Comparative value of NYHA functional class and quality-of-life questionnaire scores in assessing heart failure. J Cardiopulm Rehabil Prev. 2010;30:101-105. [PMID: 19952769 DOI: 10.1097/hcr.0b013e3181be7e47]

Haemodynamic determinants of quality of life in chronic heart failure

Background

Heart failure patients demonstrate reduced functional capacity, hemodynamic function, and quality of life (QOL) which are associated with high mortality and morbidity rate. The aim of the present study was to assess the relationship between functional capacity, hemodynamic response to exercise and QOL in chronic heart failure.

Methods

A single-centre prospective study recruited 42 chronic heart failure patients (11 females, mean age 60 ± 10 years) with reduced left ventricular ejection fraction (LVEF = 23 ± 7%). All participants completed a maximal graded cardiopulmonary exercise test with non-invasive hemodynamic (bioreactance) monitoring. QOL was assessed using Minnesota Living with Heart Failure Questionnaire.

Results

The average value of QOL score was 40 ± 23. There was a significant negative relationship between the QOL and peak O₂ consumption (r = − 0.50, p ≤ 0.01). No significant relationship between the QOL and selected exercise hemodynamic measures was found, including peak exercise cardiac power output (r = 0.15, p = 0.34), cardiac output (r = 0.22, p = 0.15), and mean arterial blood pressure (r = − 0.08, p = 0.60).

Conclusion

Peak O₂ consumption, but not hemodynamic response to exercise, is a significant determinant of QOL in chronic heart failure patients.

The Efficacy and Safety of Sacubitril/Valsartan in Heart Failure Patients: A Review

Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, has been approved for the treatment of HF. At present, there have been few systematic and detailed reviews discussing the efficacy and safety of sacubitril/valsartan in HF. In this review, we first introduced the pharmacological mechanisms of sacubitril/valsartan, including the reduction in the degradation of natriuretic peptides in the natriuretic peptide system and inhibition of the renin-angiotensin system. Then, we summarized the efficacy of sacubitril/valsartan in HF patients with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF) including the reduction in risks of mortality and hospitalization, reversal of cardiac remodeling, regulation of biomarkers of HF, improvement of the quality of life, antiarrhythmia, improving renal dysfunction and regulation of metabolism. Finally, we discussed the safety and tolerability of sacubitril/valsartan in the treatment of HFrEF or HFpEF. Compared with ACEIs/ARBs or placebo, sacubitril/valsartan showed good safety and tolerability, although the risk of hypotension might be high. In conclusion, the overwhelming majority of studies show that sacubitril/valsartan is effective and safe in the treatment of HFrEF patients but that it has little benefit in HFpEF patients. Sacubitril/valsartan will probably be a promising anti-HF drug in the near future.

Biomarkers-based personalized follow-up in chronic heart failure improves patient's outcomes and reduces care associate cost

BACKGROUND

Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF).

METHODS

This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient's outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data.

RESULTS

Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year.

CONCLUSIONS

A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

P-wave terminal force in lead V1 is a predictive indicator for the diagnosis of tuberculous constrictive pericarditis

OBJECTIVES

The purpose of this study is to explore the value of P-wave terminal force in lead V1 (PTFV1) in the clinical diagnosis of tuberculous constrictive pericarditis (TCP).

METHODS

A total of 53 patients with TCP and 64 patients with tuberculous exudative pericarditis were enrolled in this retrospective study. The demographic and clinical characteristics were collected, including gender, age, the course of disease and New York Heart Association (NYHA) classification. Besides, echocardiography data also were obtained, including left atrial diameter, left ventricular end-diastolic diameter and left ventricular ejection fraction. In addition, the parameters of electrocardiogram (ECG) were obtained, such as heart rate, the time from the corrected ORS wave origin to T-wave terminal, atrial fibrillation, right bundle branch block, atrial premature beat, and PTFV1 value.

