Effect of Functional Health-Related Quality of Life on Long-Term Survival After Cardiac Surgery

Identifying coronary artery bypass grafting patients at high risk for adverse long-term prognosis using serial health-related quality of life assessments

BACKGROUND

Patients who undergo coronary artery bypass grafting (CABG) are known to be at a significant risk of experiencing long-term adverse events, emphasizing the importance of regular assessments. Evaluating health-related quality of life (HRQoL) serves as a direct method to gauge prognosis. Our objective is to ascertain the prognostic significance of consecutive HRQoL assessments using the Physical Component Summary (PCS) and Mental Component Summary (MCS) derived from the Short-Form 36 (SF-36) health survey in CABG patients.

METHODS

The study population consisted of 433 patients who underwent isolated elective CABG at Fuwai Hospital between 2012 and 2013. SF-36 assessments were conducted during both the hospitalization period and follow-up. The primary endpoint of the study was all-cause mortality, while the secondary outcome was a composite measure including death, myocardial infarction, stroke, and repeat revascularization. We assessed the relationships between the PCS and MCS at baseline, as well as their changes during the first 6 months after the surgery (referred to as ΔPCS and ΔMCS, respectively), and the observed outcomes.

RESULTS

The patients were followed for an average of 6.28 years, during which 35 individuals (35/433, 8.1%) died. After adjusting for clinical variables, it was observed that baseline MCS scores (hazard ratio [HR] for a 1-standard deviation [SD] decrease, 1.57; 95% confidence interval [CI], 1.07-2.30) and ΔMCS (HR for a 1-SD decrease, 1.67; 95% CI, 1.09-2.56) were associated with all-cause mortality. However, baseline PCS scores and ΔPCS did not exhibit a significant relationship with all-cause mortality. Notably, there was a dose-response relationship observed between ΔMCS and the likelihood of all-cause mortality (HRs for the 2nd, 3rd and 4th quartiles compared to the 1st quartile, 0.33, 0.45 and 0.11, respectively).

CONCLUSIONS

Baseline MCS and changes in MCS were independent predictors for long-term mortality of CABG. Better mental health status and recovery indicated better prognosis.

Assessment of quadriceps muscle mass by ultrasound in the postoperative period of cardiac surgery

BACKGROUND

Patients undergoing cardiac surgery are exposed to many factors that activate catabolic and inflammatory pathways, which affect skeletal muscle and are, therefore, related to unfavorable hospital outcomes. Given the limited information on the behavior of muscle mass in critically ill patients, the objective of this study was to evaluate the impact on quantitative and qualitative measurements of quadriceps muscle mass using ultrasound after cardiac surgery. To accomplish this, a prospective, descriptive, and correlational study was conducted at a tertiary care hospital. Quadriceps muscle mass was evaluated via ultrasound in 31 adult patients in the postoperative period of cardiac surgery, with daily follow-up until postoperative day 7, as well as an assessment of associations with negative outcomes at 28 days.

RESULTS

A 16% reduction in the cross-sectional area of the rectus femoris was found (95% CI 4.2-3.5 cm2; p 0.002), as well as a 24% reduction in the pennation angle of the rectus femoris (95% CI 11.1-8.4 degrees; p: 0.025). However, changes in the thickness of the rectus femoris, vastus internus, vastus lateralis, the length of the fascicle of the vastus lateralis, the pennation angle of the vastus lateralis, the sarcopenia index, and the Hekmat score were not statistically significant. There was no significant association between quadriceps muscle mass measurements and Intensive Care Unit (ICU) length stay or 28-day mortality.

CONCLUSIONS

Patients in the postoperative period of cardiac surgery evaluated by ultrasound exhibit both quantitative and qualitative changes in quadriceps muscle mass. A significant reduction in muscle mass is observed but this is not associated with unfavorable outcomes.

Heart Disease and Ageing: The Roles of Senescence, Mitochondria, and Telomerase in Cardiovascular Disease

During ageing molecular damage leads to the accumulation of several hallmarks of ageing including mitochondrial dysfunction, cellular senescence, genetic instability and chronic inflammation, which contribute to the development and progression of ageing-associated diseases including cardiovascular disease. Consequently, understanding how these hallmarks of biological ageing interact with the cardiovascular system and each other is fundamental to the pursuit of improving cardiovascular health globally. This review provides an overview of our current understanding of how candidate hallmarks contribute to cardiovascular diseases such as atherosclerosis, coronary artery disease and subsequent myocardial infarction, and age-related heart failure. Further, we consider the evidence that, even in the absence of chronological age, acute cellular stress leading to accelerated biological ageing expedites cardiovascular dysfunction and impacts on cardiovascular health. Finally, we consider the opportunities that modulating hallmarks of ageing offer for the development of novel cardiovascular therapeutics.

Standardized Assessment of Global activities in the Elderly scale in adult cardiac surgery patients

BACKGROUND

Different instruments have been used to assess ability to perform everyday functional activities, such as activities of daily living (ADL) and instrumental activities of daily living (IADL). No measures of functional activity have been validated in cardiac surgery. We assessed the reliability and validity of the Standardized Assessment of Global activities in the Elderly (SAGE) scale.

METHODS

We undertook an observational sub-study of VISION Cardiac Surgery. Patients were assessed post-discharge after cardiac surgery using SAGE and comparator measures to determine convergent validity. A blinded independent assessor administered SAGE by phone within 7 days to determine test-retest reliability. We sought to demonstrate a correlation of ≥0.5 between SAGE and each corresponding measure. We also sought to define the SAGE score corresponding to severe functional disability, defined using the World Health Organisation Disability Assessment Schedule (WHODAS).

RESULTS

There were 152 patients included. Inter-rater reliability was excellent (intra-class correlation coefficient=0.99; 95% confidence interval [CI], 0.98-0.99). Convergent validity was evident, ranging from adequate for the overall SAGE score (0.54; 95% CI, 0.42-0.65) to very good for the SAGE mobility sub-score (0.80; 95% CI, 0.73-0.85). SAGE was initially poorly correlated with the IADL index (-0.24) but increased to -0.60 after post-hoc adjustment of SAGE scoring. A SAGE score ≥7 was associated with severe functional disability and occurred in 42/152 (27.6%) of patients.

CONCLUSION

These results demonstrate the reliability and validity of the SAGE scale as a measure of global function in patients discharged home after cardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT01842568.

Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension?

BACKGROUND

To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT.

METHODS

Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88.

CONCLUSIONS

The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.

Characterizing Patient-Centered Postoperative Recovery After Adult Cardiac Surgery: A Systematic Review

Background

Improving postoperative recovery is important, with a national focus on postacute care, but the volume and quality of evidence in this area are not well characterized. We conducted a systematic review to characterize studies on postoperative recovery after adult cardiac surgery using patient‐reported outcome measures.

