Cognitive Impairment in Heart Failure: Issues of Measurement and Etiology

Heart Failure with Preserved Ejection Fraction: How to Deal with This Chameleon

Heart failure with preserved ejection fraction (HFpEF) is characterized by a notable heterogeneity in both phenotypic and pathophysiological features, with a growing incidence due to the increase in median age and comorbidities such as obesity, arterial hypertension, and cardiometabolic disease. In recent decades, the development of new pharmacological and non-pharmacological options has significantly impacted outcomes, improving clinical status and reducing mortality. Moreover, a more personalized and accurate therapeutic management has been demonstrated to enhance the quality of life, diminish hospitalizations, and improve overall survival. Therefore, assessing the peculiarities of patients with HFpEF is crucial in order to obtain a better understanding of this disorder. Importantly, comorbidities have been shown to influence symptoms and prognosis, and, consequently, they should be carefully addressed. In this sense, it is mandatory to join forces with a multidisciplinary team in order to achieve high-quality care. However, HFpEF remains largely under-recognized and under-treated in clinical practice, and the diagnostic and therapeutic management of these patients remains challenging. The aim of this paper is to articulate a pragmatic approach for patients with HFpEF focusing on the etiology, diagnosis, and treatment of HFpEF.

Risk evaluation of cognitive impairment in patients with heart failure: A call for action

Background

Cognitive impairment (CI) is common in patients with heart failure (HF) and impacts treatment adherence and other aspects of patient life in HF. Recognition of CI in patients with HF is therefore important. We aimed to develop a risk model with easily available patient characteristics, to identify patients with HF who are at high risk to be cognitively impaired and in need for further cognitive investigation.

Methods & results

The risk model was developed in 611 patients ≥ 60 years with HF from the TIME-CHF trial. Fifty-six (9 %) patients had CI (defined as Hodkinson Abbreviated Mental Test ≤ 7). We assessed the association between potential predictors and CI with least-absolute-shrinkage-and-selection-operator (LASSO) regression analysis. The selected predictors were: older age, female sex, NYHA class III or IV, Charlson comorbidity index ≥ 6, anemia, heart rate ≥ 70 bpm and systolic blood pressure ≥ 145 mmHg. A model that combined these variables had a c-statistic of 0.70 (0.63-0.78). The model was validated in 155 patients ≥ 60 years with HF from the ECHO study. In the validation cohort 51 (33 %) patients had CI (defined as a Mini Mental State Exam ≤ 24). External validation showed an AUC of 0.56 (0.46-0.66).

Conclusions

This risk model with easily available patient characteristics has poor predictive performance in external validation, which may be due to case-mix variation. These findings underscore the need for active screening and standardized assessment for CI in patients with HF.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Prediction of Heart Failure Symptoms and Health-Related Quality of Life at 12 Months From Baseline Modifiable Factors in Patients With Heart Failure

BACKGROUND

In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined.

OBJECTIVE

The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL.

METHODS

We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose.

RESULTS

Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-month HRQOL.

CONCLUSION

Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class.

Varied Factors were Associated with Different Types of Self-Care in Heart Failure

Poor self-care is prevalent in patients with heart failure and adversely affects heart failure symptoms, hospitalization, and mortality. Adherence rates to different types of self-care vary in patients with heart failure. The purpose of this study was to examine factors associated with medication adherence, dietary sodium adherence, and symptom management in patients with heart failure. Data were collected using questionnaires, Medication Electronic Monitoring System, and 24-hour urine sodium output (N = 94). In logistic regression analysis, social support, education level, and race were associated with medication adherence (p = .002). Gender, race, perceived control, and depressive symptoms were associated with dietary sodium adherence (p = .030). Gender, education level, and depressive symptoms were associated with symptom management (p = .006). Different factors were associated with each type of self-care. Thus, clinicians need to manage each type of self-care by considering factors associated with it.

Brain networks' functional connectivity separates aphasic deficits in stroke

OBJECTIVE

To investigate whether different language deficits are distinguished by the relative strengths of their association with the functional connectivity (FC) at rest of the language network (LN) and cingulo-opercular network (CON) after aphasic stroke.

METHODS

In a group of patients with acute stroke and left-hemisphere damage, we identified 3 distinct, yet correlated, clusters of deficits including comprehension/lexical semantic, grapheme-phoneme knowledge, and verbal executive functions. We computed partial correlations in which the contributions of a behavioral cluster and network FC of no interest were statistically regressed out.

