1
|
Bahall M, Legall G, Lalla C. Depression among patients with chronic kidney disease, associated factors, and predictors: a cross-sectional study. BMC Psychiatry 2023; 23:733. [PMID: 37817099 PMCID: PMC10566121 DOI: 10.1186/s12888-023-05249-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 10/03/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Depression with diverse etiologies is exacerbated by chronic diseases, such as chronic kidney disease (CKD), coronary artery disease (CAD), cancer, diabetes mellitus, and hypertension. This study aimed to analyse depression, its associations, and predictors among patients attending the kidney clinic of a teaching hospital. METHODS Data were collected from 01 August 2017 to 30 September 2017 via face-to-face interviews and examination of the medical records of a convenience sample of 314 patients. The patients were categorised broadly as stages I and II with an estimated glomerular filtration rate (eGFR) > 60 mls/min/1.73 m2, and with stages III, IV, and V or GFR ≤ 60 mls/ min/1.73 m2 (or CKD). The Patient Health Questionnaire (PHQ)-9 was the data collection instrument for depression-related data. RESULTS Participants were predominantly male (n = 179; 57.0%), aged over 60 years (n = 211; 67.2%), Indo-Trinbagonian (n = 237; 75.5%), and with stages III, IV, and V CKD. The two leading comorbid conditions were hypertension (83.4%) and diabetes mellitus (56.1%). Of the 261 (83.1%) patients with recorded eGFR, 113 (43.3%) had Stage III CKD. The mean depression (PHQ-9) score was 13.0/27 (±9.15), with 306 (97.5%) patients diagnosed as having depression with the following severities: mild (n = 116; 37.9%), moderate (n = 138, 45.1%), moderately severe (n = 38; 12.4%), and severe (n = 14; 4.6%). Depression was independent of sex. Nine sociodemographic variables were associated with depression; however, 'level of education', was the only predictor of depression with greater severity associated with lower levels of education. eGFR was negatively correlated with the PHQ-9 scores (Pearson's correlation, r = -0.144, p = 0.022). At least 78.3% of the patients who self-reported no depression had clinical depression (moderate, moderately severe, or severe) PHQ-9 scores ≥ 10. CONCLUSION Depression was a significant comorbidity among patients with CKD, with the majority displaying clinical depression. "Level of education" was the only predictor of depression. Self-reported depression is an unreliable method for evaluating clinical depression.
Collapse
Affiliation(s)
- Mandreker Bahall
- University of the West Indies, Eric Williams Medical Sciences Complex, Mt. Hope, Trinidad and Tobago.
| | - George Legall
- University of the West Indies, Eric Williams Medical Sciences Complex, Mt. Hope, Trinidad and Tobago
| | - Carlyle Lalla
- San Fernando General Hospital, Chancery Lane, San Fernando, Trinidad and Tobago
| |
Collapse
|
2
|
Lawson CA, Benson L, Squire I, Zaccardi F, Ali M, Hand S, Kadam U, Tay WT, Dahlstrom U, Lund LH, Savarese G, Lam CS, Khunti K, Strömberg A. Changing health related quality of life and outcomes in heart failure by age, sex and subtype. EClinicalMedicine 2023; 64:102217. [PMID: 37745020 PMCID: PMC10514432 DOI: 10.1016/j.eclinm.2023.102217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/26/2023] Open
Abstract
Background There are calls to integrate serial recordings of health related quality of life (HRQoL) into routine care, clinical trials and prognosis. Little is known about the relationship between change in HRQoL and outcomes in heart failure (HF) patients by age, sex and HF subtype. Method From the Swedish Heart Failure Registry (SwedeHF; 2008-2019), patients were categorised by reduced (<40%, HFrEF), mildly-reduced (40-49%, HFmrEF) and preserved (≥50%, HFpEF) ejection fraction. HRQoL was measured using Euro-QoL-5D visual analogue scale (EQ5D-vas), collected at baseline and 1-year. Baseline EQ5D-vas scores were categorised by: "best" (76-100), "good" (51-75), "bad" (26-50), and "worst" (0-25). Change in EQ5D-vas was categorised as 'no significant change' (<5 points increase/decrease); some worsening (5-9 points decrease); considerable worsening (≥10 points decrease); some improvement (5-9 points increase); considerable improvement (≥10 points increase). Associations with admission and death were estimated and interactions with patient sub-groups tested. Findings Among 23,553 patients (median age 74 [66-81] years, 8000 [34%] female), baseline EQ5D-vas was worse in older patients, women, and those with HFpEF compared to their respective counterparts. Compared to patients with the "best" EQ5D-vas, the adjusted associations for admission for those with "good", "bad" and "worst" EQ5D-vas were, respectively: HR 1.09 (1.04, 1.14), 1.27 (1.21, 1.33) and 1.39 (1.28, 1.51). Compared to no significant change in EQ5D-vas, the adjusted estimates for admission following some improvement, considerable improvement, some worsening and considerable worsening were, respectively: HR 0.91 (0.82, 1.01), 0.75 (0.70, 0.81), 1.04 (0.92, 1.16) and 1.25 (1.16, 1.35). Results were similar amongst groups and for HF admission and death. Interpretation Change in HRQoL was an independent indicator of risk of admission and death in people with all HF subtypes, irrespective of age and sex. Funding NIHR.