Methods and Results

From MEDLINE and Web of Science, studies were included if they prospectively assessed postoperative recovery on adult patients undergoing cardiac surgery using patient‐reported outcome measures. Six recovery domains were defined by prior literature: nociceptive symptoms, mental health, physical function, activities of daily living, sleep, and cognitive function. Of the 3432 studies, 105 articles met the inclusion criteria. The studies were small (median sample size, 119), and mostly conducted in single‐center settings (n=81; 77%). Study participants were predominantly men (71%) and white (88%). Coronary artery bypass graft was included in 93% (n=98). Studies commonly selected for elective cases (n=56; 53%) and patients with less comorbidity (n=67; 64%). Median follow‐up duration was 91 (interquartile range, 42–182) days. Studies most commonly assessed 1 domain (n=42; 40%). The studies also varied in the instruments used and differed in their reporting approach. Studies commonly excluded patients who died during the follow‐up period (n=48; 46%), and 45% (n=47) did not specify how those patients were analyzed.

Conclusions

Studies of postoperative patient‐reported outcome measures are low in volume, most often single site without external validation, varied in their approach to missing data, and narrow in the domains and diversity of patients. The evidence base for postoperative patient‐reported outcome measures needs to be strengthened.

Long-term non-institutionalized survival and rehospitalization after surgical aortic and mitral valve replacements in a large provincial cardiac surgery centre

OBJECTIVES

Long-term quality of life following open surgical valve replacement is an increasingly important outcome to patients and their caregivers. This study examines non-institutionalized survival and rehospitalization within our surgical aortic valve replacement (AVR) and mitral valve replacement (MVR) populations.

METHODS

A retrospective single-centre study of all consecutive open surgical valve replacements between 1995 and 2014 was undertaken. Clinical data were linked to provincial administrative data for 3219 patients who underwent AVR, MVR or double (aortic and mitral) valve replacement with or without concomitant coronary artery bypass grafting (CABG). Non-institutionalized survival and cumulative incidence of rehospitalization was examined up to 15 years.

RESULTS

Follow-up was complete for 96.9% of the 2146 patients who underwent AVR ± CABG (66.7% of the overall cohort), 878 who underwent MVR ± CABG (27.3%) and 195 who underwent double (aortic and mitral) valve replacement ± CABG (6.0%) with a median follow-up time of 5.6 years. Overall non-institutionalized survival was 35.4% at 15 years, and the cumulative incidence of rehospitalization was 34.4%, 63.2% and 87.0% at 1, 5 and 15 years, respectively, without significant differences between valve procedure cohorts. Both non-institutionalized survival and cumulative incidence of rehospitalization improved in more recent eras, despite increasing age and comorbidities.

CONCLUSIONS

Non-institutionalized survival and rehospitalization data for up to 15 years suggest good functional outcomes long after surgical AVR and/or MVR. Continued improvements are seen in these metrics over the past 2 decades. This provides a unique insight into the quality of life after surgical valve replacement in the ageing demographics with valvular heart disease.

Quality of Life After Cardiac Operations Based on the Minimal Clinically Important Difference Concept

BACKGROUND

Health-related quality of life (HRQOL) is an increasingly important issue in assessing the consequences of any surgical or medical intervention. Our study aimed to evaluate change in HRQOL 6 months after elective cardiac operations and to identify specific predictors of poor HRQOL.

METHODS

In this prospective, single-center study, HRQOL was evaluated before and 6 months after the operation using the Medical Outcome Study 36-Item Short Form Health Survey questionnaire and its two components: the Physical Component Summary and the Mental Component Summary. We distinguished patients with worsening of HRQOL according to the minimal clinically important difference. All consecutive adult patients undergoing cardiac operations were included.

RESULTS

The preoperative and postoperative 36-Item Short Form Health Survey questionnaires were completed by 326 patients, and 24 patients died before completing follow-up questionnaires. On the basis of the definition used, clinically significant deterioration of HRQOL was observed in 93 patients (26.6%) for the Physical Component Summary and in 99 patients (28.2%) for the Mental Component Summary. Renal replacement for acute renal failure and mechanical ventilation for longer than 48 hours were independent risk factors for Physical Component Summary and Mental Component Summary worsening or death.

CONCLUSIONS

Although our study showed overall improvement of quality of life after cardiac operations, more than one-quarter of the patients manifested deterioration of HRQOL at 6 months postoperatively. The findings from this study should help clinicians to inform patients about their likely postoperative functional status and quality of life.

Specificity of training in cardiac rehabilitation to facilitate a patient's return to strenuous work following aortic valve replacement

A 30-year-old male roughneck worker on an oil rig underwent aortic valve replacement and subsequently enrolled in the Baylor Heart and Vascular Hospital exercise-based cardiac rehabilitation (CR) program. He expressed a strong desire to return to his physically demanding job. Based on his unique job requirements, CR staff designed and implemented comprehensive tests and a 5-week specific physical training program that included 6 exercises simulating his job functions. The selected exercises are not typically prescribed in traditional CR programs but mimicked the muscular strength/endurance required to perform his job. The goals set for each of the 6 specific exercises were accomplished and resulted in the patient rapidly regaining his muscular strength through the specially designed training program. The exercise regimen was successfully completed without adverse signs or symptoms and enabled the patient to return to work within approximately 2 months of completion.

Graft patency is associated with higher health-related quality of life after coronary artery bypass surgery

Objectives

The objective of this study was to investigate whether graft patency was associated with higher health-related quality of life in coronary artery bypass grafting patients and to compare this study with the general Swedish population.

Methods

Patients were included from 3 randomized trials and 1 prospective cohort trial. The generic health-related quality of life instrument, EQ-5D (VAS and index) was used. Graft patency was assessed with computed tomography angiography. Patients were divided into 2 groups according to the number of occluded distal anastomosis: Group I with no to 1 occlusion ( n  = 209) and Group II with 2 to 4 occlusions ( n  = 24).

Results

Two hundred and thirty-three patients underwent computed tomography angiography at a mean of 7.5 (1-18) years post-operatively. The mean difference in EQ-VAS and EQ-5D index between Groups II and I after model adjustment was -19.8 (95% CI -25.3 to -14.3; P  < 0.001) and -0.13 (95% CI -0.19 to -0.08; P  < 0.001), respectively. The EQ-5D index for the study population was similar compared with the Swedish population, 0.851 and 0.832, respectively, with an effect-size of 0.112 (trivial). The EQ-5D index of the study population was higher compared with the ischemic heart disease group in the Swedish population, 0.851 vs 0.60, with an effect-size of 0.999 (large).

