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Stutsman N, Habecker B, Pavlovic N, Jurgens CY, Woodward WR, Lee CS, Denfeld QE. Sympathetic dysfunction is associated with worse fatigue and early and subtle symptoms in heart failure: an exploratory sex-stratified analysis. Eur J Cardiovasc Nurs 2024; 23:532-539. [PMID: 38196102 PMCID: PMC11257751 DOI: 10.1093/eurjcn/zvad121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 01/11/2024]
Abstract
AIMS Physical symptoms impact patients with heart failure (HF) despite treatment advancements; however, our understanding of the pathogenic mechanisms underlying HF symptoms remains limited, including sex differences therein. The objective of this study was to quantify associations between sympathetic markers [norepinephrine (NE) and 3,4-dihydroxyphenylglycol (DHPG)] and physical symptoms in patients with HF and to explore sex differences in these associations. METHODS AND RESULTS We performed a secondary analysis of combined data from two studies: outpatients with HF (n = 111), and patients prior to left ventricular assist device implantation (n = 38). Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) dyspnoea and early/subtle symptom subscales and the Functional Assessment in Chronic Illness Therapy Fatigue Scale (FACIT-F) to capture dyspnoea, early symptoms of decompensation, and fatigue. Norepinephrine and DHPG were measured with high-performance liquid chromatography with electrochemical detection. Multivariate linear regression was used to quantify associations between symptoms and sympathetic markers. The sample (n = 149) was 60.8 ± 15.7 years, 41% women, and 71% non-ischaemic aetiology. Increased plasma NE and NE:DHPG ratio were associated with worse FACIT-F scores (P = 0.043 and P = 0.013, respectively). Increased plasma NE:DHPG ratio was associated with worse HFSPS early/subtle symptoms (P = 0.025). In sex-stratified analyses, increased NE:DHPG ratio was associated with worse FACIT-F scores (P = 0.011) and HFSPS early/subtle scores (P = 0.022) among women but not men. CONCLUSION In patients with HF, sympathetic dysfunction is associated with worse fatigue and early/subtle physical symptoms with associations stronger in women than men.
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Affiliation(s)
- Nina Stutsman
- Oregon Health & Science University, School of Nursing, 3455 SW U.S. Veteran’s Hospital Road, Portland, OR 97239, USA
| | - Beth Habecker
- Oregon Health & Science University, Knight Cardiovascular Institute, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Noelle Pavlovic
- Johns Hopkins School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Corrine Y Jurgens
- Boston College, William F. Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
| | - William R Woodward
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Christopher S Lee
- Boston College, William F. Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
- Australian Catholic University, 115 Victoria Parade, Fitzroy, VIC 3065, Australia
| | - Quin E Denfeld
- Oregon Health & Science University, School of Nursing, 3455 SW U.S. Veteran’s Hospital Road, Portland, OR 97239, USA
- Oregon Health & Science University, Knight Cardiovascular Institute, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Faulkner KM, Jurgens CY, Denfeld QE, Chien CV, Thompson JH, Gelow JM, Grady KL, Lee CS. Patterns and predictors of dyspnoea following left ventricular assist device implantation. Eur J Cardiovasc Nurs 2022; 21:724-731. [PMID: 35138359 PMCID: PMC9564114 DOI: 10.1093/eurjcn/zvac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/30/2021] [Accepted: 01/24/2022] [Indexed: 11/14/2022]
Abstract
AIMS Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation. METHODS AND RESULTS This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement. CONCLUSION Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.
