The relationship between B-type natriuretic peptide and health status in patients with heart failure

BACKGROUND: Although B-type natriuretic peptide (BNP) levels have been proposed as a means of assessing disease severity in patients with heart failure, it is not known if BNP levels are correlated with health status (symptom burden, functional limitation, and quality of life). METHODS AND RESULTS: We studied 342 outpatients with systolic heart failure from 14 centers at baseline and 6 +/- 2 weeks with BNP levels and the Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific health status instrument. We assessed the correlation between KCCQ scores and BNP at baseline and changes in KCCQ according to changes in BNP levels between baseline and follow-up. Mean baseline BNP levels were 379 +/- 387 pg/mL and mean KCCQ summary scores were 62 +/- 23 points. Although baseline BNP and KCCQ were both associated with New York Heart Association classification (P < .001 for both), BNP and KCCQ were not correlated (r(2) = 0.008, P = .15). There was no significant relationship between changes in BNP and KCCQ regardless of the threshold used to define a clinically meaningful BNP change. For example, using >50% BNP change threshold, KCCQ improved by 3.7 +/- 14.2 in patients with decreasing BNP, improved by 1.7 +/- 13.6 in patients with no BNP change, and improved by 1.0 +/- 13.4 in patients with increasing BNP (P = .6). CONCLUSION: BNP and health status are not correlated in outpatients with heart failure in the short term. This suggests that these measures may assess different aspects of heart failure severity, and that physiologic measures do not reflect patients' perceptions of the impact of heart failure on their health status.     

Variability in the clinical status of patients with advanced heart failure

BACKGROUND: The importance of repeated clinical assessments of patients with heart failure is widely accepted. The frequency of such follow-up is not established and is likely to depend on the natural history and variability of patients' health status and the availability and use of appropriate treatments. METHODS AND RESULTS: We analyzed data from a multicenter prospective cohort study of heart failure outpatients comparing baseline variables including New York Heart Association (NYHA) class, summary score on the Kansas City Cardiomyopathy Questionnaire (KCCQ), and performance on a 6-minute walk test with results of a repeat evaluation at 6 weeks. We also compared patient and physician assessment of change in disease status among patients with advanced symptoms (NYHA class III with a recent antecedent hospitalization or class IV) and those with milder degrees of limitation (NYHA classes I, II, and stable III). Patients with advanced symptoms had greater short-term variability in health status as reflected by the KCCQ summary score and a visual analog scale. A greater proportion of patients with advanced heart failure experienced moderate or greater clinical change. Patient and physician global assessments were congruent with more direct measures of health status. CONCLUSION: Patients with advanced heart failure have greater short-term variability in status, supporting the need for frequent clinical follow-up and appropriate power calculations for clinical trials that are designed to measure meaningful changes over a short period.     

Safety and efficacy of enalapril in multivalvular heart disease with significant mitral stenosis--SCOPE-MS

Angiotensin-converting enzyme inhibitors (ACEI) are often used in preventing and treating heart failure due to regurgitant valve disease. The majority of patients with symptomatic rheumatic heart disease (RHD) have significant mitral stenosis (MS) and are denied ACEI therapy, because of the fear of hypotension in the presence of fixed obstruction. The authors assessed the safety and efficacy of ACEI in 109 consecutive patients with RHD and with significant mitral stenosis (mitral valve orifice, MVO < 1.5 cm2)and with NYHA class III or IV heart failure symptoms. Mean age was 33.1+/-12 years, systolic blood pressure (BP) was 111+/-10, and diastolic BP was 73+/-8 mm Hg. MS was significant in 100 patients with mitral regurgitation in 46, aortic regurgitation in 19, and pulmonary hypertension in 60 patients. After initial stabilization, enalapril 2.5 mg bid was started in hospital and titrated up to 10 mg bid over 2 weeks. NYHA status, Borg score, and 6-minute walk test were assessed at baseline, and at 1, 2, and 4 weeks. Seventy-nine of the 100 patients who completed the study had severe MS (MVO < 1.0 cm2). Enalapril was well tolerated by all study patients without hypotension or worsening of symptoms. NYHA class (3.2+/-0.5 baseline vs 2.3+/-0.5 at 4 weeks, p < 0.01) Borg Dyspnea Index (7.6+/-1.3 vs 5.6+/-1.3, p < 0.01), and 6-minute walk distance (226+/-106 vs 299+/-127 m, p < 0.01) improved significantly with enalapril. Patients with associated regurgitant lesions showed more improvement in exercise capacity (120+/-93 vs 39+/-56 m, p < 0.001). Enalapril was well tolerated in patients with RHD with moderate and severe MS. Irrespective of the valve pathology, enalapril improved functional status and exercise capacity with maximum benefit in patients with concomitant regurgitant valvular heart disease.     