Conclusions

Graft patency was associated with higher health-related quality of life in coronary artery bypass patients. This patient group reported similar function and wellbeing compared to the general Swedish population and better health status than those in the same disease group in the general population.

Clinical registration number

Clinicaltrials.gov: NCT02547194 and the Research and Development registry in Sweden: 167861.

Association of global and disease-specific health status with outcomes following continuous-flow left ventricular assist device implantation

BACKGROUND

The prognostic value of heart failure specific and global health status before and after left ventricular assist device (LVAD) implantation in the usual care setting is not well studied.

METHODS

We included 3,836 continuous-flow LVAD patients in the INTERMACS registry. Health status was measured pre-operatively and 3 months post-LVAD using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQol visual analog scale (VAS). Primary outcomes were mortality/rehospitalization. Inverse propensity weighting was used to minimize bias from missing data.

RESULTS

Pre-operative global and heart failure-specific health status were very poor: KCCQ median 34.6 (IQR 21.4-50.5); VAS median 43 (interquartile range (IQR) 25-65). Health status measures improved 3 months after LVAD placement: KCCQ median 69.3 (IQR 54.2-82.3); VAS median 75 (IQR 60-85). Pre-operative health status was not associated with death (unadjusted HR for lowest vs. highest score quartiles: 1.09 (0.85-1.41) KCCQ; 1.12 (0.85-1.49) VAS) or rehospitalization (unadjusted HR 0.83 (0.72-0.96) KCCQ; 0.99 (0.85-1.16) VAS). Three-month KCCQ was associated with mortality (unadjusted HR 2.17 (1.47-3.21); VAS was not (1.43 (0.94-2.17). Three-month KCCQ added incremental discriminatory value to the HeartMate II Risk Score for death (c-stat 0.60 to 0.66); VAS did not (c-stat 0.59 to 0.60). Three-month health status was associated with rehospitalization (unadjusted HR 1.31 (1.15-1.57) KCCQ; 1.24 (1.05-1.46) VAS), but did not add incremental discriminatory value (c-stat 0.52 to 0.55 and 0.54, respectively).

CONCLUSIONS

These real-world data suggest that pre-operative health status has limited association with outcomes after LVAD. However, persistently low health status after surgery may independently signal higher risk for subsequent death. Further study is needed to determine the clinical utility of routinely collected health status data after LVAD implantation.

Predicting long-term prognosis in stable peripheral artery disease with baseline functional capacity estimated by the Duke Activity Status Index

BACKGROUND

The ability of a simple self-assessment tool for estimated functional capacity to predict long-term prognosis in patients with established peripheral artery disease (PAD) is unknown. We investigate whether subjective measurement of functional capacity estimated by using the Duke Activity Status Index (DASI) questionnaire predicts long-term prognosis in patients with established PAD.

METHODS

We administered the DASI questionnaire to 771 stable patients with established PAD who underwent elective diagnostic coronary angiography with 5-year follow-up all-cause mortality.

RESULTS

Two hundred ten patients (27%) died over a 5-year follow-up. The lowest DASI score was associated with a 3.2-fold increased risk of 5-year all-cause mortality (unadjusted hazard ratio 3.23, 95% CI 2.19-4.75, P<.001). After adjustments for traditional risk factors, estimated glomerular filtration rate, high-sensitivity C-reactive protein, and lowest DASI score remained predictive of 5-year all-cause mortality (adjusted hazard ratio 2.09, 95% CI 1.36-3.23, P<.001). Interestingly, the lowest DASI score remained to predict 5-year all-cause mortality regardless of each PAD diagnosis subtype (including lower extremity, non-lower extremity, or carotid artery PAD), although the mortality risk was attenuated when incorporating heart disease severity in the non-lower extremity group.

CONCLUSIONS

A simple self-assessment tool of functional capacity provides an independent and incremental prognosis value for long-term adverse clinical events in stable patients with established PAD beyond each PAD diagnostic subtype.

Health-Related Quality of Life, Functional Status, and Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Health-related quality of life (HRQOL), functional status, and cardiac event-free survival are outcomes used to assess the effectiveness of interventions in patients with heart failure (HF). However, the nature of the relationships among HRQOL, functional status, and cardiac event-free survival remains unclear.

OBJECTIVE

The purpose of this study is to examine the nature of the relationships among HRQOL, functional status, and cardiac event-free survival in patients with HF.

METHODS

This was a prospective, observational study of 313 patients with HF that was a secondary analysis from a registry. At baseline, patient demographic and clinical data were collected. Health-related quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire and functional status was measured using the Duke Activity Status Index. Cardiac event-free survival data were obtained by patient interview, hospital database, and death certificate review. Multiple linear and Cox regressions were used to explore the relationships among HRQOL, functional status, and cardiac event-free survival while adjusting for demographic and clinical factors.

RESULTS

Participants (n = 313) were men (69%), white (79%), and aged 62 ± 11 years. Mean left ventricular ejection fraction was 35% ± 14%. The mean HRQOL score of 32.3 ± 20.6 indicated poor HRQOL. The mean Duke Activity Status Index score of 16.2 ± 12.9 indicated poor functional status. Cardiac event-free survival was significantly worse in patients who had worse HRQOL or poorer functional status. Patients who had better functional status had better HRQOL (P < .001). Health-related quality of life was not a significant predictor of cardiac event-free survival after entering functional status in the model (P = .54), demonstrating that it was a mediator of the relationship between HRQOL and outcome.

CONCLUSION

Functional status was a mediator between HRQOL and cardiac event-free survival. These data suggest that intervention studies to improve functional status are needed.

The Effect of Health Promoting Programs on Patient's Life Style After Coronary Artery Bypass Graft-Hospitalized in Shiraz Hospitals

Background:

Health promotion is an essential strategy for reduction of health disparities. Health promotion includes all activities that encourage optimum physical, spiritual, and mental functions. The aim of this study was to determine the impact of a Health Promotion Program (HPP) on behavior in terms of the dimensions of the Health Promoting Lifestyle Profile (HPLP) in patients after Coronary Artery Bypass Graft (CABG).

Methods and Materials:

In this clinical trial study, 80 patients who had undergone CABG surgery (2011-2012) were selected and randomly divided in two groups: Experimental and Control that investigated by (HPLP II). Then the experimental group was educated about diet, walking and stress management. The program process was followed up for three months and after tward whole variables were investigated again. The overall score and the scores for the six dimensions of the HPLP (self actualization, health responsibility, exercise, nutrition, interpersonal support and stress management) were measured in the pre- and post-test periods. Data were manually entered into SPSS version 21(IBM Corp, USA) by one the authors. Statistical analysis was performed using Student’s t-test and paired t-test. Mean standard deviation and standard error of the mean (with 95% Confidence Interval) were generated for each item.