RESULTS

We observed a double dissociation such that impairment of grapheme-phoneme knowledge was more associated with lower FC of the LN within the left hemisphere than lower FC of the CON, whereas verbal executive deficits were more related to lower FC of the CON than the LN in the left hemisphere. Furthermore, the specific association between language deficits and FC was independent of the amount of structural damage to the LN and CON.

CONCLUSION

These findings indicate that after a left-hemisphere lesion, the type of language impairment is related to the abnormal pattern of correlated activity in different networks. Accordingly, they extend the concept of a neuropsychological double dissociation from structural damage to functional network abnormalities. Finally, current results strongly argue in favor of the behavioral specificity of intrinsic brain activity after focal structural damage.

Palliation of heart failure

Heart failure is the major cause of morbidity and mortality in the United States. Stage D heart failure has a greater mortality rate than many cancers and has equivalent symptom burden and severity. There has been a paradigm shift in our understanding of the pathophysiology of heart failure. Progressive heart failure is associated with ventricular remodeling and a maladaptive neurohumoral response. Drug classes have evolved that curtail ventricular remodeling, and blunt neurohumoral responses reduce morbidity and mortality. Despite combination drug and device therapies, the management of Stage D heart failure includes palliation. Both cardiology and palliative specialists need to learn from one another in order to palliate these highly symptomatic patients. Such collaboration will enhance care and are the basis for well-conceived research trials.

Lateralized Resting-State Functional Brain Network Organization Changes in Heart Failure

Heart failure (HF) patients show brain injury in autonomic, affective, and cognitive sites, which can change resting-state functional connectivity (FC), potentially altering overall functional brain network organization. However, the status of such connectivity or functional organization is unknown in HF. Determination of that status was the aim here, and we examined region-to-region FC and brain network topological properties across the whole-brain in 27 HF patients compared to 53 controls with resting-state functional MRI procedures. Decreased FC in HF appeared between the caudate and cerebellar regions, olfactory and cerebellar sites, vermis and medial frontal regions, and precentral gyri and cerebellar areas. However, increased FC emerged between the middle frontal gyrus and sensorimotor areas, superior parietal gyrus and orbito/medial frontal regions, inferior temporal gyrus and lingual gyrus/cerebellar lobe/pallidum, fusiform gyrus and superior orbitofrontal gyrus and cerebellar sites, and within vermis and cerebellar areas; these connections were largely in the right hemisphere (p<0.005; 10,000 permutations). The topology of functional integration and specialized characteristics in HF are significantly changed in regions showing altered FC, an outcome which would interfere with brain network organization (p<0.05; 10,000 permutations). Brain dysfunction in HF extends to resting conditions, and autonomic, cognitive, and affective deficits may stem from altered FC and brain network organization that may contribute to higher morbidity and mortality in the condition. Our findings likely result from the prominent axonal and nuclear structural changes reported earlier in HF; protecting neural tissue may improve FC integrity, and thus, increase quality of life and reduce morbidity and mortality.

The Association Between Mild Cognitive Impairment and Self-care in Adults With Chronic Heart Failure: A Systematic Review and Narrative Synthesis

BACKGROUND

Emerging evidence suggests that heart failure (HF) patients who have mild cognitive impairment (MCI) may experience greater difficulty with self-care.

OBJECTIVE

This article reports a systematic review that addressed the objective "What is the evidence for an association between MCI and self-care, measured in 1 or more of the self-care domains related to HF, in adults who have a diagnosis of chronic HF?"

METHOD

We adopted Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the review and synthesis of quantitative research studies that formally measured both cognitive function and self-care in HF patients and sought to describe the relationship between these factors.

RESULTS

Ninety-one potentially relevant studies were located; 10 studies (2006-2014) were included. Because of heterogeneity in the retrieved studies, meta-analysis was not possible. Narrative synthesis found growing evidence regarding the association between MCI and adverse effects on self-care in HF. Nine studies reported significant positive associations between MCI and self-care in HF, either specifically in relation to medication adherence or more generic measures of self-care activity. One study reported a significant, negative correlation between cognitive function and self-care, suggesting that worse cognitive function was associated with better self-care; however, this is partially explained by a small sample size and mixed methodology.