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Affiliation(s)
- Kenneth M Faulkner
- Corresponding author. Tel: +1 631 444 3006, ; Present address. Stony Brook University School of Nursing, 101 Nicolls Road, Health Sciences Center Level 2, Stony Brook, NY 11794, USA
| | - Corrine Y Jurgens
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, USA
| | - Quin E Denfeld
- Oregon Health & Science University School of Nursing, 3455 SW U.S. Veterans Hospital Road, Mailcode: SN-ORD, Portland, OR 97239, USA
| | - Christopher V Chien
- University of North Carolina REX Healthcare, 2800 Blue Ridge Road, Suite 204, Raleigh, NC 27607, USA
| | - Jessica Harman Thompson
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, USA,University of Kentucky College of Nursing, 751 Rose Street, Lexington, KY 40536-0232, USA
| | - Jill M Gelow
- Providence Health, 9427 Southwest Barnes Road, Suite 599, Portland, OR 97225, USA
| | - Kathleen L Grady
- Northwestern University, 675 North Saint Clair Street, Arkes Pavilion, Suite 730, Chicago, IL 60611-3056, USA
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, USA
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Thompson JH, Faulkner K, Lee C. Adverse events in patients with a left ventricular assist device: are patient-reported outcomes affected? Eur J Cardiovasc Nurs 2021; 21:254-260. [PMID: 34453523 DOI: 10.1093/eurjcn/zvab070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/18/2021] [Accepted: 08/10/2021] [Indexed: 11/14/2022]
Abstract
AIMS Left ventricular assist devices (LVAD) are used to treat advanced heart failure, and the use of these devices in ever increasing, with over 19 000 people having had a device. However, during device therapy over 50% of patients will have some type of major adverse event. The aim of this study was to examine whether having a major adverse event, including major infection and major bleed, would alter patient-reported outcomes over time, including depressive symptoms and health-related quality of life. METHODS AND RESULTS T-tests and χ2 analyses were used to determine significant differences between patients who had an adverse event and those who did not. Latent curve growth modelling was used to evaluate change over time in those patients with and without and adverse event. The only difference between those with and without an adverse event was pre-implant depressive symptoms and health-related quality of life. The trajectories of both groups were also similar, with only differences at the pre-implant time point. CONCLUSION In response to an adverse event occurring post-LVAD implantation, we found that patient-reported outcomes, including depressive symptoms and health-related quality of life were not significantly impacted.
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Affiliation(s)
- Jessica Harman Thompson
- Boston College, Connell School of Nursing, Chestnut Hill, MA, USA.,University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40356, USA
| | - Kenneth Faulkner
- Boston College, Connell School of Nursing, Chestnut Hill, MA, USA.,Stony Brook University, School of Nursing, Stony Brook, NY, USA
| | - Christopher Lee
- Boston College, Connell School of Nursing, Chestnut Hill, MA, USA
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4
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Denfeld QE, Faulkner KM, Davis MR, Habecker BA, Chien CV, Gelow JM, Mudd JO, Hiatt SO, Grady KL, Lee CS. Exploring gender differences in trajectories of clinical markers and symptoms after left ventricular assist device implantation. Eur J Cardiovasc Nurs 2021; 20:648-656. [PMID: 34080624 DOI: 10.1093/eurjcn/zvab032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/14/2020] [Accepted: 03/23/2021] [Indexed: 11/14/2022]
Abstract
AIMS Despite well-known gender differences in heart failure, it is unknown if clinical markers and symptoms differ between women and men after left ventricular assist device (LVAD) implantation. Our aim was to examine gender differences in trajectories of clinical markers (echocardiographic markers and plasma biomarkers) and symptoms from pre- to post-LVAD implantation. METHODS AND RESULTS This was a secondary analysis of data collected from a study of patients from pre- to 1, 3, and 6 months post-LVAD implantation. Data were collected on left ventricular internal end-diastolic diameter (LVIDd) and ejection fraction (LVEF), plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), and soluble suppressor of tumorigenicity (sST2). Physical and depressive symptoms were measured using the Heart Failure Somatic Perception Scale and Patient Health Questionnaire-9, respectively. Latent growth curve modelling was used to compare trajectories between women and men. The average age of the sample (n = 98) was 53.3 ± 13.8 years, and most were male (80.6%) and had non-ischaemic aetiology (65.3%). Pre-implantation, women had significantly narrower LVIDd (P < 0.001) and worse physical symptoms (P = 0.041) compared with men. Between pre- and 6 months post-implantation, women had an increase in plasma sST2 followed by a decrease, whereas men had an overall decrease (slope: P = 0.014; quadratic: P = 0.011). Between 1 and 6 months post-implantation, women had a significantly greater increase in LVEF (P = 0.045) but lesser decline in plasmoa NT-proBNP compared with men (P = 0.025). CONCLUSION Trajectories of clinical markers differed somewhat between women and men, but trajectories of symptoms were similar, indicating some physiologic but not symptomatic gender differences in response to LVAD.
