Effects of remote patient management on self-care behaviour in heart failure patients: results from the TIM-HF2 trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research

Background

Remote patient management (RPM) in heart failure (HF) patients is a rapidly developing field of digital cardiology with beneficial clinical effects. RPM might affect HF specific self-care behaviour, which represents an important patient-reported outcome.

Purpose

To investigate the effects of RPM used in the Telemedical Interventional Management in Heart Failure II (TIM-HF2) trial on HF-specific self-care as a prespecified secondary endpoint analysis.

Methods and Results

HF patients who were recently hospitalized and do not suffer from major depression were randomized to either RPM plus Usual Care (UC) or UC only, with a 12-month follow-up. Self-reported self-care behaviour at baseline and study-end were assessed by mean differences of the 9-item European Heart Failure Self-care Behaviour Scale (EHFScBS-9). 1,538 HF patients (mean age 70.3±10.5 years, 70% men, 52% NYHA class II and 47% NYHA class III, 65% LVEF ≤45%) were included, obtaining 1,321 patients with valid baseline and follow-up questionnaires.

Self-care behaviour sum scores increased in the RPM group (n=667) from 78.7±17 to 84.5±14 and in the UC group (n=654) from 79.0±17 to 80.0±16 from baseline to 12 months (mean difference 4.58 95% CI 3.02, 6.14; p<0.001). The subgroup of patients living alone and having an inadequate (<70) baseline self-care behaviour score showed the highest improvement (8.66[3.52; 13.81]). There were significant changes between both groups in item "I weight myself every day" (MD -1.13; 95% CI -1.24, -1.02; p<0.001), and item "I take my medication as prescribed" (MD -0.06; 95% CI -0.10, -0.01; p=0.014). No relation was found between the self-care behaviour score and the efficacy of RPM on the primary and main secondary endpoints of the TIM-HF2 study.

Conclusions

RPM improves HF-specific self-care behaviour by achieving a better adherence to recommended HF regimen. Clinical endpoints were not affected by the level of self-care behaviour.

P5450Evening levels and circadian changes of salivary cortisol predict adverse events in heart failure patients with comorbid depression - a MOOD-HF substudy

Background

Depression is frequent in heart failure (HF) and associated with adverse clinical outcomes. The randomized MOOD-HF trial showed that in depressed patients with systolic heart failure (HF) the selective serotonin reuptake inhibitor escitalopram (E) improved neither survival nor depression compared to placebo (P). The hypothalamic-pituitary-adrenocortical axis is known to be altered in depression or HF. This MOOD-HF substudy aimed to clarify whether circadian salivary cortisol levels (SCL) were predictive of adverse events in depressed MOOD-HF participants and whether outcomes differed according to treatment with E.

Methods

MOOD-HF participants (all suffering from symptomatic systolic HF with left ventricular ejection fraction (LVEF) <45% and current major depression) were eligible for the present analysis if providing samples for SCL determination (luminescence immunoassay) at baseline visit (BL) and if not on oral glucocorticosteroid therapy. Depression severity was determined with the Montgomery–Åsberg Depression Rating Scale (MADRS) and LVEF measured by echocardiography.

Results

In the total study cohort (146 patients on E, 147 on P) median morning SCL at BL was 0.210 μg/dL (IQR 0.141–0.338 μg/dL) and median evening (pm) SCL 0.067 μg/dL (0.036–0.128 μg/dL, p<0.001). Median circadian change was 0.124 μg/dL (0.044–0.239 μg/dL). In patients with BL pm-SCL above the median MADRS-score was 21.7±9.1 and LVEF 33.7±8.4% respectively, in patients with pm-SCL below the median these values were 19.6±9.1 and 36.5±7.8% (p=0.048; p=0.004).

During 12 months follow-up the composite endpoint (all-cause death or rehospitalization) occurred least in E-treated patients with low pm-SCL and most often in E-treated patients with high pm-SCL (HR 2.02, 95% CI 1.12–3.65, p=0.010); patients on P had comparable event rates irrespective of BL pm-SCL (Figure A). Thus, numerically patients on E with low BL pm-SCL had lower event rates compared with corresponding P-treated patients (HR 0.76 (0.41–1.40, p=0.796)), while patients with high BL pm-SCL had higher event rates (HR 1.29 (0.74–2.24, p=0.799)) than corresponding P-treated patients. Patients with circadian SCL changes above the median receiving P experienced the composite primary endpoint least, while both subgroups with circadian SCL changes below the median and also patients with circadian SCL changes above the median on E had higher event rates (HR 0.66 (0.45–0.97, p=0.039), Figure B).

Conclusion

In depressed patients with systolic HF high pm-SCL are associated with more severe disease (depression and cardiac dysfunction). Extending primary MOOD-HF results indicating unfavourable outcomes related to E, the current findings suggest a SCL x treatment interaction with higher event rates in (sicker) patients with high pm-SCL and lower event rates in (less sick) patients with low pm-SCL when treated with the antidepressant. Low circadian changes of SCL were always associated with higher event rates.

Acknowledgement/Funding

BMBF (Grant 01 KG0702) and Lundbeck A/S Denmark

Volumetric Description of Brain Atrophy in Neuronal Ceroid Lipofuscinosis 2: Supratentorial Gray Matter Shows Uniform Disease Progression

BACKGROUND AND PURPOSE

Experimental therapies for ceroid lipofuscinosis, neuronal, 2 (CLN2), a genetic disorder of childhood associated with progressive brain atrophy, are currently being developed. Because quantitative descriptions of the natural course of brain volume loss are needed to evaluate novel therapies, we performed MR imaging volumetry of patients with CLN2 to identify a suitable MR imaging marker of disease progression.

MATERIALS AND METHODS

Thirteen patients (8 females, 5 males) were recruited from a prospective natural disease cohort of patients with neuronal ceroid lipofuscinosis. Repeated MR imaging volumetric analysis (29 datasets) was performed by using the FreeSurfer Software Suite. Follow-up time ranged from 8 months to 5.3 years. MR imaging-segmented brain volumes were correlated to patient age and clinical scores.

RESULTS

Segmented brain volumes correlated significantly with patient age (lateral ventricles, r = 0.606, P = .001; supratentorial cortical GM, r = -0.913, P < .001; supratentorial WM, r = -0.865, P < .001; basal ganglia/thalamus, r = -0.832, P < .001; cerebellar GM, r = -0.659, P < .001; cerebellar WM, r = -0.830, P < .001) and clinical scores (lateral ventricles, r = -0.692, P < .001; supratentorial cortical GM, r = 0.862, P < .001; supratentorial WM, r = 0.735, P < .001; basal ganglia/thalamus, r = 0.758, P < .001; cerebellar GM, r = 0.609, P = .001; cerebellar WM, r = 0.638, P < .001). Notably, supratentorial cortical GM showed a uniform decline across the patient cohort. During late stages of the disease when the clinical score was zero, segmented brain volumes still correlated with patient age; this finding suggests that MR imaging volumetry allows quantitative assessment of disease progression at stages when it cannot be detected by clinical assessment alone.

CONCLUSIONS

Automated MR imaging volumetry, as a nonsubjective and highly sensitive tool, is feasible in CLN2 disease and provides a quantitative basis to evaluate novel experimental therapies.