Improvement in Health-related Quality of Life After Hospitalization Predicts Event-free Survival in Patients With Advanced Heart Failure

BackgroundHealth-related quality of life (HRQOL) is a major clinical outcome for heart failure (HF) patients. We aimed to determine the frequency, durability, and prognostic significance of improved HRQOL after hospitalization for decompensated HF.Methods and ResultsWe analyzed HRQOL, measured serially using the Minnesota Living with Heart Failure Questionnaire (MLHFQ), for 425 patients who survived to discharge in a multicenter randomized clinical trial of pulmonary artery catheter versus clinical assessment to guide therapy for patients with advanced HF. All patients enrolled had 1 or more prior HF hospitalizations or chronic high diuretic doses and 1 or more symptom and 1 sign of fluid overload at admission. Improvement, defined as a decrease of more than 5 points in MLHFQ total score, occurred in 68% of patients by 1 month and stabilized. The degree of 1-month improvement differed (P < .0001 group × time interaction) between 6-month survivors and non-survivors. In a Cox regression model, after adjustment for traditional risk factors for HF morbidity and mortality, improvement in HRQOL by 1 month compared to worsening at 1 month or no change predicted time to subsequent event-free survival (P = .013).ConclusionsIn patients hospitalized with severe HF decompensation, HRQOL is seriously impaired but improves substantially within 1 month for most patients and remains improved for 6 months. Patients for whom HRQOL does not improve by 1 month after hospital admission merit specific attention both to improve HRQOL and to address high risk for poor event-free survival.     

Quadriceps Strength and Mortality in Older Patients With Heart Failure

BackgroundThis study was performed to test the hypothesis that low quadriceps isometric strength (QIS) is associated with greater risk of mortality and has the additive prognostic significance to the severity of heart failure (HF) and gait speed in older patients with HF.MethodsA retrospective cohort study was performed in 1273 patients ≥ 60 years of age with HF (mean age 75 ± 8 years, 59.1% men); all of whom were evaluated during hospitalization for usual gait speed and maximal QIS. The QIS was expressed relative to body mass (% BM). The endpoint was all-cause mortality.ResultsOver a median follow-up period of 1.59 years (interquartile range, 0.58 to 3.42 years), 224 patients died. The cutoff value based on the Youden index for the QIS discriminating those at high risk of mortality was 36.2% BM for overall, and we defined less than this cutoff point of QIS as low QIS. After adjustment for the HF risk score, the hazard ratio in low QIS was 1.55 for overall (95% confidence interval [CI], 1.17-2.06). The addition of low QIS to the HF risk score and gait speed was associated with significant increases in both net reclassification improvement (NRI, 0.239 for overall; 95% CI, 0.096-0.381) and integrated discrimination improvement (IDI, 0.004 for overall; 95% CI, 0.001-0.009) for all-cause mortality.ConclusionLow QIS was strongly associated with poor prognosis and showed complementary prognostic predictive capability to the HF risk score and gait speed in older patients with HF.     

Post-Exercise Heart Rate Recovery Independently Predicts Mortality Risk in Patients With Chronic Heart Failure

BackgroundPost-exercise heart rate recovery (HRR) is an index of parasympathetic function associated with clinical outcomes in populations with and without documented coronary heart disease. Decreased parasympathetic activity is thought to be associated with disease progression in chronic heart failure (HF), but an independent association between post-exercise HRR and clinical outcomes among such patients has not been established.Methods and ResultsWe measured HRR (calculated as the difference between heart rate at peak exercise and after 1 minute of recovery) in 202 HF subjects and recorded 17 mortality and 15 urgent transplantation outcome events over 624 days of follow-up. Reduced post-exercise HRR was independently associated with increased event risk after adjusting for other exercise-derived variables (peak oxygen uptake and change in minute ventilation per change in carbon dioxide production slope), for the Heart Failure Survival Score (adjusted HR 1.09 for 1 beat/min reduction, 95% CI 1.05-1.13, P < .0001), and the Seattle Heart Failure Model score (adjusted HR 1.08 for one beat/min reduction, 95% CI 1.05-1.12, P < .0001). Subjects in the lowest risk tertile based on post-exercise HRR (≥30 beats/min) had low risk of events irrespective of the risk predicted by the survival scores. In a subgroup of 15 subjects, reduced post-exercise HRR was associated with increased serum markers of inflammation (interleukin-6, r = 0.58, P = .024; high-sensitivity C-reactive protein, r = 0.66, P = .007).ConclusionsPost-exercise HRR predicts mortality risk in patients with HF and provides prognostic information independent of previously described survival models. Pathophysiologic links between autonomic function and inflammation may be mediators of this association.     