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Affiliation(s)
- Quin E Denfeld
- School of Nursing, Oregon Health & Science University, SN-ORD, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA
| | - Kenneth M Faulkner
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
| | - Mary Roberts Davis
- School of Nursing, Oregon Health & Science University, SN-ORD, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA
| | - Beth A Habecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.,Department of Chemical Physiology & Biochemistry, Oregon Health & Science University, Portland, OR, USA
| | - Christopher V Chien
- Department of Medicine, Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Jill M Gelow
- Providence Heart & Vascular Institute, Portland, OR, USA
| | - James O Mudd
- Providence Sacred Heart Medical Center, Spokane, WA, USA
| | - Shirin O Hiatt
- School of Nursing, Oregon Health & Science University, SN-ORD, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA
| | - Kathleen L Grady
- Department of Surgery, Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
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A Multibiomarker Latent Class Analysis in Moderate to Advanced Heart Failure: Differentiating Factors. J Cardiovasc Nurs 2020; 37:73-78. [PMID: 33109922 DOI: 10.1097/jcn.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Biomarker science in heart failure (HF) is advancing quickly in our ability to diagnosis and treat patients with this complex syndrome. Researchers are urged to not use single-marker strategies, but instead evaluate biomarkers in patterns to better understand their relationship to one another, as well as disease progression. Latent class mixture modeling allows researchers to determine novel associations between biomarkers. OBJECTIVE The objectives of this study were to identify and compare latent classes of cardiovascular biomarkers among patients with moderate to advanced HF. METHODS This was a cross-sectional study of 96 participants with moderate to advanced HF. Latent class mixture modeling was used to identify unique classes of biomarkers and their associations to sociodemographic and clinical variables. RESULTS The average age of the sample was 54 years, with most of the sample being men (77%) and having an average ejection fraction of 23%. Two unique classes of biomarkers were identified. Latent class 1 had higher levels of all biomarkers, whereas latent class 2 had lower levels. The higher biomarker class had, on average, more neurohormonal activation and fluid retention; however, the higher levels of biomarker class were not more likely to be diagnosed with advanced HF or have more comorbidities. CONCLUSION By identifying classes of biomarkers, providers may be better able to identify patients who are at risk of progressing into advanced HF quicker or those who are more likely to have more severe complications, such as fluid overload or renal disease.
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Denfeld QE, Lee CS, Woodward WR, Hiatt SO, Mudd JO, Habecker BA. Sympathetic Markers are Different Between Clinical Responders and Nonresponders After Left Ventricular Assist Device Implantation. J Cardiovasc Nurs 2020; 34:E1-E10. [PMID: 31094762 PMCID: PMC6527339 DOI: 10.1097/jcn.0000000000000580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Clinical response to left ventricular assist devices (LVADs), as measured by health-related quality of life, varies among patients after implantation; however, it is unknown which pathophysiological mechanisms underlie differences in clinical response by health-related quality of life. OBJECTIVE The purpose of this study was to compare changes in sympathetic markers (β-adrenergic receptor kinase-1 [βARK1], norepinephrine [NE], and 3,4-dihydroxyphenylglycol [DHPG]) between health-related quality of life clinical responders and nonresponders from pre- to post-LVAD implantation. METHODS We performed a secondary analysis on a subset of data from a cohort study of patients from pre- to 1, 3, and 6 months after LVAD implantation. Clinical response was defined as an increase of 5 points or higher on the Kansas City Cardiomyopathy Questionnaire Clinical Summary score from pre- to 6 months post-LVAD implantation. We measured plasma βARK1 level with an enzyme-linked immunosorbent assay and plasma NE and DHPG levels with high-performance liquid chromatography with electrochemical detection. Latent growth curve modeling was used to compare the trajectories of markers between groups. RESULTS The mean (SD) age of the sample (n = 39) was 52.9 (13.2) years, and most were male (74.4%) and received LVADs as bridge to transplantation (69.2%). Preimplantation plasma βARK1 levels were significantly higher in clinical responders (n = 19) than in nonresponders (n = 20) (P = .001), but change was similar after LVAD (P = .235). Preimplantation plasma DHPG levels were significantly lower in clinical responders than in nonresponders (P = .002), but the change was similar after LVAD (P = .881). There were no significant differences in plasma NE levels. CONCLUSIONS Preimplantation βARK1 and DHPG levels are differentiating factors between health-related quality of life clinical responders and nonresponders to LVAD, potentially signaling differing levels of sympathetic stimulation underlying clinical response.
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Affiliation(s)
- Quin E. Denfeld
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
| | - Christopher S. Lee
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - William R. Woodward
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
- Oregon Health & Science University Department of Neurology, Portland, OR, USA
| | - Shirin O. Hiatt
- Oregon Health & Science University School of Nursing, Portland, OR, USA
| | - James O. Mudd
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
| | - Beth A. Habecker
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
- Oregon Health & Science University Department of Physiology & Pharmacology, Portland, OR, USA
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7
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Faulkner KM, Jurgens CY, Denfeld QE, Lyons KS, Harman Thompson J, Lee CS. Identifying unique profiles of perceived dyspnea burden in heart failure. Heart Lung 2020; 49:488-494. [PMID: 32434702 PMCID: PMC7483352 DOI: 10.1016/j.hrtlng.2020.03.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Dyspnea is a common symptom of heart failure (HF) but dyspnea burden is highly variable. OBJECTIVES Identify distinct profiles of dyspnea burden and identify predictors of dyspnea symptom profile. METHODS A secondary analysis of data from five studies completed at Oregon Health and Science University was conducted. The Heart Failure Somatic Perception Scale was used to measure dyspnea burden. Latent class mixture modeling identified distinct profiles of dyspnea burden in a sample of HF patients (n = 449). Backwards stepwise multinomial logistic regression identified predictors of latent profile membership. RESULTS Four profiles of dyspnea burden were identified: no dyspnea/not bothered by dyspnea, mild dyspnea, moderate exertional dyspnea, and moderate exertional dyspnea with orthopnea and PND. Higher age was associated with greater likelihood of not being bothered by dyspnea than having moderate exertional dyspnea with orthopnea and PND. Higher NYHA class, anxiety, and depression were associated with greater likelihood of greater dyspnea burden. CONCLUSIONS Burden of dyspnea is highly variable among HF patients. Clinicians should account for the nuances of dyspnea and the activities that induce dyspnea when assessing HF patients.