CONCLUSIONS

These findings have implications for clinical practice. It is known that HF patients have difficulty with self-care, and the influence of cognitive function needs to be considered when providing professional support. Further research to determine the feasibility and acceptability of cognitive assessment in routine clinical care is recommended.

Evidence-Based Heart Failure Medications and Cognition

BACKGROUND

The etiology of cognitive impairment in heart failure (HF) is controversial and likely multifactorial. Physicians may hesitate to prescribe evidence-based HF medication because of concerns related to potential negative changes in cognition among a population that is already frequently impaired. We conducted a study to determine if prescription of evidence-based HF medications (specifically, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blocking agents, diuretics, and aldosterone inhibitors) was associated with cognition in a large HF sample.

METHODS

A total of 612 patients completed baseline data collection for the Rural Education to Improve Outcomes in Heart Failure clinical trial, including information about medications. Global cognition was evaluated using the Mini-Cog.

RESULTS

The sample mean (SD) age was 66 (13) years, 58% were men, and 89% were white. Global cognitive impairment was identified in 206 (34%) of the 612 patients. Prescription of evidence-based HF medications was not related to global cognitive impairment in this sample. This relationship was maintained even after adjusting for potential confounders (eg, age, education, and comorbid burden).

CONCLUSION

Prescription of evidence-based HF medications is not related to low scores on a measure of global cognitive function in rural patients with HF.

Long Term Follow-Up after a Randomized Integrated Educational and Psychosocial Intervention in Patient-Partner Dyads Affected by Heart Failure

BACKGROUND

To date, contemporary heart failure care remains patient-focused, but awareness of the partners' and families' situation is increasing. Randomized studies have mainly evaluated the short-term effects of dyadic interventions. Therefore, the aim of this study was to determine the 24-month effects of an intervention with psych-educational support in dyads of heart failure patients and their partners.

METHODS

This study used a randomized study design and 155 patient-partner dyads were enrolled. The intervention included a nurse-led program of three sessions addressing psychoeducational support.

RESULTS

The intervention did not have any effect on health, depressive symptoms or perceived control among the patient-partner dyads after 24 months. Furthermore, time to first event did not differ significantly between the intervention group and the control patients.

CONCLUSION

This study may be regarded as a first step in trying to understand dyads' need for supportive care. Individualized and more targeted interventions seem necessary to achieve a higher impact on dyad outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02398799.

Health Status and Self-care Outcomes After an Education-Support Intervention for People With Chronic Heart Failure

BACKGROUND

The rising cost of hospitalizations for heart failure (HF) care mandates intervention models to address education for self-care success. The effectiveness of memory enhancement strategies to improve self-care and learning needs further examination.

OBJECTIVE

The objective of this study was to examine the effects of an education-support intervention delivered in the home setting, using strategies to improve health status and self-care in adults/older adults with class I to III HF. Our secondary purpose was to explore participants' subjective perceptions of the intervention.

METHODS

This study used a randomized, 2-group design. Fifty people were enrolled for 9 months and tested at 4 time points-baseline; after a 3-month education-support intervention; at 6 months, after 3 months of telephone/e-mail support; and 9 months, after a 3-month period of no contact. Advanced practice registered nurses delivered the intervention. Memory enhancement methods were built into the teaching materials and delivery of the intervention. We measured the intervention's effectiveness on health status outcomes (functional status, self-efficacy, quality of life, emotional state/depressive symptoms, and metamemory) and self-care outcomes (knowledge/knowledge retention, self-care ability). Subjects evaluated the usefulness of the intervention at the end of the study.

RESULTS

The mean age of the sample was 62.4 years, with a slight majority of female participants. Participants were well educated and had other concomitant diseases, including diabetes (48%) and an unexpected degree of obesity. The intervention group showed significant improvements in functional status, self-efficacy, and quality of life (Kansas City Cardiomyopathy Questionnaire); metamemory Change and Capacity subscales (Metamemory in Adulthood Questionnaire); self-care knowledge (HF Knowledge Test); and self-care (Self-care in Heart Failure Index). Participants in both groups improved in depressive scores (Geriatric Depression Scale).

CONCLUSIONS

An in-home intervention delivered by advanced practice registered nurses was successful in several health status and self-care outcomes, including functional status, self-efficacy, quality of life, metamemory, self-care status, and HF knowledge.