Low-to-moderate alcohol intake and health status in heart failure patients

BACKGROUND: Although heart failure (HF) guidelines recommend alcohol abstinence, existing evidence indicates that alcohol may not worsen survival and no data about associations between alcohol and health status (patients' symptoms, function, and quality of life) exist. METHODS AND RESULTS: Alcohol use was quantified in 420 HF outpatients. The associations between moderate alcohol intake (1 to 60 drinks/month) and health status were assessed by comparing baseline and 1-year Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-12 (SF-12) scores between moderate and nondrinkers. No differences in baseline KCCQ or SF-12 scores between abstainers (n = 245) and moderate drinkers (n = 175) were observed (KCCQ 60.5 +/- 24 versus 61.9 +/- 23.5, P = .55; SF-12 Physical Component Score (PCS) 33.6 +/- 11.2 versus 35.3 +/- 10.2, P = .14; and SF-12 Mental Component Score (MCS) 49.1 +/- 11.1 versus 49.4 +/- 11.4, P = .78). Abstainers and drinkers also had similar 1-year KCCQ scores (65.8 +/- 24.5 versus 69.3 +/- 24.1, P = .23), mortality (10.5% versus 11.6%, P = .72) and HF hospitalizations (18.0% versus 15.4%, P = .51). Multivariable analyses controlling for baseline differences also revealed similar outcomes between abstainers and drinkers-1-year KCCQ change = 4.3 +/- 1.8 versus 5.2 +/- 2.5; P = .75), mortality (OR = 1.33, 95% CI 0.67-2.64), or HF hospitalization (OR = 1.13, 95% CI 0.60-2.11). CONCLUSION: No relationships between moderate alcohol consumption and health status or 1-year outcomes were identified in this multicenter observational study. These data do not support the need for complete alcohol abstinence for all HF patients among those who drink in moderation.     

Depression in patients with heart failure

BACKGROUND: Psychologic comorbidities, particularly depression, often accompany heart failure and add to the complexity of clinical management. We conducted a study to describe the prevalence of depression, the differences between patients with minimal versus mild to severe depression, and the correlates of depression in patients with heart failure. METHODS AND RESULTS: Data were collected from 200 patients with symptoms of heart failure resulting from systolic dysfunction. Psychologic assessment included depression, perceived control, neuroticism, educational needs, and social support/network. Patients were, on average, 57.0 (+/-12.1) years old, male (168, 84.0%), and in New York Heart Association (NYHA) class II or III (n=140, 70.0%) with a mean ejection fraction of 25.5+/-6.4%. They had an average maximal oxygen uptake of 15.8 (+/-4.6) mL x kg x min and 6-minute walk distance of 1345.0 (+/-302.1) feet. Minimal depression was described by 105 (52.5%) patients, mild by 62 (31%), moderate by 30 (15%), and severe by 3 (1.5%). The significant differences between patients with minimal depression compared to mild to severe depression were NYHA class (chi2=14.05, P=.003), maximal oxygen uptake (t=2.62, P=.010), 6-minute walk distance (t=4.22, P < .001), beta-blocker therapy (chi2=15.21, P < .001), perceived control (t=7.93, P < .001), and neuroticism (t=-8.85, P < .001). CONCLUSIONS: More than half the patients studied did not report experiencing significant depression. In those who did, both physical and psychosocial variables accounted for 48.6% of the variance. These findings warrant further research and indicate a need to test interventions aimed at enhancing perceived control, reducing neuroticism, and meeting educational needs to reduce depression in patients with heart failure.     