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Affiliation(s)
- Kenneth M Faulkner
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, United States; Stony Brook University School of Nursing, Nicolls Road, Health Sciences Center Level 2 - Room 204, Stony Brook, NY 11794, United States.
| | - Corrine Y Jurgens
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, United States
| | - Quin E Denfeld
- Oregon Health & Science University School of Nursing, 3455 SW U.S. Veterans Hospital Road | Mailcode: SN-ORD, Portland, OR 97239, United States
| | - Karen S Lyons
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, United States
| | - Jessica Harman Thompson
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, United States; University of Kentucky College of Nursing, 751 Rose Street, Lexington, KY 40536-0232, United States.
| | - Christopher S Lee
- William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA 02467, United States.
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Alonso WW, Faulkner KM, Pozehl BJ, Hupcey JE, Kitko LA, Lee CS. A longitudinal comparison of health-related quality of life in rural and urban recipients of left ventricular assist devices. Res Nurs Health 2020; 43:396-406. [PMID: 32627852 DOI: 10.1002/nur.22052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 06/23/2020] [Indexed: 12/31/2022]
Abstract
Left ventricular assist devices (LVAD) are a common treatment for advanced heart failure (HF) to improve ventricular function, symptoms, and health-related quality of life (HRQOL). Many LVAD recipients travel long distances from rural areas for LVAD implantation and follow-up care. Individuals with HF in rural settings who have not undergone LVAD implantation have reported poor HRQOL. However, to date, no studies have compared HF-specific or generic HRQOL in rural and urban LVAD recipients. The purpose of this study was to compare generic and HF-specific HRQOL longitudinally from preimplantation to 1-, 3-, and 6- months postimplant in a cohort of rural and urban LVAD recipients (n = 95; rural n = 32 and urban n = 63). We measured generic HRQOL using the European Quality of Life Visual Analog Scale and HF-specific HRQOL with the quality of life domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ). Latent growth curve modeling identified two phases of change in generic and HF-specific HRQOL: the initial response to LVAD between preimplantation and 1-month postimplant and the subsequent change between 1- and 6-months postimplant. Comparable improvements in generic HRQOL were noted in rural and urban LVAD recipients during both phases of change. Urban LVAD recipients had greater initial improvements in HF-specific HRQOL (KCCQ) compared with rural recipients (13.0 ± 5.6, p = .02), but subsequent improvements were similar among rural and urban recipients. Ongoing assessment of generic and HF-specific HRQOL is necessary during LVAD therapy.
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Affiliation(s)
- Windy W Alonso
- College of Nursing, Division of Omaha, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kenneth M Faulkner
- School of Nursing, Stony Brook University, Stony Brook, New York.,William F. Connell School of Nursing, Boston, Massachusetts
| | - Bunny J Pozehl
- College of Nursing, Division of Omaha, University of Nebraska Medical Center, Omaha, Nebraska
| | - Judith E Hupcey
- College of Nursing, University Park, The Pennsylvania State University, Pennsylvania
| | - Lisa A Kitko
- College of Nursing, University Park, The Pennsylvania State University, Pennsylvania
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Longitudinal Effects of Left Ventricular Assist Device Implantation on Global and Domain-Specific Cognitive Function. J Cardiovasc Nurs 2020; 37:31-40. [PMID: 33755380 DOI: 10.1097/jcn.0000000000000709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) are a common treatment of advanced heart failure, but cognitive dysfunction, which is common in heart failure, could limit the ability to perform postimplantation LVAD care. Implantation of an LVAD has been associated with improved cerebral perfusion and may improve cognitive function post implantation. OBJECTIVE The aim of this study was to quantify longitudinal change in cognitive function after LVAD implantation. METHODS A secondary analysis of data on 101 adults was completed to evaluate cognitive function before implantation and again at 1, 3, and 6 months post implantation of an LVAD. Latent growth curve modeling was conducted to characterize change over time. Serial versions of the Montreal Cognitive Assessment were used to measure overall (total) cognitive function and function in 6 cognitive domains. RESULT There was moderate, nonlinear improvement from preimplantation to 6 months post implantation in Montreal Cognitive Assessment total score (Hedges' g = 0.50) and in short-term memory (Hedges' g = 0.64). There also were small, nonlinear improvements in visuospatial ability, executive function, and attention from preimplantation to 6 months post implantation (Hedges' g = 0.20-0.28). The greatest improvements were observed in the first 3 months after implantation and were followed by smaller, sustained improvements or no additional significant change. CONCLUSIONS Implantation of an LVAD is associated with significant, nonlinear improvement in short-term memory and global cognitive function, with the most significant improvements occurring in the first 3 months after implantation. Clinicians should anticipate improvements in cognitive function after LVAD implantation and modify postimplantation education to maximize effectiveness of LVAD self-care.
