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.     

Depression and health status in elderly patients with heart failure: a 6-month prospective study in primary care

To determine the prevalence and effects of depression on health status among elderly outpatients with heart failure, the authors conducted a 6-month prospective cohort study of 139 older outpatients with heart failure managed in primary care and 80 of their spouses. Primary care heart failure diagnosis was confirmed through chart review. The Primary Care Evaluation of Mental Disorders psychiatric diagnostic interview and Hamilton Depression Rating Scale were administered by phone. EQ-5D feeling thermometer, Medical Outcomes Study Short Form 36-Item Questionnaire, Kansas City Cardiomyopathy Questionnaire, and heart failure symptom severity questionnaires were administered by self-report. Depression diagnoses at baseline were: major depression and/or dysthymia (n=12, 9%), minor depression (n=14, 10%), and no depression (n=113, 81%). After adjusting for age, gender, and medical comorbidity, these depression groups differed by repeated measures analysis of covariance on most health status measures including the EQ-5D feeling thermometer; Medical Outcomes Study Short Form 36-Item Questionnaire general health and physical role function subscales; Kansas City Cardiomyopathy Questionnaire total score, symptom total, physical limitations, and quality of life subscales; as well as severity of chest pain and fatigue. Depression has significant and persistent effects on health status of elderly patients with heart failure, including heart failure symptoms, physical and role function, and quality of life. This may help explain why depression has been associated with increased health care utilization and costs in this population.     

Breakfast cereals and risk of heart failure in the physicians' health study I

BACKGROUND: Heart failure (HF) is the leading cause of hospitalization among the elderly population in the United States. Consumption of grain products and dietary fiber has been shown to reduce the risk of hypertension and myocardial infarction. However, it is not known whether a higher consumption of breakfast cereals is associated with risk of HF. METHODS: This study evaluated prospectively the association between breakfast cereal intake and incident HF among 21 376 participants of the Physicians' Health Study I. Cereal consumption was estimated using a semiquantitative food frequency questionnaire. Incident HF was ascertained through annual follow-up questionnaires and validated using Framingham criteria. We used Cox regression models to estimate adjusted relative risk of HF across categories of cereal intake. RESULTS: During an average follow-up of 19.6 years, 1018 incident cases of HF occurred. For average weekly cereal consumption of 0 servings, 1 or fewer, 2 to 6, and 7 or more, hazard ratios (95% confidence intervals) for HF were 1 (reference), 0.92 (0.78-1.09), 0.79 (0.67-0.93), and 0.71 (0.60-0.85), respectively (P<.001 for trend), adjusting for age, smoking, alcohol consumption, vegetable consumption, use of multivitamins, exercise, and history of atrial fibrillation, valvular heart disease, and left ventricular hypertrophy. However, the association was limited to the intake of whole grain cereals (P <.001 for trend) but not refined cereals (P = .70 for trend). CONCLUSIONS: Our data demonstrate that a higher intake of whole grain breakfast cereals is associated with a lower risk of HF. Additional studies are warranted to confirm these findings and determine specific nutrients that are responsible for such a protection.     

Novel metabolic risk factors for heart failure.

OBJECTIVES: Our objectives were to explore novel metabolic risk factors for development of heart failure (HF). BACKGROUND: In the past decade, considerable knowledge has been gained from limited samples regarding novel risk factors for HF, but the importance of these in the general population is largely unexplored. METHODS: In a community-based prospective study of 2,321 middle-aged men free from HF and valvular disease at baseline, variables reflecting glucose and lipid metabolism and variables involved in oxidative processes were compared with established risk factors for HF (prior myocardial infarction, hypertension, diabetes, electrocardiographic left ventricular hypertrophy, smoking, obesity, and serum cholesterol) using Cox proportional hazards analyses. RESULTS: During a median follow-up time of 29 years, 259 subjects developed HF. In a multivariable Cox proportional hazards backward stepwise model, a 1-SD increase of fasting proinsulin (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.15 to 1.66) and apolipoprotein B/A-I-ratio (HR 1.27, 95% CI 1.09 to 1.48) increased the risk, whereas a 1-SD increase in serum beta-carotene (HR 0.79, 95% CI 0.66 to 0.94) decreased the risk of HF. These variables also remained significant when adjusting for acute myocardial infarction during follow-up. CONCLUSIONS: Novel variables reflecting insulin resistance and dyslipidemia, together with a low beta-carotene level, were found to predict HF independently of established risk factors. If confirmed, our observations could have large clinical implications, as they may offer new approaches in the prevention of HF.     