Validity of pedometers for measuring exercise adherence in heart failure patients

BACKGROUND: Measuring adherence to exercise is important to clinicians and researchers because inadequate adherence can adversely affect the effectiveness of an exercise program and cloud the relationship between exercise and clinical outcomes. Hence, assessment strategies for adherence to exercise, as with assessment strategies for other outcomes, must have demonstrated validity if they are to be employed with confidence. We conducted this study to determine the validity of pedometers as a measure of exercise adherence to a home-based walking program in heart failure patients. METHODS AND RESULTS: Exercise adherence was measured using pedometers in 38 patients (74% men) age 54.1 +/- 11.7 years who participated in a 12-month home-based walking program. A comparison of functional status as measured by the 6-minute walk distance and peak oxygen uptake (VO2 max) at 6 months into the exercise training program was made between 2 groups of participants who were thought to represent adherers and nonadherers: participants who demonstrated > or = 10% change in pedometer scores (n = 20) and those who showed no change in pedometer scores (n = 18) from baseline to 6 months. Patients who showed improvements in their pedometer scores over 6 months had better functional status at 6 months (6-minute walk distance 1718 +/- 46 versus 1012 +/- 25 meters, F = 5.699, P = .022; VO 2 max 17 +/- 0.7 versus 10 +/- 0.5 units, F = 7.162, P = .011) when compared with patients whose pedometers reflected minimal change in distance walked (ie, < or = 10%). CONCLUSION: Pedometers are inexpensive and readily available to both clinicians and researchers. The results of this study suggest that they may be a valid indicator of exercise adherence in heart failure patients who participate in a home-based walking program.     

Left ventricular-based cardiac stimulation post AV nodal ablation evaluation (the PAVE study)

BACKGROUND: Chronic right ventricular pacing has been reported to promote cardiac dyssynchrony. The PAVE trial prospectively compared chronic biventricular pacing to right ventricular pacing in patients undergoing ablation of the AV node for management of atrial fibrillation with rapid ventricular rates. METHODS AND RESULTS: One hundred and eighty-four patients requiring AV node ablation were randomized to receive a biventricular pacing system (n = 103) or a right ventricular pacing system (n = 81). The study endpoints were change in the 6-minute hallway walk test, quality of life, and left ventricular ejection fraction. Patient characteristics were similar (64% male; age: 69 +/- 10 years, ejection fraction: 0.46 +/- 0.16; 83%, NYHA Class II or III). At 6 months postablation, patients treated with cardiac resynchronization had a significant improvement in 6-minute walk distance, (31%) above baseline (82.9 +/- 94.7 m), compared to patients receiving right ventricular pacing, (24%) above baseline (61.2 +/- 90.0 m) (P = 0.04). There were no significant differences in the quality-of-life parameters. At 6 months postablation, the ejection fraction in the biventricular group (0.46 +/- 0.13) was significantly greater in comparison to patients receiving right ventricular pacing (0.41 +/- 0.13, P = 0.03). Patients with an ejection fraction 相似文献   

Patient preferences for heart failure treatment: utilities are valid measures of health-related quality of life in heart failure.