Results:

Results showed that score of stress management (p=.036), diet (p=.002), Spiritual Growth (p=.001) and interrelationship (p=002) increase in experimental group after intervention. Average scores after three months in the control group had no significant changes; except responsibility for health (p<.05). Results of the study revealed that comparison the scores of the experimental group were significantly different from the control group in all lifestyle aspects except for spiritual growth.

Conclusion:

This study showed that HPP on lifestyle and health promotion in patients who suffered from Coronary Heart Disease (CAD) could improve the patient’s awareness of healthy behaviors and well-being in the quality of life.

NR2 antibody is associated with quality of life in aortic valve replacement

BACKGROUND

The relationship between the potential brain injury biomarker N-methyl-D-aspartate receptor antibody and quality of life has never been assessed.

METHODS

We measured serum N-methyl-D-aspartate receptor antibody levels preoperatively in patients undergoing aortic valve replacement. Quality of life was scored using the Short Form-36 and European Quality of Life 5-Dimensions questionnaires pre- and postoperatively. We analyzed the antibody levels as a continuous variable and as a dichotomous variable with 1.8 ng mL(-1) as the cutoff.

RESULTS

Fifty-two patients (15 females) with a mean age of 71 ± 8.4 years were recruited for this study. Forty-eight (92%) patients attended the follow-up visit (405 ± 161 days). No mortality or severe neurological event was recorded. In both quality-of-life instruments, the low antibody level group (n = 35) had significantly better scores than the high antibody level group (n = 17) preoperatively. Postoperatively, the scores for both groups improved; however, the low antibody level group continued to score significantly better in most of the physical and mental health domains (p = 0.04 to <0.001). Multiple regression analyses revealed that antibody level and the 1.8 ng mL(-1) cutoff were independently related to quality of life (pre- and postoperatively).

CONCLUSIONS

Higher N-methyl-D-aspartate receptor antibody levels in aortic valve replacement patients are independently related to poorer quality of life pre- and postoperatively.

Prognostic value of estimated functional capacity incremental to cardiac biomarkers in stable cardiac patients

Background

Few studies have investigated functional capacity self‐assessment tools in either prediction of future major adverse cardiac outcomes beyond all‐cause mortality or direct comparisons with clinically available biomarkers.

Methods and Results

We estimated functional capacity using the Duke Activity Status Index (DASI) questionnaire in 8987 sequential stable patients without acute coronary syndrome who were undergoing elective diagnostic coronary angiography with 3‐year follow‐up of major adverse cardiac events (death, nonfatal myocardial infarction, or stroke). A low DASI score provided independent prediction of a 4.8‐fold increase in future risk of incident major adverse cardiac events at 3 years (quartiles 1 versus 4 hazard ratio [95% CI] 4.76 [4.03 to 5.61], P<0.001), and a 3.8‐fold increased risk after adjusting for traditional risk factors (3.77 [3.15 to 4.51], P<0.001). The prognostic value of the DASI score was evident in both primary and secondary prevention cohorts, with and without heart failure, as well as high and low C‐reactive protein and B‐type natriuretic peptide levels. The DASI score reclassified 15% of patients (P<0.001) beyond traditional risk factors in predicting future MACE.

Conclusion

A simple self‐assessment tool of functional capacity in stable patients undergoing elective diagnostic cardiac evaluation provides independent and incremental prognostic value for prediction of both significant coronary angiographic disease and long‐term adverse clinical events.

Prognostic value of estimating functional capacity with the use of the duke activity status index in stable patients with chronic heart failure

BACKGROUND

Over the years, several methods have been developed to reliably quantify functional capacity in patients with heart failure. Few studies have investigated the prognostic value of these assessment tools beyond cardiorenal prognostic biomarkers in stable patients with chronic heart failure.

METHODS AND RESULTS

We administered the Duke Activity Status Index (DASI) questionnaire, a self-assessment tool comprising 12 questions for estimating functional capacity, to 1,700 stable nonacute coronary syndrome patients with history of heart failure who underwent elective diagnostic coronary angiography with 5-year follow-up of all-cause mortality. In a subset of patients (n = 800), B-type natriuretic peptide (BNP) was measured. In our study cohort, the median DASI score was 26.2 (interquartile range [IQR] 15.5-42.7). Low DASI score provided independent prediction of a 3.3-fold increase in 5-year mortality risk (quartile 1 vs quartile 4: hazard ratio [HR] 3.33, 95% confidence interval [CI] 2.57-4.36; P < .0001). After adjusting for traditional risk factors, BNP, and estimated glomerular filtration rate, low DASI score still conferred a 2.6-fold increase in mortality risk (HR 2.57, 95% CI 1.64-4.15; P < .0001).

CONCLUSIONS

A simple self-assessment tool of functional capacity provides independent and incremental prognostic value for mortality prediction in stable patients with chronic heart failure beyond cardiorenal biomarkers.

Exercise capacity and mortality in patients with ischemic left ventricular dysfunction randomized to coronary artery bypass graft surgery or medical therapy: an analysis from the STICH trial (Surgical Treatment for Ischemic Heart Failure)

OBJECTIVES

The objective of this study was to assess the prognostic significance of exercise capacity in patients with ischemic left ventricular (LV) dysfunction eligible for coronary artery bypass graft surgery (CABG).

BACKGROUND

Poor exercise capacity is associated with mortality, but it is not known how this influences the benefits and risks of CABG compared with medical therapy.

METHODS

In an exploratory analysis, physical activity was assessed by questionnaire and 6-min walk test in 1,212 patients before randomization to CABG (n = 610) or medical management (n = 602) in the STICH (Surgical Treatment for Ischemic Heart Failure) trial. Mortality (n = 462) was compared by treatment allocation during 56 months (interquartile range: 48 to 68 months) of follow-up for subjects able (n = 682) and unable (n = 530) to walk 300 m in 6 min and with less (Physical Ability Score [PAS] >55, n = 749) and more (PAS ≤55, n = 433) limitation by dyspnea or fatigue.

RESULTS

Compared with medical therapy, mortality was lower for patients randomized to CABG who walked ≥300 m (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.59 to 0.99; p = 0.038) and those with a PAS >55 (HR: 0.79; 95% CI: 0.62 to 1.01; p = 0.061). Patients unable to walk 300 m or with a PAS ≤55 had higher mortality during the first 60 days with CABG (HR: 3.24; 95% CI: 1.64 to 6.83; p = 0.002) and no significant benefit from CABG during total follow-up (HR: 0.95; 95% CI: 0.75 to 1.19; p = 0.626; interaction p = 0.167).