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Abstract
BACKGROUND We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF), particularly in response to left ventricular assist device (LVAD) implantation. OBJECTIVE The aim of this study was to quantify the degree to which symptoms and biomarkers change in parallel from before implantation through the first 6 months after LVAD implantation in advanced HF. METHODS This was a prospective cohort study of 101 patients receiving an LVAD for the management of advanced HF. Data on symptoms (dyspnea, early and subtle symptoms [HF Somatic Perception Scale], pain severity [Brief Pain Inventory], wake disturbance [Epworth Sleepiness Scale], depression [Patient Health Questionnaire], and anxiety [Brief Symptom Inventory]) and peripheral biomarkers of myocardial stretch, systemic inflammation, and hypervolumetric mechanical stress were measured before implantation with a commercially available LVAD and again at 30, 90, and 180 days after LVAD implantation. Latent growth curve and parallel process modeling were used to describe changes in symptoms and biomarkers and the degree to which they change in parallel in response to LVAD implantation. RESULTS In response to LVAD implantation, changes in myocardial stretch were closely associated with changes in early and subtle physical symptoms as well as depression, and changes in hypervolumetric stress were closely associated with changes in pain severity and wake disturbances. Changes in systemic inflammation were not closely associated with changes in physical or affective symptoms in response to LVAD implantation. CONCLUSIONS These findings provide new insights into the many ways in which symptoms and biomarkers provide concordant or discordant information about LVAD response.
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11
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Lee CS, Faulkner KM, Thompson JH. Identifying subgroups: Part 2: Trajectories of change over time. Eur J Cardiovasc Nurs 2020; 19:444-450. [PMID: 32131616 DOI: 10.1177/1474515120911330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Methods to identify multiple trajectories of change over time are of great interest in nursing and in related health research. Latent growth mixture modeling is a data-centered analytic strategy that allows us to study questions about distinct trajectories of change in key measures or outcomes of interest. In this article, a worked example of latent growth mixture modeling is presented to help expose researchers to the use and appeal of this analytic strategy.
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Lee CS, Faulkner KM, Thompson JH. Identifying subgroups: Part 1: Patterns among cross-sectional data. Eur J Cardiovasc Nurs 2020; 19:359-365. [PMID: 32126820 DOI: 10.1177/1474515120911323] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Non-experimental designs are common in nursing and allied health research wherein study participants often represent more than a single population or interest. Hence, methods used to identify subgroups and explore heterogeneity have become popular. Latent class mixture modeling is a versatile and person-centered analytic strategy that allows us to study questions about subgroups within samples. In this article, a worked example of latent class mixture modeling is presented to help expose researchers to the nuances of this analytic strategy.
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13
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Lee CS, Gelow JM, Chien CV, Hiatt SO, Bidwell JT, Denfeld QE, Grady KL, Mudd JO. Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices. J Cardiovasc Nurs 2019; 33:144-151. [PMID: 28591005 DOI: 10.1097/jcn.0000000000000430] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD. METHODS The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD. RESULTS The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05). CONCLUSION There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.