Cerebral impairment in heart failure

Patients with heart failure (HF) exhibit a wide range of symptoms, including dyspnea, sleep-disordered breathing, autonomic abnormalities, cognitive dysfunction, and neuropsychological disturbances. These symptoms, which affect quality of life and morbidity and mortality in the condition, are largely related to structural and functional changes in the brain. There are increasing reports of brain abnormalities in HF, but often the linkages between brain injury and common HF clinical symptomatology are not clearly described. In this review, we will discuss the current evidence of brain injury and the associated clinical symptoms in HF, focusing on those brain regions that are commonly damaged in the condition. We will also provide a brief exploration of some potential mechanisms for brain injury in HF.

Incidence and predictors of cognitive decline in patients with left ventricular assist devices

BACKGROUND

After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool.

METHODS AND RESULTS

Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46-3.44; P(trend)<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05-1.92) were significantly associated with greater risk of cognitive decline.

CONCLUSIONS

Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.

Usefulness of cognitive dysfunction in heart failure to predict cardiovascular risk at 180 days

Cognitive dysfunction is common in patients with heart failure (HF). Despite the high prevalence and the adverse associations of cognitive dysfunction in HF, the prognostic implications remain poorly understood. We sought to determine the influence of cognitive dysfunction, identified using the Montreal Cognitive Assessment (MoCA), on 180-day cardiovascular events. We analyzed data on 246 participants in an observational cohort study of adults with HF. The interview-format MoCA was administered to all participants. Time to first cardiovascular event was assessed as a cumulative end point during the 180 days after enrollment. Cox proportional hazards model was used for analysis of time to first event. The MoCA score was <26 for 91 patients (37%). Patients with a MoCA score <26 were more likely to have a cardiovascular event at 180 days. MoCA score <26 remained an independent predictor of cardiovascular event risk at 180 days when adjusted for the Seattle Heart Failure Model Score and the Charlson comorbidity index (hazard ratio 1.7, 95% confidence interval 1.1 to 2.6, p = 0.03). In conclusion, in patients with HF, cognitive dysfunction identified with a MoCA score of <26 is associated with increased risk of cardiovascular events at 180 days.

'Hearts and minds': association, causation and implication of cognitive impairment in heart failure

The clinical syndrome of heart failure is one of the leading causes of hospitalisation and mortality in older adults. An association between cognitive impairment and heart failure is well described but our understanding of the relationship between the two conditions remains limited. In this review we provide a synthesis of available evidence, focussing on epidemiology, the potential pathogenesis, and treatment implications of cognitive decline in heart failure. Most evidence available relates to heart failure with reduced ejection fraction and the syndromes of chronic cognitive decline or dementia. These conditions are only part of a complex heart failure-cognition paradigm. Associations between cognition and heart failure with preserved ejection fraction and between acute delirium and heart failure also seem evident and where data are available we will discuss these syndromes. Many questions remain unanswered regarding heart failure and cognition. Much of the observational evidence on the association is confounded by study design, comorbidity and insensitive cognitive assessment tools. If a causal link exists, there are several potential pathophysiological explanations. Plausible underlying mechanisms relating to cerebral hypoperfusion or occult cerebrovascular disease have been described and it seems likely that these may coexist and exert synergistic effects. Despite the prevalence of the two conditions, when cognitive impairment coexists with heart failure there is no specific guidance on treatment. Institution of evidence-based heart failure therapies that reduce mortality and hospitalisations seems intuitive and there is no signal that these interventions have an adverse effect on cognition. However, cognitive impairment will present a further barrier to the often complex medication self-management that is required in contemporary heart failure treatment.

Effects of Cognitive Speed of Processing Training Among Older Adults With Heart Failure

OBJECTIVE

Cognitive deficits pose serious problems for older adults with heart failure (HF). Cognitive speed of processing training improves cognition among older adults but has not been examined among older adults with HF.

METHOD

Data from the ACTIVE study were used to examine the effects of cognitive speed of processing training on cognitive and functional performance among older adults with HF.

RESULTS

Of the 54 participants included in the analyses, 23 who were randomized to cognitive training performed significantly better on a composite of everyday speed of processing from pre- to post-training compared with 31 participants who were randomized to the control group, F(1, 51) = 28.67, p ≤ .001, [Formula: see text] = .360.

DISCUSSION

Results indicate that speed of processing training may improve everyday cognitive performance among older adults with HF. Future studies should investigate the longitudinal effects of cognitive training with HF patients.