Epidemiology of heart failure: the prevalence of heart failure and ventricular dysfunction in older adults over time. A systematic review

The ‘epidemic’ of heart failure seems to be changing, but precise prevalence estimates of heart failure and left ventricular dysfunction (LVD) in older adults, based on adequate echocardiographic assessment, are scarce. Systematic reviews including recent studies on the prevalence of heart failure and LVD are lacking. We aimed to assess the trends in the prevalence of LVD, and heart failure with reduced (HFrEF) and preserved ejection fraction (HFpEF) in the older population at large. A systematic electronic search of the databases Medline and Embase was performed. Studies that reported prevalence estimates in community‐dwelling people ≥60 years old were included if echocardiography was used to establish the diagnosis. In total, 28 articles from 25 different study populations were included. The median prevalence of systolic and ‘isolated’ diastolic LVD was 5.5% (range 3.3–9.2%) and 36.0% (range 15.8–52.8%), respectively. A peak in systolic dysfunction prevalence seems to have occurred between 1995 and 2000. ‘All type’ heart failure had a median prevalence rate of 11.8% (range 4.7–13.3%), with fairly stable rates in the last decade and with HFpEF being more common than HFrEF [median prevalence 4.9% (range 3.8–7.4%) and 3.3% (range 2.4–5.8%), respectively]. Both LVD and heart failure remain common in the older population at large. The prevalence of diastolic dysfunction is on the rise and currently higher than that of systolic dysfunction. The prevalence of the latter seems to have decreased in the 21st century.     

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.     

Prospective study of health status preferences and changes in preferences over time in older adults

BACKGROUND: Instructional forms of advance care planning depend on the ability of patients to predict their future treatment preferences. However, preferences may change with changes in patients' health states. METHODS: We conducted in-home interviews of 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease at least every 4 months for up to 2 years. Patients were asked to rate whether treatment for their illness would be acceptable if it resulted in 1 of 4 health states. RESULTS: The likelihood of rating as acceptable a treatment resulting in mild (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16) or severe (OR, 1.06; 95% CI, 1.03-1.09) functional disability increased with each month of participation. Patients who experienced a decline in their ability to perform instrumental activities of daily living were more likely to rate as acceptable treatment resulting in mild (OR, 1.23; 95% CI, 1.08-1.40) or severe (OR, 1.23; 95% CI, 1.11-1.37) disability. Although the overall likelihood of rating treatment resulting in a state of pain as acceptable did not change over time (OR, 0.98; 95% CI, 0.96-1.01), patients who had moderate to severe pain were more likely to rate this treatment as acceptable (OR, 2.55; 95% CI, 1.56-4.19) than were those who did not have moderate to severe pain. CONCLUSIONS: For some patients, the acceptability of treatment resulting in certain diminished states of health increases with time, and increased acceptability is more likely among patients experiencing a decline in that same domain. These changes pose a challenge to advance care planning, which asks patients to predict their future treatment preferences.     

The risk of congestive heart failure in rheumatoid arthritis: A population‐based study over 46 years

Objective

It is hypothesized that the systemic inflammation associated with rheumatoid arthritis (RA) promotes an increased risk of cardiovascular (CV) morbidity and mortality. We examined the risk and determinants of congestive heart failure (CHF) in patients with RA.

