Predictors of health status for heart failure patients

Health status is poorly understood for patients with heart failure. The purpose of this study was to determine the relative importance of relevant sociodemographic, clinical, health perception, and emotional variables in predicting health status. In this study of 87 patients, health status was conceptualized as health-related quality of life, physical activity level, and symptom burden. Hierarchical multiple regression was used to determine sociodemographic, clinical health perception, and emotional variables associated with health status. Worse New York Heart Association class, higher anxiety, and higher depression predicted worse health-related quality of life. Better New York Heart Association class and higher anxiety predicted higher levels of physical activity. Worse New York Heart Association class and higher depression predicted greater symptom burden. Traditional demographic and clinical variables were not associated with health status. Although not routinely assessed, emotional variables had a major impact on health status. Interventions to improve health status should target both physical and emotional well-being.     

Patient-reported economic burden and the health status of heart failure patients

BackgroundHeart failure (HF) guidelines recommend treatment with multiple medications to improve survival, functioning, and quality of life. Yet, HF treatments can be costly, resulting in significant economic burden for some patients. To date, there are few data on the impact of patients' perceived difficulties in affording medical care on their health outcomes.Methods and ResultsComprehensive clinical data, health status, and the perceived economic burden of 539 HF outpatients from 13 centers were assessed at baseline and 1 year later. Health status was quantified with the Kansas City Cardiomyopathy Questionnaire overall summary score. Cross-sectional and longitudinal (1-year) analyses were conducted comparing the health status of patients with and without self-reported economic burden. Patients with economic burden had significantly lower health status scores at both baseline and 1 year later. Although baseline perceptions of economic burden were associated with poorer health status, patients' perceived difficulty affording medical care at 1 year was a more important determinant of lower 1-year health status.ConclusionHF patients reporting difficulty affording their medical care had lower perceived health status than those reporting little to no economic burden. More research is needed to further evaluate this association and to determine whether addressing perceived economic difficulties affording health care can improve HF patients' health status.     

Difficulty taking medications, depression, and health status in heart failure patients

BackgroundLittle is known about medication nonadherence in heart failure populations. We evaluated the association between 1 aspect of medication nonadherence, patient-reported difficulty taking medications as directed, and health status among heart failure outpatients, and then examined whether this association was explained by depression.Methods and ResultsA total of 522 outpatients with left ventricular ejection fraction <0.40 completed clinical evaluation, Kansas City Cardiomyopathy Questionnaire (KCCQ), Medical Outcomes Study-Depression questionnaire, and categorized their difficulty taking medications (5-level Likert-scale question). Multivariable regression was used to evaluate the cross-sectional association between difficulty taking medications and health status, with incremental adjustment for medical history and depressive symptoms. Patients with difficulty taking medications (n = 64; 12.2%) had worse health status (8.2 ± 2.7 point lower mean KCCQ summary scores; P = .008) and more depressive symptoms (43.8% versus 27.1%; P = .006). Adjusting for demographic and clinical factors had little effect on the association between difficulty taking medications and health status (8.0 ± 3.2 point lower KCCQ scores; P = .01); however, the relationship was attenuated with adjustment for depressive symptoms (4.7 ± 2.9 point lower KCCQ scores; P = .11).ConclusionsAmong heart failure outpatients, difficulty taking medications is associated with worse health status. This association appears to be explained, in part, by coexistent depression. Future studies should evaluate interventions such as depression treatment to improve medication adherence and health status.     

Impact of obesity on the health status of heart failure patients

BackgroundObesity is a recognized, preventable risk factor for the development of heart failure (HF); however, little is understood about its effects on patients with established HF. Furthermore, few researchers have assessed obesity's effect on the health status of established HF patients. This study evaluated the influence of obesity on the health status, at baseline and 1 year later, on patients with established HF.Methods and ResultsComprehensive clinical data, health status, and obesity classification of 543 HF outpatients from 13 centers was assessed at baseline and 1 year later. Health status was quantified with the generic Short Form-12 and disease-specific Kansas City Cardiomyopathy Questionnaire Overall Summary score. Cross-sectional and longitudinal risk-adjusted general linear models were computed comparing the health status of patients who were classified as either underweight, normal weight, overweight, or obese. Obesity classification was not significantly associated with patients' baseline health status and did not predict 1-year health status.ConclusionsAlthough obesity has been reported to confer a survival advantage to patients with HF, it was not associated with better health status at baseline, or after 1 year, in our cohort. Better understanding of the relationship among HF, body weight, and health status is needed before evidence-based recommendations can be made regarding weight management for HF patients.     

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.     

