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Wang J, Liu H, Yue C, Yang L, Yang K, Zhao Y, Ren H, Zhang Y, Zheng Z. Identifying coronary artery bypass grafting patients at high risk for adverse long-term prognosis using serial health-related quality of life assessments. Chin Med J (Engl) 2024; 137:1069-1077. [PMID: 37620281 PMCID: PMC11062708 DOI: 10.1097/cm9.0000000000002806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Indexed: 08/26/2023] Open
Abstract
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.
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Affiliation(s)
- Juncheng Wang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Hanning Liu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chao Yue
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Limeng Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Kai Yang
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan, Hubei 430022, China
| | - Yan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Huan Ren
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ying Zhang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Kleiman NS, Van Mieghem NM, Reardon MJ, Gada H, Mumtaz M, Olsen PS, Heiser J, Merhi W, Chetcuti S, Deeb GM, Chawla A, Kiaii B, Teefy P, Chu MWA, Yakubov SJ, Windecker S, Althouse AD, Baron SJ. Quality of Life 5 Years Following Transfemoral TAVR or SAVR in Intermediate Risk Patients. JACC Cardiovasc Interv 2024; 17:979-988. [PMID: 38658126 DOI: 10.1016/j.jcin.2024.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 01/12/2024] [Accepted: 02/04/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Symptomatic patients with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR) sustain comparable improvements in health status over 5 years after transcatheter aortic valve replacement (TAVR) or SAVR. Whether a similar long-term benefit is observed among intermediate-risk AS patients is unknown. OBJECTIVES The purpose of this study was to assess health status outcomes through 5 years in intermediate risk patients treated with a self-expanding TAVR prosthesis or SAVR using data from the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial. METHODS Intermediate-risk patients randomized to transfemoral TAVR or SAVR in the SURTAVI trial had disease-specific health status assessed at baseline, 30 days, and annually to 5 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Health status was compared between groups using fixed effects repeated measures modelling. RESULTS Of the 1,584 patients (TAVR, n = 805; SAVR, n = 779) included in the analysis, health status improved more rapidly after TAVR compared with SAVR. However, by 1 year, both groups experienced large health status benefits (mean change in KCCQ-Overall Summary Score (KCCQ-OS) from baseline: TAVR: 20.5 ± 22.4; SAVR: 20.5 ± 22.2). This benefit was sustained, albeit modestly attenuated, at 5 years (mean change in KCCQ-OS from baseline: TAVR: 15.4 ± 25.1; SAVR: 14.3 ± 24.2). There were no significant differences in health status between the cohorts at 1 year or beyond. Similar findings were observed in the KCCQ subscales, although a substantial attenuation of benefit was noted in the physical limitation subscale over time in both groups. CONCLUSIONS In intermediate-risk AS patients, both transfemoral TAVR and SAVR resulted in comparable and durable health status benefits to 5 years. Further research is necessary to elucidate the mechanisms for the small decline in health status noted at 5 years compared with 1 year in both groups. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910).
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Affiliation(s)
- Neal S Kleiman
- Department of Interventional Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| | | | - Michael J Reardon
- Department of Cardiothoracic Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Hemal Gada
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleysburg, Pennsylvania, USA
| | - Mubashir Mumtaz
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pinnacle Health, Harrisburg, Pennsylvania, USA
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - John Heiser
- Department of Interventional Cardiology, Corewell Health, Grand Rapids, Michigan, USA
| | - William Merhi
- Department of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Michigan, USA
| | - Stanley Chetcuti
- Interventional Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - G Michael Deeb
- Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Atul Chawla
- Department of Cardiology, Iowa Heart Center, Des Moines, Iowa, USA
| | - Bob Kiaii
- Division of Cardiac Surgery, University of California-Davis Health, Sacramento, California, USA
| | - Patrick Teefy
- Divisions of Cardiology and Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael W A Chu
- Divisions of Cardiology and Cardiac Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Steven J Yakubov
- Interventional Cardiology, OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Stephan Windecker
- Department of Cardiology, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Suzanne J Baron
- Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
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Radulescu CI, Cersosimo A, Massussi M, Laurito A, Metra M, Chioncel O, Adamo M. Quality of life in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: tools and evidence. J Cardiovasc Med (Hagerstown) 2024; 25:259-270. [PMID: 38488063 DOI: 10.2459/jcm.0000000000001591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Aortic stenosis is the most prevalent valvular heart disease requiring intervention, especially in the elderly population. Surgical aortic valve replacement and transcatheter aortic valve implantation (TAVI) are well established treatment options for symptomatic patients with severe aortic stenosis, as they provide a significant survival benefit. Aortic stenosis may have an important impact on patients' quality of life (QoL). However, advanced age, comorbidities and frailty may limit the beneficial effect of aortic stenosis interventions in terms of QoL. Current guidelines mention the importance of frailty and avoiding the futility of interventions, but lack specific indications about decision-making. Also, there are limited data on how to specifically assess QoL in aortic stenosis patients since the most used questionnaires are validated in different populations (i.e. heart failure). The aim of this review is to summarize all the available tools for QoL assessment in patients with aortic stenosis; to report current evidence on the impact of TAVI on QoL; and to discuss the role of frailty and comorbidities in this setting.
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Affiliation(s)
- Crina-Ioana Radulescu
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
- University of Medicine and Pharmacy Carol Davila
| | - Angelica Cersosimo
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mauro Massussi
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Laurito
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Ovidiu Chioncel
- University of Medicine and Pharmacy Carol Davila
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | - Marianna Adamo
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Čelutkienė J, Čerlinskaitė-Bajorė K, Cotter G, Edwards C, Adamo M, Arrigo M, Barros M, Biegus J, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Léopold V, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Lam CSP, Voors AA, Mebazaa A, Davison B. Impact of Rapid Up-Titration of Guideline-Directed Medical Therapies on Quality of Life: Insights From the STRONG-HF Trial. Circ Heart Fail 2024; 17:e011221. [PMID: 38445950 DOI: 10.1161/circheartfailure.123.011221] [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: 09/11/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND This analysis provides details on baseline and changes in quality of life (QoL) and its components as measured by EQ-5D-5L questionnaire, as well as association with objective outcomes, applying high-intensity heart failure (HF) care in patients with acute HF. METHODS In STRONG-HF trial (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) patients with acute HF were randomized just before discharge to either usual care or a high-intensity care strategy of guideline-directed medical therapy up-titration. Patients ranked their state of health on the EQ-5D visual analog scale score ranging from 0 (the worst imaginable health) to 100 (the best imaginable health) at baseline and at 90 days follow-up. RESULTS In 1072 patients with acute HF with available assessment of QoL (539/533 patients assigned high-intensity care/usual care) the mean baseline EQ-visual analog scale score was 59.2 (SD, 15.1) with no difference between the treatment groups. Patients with lower baseline EQ-visual analog scale (meaning worse QoL) were more likely to be women, self-reported Black and non-European (P<0.001). The strongest independent predictors of a greater improvement in QoL were younger age (P<0.001), no HF hospitalization in the previous year (P<0.001), lower NYHA class before hospital admission (P<0.001) and high-intensity care treatment (mean difference, 4.2 [95% CI, 2.5-5.8]; P<0.001). No statistically significant heterogeneity in the benefits of high-intensity care was seen across patient subgroups of different ages, with left ventricular ejection fraction above or below 40%, NT-proBNP (N-terminal pro-B-type natriuretic peptide) and systolic blood pressure above or below the median value. The treatment effect on the primary end point did not vary significantly across baseline EQ-visual analog scale (Pinteraction=0.87). CONCLUSIONS Early up-titration of guideline-directed medical therapy significantly improves all dimensions of QoL in patients with HF and improves prognosis regardless of baseline self-assessed health status. The likelihood of achieving optimal doses of HF medications does not depend on baseline QoL. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03412201.
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Affiliation(s)
- Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France (G.C., A.C.-S., E.G., V.L., A.M., B.D.)
- Heart Initiative, Durham, NC (G.C., B.D.)
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Switzerland (M. Arrigo)
| | - Marianela Barros
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland (J.B., P.P.)
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania (O.C.)
| | - Alain Cohen-Solal
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France (A.C.-S.)
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece (G.F.)
| | - Etienne Gayat
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, France (A.K.)
| | - Valentine Léopold
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Maria Novosadova
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Peter S Pang
- Departments of Emergency Medicine and Medicine, Indiana University School of Medicine, Indianapolis (P.S.P.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Poland (J.B., P.P.)
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Nigeria (H.S.)
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (K.S.)
| | - Koji Takagi
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
| | - Jozine M Ter Maaten
- Department of Cardiology, Medical Centre Groningen, the Netherlands (J.M.T.M., A.A.V.)
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M. Adamo, M.M., M.P., D.T.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.)
- Baim Institute for Clinical Research, Boston, MA (C.S.P.L.)
- University Medical Centre Groningen, the Netherlands (C.S.P.L.)
| | - Adriaan A Voors
- Department of Cardiology, Medical Centre Groningen, the Netherlands (J.M.T.M., A.A.V.)
| | - Alexandre Mebazaa
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France (E.G., V.L., A.M.)
| | - Beth Davison
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Lithuania (J.Č., K.Č-B.)
- Heart Initiative, Durham, NC (G.C., B.D.)
- Momentum Research, Inc, Durham, NC. (G.C., C.E., M.B., M.N., K.T., B.D.)
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Wohlfahrt P, Jenča D, Melenovský V, Stehlik J, Spertus JA, Mrázková J, Šramko M, Kotrč M, Želízko M, Adámková V, Piťha J, Kautzner J. Remote Heart Failure Symptoms Assessment After Myocardial Infarction Identifies Patients at Risk for Death. J Am Heart Assoc 2024; 13:e032505. [PMID: 38193321 PMCID: PMC10926820 DOI: 10.1161/jaha.123.032505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/03/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Heart failure is a common complication after myocardial infarction (MI) and is associated with increased mortality. Whether remote heart failure symptoms assessment after MI can improve risk stratification is unknown. The authors evaluated the association of the 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) with all-cause mortality after MI. METHODS AND RESULTS Prospectively collected data from consecutive patients hospitalized for MI at a large tertiary heart center between June 2017 and September 2022 were used. Patients remotely completed the KCCQ 1 month after discharge. A total of 1135 (aged 64±12 years, 26.7% women) of 1721 eligible patients completed the KCCQ. Ranges of KCCQ scores revealed that 30 (2.6%), 114 (10.0%), 274 (24.1%), and 717 (63.2%) had scores <25, 25 to 49, 50 to 74, and ≥75, respectively. During a mean follow-up of 46 months (interquartile range, 29-61), 146 (12.9%) died. In a fully adjusted analysis, KCCQ scores <50 were independently associated with mortality (hazard ratio [HR], 6.05 for KCCQ <25, HR, 2.66 for KCCQ 25-49 versus KCCQ ≥50; both P<0.001). Adding the 30-day KCCQ to clinical risk factors improved risk stratification: change in area under the curve of 2.6 (95% CI, 0.3-5.0), Brier score of -0.6 (95% CI, -1.0 to -0.2), and net reclassification improvement of 0.71 (95% CI, 0.45-1.04). KCCQ items most strongly associated with mortality were walking impairment, leg swelling, and change in symptoms. CONCLUSIONS Remote evaluation of heart failure symptoms using the KCCQ among patients recently discharged for MI identifies patients at risk for mortality. Whether closer follow-up and targeted therapy can reduce mortality in high-risk patients warrants further study.
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Affiliation(s)
- Peter Wohlfahrt
- Department of Preventive CardiologyInstitute for Clinical and Experimental MedicinePragueCzech Republic
- First Medical SchoolCharles UniversityPragueCzech Republic
| | - Dominik Jenča
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
- Third Medical School, Charles UniversityPragueCzech Republic
| | - Vojtěch Melenovský
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Josef Stehlik
- University of Utah School of MedicineSalt Lake CityUTUSA
| | - John A. Spertus
- University of Missouri Kansas City’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart InstituteKansas CityMOUSA
| | - Jolana Mrázková
- Experimental Medicine CentreInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Marek Šramko
- First Medical SchoolCharles UniversityPragueCzech Republic
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Martin Kotrč
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Michael Želízko
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Věra Adámková
- Department of Preventive CardiologyInstitute for Clinical and Experimental MedicinePragueCzech Republic
| | - Jan Piťha
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
| | - Josef Kautzner
- Department of CardiologyInstitute for Clinical and Experimental Medicine (IKEM)PragueCzech Republic
- Medical and Dentistry SchoolPalacký UniversityOlomoucCzech Republic
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6
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Kleissl-Muir S, Owen A, Rasmussen B, Zinn C, Driscoll A. Effects of a low carbohydrate diet on heart failure symptoms and quality of life in patients with diabetic cardiomyopathy: A randomised controlled trial pilot study. Nutr Metab Cardiovasc Dis 2023; 33:2455-2463. [PMID: 37798235 DOI: 10.1016/j.numecd.2023.08.015] [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: 05/11/2023] [Revised: 07/06/2023] [Accepted: 08/21/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND AIMS Heart failure, insulin resistance and/or type 2 diabetes mellitus coexist in the syndrome that is diabetic cardiomyopathy. Patients with diabetic cardiomyopathy experience high symptom burden and poor quality of life. We tested the hypothesis that a low carbohydrate diet improves heart failure symptoms and quality of life in patients with diabetic cardiomyopathy. METHODS AND RESULTS We conducted a 16-week randomised controlled pilot trial comparing the effects of a low carbohydrate diet (LC) to usual care (UC) in 17 adult patients with diabetic cardiomyopathy. New York Heart Association classification, weight, thirst distress and quality of life scores as well as blood pressure and biochemical data were assessed at baseline and at 16 weeks. Thirteen (n = 8 LC; n = 5 UC) patients completed the trial. The low carbohydrate diet induced significant weight loss in completers (p = 0.004). There was a large between-group difference in systolic blood pressure at the end of the study (Hedges's g 0.99[-014,2.08]). There were no significant differences in thirst or quality of life between groups. CONCLUSION This is the first clinical trial utilising the low carbohydrate dietary approach in patients with diabetic cardiomyopathy in an outpatient setting. A low carbohydrate diet can lead to significant weight loss in patients with diabetic cardiomyopathy. Future clinical trials with larger samples and that focus on fluid and sodium requirements of patients with diabetic cardiomyopathy who engage in a low carbohydrate diet are warranted. CLINICAL TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trial Registry (ANZCTR): ACTRN12620001278921. DATE OF REGISTRATION 26th November 2020.