CONCLUSIONS

These observations suggest that patients with ischemic left ventricular dysfunction and poor exercise capacity have increased early risk and similar 5-year mortality with CABG compared with medical therapy, whereas those with better exercise capacity have improved survival with CABG. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).

Comprehensive prospective cognitive and physical function assessment in elderly patients undergoing transcatheter aortic valve implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) is occasionally associated with stroke and silent cerebral ischemia, which may affect cognitive and functional performance. The aim of this study was to evaluate the changes in cognitive performance and functional status following TAVI.

METHODS

We performed a comprehensive prospective functional, cognitive and quality of life (QOL) evaluation in consecutive patients who underwent TAVI using the CoreValve device (Medtronic Inc.). The evaluation was performed at baseline and 1 month after the procedure and included the 36-item Short-Form Health Survey for QOL assessment, Mini-Mental State Examination (MMSE), quantitative clock drawing test (Rouleau), color trails test, Cognistat evaluation, Barthel Index and Duke Activity Status Index.

RESULTS

A total of 36 patients completed the full pre- and post-TAVI evaluation. Mean age was 82.2 ± 4.2 years (52.8% men); 94.5% of patients had low functional class (New York Heart Association III/IV), and 13.9% had prior stroke. After the procedure, all patients had improved functional status and valve hemodynamics. At 1 month, there was a significant improvement in the MMSE and Cognistat evaluations (from 25.9 ± 3.3 to 27.6 ± 2.4, p < 0.001, and from 5 ± 1 to 5.7 ± 0.7, p = 0.001, respectively).

CONCLUSIONS

Our preliminary results of a comprehensive assessment of patients undergoing TAVI indicate favorable results for both functional performance and cognitive function early after the procedure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Translation and cross-cultural adaptation of the Duke activity status index to Brazilian Portuguese

INTRODUCTION: The limited number of valid and reliable questionnaires for the evaluation of exercise tolerance has stimulated the development of simple international assessment tools for this purpose, one of the most widely used of which is the Duke Activity Status Index (DASI). However, this index has not yet been translated and adapted to the Portuguese language. OBJECTIVE: To develop a Brazilian version of the DASI and cross-culturally adapt it for the evaluation of cardiorespiratory fitness among patients with cardiovascular disease in Brazil. MATERIALS AND METHODS: The translation process involved four stages: initial translation, back-translation, multidisciplinary committee review and pre-test with 16 subjects (8 cardiac patients and 8 healthy individuals). Patients were screened from outpatient Cardiac Surgery, São Paulo Hospital. The Mann-Whitney and chi-square tests were employed to determine differences between controls and individuals with heart disease. RESULTS: The sample was characterized by individuals aged ≥ 50 years who were mainly from the southeastern region of Brazil (62.5%) and were non-smokers (56.2%). Less than half of the cohort was considered physically active (43.75%). The level of non-understanding was less than 10% of the sample. Doubts were prevalent among individuals with heart disease (75%) regarding the level of fatigue caused when performing a task. CONCLUSION: The present findings demonstrate that the DASI was successfully translated and adapted to Brazilian Portuguese.

Quality of life six months after lung cancer surgery is associated with long-term survival

BACKGROUND

The aim of this study was to analyze the association between quality of life six months following lung cancer surgery and survival.

METHODS

In a prospective population-based cohort study, quality of life was estimated by the Medical Outcomes Study 36-Item Short Form (SF-36) questionnaire before and six months after surgery for lung cancer. Cox regression models adjusting for potential confounding factors were used to analyze the association between SF-36 scores six months after surgery and survival. We also estimated the risk of death in patients scoring below the normal population mean at six months after surgery.

RESULTS

We included 249 patients, and 79 patients were excluded because of histopathology other than primary lung cancer. After six months, 11 patients had died, and 18 patients did not respond to the second SF-36 questionnaire, leaving a study population of 141 patients with SF-36 data from both baseline and follow-up. During a median follow-up of 4.0 years, 35 deaths occurred. The SF-36 physical and mental component summary scores assessed at six months after lung cancer surgery were significantly associated with survival. Mental component summary scores below the mean of the age- and gender-matched normal population were associated with a three-fold increase in the risk of death.

CONCLUSIONS

Quality of life scores six months after surgery contained prognostic information regarding long-term survival that was independent of baseline scores. If these findings can be validated, cross-sectional post-treatment measurements of quality of life can prove valuable, especially when baseline information is unavailable.

Prognostic value of preoperative quality of life on mortality after isolated elective myocardial revascularization

OBJECTIVES

This study evaluates whether a low preoperative quality of life (QoL), measured with the EuroQoL instruments EQ-5D and EQ-visual analogue scale (VAS) can be used as a predictor of mortality after elective isolated myocardial revascularization.

METHODS

A total of 2501 patients, with a mean age of 65.3 ± 9.4 (range 18-93) years and a mean additive EuroSCORE of 2.7 ± 2.1 (0-12), undergoing an elective isolated coronary artery bypass graft between January 2002 and June 2011 completed preoperative EQ-5D and EQ-VAS.

RESULTS

Hospital mortality [1.0% (25/2501 patients)] and 30-day mortality [1.2% (29/25 patients)] were the studied outcomes. The EQ-5D was 0.69 ± 0.26 (-0.30 to 1.0) with a median of 0.77 and the EQ-VAS was 59.7 ± 22.4 (0-100) with a median of 60. Regression analysis showed a significant correlation between hospital mortality and EQ-5D (P = 0.016) and EQ-VAS (P = 0.033). There is a significant correlation between 30-day mortality and EQ-5D (P = 0.048), but not for EQ-VAS (P = 0.06). The c-statistics (95% confidence interval) for EQ-5D and EQ-VAS for predicting hospital mortality are 0.36 (0.24-0.46) and 0.33 (0.23-0.42), respectively. The c-statistics for predicting 30-day mortality are 0.39 (0.30-0.49) for EQ-5D and 0.35 (0.26-0.44) for EQ-VAS.

CONCLUSIONS

Based on these results, we conclude that, in isolation, poor low preoperative EQ-5D and EQ-VAS scores do not contribute to deciding which patients should undergo cardiac surgery.

Obesity, health status, and 7-year mortality in percutaneous coronary intervention: in search of an explanation for the obesity paradox

BACKGROUND

Obesity is a growing health problem and is associated with adverse outcomes in coronary artery disease (CAD). However, recent studies have shown better survival in cardiovascular patients with overweight or obesity, which has been referred to as the "obesity paradox". As there is no clear understanding of the phenomenon, we examined the association between body mass index (BMI) and all-cause mortality in patients treated with percutaneous coronary intervention (PCI) at 7-year follow-up, and the potential role of health status in explaining the obesity paradox.