Long-term Risk of Death and Hospitalization in Patients With Heart Failure and Takotsubo Syndrome: Insights From a Nationwide Cohort

BackgroundData concerning the long-term risk of heart failure (HF) in patients with takotsubo syndrome (TTS) are sparse. We compared the rates of death and hospitalization due to HF with matched individuals from the background population and patients with ST-segment elevation myocardial infarction (STEMI).MethodsIn this nationwide observational cohort study, all patients with first-time TTS (2011–2018) who were alive at discharge were identified by using data from Danish nationwide registries. These were matched for age and sex with individuals from the background population (1:4 matching) and with patients with STEMI who were alive at discharge (1:3 matching).ResultsA total of 881 patients with TTS who were alive at discharge were identified (median age 70 years; 89.4% men). During a mean follow-up of 2.9 years, the incidence rates of death, HF hospitalization, and TTS recurrence in survivors of TTS were 6.9, 0.9 and 1.1 events per 100 person-years. The corresponding absolute 3-year risks were 9.3%, 1.8% and 2.5%, respectively. Survivors of TTS had higher associated rates of death compared with the background population (hazard ratio [HR] 2.05 [95% CI, 1.62–2.60]) and survivors of STEMI (HR 1.69 [1.34–2.13]). Similarly, survivors of TTS had higher associated rates of hospitalization due to HF compared with the background population (HR 4.24 [1.88–9.53]), but lower rates compared with survivors of STEMI (HR 0.34 [0.20–0.56]). Propensity-score matched analyses yielded similar results.ConclusionsSurvivors of TTS had significantly higher associated mortality rates than the background population and survivors of STEMI. Survivors of TTS had lower HF hospitalization rates than survivors of STEMI, but the rates were higher than those of the background population.     

Six Minute Walk Test Predicts Long-Term All-Cause Mortality and Heart Failure Rehospitalization in African-American Patients Hospitalized With Acute Decompensated Heart Failure

BackgroundThe prognostic value of the 6-minute walk test (6MWT) has been described in patients with heart failure (HF); however, limited data are available in an African-American (AA) population. We prospectively evaluated the usefulness of the 6MWT in predicting mortality and HF rehospitalization in AA patients with acute decompensated HF.Methods and ResultsTwo hundred AA patients (63.1% men, mean age 55.7 ± 12.9 years) with acute decompensated HF were prospectively studied. Patients were followed to assess 40-month all-cause mortality and 18-month HF rehospitalization. The median distance walked on the 6MWT was 213 m. Of the 198 patients with available mortality data, 59 patients (29.8%) died. Of the 191 patients with available rehospitalization data, 114 (59.7%) were rehospitalized for worsening HF. For patients who walked ≤200 m during the 6MWT, mortality was 41% compared with 19% in patients who walked >200 m (P = .001). For patients who walked ≤200 m during the 6MWT, HF rehospitalization was 68% compared with 52% in those who walked >200 m (P = .027). Multivariate Cox regression analysis showed that 6MWT distance ≤200 m was the strongest predictor of mortality (adjusted hazard ratio [HR], 2.14; confidence interval [CI], 1.20 to 3.81; P = .01) and HF rehospitalization (adjusted HR, 1.62; CI, 1.10 to 2.39; P = .015).ConclusionsIn AA patients hospitalized with acute decompensated HF, 6MWT strongly and independently predicts long-term all-cause mortality and HF rehospitalization.     

Prognostic Impact of Pulmonary Artery Pulsatility Index (PAPi) in Patients With Advanced Heart Failure: Insights From the ESCAPE Trial

Background

The pulmonary artery pulsatility index (PAPi), defined as the ratio of pulmonary artery pulse pressure to right atrial pressure, emerged as a powerful predictor of right ventricular (RV) failure in patients with acute inferior myocardial infarction and those undergoing left ventricular assist device placement; however, its prognostic utility in the advanced heart failure population remains largely unknown.

Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life

Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.     

