in depressed and nondepressed participants. The sample consisted of a depressed group of patients with heart failure enrolled in an NIMH-supported clinical trial of sertraline versus placebo in depressed heart failure patients, and a nondepressed comparator group of heart failure patients. Plasma was obtained from blood samples provided by participants at baseline, and samples were profiled on GC-MS and LC-MS metabolomics platforms for biochemical content. A number of biochemicals were significantly different between groups, with depressed participants showing higher concentrations of several amino acids and dicarboxylic fatty acids. These results are consistent with prior findings where changes in neurotransmitter systems and fatty acid metabolism were shown to associate with the depressed state. It is unclear what role heart failure may have played in these differing concentrations.

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

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

Association of polymorphism in the human mu-opioid receptor OPRM1 gene with proinflammatory cytokine levels and health perception

Recent studies in psychoneuroimmunology have indicated that proinflammatory cytokines cause several diseases and behaviors that overlap symptomatically with depression. It is known that the endogenous opioid peptide beta-endorphin regulates proinflammatory cytokine secretion from peripheral immune cells via mu-opioid receptor-dependent mechanisms. Therefore, it is possible that the functional polymorphism of the mu-opioid receptor gene (OPRM1, SNP: A118G) influences peripheral circulating proinflammatory cytokine levels and the health-related quality of life (QOL) even in healthy populations. In this study, we compared the serum concentrations of several proinflammatory cytokines (interleukin-2 (IL-2), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma)) and the health-related QOL between OPRM1 genotypes. Interestingly, serum concentrations of IL-6, TNF-alpha, and IFN-gamma were significantly lower and the general health score was significantly higher in carriers of the G allele, who show a strong binding of beta-endorphin to the mu-opioid receptor as compared to individuals without the G allele. Correlation analysis indicated that the general health score was negatively correlated with the IL-6 serum concentration. These results suggest that the sensitive endogenous opioid system in carriers of the G allele may suppress proinflammatory cytokine secretion from peripheral immune cells; consequently, it may influence the health perception.