Longitudinal Differences in Cognitive Functioning Among Older Adults With and Without Heart Failure

Objective: Secondary data analyses were conducted to examine cognitive function and longitudinal cognitive decline among older adults with and without heart failure (HF). Method: Data from the Advanced Cognitive Training for Independent and Vital Elderly study were used to compare baseline ( N = 2,790) and longitudinal ( n = 692) changes in memory, reasoning, and speed of processing performance among participants ( M age = 73.61, SD = 5.89) who self-reported HF at baseline, developed HF over time, or never reported HF. Results: At baseline, there were differences in memory and speed of processing with participants who never reported HF performing better than those who reported developing HF over time, and those who reported HF at baseline performing the worst ( ps < .05). Longitudinally, participants with self-reported HF at baseline showed declines in reasoning over time. Discussion: The results indicate that cognitive difficulties in memory and speed may occur prior to a HF diagnosis, while those with HF may experience steeper declines in reasoning as measured by word series test.

Mood and health-related quality of life among pediatric patients with heart failure

Adult patients with heart failure (HF) commonly experience depression, with morbid and mortal consequences. However, mood disorders in pediatric patients with HF are poorly understood. This study examined mood and health-related quality of life (HRQOL) in children with HF and compared them cross-sectionally with those of healthy control subjects and heart transplant (Htx) recipients with good heart function. The 62 participants in this study were divided into three groups: HF subjects (n = 15), Htx subjects (n = 23), and healthy control subjects (n = 24). The HF subjects all had chronic HF with a left ventricular ejection fraction lower than 35 %. All the participants completed the Mini-Mental State Examination (MMSE), the Childhood Depression Inventory (CDI), and the Pediatric Quality-of-Life Inventory Cardiac Module (PedsQL CM). Overall, the MMSE scores and CDI subscale scores were similar for all the groups. The HF and Htx participants scored similarly on the PedsQL CM subscales for HRQOL, treatment anxiety, perceived physical appearance, cognitive function, and communication. However, the HF group had a significantly lower HRQOL related to heart problems and treatment than the Htx group. The prevalence of depression among children with HF is not as high as reported in the adult HF literature. However, certain aspects of HRQOL experienced by pediatric HF patients still suffer, especially those related to heart problems and treatment. Health-related QOL tended to be better for the Htx participants than for the HF participants. Exploring developmental and psychosocial outcomes is critical for patients with HF, especially because it has an impact on vital developmental, academic, and social outcomes.

Cognitive profile in persons with systolic and diastolic heart failure

Persons with heart failure (HF) have four times the risk of having cognitive impairment compared with the general population and display different patterns of cognitive impairment. This secondary analysis of a published cross-sectional study of 90 community-dwelling adults examined the Montreal Cognitive Assessment (MoCA) scores and HF differentiated as systolic and diastolic HF. Mean MoCA score was 22.9 (standard deviation±2.31) in persons with systolic HF (n=69) and 24.8 (standard deviation±2.76) in persons with diastolic HF (n=21) with statistically significant mean difference between groups (t=-2.025, P=.030). Independent t test on the eight MoCA domain scores and systolic and diastolic HF indicated significance on visuo-spatial/executive function (P=.026), attention (P=.049), abstraction (P=.014), and delayed recall (P=.048). Findings from this study support the need for including persons with systolic and diastolic HF in future researches on identifying varying cognitive profiles to plan tailored cognitive intervention.

The meanings associated with medicines in heart failure patients

BACKGROUND

The purpose of this study was to explore the theoretical linkages between symptom experiences and meaning associated with medication adherence. The specific objectives were to evaluate the key constructs of Meaning-Response theory for understanding medication adherence in patients with chronic heart failure; to assess the influence of symptom persistence on the meaning associated with prescribed medicines; and to explore the extent to which meaningful associations improve medication adherence. Among patients with heart failure, poor medication adherence occurs in over half of the population, resulting in high rates of symptom exacerbation, avoidable hospitalization, and death. Nurses play a key role in facilitating self-management skills, but patients' perceptions of the relationship between symptoms and medicines is not clear.

METHODS

Using a prospective mixed methods design, the study assessed patients' (n=10) perception of chronic heart failure symptoms and medication adherence. Patients completed guided interviews related to six concepts of meaning ascribed to medication use and four standardized measures of medication-related beliefs, behaviours, symptoms, and satisfaction.