Methods

We assembled a population‐based, retrospective incidence cohort from among all individuals living in Rochester, Minnesota, in whom RA (defined according to the American College of Rheumatology 1987 criteria) was first diagnosed between 1955 and 1995, and an age‐ and sex‐matched non‐RA cohort. After excluding patients in whom CHF occurred before the RA index date, all subjects were followed up until either death, incident CHF (defined according to the Framingham Heart Study criteria), migration from the county, or until January 1, 2001. Detailed information from the complete medical records (including all inpatient and outpatient care provided by all local providers) regarding RA, ischemic heart disease, and traditional CV risk factors was collected. Cox models were used to estimate the effect of RA on the development of CHF, adjusting for CV risk factors and/or ischemic heart disease.

Results

The study population included 575 patients with RA and 583 subjects without RA. The CHF incidence rates were 1.99 and 1.16 cases per 100 person‐years in patients with RA and in non‐RA subjects, respectively (rate ratio 1.7, 95% confidence interval [95% CI] 1.3–2.1). After 30 years of followup, the cumulative incidence of CHF was 34.0% in patients with RA and 25.2% in non‐RA subjects (P< 0.001). RA conferred a significant excess risk of CHF (hazard ratio [HR] 1.87, 95% CI 1.47–2.39) after adjusting for demographics, ischemic heart disease, and CV risk factors. The risk was higher among patients with RA who were rheumatoid factor (RF) positive (HR 2.59, 95% CI 1.95–3.43) than among those who were RF negative (HR 1.28, 95% CI 0.93–1.78).

Conclusion

Compared with persons without RA, patients with RA have twice the risk of developing CHF. This excess risk is not explained by traditional CV risk factors and/or clinical ischemic heart disease.

     

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.     

The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years

OBJECTIVE: It is hypothesized that the systemic inflammation associated with rheumatoid arthritis (RA) promotes an increased risk of cardiovascular (CV) morbidity and mortality. We examined the risk and determinants of congestive heart failure (CHF) in patients with RA. METHODS: We assembled a population-based, retrospective incidence cohort from among all individuals living in Rochester, Minnesota, in whom RA (defined according to the American College of Rheumatology 1987 criteria) was first diagnosed between 1955 and 1995, and an age- and sex-matched non-RA cohort. After excluding patients in whom CHF occurred before the RA index date, all subjects were followed up until either death, incident CHF (defined according to the Framingham Heart Study criteria), migration from the county, or until January 1, 2001. Detailed information from the complete medical records (including all inpatient and outpatient care provided by all local providers) regarding RA, ischemic heart disease, and traditional CV risk factors was collected. Cox models were used to estimate the effect of RA on the development of CHF, adjusting for CV risk factors and/or ischemic heart disease. RESULTS: The study population included 575 patients with RA and 583 subjects without RA. The CHF incidence rates were 1.99 and 1.16 cases per 100 person-years in patients with RA and in non-RA subjects, respectively (rate ratio 1.7, 95% confidence interval [95% CI] 1.3-2.1). After 30 years of followup, the cumulative incidence of CHF was 34.0% in patients with RA and 25.2% in non-RA subjects (P< 0.001). RA conferred a significant excess risk of CHF (hazard ratio [HR] 1.87, 95% CI 1.47-2.39) after adjusting for demographics, ischemic heart disease, and CV risk factors. The risk was higher among patients with RA who were rheumatoid factor (RF) positive (HR 2.59, 95% CI 1.95-3.43) than among those who were RF negative (HR 1.28, 95% CI 0.93-1.78). CONCLUSION: Compared with persons without RA, patients with RA have twice the risk of developing CHF. This excess risk is not explained by traditional CV risk factors and/or clinical ischemic 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.     