METHODS

Consecutive PCI patients (72.5% men; mean age 62.0 ± 11.2 years, range [27-90]years) from the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry completed the 36-item short-form health survey (SF-36) to assess health status at baseline. Patients were classified into a normal weight, overweight or obesity group.

RESULTS

The prevalence of normal weight was 34.7% (354/1019), overweight was seen in 45.9% (468/1019) of patients, and 19.3% (197/1019) was obese. After a median follow-up of 7.0 ± 1.7 years, 163 deaths (16.0%) from any cause were recorded. Cumulative hazard functions differed significantly for the obese and overweight group when compared to the normal weight group (log-rank X(2)=6.59, p<0.05). In multivariable analysis, overweight, but not obesity, remained associated with a lower risk for all-cause mortality (HR=0.60, 95%CI [0.42-0.86], p=0.005). Additionally, after adding the 8 health status SF-36 domains to the multivariate model, the association between overweight and mortality remained unchanged.

CONCLUSION

In our study population overweight, but not obesity, was associated with a lower risk for 7-year mortality in PCI patients. Health status as measured with the SF-36 did not seem to play a role in explaining the obesity paradox.

A multinational study of the influence of health-related quality of life on in-hospital outcome after coronary artery bypass graft surgery

BACKGROUND

The effect of health-related quality of life on in-hospital outcomes after coronary artery bypass grafting surgery has not been investigated in international multicenter studies. We hypothesized that poor preoperative health status is associated with mortality and length of hospital stay.

METHODS

In the Multicenter Study of Perioperative Ischemia Epidemiology II, preoperative Short-Form 12, Mental Component Summary (MCS), and Physical Component Summary (PCS) scores were obtained prospectively from 4,811 patients (3,834 men, 977 women) undergoing coronary artery bypass grafting surgery at 72 centers in 17 countries. Primary outcome measures were in-hospital mortality and prolonged (>14 days) length of hospital stay.

RESULTS

One hundred fifty-one patients (3.1%) died. After adjustment for regional differences, a 10-point reduction in MCS score was associated with higher mortality risk (odds ratio [OR] 1.17, 95% CI 1.004-1.37, P = .04) and prolonged hospital stay (OR 1.11, 95% CI 1.01-1.21, P = .03). The preoperative PCS score was not associated with mortality risk but significantly predicted prolonged length of hospital stay (OR 1.20, 95% CI 1.09-1.33, P < .001). There was no significant interaction between gender and either the MCS or the PCS score.

DISCUSSION

The preoperative PCS predicted prolonged postoperative hospital stay, whereas the preoperative MCS score was an independent predictor of both prolonged length of hospital stay and mortality. Preoperative assessment of health-related quality of life factors with the Short-Form 12 might be a useful tool for risk stratification and planning for hospital discharge and rehabilitation.

Depression and self-reported functional status: impact on mortality following acute myocardial infarction

OBJECTIVE

The cause of increased post-AMI (acute myocardial infarction) mortality associated with depression remains poorly elucidated. The objective of this study was to examine the extent to which self-reported cardiac functional status accounted for depression-mortality associations following AMI.

METHODS

Using a prospective cohort design (n = 1941), the authors obtained self-reported measures of depression and developed profiles of the patients' pre-hospitalization cardiac risks, co-morbid conditions and drugs and revascularization procedures during or following index AMI hospitalization. To create these profiles, the patients' self-reports were retrospectively linked to no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, income, cardiovascular risk, co-morbid conditions, selected process-of-care factors and self-reported cardiac functional status.

RESULTS

Depression was strongly correlated with 2-year mortality rate [crude hazard ratio (HR) of severe vs. minimal depression category, 2.48 (95% CI 1.20-5.15); P = 0.01]. However, after sequential adjustment for age, sex, income and self-reported cardiac functional status, the effect of depression was greatly attenuated [adjusted HR for severe vs. minimal depression category, 1.35 (95% CI 0.63-2.87); P = 0.44]. Cardiac risk factors and non-cardiac co-morbidities had negligible explanatory effect.

DISCUSSION

The main factor determining the increased mortality rate in depressed patients is self-reported cardiac functional status. Efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status.

Performance-based functional assessment of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Very few data exist on the functional evaluation of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aims of this prospective study were (1) to evaluate the Duke Activity Status Index (DASI) as a measure of functional status pre-TAVI and post-TAVI, (2) to determine the clinical parameters associated with DASI changes after TAVI, and (3) to compare functional status as evaluated by DASI and the New York Heart Association (NYHA) class with exercise capacity as evaluated by the 6-minute walk test (6MWT) in such patients.

METHODS

A total of 76 patients (80 ± 8 years old) who underwent successful TAVI were included. All patients completed the DASI self-questionnaire at baseline and at 6 months after TAVI, and 46 patients also performed a 6MWT.

RESULTS

The mean DASI increased from 10.3 ± 5.4 to 16.3 ± 8.3 at 6 months after TAVI (P < .0001). However, the DASI did not change or even decreased to some extent in 30% of patients after TAVI. Renal dysfunction as evaluated by the estimated glomerular filtration rate was identified as the independent predictor of DASI impairment after TAVI (OR 1.7 for each decrease in estimated glomerular filtration rate of 10 mL/min/1.73 m(2), 95% CI 1.3-2.3, P = .005). The mean distance walked increased from 165.9 ± 77.6 to 211.8 ± 78.7 m (P = .0001) at follow-up. The DASI showed a good correlation with the distance walked at baseline (r = 0.55, P < .0001) and at follow-up (r = 0.66, P < .0001). The NYHA class improved to some degree in all but 5 patients; however, the NYHA class did not correlate with the results of DASI and the 6MWT.

CONCLUSIONS

Transcatheter aortic valve implantation was associated with a significant increase in functional status at 6-month follow-up as evaluated by the DASI, although no improvement was observed in about one third of patients. The presence of baseline renal dysfunction better determined this lack of improvement in functional status. The DASI, but not the NYHA class, correlated with distance walked in the 6MWT. These results suggest that the DASI might become a useful tool for evaluating both candidates for and the impact of TAVI procedures.

