Comorbidity "depression" in heart failure - Potential target of patient education and self-management

A patient with heart failure, who is frail: How does this affect therapeutic decisions?

Patients with heart failure (HF) are heterogeneous, not only related to comorbidities but also in the presentation of frailty syndrome. Frailty syndrome also affects patients with HF across the lifespan. Frailty in patients with HF has a significant impact on clinical features, diagnosis, management, adverse medical outcomes and costs. In everyday clinical practice, frail patients with HF require an individualized approach, often imposing the need to modify therapeutic decisions. The aim of this review is to illustrate how frailty and multimorbidity in HF can affect therapeutic decisions. The scientific evidence underlying this publication was obtained from an analysis of papers indexed in the PubMed database. The search was limited to articles published between 1990 and July 2022. The search was limited to full-text papers published in English. The database was searched for relevant MeSH phrases and their combinations and keywords including: "elderly, frail"; "frailty, elderly"; "frail older adults"; "frailty, older adults"; "adult, frail older"; "frailty, heart failure"; "frailty, multimorbidity"; "multimorbidity, heart failure"; "multimorbidity, elderly"; "older adults, cardiovascular diseases". In therapeutic decisions regarding patients with HF, additionally burdened with multimorbidity and frailty, it becomes necessary to individualize the approach in relation to optimization and treatment of coexisting diseases, frailty assessment, pharmacological and non-pharmacological treatment and in the implementation of invasive procedures in the form of implantable devices or cardiac surgery.

Effectiveness of Nurse-Led Heart Failure Self-Care Education on Health Outcomes of Heart Failure Patients: A Systematic Review and Meta-Analysis

Poor self-care behaviors can lead to an increase in the risk of adverse health outcomes among patients with heart failure. Although a number of studies have investigated the effectiveness of nurse-led self-care education, the evidence regarding the effects of nurse-led intervention in heart failure remains uncertain. This study aimed to evaluate evidence on the effectiveness of nurse-led heart failure self-care education on health outcomes in patients with heart failure. To identify studies testing nurse-led education designed to improve self-care among heart failure patients, comprehensive search methods were used between January 2000 and October 2019 to systematically search six electronic databases: PubMed, CINAHL, Embase, Cochrane library, Web of Science, and SCOPUS. All the eligible study data elements were independently assessed and analyzed using random-effects meta-analysis methods. Of 612 studies, eight articles were eligible for this study. Nurse-led heart failure self-care education significantly reduced the risk of all-cause readmission (risk ratio (RR) = 0.75, 95% confidence interval (CI) = 0.66–0.85), heart failure specific readmission (RR = 0.60, 95% CI = 0.42–0.85), and all-cause mortality or readmission (RR = 0.71, 95% CI = 0.61–0.82). However, nurse-led heart failure self-care education was not associated with improvements in the quality of life and heart failure knowledge. Studies on the effectiveness of nurse-led heart failure self-care education mostly report only the positive effects on patients’ health outcomes, whereas evidence of the effectiveness of the nurse-led approach is still limited. Therefore, high quality randomized controlled trials with detailed and explicit descriptions on the components of the interventions are needed.

Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system

BACKGROUND

Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management. This qualitative case study examines perceptions of care among providers and administrators in a large, urban health system in Canada, and how the CCM might inform redesign of care to improve health system functioning.

METHODS

Sixteen semi-structured interviews were conducted between August 2014 and January 2016. Interpretive analysis was conducted to identify how informants perceive care among this population and the extent to which the design of heart failure care aligns with elements of the CCM.

RESULTS

Current care approaches could better align with CCM elements. Key changes to improve health system functioning for complex heart failure patients that align with the CCM include closing knowledge gaps, standardizing treatment, improving interdisciplinary communication and improving patient care pathways following hospital discharge.

CONCLUSIONS

The CCM can be used to guide health system design and interventions for frail and multi-morbid heart failure patients. Addressing care- and service-delivery barriers has important clinical, administrative and economic implications.

Unravelling heart failure nurses' education: Content comparison of heart failure nurses' education in three European Society of Cardiology states and the Heart Failure Association heart failure curriculum

AIMS

The European Society of Cardiology (ESC) guidelines state that heart failure nurse specialists (heart-failure nurses) with specific competences are essential for a successful heart-failure-management programme. Thus, the Heart Failure Association (HFA) of the ESC developed the heart failure nurse curriculum (HFA curriculum). Several ESC member states developed cardiovascular education programmes to enable nurses to deliver high specialist care, but little is known of whether these curricula are in line with the HFA curriculum. Therefore, this paper describes the extent to which cardiovascular education programmes in Belgium, The Netherlands and Germany correspond to the HFA curriculum.