Current risk of heart catheterization study and angiocardiography in children. A prospective study

Parental permission for cardiac catheterization assumes detailed information about the character and frequency of all potential and inevitable threatening complications despite of maximal care. However, data on this subject were derived mainly from older and/or retrospective studies. In order to evaluate the actual risk we performed a prospective study lasting 11 months. All complications occurring during the 24 h following this invasive procedure were recorded. During 462 consecutive cardiac catheterizations in 421 patients (including 24 balloon-atrio-septostomies and five myocardial biopsies) there were complications requiring treatment in 18.2% of all examinations. There was no lethal complication. The following complications were documented: arrhythmia 6.5%, acidosis 6.1%, problems due to catheterizing an arterial or venous vessel 3.9% and 0.4% respectively; acute blood loss 1.5%, and problems concerning the probe in general 1.1%. In a frequency of less than 1% we encountered hypoxic spells, myocardial ischemia, hypoventilation/respiratory failure, febrile reaction, and allergic reactions due to contrast media. Contrary to data of the literature we could show a significant reduction of the risks involved in this examination. The following factors have contributed to this improvement: 1) a more careful patient selection for this invasive procedure; 2) a more experienced examiner; 3) better monitoring during the procedure; 4) a more detailed diagnostic work-up prior to the examination; and 5) better premedication of the patient.     

Employment status at time of first hospitalization for heart failure is associated with a higher risk of death and rehospitalization for heart failure

Aims

Employment status at time of first heart failure (HF) hospitalization may be an indicator of both self‐perceived and objective health status. In this study, we examined the association between employment status and the risk of all‐cause mortality and recurrent HF hospitalization in a nationwide cohort of patients with HF.

Methods and results

We identified all patients of working age (18–60 years) with a first HF hospitalization in the period 1997–2015 in Denmark, categorized according to whether or not they were part of the workforce at time of the index admission. The primary outcome was death from any cause and the secondary outcome was readmission for HF. Cumulative incidence curves, binomial regression and Cox regression models were used to assess outcomes. Of 25 571 patients with a first hospitalization for HF, 15 428 (60%) were part of the workforce at baseline. Patients in the workforce were significantly younger (53 vs. 55 years) more likely to be male (75% vs 64%) and less likely to have diabetes (13% vs 22%) and chronic obstructive pulmonary disease (5% vs 10%) (all P < 0.0001). Not being part of the workforce was associated with a significantly higher risk of death [hazard ratio (HR) 1.59; 95% confidence interval (CI) 1.50–1.68] and rehospitalization for HF (HR 1.09; 95% CI 1.05–1.14), in analyses adjusted for age, sex, co‐morbidities, education level, calendar time, and duration of first HF hospitalization.

Conclusion

Not being part of the workforce at time of first HF hospitalization was independently associated with increased mortality and recurrent HF hospitalization.

     

Chronic heart failure and risk of hospitalization with pneumonia: A population-based study

BackgroundChronic heart failure may increase risk of pneumonia due to alveoli flooding and reduced microbial clearance. We examined whether chronic heart failure is a risk factor for pneumonia-related hospitalization.MethodsIn this large population-based case–control study we identified adult patients with a first-time primary or secondary discharge diagnosis of viral or bacterial pneumonia between 1994 and 2008, using health care databases in Northern Denmark. For each case, ten sex- and age-matched population controls were selected from Denmark's Civil Registration System. We used conditional logistic regression to compute relative risk (RR) for pneumonia-related hospitalization among persons with and without pre-existing heart failure, overall and stratified by medical treatment. We controlled for a wide range of comorbidities, socioeconomic markers and immunosuppressive treatment.ResultsThe study included 67,162 patients with a pneumonia-related hospitalization and 671,620 population controls. The adjusted OR for pneumonia-related hospitalization among persons with previous heart failure was 1.81 (95% confidence interval (CI): 1.76–1.86) compared with other individuals. The adjusted pneumonia RR was lower for heart failure patients treated with thiazides only (adjusted OR = 1.56, 95% CI: 1.46–1.67), as compared with patients whose treatment included loop-diuretics and digoxin as a marker of increased severity (adjusted OR = 1.95, 95% CI: 1.85–2.06) or both loop-diuretics and spironolactone (adjusted OR = 2.02, 95% CI: 1.90–2.15). The population-attributable risk of pneumonia hospitalizations caused by heart failure in our population was 6.2%.ConclusionsPatients with chronic heart failure, in particular those using loop diuretics, have markedly increased risk of hospitalization with pneumonia.     