RESULTS

This study suggests that patients' perception of meaning associated with medication taking was categorized as positive, negative, or absent. Symptom persistence influenced a majority of patient beliefs in the efficacy medicines, and patients with more positive meaningful associations with their medicines were more likely to remain adherent during the course of this study.

CONCLUSIONS

Development of meaningful associations with medicines may improve long-term adherence with prescribed medication in heart failure.

Cognition in heart failure: an overview of the concepts and their measures

PURPOSE

To review cognitive impairment and explore current measurement concerns faced by nurse practitioners caring for individuals with heart failure.

DATA SOURCES

Review of peer-reviewed research articles published on the topic.

CONCLUSIONS

Cognitive impairment is prevalent among individuals with heart failure. Impairment frequently involves one or more domains, including attention, memory, and executive function. No gold standard screening measure was identified from the reviewed literature.

IMPLICATIONS FOR PRACTICE

It is imperative that clinicians are aware of cognitive impairment and its implications for their patients with heart failure. Cognitive impairment likely contributes to multiple clinical implications, including a decreased ability to attend to and comprehend patient education materials and an inability to appropriately assess and self-manage symptoms.

Differing pattern of ambulatory blood pressure in very elderly men expresses dynamics in atherosclerotic load in the senescence

To assess an impact of vascular risk factors on ambulatory blood pressure measurement (ABPM) in the elderly, we followed up a population-based cohort of men from 68 until 82 years, when 104 survivors underwent ABPM. Results. At age 68, hypertension and high clinic blood pressure (CBP) did not predict ABPM level. Smoking and low ankle-brachial index (ABI) predicted higher ABPM variability and pulse pressure (PP), but not absolute ABPM values. At age 82, hypertension, high or increasing CBP, strongly positively correlated with all variables of ABPM. Carotid stenosis, low or declining ABI during followup, correlated with higher nocturnal ABPM and PP. Concluding. Hypertension and vascular risk factors in a cohort of 68-year-old men do not result in higher ABPM at age 82, possibly due to inflection point in their pressure development. Higher ABPM reflects instead an increasing CBP and aggravating atherosclerosis during the preceding decade in that part of the cohort with previously favorable risk factor status.

Phenomenon of declining blood pressure in elderly--high systolic levels are undervalued with Korotkoff method

Background

Systolic blood pressure (SBP) decline has been reported in octogenarians. The aim was to study if it could be observed while measuring SBP with two methods: Korotkoff (K-BP) and Strain-Gauge-Finger-Pletysmography (SG-BP), and which of them were more reliable in expressing vascular burden.

Methods

A cohort of 703 men from a population of Malmö, Sweden, were included in "Men born in 1914-study" and followed-up at ages: 68 and 81 years. 176 survivors were examined with K-BP and SG-BP at both ages, and 104 of them with Ambulatory Blood Pressure at age 81/82. Ankle Brachial Index (ABI) was measured on both occasions, and Carotid Ultrasound at age 81.

Results

From age 68 to 81, mean K-BP decreased in the cohort with mean 8.3 mmHg, while SG-BP increased with 13.4 mmHg. K-BP decreased in 55% and SG-BP in 31% of the subjects. At age 81, K-BP was lower than SG-BP in 72% of subjects, and correlated to high K-BP at age 68 (r = --.22; p < .05). SG-BP at age 81 was correlated with mean ambulatory 24-h SBP (r = .480; p < .0001), daytime SBP (r = .416; p < .0001), nighttime SBP (r = .395; p < .0001), and daytime and nighttime Pulse Pressure (r = .452; p < .0001 and r = .386; p < .0001). KB-BP correlated moderately only with nighttime SBP (r = .198; p = .044), and daytime and nightime pulse pressure (r = .225; p = .021 and r = .264; p = .007). Increasing SG-BP from age 68 to 81, but not K-BP, correlated with: 24-h, daytime and nighttime SBP, and mean daytime and nighttime Pulse Pressure. Increasing SG-BP was also predicted by high B-glucose and low ABI at age 68, and correlated with carotid stenosis and low ABI age 81, and the grade of ABI decrease over 13 years.

Conclusion

In contrast to K-BP, values of SG-BP in octogenarians strongly correlated with Ambulatory Blood Pressure. The SG-BP decline in the last decade was rare, and increasing SG-BP better than K-BP reflected advanced atherosclerosis. It should be aware, that K-BP underdetected 46% of subjects with SG-BP equal/higher than 140 mmHg at age 81, which may lead to biased associations with risk factors due to differential misclassification by age.