BACKGROUND: Current standards hold that cost-effectiveness analyses should incorporate measures of both quantity and quality of life, and that quality of life in this context is best measured by a utility. We sought to measure utility scores for patients with heart failure and to assess their validity as measures of health-related quality of life (HRQL). METHODS AND RESULTS: We studied 50 patients with heart failure. We measured utilities with the time trade-off technique, exercise capacity with a 6-minute walk test, and HRQL with the Minnesota Living With Heart Failure questionnaire, the Medical Outcomes Study Short Form-36 (SF-36) questionnaire, and a visual analogue score. Validity was assessed by establishing correlation between utilities and these other measures. Mean utility score was 0.77 +/- 0.28. There were significant (P < .05) curvilinear relationships between utility score and visual analogue score, the physical function summary scale of the SF-36, 6-minute walk distance, and the Living With Heart Failure score. Utility scores on retest at 1 week were unchanged in a subset of 12 patients. Utilities did not vary systematically with age, sex, or ethnicity. CONCLUSION: Utilities are valid measures of HRQL in patients with heart failure, and cost-effectiveness analyses of heart failure treatments incorporating utilities in the outcome measure can be meaningful.     

Transcatheter transplantation of autologous skeletal myoblasts in postinfarction patients with severe left ventricular dysfunction.

PURPOSE: To report a case-controlled safety and feasibility study of transcatheter transplantation of autologous skeletal myoblasts as a stand-alone procedure in patients with ischemic heart failure. METHODS: Six men (mean age 66.2+/-7.2 years) were eligible for transcatheter transplantation of autologous skeletal myoblasts cultured from quadriceps muscle biopsies. Six other men (mean age 65.7+/-6.3 years) were selected as matched controls (no muscle biopsies). A specially designed injection catheter was advanced through a femoral sheath into the left ventricle cavity, where myoblasts in solution (0.2 mL/injection) were injected into the myocardium via a 25-G needle. At baseline and in follow-up, both groups underwent Holter monitoring, a 6-minute walk test, New York Heart Association (NYHA) class determination, and echocardiography with dobutamine challenge. RESULTS: Skeletal myoblast transplantation was technically successful in all 6 patients with no complications; 19+/-10 injections were performed per patient (210 x 10(6)+/-150 x 10(6) cells implanted per patient). Left ventricular ejection fraction (LVEF) rose from 24.3%+/-6.7% at baseline to 32.2%+/-10.2% at 12 months after myoblast implantation (p=0.02 versus baseline and p<0.05 versus controls); in matched controls, LVEF decreased from 24.7%+/-4.6% to 21.0%+/-4.0% (p=NS). Walking distance and NYHA functional class were significantly improved at 1 year (p=0.02 and p=0.001 versus baseline, respectively), whereas matched controls were unchanged. CONCLUSIONS: Transcatheter transplantation of autologous skeletal myoblasts for severe left ventricular dysfunction in postinfarction patients is feasible, safe, and promising. Scrutiny with randomized, double-blinded, multicenter trials appears warranted.     

Nonexcitatory, cardiac contractility modulation electrical impulses: Feasibility study for advanced heart failure in patients with normal QRS duration

BACKGROUND: Cardiac contractility modulation signals are associated with acutely improved hemodynamics, but chronic clinical impact is not defined. OBJECTIVES: The purpose of this randomized, double-blind, pilot study was to determine the feasibility of safely and effectively delivering cardiac contractility modulation signals in patients with heart failure. METHODS: Forty-nine subjects with ejection fraction <35%, normal QRS duration (105 +/- 15 ms), and New York Heart Association (NYHA) class III or IV heart failure despite medical therapy received a cardiac contractility modulation pulse generator. Patients were randomized to have their devices programmed to deliver cardiac contractility modulation signals (n = 25, treatment group) or to remain off (n = 24, control group) for 6 months. Evaluations included NYHA class, 6-minute walk, cardiopulmonary stress test, Minnesota Living with Heart Failure Questionnaire, and Holter monitoring. RESULTS: Although most baseline features were balanced between groups, ejection fraction (31.4% +/- 7.4% vs 24.9% +/- 6.5%, P = .003), end-diastolic dimension (52.1 +/- 21.4 mm vs 62.5 +/- 6.2 mm, P = .01), peak VO(2) (16.0 +/- 2.9 mL O(2)/kg/min vs 14.3 +/- 2.8 mL O(2)/kg/min, P = .02), and anaerobic threshold (12.3 +/- 2.5 mL O(2)/kg/min vs 10.6 +/- 2.4 mL O(2)/kg/min, P = .01) were worse in the treatment group than in the control group. Nevertheless, one death occurred in the control group, and more patients in the treatment group were free of hospitalization for any cause at 6 months (84% vs 62%). No change in ectopy was observed. Compared with baseline, 6-minute walk (13.4 m), peak VO(2) (0.2 mL O(2)/kg/min), and anaerobic threshold (0.8 mL O(2)/kg/min) increased more in the treatment group than in control. None of these differences were statistically significant (small sample size). NYHA and Minnesota Living with Heart Failure Questionnaire changed similarly in the two groups. CONCLUSION: Despite a sicker population in the treatment group, no specific safety concerns emerged with chronic cardiac contractility modulation signal administration. Further study is required to definitively define the safety and efficacy of cardiac contractility modulation signals.     