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Affiliation(s)
| | - Alice Owen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Bodil Rasmussen
- Deakin University School of Nursing and Midwifery, Geelong, VIC, Australia; Human Potential Centre, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand; School of Nursing and Midwifery, Centre for Quality and Patient Safety, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia; The Centre for Quality and Patient Safety, Institute of Health Transformation -Western Health Partnership, Western Health, St Albans, VIC, Australia; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark and Steno Diabetes Centre, Odense M, Denmark
| | - Caryn Zinn
- Human Potential Centre, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Andrea Driscoll
- Deakin University School of Nursing and Midwifery, Geelong, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Cardiology, Austin Health, Heidelberg, VIC, Australia; School of Nursing and Midwifery, Centre for Quality and Patient Safety, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
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Gonnah AR, Abdelwahab M, Taylor R, Labib A, Masoud O, Debski M, Abdelaziz HK, Roberts DH. Health-related quality of life following TAVI or cardiac surgery in patients at intermediate and low risk: a systematic review and meta-analysis. Clin Med (Lond) 2023; 23:594-605. [PMID: 38065591 PMCID: PMC11046617 DOI: 10.7861/clinmed.2023-0258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Recent randomised trials have shown that clinical outcomes with transcatheter aortic valve implantation (TAVI) are non-inferior to surgical aortic valve replacement (SAVR) in patients with symptomatic aortic stenosis at intermediate to low risk. Health-related quality of life (HrQoL) outcomes in these patient groups remain uncertain. A systematic search of the literature was conducted that included nine trials and 11,295 patients. Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific measure and EuroQol-5D (EQ-5D) (a generic health status tool) changes were the primary outcomes. New York Heart Association (NYHA) classification was the secondary outcome. Improvement in KCCQ scores was greater with TAVI (mean difference (MD)=13.56, 95% confidence interval (CI) 11.67-15.46, p<0.001) at 1 month, as was the improvement in EQ-5D (MD=0.07, 95% CI 0.05-0.08, p<0.001). There was no difference in KCCQ (MD=1.05, 95% CI -0.11 to 2.21, p=0.08) or EQ-5D (MD=-0.01, 95% CI -0.03 to 0.01), p=0.37) at 12 months. NYHA functional class 3/4 was lower in patients undergoing TAVI at 1 month (MD=0.51, 95% CI 0.34-0.78, p=0.002), but there was no difference at 12 months (MD=1.10; 95% CI 0.87-1.38, p=0.43). Overall, TAVI offers early benefit in HRQoL outcomes compared with SAVR, but they are equivalent at 12 months.
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Affiliation(s)
| | | | - Rebecca Taylor
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Aser Labib
- Southport and Ormskirk NHS Foundation Trust, Southport, UK
| | - Omar Masoud
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Maciej Debski
- University of East Anglia, Norwich, UK and research fellow, Norfolk and Norwich University Hospital, Norwich, UK
| | | | - David Hesketh Roberts
- Lancashire Cardiac Centre, Blackpool, UK, and honorary senior lecturer, University of Liverpool, Merseyside Liverpool
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Albarrati AM, Altimani R, Almogbel O, Alnahdi AH, Almurdi MM, Abuammah A, Nazer R. Reliability and Validity of Kansas City Cardiomyopathy Questionnaire in Arabic Patients with Chronic Heart Failure. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1910. [PMID: 38003959 PMCID: PMC10673578 DOI: 10.3390/medicina59111910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 11/26/2023]
Abstract
Background: The Kansas City Cardiomyopathy Questionnaire (KCCQ) is the most specific and widely used questionnaire for assessing health-related quality of life (HRQoL) in chronic heart failure (CHF). This study aimed to examine reliability and validity of the KCCQ in Arabic patients with CHF. Material and Methods: Patients with CHF filled out the Arabic versions of the Minnesota Living with Heart Failure (MLHF) and KCCQ questionnaire, and performed a six-minute walk test (6MWT) on their first visit. On the return, the patients filled out the KCCQ along with the global rating of change (GRC) scale. Internal consistency, test-retest reliability, and construct validity were examined. Results: A total of 101 Arabic patients with CHF, with a mean (SD) age of 55 (11) years old, completed the study. The Cronbach's alpha was 0.97, and the ICC2,1 = 0.95 (95%CI: 0.92 to 0.97, p < 0.001). The Arabic version of KCCQ was correlated with the MLHF (r = -0.57, p = 0.01) and with the 6MWT (r = 0.70, p < 0.001). Conclusions: The Arabic version of KCCQ is a reliable and valid measure of HRQoL, which could be utilized in routine clinical practice for Arabic-speaking patients with CHF.
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Affiliation(s)
- Ali M. Albarrati
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (A.H.A.); (M.M.A.)
| | | | - Osama Almogbel
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (O.A.); (A.A.); (R.N.)
| | - Ali H. Alnahdi
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (A.H.A.); (M.M.A.)
| | - Muneera M. Almurdi
- Rehabilitation Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (A.H.A.); (M.M.A.)
| | - Aliah Abuammah
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (O.A.); (A.A.); (R.N.)
| | - Rakan Nazer
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh 11461, Saudi Arabia; (O.A.); (A.A.); (R.N.)
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9
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Alarouri HS, El Shaer A, Ponce AC, Mahayni A, Sulaiman S, Samimi S, Alkhouli M. Prognostic Value of Patient-Reported Outcomes in Predicting Long-Term Mortality After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2023; 12:e030383. [PMID: 37750586 PMCID: PMC10727265 DOI: 10.1161/jaha.123.030383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/31/2023] [Indexed: 09/27/2023]
Abstract
Background Patient-reported outcome measures have been shown to have important prognostic value after various cardiac interventions. We assessed the association between the change in Kansas City Cardiomyopathy Questionnaire 12 (KCCQ-12) score after transcatheter aortic valve replacement and mortality. Methods and Results We included patients who underwent transcatheter aortic valve replacement at Mayo Clinic between February 2012 to June 2022 and who completed a KCCQ-12 before and 30 to 45 days after the procedure. Patients were categorized into 3 groups: those who experienced significant (>+19 points; group 1), modest (1-19 points; group 2), and no (≤0 points; group 3) improvement. A total of 1124 patients were included: 60.8% men; 97.6% White. Mean age was 79.4±8.3 years, baseline KCCQ-12 score was 53.9±24.5, and median Society of Thoracic Surgeons score was 4.9% (interquartile range, 3.1-8.0). At 45 days, the mean change in KCCQ-12 score was 19±24 points; 46.3% (n=520) of patients had a significant improvement in their KCCQ-12 score, while 33.4% (n=375) and 20.4% (n=229) had modest and no improvement, respectively. Median survival was higher in group 1 (5.7±0.2 years) compared with groups 2 and 3 (5.1±0.3 and 4.1±0.4 years, respectively; P<0.001). Compared with patients in group 1, those in groups 2 and 3 had higher long-term risk-adjusted mortality (adjusted hazard ratios, 1.54 [95% CI, 1.20-1.96], and 2.30 [95% CI, 1.74-3.04], respectively). Conclusions Patients who experience modest or no improvement in KCCQ-12 score after transcatheter aortic valve replacement have substantially higher long-term mortality. Delta KCCQ-12 is a cost-effective, efficient tool that can identify patients at increased risk of death at long-term follow-up post-transcatheter aortic valve replacement.
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Affiliation(s)
| | - Ahmed El Shaer
- Department of Internal MedicineUniversity of Wisconsin Hospitals & ClinicsMadisonWIUSA
| | | | - Abdulah Mahayni
- Department of Cardiovascular DiseaseMayo ClinicRochesterMNUSA
| | - Samian Sulaiman
- Department of Cardiovascular DiseaseWest Virginia UniversityMorgantownWVUSA
| | - Sahar Samimi
- Department of Cardiovascular DiseaseMayo ClinicRochesterMNUSA
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10
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Soloveva A, Gale CP, Han NT, Hurdus B, Aktaa S, Palin V, Mebrahtu TF, Van Spall H, Batra G, Dondo TB, Bäck M, Munyombwe T. Associations of health-related quality of life with major adverse cardiovascular and cerebrovascular events for individuals with ischaemic heart disease: systematic review, meta-analysis and evidence mapping. Open Heart 2023; 10:e002452. [PMID: 37890894 PMCID: PMC10619110 DOI: 10.1136/openhrt-2023-002452] [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: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 10/29/2023] Open
Abstract
OBJECTIVE To investigate the association between health-related quality of life (HRQoL) and major adverse cardiovascular and cerebrovascular events (MACCE) in individuals with ischaemic heart disease (IHD). METHODS Medline(R), Embase, APA PsycINFO and CINAHL (EBSCO) from inception to 3 April 2023 were searched. Studies reporting association of HRQoL, using a generic or cardiac-specific tool, with MACCE or components of MACCE for individuals with IHD were eligible for inclusion. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the studies. Descriptive synthesis, evidence mapping and random-effects meta-analysis were performed stratified by HRQoL measures and effect estimates. Between-study heterogeneity was assessed using the Higgins I2 statistic. RESULTS Fifty-one articles were included with a total of 134 740 participants from 53 countries. Meta-analysis of 23 studies found that the risk of MACCE increased with lower baseline HeartQoL score (HR 1.49, 95% CI 1.16 to 1.93) and Short Form Survey (SF-12) physical component score (PCS) (HR 1.39, 95% CI 1.28 to 1.51). Risk of all-cause mortality increased with a lower HeartQoL (HR 1.64, 95% CI 1.34 to 2.01), EuroQol 5-dimension (HR 1.17, 95% CI 1.12 to 1.22), SF-36 PCS (HR 1.29, 95% CI 1.19 to 1.41), SF-36 mental component score (HR 1.18, 95% CI 1.08 to 1.30). CONCLUSIONS This study found an inverse association between baseline values or change in HRQoL and MACCE or components of MACCE in individuals with IHD, albeit with between-study heterogeneity. Standardisation and routine assessment of HRQoL in clinical practice may help risk stratify individuals with IHD for tailored interventions. PROSPERO REGISTRATION NUMBER CRD42021234638.
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Affiliation(s)
- Anzhela Soloveva
- Department of Cardiology, Almazov National Medical Research Centre, Sankt-Peterburg, Russian Federation
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine/Leeds Institute of Data analytics, University of Leeds, Leeds, UK
| | - Naung Tun Han
- Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Ben Hurdus
- Leeds Institute of Cardiovascular and Metabolic Medicine/Leeds Institute of Data analytics, University of Leeds, Leeds, UK
| | - Suleman Aktaa
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Victoria Palin
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Teumzghi F Mebrahtu
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Harriette Van Spall
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Gorav Batra
- Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tatendashe Bernadette Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicine/Leeds Institute of Data analytics, University of Leeds, Leeds, UK
| | - Maria Bäck
- Department of Medical and Health Sciences, Linköping University, Linkoping, Sweden
| | - Theresa Munyombwe
- Leeds Institute of Cardiovascular and Metabolic Medicine/Leeds Institute of Data analytics, University of Leeds, Leeds, UK
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11
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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.
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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
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12
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Siddiqi TJ, Anker SD, Filippatos G, Ferreira JP, Pocock SJ, Böhm M, Brueckmann M, Chopra VK, Iwata T, Januzzi J, Piña IL, Ponikowski P, Senni M, Vedin O, Verma S, Zhang Y, Zannad F, Packer M, Butler J. Health status across major subgroups of patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2023; 25:1623-1631. [PMID: 36974746 DOI: 10.1002/ejhf.2831] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/10/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
AIMS There are limited data on health status and changes in it over time across major subgroups of patients with heart failure and preserved ejection fraction (HFpEF), including ejection fraction spectrum, age, sex, region, body mass index (BMI), and comorbidities including diabetes, chronic kidney disease (CKD), anaemia, and atrial fibrillation/flutter. METHODS AND RESULTS In the EMPEROR-Preserved trial, the Kansas City Cardiomyopathy Questionnaire (KCCQ) was assessed at baseline, 12, 32 and 52 weeks. Determinants of baseline KCCQ score and change over time, and the impact of empagliflozin on KCCQ scores were studied in specified subgroups. A Cox model was used to assess the association between 5- and 10-point increase and 5-point decrease in KCCQ score from baseline to week 12 and later outcomes. Among 2979 participants in the placebo arm, mean KCCQ clinical summary score (CSS) was 70.7 (20.8). Older age, female sex, BMI, anaemia, and a history of diabetes, and CKD were associated with worse scores. KCCQ-CSS score improved during follow-up; patients with atrial fibrillation/flutter at enrollment (p trend = 0.014) and CKD (p trend < 0.001) had less improvement. A 5-point increase in KCCQ-CSS at week 12 was associated with lower risk of cardiovascular death or heart failure hospitalization (5%), cardiovascular death (8%), and first heart failure hospitalization (4%) subsequently. A similar trend was seen with KCCQ total symptom score (TSS) and overall summary score (OSS). Empagliflozin improved KCCQ-CSS, -TSS and -OSS scores similarly across subgroups studied except for greater improvement in patients with the highest BMI (p trend = 0.153, 0.08 and 0.078, respectively). CONCLUSION Health status in patients with HFpEF is impaired, especially in elderly, women, and those with obesity and comorbidities. Empagliflozin improved health status among all key subgroups studied with a greater effect in obese patients.
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Affiliation(s)
- Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
- German Centre for Cardiovascular Research partner site, Berlin, Germany
- Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Chaidari, Greece
| | - João Pedro Ferreira
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
- Inserm, Centre d'Investigations Cliniques - Plurithématique 14-33, Université de Lorraine, Nancy, France
- Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - James Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - Ileana L Piña
- Central Michigan University, Mount Pleasant, MI, USA
| | | | - Michele Senni
- Cardiology Division, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ola Vedin
- Boehringer Ingelheim AB, Stockholm, Sweden
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yuhui Zhang
- Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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13
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Frank D, Kennon S, Bonaros N, Romano M, Di Mario C, van Ginkel DJ, Bor W, Kasel M, De Backer O, Hachaturyan V, Lüske CM, Kurucova J, Bramlage P, Styra R. Quality of Life Measures in Aortic Stenosis Research: A Narrative Review. Cardiology 2023; 148:556-570. [PMID: 37442111 PMCID: PMC10733944 DOI: 10.1159/000531465] [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: 07/04/2022] [Accepted: 05/31/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS. SUMMARY We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ). KEY MESSAGES There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.