Collapse
Affiliation(s)
- Claire A. Lawson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
| | | | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
- Karolinska Institutet, Stockholm, Sweden
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, University of Leicester, Leicestershire, United Kingdom
- Diabetes Centre, University of Leicester, Leicestershire, United Kingdom
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), University of Leicester, Leicestershire, United Kingdom
| | - Mohammad Ali
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre –Cardiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Simon Hand
- Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | - Umesh Kadam
- Health Sciences, University of Leicester, Leicestershire, United Kingdom
| | | | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Lars H. Lund
- Karolinska Institutet, Stockholm, Sweden
- Duke-National University of Singapore, Singapore
| | | | | | - Kamlesh Khunti
- Leicester Real World Evidence Unit, University of Leicester, Leicestershire, United Kingdom
- Diabetes Centre, University of Leicester, Leicestershire, United Kingdom
- National Institute for Health Research (NIHR) Applied Research Collaboration - East Midlands (ARC-EM), University of Leicester, Leicestershire, United Kingdom
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, and Department of Cardiology, Linkoping University, Sweden
| |
Collapse
|
3
|
Johansson I, Balasubramanian K, Bangdiwala S, Mielniczuk L, Hage C, Sharma SK, Branch K, Zhu J, Kragholm K, Sliwa K, Alla F, Yonga G, Roy A, Orlandini A, Grinvalds A, McCready T, Pogosova N, Störk S, McMurray JJ, Conen D, Yusuf S. Factors associated with health‐related quality of life in heart failure in 23,000 patients from 40 countries: Results of the
G‐CHF
Research Program. Eur J Heart Fail 2022; 24:1478-1490. [DOI: 10.1002/ejhf.2535] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Isabelle Johansson
- Population Health Research Institute McMaster University Hamilton Canada
- Department of Health Research Methods, Evidence, and Impact McMaster University Faculty of Health Sciences Hamilton
| | | | - Shrikant Bangdiwala
- Population Health Research Institute McMaster University Hamilton Canada
- Department of Health Research Methods, Evidence, and Impact McMaster University Faculty of Health Sciences Hamilton
| | - Lisa Mielniczuk
- Division of Cardiology University of Ottawa Heart Institute, Ottawa Ontario
| | - Camilla Hage
- Karolinska University Hospital Heart, Vascular and Neuro Theme Heart Failure Section
- Karolinska Institutet Department of Medicine Cardiology Unit
| | | | - Kelly Branch
- Division of Cardiology University of Washington School of Medicine Seattle
| | - Jun Zhu
- 3 Fuwai Hospital, CAMS & PUMC China
| | | | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Faculty of Health Sciences University of Cape Town
| | - Francois Alla
- Bordeaux Population Health Research Center. Inserm Université de Bordeaux Bordeaux France
- Prevention department, CHU, Bordeaux, France. Bordeaux Population Health Research Center. Inserm Université de Bordeaux Bordeaux France
| | | | - Ambuj Roy
- Department of Cardiology All India Institute of Medical Sciences, New Delhi Delhi India
| | | | - Alex Grinvalds
- Population Health Research Institute McMaster University Hamilton Canada
| | - Tara McCready
- Population Health Research Institute McMaster University Hamilton Canada
| | - Nana Pogosova
- National Medical Research Center of Cardiology Moscow Russia
| | - Stefan Störk
- Comprehensive Heart Failure Center University and University Hospital Würzburg Würzburg Germany
| | | | - David Conen
- Population Health Research Institute McMaster University Hamilton Canada
- Department of Health Research Methods, Evidence, and Impact McMaster University Faculty of Health Sciences Hamilton
| | - Salim Yusuf
- Population Health Research Institute McMaster University Hamilton Canada
- Department of Health Research Methods, Evidence, and Impact McMaster University Faculty of Health Sciences Hamilton
| | | |
Collapse
|
4
|
Vu K, Claggett BL, John JE, Skali H, Solomon SD, Mosley TH, Williams JE, Kucharska‐Newton A, Biering‐Sørensen T, Shah AM. Depressive Symptoms, Cardiac Structure and Function, and Risk of Incident Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction in Late Life. J Am Heart Assoc 2021; 10:e020094. [PMID: 34796739 PMCID: PMC9075356 DOI: 10.1161/jaha.120.020094] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 05/24/2021] [Indexed: 12/31/2022]
Abstract
Background Depressive symptoms are associated with heightened risk of heart failure (HF), but their association with cardiac function and with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) in late life is unclear. We aimed to determine the prevalence of depression in HFpEF and in HFrEF in late life, and the association of depressive symptoms with cardiac function and incident HFpEF and HFrEF. Methods and Results We studied 6025 participants (age, 75.3±5.1 years; 59% women; 20% Black race) in the ARIC (Atherosclerosis Risk in Communities) study at visit 5 who underwent echocardiography and completed the Center for Epidemiologic Studies Depression Scale questionnaire. Among HF-free participants (n=5086), associations of Center for Epidemiologic Studies Depression Scale score with echocardiography and incident adjudicated HFpEF and HFrEF were assessed using multivariable linear and Cox proportional hazards regression. Prevalent HFpEF, but not HFrEF, was associated with a higher prevalence of depression compared with HF-free participants (P<0.001 and P=0.59, respectively). Among HF-free participants, Center for Epidemiologic Studies Depression Scale score was not associated with cardiac structure and function after adjusting for demographics and comorbidities (all P>0.05). Over 5.5-year follow-up, higher Center for Epidemiologic Studies Depression Scale score was associated with heightened risk of incident HFpEF (hazard ratio [HR] [95% CI], 1.06 [1.04-1.12]; P=0.02), but not HFrEF (HR [95% CI], 1.02 [0.96-1.08]; P=0.54), independent of echocardiographic measures, NT-proBNP (N-terminal pro-B-type natriuretic peptide), troponin, and hs-CRP (high-sensitivity C-reactive protein) (HR [95% CI], 1.06 [1.00-1.12]; P=0.04). Conclusions Worse depressive symptoms predict incident HFpEF in late life, independent of common comorbidities, cardiac structure and function, and prognostic biomarkers. Further studies are necessary to understand the mechanisms linking depression to risk of HFpEF.