Bedside B-type natriuretic peptide and functional capacity in chronic heart failure

OBJECTIVES: To determine if B-type natriuretic peptide (BNP) measurement could be useful in determination of functional capacity in patients suffering from chronic heart failure. BACKGROUND: Evaluating functional capacity is a crucial factor in the follow-up of patients with chronic heart failure. There are numerous methods for measuring functional capacity and their relative merits remain under discussion. Clinical classifications are very subjective and other methods are difficult to use in clinical practice. METHODS: We evaluated functional capacity in 151 consecutive patients using the 6-min walk test. All patients were clinically classified using the New York Heart Association (NYHA) classification. We measured BNP plasma levels using a bedside BNP test. RESULTS: Six minute walk test performance decreased through NYHA classes 1 to 4 (469+/-87, 411+/-82, 325+/-83 and 196+/-63 m, respectively, P<0.01) and BNP levels increased through NYHA classes 1 to 4 (26.3+/-7.2, 73+/-13, 401+/-74 and 924+/-84 pg/ml, respectively, P<0.001). There was a significant correlation between 6-min walk test performance and BNP plasma levels (R=0.69 P<0.001) and a weaker correlation between BNP and left ventricular ejection fraction (R=0.45 P<0.04). In some patients there was a mismatch between NYHA classification and 6-min walk test performance. In all cases BNP could correct the clinical estimation of functional capacity. When we divided the patients into three sub-groups within each NYHA class, we showed that using BNP could better define functional capacity in patients suffering from chronic heart failure in NYHA classes I to III. CONCLUSION: The measurement of BNP levels thus usefully supplements the clinical examination. The existence of bedside BNP testing methods facilitates its use in routine clinical practice. It also permits easier follow-up of patients with chronic heart failure.     

Heart rate behaviour at different stages of congestive heart failure.

Depressed heart rate variation has been shown to predict a high mortality rate in patients with severe congestive heart failure. To determine whether the degree of altered heart rate correlates with the clinical state, 24-h Holter monitoring was performed in 21 patients (mean ejection fraction: 18 +/- 11%) at baseline and after 6 months of oral therapy. At baseline, the overall 24-h heart rate variation and night/day heart rate ratio was reduced, depending on the NYHA functional class. The typical morphology of R-R interval histograms was a sensitive marker of the clinical state at baseline: the higher the NYHA class, the smaller the R-R interval variability and standard deviation of R-R intervals (total variability NYHA III versus II: P less than 0.05). Clinical deterioration after 6 months (n = 8) was accompanied by a tendency to further shortening of the mean total R-R interval variability (676 +/- 34 to 586 +/- 25 ms). This was shown in three patients, who were reclassified to NYHA class IV. In stable patients (n = 5) and those with clinical improvement (n = 8) no significant change in R-R variability was observed. It is concluded that variations in R-R interval histogram shapes correspond to different NYHA functional classes. While severe clinical disease progression may be associated with further reductions in the heart rate variability, improvement in the clinical state of congestive heart failure is not necessarily associated with changes in heart rate behaviour.     