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Affiliation(s)
- Derk Frank
- Department of Internal Medicine III (Cardiology, Angiology and Critical Care), UKSH University Clinical Center Schleswig-Holstein and DZHK (German Centre for Cardiovascular Research), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Simon Kennon
- Department of Cardiology, Barts Heart Centre, St. Bartholomew’s Hospital, London, UK
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Mauro Romano
- Department of Thoracic and Cardiovascular Surgery, Department of Interventional Cardiology, Hôpital Privé Jacques Cartier, Massy, France
| | - Carlo Di Mario
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Dirk-Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Wilbert Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Markus Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ole De Backer
- Interventional Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark
| | | | - Claudia M. Lüske
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Rima Styra
- Department of Psychiatry, University Health Network, Toronto, ON, Canada
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14
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Angélico-Gonçalves A, Leite AR, Neves JS, Saraiva F, Brochado L, Oliveira AC, Butler J, Packer M, Zannad F, Vasques-Nóvoa F, Leite-Moreira A, Ferreira JP. Changes in health-related quality of life and treatment effects in chronic heart failure: A meta-analysis. Int J Cardiol 2023:S0167-5273(23)00726-X. [PMID: 37211049 DOI: 10.1016/j.ijcard.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Heart failure (HF) is associated with poor health status, and high morbi-mortality. However, it is not well established how health status changes correlate with treatment effects on clinical outcomes. Our aim was to study the association between treatment-induced changes in health-status, assessed by Kansas City Cardiomyopathy Questionnaire 23 (KCCQ-23) and clinical outcomes in chronic HF. METHODS Systematic search of phase III-IV pharmacological RCTs in chronic HF that assessed KCCQ-23 changes and clinical outcomes throughout follow-up. We studied the association between treatment induced changes in KCCQ-23 and treatment effects on clinical outcomes (HF hospitalization or cardiovascular death, HF hospitalization, cardiovascular death, and all-cause death) using weighted random-effects meta-regression. RESULTS Sixteen trials were included, enrolling a total of 65,664 participants. Treatment induced KCCQ-23 changes were moderately correlated with treatment effects on the combined outcome of HF hospitalization or cardiovascular mortality (regression coefficient (RC) = -0.047, 95%CI: -0.085 to -0.009; R2 = 49%), a correlation that was mainly driven by HF hospitalization (RC = -0.076, 95%CI: -0.124 to -0.029; R2 = 56%). Correlations of treatment induced KCCQ-23 changes with cardiovascular death (RC = -0.029, 95%CI: -0.073 to 0.015; R2 = 10%) and all-cause death (RC = -0.019, 95%CI: -0.057 to 0.019; R2 = 0%) were weak and non-significant. CONCLUSIONS Treatment-induced changes in KCCQ-23 were moderately correlated with treatment-effects on HF hospitalizations but were not correlated with the effects on cardiovascular and all-cause mortality. Treatment-induced changes in patient-centered outcomes (i.e., KCCQ-23) may reflect non-fatal symptomatic changes in the clinical course of HF leading to hospitalization.
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Affiliation(s)
- António Angélico-Gonçalves
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Internal Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana Rita Leite
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Endocrinology and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - João Sérgio Neves
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Endocrinology and Metabolism, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Francisca Saraiva
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liliana Brochado
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Cristina Oliveira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, United States of America; Department of Medicine, University of Mississippi, Jackson, MS, United States of America
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, United States of America; Imperial College, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques, - Plurithématique 14-33 and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Francisco Vasques-Nóvoa
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - João Pedro Ferreira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Chillo P, Mlay J, Akanyirige PW, Majani N, Janabi M, Kaaya S, Hawkins C, Hirschhorn LR. Adapting and usability testing of the Kansas city cardiomyopathy questionnaire (KCCQ) in a heart failure clinic in Tanzania: the Swahili KCCQ. BMC Cardiovasc Disord 2023; 23:242. [PMID: 37149565 PMCID: PMC10163850 DOI: 10.1186/s12872-023-03265-0] [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: 10/22/2022] [Accepted: 04/26/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND The integration of patient-reported outcome measures (PROMS) into health care delivery systems is being increasingly recognized as an important component of quality, person-centered care, especially for chronic illnesses like congestive heart failure (CHF). However, while PROMS are increasingly being used to follow up CHF patients in high income countries, their use in sub-Saharan Africa is still limited. We adapted the Kansas City Cardiomyopathy Questionnaire (KCCQ-23), an internationally validated, CHF-specific PROM and tested its use in measuring outcomes in an outpatient CHF clinic at a cardiac referral hospital in Tanzania. METHODS Adaptation of the KCCQ-23 included translation into Swahili by linguistic experts, in-depth cognitive debriefing in native Swahili-speaking CHF patients, and input from Tanzanian Cardiologists, PROMS experts, and the tool developer. Using a cross-sectional design, we tested the usability and observed the results of the translated KCCQ-23 in a convenience sample of 60 CHF patients attending outpatient clinic at the Jakaya Kikwete Cardiac Institute (JKCI) in Dar es Salaam. RESULTS The survey was successfully completed by 59 (98.3%) of 60 enrolled participants. The mean (SD) age of participants was 54.9 (14.8) years (range 22-83), 30.5% were women and 72.2% had class 3 or 4 New York Heart Association (NYHA) symptoms at enrollment. The overall KCCQ-23 score was low, with a mean (SD) score of 21.7 (20.4) indicating generally very poor to poor patient reported outcomes in this population. The mean (SD) scores for the specific KCCQ-23 domains were 15.25 (24.2) for social limitation, 23.8 (27.4) for physical limitation, 27.1 (24.1) for quality of life and 40.7 (17.0) for self-efficacy. No socio-demographic or clinical characteristics were associated with their overall KCCQ-23 scores. Comparing the short version (KCCQ-12) with the full KCCQ-23 revealed excellent correlation between the two (r = 0.95; p < 0.0001). CONCLUSIONS We successfully translated a validated tool, the Swahili KCCQ, for use in improving the care of patients with CHF in Tanzania and a broader population of Swahili-speaking patients. Both the Swahili KCCQ-12 and KCCQ-23 can be used, with similar outcomes. Work to expand the use of the tool in the clinic and other settings is planned.
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Affiliation(s)
- Pilly Chillo
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania.
| | - Jackson Mlay
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | - Mohamed Janabi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Sylvia Kaaya
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Claudia Hawkins
- Feinberg School of Medicine, Northwestern University, Evanston, USA
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16
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Thomas M, Spertus JA, Andrei AC, Wu T, Farr SL, Warzecha A, Grady KL. Association Between Caregiver Burden and Patient Recovery After Left Ventricular Assist Device Implantation: Insights From Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support. J Cardiovasc Nurs 2023; 38:237-246. [PMID: 37027128 PMCID: PMC10885691 DOI: 10.1097/jcn.0000000000000972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
INTRODUCTION After left ventricular assist device (LVAD) implantation, caregivers may experience increasing burden because of new roles and responsibilities. We examined the association between caregiver burden at baseline and patient recovery after long-term LVAD implantation in patients ineligible for heart transplantation. METHODS Between October 1, 2015, and December 31, 2018, data from 60 patients with a long-term LVAD (age, 60-80 years) and caregivers through 1 postoperative year were analyzed. Caregiver burden was measured using the Oberst Caregiving Burden Scale, a validated instrument used for measuring caregiver burden. Patient recovery post-LVAD implantation was defined by change in Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) overall summary score and rehospitalizations over 1 year. Multivariable regression models (least-squares for change in KCCQ-12 and Fine-Gray cumulative incidence for rehospitalizations) were used to assess for association with caregiver burden. RESULTS Patients were 69.4 ± 5.5 years old, 85% men, and 90% White. Over the first year post-LVAD implantation, there was a 32% cumulative probability of rehospitalization; 72% (43/60) of patients had an improvement of ≥5 points in KCCQ-12 scores. Caregivers were 61.2 ± 11.5 years old, 93% women, 81% White, and 85% married. Median Oberst Caregiving Burden Scale Difficulty and Time scores at baseline were 1.13 and 2.27, respectively. Higher caregiver burden was not significantly associated with hospitalizations or change in patient health-related quality of life during the first year post-LVAD implantation. CONCLUSIONS Higher caregiver burden at baseline was not associated with patient recovery in the first year after LVAD implantation. Understanding the associations between caregiver burden and patient outcomes after LVAD implantation is important as excessive caregiver burden is a relative contraindication for LVAD implantation.
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Affiliation(s)
- Merrill Thomas
- University of Missouri-Kansas City School of Medicine
- Saint Luke’s Mid America Heart Institute
| | - John A. Spertus
- University of Missouri-Kansas City School of Medicine
- Saint Luke’s Mid America Heart Institute
| | | | - Tingqing Wu
- Feinberg School of Medicine, Northwestern University
| | - Stacy L. Farr
- University of Missouri-Kansas City School of Medicine
- Saint Luke’s Mid America Heart Institute
| | - Anna Warzecha
- Feinberg School of Medicine, Northwestern University
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17
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Teramoto K, Tay WT, Tromp J, Katherine Teng TH, Chandramouli C, Ouwerkerk W, Lawson CA, Huang W, Hung CL, Chopra V, Anand I, Mark Richards A, Lam CSP. Patient-Reported Versus Physician-Assessed Health Status in Heart Failure With Reduced and Preserved Ejection Fraction From ASIAN-HF Registry. Circ Cardiovasc Qual Outcomes 2023; 16:e009134. [PMID: 36484254 DOI: 10.1161/circoutcomes.122.009134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to assess if discordance between patient-reported Kansas City Cardiomyopathy Questionnaire (KCCQ)-overall summary (os) score and physician-assessed New York Heart Association (NYHA) class is common among patients with heart failure (HF) with reduced or preserved ejection fraction, and determine its association with outcomes. METHODS A total of 4818 patients with HF were classified according to KCCQ-os score (range 0-100, dichotomized by median value 71.9 into high [good] versus low [bad]) and NYHA class (I/II [good] or III/IV [bad]) as concordant good (low NYHA class, high KCCQ-os score), concordant bad (high NYHA class, low KCCQ-os score), discordant worse NYHA class (high NYHA class, high KCCQ-os score), and discordant worse KCCQ-os score (low NYHA class, low-KCCQ-os score). The composite of HF hospitalization or death at 1 year was compared across groups. RESULTS There were 2070 (43.0%) concordant good, 1099 (22.8%) concordant bad, 331 (6.9%) discordant worse NYHA class, and 1318 (27.4%) discordant worse KCCQ-os score patients. Compared with concordant good, adverse outcomes were the highest in concordant bad (HR, 2.7 [95% CI, 2.2-3.5]) followed by discordant worse KCCQ-os score (HR, 1.8 [95% CI, 1.4-2.2]) and discordant worse NYHA class (HR, 1.5 [95% CI, 1.0-2.3]); with no modification by HF phenotype (preserved versus reduced ejection fraction, Pinteraction=0.52). At 6 months, 1403 (48%) experienced clinically significant improvement in KCCQ-os score (≥5 points increase over 6 months). Patients with improved KCCQ-os at 6 months (HR, 0.65 [95% CI, 0.47-0.92]) had better outcomes and the association was not modified by HF phenotype (Pinteraction=0.40). CONCLUSIONS One-third of patients with HF had discordance between patient-reported and clinician-assessed health status, largely attributable to worse patient-reported outcomes. Such discordance, particularly in those with discordantly worse KCCQ, should alert physicians to an increased risk of HF hospitalization and death, and prompt further assessment for potential drivers of worse patient-reported outcomes relative to physicians' assessment.
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Affiliation(s)
- Kanako Teramoto
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,National Cerebral and Cardiovascular Center, Osaka, Japan (K.T.)
| | - Wan Ting Tay
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.)
| | - Jasper Tromp
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Saw Swee Hock School of Public Health National University of Singapore and the National University Health System (J.T.)
| | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,School of Allied Health, University of Western Australia, Perth, Australia (T.-H.K.T.)
| | - Chanchal Chandramouli
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., T.-H.K.T., C.C., C.S.P.L.)
| | - Wouter Ouwerkerk
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Amsterdam Medical Center, Department of Dermatology, The Netherlands (W.O.)
| | - Claire A Lawson
- Department of Cardiovascular Research, University of Leicester, United Kingdom (C.A.L.)
| | - Weiting Huang
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.)
| | | | - Vijay Chopra
- Max Super Specialty Hospital, New Delhi, India (V.C.)
| | - Inder Anand
- Cardiovascular division, University of Minnesota, Minneapolis (I.A.)
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore (A.M.R.).,Christchurch Heart Institute, University of Otago, New Zealand (A.M.R.)
| | - Carolyn S P Lam
- National Heart Centre Singapore (K.T., W.T.T., J.T., T.-H.K.T., C.C., W.O., W.H., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., T.-H.K.T., C.C., C.S.P.L.).,Department of Cardiology, University Medical Center Groningen, The Netherlands (C.S.P.L.)