Association of functional and health status measures in heart failure

BackgroundA wide variety of instruments have been used to assess the functional capabilities and health status of patients with chronic heart failure (HF), but it is not known how well these tests are correlated with one another, nor which one has the best association with measured exercise capacity.Methods and ResultsForty-one patients with HF were assessed with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing, the Duke Activity Status Index (DASI), the Veterans Specific Activity Questionnaire (VSAQ), the Kansas City Cardiomyopathy Questionnaire (KCCQ), and 6-minute walk distance. Pretest clinical variables, including age, resting pulmonary function tests (forced expiratory volume in 1 s and forced vital capacity), and ejection fraction (EF) were also considered. The association between performance on these functional tools, clinical variables, and exercise test responses including peak VO₂ and the VO₂ at the ventilatory threshold, was determined. Peak oxygen uptake (VO₂) was significantly related to VO₂ at the ventilatory threshold (r = 0.76, P < .001) and estimated METs from treadmill speed and grade (r = 0.72, P < .001), but had only a modest association with 6-minute walk performance (r = 0.49, P < .01). The functional questionnaires had modest associations with peak VO₂ (r = 0.37, P < .05 and r = 0.26, NS for the VSAQ and DASI, respectively). Of the components of the KCCQ, peak VO₂ was significantly related only to quality of life score (r = 0.46, P < .05). Six-minute walk performance was significantly related to KCCQ physical limitation (r = 0.53, P < .01) and clinical summary (r = 0.44, P < .05) scores. Among pretest variables, only age and EF were significantly related to peak VO₂ (r = −0.58, and 0.46, respectively, P < .01). Multivariately, age and KCCQ quality of life score were the only significant predictors of peak VO₂, accounting for 72% of the variance in peak VO₂.ConclusionCommonly used functional measures, symptom tools, and quality of life assessments for patients with HF are poorly correlated with one another and are only modestly associated with exercise test responses. These findings suggest that exercise test responses, non-exercise test estimates of physical function, and quality of life indices reflect different facets of health status in HF and one should not be considered a surrogate for another.     

Assessing health literacy in heart failure patients

Background

Health literacy has important implications for health interventions and clinical outcomes. The Shortened Test of Functional Health Literacy in Adults (S-TOFHLA) is a timed test used to assess health literacy in many clinical populations. However, its usefulness in heart failure (HF) patients, many of whom are elderly with compromised cognitive function, is unknown. We investigated the relationship between the S-TOFHLA total score at the recommended 7-minute limit and with no time limit (NTL).

Methods and Results

We enrolled 612 rural-dwelling adults with HF (mean age 66.0 ± 13.0 years, 58.8% male). Characteristics affecting health literacy were identified by multiple regression. Percentage of correct scores improved from 71% to 86% (mean percent change 15.1 ± 18.1%) between the 7-minute and NTL scores. Twenty-seven percent of patients improved ≥1 literacy level with NTL scores (P < .001). Demographic variables explained 24.2% and 11.1% of the variance in % correct scores in the 7-minute and the NTL scores, respectively. Female gender, younger age, higher education, and higher income were related to higher scores.

Conclusion

Patients with HF may be inaccurately categorized as having low or marginal health literacy when the S-TOFHLA time limits are enforced. New ways to assess health literacy in older adults are needed.     

Association between the nurse-led program with mental health status,quality of life,and heart failure rehospitalization in chronic heart failure patients

The nurse-led program is associated with a short-term improvement of mental health status (MHS) and quality of life (QOL) in patients with chronic heart failure (CHF). Nonetheless, the long-term effect of this program is undetermined. The aims of the current study were to evaluate the 1-year effects of the nurse-led program on MHS, QOL, and heart failure (HF) rehospitalization among patients with CHF.CHF patients in the control group received standard care, and patients in the treatment group received standard care plus telehealth intervention including inquiring patients’ medical condition, providing feedbacks, counseling and providing positive and emotional talk with the patients. At the third, sixth, and twelfth month''s follow-up, patients were called by registered nurses to assess the Mental Health Inventory-5 (MHI-5) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. HF rehospitalization was also assessed.A total of 300 patients were included and 46% (n = 138) of the patients were in the treatment group. There were no significant between-group differences in the MHI-5 and KCCQ scores at baseline. In the control group, the MHI-5 score was gradually decreased with follow-up and the score was significantly lower than that in the treatment group since the third month''s follow-up (63.5 ± 10.6 vs 73.6 ± 10.3). Compared with the treatment group, KCCQ score was lower in the control group from the third month''s follow-up (64.3 ± 10.6 vs 73.5 ± 12.3) until the end of the twelfth months’ follow-up (45.3 ± 11.2 vs 60.8 ± 11.1). During 12 months’ follow-up, the proportion of patients who experienced HF rehospitalization was lower in the treatment group (19.6% vs 24.1%). After adjusting for covariates, the utilization of the nurse-led program, and increase of MHI-5 and KCCQ scores were associated with reduced risk of HF rehospitalization.The nurse-led program is beneficial for the improvement of MHS and QOL for CHF patients, which might contribute to the reduction of HF rehospitalization.     