Collapse
Affiliation(s)
- Katja Vu
- Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
- Herlev and Gentofte HospitalUniversity of CopenhagenCopenhagenDenmark
| | | | - Jenine E. John
- Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Hicham Skali
- Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | | | | | | | | | | | - Amil M. Shah
- Brigham and Women’s HospitalHarvard Medical SchoolBostonMA
| |
Collapse
|
5
|
Cosiano MF, Tobin R, Mentz RJ, Greene SJ. Physical Functioning in Heart Failure With Preserved Ejection Fraction. J Card Fail 2021; 27:1002-1016. [PMID: 33991684 DOI: 10.1016/j.cardfail.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, yet interventions and therapies to improve outcomes remain limited. There has been increasing attention towards the impact of comorbidities and physical functioning (PF) on poor clinical outcomes within this population. In this review, we summarize and discuss the literature on PF in HFpEF, its association with clinical and patient-centered outcomes, and future advances in the care of HFpEF with respect to PF. Multiple PF metrics have been demonstrated to provide prognostic value within HFpEF, yet the data are less robust compared with other patient populations, highlighting the need for further investigation. The evaluation and detection of poor PF provides a potential strategy to improve care in HFpEF, and future studies are needed to understand if modulating PF improves clinical and/or patient-reported outcomes. LAY SUMMARY: • Patients with heart failure with preserved ejection fraction (HFpEF) commonly have impaired physical functioning (PF) demonstrated by limitations across a wide range of common PF metrics.• Impaired PF metrics demonstrate prognostic value for both clinical and patient-reported outcomes in HFpEF, making them plausible therapeutic targets to improve outcomes.• Clinical trials are ongoing to investigate novel methods of detecting, monitoring, and improving impaired PF to enhance HFpEF care.Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, yet interventions and therapies to improve outcomes remain limited. As such, there has been increasing focus on the impact of physical performance (PF) on clinical and patient-centered outcomes. In this review, we discuss the state of PF in patients with HFpEF by examining the multitude of PF metrics available, their respective strengths and limitations, and their associations with outcomes in HFpEF. We highlight future advances in the care of HFpEF with respect to PF, particularly regarding the evaluation and detection of poor PF.
Collapse
Affiliation(s)
| | | | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine; Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine; Duke Clinical Research Institute, Durham, North Carolina.
| |
Collapse
|
6
|
Liu J, Guo Z, Fan M, Liang W, He X, Wu D, Dong Y, Zhu W, Liu C. Major depression and clinical outcomes in patients with heart failure with preserved ejection fraction. Eur J Clin Invest 2021; 51:e13401. [PMID: 32910827 DOI: 10.1111/eci.13401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Limited data have been published concerning about depression in heart failure with preserved ejection fraction (HFpEF). Besides, among HFpEF patients with depression, the efficacy of antidepressants is poorly defined. Therefore, our current study was aimed to examine the relationship between major depression and clinical outcomes in HFpEF patients and further address the effects of antidepressants on prognosis in patients with major depression and HFpEF. METHODS A total of 1431 patients enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT) were divided into 2 groups according to the baseline depression status. Major depression was diagnosed if the Patient Health Questionnaire-9 score (PHQ-9) ≥ 10. Univariable and multivariable Cox proportional hazards models tested the association of major depression with outcomes and the effects of antidepressants among HFpEF patients with major depression during a follow-up of 6 years. RESULTS 26.7% (382/1431) of patients were diagnosed with major depression. After multivariable adjustment, major depression at baseline was not significantly associated with cardiovascular outcomes (fully adjusted hazard ratio (aHR) 0.95 [0.76-1.18] for primary outcomes; aHR: 0.86 [0.67-1.10] for HF hospitalization; aHR: 1.06 [0.91-1.23] for any hospitalization; aHR: 1.00 [0.70-1.43] for cardiovascular death; aHR: 1.24 [0.96-1.61] for all-cause death). Additionally, among HFpEF patients with major depression, the use of antidepressants was not associated with adverse events (P > .05 for all analyses). CONCLUSIONS In HFpEF patients, major depression at baseline did not increase mortality or rehospitalization. Additionally, treatment with antidepressants might not improve prognosis among HFpEF patients with major depression. Future studies are warranted to explore the effects of antidepressants on HFpEF patients with depression.
Collapse
Affiliation(s)
- Jian Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.,Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China
| | - Zejun Guo
- The hospital of South China Normal University, Guangzhou, PR China
| | - Meida Fan
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China.,Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Weihao Liang
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China
| | - Xin He
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China
| | - Dexi Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China
| | - Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, PR China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China
| |
Collapse
|
7
|
Chandra A, Alcala MA, Claggett B, Desai AS, Fang JC, Heitner JF, Liu J, Pitt B, Solomon SD, Pfeffer MA, Lewis EF. Associations Between Depressive Symptoms and HFpEF-Related Outcomes. JACC-HEART FAILURE 2020; 8:1009-1020. [DOI: 10.1016/j.jchf.2020.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022]
|
8
|
O’Kelly AC, Lau ES. Sex Differences in HFpEF. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00856-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
9
|
A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-being in Patients With Heart Failure. J Cardiopulm Rehabil Prev 2020; 39:403-408. [PMID: 31397771 DOI: 10.1097/hcr.0000000000000430] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms. METHODS Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU. RESULTS Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to -345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to -127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, -35 to -374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, -1 to 3, P = .27). CONCLUSIONS Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU.
Collapse
|
10
|
Reddy YN, Rikhi A, Obokata M, Shah SJ, Lewis GD, AbouEzzedine OF, Dunlay S, McNulty S, Chakraborty H, Stevenson LW, Redfield MM, Borlaug BA. Quality of life in heart failure with preserved ejection fraction: importance of obesity, functional capacity, and physical inactivity. Eur J Heart Fail 2020; 22:1009-1018. [DOI: 10.1002/ejhf.1788] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Aruna Rikhi
- Division of CardiologyDuke University Durham NC USA
| | - Masaru Obokata
- Division of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Sanjiv J. Shah
- Division of CardiologyNorthwestern University Chicago IL USA
| | | | | | - Shannon Dunlay
- Division of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | | | | | | | | | | |
Collapse
|
11
|
Honigberg MC, Lau ES, Jones AD, Coles A, Redfield MM, Lewis GD, Givertz MM. Sex Differences in Exercise Capacity and Quality of Life in Heart Failure With Preserved Ejection Fraction: A Secondary Analysis of the RELAX and NEAT-HFpEF Trials. J Card Fail 2020; 26:276-280. [PMID: 31945458 DOI: 10.1016/j.cardfail.2020.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few studies have compared clinical characteristics, echocardiographic parameters, exercise capacity, and quality of life between women and men with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS Subjects in the NIH-sponsored RELAX (N = 216) and NEAT (N = 107) trials completed baseline echocardiography, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and 6-minute walk test (6MWT). In an exploratory analysis, multivariable linear regression models were used to associate clinical and imaging characteristics with baseline 6MWT distance and MLHFQ score in women and men. Our cohort included 158 (49%) men and 165 (51%) women. Men had higher prevalence of atrial arrhythmias, ischemic heart disease, diabetes, anemia, and left ventricular (LV) hypertrophy. 6MWT and MLHFQ score did not differ between sexes. In multivariable analysis, ischemic heart disease, diastolic dysfunction, and exercise capacity predicted MLHFQ score for men, whereas only age and body mass index predicted MLHFQ score for women. CONCLUSIONS Men with HFpEF had more comorbidities and LV hypertrophy than women with HFpEF. In men, quality of life was associated with diastolic dysfunction, ischemic heart disease, and exercise capacity. Further research is needed to identify determinants of quality of life in women with HFpEF.