Nurse-Enhanced Memory Intervention in Heart Failure: the MEMOIR study

BACKGROUND

Many patients with heart failure (HF) have cognitive deficits, including memory loss.

OBJECTIVES

The aim of this study was to evaluate the efficacy of a cognitive training intervention on memory (primary outcome), working memory, psychomotor speed, executive function, and performance of cognitive activities and instrumental activities of daily living (IADLs).

METHODS AND RESULTS

Forty patients with HF were randomly assigned to the computerized plasticity-based cognitive training intervention called Brain Fitness or to the health education active control intervention. Advanced practice nurses made weekly home visits to assess symptoms and monitor intervention adherence. Patients completed demographic and clinical data (baseline), neuropsychologic tests (baseline and 8 and 12 weeks), and measures of cognitive and IADLs performance (baseline and 12 weeks) and satisfaction (12 weeks). Linear mixed models analyses indicated a significant group by time interaction for delayed recall memory (P = .032) and a significant time effect for total (list learning) (P < .001) and delayed (P = .015) recall memory, psychomotor speed (P = .029), and performance of IADLs (P = .006). Intervention adherence and patient satisfaction were high.

CONCLUSIONS

To our knowledge, this was the first test of Brain Fitness in HF. Although it was a preliminary study with limitations, results support the need for a larger randomized controlled trial to determine whether the memory loss of HF is amenable to plasticity-based interventions.

Cognitive dysfunctions in intensive cardiac care unit

BACKGROUND

Cognitive impairment is gaining recognition as sequelae of heart failure and the ICCU environment adds to their worsening symptoms.

OBJECTIVES

To determine cognitive dysfunctions in patients with heart disease admitted in intensive cardiac care unit (ICCU) and to compare it with patients admitted in general medical wards with heart disease.

MATERIALS AND METHODS

A total of 30 patients admitted to ICCU with heart disease were taken for the study and compared to patients with heart disease admitted in general medicine wards (except ICCU). The tools used were SMMSE (Standardized Mini Mental State Examination) and BCRS (Brief Cognitive Rating Scale). Statistical tests used were Student 't' test and Chi-Square test.

RESULTS

This study showed cognitive dysfunctions in the domains of orientation, attention and constructional ability as measured by SMMSE and cognitive dysfunction in the domain of concentration as measured by BCRS. Overall cognitive dysfunctions were present in the total score of both SMMSE and BCRS scale, which was statistically very highly significant.

CONCLUSION

The results showed that the patients in ICCU had cognitive dysfunctions in the domains of orientation, attention, constructional ability and concentration. Overall cognitive dysfunctions were found in the total scores of SMMSE and BCRS, thus signifying a global cognitive deficit.

Quality of life in patients with heart failure: ask the patients

BACKGROUND

Heart failure (HF) is a progressive clinical condition that results in substantial impairment of quality of life (QOL). Helping patients maintain optimal QOL is essential. QOL reflects patients' subjective perceptions about the impact of a clinical condition and its treatment on daily life; however, definitions in the literature vary widely and few reflect the patient's perspective.

PURPOSE

The study explored how patients with HF define and perceive QOL.

METHODS

Qualitative data were obtained from 14 men and 6 women with HF (mean age 58 +/- 10 years) using semistructured open-ended interviews. The interviews were analyzed using content analysis.

RESULTS

Patients with HF defined QOL as their ability to 1) perform desired physical and social activities to meet their and their family's needs; 2) maintain happiness; and 3) engage in fulfilling relationships with others. Patients perceived a variety of factors as positively or negatively affecting QOL: physical (symptoms and good or poor physical status), psychologic (mood and positive or negative perspective), economic (financial status), social (social support and ability for social activities), spiritual, and behavioral (self-care). Patients perceived that HF had a serious impact on QOL, but most evaluated their QOL as good nonetheless.

CONCLUSION

Patients' definition of QOL reflected not only the impact of HF on their daily life but also their active pursuit of happiness. Patients' self-evaluation of QOL reflected the negative impact of HF and patients' altered expectations of what constituted good QOL.