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Affiliation(s)
- Christopher S Lee
- Christopher S. Lee, PhD, RN, FAHA, FAAN, FHFSA Carol A. Lindeman Distinguished Professor, School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Christopher V. Chien, MD Assistant Professor, REX Healthcare, University of North Carolina, Raleigh. Shirin O. Hiatt, MPH, MS, RN Project Coordinator, School of Nursing, Oregon Health & Science University, Portland. Julie T. Bidwell, PhD, RN Post-doctoral Fellow, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. Quin E. Denfeld, PhD, RN Post-doctoral Fellow, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Kathleen L. Grady, PhD, RN, FAHA, FAAN, FHFSA Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. James O. Mudd, MD Associate Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland
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Tosto C, Adamo L, Craddock H, Di Blasi M, Girgenti R, Clemenza F, Carney RM, Ewald G. Relationship between device acceptance and patient-reported outcomes in Left Ventricular Assist Device (LVAD) recipients. Sci Rep 2019; 9:10778. [PMID: 31346241 PMCID: PMC6658659 DOI: 10.1038/s41598-019-47324-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
The number of Left Ventricular Assist Devices (LVADs) implanted each year is rising. Nevertheless, there are minimal data on device acceptance after LVAD implant, and on its relationship with patient-reported outcomes. We designed a cross-sectional study to address this knowledge gap and test the hypothesis that low device acceptance is associated with poorer quality of life, depression and anxiety. Self-report questionnaires were administered to assess quality of life (12-item Kansas City Cardiomyopathy Questionnaire quality of life subscale), level of anxiety (7-item Generalized Anxiety Disorder; GAD-7), level of depression (9-item Patient Health Questionnaire; PHQ-9) and device acceptance (Florida Patient Acceptance Survey; FPAS) to 101 consecutive patients presenting to LVAD clinic. Regression analysis showed a strong correlation between device acceptance and both psychological distress (p < 0.001) and quality of life (p < 0.001). Analysis of the sub-scales of the FPAS showed that patients had significant body image concerns, but return to function and device-related distress were the main drivers of the observed correlation between device acceptance and patient well-being. Younger age was associated with lower device acceptance (r = 0.36, p < 0.001) and lower quality of life (r = 0.54, p < 0.001). These findings suggest that interventions targeting device acceptance should be explored to improve outcomes in LVAD recipients.
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Affiliation(s)
- Crispino Tosto
- From the University of Palermo, Department of Psychological and Educational Sciences, Palermo, Italy
| | - Luigi Adamo
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Heidi Craddock
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Maria Di Blasi
- From the University of Palermo, Department of Psychological and Educational Sciences, Palermo, Italy
| | | | | | - Robert M Carney
- From the Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
| | - Gregory Ewald
- From the Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Lee CS, Denfeld QE, Aouizerat BE, Jurgens CY, Chien CV, Aarons E, Gelow JM, Hiatt SO, Mudd JO. Comparative symptom biochemistry between moderate and advanced heart failure. Heart Lung 2018; 47:565-575. [PMID: 30314637 PMCID: PMC6530561 DOI: 10.1016/j.hrtlng.2018.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF). OBJECTIVES The purpose of this paper was to compare relationships between peripheral biomarkers of HF pathogenesis and physical symptoms between patients with advanced versus moderate HF. METHODS This was a two-stage phenotype sampling cohort study wherein we examined patients with advanced HF undergoing ventricular assist device implantation in the first stage, and then patients with moderate HF (matched adults with HF not requiring device implantation) in the second stage. Linear modeling was used to compare relationships among biomarkers and physical symptoms between cohorts. RESULTS Worse myocardial stress, systemic inflammation and endothelial dysfunction were associated with worse physical symptoms in moderate HF (n=48), but less physical symptom burden in advanced HF (n=48). CONCLUSIONS Where patients are in the HF trajectory needs to be taken into consideration when exploring biological underpinnings of physical HF symptoms.
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Affiliation(s)
- Christopher S Lee
- Professor and Associate Dean for Research, Boston College William F. Connell School of Nursing, 140 Commonwealth Avenue, Maloney Hall 226, Chestnut Hill, MA, United States.
| | - Quin E Denfeld
- Oregon Health & Science School of Nursing, Portland, OR, United States
| | - Bradley E Aouizerat
- New York University Department of Oral and Maxillofacial Surgery, New York, NY, United States
| | - Corrine Y Jurgens
- Stony Brook University School of Nursing, Stony Brook, NY, United States
| | | | - Emily Aarons
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, United States
| | | | - Shirin O Hiatt
- Oregon Health & Science University School of Nursing, Portland, OR, United States
| | - James O Mudd
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, United States
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Denfeld QE, Mudd JO, Hasan W, Gelow JM, Hiatt SO, Winters-Stone K, Lee CS. Exploring the relationship between β-adrenergic receptor kinase-1 and physical symptoms in heart failure. Heart Lung 2018; 47:281-284. [PMID: 29803296 DOI: 10.1016/j.hrtlng.2018.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/04/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The relationship between physical heart failure (HF) symptoms and pathophysiological mechanisms is unclear. OBJECTIVE To quantify the relationship between plasma β-adrenergic receptor kinase-1 (βARK1) and physical symptoms among adults with HF. METHODS We performed a secondary analysis of data collected from two studies of adults with HF. Plasma βARK1 was quantified using an enzyme-linked immunosorbent assay. Physical symptoms were measured with the HF Somatic Perception Scale (HFSPS). Generalized linear modeling was used to quantify the relationship between βARK1 and HFSPS scores. RESULTS The average age (n = 94) was 54.5 ± 13.1 years, 76.6% were male, and a majority (83.0%) had Class III or IV HF. βARK1 was significantly associated with HFSPS scores (β = 0.22 ± 0.10, p = 0.038), adjusting for other predictors of physical symptoms (model R2 = 0.250, F(7, 70) = 3.34, p = 0.004). CONCLUSIONS Higher βARK1 is associated with worse physical HF symptoms, pinpointing a potential pathophysiologic underpinning.