Collapse
Affiliation(s)
- Michael C Honigberg
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Emily S Lau
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Aaron D Jones
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Adrian Coles
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Gregory D Lewis
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
12
|
Chandra A, Vaduganathan M, Lewis EF, Claggett BL, Rizkala AR, Wang W, Lefkowitz MP, Shi VC, Anand IS, Ge J, Lam CS, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, Van Veldhuisen DJ, Zannad F, Zile MR, McMurray JJ, Solomon SD. Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction. JACC-HEART FAILURE 2019; 7:862-874. [DOI: 10.1016/j.jchf.2019.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
|
13
|
Steinberg BA, Piccini JP. Tackling Patient-Reported Outcomes in Atrial Fibrillation and Heart Failure: Identifying Disease-Specific Symptoms? Cardiol Clin 2019; 37:139-146. [PMID: 30926015 DOI: 10.1016/j.ccl.2019.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) and heart failure (HF) both significantly affect morbidity and mortality and also account for high symptom burden and impaired health-related quality of life (hrQoL). Several well-designed and broadly implemented patient-reported outcome instruments are available for both AF and HF and can easily measure hrQoL in each disease process. A better understanding of the diverse phenotypes of AF and HF, as well as the heterogeneous treatment effects of disease-specific interventions, is necessary to further disentangle the complex relationship between symptoms of AF and HF.
Collapse
Affiliation(s)
- Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, NC, USA; Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke Clinical Research Institute, DUMC #3115, Durham, NC 27705, USA
| |
Collapse
|
14
|
Isobe M. The Heart Failure "Pandemic" in Japan: Reconstruction of Health Care System in the Highly Aged Society. JMA J 2019; 2:103-112. [PMID: 33615020 PMCID: PMC7889807 DOI: 10.31662/jmaj.2018-0049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/21/2019] [Indexed: 12/24/2022] Open
Abstract
An increase in the number of patients with heart failure is an international health-related problem. In advanced countries, the number of such patients has rapidly increased since the beginning of the 21st century, raising an important issue regarding medical practice and public health. In 2010, the concept of “heart failure pandemic” was proposed, and it has been recognized as a global social/economic issue. In particular, the number of elderly patients with heart failure has increased with the rapid aging of society and a decrease in the number of children in Japan. A rapid increase in the number of heart failure patients increases stress and social disease-related/medical economic burdens on individuals and their families. The prognosis of patients with chronic heart failure is unfavorable, and the quality of life markedly reduces. To improve the prognosis of elderly patients with heart failure and reduce the readmission rate, the innovation of a medical-care-providing system for heart failure is required. In addition to the provision of medical practice based on a potent heart failure disease control program, manifold strategies, such as lifestyle improvements, self-care practice, cardiac rehabilitation, and environmental intervention, are essential. It is necessary to innovate hospital-based medical practice to a regional-care-system-based medical care system. In addition, to efficiently promote future heart failure strategies, an investigational study with disease registration must be conducted. Recently a new basic act on countermeasures to cardiovascular diseases has been established which may help the reform for this purpose.
Collapse
|
15
|
Husain MI, Chaudhry IB, Husain MO, Abrol E, Junejo S, Saghir T, Ur Rahman R, Soomro K, Bassett P, Khan SA, Carvalho AF, Husain N. Depression and congestive heart failure: A large prospective cohort study from Pakistan. J Psychosom Res 2019; 120:46-52. [PMID: 30929707 DOI: 10.1016/j.jpsychores.2019.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Evidence demonstrates the detrimental impact of depression in patients with congestive heart failure (CHF), however, large-scale prospective data from Low and Middle Income Countries (LMICs) is limited. We assessed the prevalence of depression in a large sample with CHF from Karachi, Pakistan, and the impact of depression on all-cause mortality, disability and health-related quality of life (QoL). METHODS 1009 patients diagnosed with CHF were recruited from public hospitals in Karachi, Pakistan. Patients were screened for depression at baseline using the Beck Depression Inventory (BDI) and the diagnosis was confirmed using the Clinical Interview Schedule-Revised (CIS-R). Health-related QoL and disability were measured using the EuroQol (EQ-5D) and Brief Disability Questionnaire respectively at baseline and after a 6-month follow-up. RESULTS A total of 670 (66%) patients were depressed at baseline and 821 participants completed 6-month follow up assessments (retention rate: 81%). At baseline, lower income (p < 0.001) and lower education level (p = 0.03) were associated with higher BDI scores. Higher BDI scores were associated with a history of depression (p < 0.001), higher NYHA class (p < 0.001), diabetes (p < 0.001), COPD (p = 0.007), renal disease (p < 0.001) and stroke (p = 0.02). 145 participants were deceased at 6-months. Regression analysis showed that at follow up, higher BDI scores in depressed participants were associated with higher all-cause mortality (OR 1.23 (95% CI: 1.11-1.36); p < 0.001). CONCLUSION The rate of depression was high among Pakistani patients with CHF. Severity of depression correlated with increased mortality. Further research on controlled intervention trials in this population is warranted.