Use of the elderly risk assessment (ERA) index to predict 2-year mortality and nursing home placement among community dwelling older adults

The objective was to determine the relationship between a high score on the ERA index and 2-year mortality and nursing home placement. As of January 1, 2005, 12,650 community-dwelling patients over 60 years of age were impaneled with a primary care practice at the Mayo Clinic in Rochester, MN. This was a retrospective cohort study utilizing an administrative risk score, the ERA score. Primary outcomes were 2-year mortality and 2-year nursing home placement. The predictor variable was ERA score. Relative risk estimates were used to describe the association between the ERA index and mortality and nursing home placement. The relative risk of 2-year mortality was 51.4 (95% confidence interval=CI=28.0-94.4) in patients in the highest risk group compared to the lowest group. The relative risk of nursing home placement was 113.2 (95% CI=76.1-168.4). Patients with high ERA scores are at high risk for 2-year mortality and 2-year nursing home placement. These findings suggest that the utilization of an electronic risk score can help identify patients at risk for death or nursing home placement. Clinically, the identification of high risk individuals may be useful for utilization of clinical case management.

Influence of a symptom management telehealth intervention on older adults' early recovery outcomes after coronary artery bypass surgery

OBJECTIVE

The study objective was to examine the effect of a symptom management (SM) telehealth intervention on physical activity and functioning and to describe the health care use of older adult patients (aged > 65 years) after coronary artery bypass surgery (CABS) by group (SM intervention group and usual care group).

METHODS

A randomized clinical trial design was used. The study was conducted in 4 Midwestern tertiary hospitals. The 6-week SM telehealth intervention was delivered by the Health Buddy (Health Hero Network, Palo Alto, CA). Measures included Modified 7-Day Activity Interview, RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA), physical activity and exercise diary, Medical Outcomes Study Short-Form 36, and subjects' self-report and provider records of health care use. Follow-up times were 3 and 6 weeks and 3 and 6 months after CABS.

RESULTS

Subjects (N = 232) had a mean age of 71.2 (+4.7) years. There were no significant interactions using repeated-measures analyses of covariance. There was a significant group effect for average kilocalories/kilogram/day of estimated energy expenditure as measured by the RT3 accelerometer, with the usual care group having a higher estimated energy expenditure. Both groups had significant improvements over time for role-physical, vitality, and mental functioning. Both groups had similar health care use.

CONCLUSION

Subjects were able to return to preoperative levels of functioning between 3 and 6 months after CABS and to increase their physical activity over reported preoperative levels of activity. Further study of those patients undergoing CABS who could derive the most benefit from the SM intervention is warranted.

Symptom burden clusters and their impact on psychosocial functioning following coronary artery bypass surgery

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.

Quality of life in long-term survivors of acute pulmonary embolism

BACKGROUND

To our knowledge, studies evaluating the quality of life (QoL) in patients with a history of acute pulmonary embolism (PE) are not available, even though QoL is a key outcome component of medical care and a predictor of disease-specific prognosis.

METHODS

As part of a large follow-up study, the Short Form 36 (SF-36) was presented to consecutive patients who had survived one or more episodes of acute PE. The results of all nine subscales of the SF-36 were compared with sex- and age-adjusted Dutch population norms. Single and multivariate analyses were performed to identify independent determinants of the QoL in our study population.

RESULTS

The SF-36 was completed by 392 patients. Except for the health change subscale, patients had substantially lower QoL than population norms on all eight remaining subscales. After multivariate analysis, the time interval between the last thromboembolic episode and study inclusion was inversely related to QoL, and significant determinants of poor QoL were prior PE, age, obesity, active malignancy, and cardiopulmonary comorbid conditions. Regression models that included all identified significant determinants proved to be quite modest predictors for QoL in the individual patient. Awareness of illness, coping mechanisms, and self-management behavior might be additional important indicators of QoL in our study population but require further investigation.

CONCLUSION

We identified several PE- and non-PE-related determinants of QoL in patients with a history of acute PE, which is impaired compared with sex- and age-adjusted population norms. QoL after acute PE should be studied more extensively and added as a standard measure to outcome studies.

Health-related quality of life and long-term mortality in patients treated with percutaneous coronary intervention

BACKGROUND

Health status has become increasingly important as an outcome measure in patients with cardiovascular disease. Poor patient-rated health status has been shown to predict mortality in patients with coronary artery disease and heart failure. In patients treated with percutaneous coronary intervention (PCI), we examined whether poor health status predicts 6-year mortality and whether a decline in health status is associated with adverse clinical outcome.

METHODS

Consecutive patients (N = 872) treated with PCI as part of the RESEARCH registry, completed the 36-item Short-Form Health Survey (SF-36) at 1 and 12 months post-PCI.

RESULTS

The SF-36 domains physical functioning (hazard ratio [HR] 2.59, 95% CI 1.61-4.16), social functioning (HR 2.76, 95% CI 1.74-4.37), role limitations due to physical functioning (HR 2.45, CI 1.52-3.92), mental health (HR 2.12, 95% CI 1.35-3.31), vitality (HR 1.73, 95% CI 1.09-2.74), bodily pain (HR 2.25, 95% CI 1.43-3.54), and general health (HR 2.46, 95% CI 1.57-3.87) were associated with 6-year mortality. A decline in health status was not related with higher 6-year mortality.

CONCLUSIONS

Health status domains as measured with the SF-36 predicted death at 6-year follow-up in PCI patients treated with drug-eluting stenting, independent of demographic and clinical characteristics. In contrast, a decline in health status between 1 and 12 months post index procedure, as measured with the SF-36, was not associated with 6-year mortality in PCI patients treated with drug-eluting stenting.

Physical distress is associated with cardiovascular events in a high risk population of elderly men

Background

Self-reported health perceptions such as physical distress and quality of life are suggested independent predictors of mortality and morbidity in patients with established cardiovascular disease. This study examined the associations between these factors and three years incidence of cardiovascular events in a population of elderly men with long term hyperlipidemia.

Methods

We studied observational data in a cohort of 433 men aged 64–76 years from a prospective, 2 × 2 factorial designed, three-year interventional trial. Information of classical risk factors was obtained and the following questionnaires were administered at baseline: Hospital Anxiety and Depression Scale, Physical Symptom Distress Index and Life Satisfaction Index. The occurrence of cardiovascular death, myocardial infarction, cerebrovascular incidences and peripheral arterial disease were registered throughout the study period. Continuous data with skewed distribution was split into tertiles. Hazard ratios (HR) were calculated from Cox regression analyses to assess the associations between physical distress, quality of life and cardiovascular events.

Results

After three years, 49 cardiovascular events were registered, with similar incidence among subjects with and without established cardiovascular disease. In multivariate analyses adjusted for age, smoking, systolic blood pressure, serum glucose, HADS-anxiety and treatment-intervention, physical distress was positively associated (HR 3.1, 95% CI 1.2 – 7.9 for 3^rd versus 1^st tertile) and quality of life negatively associated (HR 2.6, 95% CI 1.1–5.8 for 3^rd versus 1^st tertile) with cardiovascular events. The association remained statistically significant only for physical distress (hazard ratio 2.8 95% CI 1.2 – 6.8, p < 0.05) when both variables were evaluated in the same model.