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18
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Zheng J, Parizo JT, Spertus JA, Heidenreich PA, Sandhu AT. Cost-effectiveness of Empagliflozin in Patients With Heart Failure With Preserved Ejection Fraction. JAMA Intern Med 2022; 182:1278-1288. [PMID: 36342696 PMCID: PMC9641590 DOI: 10.1001/jamainternmed.2022.5010] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022]
Abstract
Importance In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear. Objective To estimate the cost-effectiveness of empagliflozin in patients with HFpEF. Design, Setting, and Participants This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure-specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients. Exposures Empagliflozin or standard of care. Main Outcomes and Measures Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio. Results A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations. Conclusions and Relevance In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, California
| | - Justin T. Parizo
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - John A. Spertus
- St Luke’s Mid America Heart Institute, University of Missouri–Kansas City
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
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19
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Considerations in the Interpretation of Patient-Reported Outcomes in Heart Failure With Reduced and Preserved Ejection Fraction. J Card Fail 2022; 28:1661-1663. [PMID: 36243341 DOI: 10.1016/j.cardfail.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 12/15/2022]
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20
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Whellan D, McCarey MM, Chen H, Nelson MB, Pastva AM, Duncan P, Mentz RJ, Kitzman DW, Reeves G, Reed SD. Quality of Life Trajectory and Its Mediators in Older Patients With Acute Decompensated Heart Failure Receiving a Multi-Domain Rehabilitation Intervention: Results From the Rehabilitation Therapy in Older Acute Heart Failure Patients Trial. Circ Heart Fail 2022; 15:e009695. [PMID: 36345825 PMCID: PMC9771880 DOI: 10.1161/circheartfailure.122.009695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND As patients with heart failure experience worsening of their condition, including acute decompensated heart failure, quality of life deteriorates. However, the trajectory of quality of life changes and their determinants in the context of the Rehabilitation Therapy in Older Acute Heart Failure Patients trial physical rehabilitation intervention are unknown. METHODS Patients ≥60 years old admitted for acute decompensated heart failure (n=349) were randomized to either attention control or intervention. Quality of life outcomes (Kansas City Cardiomyopathy Questionnaire; 12-Item Short-Form Health Survey) were measured at baseline (inpatient), 1 month, and 3 months. Intervention effects were assessed using linear mixed effects regression, including covariates to model the main effects of the intervention and timing of outcome assessments. Mediation analysis determined if changes in Kansas City Cardiomyopathy Questionnaire were due to improvement in physical function (short physical performance battery, 6-minute walk distance). RESULTS Baseline Kansas City Cardiomyopathy Questionnaire summary score was similarly poor in the intervention and control arms (40.2±20.6 versus 41.5±20.6). Although the intervention experienced nominally greater Kansas City Cardiomyopathy Questionnaire improvement than control at 1 month (64.7±1.9 versus 61.1±1.9, P=0.13), the difference was not statistically significant until 3 months (67.7±1.9 versus 60.8±1.9, P=0.004). Twelve-Item Short-Form Health Survey Physical and Mental Composite Scores increased in both arms at 1 month and continued improvement only in the intervention. The 3-month improvement in short physical performance battery score explained 64.1% of the improvement in Kansas City Cardiomyopathy Questionnaire (P<0.001). CONCLUSIONS In older patients hospitalized for acute decompensated heart failure, quality of life improves in the first month after discharge. The quality of life benefit of a post-discharge physical rehabilitation intervention is detected early with large significant improvements at 3 months achieved primarily through improvement in short physical performance battery. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT02196038.
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Affiliation(s)
- David Whellan
- Department of Medicine, Sidney Kimmel Medical College (D.W.), Thomas Jefferson University, Philadelphia, PA
| | - Melissa M McCarey
- Jefferson Clinical Research Institute (M.M.M.), Thomas Jefferson University, Philadelphia, PA
| | - Haiying Chen
- Department of Biostatistics and Data Science (H.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - M Benjamin Nelson
- Section on Cardiovascular Medicine, Department of Internal Medicine (M.B.N., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Amy M Pastva
- Doctor of Physical Therapy Division, Department of Orthopaedic Surgery (A.M.P.), Duke University School of Medicine, Durham, NC
| | - Pamela Duncan
- Department of Neurology (P.D.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Robert J Mentz
- Division of Cardiology and Duke Clinical Research Institute (R.J.M.), Duke University School of Medicine, Durham, NC
| | - Dalane W Kitzman
- Section on Cardiovascular Medicine, Department of Internal Medicine (M.B.N., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
- Section on Geriatrics, Department of Internal Medicine (D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Gordon Reeves
- Novant Health Heart and Vascular Institute, Charlotte, NC (G.R.)
| | - Shelby D Reed
- Department of Population Health Sciences (S.D.R.), Duke University School of Medicine, Durham, NC
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21
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Lawson CA, Lam C, Jaarsma T, Kadam U, Stromberg A, Ali M, Tay WT, Clayton L, Khunti K, Squire I. Developing a core outcome set for patient-reported symptom monitoring to reduce hospital admissions for patients with heart failure. Eur J Cardiovasc Nurs 2022; 21:830-839. [PMID: 35404418 DOI: 10.1093/eurjcn/zvac019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/29/2022]
Abstract
AIMS In patients with heart failure (HF), hospitalization rates are increasing, particularly for non-HF causes and over half may be avoidable. Self-monitoring of symptoms plays a key part in the early identification of deterioration. Our objective was to develop expert consensus for a core outcome set (COS) of symptoms to be monitored by patients, using validated single-item patient-reported outcome measures (PROMs), focused on the key priority of reducing admissions in HF. METHODS AND RESULTS A rigorous COS development process incorporating systematic review, modified e-Delphi and nominal group technique (NGT) methods. Participants included 24 HF patients, 4 carers, 29 HF nurses, and 9 doctors. In three Delphi and NGT rounds, participants rated potential outcomes on their importance before a HF or a non-HF admission using a 5-point Likert scale. Opinion change between rounds was assessed and a two-thirds threshold was used for outcome selection.Item generation using systematic review identified 100 validated single-item PROMs covering 34 symptoms or signs, relevant to admission for people with HF. De-duplication and formal consensus processes, resulted in a COS comprising eight symptoms and signs; shortness of breath, arm or leg swelling, abdomen bloating, palpitations, weight gain, chest pain, anxiety, and overall health. In the NGT, a numerical rating scale was selected as the optimal approach to symptom monitoring. CONCLUSION Recognition of a range of HF-specific and general symptoms, alongside comorbidities, is an important consideration for admission prevention. Further work is needed to validate and integrate the COS in routine care with the aim of facilitating faster identification of clinical deterioration.
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Affiliation(s)
- Claire A Lawson
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
| | - Carolyn Lam
- National Heart Centre Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,University Medical Centre Groningen, Groningen, The Netherlands.,The George Institute for Global Health, Newton, NSW, Australia
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Umesh Kadam
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Anna Stromberg
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Mohammad Ali
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
| | | | - Louise Clayton
- Department of Cardiology, University Hospitals of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, Leicestershire LE5 4PW, UK
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22
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Cedars A, Joseph S. Don't tell your patients where they are, let them tell you. Eur J Heart Fail 2022; 24:2105-2107. [PMID: 36088541 DOI: 10.1002/ejhf.2682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Ari Cedars
- Divisions of Pediatric and Adult Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Susan Joseph
- Division of Cardiology, University of Maryland, Baltimore, MD, USA
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23
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Nagamine T, Gillette B, Kahoun J, Burghaus R, Lippert J, Saxena M. Data-driven identification of heart failure disease states and progression pathways using electronic health records. Sci Rep 2022; 12:17871. [PMID: 36284167 PMCID: PMC9596465 DOI: 10.1038/s41598-022-22398-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/13/2022] [Indexed: 01/20/2023] Open
Abstract
Heart failure (HF) is a leading cause of morbidity, healthcare costs, and mortality. Guideline based segmentation of HF into distinct subtypes is coarse and unlikely to reflect the heterogeneity of etiologies and disease trajectories of patients. While analyses of electronic health records show promise in expanding our understanding of complex syndromes like HF in an evidence-driven way, limitations in data quality have presented challenges for large-scale EHR-based insight generation and decision-making. We present a hypothesis-free approach to generating real-world characteristics and progression patterns of HF. Patient disease state snapshots are extracted from the complaints mentioned in unstructured clinical notes. Typical disease states are generated by clustering and characterized in terms of their distinguishing features, temporal relationships, and risk of important clinical events. Our analysis generates a comprehensive "disease phenome" of real-world patients computed from large, noisy, secondary-use EHR datasets created in a routine clinical setting.
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Affiliation(s)
| | - Brian Gillette
- grid.137628.90000 0004 1936 8753Department of Surgery, NYU Langone Long Island, Mineola, NY USA ,Department of Foundations of Medicine, NYU Long Island School of Medicine, Mineola, NY USA
| | - John Kahoun
- Droice Research, New York, NY USA ,Clinical Informatics, CityMD, New York, NY USA
| | - Rolf Burghaus
- grid.420044.60000 0004 0374 4101Bayer AG, Wuppertal, Germany
| | - Jörg Lippert
- grid.420044.60000 0004 0374 4101Bayer AG, Wuppertal, Germany
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24
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Garcia RA, Jones PG, Jeong K, Rothenberger SD, Chan PS, Belnap BH, Anderson AM, Rollman BL, Spertus JA. Prognostic implications of a one-item health literacy screen on health status outcomes among heart failure patients with depression. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 22:100214. [PMID: 37946716 PMCID: PMC10635579 DOI: 10.1016/j.ahjo.2022.100214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/12/2023]
Abstract
Background Health literacy (HL) is the degree to which individuals can obtain, process, and understand basic health information and services. Although low HL portends greater risk for clinical events, its association with heart failure (HF)-specific health status- patients' symptoms, function and quality of life- is poorly understood. We thus explored the association of low HL with health status outcomes in depressed patients with HF, for whom treatment regimens can be complex. Methods Participants with HF with reduced ejection fraction and depression, from the Hopeful Heart trial, were categorized as having low or adequate HL at baseline using a validated, 1-item HL screen. HF-specific health status was measured at baseline, 3, 6, and 12 months using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Using serial risk-adjusted linear regression models, we assessed the association of HL with baseline, 12-month and 12-month change in the KCCQ Overall Summary (OS) scores (range 0-100; lower scores = worse health status). Results Among 629 participants, 35 % had low HL. Those with low HL had lower health status at all time points, including at 12 months after discharge (-9.8 points, 95%CI [-14.3, -5.3], p < 0.001), with poorer improvements in KCCQ-OS scores after accounting for baseline health status (-6.4 points, 95%CI [-10.5, -2.3], p = 0.002). Conclusions In those with HF and depression, low HL was common and associated with worse HF-specific health status and poorer improvement over time. A brief HL screen can identify patients at risk for poorer health status outcomes and for whom additional interventions may be warranted.
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Affiliation(s)
- R. Angel Garcia
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, United States of America
| | - Philip G. Jones
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, United States of America
| | - Kwonho Jeong
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Research on Healthcare Data Center, University of Pittsburgh School of Medicine, United States of America
| | - Scott D. Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Research on Healthcare Data Center, University of Pittsburgh School of Medicine, United States of America
| | - Paul S. Chan
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, United States of America
| | - Bea Herbeck Belnap
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, United States of America
| | - Amy M. Anderson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, United States of America
| | - Bruce L. Rollman
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, United States of America
| | - John A. Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, United States of America
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25
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Butler J, Shahzeb Khan M, Lindenfeld J, Abraham WT, Savarese G, Salsali A, Zeller C, Peil B, Filippatos G, Ponikowski P, Anker SD. Minimally Clinically Important Difference in Health Status Scores in Patients With HFrEF vs HFpEF. JACC. HEART FAILURE 2022; 10:651-661. [PMID: 35780032 DOI: 10.1016/j.jchf.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/02/2022] [Accepted: 03/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Differences in clinically important thresholds in patient-reported outcomes measures such as the Kansas City Cardiomyopathy Questionnaire (KCCQ) remain less well-established in patients with heart failure with preserved ejection fraction (HFpEF) versus heart failure with reduced ejection fraction (HFrEF). OBJECTIVES The purpose of this study was to estimate meaningful thresholds for improvement or deterioration in the KCCQ-Total Symptom Score (TSS) in patients with HFrEF versus HFpEF. METHODS This secondary analysis of EMPERIAL program used anchor- and distribution-based approaches to estimate thresholds for improvement or deterioration in the KCCQ-TSS using Patient Global Impression of Severity (PGIS) as the primary anchor. Mean change in KCCQ-TSS from baseline to week 12 was calculated for each PGIS. RESULTS A total of 312 HFrEF and 315 HFpEF patients were enrolled. At week 12, mean changes in KCCQ-TSS corresponding to PGIS changes of "any improvement," "1-category improvement," and "1-category deterioration" were 13 ± 17, 12 ± 17, -3 ± 16 points in HFrEF, and 15 ± 18, 13 ± 17, -7 ± 18 points in HFpEF. Threshold for meaningful within-patient change in KCCQ-TSS was ≥9 points in HFrEF and ≥7 points in HFpEF patients. Sensitivity and specificity of ≥9 points/≥7 points change was 0.65 and 0.70 for HFrEF and 0.64 and 0.66 for HFpEF. Cumulative distribution function curves of KCCQ-TSS change from baseline to week 12 showed a shift to higher scores in both HFrEF and HFpEF patients. CONCLUSIONS In the EMPERIAL program, a change in KCCQ-TSS of ≥9 points in HFrEF and ≥7 points in HFpEF represents the minimal clinically important difference for improvement, confirming the broad range of 5-10 points as meaningful thresholds.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA.
| | | | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet; and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA; Faculty of Medicine, Rutgers University, New Brunswick, New Jersey
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim AM Rhein, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
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26
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Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Comin-Colet J, Ferreira JP, Mentz RJ, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Voors AA. Effects of Empagliflozin on Symptoms, Physical Limitations, and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial. Circulation 2022; 146:279-288. [PMID: 35377706 PMCID: PMC9311476 DOI: 10.1161/circulationaha.122.059725] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure experience poor health status, including a high burden of symptoms and physical limitations, and poor quality of life. SGLT2 (sodium-glucose cotransporter 2) inhibitors improve health status in chronic heart failure, but their effect on these outcomes in acute heart failure is not well characterized. We investigated the effects of the SGLT2 inhibitor empagliflozin on symptoms, physical limitations, and quality of life, using the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the EMPULSE trial (Empagliflozin in Patients Hospitalized With Acute Heart Failure Who Have Been Stabilized). METHODS Patients hospitalized for acute heart failure were randomized to empagliflozin 10 mg daily or placebo for 90 days. The KCCQ was assessed at randomization and 15, 30, and 90 days. The effects of empagliflozin on the primary end point of clinical benefit (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in KCCQ Total Symptom Score [TSS] change from baseline to 90 days) were examined post hoc across the tertiles of baseline KCCQ-TSS. In prespecified analyses, changes (randomization to day 90) in KCCQ domains, including TSS, physical limitations, quality of life, clinical summary, and overall summary scores were evaluated using a repeated measures model. RESULTS In total, 530 patients were randomized (265 each arm). Baseline KCCQ-TSS was low overall (mean [SD], 40.8 [24.0] points). Empagliflozin-treated patients experienced greater clinical benefit across the range of KCCQ-TSS, with no treatment effect heterogeneity (win ratio [95% CIs] from lowest to highest tertile: 1.49 [1.01-2.20], 1.37 [0.94-1.99], and 1.48 [1.00-2.20], respectively; P for interaction=0.94). Beneficial effects of empagliflozin on health status were observed as early as 15 days and persisted through 90 days, at which point empagliflozin-treated patients experienced a greater improvement in KCCQ TSS, physical limitations, quality of life, clinical summary, and overall summary (placebo-adjusted mean differences [95% CI]: 4.45 [95% CI, 0.32-8.59], P=0.03; 4.80 [95% CI, 0.00-9.61], P=0.05; 4.66 [95% CI, 0.32-9.01], P=0.04; 4.85 [95% CI, 0.77-8.92], P=0.02; and 4.40 points [95% CI, 0.33-8.48], P=0.03, respectively). CONCLUSIONS Initiation of empagliflozin in patients hospitalized for acute heart failure produced clinical benefit regardless of the degree of symptomatic impairment at baseline, and improved symptoms, physical limitations, and quality of life, with benefits seen as early as 15 days and maintained through 90 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT0415775.