Collapse
Affiliation(s)
- Muhammad I Husain
- Department of Psychiatry, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada.
| | | | - Muhammad O Husain
- School of Biological Sciences, University of Manchester, Manchester, UK.
| | - Esha Abrol
- Division of Psychiatry, University College London (UCL), London, UK.
| | - Shahid Junejo
- City Hospital Sunderland NHS Foundation Trust, Sunderland, UK.
| | - Tahir Saghir
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | | | | | - Paul Bassett
- Pakistan Institute of Living and Learning, Karachi, Pakistan.
| | - Sakina A Khan
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - André F Carvalho
- Department of Psychiatry, Centre for Addiction and Mental Health (CAMH), University of Toronto, Toronto, ON, Canada.
| | | |
Collapse
|
16
|
Bahall M. Prevalence and associations of depression among patients with cardiac diseases in a public health institute in Trinidad and Tobago. BMC Psychiatry 2019; 19:4. [PMID: 30616551 PMCID: PMC6323684 DOI: 10.1186/s12888-018-1977-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 12/07/2018] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Psychosocial issues are major determinants as well as consequences of cardiovascular disease (CVD). This study sought to assess the prevalence and identify factors associated with depression among patients with cardiac disease in a public health institute in Trinidad and Tobago. METHODS A cross-sectional study was conducted with a convenience sample of 388 hospitalised, stable, adult patients with cardiac disease admitted in the only tertiary public health institute in South Trinidad. Patients were identified and interviewed 3 to 5 days after admission using a questionnaire comprising questions on demographic, medical, and lifestyle issues and the 9-item Patient Health Questionnaire (PHQ-9). RESULTS The prevalence of clinically significant depression (PHQ-9 > 9) among hospitalised patients with cardiac disease was 40.0%. However, the prevalence of non-minimal depression (PHQ-9 ≥ 5) in this study was 78.4%. It was greater among women (83.1%) than among men (72.9%). Non-minimal depression was associated with sex (p = 0.015), employment status (p = 0.007), hypertension (p = 0.017), stressful life (p ≤ 0.001), feelings of depression (p ≤ 0.001), regular exercise (p ≤ 0.001), and living alone (p = 0.006). Age, ethnicity, education level, income, or religious affiliations were not associated (p > 0.05) with depression. Participants diagnosed with depression commonly reported feeling tired (81.2%), having trouble sleeping (74.7%), and moving/speaking slowly (73.5%). Patients with self-claimed depression (past or current) were four times more likely to have depression and those with self-reported stress and loneliness were twice as likely to have depression. Employed patients and those who exercised regularly were approximately 50% less likely to have depression. CONCLUSIONS Clinical depression prevalence among hospitalised patients with cardiac disease was 40.0%. Approximately twice as many (78.4%) had non-minimal depression, with higher prevalence among women. Employment, sex, hypertension, stressful life, feelings of depression, regular exercise, and living alone were associated with non-minimal depression. Patients with self-claimed depression, stress, and those living alone had a much higher likelihood of having depression, while those who were employed and exercised regularly were approximately half as likely to have depression.
Collapse
Affiliation(s)
- Mandreker Bahall
- School of Medicine and Arthur Lok Jack Graduate School of Business, University of the West Indies, St. Augustine, House #57 LP 62, Calcutta Road Number 3, McBean, Couva Trinidad, Trinidad and Tobago.
| |
Collapse
|
17
|
Streng KW, Nauta JF, Hillege HL, Anker SD, Cleland JG, Dickstein K, Filippatos G, Lang CC, Metra M, Ng LL, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zwinderman AH, Zannad F, Damman K, van der Meer P, Voors AA. Non-cardiac comorbidities in heart failure with reduced, mid-range and preserved ejection fraction. Int J Cardiol 2018; 271:132-139. [PMID: 30482453 DOI: 10.1016/j.ijcard.2018.04.001] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/19/2018] [Accepted: 04/02/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Comorbidities play a major role in heart failure. Whether prevalence and prognostic importance of comorbidities differ between heart failure with preserved ejection fraction (HFpEF), mid-range (HFmrEF) or reduced ejection fraction (HFrEF) is unknown. METHODS Patients from index (n = 2516) and validation cohort (n = 1738) of The BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF) were pooled. Eight non-cardiac comorbidities were assessed; diabetes mellitus, thyroid dysfunction, obesity, anaemia, chronic kidney disease (CKD, estimated glomerular filtration rate < 60 mL/min/1.73 m2), COPD, stroke and peripheral arterial disease. Patients were classified based on ejection fraction. The association of each comorbidity with quality of life (QoL), all-cause mortality and hospitalisation was evaluated. RESULTS Patients with complete comorbidity data were included (n = 3499). Most prevalent comorbidity was CKD (50%). All comorbidities showed the highest prevalence in HFpEF, except for stroke. Prevalences of HFmrEF were in between the other entities. COPD was the comorbidity associated with the greatest reduction in QoL. In HFrEF, almost all were associated with a significant reduction in QoL, while in HFpEF only CKD and obesity were associated with a reduction. Most comorbidities in HFrEF were associated with an increased mortality risk, while in HFpEF only CKD, anaemia and COPD were associated with higher mortality risks. CONCLUSIONS The highest prevalence of comorbidities was seen in patients with HFpEF. Overall, comorbidities were associated with a lower QoL, but this was more pronounced in patients with HFrEF. Most comorbidities were associated with higher mortality risks, although the associations with diabetes were only present in patients with HFrEF.