RESULTS

No significant differences were found in age, gender, the course of disease, echocardiography results, ECG parameters (in addition to PTFV1) between patients with TCP and patients with tuberculous exudative pericarditis. The percentage of patients located in NYHA class IV in the patients with TCP was significantly higher than those of patients with tuberculous exudative pericarditis (p = 0.041). Moreover, the incidence rate of abnormal PTFV1 (≤ -0.04 mm·s) was obviously higher in patients with TCP than those of patients with tuberculous exudative pericarditis (64.2% vs 9.4%, p < 0.001).

CONCLUSIONS

Abnormal PTFV1 (≤ -0.04 mm·s) is associated with TCP, and PTFV1 may be a potential novel diagnostic indicator for TCP diagnosis.

A shared-parameter continuous-time hidden Markov and survival model for longitudinal data with informative dropout

A shared-parameter approach for jointly modeling longitudinal and survival data is proposed. With respect to available approaches, it allows for time-varying random effects that affect both the longitudinal and the survival processes. The distribution of these random effects is modeled according to a continuous-time hidden Markov chain so that transitions may occur at any time point. For maximum likelihood estimation, we propose an algorithm based on a discretization of time until censoring in an arbitrary number of time windows. The observed information matrix is used to obtain standard errors. We illustrate the approach by simulation, even with respect to the effect of the number of time windows on the precision of the estimates, and by an application to data about patients suffering from mildly dilated cardiomyopathy.

Neuroticism personality trait is associated with Quality of Life in patients with Chronic Heart Failure

AIM: To evaluate Quality of life (QoL) in chronic heart failure (CHF) in relation to Neuroticism personality trait and CHF severity.

METHODS: Thirty six consecutive, outpatients with Chronic Heart Failure (6 females and 30 males, mean age: 54 ± 12 years), with a left ventricular ejection fraction ≤ 45% at optimal medical treatment at the time of inclusion, were asked to answer the Kansas City Cardiomyopathy Questionnaire (KCCQ) for Quality of Life assessment and the NEO Five-Factor Personality Inventory for personality assessment. All patients underwent a symptom limited cardiopulmonary exercise testing on a cycle-ergometer, in order to access CHF severity. A multivariate linear regression analysis using simultaneous entry of predictors was performed to examine which of the CHF variables and of the personality variables were correlated independently to QoL scores in the two summary scales of the KCCQ, namely the Overall Summary Scale and the Clinical Summary Scale.

RESULTS: The Neuroticism personality trait score had a significant inverse correlation with the Clinical Summary Score and Overall Summary Score of the KCCQ (r = -0.621, P < 0.05 and r = -0.543, P < 0.001, respectively). KCCQ summary scales did not show significant correlations with the personality traits of Extraversion, Openness, Conscientiousness and Agreeableness. Multivariate linear regression analysis using simultaneous entry of predictors was also conducted to determine the best linear combination of statistically significant univariate predictors such as Neuroticism, VE/VCO₂ slope and VO₂ peak, for predicting KCCQ Clinical Summary Score. The results show Neuroticism (β = -0.37, P < 0.05), VE/VCO₂ slope (β = -0.31, P < 0.05) and VO₂ peak (β = 0.37, P < 0.05) to be independent predictors of QoL. In multivariate regression analysis Neuroticism (b = -0.37, P < 0.05), the slope of ventilatory equivalent for carbon dioxide output during exercise, (VE/VCO₂ slope) (b = -0.31, P < 0.05) and peak oxygen uptake (VO₂ peak), (b = 0.37, P < 0.05) were independent predictors of QoL (adjusted R2 = 0.64; F = 18.89, P < 0.001).

CONCLUSION: Neuroticism is independently associated with QoL in CHF. QoL in CHF is not only determined by disease severity but also by the Neuroticism personality trait.