Conclusion

Physical distress, but not quality of life, was independently associated with increased risk of cardiovascular events in an observational study of elderly men predominantly without established cardiovascular disease.

Trial Registration

Trial registration: NCT00764010

Health status as a risk factor in cardiovascular disease: a systematic review of current evidence

BACKGROUND

Patient-perceived health status is receiving increased recognition as a patient-centered outcome in chronic heart failure (CHF) and coronary artery disease (CAD), but poor health status is also associated with adverse prognosis. In this systematic review, we examined current evidence on the influence of health status on prognosis in CHF and CAD.

METHODS

We conducted a search of PubMed using a set of a priori-defined search terms, the Web of Science for newly cited articles, and the reference lists of eligible articles, resulting in 34 articles.

RESULTS

Poor physical health status was a significant predictor for adverse health outcomes in patients with CHF and CAD. In CHF, poor physical health status seemed to be a stronger predictor of hospitalization than mortality. Little evidence was found that poor mental health status is associated with adverse prognosis in CHF and CAD. A disease-specific measure was a better predictor in CHF, but not in CAD. The majority of studies adjusted for an objective measure of disease severity. Neither the index event nor time to follow-up appeared to influence the predictive value of health status.

CONCLUSIONS

Poor physical health status is associated with adverse CAD and CHF prognosis. Heterogeneity across studies makes definitive conclusions difficult as to which components of health status may be detrimental to patients' health, and how health status as a potential risk factor should be assessed, monitored, and intervened upon in clinical practice.

Health-related quality of life after cardiac surgery

Health-related quality of life (HRQOL) assessments are designed to reflect a patient's perspective of how a disease has affected their overall health status. Patient-centered outcomes are of value both for risk assessment and as an outcome measure. Strategies for analyzing HRQOL data are inconsistent primarily because the data frequently do not meet underlying assumptions of traditional methods for statistical analyses and require a careful analytic approach.

Clinical and prognostic value of Duke's Activity Status Index along with plasma B-type natriuretic peptide levels in chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

The Duke Activity Status Index (DASI) provides an accurate estimate of functional capacity in patients with chronic heart failure (HF). The aim of this study was to evaluate the prognostic value of the DASI against well-established prognostic factors in 130 consecutive patients hospitalized for worsening HF symptoms (mean age 64 +/- 12 years, mean left ventricular ejection fraction 26 +/- 7%), followed for 9 months for major cardiovascular events, defined as death or hospitalization for HF decompensation. During follow-up, 77 of 130 patients (59%) experienced major cardiovascular events after a median time of 60 days (range 5 to 220). Patients with eventful courses were in higher New York Heart Association functional classes (p = 0.001) and had shorter 6-minute walking distances (p = 0.041), lower ejection fractions (p <0.001), higher plasma B-type natriuretic peptide (BNP) levels at hospital admission and discharge (both p <0.001), and lower DASI scores (16 +/- 12 vs 25 +/- 17, p = 0.003). In multivariate Cox regression analysis including all these variables, only BNP level at discharge (p = 0.006) and DASI score (p = 0.047) were independently associated with event-free survival. A BNP cutoff of 697 pg/ml predicted future events with 59% sensitivity and 86% specificity, while a DASI score cutoff of 8 had 76% sensitivity and 25% specificity. The combination of the 2 cutoffs predicted events with 33% sensitivity and 95% specificity. Event-free survival was significantly lower in patients with the 2 markers positive (BNP >697 pg/ml and DASI score <8) compared with those with with 2 markers negative (63 +/- 27 vs 183 +/- 15 days, log-rank p <0.0001). In conclusion, functional status assessment by the DASI bears prognostic value, and its combination with plasma BNP may provide quite specific risk stratification in patients with chronic HF.

Can health-related quality of life predict survival in adults with cystic fibrosis?

RATIONALE

Advances in the management of cystic fibrosis have led to a significant improvement in survival, although marked differences between individuals are still observed. The value of patient-reported health-related quality of life scores in predicting survival in adults with cystic fibrosis is unknown.

OBJECTIVES

To evaluate whether patient-reported health-related quality of life could predict survival in cystic fibrosis.

METHODS

From 1996 to 1997 a consecutive series of 223 patients were recruited to evaluate the Cystic Fibrosis Quality of Life Questionnaire. Demographic (age, sex), clinical (FEV(1)% predicted, body mass index, diabetes, B. Cepacia complex, intravenous access device, nutritional and lung transplant status) and health-related quality of life variables were recorded (Cystic Fibrosis Quality of Life Questionnaire and the SF-36). These data were used as baseline measures to explore the prognostic association of health-related quality of life and subsequent survival.

MEASUREMENTS AND MAIN RESULTS

At the census date (December 31, 2006) 154 (69.1%) adults were alive, 66 (29.6%) had died, and three (1.3%) were lost to follow-up. Cox proportional hazards models and bootstrapping procedures examined if health-related quality of life domains predicted survival after adjusting for the demographic and clinical factors. The physical functioning domain of the Cystic Fibrosis Quality of Life Questionnaire and the pain domain of the Short Form-36 had the strongest statistical associations with survival.

CONCLUSIONS

Aspects of patient-reported quality of life serve as prognostic measures of survival beyond a number of previously known factors in cystic fibrosis. This needs to be investigated further in a larger longitudinal study.

Neuropsychologic and quality-of-life outcomes after coronary artery bypass surgery with and without cardiopulmonary bypass: a prospective randomized trial

OBJECTIVES

The objective of this study was to compare neuropsychologic and quality-of-life outcomes of patients undergoing off-pump coronary artery bypass surgery to those undergoing coronary artery bypass graft surgery using conventional cardiopulmonary bypass.

DESIGN

A prospective randomized trial of coronary artery bypass graft surgery with and without the use of cardiopulmonary bypass.

SETTING

A cardiothoracic surgery unit at a tertiary hospital.

PARTICIPANTS

Sixty-six patients undergoing coronary artery bypass graft surgery and a control group of 50 participants not undergoing cardiac surgery.

INTERVENTIONS

Patients were randomized to receive coronary artery bypass graft surgery with cardiopulmonary bypass or randomized to coronary artery bypass graft surgery without the use of cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

The proportions of neuropsychologic deficits and improvement in quality-of-life were comparable regardless of whether patients were randomized to receive off-pump coronary artery bypass graft surgery or conventional coronary artery graft surgery with cardiopulmonary bypass.

CONCLUSIONS

Patients receiving coronary artery bypass grafts without cardiopulmonary bypass did not show fewer cognitive deficits or greater improvement in quality of life.