Collapse
Affiliation(s)
- Koen W Streng
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan F Nauta
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - John G Cleland
- National Heart & Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, Athens, Greece
| | - Chim C Lang
- School of Medicine Centre for Cardiovascular and Lung Biology, Division of Medical Sciences, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland and Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Dirk J van Veldhuisen
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Aeilko H Zwinderman
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Faiez Zannad
- Inserm CIC 1433, Université de Lorrain, CHU de Nancy, Nancy, France
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
| |
Collapse
|
18
|
Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
Collapse
Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
| | | |
Collapse
|
19
|
Comorbidity health pathways in heart failure patients: A sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry. PLoS Med 2018; 15:e1002540. [PMID: 29584734 PMCID: PMC5870940 DOI: 10.1371/journal.pmed.1002540] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/21/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Optimally treated heart failure (HF) patients often have persisting symptoms and poor health-related quality of life. Comorbidities are common, but little is known about their impact on these factors, and guideline-driven HF care remains focused on cardiovascular status. The following hypotheses were tested: (i) comorbidities are associated with more severe symptoms and functional limitations and subsequently worse patient-rated health in HF, and (ii) these patterns of association differ among selected comorbidities. METHODS AND FINDINGS The Swedish Heart Failure Registry (SHFR) is a national population-based register of HF patients admitted to >85% of hospitals in Sweden or attending outpatient clinics. This study included 10,575 HF patients with patient-rated health recorded during first registration in the SHFR (1 February 2008 to 1 November 2013). An a priori health model and sequences-of-regressions analysis were used to test associations among comorbidities and patient-reported symptoms, functional limitations, and patient-rated health. Patient-rated health measures included the EuroQol-5 dimension (EQ-5D) questionnaire and the EuroQol visual analogue scale (EQ-VAS). EQ-VAS score ranges from 0 (worst health) to 100 (best health). Patient-rated health declined progressively from patients with no comorbidities (mean EQ-VAS score, 66) to patients with cardiovascular comorbidities (mean EQ-VAS score, 62) to patients with non-cardiovascular comorbidities (mean EQ-VAS score, 59). The relationships among cardiovascular comorbidities and patient-rated health were explained by their associations with anxiety or depression (atrial fibrillation, odds ratio [OR] 1.16, 95% CI 1.06 to 1.27; ischemic heart disease [IHD], OR 1.20, 95% CI 1.09 to 1.32) and with pain (IHD, OR 1.25, 95% CI 1.14 to 1.38). Associations of non-cardiovascular comorbidities with patient-rated health were explained by their associations with shortness of breath (diabetes, OR 1.17, 95% CI 1.03 to 1.32; chronic kidney disease [CKD, OR 1.23, 95% CI 1.10 to 1.38; chronic obstructive pulmonary disease [COPD], OR 95% CI 1.84, 1.62 to 2.10) and with fatigue (diabetes, OR 1.27, 95% CI 1.13 to 1.42; CKD, OR 1.24, 95% CI 1.12 to 1.38; COPD, OR 1.69, 95% CI 1.50 to 1.91). There were direct associations between all symptoms and patient-rated health, and indirect associations via functional limitations. Anxiety or depression had the strongest association with functional limitations (OR 10.03, 95% CI 5.16 to 19.50) and patient-rated health (mean difference in EQ-VAS score, -18.68, 95% CI -23.22 to -14.14). HF optimizing therapies did not influence these associations. Key limitations of the study include the cross-sectional design and unclear generalisability to other populations. Further prospective HF studies are required to test the consistency of the relationships and their implications for health. CONCLUSIONS Identification of distinct comorbidity health pathways in HF could provide the evidence for individualised person-centred care that targets specific comorbidities and associated symptoms.
Collapse
|
20
|
Lewis EF, Claggett B, Shah AM, Liu J, Shah SJ, Anand I, O’Meara E, Sweitzer NK, Rouleau JL, Fang JC, Desai AS, Retta TM, Solomon SD, Heitner JF, Stamos TD, Boineau R, Pitt B, Pfeffer MA. Racial Differences in Characteristics and Outcomes of Patients With Heart Failure and Preserved Ejection Fraction in the Treatment of Preserved Cardiac Function Heart Failure Trial. Circ Heart Fail 2018; 11:e004457. [DOI: 10.1161/circheartfailure.117.004457] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 02/21/2018] [Indexed: 12/23/2022]
Abstract
Background:
Black patients have been shown to have different baseline characteristics and outcomes compared with nonblack patients in cohort studies. However, few studies have focused on heart failure (HF) with preserved ejection fraction (HFpEF) patients. We aimed to determine the difference in cardiovascular outcomes in black and nonblack patients with HFpEF and to determine the relative efficacy and safety of spironolactone in black and nonblack patients.
Methods and Results:
Patients with HFpEF, randomized to spironolactone versus placebo in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) in North and South America, were grouped according to self-described black and nonblack race. Black HFpEF patients (n=302) were younger and were more likely to have diabetes mellitus and hypertension than nonblack patients but had similar HFpEF severity. Black patients had higher risk for the primary outcome (hazard ratio [HR], 1.34; 95% confidence interval, 1.06–1.71;
P
=0.02) and first HF hospitalization (HR, 1.51; 95% confidence interval, 1.167–1.97;
P
=0.002)], but no significant difference in cardiovascular mortality risk (HR, 0.78; 95% confidence interval, 0.51–1.20;
P
=0.326). In black and nonblack patients, randomization to spironolactone conferred similar efficacy in the primary outcome (HR, 0.83 versus 0.79;
P
for interaction=0.49), HF hospitalization (HR, 0.67 versus 0.82;
P
for interaction=0.76), and cardiovascular mortality (
P
for interaction=0.19). The risk of hyperkalemia and worsening renal function with spironolactone and study drug adherence were also similar.
Conclusions:
Black patients with HFpEF have a higher HF hospitalization risk than nonblack patients, but spironolactone is similarly effective and safe in both groups.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT00094302.