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Affiliation(s)
- Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Germany (C.E.A.)
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN (S.P.C.).,Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville (S.P.C.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, The Institute of Biomedical Research of Bellvitge (IDIBELL), Barcelona, Spain (J.C.-C.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F.).,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (R.J.M.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.)
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (J.T.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.B.).,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (J.P.B.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.).,Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (A.A.V.)
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27
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Wang N, Hales S, Gallagher R, Tofler G. Predictors and outcomes of quality of life in elderly patients with heart failure. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 19:100188. [PMID: 38558866 PMCID: PMC10978342 DOI: 10.1016/j.ahjo.2022.100188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 04/04/2024]
Abstract
Study objective This study aims to identify predictors of health related quality of life (HRQoL) among patients with heart failure (HF) and assess whether HRQoL was a predictor of rehospitalisation and mortality, and if age influenced the findings. Design Observational cohort study. Setting Seven hospitals in the Northern Sydney Local Health District, Sydney, Australia. Participants Community dwelling patients who completed a Minnesota Living with HF questionnaire (MLHFQ) within 30 days of discharge after a HF hospitalisation. Main outcome measure Multivariable linear regression models were used to identify predictors of MLHFQ scores (higher score = worse HRQoL) and adjusted Cox regression models to assess the impact of MLHFQ scores on one-year rehospitalisation and mortality. Separate analyses were conducted for those aged ≤80 or >80 years. Results 1911 patients of mean age 79 years (57 % aged >80 years) were included in this analysis. Among those aged ≤80 years; younger age, lower haemoglobin and presenting symptoms at hospitalisation of exertional dyspnoea, peripheral oedema and fatigue were predictors of worse post-discharge MLHFQ scores. In patients aged >80 years, living alone, chronic kidney disease, exertional dyspnoea and peripheral oedema were predictors of worse MLHFQ scores. Worse MLHFQ scores predicted one-year HF readmissions in those aged >80 years (HR 1.22, 95 % CI 1.07-1.37) but not those aged ≤80 years (HR 0.90 95 % CI 0.71-1.10). Conclusions In-hospital predictors can be identified for worse HRQoL post-discharge for HF. These vary according to age, and should be addressed prior to discharge.
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Affiliation(s)
- Nelson Wang
- Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, Sydney, Australia
- The George Institute for Global Health, UNSW, Sydney, Australia
| | | | | | - Geoffrey Tofler
- Sydney Medical School, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
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28
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Quality of Life in Older Patients after a Heart Failure Hospitalization: Results from the SENECOR Study. J Clin Med 2022; 11:jcm11113035. [PMID: 35683423 PMCID: PMC9181457 DOI: 10.3390/jcm11113035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Information about health-related quality of life (HRQoL) in heart failure (HF) in older adults is scarce. Methods: We aimed to describe the HRQoL of the SENECOR study cohort, a single-center, randomized trial comparing the effects of multidisciplinary intervention by a geriatrician and a cardiologist (intervention group) to that of a cardiologist alone (control group) in older patients with a recent HF hospitalization. Results: HRQoL was assessed by the short version of the disease-specific Kansas Cardiomyopathy Questionnaire (KCCQ-12) in 141 patients at baseline and was impaired (KCCQ-12 < 75) in almost half of the cohort. Women comprised 50% of the population, the mean age was 82.2 years, and two-thirds of patients had preserved ejection fraction. Comorbidities were highly prevalent. Patients with impaired HRQoL had a worse NYHA functional class, a lower NT-proBNP, a lower Barthel index, and a higher Clinical Frailty Scale. One-year all-cause mortality was 22.7%, significantly lower in the group with good-to-excellent HRQoL (14.5% vs. 30.6%; hazard ratio 0.28; 95% confidence interval 0.10−0.78; p = 0.014). In the group with better HRQoL, all-cause hospitalization was lower, and there was a trend towards lower HF hospitalization. Conclusions: The KCCQ-12 questionnaire can provide inexpensive prognostic information even in older patients with HF. (Funded by grant Primitivo de la Vega, Fundación MAPFRE. ClinicalTrials number, NCT03555318).
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29
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Völler H, Bindl D, Nagels K, Hofmann R, Vettorazzi E, Wegscheider K, Fleck E, Störk S, Nagel E. The First Year of Noninvasive Remote Telemonitoring in Chronic Heart Failure Is not Cost Saving but Improves Quality of Life: The Randomized Controlled CardioBBEAT Trial. Telemed J E Health 2022; 28:1613-1622. [PMID: 35325562 PMCID: PMC9700331 DOI: 10.1089/tmj.2022.0021] [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: 01/11/2022] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Remote telemonitoring (RTM) for patients with chronic heart failure (HF) holds promise to improve prognosis and well-being beyond the standard of care (SoC). The CardioBBEAT trial assessed the health economic and clinical impact of an interactive bidirectional RTM system (Motiva®) versus SoC for patients with HF and a reduced ejection fraction (HFrEF), in Germany. Methods: This multicenter, randomized controlled trial enrolled 621 patients with HFrEF (mean age 63.0 ± 11.5 years, 88% men). The primary endpoint was the integrated effect of the intervention on total costs and nonhospitalized days alive after 12 months, reported as incremental cost-effectiveness ratio (ICER). Costs (in k€) were based on actual charges of patients' statutory health insurance. Among secondary outcome measures were mortality and disease-specific quality of life. Results: We found a neutral effect on nonhospitalized days alive (RTM mean 341 ± 59 days, SoC 346 ± 45 days; p = 0.298) associated with increased total costs (RTM 18.5 ± 39.5 k€, SoC 12.8 ± 22.0 k€; p = 0.046). This yielded an ICER of -1.15 k€/day. RTM did not impact mortality risk. All quality of life scales were consistently and meaningfully improved in the RTM group at 12 months compared to SoC (all p < 0.01). Conclusions: The first 12 months of RTM were not cost-effective compared to SoC in patients with HFrEF, but associated with a relevant improvement in disease-specific quality of life. The balanced assessment of the potential benefit of RTM requires integration of both the societal and patient perspective. ClinTrials.gov (NCT02293252).
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Affiliation(s)
- Heinz Völler
- Center of Rehabilitation Research, University of Potsdam, Potsdam, Germany
- Klinik am See, Rüdersdorf, Germany
| | - Dominik Bindl
- Chair of Healthcare Management and Health Services Research, University of Bayreuth, Bayreuth, Germany
| | - Klaus Nagels
- Chair of Healthcare Management and Health Services Research, University of Bayreuth, Bayreuth, Germany
| | - Reiner Hofmann
- Chair of Healthcare Management and Health Services Research, University of Bayreuth, Bayreuth, Germany
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Eckart Fleck
- German Heart Institute Berlin, University of Berlin, Berlin, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Germany, Würzburg, Germany
| | - Eckhard Nagel
- Institute for Healthcare Management and Health Science, University of Bayreuth, Bayreuth, Germany
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30
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Lewis GD, Docherty KF, Voors AA, Cohen-Solal A, Metra M, Whellan DJ, Ezekowitz JA, Ponikowski P, Böhm M, Teerlink JR, Heitner SB, Kupfer S, Malik FI, Meng L, Felker GM. Developments in Exercise Capacity Assessment in Heart Failure Clinical Trials and the Rationale for the Design of METEORIC-HF. Circ Heart Fail 2022; 15:e008970. [PMID: 35236099 DOI: 10.1161/circheartfailure.121.008970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a highly morbid condition for which exercise intolerance is a major manifestation. However, methods to assess exercise capacity in HFrEF vary widely in clinical practice and in trials. We describe advances in exercise capacity assessment in HFrEF and a comparative analysis of how various therapies available for HFrEF impact exercise capacity. Current guideline-directed medical therapy has indirect effects on cardiac performance with minimal impact on measured functional capacity. Omecamtiv mecarbil is a novel selective cardiac myosin activator that directly increases cardiac contractility and in a phase 3 cardiovascular outcomes study significantly reduced the primary composite end point of time to first heart failure event or cardiovascular death in patients with HFrEF. The objective of the METEORIC-HF trial (Multicenter Exercise Tolerance Evaluation of Omecamtiv Mecarbil Related to Increased Contractility in Heart Failure) is to assess the effect of omecamtiv mecarbil versus placebo on multiple components of functional capacity in HFrEF. The primary end point is to test the effect of omecamtiv mecarbil compared with placebo on peak oxygen uptake as measured by cardiopulmonary exercise testing after 20 weeks of treatment. METEORIC-HF will provide state-of-the-art assessment of functional capacity by measuring ventilatory efficiency, circulatory power, ventilatory anaerobic threshold, oxygen uptake recovery kinetics, daily activity, and quality-of-life assessment. Thus, the METEORIC-HF trial will evaluate the potential impact of increased myocardial contractility with omecamtiv mecarbil on multiple important measures of functional capacity in ambulatory patients with symptomatic HFrEF. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT03759392.
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Affiliation(s)
- Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston (G.D.L.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (K.F.D.)
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, the Netherlands (A.A.V.)
| | - Alain Cohen-Solal
- Paris University, UMR-S 942, Department of Cardiology, Lariboisiere Hospital, Assistance Publique Hopitaux de Paris, France (A.C.-S.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.M.)
| | - David J Whellan
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA (D.J.W.)
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Michael Böhm
- Department of Internal Medicine, Saarland University, Homburg, Germany. (M.B.).,Department of Cardiology, Saarland University, Homburg, Germany. (M.B.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and University of California San Francisco (J.R.T.)
| | - Stephen B Heitner
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Stuart Kupfer
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Fady I Malik
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Lisa Meng
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - G Michael Felker
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, NC (G.M.F.)
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31
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Spertus JA, Birmingham MC, Nassif M, Damaraju CV, Abbate A, Butler J, Lanfear DE, Lingvay I, Kosiborod MN, Januzzi JL. The SGLT2 inhibitor canagliflozin in heart failure: the CHIEF-HF remote, patient-centered randomized trial. Nat Med 2022; 28:809-813. [PMID: 35228753 PMCID: PMC9018422 DOI: 10.1038/s41591-022-01703-8] [Citation(s) in RCA: 113] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/13/2022] [Indexed: 02/07/2023]
Abstract
Large traditional clinical trials suggest that sodium-glucose co-transporter 2 inhibitors improve symptoms in patients with heart failure and reduced ejection fraction (HFrEF) and in patients with heart failure and preserved ejection fraction (HFpEF). In the midst of the Coronavirus Disease 2019 pandemic, we sought to confirm these benefits in a new type of trial that was patient centered and conducted in a completely remote fashion. In the CHIEF-HF trial ( NCT04252287 ), 476 participants with HF, regardless of EF or diabetes status, were randomized to 100 mg of canagliflozin or placebo. Enrollment was stopped early due to shifting sponsor priorities, without unblinding. The primary outcome was change in the Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ TSS) at 12 weeks. The 12-week change in KCCQ TSS was 4.3 points (95% confidence interval, 0.8-7.8; P = 0.016) higher with canagliflozin than with placebo, meeting the primary endpoint. Similar effects were observed in participants with HFpEF and in those with HFrEF and in participants with and without diabetes, demonstrating that canagliflozin significantly improves symptom burden in HF, regardless of EF or diabetes status. This randomized, double-blind trial, conducted without in-person interactions between doctor and patient, can serve as a model for future all-virtual clinical trials.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO, USA.
| | | | - Michael Nassif
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO, USA
| | - C V Damaraju
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Antonio Abbate
- Wright Center for Clinical and Translation Research and Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO, USA
| | - James L Januzzi
- Massachusetts General Hospital, Harvard Medical School and Baim Institute for Clinical Research, Boston, MA, USA
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32
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Fezza GC, Sansone S, Nolan RP. Therapeutic components of digital counseling for chronic heart failure. Front Psychiatry 2022; 13:888524. [PMID: 36339841 PMCID: PMC9631313 DOI: 10.3389/fpsyt.2022.888524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Task force statements support the use of cognitive behavioral therapy (CBT) and motivational interviewing (MI) to promote self-care in chronic heart failure (CHF) patients. Digital counseling interventions have the potential to complement conventional programs. However, therapeutic components of digital programs associated with improved outcomes are not clearly established. OBJECTIVE Identify therapeutic components of the Canadian e-Platform to Promote Behavioral Self-Management in Chronic Heart Failure (CHF-CePPORT) protocol that were associated with improved health-related quality of life (HRQL). MATERIALS AND METHODS Ordinal logistic regression was used to identify therapeutic components of the CHF-CePPORT protocol. The primary outcome was the 12-month Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) tertile. Logistic regressions determined the association between 12-month KCCQ-OS tertile, using logon hours for key segments of the protocol, modality of content delivery, and clinical themes. RESULTS A total of 117 patients were enrolled in the e-Counseling arm of the CHF-CePPORT trial. Median age was 60 years (IQR 52-69). Total logon hours in the initial 4-month segment of CHF-CePPORT (Sessions 1-16) was associated with increased 12-month KCCQ-OS tertile (Odds Ratio, OR = 1.31, 95% CI, 1.1-1.5, P = 0.001). Within sessions 1-16, improved KCCQ-OS was associated with logon hours for self-assessment tools/trackers (OR = 1.49, 95% CI, 1.1-2.0, P = 0.007), and videos (OR = 1.57, 95% CI, 1.03-2.4, P = 0.04), but not for CHF information pages. CONCLUSION This study highlights the importance of using evidence-based guidelines from CBT and MI as core components of digital counseling, delivered through videos and interactive tools/trackers, to improve HRQL with CHF.