Effect of biventricular pacing on heart rate variability in patients with chronic heart failure

BACKGROUND: Biventricular pacing is emerging as a long-term therapy for symptomatic heart failure. Analysis of heart rate variability (HRV) has become an important predictive tool in this syndrome. AIM OF THE STUDY: To assess whether chronic resynchronization therapy can affect HRV in patients with heart failure. METHODS AND RESULTS: Thirteen patients with heart failure were studied (mean age+/-1 S.E. 65+/-2.2 years, QRS 195+/-5.3 ms, NYHA class 3.2+/-0.1, LVEF 21+/-1.7%). The protocol included a preliminary no pacing period for 1 month following device implantation. Twenty-four hour Holter ECG recordings were performed at the end of this period (baseline) and after 3 months of biventricular stimulation (VDD mode). Prior to and following pacing patients underwent NYHA class evaluation, 6-min walk test, Quality of Life Assessment and a cardiopulmonary exercise test. Biventricular pacing improved functional class (P<0.0001) and Quality of life (P<0.0001), increased 6-min walk distance, (P=0.008) and exercise duration (P<0.0001) but had no significant effect on peak exercise VO(2). Resynchronization therapy increased mean 24-h RR (922+/-58 vs. 809+/-41 ms at baseline, P=0.006), SDNN (111+/-11 vs. 83+/-8 ms, P=0.003), SDNN-I (56+/-10 vs. 40+/-5 ms, P=0.02), rMSSD (66+/-14 vs. 41+/-8 ms, P=0.003), Total Power (5724+/-1875 vs. 2074+/-553 ms(2), P=0.03), Ultra Low Frequency Power (1969+/-789 vs. 653+/-405 ms(2), P=0.03) and Very Low Frequency Power (2407+/-561 vs. 902+/-155 ms(2), P=0.004). CONCLUSION: Biventricular pacing in heart failure improves autonomic function by increasing HRV. This may have important prognostic implications.     

心脏再同步化治疗心衰的手术操作和疗效回顾

目的:探讨和总结心脏再同步化治疗(CRT)器治疗心衰的疗效。方法:21例心功能Ⅲ～Ⅳ级的心力衰竭患者,符合左室射血分数(LVEF)35%、心电图QRS波宽度≥160ms、左室舒张末期内径60mm的CRT建议标准。评价手术时间、X线曝光时间和术前后的单次最远行走距离、6min步行距离、NYHA心功能分级。结果:经左侧(n=20)和右侧锁骨下静脉(n=1)CRT的手术时间分别为(143.3±30.8)min和235min,而X线曝光时间分别为(19.7±15.5)min和75min;CRT术后单次最远行走距离显著增加[(921.7±253.8)m:(675.8±172.1)m,P0.01],6min步行距离术后较术前显著增加[(409.8±43.6)m:(292.5±55.6)m,P0.01],而NYHA心功能IV级者所占的百分率术后比术前显著减少(23.8%:85.7%,P0.01)。结论:对左室射血分数35%、心电图QRS波宽度≥160ms、左室舒张末期内径60mm的心衰患者,行CRT可显著改善6min步行距离和NYHA心功能分级。     

Trimetazidine in correction of chronic heart failure in patients with ischemic heart disease

Twenty patients with NYHA class II-IV heart failure and ejection fraction below 40% received standard therapy (control period) or standard therapy plus open trimetazidine (20 mg t.i.d.) for 3 months in a cross-over design. Therapy with trimetazidine was associated with attenuation of clinical signs of heart failure (average NYHA class 2.90-/+0.10, 2.27-/+0.20 and 2.88-/+0.13, p<0.05, at baseline, after trimetazidine and control period, respectively), improvement of results of 6-minute walk test (average distance 321-/+19, 375-/+20 m, p<0.02, and 303-/+17 m at baseline, after trimetazidine and control period, respectively), increase of left ventricular ejection fraction (from 34.1-/+2.0 to 38.1-/+1.8%, p<0.05) and improvement of quality of life. Thus in patients with heart failure addition of trimetazidine to standard therapy for 3 months produced positive effect on clinical and hemodynamic status, exercise tolerance and quality of life.     