Adequate energy-protein intake is not enough to improve nutritional and metabolic status in muscle-depleted patients with chronic heart failure

BACKGROUND: An adequate energy-protein intake (EPI) when combined with amino acid supplementation may have a positive impact on nutritional and metabolic status in patients with chronic heart failure (CHF). METHODS AND RESULTS: Thirty eight stable CHF patients (27 males, 73.5+/-4 years; BMI 22.5+/-1.4 kg/m2), with severe depletion of muscle mass and were randomised to oral supplements of essential amino acids 8 g/day (EAA group; n=21) or no supplements (controls; n=17). All patients had adequate EPI (energy> or =30 kcal/kg; proteins >1.1 g/kg). At baseline and 2-months after randomisation, the patients underwent metabolic (plasma lactate, pyruvate concentration; serum insulin level; estimate of insulin resistance by HOMA index), nutritional (measure of nitrogen balance), and functional (exercise test, walking test) evaluations. Body weight increased by >1 kg in 80% of supplemented patients (mean 2.96 kg) and in 30% of controls (mean 2.3 kg) (interaction <0.05). Changes in arm muscle area, nitrogen balance, and HOMA index were similar between the two treatment groups. Plasma lactate and pyruvate levels increased in controls (p<0.01 for both) but decreased in the supplemented group (p<0.01 and 0.02 respectively). EAA supplemented patients but not controls improved both exercise output and peak oxygen consumption and walking test. CONCLUSIONS: Adequate EPI when combined with essential amino acid supplementation may improve nutritional and metabolic status in most muscle-depleted CHF patients.     

Depression and health status in patients with advanced heart failure: a prospective study in tertiary care

BACKGROUND: Depression impairs health status among patients with coronary disease. The effect of depression on patients with heart failure has been studied to date only in hospitalized patients. METHODS AND RESULTS: Prospective cohort study of 113 outpatients with advanced heart failure. At baseline, 19% (n = 21) had major depression or dysthymia, 9% (n = 10) had minor depression, and 72% (n = 82) had no current depression diagnosis. Repeated measures analyses of covariance adjusting for demographic and clinical differences demonstrated that the depression groups differed on observed function (6-minute walk distance [F = 4.8, P = .01]), and self-reported generic (SF-36) and disease-specific (Kansas City Cardiomyopathy Questionnaire) health status. Depression groups also differed in severity of self-reported breathlessness, chest pain, and fatigue. Subject- and spouse-reported role function also differed between the groups. Partial correlation (controlling for the same covariates) between baseline Hamilton Depression Scale scores and these outcomes was highly significant at baseline and follow-up. CONCLUSIONS: Depression is prospectively associated with poorer health status in patients with advanced heart failure. Physical and role function, symptom severity, and quality of life are all significantly affected.     

Dietary fat intake and proinflammatory cytokine levels in patients with heart failure

BACKGROUND: Dietary fat intake affects proinflammatory cytokine levels of healthy adults. Whether dietary fats have similar effects in patients with heart failure (HF) is unknown. The purposes of this study were to determine (1) effect of dietary fat on interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, and soluble receptors sTNF-R1 and sTNF-R2 levels in patients with HF and (2) subsequent impact of these levels on event-free survival. METHODS AND RESULTS: Forty-two patients provided 4-day food diaries and blood for cytokines. Event-free survival curves were calculated by Kaplan-Meier method and groups compared using log-rank test. IL-6 was not related to fat intake. TNF-alpha levels were elevated in patients with diets higher versus lower in saturated (6.9 +/- 5 versus 4.2 +/- 2 pg/mL) and trans fats (6.8 +/- 4.5 versus 4.5 +/- 2.8 pg/mL). Patients consuming diets higher in polyunsaturated fats had lower sTNF-R1 (2391 +/- 1010 versus 3373 +/- 2098 pg/mL) and sTNF-R2 (3803 +/- 1187 versus 5974 +/- 3275 pg/mL) levels. Higher omega-3 intake produced similar results: sTNF-R1 (2323 +/- 1304 versus 3307 +/- 1973) and sTNF-R2 (4117 +/- 2646 versus 5409 +/- 2801). Event-free survival was decreased in patients with higher TNF-alpha and sTNF-R1 levels. CONCLUSION: Dietary fat intake may affect proinflammatory cytokine levels in patients with HF. Research to determine whether changing composition of dietary fat can alter proinflammatory cytokine activity of HF patients is warranted.     