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Affiliation(s)
- Quin E Denfeld
- Oregon Health & Science University School of Nursing, Portland, OR, USA.
| | - James O Mudd
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
| | - Wohaib Hasan
- Cedars-Sinai Medical Center, West Hollywood, CA, USA
| | - Jill M Gelow
- Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA
| | - Shirin O Hiatt
- Oregon Health & Science University School of Nursing, Portland, OR, USA
| | - Kerri Winters-Stone
- Oregon Health & Science University School of Nursing, Portland, OR, USA; Oregon Health & Science University Knight Cancer Institute, Portland, OR, USA
| | - Christopher S Lee
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
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Denfeld QE, Habecker BA, Woodward WR. Measurement of plasma norepinephrine and 3,4-dihydroxyphenylglycol: method development for a translational research study. BMC Res Notes 2018; 11:248. [PMID: 29673396 PMCID: PMC5909231 DOI: 10.1186/s13104-018-3352-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/11/2018] [Indexed: 01/27/2023] Open
Abstract
Objective Norepinephrine (NE), a sympathetic neurotransmitter, is often measured in plasma as an index of sympathetic activity. To better understand NE dynamics, it is important to measure its principal metabolite, 3,4-dihydroxyphenylglycol (DHPG), concurrently. Our aim was to present a method, developed in the course of a translational research study, to measure NE and DHPG in human plasma using high performance liquid chromatography with electrochemical detection (HPLC-ED). Results After pre-purifying plasma samples by alumina extraction, we used HPLC-ED to separate and quantify NE and DHPG. In order to remove uric acid, which co-eluted with DHPG, a sodium bicarbonate wash was added to the alumina extraction procedure, and we oxidized the column eluates followed by reduction because catechols are reversibly oxidized whereas uric acid is irreversibly oxidized. Average recoveries of plasma NE and DHPG were 35.3 ± 1.0% and 16.3 ± 1.1%, respectively, and there was no detectable uric acid. Our estimated detection limits for NE and DHPG were approximately 85 pg/mL (0.5 pmol/mL) and 165 pg/mL (0.9 pmol/mL), respectively. The measurement of NE and DHPG in human plasma has wide applicability; thus, we describe a method to quantify plasma NE and DHPG in a laboratory setting as a useful tool for translational and clinical research. Electronic supplementary material The online version of this article (10.1186/s13104-018-3352-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Quin E Denfeld
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA. .,Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR, USA. .,School of Nursing, Oregon Health & Science University, 3455 S.W. U.S. Veterans Hospital Road, Mail code: SN-ORD, Portland, OR, 97239-2941, USA.
| | - Beth A Habecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.,Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR, USA
| | - William R Woodward
- Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR, USA.,Department of Neurology, Oregon Health & Science University, Portland, OR, USA
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Bidwell JT, Lyons KS, Mudd JO, Grady KL, Gelow JM, Hiatt SO, Chien CV, Lee CS. Patient and Caregiver Determinants of Patient Quality of Life and Caregiver Strain in Left Ventricular Assist Device Therapy. J Am Heart Assoc 2018; 7:e008080. [PMID: 29514804 PMCID: PMC5907562 DOI: 10.1161/jaha.117.008080] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/03/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although current guidelines emphasize the importance of social support to the success of left ventricular assist device (LVAD) therapy, few studies examine the influence of the caregiver on patient outcomes or quantify the impact of LVAD caregiving on caregiver outcomes. The purpose of this analysis was to identify patient and caregiver determinants of patient quality of life (QOL) and caregiver strain in response to LVAD therapy. METHODS AND RESULTS Data on patients receiving LVAD therapy and their caregivers (n=50 dyads) were prospectively collected pre-implantation and 1, 3, and 6 months post-implantation. Growth curve modeling was used to describe change in patient QOL (Kansas City Cardiomyopathy Questionnaire) and caregiver strain (Multidimensional Caregiver Strain Index). Patient QOL improved most in the first month (β=23.22±3.76, P<0.001), followed by gradual gains over 6 months (β=1.90±0.64, P<0.01). Caregivers experienced worsening of strain in the first month (β=4.30±1.42, P<0.01), followed by gradual resolution to pre-implantation levels by 6 months (β=-0.71±0.23, P<0.01). Worse pre-implantation patient symptoms were associated with greater improvement in patient QOL (β=0.53±0.19, P<0.01) but worsening caregiver strain (β=0.15±0.07, P=0.04). Better relationship quality was associated with greater improvement in patient QOL (β=14.39±5.85, P=0.01) and less pre-implantation caregiver strain (β=-9.31±2.28, P<0.001). Nonspousal caregivers experienced less pre-implantation strain (β=-8.60±3.10, P=0.01), and patients with nonspousal caregivers had less improvement in QOL (β=-3.70±1.62, P=0.02). CONCLUSIONS A combination of patient and caregiver characteristics predicts patient and caregiver response to LVAD therapy. Including caregiver factors in future studies may be helpful in developing interventions that improve patient and caregiver outcomes, together.