Long-term follow-up of cardiac resynchronization therapy in patients with end-stage heart failure

Long-term follow-up of cardiac resynchronization therapy. INTRODUCTION: Cardiac resynchronization therapy (CRT) has been introduced to treat patients with end-stage heart failure, and results of this technique are promising. The aim of our study was to assess the sustained benefit of CRT in a large patient cohort with end-stage heart failure at long-term follow-up. In addition, the prognosis of responders and nonresponders was evaluated. METHODS AND RESULTS: 125 patients with end-stage heart failure, NYHA class III or IV, LVEF<35%, QRS duration>120 msec and left bundle branch block morphology received a biventricular device. At baseline and 6 months after implantation the following parameters were evaluated: NYHA class, Minnesota Quality of life score, QRS duration on surface ECG, 6-minute walking distance and LVEF. Follow-up was obtained up to 3 years. After 6 months, patients were divided in clinical responders and nonresponders according to improvement in NYHA class. All clinical parameters improved significantly at 6-month follow-up. Hospitalization for heart failure was 3.8+/-4.9 days/year before and 0.7+/-1.6 days/year after CRT. Survival at 1-, 2-, and 3-year follow-up was 93%, 88%, and 85%, respectively. Responders (78%) showed a significantly better survival than nonresponders at 2- and 3-year follow-up (96% and 93% for responders versus 81% and 73% for nonresponders, P<0.05). CONCLUSION: The improvement in functional status and symptoms after CRT is maintained at long-term follow-up (up to 3 years). The clinical improvement was associated with a significant reduction in hospitalization rate which was also maintained over the years. Preimplantation selection of responders may result in even better long-term survival.     

Correlates of health-related quality of life among lower-income, urban adults with congestive heart failure

BACKGROUND: Improving health-related quality of life (HRQL) is a primary goal in the treatment of patients with congestive heart failure (CHF), yet few studies have explored correlates of HRQL among CHF patients. OBJECTIVES: We report on the association of demographic and pathophysiologic measures, social-cognitive measures, and environmental variables with HRQL as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), Chronic Heart Failure (CHQ), and a single question of perceived overall health (PH). METHODS: Cross-sectional data were obtained from the baseline interview and electronic medical records of 212 patients 50 years of age and older who were enrolled during the first 7 months of a medication adherence study. RESULTS: Mean age was 63; 32% were male; 53% were black; the mean Charlson comorbidity score was 3.7; and the mean New York Heart Association class was 2.1. Correlations between KCCQ and CHQ subscale scores and PH ranged from 0.16 to 0.37. Multivariate regression analyses showed that the pathophysiologic measures ejection fraction and comorbidity were not associated with any of the HRQL measures. Overall PH was associated with greater age and more positive health beliefs. Persons of greater age, males, and black respondents had higher CHF-specific HRQL scores, as did persons reporting more positive health beliefs, greater income, social support, and communication with their physician. Variance explained ranged from 14 to 33%. CONCLUSION: These cross-sectional data highlight the potential significance of social and behavioral factors in CHF-specific HRQL.     