Simple measures of function and symptoms in hospitalized heart failure patients predict short-term cardiac event-free survival

Background. Heart failure (HF) is a prevalent chronic condition where patients experience numerous uncomfortable symptoms, low functional status, and high mortality rates. Objective. To determine whether function and/or symptoms predict cardiac event-free survival in hospitalized HF patients within 90 days of hospital discharge. Methods. Inpatients (N = 32) had HF symptoms assessed with 4 yes/no questions. Function was determined with NYHA Classification, Katz Index of Activities of Daily Living (ADLs), and directly with the short physical performance battery (SPPB). Survival was analyzed with time to the first postdischarge cardiac event with events defined as cardiac rehospitalization, heart transplantation, or death. Results. Mean age was 58.2 ± 13.6 years. Patient reported ADL function was nearly independent (5.6 ± 1.1) while direct measure (SPPB) showed moderate functional limitation (6.4 ± 3.1). Within 90 days, 40.6% patients had a cardiac event. At discharge, each increase in NYHA Classification was associated with a 3.4-fold higher risk of cardiac events (95% CI 1.4–8.5). Patients reporting symptoms of dyspnea, fatigue, and orthopnea before discharge had a 4.0-fold, 9.7-fold, and 12.8-fold, respectively, greater risk of cardiac events (95% CI 1.2–13.2; 1.2–75.1; 1.7–99.7). Conclusions. Simple assessments of function and symptoms easily performed at discharge may predict short-term cardiac outcomes in hospitalized HF patients.

High intensity, interval exercise improves quality of life of patients with chronic heart failure: a randomized controlled trial

BACKGROUND

The aim of this study was to evaluate the effect of high intensity, interval exercise on quality of life (QoL) and depression status, in chronic heart failure (CHF) patients.

METHODS

A randomized controlled trial (phase III). Of the 100 consecutive CHF patients (NYHA classes II-IV, ejection fraction ≤ 50%) that were randomly allocated to exercise intervention (n = 50, high-intensity intermittent endurance training 30 s at 100% of max workload, 30 s at rest, for 45 min/day-by-12 weeks) or no exercise advice (n = 50), 72 (exercise group, n = 33, 63 ± 9 years, 88% men, 70% ischemic CHF and control group, n = 39, 56 ± 11 years, 82% men, 70% ischemic CHF) completed the study. QoL was assessed using the validated and translated Minnesota Living with Heart Failure questionnaire. Depressive symptomatology was evaluated using the validated and translated Zung Depression Rating Scale (ZDRS). Maximal oxygen uptake (VO(2max)) and carbon dioxide production (VCO(2max)) were also measured breath-by-breath.

RESULTS

Data analysis demonstrated that in the intervention group MLHFQ score was reduced by 66% (P = 0.003); 6-min-walk distance increased by 13% (P < 0.05), VO(2max) level increased by 31% (P = 0.001), VCO(2max) level increased by 28% (P = 0.001) and peak power output increased by 25% (P = 0.001), as compared with the control group.

CONCLUSION

High intensity, systematic aerobic training, could be strongly encouraged in CHF patients, since it improves QoL, by favorably modifying their fitness level.

The mental health and quality of life of adult patients with congenital heart disease

BACKGROUND

The quality of life (QoL) of adults with congenital heart disease (CHD) has gained significant interest. In addition to medical problems, many patients with CHD face psychosocial, educational, and behavioral challenges. However, few studies have examined the relationship between disease severity and QoL in adults with CHD.

METHODS

Eighty-five patients (50 men, 35 women) aged 20-52 years (median, 26.5 years) were enrolled. Patients underwent a QoL, Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) survey. The scores were compared with those of age- and gender-matched population data according to the degree of underlying CHD. Disease severity was classified in relation to initial diagnosis, illness course, and current functional status (New York Heart Association [NYHA] class, ability index, CHD functional index, ventricular ejection fraction, and peak VO2).