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Affiliation(s)
- Gabriel C Fezza
- Behavioral Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Health, York University, Toronto, ON, Canada
| | - Stephanie Sansone
- Behavioral Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Health, York University, Toronto, ON, Canada
| | - Robert P Nolan
- Behavioral Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Ted Rogers Centre for Heart Research, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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DeVore AD, Hill CL, Thomas LE, Albert NM, Butler J, Patterson JH, Hernandez AF, Williams FB, Shen X, Spertus JA, Fonarow GC. Identifying patients at increased risk for poor outcomes from heart failure with reduced ejection fraction: the PROMPT-HF risk model. ESC Heart Fail 2021; 9:178-185. [PMID: 34791838 PMCID: PMC8787961 DOI: 10.1002/ehf2.13709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/04/2021] [Accepted: 10/29/2021] [Indexed: 01/14/2023] Open
Abstract
Aims We aimed to develop a risk prediction tool that incorporated both clinical events and worsening health status for patients with heart failure (HF) with reduced ejection fraction (HFrEF). Identifying patients with HFrEF at increased risk of a poor outcome may enable proactive interventions that improve outcomes. Methods and results We used data from a longitudinal HF registry, CHAMP‐HF, to develop a risk prediction tool for poor outcomes over the next 6 months. A poor outcome was defined as death, an HF hospitalization, or a ≥20‐point decrease (or decrease below 25) in 12‐item Kansas City Cardiomyopathy Questionnaire (KCCQ‐12) overall summary score. Among 4546 patients in CHAMP‐HF, 1066 (23%) experienced a poor outcome within 6 months (1.3% death, 11% HF hospitalization, and 11% change in KCCQ‐12). The model demonstrated moderate discrimination (c‐index = 0.65) and excellent calibration with observed data. The following variables were associated with a poor outcome: age, race, education, New York Heart Association class, baseline KCCQ‐12, atrial fibrillation, coronary disease, diabetes, chronic kidney disease, smoking, prior HF hospitalization, and systolic blood pressure. We also created a simplified model with a 0–10 score using six variables (New York Heart Association class, KCCQ‐12, coronary disease, chronic kidney disease, prior HF hospitalization, and systolic blood pressure) with similar discrimination (c‐index = 0.63). Patients scoring 0–3 were considered low risk (event rate <20%), 4–6 were considered intermediate risk (event rate 20–40%), and 7–10 were considered high risk (event rate >40%). Conclusions The PROMPT‐HF risk model can identify outpatients with HFrEF at increased risk of poor outcomes, including clinical events and health status deterioration. With further validation, this model may help inform therapeutic decision making.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Claude Larry Hill
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA
| | - Laine E Thomas
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Tran AT, Fonarow GC, Arnold SV, Jones PG, Thomas LE, Hill CL, DeVore AD, Butler J, Albert NM, Spertus JA. Risk Adjustment Model for Preserved Health Status in Patients With Heart Failure and Reduced Ejection Fraction: The CHAMP-HF Registry. Circ Cardiovasc Qual Outcomes 2021; 14:e008072. [PMID: 34615366 DOI: 10.1161/circoutcomes.121.008072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Health status outcomes are increasingly being promoted as measures of health care quality, given their importance to patients. In heart failure (HF), an American College of Cardiology/American Heart Association Task Force proposed using the proportion of patients with preserved health status as a quality measure but not as a performance measure because risk adjustment methods were not available. METHODS We built risk adjustment models for alive with preserved health status and for preserved health status alone in a prospective registry of outpatients with HF with reduced ejection fraction across 146 US centers between December 2015 and October 2017. Preserved health status was defined as not having a ≥5-point decrease in the Kansas City Cardiomyopathy Questionnaire Overall Summary score at 1 year. Using only patient-level characteristics, hierarchical multivariable logistic regression models were developed for 1-year outcomes and validated using data from 1 to 2 years. We examined model calibration, discrimination, and variability in sites' unadjusted and adjusted rates. RESULTS Among 3932 participants (median age [interquartile range] 68 years [59-75], 29.7% female, 75.4% White), 2703 (68.7%) were alive with preserved health status, 902 (22.9%) were alive without preserved health status, and 327 (8.3%) had died by 1 year. The final risk adjustment model for alive with preserved health status included baseline Kansas City Cardiomyopathy Questionnaire Overall Summary, age, race, employment status, annual income, body mass index, depression, atrial fibrillation, renal function, number of hospitalizations in the past 1 year, and duration of HF (optimism-corrected C statistic=0.62 with excellent calibration). Similar results were observed when deaths were ignored. The risk standardized proportion of patients alive with preserved health status across the 146 sites ranged from 62% at the 10th percentile to 75% at the 90th percentile. Variability across sites was modest and changed minimally with risk adjustment. CONCLUSIONS Through leveraging data from a large, outpatient, observational registry, we identified key factors to risk adjust sites' proportions of patients with preserved health status. These data lay the foundation for building quality measures that quantify treatment outcomes from patients' perspectives.
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Affiliation(s)
- Andy T Tran
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.T.T., S.V.A., P.G.J., J.A.S.).,University of Missouri-Kansas City (A.T.T., S.V.A., P.G.J., J.A.S.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center (G.C.F.)
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.T.T., S.V.A., P.G.J., J.A.S.).,University of Missouri-Kansas City (A.T.T., S.V.A., P.G.J., J.A.S.)
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.T.T., S.V.A., P.G.J., J.A.S.).,University of Missouri-Kansas City (A.T.T., S.V.A., P.G.J., J.A.S.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (L.E.T., C.L.H., A.D.D.)
| | - C Larry Hill
- Duke Clinical Research Institute, Durham, NC (L.E.T., C.L.H., A.D.D.)
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (L.E.T., C.L.H., A.D.D.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D.)
| | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure-Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH (N.M.A.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (A.T.T., S.V.A., P.G.J., J.A.S.).,University of Missouri-Kansas City (A.T.T., S.V.A., P.G.J., J.A.S.)
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Hu D, Liu J, Zhang L, Bai X, Tian A, Huang X, Zhou K, Gao M, Ji R, Miao F, Li J, Li W, Ge J, He G, Li J. Health Status Predicts Short- and Long-Term Risk of Composite Clinical Outcomes in Acute Heart Failure. JACC-HEART FAILURE 2021; 9:861-873. [PMID: 34509406 DOI: 10.1016/j.jchf.2021.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES This study aims to examine the association between the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 score and the 30-day and 1-year rates of composite events of cardiovascular death and heart failure (HF) rehospitalization in patients with acute HF. BACKGROUND Few studies reported the prognostic effects of KCCQ in acute HF. METHODS This study prospectively enrolled adult patients hospitalized for HF from 52 hospitals in China and collected the KCCQ-12 score within 48 hour of index admission. The study used multivariable Cox regression to examine the association between KCCQ-12 score and 30-day and 1-year composite events and was further stratified by new-onset HF and acutely decompensated chronic heart failure (ADCHF). Subgroup analyses were performed to explore the potential heterogeneity. The study evaluated the incremental prognostic value of KCCQ-12 score over N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and established risk scores by C-statistics, net reclassification improvement, and integrated discrimination improvement. RESULTS Among 4,898 patients, 29.4% had new-onset HF. After adjustment, each 10-point decrease in the KCCQ-12 score was associated with a 13% increase in 30-day risk and a 7% increase in 1-year risk. The associations were consistent regardless of new-onset HF or ADCHF, age, sex, left ventricular ejection fraction, New York Heart Association functional class, NT-proBNP level, comorbidities, and renal function. Adding KCCQ-12 score to NT-proBNP and established risk scores significantly improved prognostic capabilities measured by C-statistics, net reclassification improvement, and integrated discrimination improvement. CONCLUSIONS In acute HF, a poor KCCQ-12 score predicted short- and long-term risks of cardiovascular death and HF rehospitalization. KCCQ-12 could serve as a convenient tool for rapid initial risk stratification and provide additional prognostic value over NT-proBNP and established risk scores.
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Affiliation(s)
- Danli Hu
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Jiamin Liu
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Lihua Zhang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Xueke Bai
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Aoxi Tian
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Xinghe Huang
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Ke Zhou
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, People's Republic of China
| | - Min Gao
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Runqing Ji
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Fengyu Miao
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Jiaying Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Wei Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Jinzhuo Ge
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Guangda He
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, NHC Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, People's Republic of China; Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China.
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Prognostic Importance of Health Status Versus Functional Status in Heart Failure and Secondary Mitral Regurgitation. JACC-HEART FAILURE 2021; 9:684-692. [PMID: 34391740 DOI: 10.1016/j.jchf.2021.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study sought to understand the extent to which health status and exercise capacity are independently associated with long-term outcomes in patients with heart failure (HF) and secondary mitral regurgitation (MR). BACKGROUND Secondary MR in patients with HF leads to impaired health status (Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS]) and exercise capacity (6-minute walk distance [6MWD]), both of which improve after transcatheter mitral valve repair (TMVr). METHODS The study used data from the COAPT trial (N = 604) to examine the association of baseline KCCQ-OS and 6MWD with 2-year mortality and HF hospitalization, adjusting for treatment arm and patient factors. We also examined the association of change in KCCQ-OS and 6MWD from baseline to 1 month with risk of outcomes from 1 month to 2 years. Interactions of KCCQ-OS and 6MWD with treatment assignment were explored. RESULTS Mean baseline KCCQ-OS was 53 ± 23 points, and 6MWD was 240 ± 125 meters. In models including both measures, greater baseline 6MWD (but not KCCQ-OS) was associated with reduced 2-year mortality (HR per 125 meters: 0.75, 95% CI: 0.61-0.92). When stratified by treatment group, both baseline KCCQ-OS and 6MWD were independently associated with HF hospitalization in patients treated with medical therapy, whereas only KCCQ-OS was associated with HF hospitalization in patients treated with TMVr. In separate analyses, 1-month improvements in KCCQ-OS and 6MWD were each associated with lower subsequent risk of mortality and HF hospitalization, independent of treatment group. CONCLUSIONS Among patients with HF and severe secondary MR, assessment of both health status and exercise capacity provide complementary prognostic information for patients with HF and severe secondary MR-both before and after TMVr. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial]; NCT01626079).
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Parizo JT, Goldhaber-Fiebert JD, Salomon JA, Khush KK, Spertus JA, Heidenreich PA, Sandhu AT. Cost-effectiveness of Dapagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:926-935. [PMID: 34037681 DOI: 10.1001/jamacardio.2021.1437] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, dapagliflozin was shown to reduce cardiovascular mortality and hospitalizations due to heart failure while improving patient-reported health status. However, the cost-effectiveness of adding dapagliflozin therapy to standard of care (SOC) is unknown. Objective To estimate the cost-effectiveness of dapagliflozin therapy among patients with chronic heart failure with reduced ejection fraction (HFrEF). Design, Setting, and Participants This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, and utilities from the DAPA-HF trial and other published literature. Costs were derived from published sources. Patients with HFrEF included subgroups based on diabetes status and health status impairment due to heart failure. We compiled parameters from the literature including DAPA-HF, on which our model is based, and many other sources from December 2019 to February 27, 2021. We performed our analysis in February 2021. Exposures Dapagliflozin or SOC. Main Outcomes and Measures Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), costs, and the cost per QALY gained (incremental cost-effectiveness ratio). Results In the model, dapagliflozin therapy yielded a mean of 0.78 additional life-years and 0.46 additional QALYs compared with SOC at an incremental cost of $38 212, resulting in a cost per QALY gained of $83 650. The cost per QALY was similar for patients with or without diabetes and for patients with mild or moderate impairment of health status due to heart failure. The cost-effectiveness was most sensitive to estimates of the effect on mortality and duration of therapy effectiveness. If the cost of dapagliflozin decreased from $474 to $270 (43% decline), the cost per QALY gained would drop below $50 000. Conclusions and Relevance These findings suggest that dapagliflozin provides intermediate value compared with SOC, based on American College of Cardiology/American Heart Association benchmarks. Additional data regarding the magnitude of mortality reduction would improve the precision of cost-effectiveness estimates.
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Affiliation(s)
- Justin T Parizo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Joshua A Salomon
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, The Freeman Spogli Institute, Department of Medicine, Stanford University, Stanford, California
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - John A Spertus
- St Luke's Mid America Heart Institute, University of Missouri-Kansas City
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.,Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Magnusson P, Mattsson G, Wallhagen M, Karlsson J. Health-related quality of life in patients with implantable cardioverter defibrillators in Sweden: a cross-sectional observational trial. BMJ Open 2021; 11:e047053. [PMID: 34244266 PMCID: PMC8273444 DOI: 10.1136/bmjopen-2020-047053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Decisions regarding implantable cardioverter defibrillators (ICDs) must consider information about presumed health-related quality of life (HRQL). The purpose of the study was to assess HRQL in patients with ICD and compare it to a Swedish age-matched and sex-matched population. DESIGN Cross-sectional observational trial. SETTING Swedish ICD cohort. INTERVENTIONS Short form 36 (SF-36) questionnaires from ICD recipients implanted 2007-2017 (response rate 77.2%) were analysed using Mann-Whitney U test and effect size (ES). RESULTS In total, 223 patients (mean age 71.1±9.7 years, 82.1% men) were included. In most SF-36 domains (physical functioning (PF), role physical, general health (GH), vitality, social functioning and mental health), the score for patients with ICD was significantly lower (ES range 0.23-0.41, ie, small difference) than norms, except for bodily pain and role emotional. Both the physical component summary (PCS) and the mental component summary (MCS) scores had ES=0.31. Men and women had similar scores. Primary and secondary prevention patients scored similarly, except for worse GH in primary prevention (p=0.016, ES=0.35). Atrial fibrillation was associated with worse PF (ES=0.41) and PCS (ES=0.38). Appropriate therapy, inappropriate shock or complications requiring surgery were not associated with lower scores in any domain. In primary prevention due to ischaemic versus non-ischaemic cardiomyopathy, no domain was significantly different. PCS decreased with higher age strata (p=0.002) in contrast to MCS (p=0.986). CONCLUSIONS Patients with ICDs have lower physical and mental HRQL than age-matched and sex-matched norms; however, the ESs are small. HRQL is similar regardless of sex, primary/secondary prevention indication, appropriate therapy, inappropriate shock or complications, but decreases with advancing age.