Collapse
Affiliation(s)
- Eldrin F. Lewis
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Amil M. Shah
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Jiankang Liu
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Sanjiv J. Shah
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Inder Anand
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Eileen O’Meara
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Nancy K. Sweitzer
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Jean L. Rouleau
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - James C. Fang
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Akshay S. Desai
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Tamrat M. Retta
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Scott D. Solomon
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - John F. Heitner
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Thomas D. Stamos
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Robin Boineau
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Bertram Pitt
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| | - Marc A. Pfeffer
- From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (E.F.L., B.C., A.M.S., J.L., A.S.D., S.D.S., M.A.P.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Veterans Affairs Medical Center Minneapolis, Minnesota (I.A.); University of Minnesota Medical School, Minneapolis (I.A.); Veterans Affairs Medical Center at San Diego, CA (I.A.); Montreal Heart Institute, Quebec, Canada (J.L.R., E.O.); Department of
| |
Collapse
|
21
|
Lewis EF, Claggett BL, McMurray JJV, Packer M, Lefkowitz MP, Rouleau JL, Liu J, Shi VC, Zile MR, Desai AS, Solomon SD, Swedberg K. Health-Related Quality of Life Outcomes in PARADIGM-HF. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003430. [DOI: 10.1161/circheartfailure.116.003430] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Eldrin F. Lewis
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Brian L. Claggett
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - John J. V. McMurray
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Milton Packer
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Martin P. Lefkowitz
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Jean L. Rouleau
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Jiankang Liu
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Victor C. Shi
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Michael R. Zile
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Akshay S. Desai
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Scott D. Solomon
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Karl Swedberg
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| |
Collapse
|
22
|
Ambrosy AP, Cerbin LP, DeVore AD, Greene SJ, Kraus WE, O'Connor CM, Piña IL, Whellan DJ, Wojdyla D, Wu A, Mentz RJ. Aerobic exercise training and general health status in ambulatory heart failure patients with a reduced ejection fraction-Findings from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION)trial. Am Heart J 2017; 186:130-138. [PMID: 28454828 DOI: 10.1016/j.ahj.2016.12.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/15/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Although aerobic exercise improves quality of life as assessed by a disease-specific instrument in ambulatory HF patients with a reduced ejection fraction (EF), the impact of an exercise intervention on general health status has not been previously reported. METHODS A secondary analysis was performed of the HF-ACTION trial (ClinicalTrials.gov Number: NCT00047437), which enrolled 2331 medically stable outpatients with HF and an EF ≤35% and randomized them to aerobic exercise training, consisting of 36 supervised sessions followed by home-based training versus usual care for a median follow-up of 30 months. The EuroQOL 5-dimension questionnaire (EQ-5D) was administered to study participants at baseline, 3 months, and 12 months. EQ-5D includes functional dimensions (ie, mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), which were mapped to corresponding utility scores (ie, 0=death and 1=perfect health), and a visual analogue scale (VAS) ranging from 0 (ie, "worst imaginable health state") to 100 (ie, "best imaginable health state"). RESULTS Study participants had a median (25th, 75th) age of 59 (51, 68) years and 71% were male. A history of ischemic heart disease was reported in 51% of participants and the EF was 25% (20%, 30%). Baseline VAS and mapped utility scores were 65±19 and 0.81±0.14. Exercise training led to an improvement in VAS score compared with usual care from baseline to 3 months (exercise training: 6±17 vs usual care: 3±20; P <.01) although there were no further significant changes at 12 months. Aerobic exercise training did not favorably change mapped utility scores over either timeframe. After multivariable adjustment, lower mapped utility (hazard ratio [HR] 1.19 per 0.1 decrease, 95% CI 1.09-1.29; P < .0001) and VAS scores (HR 1.05 per 10 point decrease, 95% CI 1.02-1.08; P < .01) at baseline were associated with increased risk of death or hospitalization. CONCLUSION Ambulatory HF patients with a reduced EF had impaired health status at baseline which was associated with increased morbidity and mortality, in part mitigated by a structured aerobic exercise regimen.
Collapse
Affiliation(s)
- Andrew P Ambrosy
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Adam D DeVore
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Stephen J Greene
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - William E Kraus
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Durham, NC, USA; Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | | | | | - Angie Wu
- Duke Clinical Research Institute, Durham, NC, USA
| | - Robert J Mentz
- Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
23
|
Lewis EF, Kim HY, Claggett B, Spertus J, Heitner JF, Assmann SF, Kenwood CT, Solomon SD, Desai AS, Fang JC, McKinlay SA, Pitt BA, Pfeffer MA. Impact of Spironolactone on Longitudinal Changes in Health-Related Quality of Life in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial. Circ Heart Fail 2016; 9:e001937. [PMID: 26962133 DOI: 10.1161/circheartfailure.114.001937] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction patients have equally impaired health-related quality of life (HRQL) compared with those with HF with reduced ejection fraction, but limited studies have evaluated the impact of therapies on changes in HRQL. METHODS AND RESULTS Patients ≥50 years of age, with symptomatic HF and left ventricular ejection fraction ≥45%, were enrolled in Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) and randomized to spironolactone or placebo. Patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), which was the primary HRQL instrument, and EQ5D visual analog scale at baseline, 4 months, 12 months, and annually thereafter. McMaster Overall Treatment Evaluation was assessed at 4 and 12 months to assess global change scores. Change scores (+SD) were calculated to determine between-group differences, and multivariable repeated-measures models were created to identify other factors associated with change scores. Paired KCCQ data were available for 91.7% of 3445 TOPCAT patients. By 4 months, the mean change in KCCQ was 7.7±16 and mean change in EQ5D visual analog scale was 4.7±16. Adjusted mean changes in KCCQ for the spironolactone group were significantly better than those for the placebo group at 4-month (1.54 better; P=0.002), 12-month (1.35 better; P=0.02), and 36-month (1.86 better; P=0.02) visits. No between-group differences in EQ5D visual analog scale change scores or McMaster Overall Treatment Evaluation were noted. Older age, obesity, current smoking, New York Heart Association class III/IV, and comorbid illnesses were associated with declines in KCCQ scores. Use of spironolactone was an independent predictor of improved KCCQ scores. CONCLUSIONS In symptomatic HF with preserved ejection fraction patients, use of spironolactone was associated with an improvement in HF-specific HRQL. Several modifiable risk factors were associated with HRQL deterioration. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
Collapse
Affiliation(s)
- Eldrin F Lewis
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.).
| | - Hae-Young Kim
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - John Spertus
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - John F Heitner
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Susan F Assmann
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Christopher T Kenwood
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Scott D Solomon
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Akshay S Desai
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - James C Fang
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Sonia A McKinlay
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Bertram A Pitt
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | | |
Collapse
|
24
|
Abstract
The field of quality-of-life (QOL) measurement grew out of attempts in the 1960s and 1970s to connect the ever-increasing levels of public expenditure on technology-based health care for chronic diseases with evidence of the benefits and harms to patients. Most of the concepts, methods, and standards for measuring QOL were derived from psychometrics, but the degree to which current tools adhere to these methods varies greatly. Despite the importance of QOL, patient-reported outcomes are not measured in most cardiovascular clinical trials. Lack of familiarity with QOL measures and their interpretation, and unrealistic expectations about the information these measures can provide, are obstacles to their use. Large clinical trials of revascularization therapy for coronary artery disease and medical treatments for heart failure show small-to-moderate QOL effects, primarily detected with disease-specific instruments. Larger treatment effects, seen in trials of device therapy for heart failure and ablation therapy for atrial fibrillation, have been detected with both generic and disease-specific instruments. A large gap remains between the parameters currently being measured in clinical research and the data needed to incorporate the 'patient's voice' into therapeutic decision-making.
