Composite risk scores and depression as predictors of competing waiting-list outcomes: the Waiting for a New Heart Study

Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy

Background The relevance of sex and preimplant factors for clinical outcomes among patients with left ventricular assist devices intended for destination therapy is unclear. Methods and Results INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) data (2006-2017) from 6771 men and 1690 women with left ventricular assist devices as destination therapy were analyzed to evaluate the contribution of preimplant clinical, demographic, and clinically judged psychosocial characteristics to time until death, heart transplant, device explant due to recovery, or complication-related device replacement. Associations of sex with time until each competing outcome were evaluated using cumulative incidence functions and event-specific Cox proportional hazards models. Women were younger, more likely to have nonischemic diagnoses, and reported less substance abuse but were more likely to be unmarried, not working for an income, overweight, and depressed than men. After 2 years, women had higher probabilities for recovery (3.7% versus 1.6%, P<0.001) and device replacement (12.1% versus 10%, P=0.019) than men but not for death and transplant (P>0.12). The sex differences remained after controlling for covariates (adjusted hazard ratio [HR_adj] recovery, 1.85; 95% CI, 1.30-2.70; P<0.001; HR_adj device replacement, 1.22; 95% CI, 1.04-1.33; P=0.015). Female-specific diagnoses (eg, postpartum heart failure) contributed to women's enhanced rate of recovery. Demographic and psychosocial factors were unrelated to women's increased event rates. Conclusions In destination therapy, women have higher rates of device replacement and recovery than men. The latter was partly explained by female-specific diagnoses. Standardized assessments of psychosocial characteristics are needed to elucidate their association with sex differences in outcomes.

Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up

We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.

A Systematic Review for Variables to Be Collected in a Transplant Database for Improving Risk Prediction

BACKGROUND

This systematic review was commissioned to identify new variables associated with transplant outcomes that are not currently collected by the Organ Procurement and Transplantation Network (OPTN).

METHODS

We identified 81 unique studies including 1 193 410 patients with median follow-up of 36 months posttransplant, reporting 108 unique risk factors.

RESULTS

Most risk factors (104) were recipient related; few (4) were donor related. Most risk factors were judged to be practical and feasible to routinely collect. Relative association measures were small to moderate for most risk factors (ranging between 1.0 and 2.0). The strongest relative association measure for a heart transplant outcome with a risk factor was 8.6 (recipient with the previous Fontan operation), for a kidney transplant 2.8 (sickle cell nephropathy as primary cause of end-stage renal disease), for a liver transplant 14.3 (recipient serum ferritin >500 µg/L), and for a lung transplant 6.3 (Burkholderia cepacia complex infection for 1 y or less). OPTN may consider some of these 108 variables for future collection to enhance transplant research and clinical care.

CONCLUSIONS

Evidence-based approaches can be used to determine variables collected in databases and registries. Several candidate variables have been identified for OPTN.

The Relationship Between Spiritual Health and Quality of Life of Heart Transplant Candidates

The heart transplantation is a stressful event, and its waiting time is often associated with worsening of clinical conditions and deterioration of the patient's quality of life. Spirituality plays an important role in mental health, so the present study was conducted to investigate the relationship between spiritual health and quality of life of patients undergoing cardiac transplantation. The present descriptive study was performed on 48 patients undergoing cardiac transplantation at the Shahid Rajaee Cardiovascular Center in Tehran during the first half of 2016. The data were collected by Ellisan-Palutzian Spiritual Well-Being Scale, Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Iranian Heart Failure Quality of Life Questionnaire (IHF-QOL). We used the SPSS v.20 software to analyze the data via descriptive statistics, parametric and non-parametric correlation and regression tests. The majority of patients (60.4%) had high spiritual health with a median score of 105, and its religious dimension was reported better (P < 0.001 and r = 0.591). With a mean of 63.23 ± 23.25, the quality of life of the majority of patients (75%) was at a poor level based on the Minnesota questionnaire. According to the IHF-QOL, the median total score was 39.50. There was a significant relationship between spiritual health score and quality of life in both questionnaires (MLHFQ: P = 0.006 and r = - 394; IHF-QOL: P = 0.022 and r = 0.329). Considering the positive relationship between spiritual health and quality of life of patients in this study, it is recommended to implement spiritual care and provide fulfillment for various needs of patients along with other medical care services.