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Affiliation(s)
- Julie T Bidwell
- Oregon Health and Science University School of Nursing, Portland, OR
| | - Karen S Lyons
- Oregon Health and Science University School of Nursing, Portland, OR
| | - James O Mudd
- Oregon Health and Science University Knight Cardiovascular Institute, Portland, OR
| | - Kathleen L Grady
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jill M Gelow
- Oregon Health and Science University Knight Cardiovascular Institute, Portland, OR
| | - Shirin O Hiatt
- Oregon Health and Science University School of Nursing, Portland, OR
| | | | - Christopher S Lee
- Oregon Health and Science University School of Nursing, Portland, OR
- Oregon Health and Science University Knight Cardiovascular Institute, Portland, OR
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Bidwell JT, Lyons KS, Mudd JO, Gelow JM, Chien CV, Hiatt SO, Grady KL, Lee CS. Quality of Life, Depression, and Anxiety in Ventricular Assist Device Therapy: Longitudinal Outcomes for Patients and Family Caregivers. J Cardiovasc Nurs 2017; 32:455-463. [PMID: 27811585 PMCID: PMC5413439 DOI: 10.1097/jcn.0000000000000378] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients who receive ventricular assist device (VAD) therapy typically rely on informal caregivers (family members or friends) to assist them in managing their device. OBJECTIVE The purpose of this study is to characterize changes in person-oriented outcomes (quality of life [QOL], depression, and anxiety) for VAD patients and their caregivers together from pre-implantation to 3 months post-implantation. METHODS This was a formal interim analysis from an ongoing prospective study of VAD patients and caregivers (n = 41 dyads). Data on person-oriented outcomes (QOL: EuroQol 5 Dimensions Visual Analog Scale; depression: Patient Health Questionnaire-8; anxiety: Brief Symptom Inventory) were collected at 3 time points (just prior to implantation and at 1 and 3 months post-implantation). Trajectories of change for patients and caregivers on each measure were estimated using latent growth modeling with parallel processes. RESULTS Patients' QOL improved significantly over time, whereas caregiver QOL worsened. Depression and anxiety also improved significantly among patients but did not change among caregivers. There was substantial variability in change on all outcomes for both patients and their caregivers. CONCLUSIONS This is the first quantitative study of VAD patient-caregiver dyads in modern devices that describes change in person-oriented outcomes from pre-implantation to post-implantation. This work supports the need for future studies that account for the inherent relationships between patient and caregiver outcomes and examine variability in patient and caregiver responses to VAD therapy.
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Affiliation(s)
- Julie T Bidwell
- Julie T. Bidwell, PhD, RN Predoctoral Fellow, Oregon Health & Science University School of Nursing, Portland. Karen S. Lyons, PhD, FGSA Associate Professor, Oregon Health & Science University School of Nursing, Portland. James O. Mudd, MD Associate Professor, Oregon Health & Science University Knight Cardiovascular Institute, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Oregon Health & Science University Knight Cardiovascular Institute, Portland. Christopher V. Chien, MD Assistant Professor, Oregon Health & Science University Knight Cardiovascular Institute, Portland. Shirin O. Hiatt, MPH, MS, RN Research Associate, Oregon Health & Science University School of Nursing, Portland. Kathleen L. Grady, PhD, MS, RN, FAHA, FHSA, FAAN Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Christopher S. Lee, PhD, RN, FAHA, FHFSA, FAAN Associate Professor, Oregon Health & Science University School of Nursing and Knight Cardiovascular Institute, Portland
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