Collapse
Affiliation(s)
- Daniel B Mark
- Duke Clinical Research Institute, 2400 Pratt Avenue, Room 0311, PO Box 17969, Durham, North Carolina 27715, USA
| |
Collapse
|
25
|
Joyce E, Chung C, Badloe S, Odutayo K, Desai A, Givertz MM, Nohria A, Lakdawala NK, Stewart GC, Young M, Weintraub J, Stevenson LW, Lewis EF. Variable Contribution of Heart Failure to Quality of Life in Ambulatory Heart Failure With Reduced, Better, or Preserved Ejection Fraction. JACC-HEART FAILURE 2016; 4:184-93. [PMID: 26874379 DOI: 10.1016/j.jchf.2015.12.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/30/2015] [Accepted: 12/09/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The relative contribution of heart failure (HF) compared with other medical and nonmedical factors on diminished quality of life (QOL) across subtypes with reduced, better, and preserved left ventricular ejection fraction (LVEF) in a large ambulatory HF population was evaluated. BACKGROUND Dominant factors influencing limited QOL in patients with HF have not been investigated. METHODS Before routine HF clinic visits, 726 patients with ambulatory HF (mean age 56 ± 15 years, 37% women) completed a 1-page questionnaire that assessed QOL and relative contributions of HF compared with other medical and nonmedical factors to their QOL limitations. Visual analogue scales were used to assess overall QOL, breathing, and energy level. Results were compared across reduced (57%), preserved (16%) and better (improvement in LVEF ≥50%) (19%) subtypes. RESULTS Just under one-half of patients (48%) rated QOL as limited dominantly by HF, 19% rated HF and medical problems as equally limiting, 18% cited medical problems as dominant, and 15% cited nonmedical factors. Patients with HF with better LVEF had the highest overall QOL score and less dyspnea burden than those with HF with preserved EF. Independent correlates of HF-dominated diminished QOL were prior cardiac surgery, worse New York Heart Association functional class, renin-angiotensin-aldosterone antagonism, use of diuretic agents, lower body mass index, lower LVEF, and lack of arthritis or history of cancer. CONCLUSIONS Fewer than one-half of patients with ambulatory HF rated HF as the greatest limitation to their QOL, suggesting that this important outcome will be difficult to affect by HF-targeted therapies alone, particularly in those with higher LVEFs and comorbidities. Patients with HF with better LVEF represent a distinct subtype with better overall QOL.
Collapse
Affiliation(s)
- Emer Joyce
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Christine Chung
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Sabrina Badloe
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Kayode Odutayo
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Akshay Desai
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Michael M Givertz
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Anju Nohria
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Neal K Lakdawala
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Garrick C Stewart
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Michelle Young
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Joanne Weintraub
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Lynne W Stevenson
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Eldrin F Lewis
- Center for Advanced Heart Disease, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
26
|
Nahlén Bose C, Persson H, Björling G, Ljunggren G, Elfström ML, Saboonchi F. Evaluation of a Coping Effectiveness Training intervention in patients with chronic heart failure - a randomized controlled trial. Eur J Cardiovasc Nurs 2016; 15:537-548. [PMID: 26733462 DOI: 10.1177/1474515115625033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 12/08/2015] [Accepted: 12/10/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Impaired emotional well-being has detrimental effects on health outcomes in patients with chronic heart failure (CHF). AIMS To evaluate a nurse-led Coping Effectiveness Training (CET) group intervention for patients with CHF. It was hypothesized that CET would increase emotional well-being (primary outcome) and health-related quality (HRQoL) of life and improve clinical outcomes. Furthermore, changes in appraisal and coping as mediators of the intervention effect were examined. METHODS Participants were randomized to either control group (n=51) receiving standard health care or CET intervention group (n=52). Self-assessments of positive affect, negative affect, depression, anxiety, HRQoL, illness perception, coping strategies and social support were performed pre- and post-intervention and after six weeks, six months and 12 months. Time to death and hospitalizations were measured during the entire follow-up (median 35 months, interquartile range 11 months). RESULTS No significant improvements for emotional well-being and HRQoL in the intervention group compared with the control group were found. After excluding patients with clinical anxiety and depression at baseline the intervention group had significantly lower negative affect (p = 0.022). There were no significant differences regarding cardiovascular events between the groups. The intervention group had greater sense of control over their illness in the short-term (p = 0.036). CONCLUSION CET intervention was found to increase sense of control over the illness in the short term. Psychosocial support programmes, like CET, for patients with CHF is currently lacking evidence for implementing in clinical practice. However, the results provide a basis for future studies with a modified CET intervention design and increased study size.
Collapse
Affiliation(s)
- Catarina Nahlén Bose
- The Swedish Red Cross University College, Stockholm, Sweden .,Department of Clinical Sciences Danderyd Hospital AB, Karolinska Institutet, Stockholm, Sweden
| | - Hans Persson
- Department of Clinical Sciences Danderyd Hospital AB, Karolinska Institutet, Stockholm, Sweden
| | - Gunilla Björling
- The Swedish Red Cross University College, Stockholm, Sweden.,Department of Clinical Sciences Danderyd Hospital AB, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Ljunggren
- Public Healthcare Services Committee Administration, Stockholm County Council, Sweden.,Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Magnus L Elfström
- Mälardalen University, Academy of Health, Care and Social Welfare, Eskilstuna/Västerås, Sweden
| | - Fredrik Saboonchi
- The Swedish Red Cross University College, Stockholm, Sweden.,Department of Clinical Neuroscience, Division of Insurance Medicine, Administration, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|