RESULTS

There was no significant correlation between disease severity and current functional status assessed by BDI and BAI. Patients who stated that they were religious had better scores for resilience (p=0.031), physical QoL (p=0.008), and environmental QoL (p=0.025). Environmental QoL scores were higher in patients who fully understood their disease (p=0.004). Current NYHA functional class was associated with scores for psychological resilience.

CONCLUSIONS

CHD severity had a detrimental impact on resilience only when measured in terms of poor functional status. The initial diagnosis and course of the illness influence QoL and perceived health. Good psychosocial adaptation could be the result of close family relationships and involvement, making mental adjustment easier.

Association between maximal aerobic capacity and psychosocial factors in adults with moderate-to-severe asthma

BACKGROUND

The symptoms of asthma impair health-related quality of life (HRQoL), increase anxiety and depression and may keep subjects from engaging in physical exercise. Physical inactivity has been related to poor asthma outcomes; however, the association between physical fitness and psychosocial disorders remains poorly understood.

OBJECTIVE

To verify the association between aerobic capacity, HRQoL, and psychological distress in adults with moderate or severe persistent asthma who were clinically stable.

METHODS

Eighty-eight participants (68 females) with either moderate or severe persistent asthma (age range, 20-60 years) who were under medical treatment for at least 6 months and considered clinically stable were studied. Participants were evaluated on two non-consecutive days. On the first day, the HRQoL, depression and anxiety levels and pulmonary function were assessed. On the second day, subjects underwent cardiopulmonary exercise testing.

RESULTS

Using the agglomerative cluster approach, two clusters were identified: 21 participants (24%) were grouped in Cluster 1, and 67 (76%) were grouped in Cluster 2. Asthmatic subjects from Cluster 1 exhibited increased aerobic capacity, better HRQoL and lower depression levels than did subjects in Cluster 2 (p < .05). No difference was observed between the clusters with respect to gender, age, body mass index (BMI) or pulmonary function (p > .05). The discriminant function model exhibits good accuracy (R(2) = 0.79) and predicted 93% of the case allocations.

CONCLUSION

Our results suggest an association between reduced exercise capacity, low HRQoL and increases in depressive symptoms in clinically stable asthmatic subjects. These results suggest the need to assess physical fitness and psychosocial distress during asthma treatment and the importance of a multidisciplinary approach.

Using Novel Technology to Determine Mobility Among Hospitalized Heart Failure Patients: A Pilot Study

BACKGROUND

Patients with heart failure (HF) experience frequent rehospitalizations and poor functional capacity. Early hospital mobility may prevent functional decline, but mobility patterns among hospitalized HF patients are not yet known. Accelerometers may provide a method to monitor and measure patient mobility objectively. Therefore, the purpose of this study was to describe mobility and function using accelerometers among hospitalized HF patients.

METHODS

Wireless accelerometers were attached to the thigh and ankle of previously ambulatory hospitalized HF patients (n = 32) continuously for up to 5 days, beginning on the second day of hospitalization. The mean proportion of time spent lying, sitting, and standing or walking daily was measured. Ability to perform activities of daily living (ADLs) and physical function was measured using the Katz Index and Short Physical Performance Battery (SPPB).

RESULTS

Patients' mean age was 58.2 ± 13.6 and 78% (n = 25) were male. Mean New York Heart Association Class upon enrollment and at the end of the study period was 2.9 ± 0.8 and 2.2 ± 0.8 respectively. A mean Katz Index of 5.6 ± 1.1 upon enrollment demonstrated minimal dependence on assistance for completion of ADLs (possible scores 0 - 6). However, mobility testing revealed low physical function, with mean SPPB scores of 6.4 ± 3.1 (possible scores 0 - 12). During hospitalization, 70% of the measured hospital stay (16.8 hours/day) was spent lying in bed. The average time spent standing or walking was 4.1%, or 59 minutes per day and the range was 0-10% (0 - 150 minutes).