Canine-Assisted Therapy in Hospitalized Patients Awaiting Heart Transplantation

OBJECTIVES

Patients awaiting heart transplantation can be listed for prolonged periods of time and, as a result, the prevalence of anxiety and depression is high. Our study evaluates the feasibility of canine-assisted therapy (CAT) in this population.

METHODS

A prospective, multicenter study was performed on all status 1a patients admitted during a 12-month period to await transplantation. Patients were asked to complete the Generalized Anxiety Disorder 7-item scale and the Patient Health Questionnaire-9 at baseline, week 2, and week 6, and the Perceived Stress Scale at baseline and week 4. At the conclusion of the study, patients completed a questionnaire assessing the overall efficacy of CAT.

RESULTS

Baseline measures demonstrated high levels of anxiety, depression, and stress. The complete Generalized Anxiety Disorder 7-item scale (average score 10.9 vs 8; P = 0.14) and the Patient Health Questionnaire-9 (average score 12.3 vs 9.5; P = 0.057) scores decreased from baseline to week 6 and the Perceived Stress Scale (average score 29.8 vs 27; P = 0.16) decreased from baseline to week 4 with trends toward significance. All of the patients perceived CAT as improving the overall quality of hospitalization, would recommend CAT to other patients, and would elect for CAT during subsequent admissions. No infectious concerns were reported.

CONCLUSIONS

Anxiety, stress, and depression are prevalent among 1a heart transplantation candidates, and CAT is a welcomed adjunct to the usual medical care in this population.

Role of Depression and Social Isolation at Time of Waitlisting for Survival 8 Years After Heart Transplantation

Background

We evaluated depression and social isolation assessed at time of waitlisting as predictors of survival in heart transplant (HTx) recipients.

Methods and Results

Between 2005 and 2006, 318 adult HTx candidates were enrolled in the Waiting for a New Heart Study, and 164 received transplantation. Patients were followed until February 2013. Psychosocial characteristics were assessed by questionnaires. Eurotransplant provided medical data at waitlisting, transplantation dates, and donor characteristics; hospitals reported medical data at HTx and date of death after HTx. During a median follow‐up of 70 months (<1–93 months post‐HTx), 56 (38%) of 148 transplanted patients with complete data died. Depression scores were unrelated to social isolation, and neither correlated with disease severity. Higher depression scores increased the risk of dying (hazard ratio=1.07, 95% confidence interval, 1.01, 1.15, P=0.032), which was moderated by social isolation scores (significant interaction term; hazard ratio = 0.985, 95% confidence interval, 0.973, 0.998; P=0.022). These findings were maintained in multivariate models controlling for covariates (P values 0.020–0.039). Actuarial 1‐year/5‐year survival was best for patients with low depression who were not socially isolated at waitlisting (86% after 1 year, 79% after 5 years). Survival of those who were either depressed, or socially isolated or both, was lower, especially 5 years posttransplant (56%, 60%, and 62%, respectively).

Conclusions

Low depression in conjunction with social integration at time of waitlisting is related to enhanced chances for survival after HTx. Both factors should be considered for inclusion in standardized assessments and interventions for HTx candidates.

Balloon Pumps Inserted via the Subclavian Artery: Bridging the Way to Heart Transplant

Intra-aortic balloon pumps have traditionally been inserted via the femoral artery, limiting patients' activity and exposing patients to complications of immobility. For patients awaiting cardiac transplant, these complications may threaten a successful outcome, or at the least, complicate recuperation after transplant. A novel approach to insertion of balloon pumps via the subclavian artery is presented here, including routine nursing care, complications and related nursing actions, and experience with and advantages of this method. A team approach to care of these patients, including rehabilitation and exercise protocols, is recommended.

Smoking Status at Time of Listing for a Heart Transplant Predicts Mortality on the Waiting List

Objective:

We examined the association of smoking status at time of listing with waitlist mortality among heart transplant (HTx) candidates.

Participants and Design:

Data were analyzed from 316 participants (aged 53 ± 11; 18% female) of the Waiting for a New Heart Study, a prospective observational study of patients newly listed for HTx at 17 hospitals.