Reduction in alcohol consumption and health status

Aims This study investigated the association between alcohol consumption and health status using cross‐sectional national survey data. Measurements and design This study relied upon self‐report data collected by the 2004 and 2007 Australian National Drug Strategy Household (NDSH) surveys. Households were selected using a multi‐stage, stratified‐area, random sample design. Both surveys used combinations of the drop‐and‐collect and computer‐assisted telephone interview approaches. Respondents were questioned about their current and past drinking, the presence of formal diagnosis for specific diseases (heart disease, type 2 diabetes, hypertension, cancer, anxiety, depression) and self‐perceived general health status. Associations between drinking status, the presence of diagnoses and self‐perceptions of general health status among respondents aged 18+ and 45+ were assessed using multivariate logistic regression. Setting and participants Males and females aged 18 years or older and resident in Australia. The sample sizes for the 2004 and 2007 NDSH surveys were 24 109 and 23 356, respectively. Findings Respondents with a diagnosis of diabetes, hypertension and anxiety were more likely to have reduced or stopped alcohol consumption in the past 12 months. The likelihood of having reduced or ceased alcohol consumption in the past 12 months increased as perceived general health status declined from excellent to poor. Conclusions Experience of ill health is associated with subsequent reduction or cessation of alcohol consumption. This may at least partly underlie the observed ‘J‐shape’ function relating alcohol consumption to premature mortality.     

Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure

OBJECTIVES: The purpose of this study was to assess whether depressive symptoms are independently associated with changes in heart failure (HF)-specific health status. BACKGROUND: Depression is common in patients with HF, but the impact of depressive symptoms on the health status of these patients over time is unknown. METHODS: We conducted a multicenter prospective cohort study of outpatients with HF. Data from 460 patients who completed a baseline Medical Outcomes Study-Depression Questionnaire and both a baseline and follow-up (6 +/- 2 weeks) Kansas City Cardiomyopathy Questionnaire (KCCQ) were analyzed. The KCCQ measures HF-specific health status, including symptoms, physical and social function, and quality of life. Multivariable regression was used to evaluate depressive symptoms as a predictor of change in KCCQ scores, adjusting for baseline KCCQ scores and other patient variables. The primary outcome was change in KCCQ summary scores (range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change). RESULTS: Approximately 30% (139/460) of the patients had significant depressive symptoms at baseline. Depressed patients had markedly lower baseline KCCQ summary scores (beta = -19.6; p < 0.001). After adjustment for potential confounders, depressed patients were at risk for significant worsening of their HF symptoms, physical and social function, and quality of life (average change in KCCQ summary score = -7.1 points; p < 0.001). Depressive symptoms were the strongest predictor of decline in health status in the multivariable models. CONCLUSIONS: Depressive symptoms are a strong predictor of short-term worsening of HF-specific health status. The recognition and treatment of depression may be an important component of HF care.     

Dietary intake of various nutrients in older patients with congestive heart failure

BACKGROUND AND AIMS: Anorexia, nausea and premature satiety with eating, prevalent in congestive heart failure (CHF), have been held responsible for reduced dietary intake and deficiency of magnesium, potassium and probably other nutrients. Since solid data is not available, this study was undertaken with the following aims (1) to assess dietary intake in CHF, (2) to compare dietary intake in older CHF patients with a similar patient population free of CHF (control group), and (3) to evaluate these data in patients with moderate versus severe CHF. METHODS AND RESULTS: Dietary intake of 57 consecutively hospitalized furosemide-treated CHF patients over the age of 60 was compared with that of 40 similar patients free of CHF. In addition, a statistical analysis was performed comparing the data of the 37 patients with moderate versus the 20 patients with severe CHF. Dietary content of various nutrients was assessed with the food frequency recall technique. Dietary intake was comparable in the two respective pairs of groups. However, the intake of magnesium, calcium, zinc, copper, manganese, energy, thiamin, riboflavin, and folate in all subgroups fell short of recommended levels for intake, while vitamins A, C and niacin contents exceeded those recommended. Intakes of potassium and proteins were within the recommended values. CONCLUSIONS: CHF per se, even severe CHF, is not responsible for a reduced dietary intake of various nutrients. A population-related dietary culture, old age or other chronic conditions, rather than CHF, might be mainly involved. The increased intake of vitamins A, C and niacin in our patients may be attributed to the high content of fruits and vegetables in the Mediterranean diet. Insufficient intake of the above-mentioned group of electrolytes and essential nutrients may contribute to the frequently observed negative balance of some of them. This is especially relevant in furosemide-treated CHF patients. Therefore, supplementation should be considered.