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Affiliation(s)
- Peter Magnusson
- Institution of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Centre for Resarch and Development Region Gävleborg, Uppsala University, Gävle, Sweden
- Faculty of Health and Occupational Studies, Department of Caring Sciences, University of Gävle, Gävle, Sweden
| | - Gustav Mattsson
- Centre for Resarch and Development Region Gävleborg, Uppsala University, Gävle, Sweden
| | - Marita Wallhagen
- Faculty of Engineering and Sustainable Development; Department of Building, Energy and Sustainability Science, University of Gävle, Gävle, Sweden
| | - Jan Karlsson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Spertus JA, Fine JT, Elliott P, Ho CY, Olivotto I, Saberi S, Li W, Dolan C, Reaney M, Sehnert AJ, Jacoby D. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): health status analysis of a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2021; 397:2467-2475. [PMID: 34004177 DOI: 10.1016/s0140-6736(21)00763-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Improving symptoms is a primary treatment goal in patients with obstructive hypertrophic cardiomyopathy. Currently available pharmacological options for hypertrophic cardiomyopathy are not disease-specific and are often inadequate or poorly tolerated. We aimed to assess the effect of mavacamten, a first-in-class cardiac myosin inhibitor, on patients' health status-ie, symptoms, physical and social function, and quality of life. METHODS We did a health status analysis of EXPLORER-HCM, a phase 3, double-blind, randomised, placebo-controlled trial. The study took place at 68 clinical cardiovascular centres in 13 countries. Adult patients (≥18 years) with symptomatic obstructive hypertrophic cardiomyopathy (gradient ≥50 mm Hg and New York Heart Association class II-III) were randomly assigned (1:1) to mavacamten or placebo for 30 weeks, followed by an 8-week washout period. Both patients and staff were masked to study treatment. The primary outcome for this secondary analysis was the Kansas City Cardiomyopathy Questionnaire (KCCQ), a well validated disease-specific measure of patients' health status. It was administered at baseline and weeks 6, 12, 18, 30 (end of treatment), and 38 (end of study). Changes from baseline to week 30 in KCCQ overall summary (OS) score and all subscales were analysed using mixed model repeated measures. This study is registered with ClinicalTrials.gov, NCT03470545. FINDINGS Between May 30, 2018, and July 12, 2019, 429 adults were assessed for eligibility, of whom 251 (59%) were enrolled and randomly assigned. Of 123 patients randomly assigned to mavacamten, 92 (75%) completed the KCCQ at baseline and week 30 and of the 128 patients randomly assigned to placebo 88 (69%) completed the KCCQ at baseline and week 30. At 30 weeks, the change in KCCQ-OS score was greater with mavacamten than placebo (mean score 14·9 [SD 15·8] vs 5·4 [13·7]; difference +9·1 [95% CI 5·5-12·8]; p<0·0001), with similar benefits across all KCCQ subscales. The proportion of patients with a very large change (KCCQ-OS ≥20 points) was 36% (33 of 92) in the mavacamten group versus 15% (13 of 88) in the placebo group, with an estimated absolute difference of 21% (95% CI 8·8-33·4) and number needed to treat of five (95% CI 3-11). These gains returned to baseline after treatment was stopped. INTERPRETATION Mavacamten markedly improved the health status of patients with symptomatic obstructive hypertrophic cardiomyopathy compared with placebo, with a low number needed to treat for marked improvement. Given that the primary goals of treatment are to improve symptoms, physical and social function, and quality of life, mavacamten represents a new potential strategy for achieving these goals. FUNDING MyoKardia, a Bristol Myers Squibb company.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA.
| | - Jennifer T Fine
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Perry Elliott
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Carolyn Y Ho
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Wanying Li
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | | | | | - Amy J Sehnert
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Michelis KC, Grodin JL, Zhong L, Pandey A, Toto K, Ayers CR, Thibodeau JT, Drazner MH. Discordance Between Severity of Heart Failure as Determined by Patient Report Versus Cardiopulmonary Exercise Testing. J Am Heart Assoc 2021; 10:e019864. [PMID: 34180246 PMCID: PMC8403334 DOI: 10.1161/jaha.120.019864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Patient‐reported outcomes may be discordant to severity of illness as assessed by objective parameters. The frequency of this discordance and its influence on clinical outcomes in patients with heart failure is unknown. Methods and Results In HF‐ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training), participants (N=2062) had baseline assessment of health‐related quality of life via the Kansas City Cardiomyopathy Clinical Summary score (KCCQ‐CS) and objective severity by cardiopulmonary stress testing (minute ventilation [VE]/carbon dioxide production [VCO2] slope). We defined 4 groups by median values: 2 concordant (lower severity: high KCCQ‐CS and low VE/VCO2 slope; higher severity: low KCCQ‐CS and high VE/VCO2 slope) and 2 discordant (symptom minimizer: high KCCQ‐CS and high VE/VCO2 slope; symptom magnifier: low KCCQ‐CS and low VE/VCO2 slope). The association of group assignment with mortality was assessed in adjusted Cox models. Symptom magnification (23%) and symptom minimization (23%) were common. Despite comparable KCCQ‐CS scores, the risk of all‐cause mortality in symptom minimizers versus concordant–lower severity participants was increased significantly (hazard ratio [HR], 1.79; 95% CI, 1.27–2.50; P<0.001). Furthermore, despite symptom magnifiers having a KCCQ‐CS score 28 points lower (poorer QOL) than symptom minimizers, their risk of mortality was not increased (HR, 0.79; 95% CI, 0.57–1.1; P=0.18, respectively). Conclusions Severity of illness by patient report versus cardiopulmonary exercise testing was frequently discordant. Mortality tracked more closely with the objective data, highlighting the importance of relying not only on patient report, but also objective data when risk stratifying patients with heart failure.
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Affiliation(s)
- Katherine C Michelis
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Justin L Grodin
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Lin Zhong
- Division of Bioinformatics Department of Clinical Sciences University of Texas Southwestern Medical Center Dallas TX
| | - Ambarish Pandey
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Kathleen Toto
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Colby R Ayers
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Jennifer T Thibodeau
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Mark H Drazner
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
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Garcia RA, Benton MC, Spertus JA. Patient-Reported Outcomes in Patients with Cardiomyopathy. Curr Cardiol Rep 2021; 23:91. [PMID: 34121150 DOI: 10.1007/s11886-021-01511-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW As medicine strives to become more patient-centered, patient-reported outcomes (PROs) are often used to describe patients' symptoms, function, and quality of life. This review describes the key concepts of PROs specific to heart failure in clinical trials and their potential role in clinical practice. RECENT FINDINGS As the Food and Drug Administration has increasingly emphasized how it values PROs as clinical outcome assessments, including its recent qualification of the Kansas City Cardiomyopathy Questionnaire (KCCQ), clinical trials have increasingly used them to evaluate novel therapies. This has been enhanced by an increasing understanding of how to interpret KCCQ scores. Its use in clinical practice, including the importance of providers sharing results with their patients, is just emerging. PROs provide unique insights into the benefits of treatment from patients' perspectives and while their role in clinical care is just beginning, they offer an important opportunity to improve the patient-centeredness of care.
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Affiliation(s)
- Raul Angel Garcia
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO, 64111, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mary C Benton
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO, 64111, USA.,University of Missouri-Kansas City, Kansas City, MO, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO, 64111, USA. .,University of Missouri-Kansas City, Kansas City, MO, USA.
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Greene SJ, Butler J, Spertus JA, Hellkamp AS, Vaduganathan M, DeVore AD, Albert NM, Duffy CI, Patterson JH, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Comparison of New York Heart Association Class and Patient-Reported Outcomes for Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:522-531. [PMID: 33760037 DOI: 10.1001/jamacardio.2021.0372] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance It is unclear how New York Heart Association (NYHA) functional class compares with patient-reported outcomes among patients with heart failure (HF) in contemporary US clinical practice. Objective To characterize longitudinal changes and concordance between NYHA class and the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS), and their associations with clinical outcomes. Design, Setting, and Participants This cohort study included 2872 US outpatients with chronic HF with reduced ejection fraction across 145 practices enrolled in the CHAMP-HF registry between December 2015 and October 2017. All patients had complete NYHA class and KCCQ-OS data at baseline and 12 months. Longitudinal changes and correlations between the 2 measure were examined. Multivariable models landmarked at 12 months evaluated associations between improvement in NYHA and KCCQ-OS from baseline to 12 months with clinical outcomes occurring from months 12 through 24. Statistical analyses were performed from March to August 2020. Exposure Change in health status, as defined by 12-month change in NYHA class or KCCQ-OS. Main Outcomes and Measures All-cause mortality, HF hospitalization, and mortality or HF hospitalization. Results In total, 2872 patients were included in this analysis (median [interquartile range] age, 68 [59-75] years; 872 [30.4%] were women; and 2156 [75.1%] were of White race). At baseline, 312 patients (10.9%) were NYHA class I, 1710 patients (59.5%) were class II, 804 patients (28.0%) were class III, and 46 patients (1.6%) were class IV. For KCCQ-OS, 1131 patients (39.4%) scored 75 to 100 (best health status), 967 patients (33.7%) scored 50 to 74, 612 patients (21.3%) scored 25 to 49, and 162 patients (5.6%) scored 0 to 24 (worst health status). At 12 months, 1002 patients (34.9%) had a change in NYHA class (599 [20.9%] with improvement; 403 [14.0%] with worsening) and 2158 patients (75.1%) had a change of 5 or more points in KCCQ-OS (1388 [48.3%] with improvement; 770 [26.8%] with worsening). The most common trajectory for NYHA class was no change (1870 [65.1%]), and the most common trajectory for KCCQ-OS was an improvement of at least 10 points (1047 [36.5%]). After adjustment, improvement in NYHA class was not associated with subsequent clinical outcomes, whereas an improvement of 5 or more points in KCCQ-OS was independently associated with decreased mortality (hazard ratio, 0.59; 95% CI, 0.44-0.80; P < .001) and mortality or HF hospitalization (hazard ratio, 0.73; 95% CI, 0.59-0.89; P = .002). Conclusions and Relevance Findings of this cohort study suggest that, in contemporary US clinical practice, compared with NYHA class, KCCQ-OS is more sensitive to clinically meaningful changes in health status over time. Changes in KCCQ-OS may have more prognostic value than changes in NYHA class.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City
| | | | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M Albert
- Nursing Institute and Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina.,Assistant Editor for Statistics, JAMA Cardiology
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.,Associate Editor, JAMA Cardiology
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles.,Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
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Johansson I, Joseph P, Balasubramanian K, McMurray JJV, Lund LH, Ezekowitz JA, Kamath D, Alhabib K, Bayes-Genis A, Budaj A, Dans ALL, Dzudie A, Probstfield JL, Fox KAA, Karaye KM, Makubi A, Fukakusa B, Teo K, Temizhan A, Wittlinger T, Maggioni AP, Lanas F, Lopez-Jaramillo P, Silva-Cardoso J, Sliwa K, Dokainish H, Grinvalds A, McCready T, Yusuf S. Health-Related Quality of Life and Mortality in Heart Failure: The Global Congestive Heart Failure Study of 23 000 Patients From 40 Countries. Circulation 2021; 143:2129-2142. [PMID: 33906372 DOI: 10.1161/circulationaha.120.050850] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries. METHODS We used the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years. RESULTS The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa [mean± SE, 39.5±0.3], highest in Western Europe [62.5±0.4]). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17-1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 [95% CI, 1.03-1.14]; strongest association in Eastern Europe: HR, 1.31 [95% CI, 1.21-1.42]; interaction P<0.0001). Lower HRQL predicted death in patients with New York Heart Association class I or II and III or IV symptoms (HR, 1.17 [95% CI, 1.14-1.19] and HR, 1.14 [95% CI, 1.12-1.17]; interaction P=0.13) and was a stronger predictor for the composite outcome in New York Heart Association class I or II versus class III or IV (HR 1.15 [95% CI, 1.13-1.17] versus 1.09 [95% CI, [1.07-1.11]; interaction P<0.0001). HR for death was greater in ejection fraction ≥40 versus <40% (HR, 1.23 [95% CI, 1.20-1.26] and HR, 1.15 [95% CI, 1.13-1.17]; interaction P<0.0001). CONCLUSION HRQL is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mildly and severe symptomatic HF, and among patients with preserved and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078166.
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Affiliation(s)
- Isabelle Johansson
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.).,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Canada (S.Y., I.J.)
| | - Philip Joseph
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - Kumar Balasubramanian
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M.)
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden (L.H.L.).,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden (L.H.L.)
| | - Justin A Ezekowitz
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E.)
| | - Deepak Kamath
- Division of Clinical Research and Training, St John's Research Institute, India (D.K.)
| | - Khalid Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.A.)
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (A.B.-G.).,Department of Medicine, Universitat Autonoma Barcelona, CIBERCV, Spain (A.B.-G.)
| | - Andrzej Budaj
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland (A.B.)
| | - Antonio L L Dans
- Department of Cardiac Sciences, University of Philippines, Manila, Philippines (A.L.L.D.)
| | - Anastase Dzudie
- Douala General Hospital, Cameroon (A.D.).,Clinical Research Education, Networking and Consultancy, Douala, Cameroon (A.D.).,Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon (A.D.)
| | | | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Kamilu M Karaye
- Department of Medicine, Aminu Kano Teaching Hospital and Bayero University Kano, Nigeria (K.M.K.)
| | - Abel Makubi
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania (A.M.)
| | - Bianca Fukakusa
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - Koon Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - Ahmet Temizhan
- Ankara City Hospital, Department of Cardiology, University of Health Sciences, Turkey (A.T.)
| | | | - Aldo P Maggioni
- ANMCO Research Center, Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy (A.P.M.)
| | | | - Patricio Lopez-Jaramillo
- Masira Research Institute, UDES, Bucaramanga, Colombia (P.L.-J.).,Facultad de Ciencias de la Salud, UTE, Quito, Ecuador (P.L.-J.)
| | - José Silva-Cardoso
- Faculty of Medicine, University of Porto, Sao Joao University Hospital Centre, Porto, Portugal (J.S.-C.)
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa (K.S.)
| | - Hisham Dokainish
- Echocardiography Laboratory, Circulate Cardiac and Vascular Centre, Burlington, Canada (H.D.)
| | - Alex Grinvalds
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - Tara McCready
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.).,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Canada (S.Y., I.J.)