Sleep disturbance in people with heart failure: implications for self-care

Heart failure (HF) is associated with high levels of sleep disturbance and sleep disorders, including insomnia, periodic limb movements during sleep, and sleep disordered breathing. Recent studies underscore the importance of disturbances in sleep, a multidimensional biobehavioral phenomenon, to the pathophysiological processes associated with the development of HF, excess morbidity and mortality, and decrements in quality of life and functional performance. Managing disturbed sleep requires specific self-care strategies that must be incorporated into other self-care tasks associated with HF. Decrements in functioning associated with disturbed sleep may also have a negative impact on the self-care capacity and self-care behaviors of people with HF. The purposes of this article are to evaluate the state of the science relative to the nature of sleep disturbance experienced by people with HF and to discuss the implications of sleep, sleep disorders, and sleep-promoting interventions for self-care of people with HF.

Cognitive functioning and chronic heart failure: a review of the literature (2002-July 2007)

PURPOSE

The purposes of this article are to (1) summarize the state of the science about cognitive impairment and heart failure (HF) using the results of a literature search of publications from 2002 through July 2007; (2) provide a focused review of the studies that used a prospective, longitudinal design with measurement at 2 or more time points in order to identify change in cognitive functioning; and (3) identify gaps and priorities for future studies.

METHODS

A computer search of the literature from 2002 through July 2007 was conducted. All of the resulting 97 references were reviewed, categorized into 8 groups, and evaluated.

RESULTS

The 97 studies were categorized as follows: those not directly related to cognitive impairment (n = 15); comments, letters to the editor, and brief summaries (n = 11); reviews (n = 15); data-based publications using screening measures (n = 14); data-based publications using neuropsychological tests (n = 10); data-based publications assessing brain structure and functioning (n = 22); and data-based publications of populations other than HF in which HF emerged as a correlate/predictor of cognitive impairment (n = 10). Many investigators have reported that patients with HF had cognitive impairments compared with healthy persons without HF; approximately 25% to 50% of HF patients experience cognitive impairments. Patients with HF have been found to have structural and functional brain changes, including losses in gray matter in specific areas, areas of silent stroke, and decreased cerebral perfusion. Gaps in our knowledge and future research priorities are proposed.

CONCLUSIONS

Future studies are urgently needed to identify mechanisms of cognitive impairment in HF, prospectively identify changes in cognitive functioning that occur over time, and evaluate screening measures for use in clinical settings.

Sleep-disordered breathing, cognitive functioning, and adherence in heart failure: linked through pathology?

Heart failure (HF) is well recognized as a condition resulting from chronic neurohormonal activation. Sleep-disordered breathing (SDB) as a neurohormonal disorder is less recognized. In SDB, whether obstructive or central in nature, nightly repetitive cycles of hypoxia-reoxygenation produce intense sympathetic activation and deprive the body of much needed sleep. Both HF and SDB are associated with fatigue, cognitive impairment, and challenges for adherence to prescribed therapies. Together, the combination of HF and SDB can have particularly ominous consequences for cognitive functioning, decision making, adherence and, ultimately, outcomes. The suboptimal adherence seen in patients with both HF and SDB may result from a neurohormonal synergism that exists between the 2 conditions.

Initial validity and reliability of the SCCAN: using tailored testing to assess adult cognition and communication

PURPOSE

The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; L. Milman & A. Holland, 2007) was developed in the hospital setting to address changes in assessment practice. The SCCAN was designed to provide an overview of impairment and activity limitations across 8 cognitive scales (Speech Comprehension, Oral Expression, Reading, Writing, Orientation, Attention, Memory, and Problem Solving). The scales were developed using item response theory so that tailored testing could be implemented to reduce test administration time. This research investigated the validity and reliability of the SCCAN.

METHOD

A battery of neuropsychological tests was administered to 40 neurologically healthy control participants and 51 participants diagnosed with left-hemisphere pathology, right-hemisphere pathology, or probable Alzheimer's disease. Analyses were performed to assess test sensitivity and specificity, construct validity, administration time, and reliability.

RESULTS

The test accurately classified 95% of the control participants and 98% of the participants diagnosed with neurological disorders. Results indicate that the test also differentiated the performance profiles of the 3 clinical populations. In addition, test scores correlated significantly with external measures of the same cognitive areas. Mean administration time was 34 min. Test-retest stability (r = .96, p < .001) and internal consistency (r = .99, p < .001) coefficients were both significant, indicating that tailored testing procedures generated reliable test scores.