CONCLUSIONS

Immobility was pervasive as HF patients spent almost all of their time sitting or lying in bed despite their baseline ambulatory status and improved NYHA class.

Heart failure survival score in patients with Chagas disease: correlation with functional variables

INTRODUCTION AND OBJECTIVES

Chagas disease is a prevalent cause of heart failure in Latin America, and its prognosis is worse than other etiologies. The Heart Failure Survival Score has been used to assess prognosis in patients with heart failure; however, this score has not yet been studied in patients with Chagas cardiopathy.

METHODS

The Heart Failure Survival Score was calculated in 55 patients with severe left ventricular systolic dysfunction due to Chagas disease. Correlations were assessed between the Heart Failure Survival Score and variables obtained from, cardiopulmonary exercise tests, quality-of-life measures, and 6-minute walking tests.

RESULTS

Patients were distributed among New York Heart Association classes II-IV; 89% were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, 62% were taking beta-blockers, 86% were taking diuretics, and 74% were taking aldosterone receptor blockers. The mean Heart Failure Survival Score was 8.75 (0.80). The score correlated well with cardiopulmonary test variables such as peak oxygen uptake (0.662; P<.01), oxygen uptake at the anaerobic threshold (0.644; P<.01), ventilation carbon dioxide efficiency slope (-0.417; P<.01), oxygen pulse (0.375; P<.01), oxygen uptake efficiency slope (0.626; P<.01), 6-minute walking test (0.370; P<.01), left ventricle ejection fraction (0.650; P=.01), and left atrium diameter (-0.377; P<.01). There was also a borderline significant correlation between the Heart Failure Survival Score and quality of life (-0.283; P<.05).

CONCLUSIONS

In heart failure patients with Chagas disease, the Heart Failure Survival Score correlated well with the main prognostic functional test variables.

The role of NT-proBNP in explaining the variance in anaerobic threshold and VE/VCO(2) slope

PURPOSE

We investigated whether anaerobic threshold (AT) and ventilatory efficiency (minute ventilation/carbon dioxide production slope, VE/VCO2 slope), both significantly associated with mortality, can be predicted by questionnaire scores and/or other laboratory measurements.

METHODS

Anaerobic threshold and VE/VCO(2) slope, plasma N-terminal pro-brain natriuretic peptide (NT-proBNP), and the echocardiographic markers left ventricular ejection fraction (LVEF) and left atrial (LA) diameter were measured in 62 patients with heart failure (HF), who also completed the Minnesota Living with Heart Failure Questionnaire (MLHF), and the Specific Activity Questionnaire (SAQ). Linear regression models, adjusting for age and gender, were fitted.

RESULTS

While the etiology of HF, SAQ score, MLHF score, LVEF, LA diameter, and logNT-proBNP were each significantly predictive of both AT and VE/VCO2 slope on stepwise multiple linear regression, only SAQ score (P < .001) and logNT-proBNP (P = .001) were significantly predictive of AT, explaining 56% of the variability (adjusted R(2) = 0.525), while logNT-proBNP (P < .001) and etiology of HF (P = .003) were significantly predictive of VE/VCO(2) slope, explaining 49% of the variability (adjusted R(2) = 0.45). The area under the ROC curve for NT-proBNP to identify patients with a VE/VCO(2) slope greater than 34 and AT less than 11 mL · kg(-1) · min(-1) was 0.797; P < .001 and 0.712; P = .044, respectively. A plasma concentration greater than 429.5 pg/mL (sensitivity: 78%; specificity: 70%) and greater than 674.5 pg/mL (sensitivity: 77.8%; specificity: 65%) identified a VE/VCO(2) slope greater than 34 and AT lower than 11 mL · kg(-1) · min(-1), respectively.

CONCLUSIONS

NT-proBNP is independently related to both AT and VE/VCO(2) slope. Specific Activity Questionnaire score is independently related only to AT and the etiology of HF only to VE/VCO(2) slope.