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Aladin AI, Whellan D, Mentz RJ, Pastva AM, Nelson MB, Brubaker P, Duncan P, Reeves G, Rosenberg P, Kitzman DW. Relationship of physical function with quality of life in older patients with acute heart failure. J Am Geriatr Soc 2021; 69:1836-1845. [PMID: 33837953 DOI: 10.1111/jgs.17156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Older patients with acute decompensated heart failure (ADHF) have severely impaired physical function (PF) and quality of life (QOL). However, relationships between impairments in PF and QOL are unknown but are relevant to clinical practice and trial design. METHODS We assessed 202 consecutive patients hospitalized with ADHF in the multicenter Rehabilitation Therapy in Older Acute HF Patients (REHAB-HF) Trial. PF measures included Short Physical Performance Battery (SPPB) and 6-min walk distance (6MWD). Disease-specific QOL was assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ). General QOL was assessed by the Short Form-12 (SF-12) and EuroQol-5D-5L. PF was evaluated as a predictor of QOL using stepwise regression adjusted for age, sex, race, and New York Heart Association class. RESULTS Participants were 72 ± 8 years, 54% women, 55% minority race, 52% with reduced ejection fraction, and body mass index 33 ± 9 kg/m2 . Participants had severe impairments in PF (6MWD 185 ± 99 m, SPPB 6.0 ± 2.5 units) and disease-specific QOL (KCCQ Overall Score 41 ± 21 and Physical Score 47 ± 24) and general QOL (SF-12 Physical Score 28 ± 9 and EuroQol Visual Analog Scale 57 ± 23). There were modest, statistically significant correlations between 6MWD and KCCQ Overall, KCCQ Physical Limitation, and SF-12 Physical Scores (r = 0.23, p < 0.001; r = 0.30, p < 0.001; and r = 0.24, p = 0.001, respectively); and between SPPB and KCCQ Physical and SF-12 Physical Scores (r = 0.20, p = 0.004, and r = 0.19, p = 0.007, respectively). Both 6MWD and SPPB were correlated with multiple components of the EuroQol-5D-5L. 6MWD was a significant, weak predictor of KCCQ Overall Score and SF-12 Physical Score (estimate = 0.05 ± 0.01, p < 0.001 and estimate = 0.05 ± 0.02, p = 0.012, respectively). SPPB was a significant, weak predictor of KCCQ Physical Score and SF-12 Physical Score (estimate = 1.37 ± 0.66, p = 0.040 and estimate = 0.54 ± 0.25, p = 0.030, respectively). CONCLUSION In older, hospitalized ADHF patients, PF and QOL are both severely impaired but are only modestly related, suggesting that PF and QOL provide complementary information and assessment of both should be considered to fully assess clinically meaningful patient-oriented outcomes.
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Affiliation(s)
- Amer I Aladin
- Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - David Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Amy M Pastva
- Division of Physical Therapy, Duke University School of Medicine, Durham, North Carolina, United States
| | - M Benjamin Nelson
- Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Peter Brubaker
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, North Carolina, United States
| | - Pamela Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - Gordon Reeves
- Novant Health Heart and Vascular Institute, Charlotte, North Carolina, United States
| | - Paul Rosenberg
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dalane W Kitzman
- Section of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
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Lindenfeld J, Abraham WT, Grayburn PA, Kar S, Asch FM, Lim DS, Nie H, Singhal P, Sundareswaran KS, Weissman NJ, Mack MJ, Stone GW. Association of Effective Regurgitation Orifice Area to Left Ventricular End-Diastolic Volume Ratio With Transcatheter Mitral Valve Repair Outcomes: A Secondary Analysis of the COAPT Trial. JAMA Cardiol 2021; 6:427-436. [PMID: 33533873 DOI: 10.1001/jamacardio.2020.7200] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Transcatheter mitral valve repair (TMVr) plus maximally tolerated guideline-directed medical therapy (GDMT) reduced heart failure (HF) hospitalizations (HFHs) and all-cause mortality (ACM) in symptomatic patients with HF and secondary mitral regurgitation (SMR) compared with GDMT alone in the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation (COAPT) trial but not in a similar trial, Multicenter Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR), possibly because the degree of SMR relative to the left ventricular end-diastolic volume index (LVEDVi) was substantially lower. Objective To explore contributions of the degree of SMR using the effective regurgitation orifice area (EROA), regurgitant volume (RV), and LVEDVi to the benefit of TMVr in the COAPT trial. Design, Setting, and Participants This post hoc secondary analysis of the COAPT randomized clinical trial performed December 27, 2012, to June 23, 2017, evaluated a subgroup of COAPT patients (group 1) with characteristics consistent with patients enrolled in MITRA-FR (n = 56) (HF with grade 3+ to 4+ SMR, left ventricular ejection fraction of 20%-50%, and New York Heart Association function class II-IV) compared with remaining (group 2) COAPT patients (n = 492) using the end point of ACM or HFH at 24 months, components of the primary end point, and quality of life (QOL) (per the Kansas City Cardiomyopathy Questionnaire overall summary score) and 6-minute walk distance (6MWD). The same end points were evaluated in 6 subgroups of COAPT by combinations of EROA and LVEDVi and of RV relative to LVEDVi. Interventions Interventions were TMVr plus GDMT vs GDMT alone. Results A total of 548 participants (mean [SD] age, 71.9 [11.2] years; 351 [64%] male) were included. In group 1, no significant difference was found in the composite rate of ACM or HFH between TMVr plus GDMT vs GDMT alone at 24 months (27.8% vs 33.1%, P = .83) compared with a significant difference at 24 months (31.5% vs 50.2%, P < .001) in group 2. However, patients randomized to receive TMVr vs those treated with GDMT alone had significantly greater improvement in QOL at 12 months (mean [SD] Kansas City Cardiomyopathy Questionnaire summary scores: group 1: 18.36 [5.38] vs 0.43 [4.00] points; P = .01; group 2: 16.54 [1.57] vs 5.78 [1.82] points; P < .001). Group 1 TMVr-randomized patients vs those treated with GDMT alone also had significantly greater improvement in 6MWD at 12 months (mean [SD] paired improvement: 39.0 [28.6] vs -48.0 [18.6] m; P = .02). Group 2 TMVr-randomized patients vs those treated with GDMT alone tended to have greater improvement in 6MWD at 12 months, but the difference did not reach statistical significance (mean [SD] paired improvement: 35.0 [7.7] vs 16.0 [9.1] m; P = .11). Conclusions and Relevance A small subgroup of COAPT-resembling patients enrolled in MITRA-FR did not achieve improvement in ACM or HFH at 24 months but had a significant benefit on patient-centered outcomes (eg, QOL and 6MWD). Further subgroup analyses with 24-month follow-up suggest that the benefit of TMVr is not fully supported by the proportionate-disproportionate hypothesis. Trial Registration ClinicalTrials.gov Identifier: NCT01626079.
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Affiliation(s)
- JoAnn Lindenfeld
- Advanced Heart Failure, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus
| | - Paul A Grayburn
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Dallas, Texas
| | - Saibal Kar
- Center of Advanced Cardiac and Vascular Interventions, Los Angeles, California
| | | | - D Scott Lim
- Division of Cardiology, University of Virginia, Charlottesville
| | | | | | | | | | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Spertus JA, Birmingham MC, Butler J, Lingvay I, Lanfear DE, Abbate A, Kosiborod ML, Fawcett C, Burton P, Damaraju CV, Januzzi JL, Whang J. Novel Trial Design: CHIEF-HF. Circ Heart Fail 2021; 14:e007767. [PMID: 33724883 PMCID: PMC7982129 DOI: 10.1161/circheartfailure.120.007767] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. The expense of clinical trials mandates new strategies to efficiently generate evidence and test novel therapies. In this context, we designed a decentralized, patient-centered randomized clinical trial leveraging mobile technologies, rather than in-person site visits, to test the efficacy of 12 weeks of canagliflozin for the treatment of heart failure, regardless of ejection fraction or diabetes status, on the reduction of heart failure symptoms.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.S., M.K.)
| | | | | | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX (I.L.)
| | | | | | - Mikhail L Kosiborod
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.S., M.K.)
| | | | - Paul Burton
- Janssen Research & Development, LLC Titusville, NJ (C.V.D., P.B.)
| | - C V Damaraju
- Janssen Research & Development, LLC Titusville, NJ (C.V.D., P.B.)
| | | | - John Whang
- Janssen Scientific Affairs, LLC Titusville, NJ (M.B.,J.W.)
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Thomas M, Jones PG, Cohen DJ, Suzanne AV, Magnuson EA, Wang K, Thourani VH, Fonarow GC, Sandhu AT, Spertus JA. Predicting the EQ-5D utilities from the Kansas City Cardiomyopathy Questionnaire in patients with heart failure. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:388-396. [PMID: 33724402 DOI: 10.1093/ehjqcco/qcab014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Evaluation of health status benefits, cost-effectiveness, and value of new heart failure therapies is critical for supporting their use. The Kansas City Cardiomyopathy Questionnaire (KCCQ) measures patients' heart failure-specific health status but does not provide utilities needed for cost-effectiveness analyses. We mapped the KCCQ scores to EQ-5D scores so that estimates of societal-based utilities can be generated to support economic analyses. METHODS Using data from two US cohort studies, we developed models for predicting EQ-5D utilities (3L and 5L versions) from the KCCQ (23- and 12-item versions). In addition to predicting scores directly, we considered predicting the five EQ-5D health state items and deriving utilities from the predicted responses, allowing different countries' health state valuations to be used. Model validation was performed internally via bootstrap and externally using data from two clinical trials. Model performance was assessed using R2, mean prediction error, mean absolute prediction error, and calibration of observed vs. predicted values. RESULTS The EQ-5D-3L models were developed from 1000 health status assessments in 547 patients with heart failure and reduced ejection fraction (HFrEF), while the EQ-5D-5L model was developed from 3925 patients with HFrEF. For both versions, models predicting individual EQ-5D items performed as well as those predicting utilities directly. The selected models for the 3L had internally validated R2 of 48.4-50.5% and 33.7-45.6% on external validation. The 5L version had validated R2 of 57.7%. CONCLUSION Mappings from the KCCQ to the EQ-5D can yield the estimates of societal-based utilities to support cost-effectiveness analyses when EQ-5D data are not available.
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Affiliation(s)
- Merrill Thomas
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Philip G Jones
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - David J Cohen
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Arnold V Suzanne
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Elizabeth A Magnuson
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - Kaijun Wang
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, 95 Collier Road Northwest, Suite 5015, Atlanta, GA 30309, USA
| | - Gregg C Fonarow
- Department of Internal Medicine, Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, 100 UCLA Medical Plaza, Suite 630, Los Angeles, CA 90095, USA
| | - Alexander T Sandhu
- Division of Cardiology, Department of Medicine, Stanford University, 300 Pasteur Dr, Stanford, CA 94305, USA
| | - John A Spertus
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
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Stogios N, Fezza G, Wong JV, Ross HJ, Farkouh ME, Nolan RP. Current challenges for using the Kansas City Cardiomyopathy Questionnaire to obtain a standardized patient-reported health status outcome. Eur J Heart Fail 2021; 23:205-207. [PMID: 33619798 PMCID: PMC8049137 DOI: 10.1002/ejhf.2139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Nicolette Stogios
- Behavioural Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gabriel Fezza
- Behavioural Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Health, York University, Toronto, ON, Canada
| | - Julia V Wong
- Behavioural Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada
| | - Heather J Ross
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Michael E Farkouh
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Robert P Nolan
- Behavioural Cardiology Research Unit, University Health Network (UHN), Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
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Arnold SV, Butler J, Spertus JA. Standardizing the standard: reporting health status in clinical trials. Eur J Heart Fail 2021; 23:203-204. [PMID: 33543813 DOI: 10.1002/ejhf.2117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
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Hejjaji V, Cohen DJ, Carroll JD, Li Z, Manandhar P, Vemulapalli S, Nelson AJ, Malik AO, Mack MJ, Spertus JA, Arnold SV. Practical Application of Patient-Reported Health Status Measures for Transcatheter Valve Therapies: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry. Circ Cardiovasc Qual Outcomes 2021; 14:e007187. [PMID: 33596663 PMCID: PMC7982132 DOI: 10.1161/circoutcomes.120.007187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Health status assessment is essential for documenting the benefit of transcatheter aortic valve replacement (TAVR) or transcatheter mitral valve repair on patients’ symptoms, function, and quality of life. Health status can also be a powerful marker for subsequent clinical outcomes, but its prognostic importance around the time of both TAVR and transcatheter mitral valve repair has not been fully defined.
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Affiliation(s)
- Vittal Hejjaji
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (V.H., A.O.M., J.A.S., S.V.A.).,Department of Cardiovascular Medicine, University of Missouri-Kansas City (V.H., D.J.C., A.O.M., J.A.S., S.V.A.)
| | - David J Cohen
- Department of Cardiovascular Medicine, University of Missouri-Kansas City (V.H., D.J.C., A.O.M., J.A.S., S.V.A.)
| | - John D Carroll
- Department of Cardiovascular Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.D.C.)
| | - Zhuokai Li
- Department of Cardiovascular Medicine, Duke Clinical Research Institute, Durham, NC (Z.L., P.M., S.V., A.J.N.)
| | - Pratik Manandhar
- Department of Cardiovascular Medicine, Duke Clinical Research Institute, Durham, NC (Z.L., P.M., S.V., A.J.N.)
| | - Sreekanth Vemulapalli
- Department of Cardiovascular Medicine, Duke Clinical Research Institute, Durham, NC (Z.L., P.M., S.V., A.J.N.)
| | - Adam J Nelson
- Department of Cardiovascular Medicine, Duke Clinical Research Institute, Durham, NC (Z.L., P.M., S.V., A.J.N.)
| | - Ali O Malik
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (V.H., A.O.M., J.A.S., S.V.A.).,Department of Cardiovascular Medicine, University of Missouri-Kansas City (V.H., D.J.C., A.O.M., J.A.S., S.V.A.)
| | - Michael J Mack
- Department of Cardiovascular Medicine, Baylor Scott and White Health, Plano, TX (M.J.M.)
| | - John A Spertus
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (V.H., A.O.M., J.A.S., S.V.A.).,Department of Cardiovascular Medicine, University of Missouri-Kansas City (V.H., D.J.C., A.O.M., J.A.S., S.V.A.)
| | - Suzanne V Arnold
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (V.H., A.O.M., J.A.S., S.V.A.).,Department of Cardiovascular Medicine, University of Missouri-Kansas City (V.H., D.J.C., A.O.M., J.A.S., S.V.A.)
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