Sitagliptin and the risk of hospitalization for heart failure: A population-based study

Background

Saxagliptin was associated with an increased risk of hospitalization for heart failure (HHF) in diabetic patients with high cardiovascular risk. This study assessed the risk of HHF during an exposure to sitagliptin in general diabetic patients.

Methods

In Taiwan National Health Insurance research database, a study of the beneficiaries aged ≥ 45 years with diabetes treated with or without sitagliptin between March 2009 and July 2011 was conducted. Patients treated with sitagliptin were matched to patients never exposed to a dipeptidyl peptidase-4 (DPP-4) inhibitor by the propensity score methodology. The outcome measures were the first and the total number of HHF, and mortality for heart failure or all causes.

Results

A total of 8288 matched pairs of patients were analyzed. During a median of 1.5 years, the first event of HHF occurred in 339 patients with sitagliptin and 275 patients never exposed to a DPP-4 inhibitor (hazard ratio: 1.21, 95% confidence interval: 1.04–1.42, P = 0.017); all-cause mortality was similar (hazard ratio: 0.87, 95% confidence interval: 0.74–1.03, P = 0.109). The risk for HHF was proportional to exposure (hazard ratio: 1.09, 95% confidence interval: 1.06–1.11, P < 0.001 for every 10% increase in adherence to sitagliptin). Overall, there were 935 events of HHF, in which the association between the number of HHF and the adherence to sitagliptin was linear. The greatest total number of HHF occurred in the patients with the highest adherence.

Conclusions

The use of sitagliptin was associated with a higher risk of HHF but no excessive risk for mortality was observed.     

Serum copper-to-zinc ratio is associated with heart failure and improves risk prediction in middle-aged and older Caucasian men: A prospective study

Background and aimsSerum copper (Cu) and zinc (Zn) may play a role in the development of adverse cardiovascular outcomes including heart failure (HF). Serum Cu/Zn-ratio has been shown to be a risk indicator for cardiovascular disease, but its relationship with HF has not been previously investigated. We aimed to assess the association between Cu/Zn-ratio and incident HF risk using a prospective cohort study.Methods and resultsStudy participants were recruited in eastern Finland with baseline examinations carried out between March 1998 and December 2001. Serum levels of Cu and Zn were measured using atomic absorption spectrometry in 1866 men aged 42–61 years without a history of HF at baseline. Multivariable-adjusted hazard ratios (HRs) with confidence intervals (CIs) were calculated for incident HF. During 26.5 years median follow-up, 365 HF cases occurred. Restricted cubic splines suggested linear relationships of serum Cu/Zn-ratio, Cu and Zn with HF risk. A unit increase in Cu/Zn-ratio was associated with an increased HF risk in analysis adjusted for several potential confounders including nutritional factors such as total energy intake, intake of fruits, berries and vegetables, and red meat (HR 1.63; 95% CI 1.06–2.51). The corresponding multivariable-adjusted HRs (95% CIs) for serum Cu and Zn were 2.42 (1.32–4.44) and 1.34 (0.50–3.63), respectively. Addition of Cu/Zn-ratio to a HF risk prediction model was associated with improved risk prediction.ConclusionIn middle-aged and older Finnish men, increased serum Cu/Zn-ratio is associated with an increased risk of HF in a linear dose-response fashion and might improve HF risk assessment.