Heart failure disease management in an indigent population

BACKGROUND: Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pretransplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates. METHODS AND RESULTS: We studied 35 patients with heart failure with left ventricular ejection fraction (EF) /=2 per year (group A) and 21 patients referred by their primary care physicians because they were difficult to manage (group B). Group A patients were New York Heart Association (NYHA) class III or IV, aged 25 to 87 years (mean 57 +/- 17 SD) and had an EF of 15% to 45% (29% +/- 11%). Group B patients were NYHA class II or III, aged 35 to 86 (57 +/- 16) years and had an EF of 20% to 45% (28% +/- 10%). Data were compared for the year before enrollment in the MDMP and the year afterward. In group A hospital admissions decreased from 33 to 3, a 91% reduction, and NYHA class improved to class II-III (P <.001). In group B hospital admissions decreased from 9 to 0, and NYHA class improved to class I-II (P <.001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000 per year or $4600 per patient. CONCLUSIONS: A multidisciplinary heart failure program can improve functional status and reduce hospitalization and net costs compared with conventional care in indigent non-transplant candidate patients.     

Effect of exercise training in patients with heart failure: a pilot study on autonomic balance assessed by heart rate variability.

BACKGROUND: Heart rate variability (HRV) is decreased in patients with congestive heart failure (CHF) and is a prognostic marker in this disease. Exercise training is now regarded as an important part of the treatment of patients with CHF, but the effect on HRV and the association between this effect and the effect on neurohormones are not well assessed. METHODS: Heart rate recording was performed in 12 patients with CHF (mean age 67+/-8 years) with CHF NYHA functional class III, before and after 12 weeks of exercise training. The association with exercise capacity and serum levels of atrial natriuretic peptide was assessed. We also evaluated the correlation between HRV and survival at follow-up 87 months later. RESULTS: At baseline there was a significant correlation between mean heart rate and work performed during max cycle test (r=0.650, P=0.022) and the HRV parameter standard deviation normal to normal (SDNN) (r=0.678, P=0.015). After exercise training there was a significant increase in work performed (30.3+/-14.2 versus 38.1+/-14.1 kJ), 6-min walk test (502+/-88 versus 552+/-59 m, P=0.006) and SDNN (117.3+/-40.7 versus 128.6+/-42.3 ms, P=0.028). At 87 months of follow-up, there was a borderline significant difference between survivors and non-survivors. Only the survivors had a significant increase in SDNN after exercise training. CONCLUSION: This pilot study demonstrates an improvement with regard to parameters for HRV after exercise training in patients with CHF. The study suggests that the positive effect of exercise training in patients with CHF involves an attenuation of the reduced HRV response, and that this improvement might have prognostic significance.     

心脏再同步化联合美托洛尔缓释片治疗老年扩张型心肌病心力衰竭的临床观察

目的观察心脏再同步化(cardiac resynchronization therapy,CRT)联合美托洛尔缓释片治疗老年扩张型心肌病顽固性心力衰竭的疗效。方法回顾性分析2010年6月至2012年3月绍兴第二医院,药物治疗效果不佳行右心房加CRT的老年扩张型心肌病顽固性心力衰竭患者21例的临床资料。18例患者植入右心房、右心室和冠状静脉左心室分支电极导线,行房室顺序CRT;3例心房颤动患者植入右心室和冠状静脉左心室分支电极导线。所有患者均服用美托洛尔缓释片,剂量(62.45±18.25)mg。术后4周、12周跟踪随访患者,观察心功能分级、6 min步行距离的变化、左心室舒张末期内径,左心室射血分数及二尖瓣反流。结果右心房、右心室和左心室导线感知和起搏参数均符合起搏要求,随访中亦未发现导线移位和功能障碍。起搏后QRS间期明显缩短,差异有统计学意义[(126±18)ms vs.(156±23)ms,P<0.05]。术后随访4周心功能分级提高到Ⅱ～Ⅲ级,左心室舒张末期内径为(62.5±17.6)mm,射血分数40%±13%,二尖瓣中度反流,6 min步行距离(486±189)m;12周时随访左心室舒张末期内径(56.5±12.4)mm,射血分数46%±17%,二尖瓣轻中度反流,6 min步行距离(565±139)m。结论CRT联合美托洛尔缓释片治疗可以缓解老年扩张型心肌病顽固性心力衰竭患者的症状,改善心功能,提高运动耐量,减轻二尖瓣反流。