Results:

During the study period (April 2005 to March 2010), 14% of those who never smoked died, 18% among former smokers died, and almost half (42%) died among those who reported smoking at time of wait listing. Multivariate Cox regression models controlling for age, sex, and disease severity revealed smoking at time of listing was associated with significantly higher risk of mortality compared to never smoking (hazard ratio [HR] = 3.43; P = .03). The relationship between smoking and mortality risk appeared to follow a dose-dependent pattern: adjusted HRs were 1.80 for those who quit ≤1 year ago, 1.25 for those who quit >1 to 10 years ago, and 0.90 for those quit >10 years ago, compared to never smokers. Smoking at time of listing may increase risk of mortality during the waiting period, indicating the need for improved strategies to achieve smoking cessation as early as possible in the course of HTx.

Quality of life and emotional distress early after left ventricular assist device implant: a mixed-method study

Patients who temporarily or permanently rely on left ventricular assist devices (LVADs) for end-stage heart failure face complex psychological, emotional, and relational problems. We conducted a mixed-method study to investigate quality of life, psychological symptoms, and emotional and cognitive reactions after LVAD implant. Twenty-six patients admitted to cardiac rehabilitation were administered quality of life questionnaires (Short Form 36 of the Medical Outcomes Study and Minnesota Living with Heart Failure Questionnaire), the Hospital Anxiety and Depression Scale, and the Coping Orientation for Problem Experiences inventory, and underwent three in-depth unstructured interviews within 2 months after LVAD implant. Quality of life assessment (Short Form 36) documented persistently low physical scores whereas mental component scores almost achieved normative values. Clinically relevant depression and anxiety were observed in 18 and 18% of patients, respectively; avoidant coping scores correlated significantly with both depression and anxiety (Pearson correlation coefficients 0.732, P < 0.001 and 0.764, P < 0.001, respectively). From qualitative interviews, factors that impacted on LVAD acceptance included: device type, disease experience during transplant waiting, nature of the assisted organ, quality of patient-doctor communication, the opportunity of sharing the experience, and recipient's psychological characteristics. Quality of life improves early after LVAD implant, but emotional distress may remain high. A multidimensional approach that takes into account patients' psychological characteristics should be pursued to enhance LVAD acceptance.

Cardiac threat appraisal and depression after first myocardial infarction

The present study investigated cardiac threat appraisal and its association with depression after first myocardial infarction (MI). A semi-structured interview allowing for DSM-IV-axis I diagnoses was administered to 36 patients after first MI. Patients completed self-reports 5–15 days after the MI (time 1), 6–8 weeks later (time 2), and again 6 months later (time 3). Assessments at time 1 included indices of cardiac threat appraisal, locus of control, coping, and depression while at time 2 and time 3 only measures of depression were obtained. Cardiac threat appraisal was significantly correlated with depression at time 1, but was unrelated to depression scores at time 2 and time 3. Furthermore, there was a significant inverse association between cardiac threat appraisal and the subscales “search for affiliation” and “threat minimization” of the coping questionnaire. Additionally, “search for affiliation” correlated negatively with depression scores at time 1 and time 3, and “threat minimization” negatively with depression scores at time 1 and time 2. These results suggest a significant association between cardiac threat appraisal and depressive symptoms shortly after MI. Practical implications for treatment are discussed.

Beyond rose colored glasses: the adaptive role of depressive and anxious symptoms among individuals with heart failure who were evaluated for transplantation

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.

Patients' sex and emotional support as predictors of death and clinical deterioration in the waiting for a new heart study: results from the 1-year follow-up

CONTEXT

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

OBJECTIVE

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

DESIGN, SETTING, AND PARTICIPANTS

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs. low support]) were assessed at the time of wait-listing. Main Outcomes-Time until death/delisting due to deteriorated tealth, considering competing outcomes (e.g., transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models.

RESULTS

By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs. 8.6%) and being a past or current smoker (80.4% vs. 56.9%). More women than men had low vocational level (93.1% vs. 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04-5.12; P = .04); low emotional support further tended to increase the risk for this outcome (P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04-4.82; P = .04).

CONCLUSION

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.

Patients' Sex and Emotional Support as Predictors of Death and Clinical Deterioration in the Waiting for a New Heart Study: Results from the 1-Year Follow-up

Context

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

Objective

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

Design, Setting, and Participants

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs low support]) were assessed at the time of wait-listing.

Main Outcomes

Time until death/delisting due to deteriorated health, considering competing outcomes (eg, transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models. Results—By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs 8.6%) and being a past or current smoker (80.4% vs 56.9%). More women than men had low vocational level (93.1% vs 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04–5.12; P = .04); low emotional support further tended to increase the risk for this outcome ( P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04–4.82; P = .04).

Conclusion

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.