METHODS AND RESULTS

A case study approach was adopted to obtain an in-depth understanding of the programme contents in relation to the HFA curriculum. For this purpose, representatives of the educational programmes and/or delegates of the national cardiovascular nursing organization shared their educational curricula. All of the studied cardiovascular education programmes aim to provide heart failure and/or cardiovascular nurses with essential competences for implementation of evidence based and guideline derived care. However, every cardiovascular education programme has a different focus/area of attention. Cardiovascular education in Belgium discusses aspects of all core-learning objectives of the HFA curriculum and emphasizes mostly knowledge aspects of these. Learning objectives in cardiovascular education in The Netherlands focus on chronic diseases in general and on learning objectives concerning patient education, support in self-care and management of device and pharmacological therapy. Cardiovascular education in Germany discusses most learning objectives; however, not all learning objectives receive equal attention.

CONCLUSIONS

Although local cardiovascular education programmes adopt certain aspects of the HF curriculum, the curriculum as a whole is not adopted.

Effect of family education program on cognitive impairment, anxiety, and depression in persons who have had a stroke: A randomized, controlled study

People who have had a stroke face high risks of cognitive impairment, anxiety, and depression. Health education for family members contributes to better outcomes in various diseases, but the effects of health education on family members of people who have had a stroke are unclear. The aim of the present study was to evaluate the effects of the family member education program (FMEP) on cognitive impairment, anxiety, and depression in persons who have had a stroke. In total, 144 persons who experienced a stroke were randomly allocated to the FMEP group or control group (1:1 ratio). In the FMEP group, the FMEP and conventional treatment were provided, while in control group only conventional treatment was provided. The increase in the Montreal Cognitive Assessment (MOCA) score from baseline to 12 months (M12 - baseline) in the FMEP group was higher compared with the control group, and the FMEP led to a decreased cognitive impairment rate (MOCA score ≤26) after 12 months compared to the control group. Changes in the Hospital Anxiety and Depression Scale anxiety and depression score (M12 - baseline) decreased in the FMEP group compared with the control group. Fewer participants with depression and a lower depression grade were observed in the FMEP group compared with the control group. The FMEP could reduce cognitive impairment, anxiety, and depression in persons who have had a stroke.

Nutritional Status and Energy Intake as Predictors of Functional Status After Cardiac Rehabilitation in Elderly Inpatients With Heart Failure - A Retrospective Cohort Study

BACKGROUND

Whether the short-term effect of cardiac rehabilitation (CR) in elderly patients with heart failure (HF) is influenced by nutritional status is uncertain, so the present study investigated the effect of nutritional status on functional recovery after CR in elderly HF inpatients.Methods and Results:We enrolled 145 patients admitted for treatment of HF who were aged ≥65 years and had a low functional status defined as a Barthel index (BI) score ≤85 points at the commencement of CR. Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF) and total energy intake per day. The primary endpoint was functional status determined by the BI score at discharge. The median CR period was 20 days (interquartile range: 14-34 days), and 87 patients (60%) were functionally dependent (BI score ≤85) at discharge. Multivariate logistic regression analysis showed that MNA-SF score (odds ratio [OR]: 0.76, P=0.02) and total energy intake at the commencement of CR (OR: 0.91, P=0.02) were independent predictors of functional dependence after CR. MNA-SF score ≤7 and total energy intake ≤24.5 kcal/kg/day predicted functional dependence at discharge with moderate sensitivity and specificity.

CONCLUSIONS

MNA-SF score and total energy intake at the commencement of CR are novel predictors of the extent of functional recovery of elderly HF inpatients after in-hospital CR.

The effect of nurse-led group discussions by race on depressive symptoms in patients with heart failure

BACKGROUND

African Americans with heart failure (HF) have the highest rates of depression among all ethnicities in the USA.

OBJECTIVES

To compare the effects by race on depressive symptoms and topics discussed in the first clinic appointment after HF hospitalization.

METHODS

This study is a secondary analysis of data from a randomized clinical trial testing a patient group discussion of HF self-management with 93 Caucasians and 77 African Americans.

RESULTS

Reduction in depressive symptoms was significantly greater among African American patients within the intervention group (F = 3.99, p = .047) than controls. There were significant differences by race in four topics (dietitian referral, appointment date, help preparing discussion questions, and advice on worsening HF symptoms) concerning patient-physician discussions.

CONCLUSION

The intervention showed greater effect in reducing depressive symptoms among African Americans than Caucasians. Preparing patients for discussions at physician appointments on diet, depressive symptoms, and HF symptoms is recommended.