Left Atrial Stiffness Index Independently Predicts Exercise Intolerance and Quality of Life in Older,Obese Patients With Heart Failure With Preserved Ejection Fraction

BackgroundHeart failure with preserved ejection fraction (HFpEF) is the fastest growing form of HF and is associated with high morbidity and mortality. The primary chronic symptom in HFpEF is exercise intolerance, associated with reduced quality of life. Emerging evidence implicates left atrial (LA) dysfunction as an important pathophysiologic mechanism. Here we extend prior observations by relating LA dysfunction to peak oxygen uptake (peak VO₂), physical function (distance walked in 6 minutes [6MWD]) and quality of life (Kansas City Cardiomyopathy Questionnaire).Methods and ResultsWe compared 75 older, obese, patients with HFpEF with 53 healthy age-matched controls. LA strain was assessed by magnetic resonance cine imaging using feature tracking. LA function was defined according to its 3 distinct phases, with the LA serving as a reservoir during systole, as a conduit during early diastole, and as a booster pump at the end of diastole. The LA stiffness index was calculated as the ratio of early mitral inflow velocity-to-early annular tissue velocity (E/e’, by Doppler ultrasound examination) and LA reservoir strain. HFpEF had a decreased reservoir strain (16.4 ± 4.4% vs 18.2 ± 3.5%, P = .018), lower conduit strain (7.7 ± 3.3% vs 9.1 ± 3.4%, P = .028), and increased stiffness index (0.86 ± 0.39 vs 0.53 ± 0.18, P < .001), as well as decreased peak VO₂, 6MWD, and lower quality of life. Increased LA stiffness was independently associated with impaired peak VO₂ (β = 9.0 ± 1.6, P < .001), 6MWD (β = 117 ± 22, P = .003), and Kansas City Cardiomyopathy Questionnaire score (β = –23 ± 5, P = .001), even after adjusting for clinical covariates.Conclusions: LA stiffness is independently associated with impaired exercise tolerance and quality of life and may be an important therapeutic target in obese HFpEF.RegistrationNCT00959660     

Effects of Levosimendan on Quality of Life and Emotional Stress in Advanced Heart Failure Patients

AIM: Levosimendan improves central hemodynamics and symptoms in acutely decompensated chronic heart failure (CHF) patients. However, its effects on quality of life, emotional stress and functional capacity of patients with advanced CHF have not been properly investigated. METHODS AND RESULTS: Sixty-three advanced CHF patients (NYHA III-IV, LVEF<30%) were randomized (2:1) to receive either a 24-h levosimendan infusion of 0.1 mug/kg/min or placebo. Questionnaires addressing quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ), functional and overall, Duke's Activity Status Index (DASI)] and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory (BDI)], as well as plasma BNP and 6-min walking distance (6MWT as a marker of exercise capacity) were assessed before treatment and at hospital discharge. A significant improvement in NYHA class (2.1 +/- 0.7 from 3.3 +/- 0.7, p < 0.01), 6 MWT (305 +/- 152 from 215 +/- 142 m, p < 0.01) and plasma BNP (598 +/- 398 from 1,078 +/- 756 pg/ml, p < 0.01) was observed post-treatment only in levosimendan-treated group. KCCQ functional (45 +/- 19 from 35 +/- 17%, p < 0.05) and overall (34 +/- 13 from 28 +/- 11%, p < 0.05), DASI (26 +/- 13 from 22 +/- 12, p < 0.05), Zung SDS (38 +/- 12 from 42 +/- 13, p < 0.01) and BDI (11 +/- 6 from 14 +/- 8, p < 0.05) scores also improved in levosimendan-treated patients, while remained unchanged in the placebo group. The hospital length stay was shorter in levosimendan group compared to placebo (3.2 +/- 1.7 versus 5.8 +/- 2.1 days, p < 0.01). Levosimendan-induced BNP reduction was significantly correlated with concomitant increase in 6MWT (r = 0.643, p < 0.001) as well as with the decrease of BDI (r = 0.30, p < 0.05) and Zung SDS (r = 0.25, p = 0.05). CONCLUSION: Levosimendan seems to have a beneficial effect on quality of life, physical activity and emotional stress in advanced CHF patients, reducing concurrently hospitalization length.     

Prolonged Electrocardiogram QRS Duration Independently Predicts Long-Term Mortality in Patients Hospitalized for Heart Failure With Preserved Systolic Function

BackgroundProlonged electrocardiogram (ECG) QRS duration (≥120 ms) is a risk factor for death in systolic heart failure, but its effects in heart failure with preserved systolic function (HFPSF) have not been extensively studied. We hypothesized that prolonged ECG QRS duration would independently predict long-term mortality in hospitalized HFPSF patients.Methods and ResultsWe analyzed 872 HFPSF patients (defined as left ventricular ejection fraction ≥50%) admitted to Michigan community hospitals between 2002 and 2004 and followed for a median of 660 days. We used Cox proportional hazards models to assess mortality hazard for prolonged QRS duration (≥120 ms) on the last available predischarge ECG, first on a univariable basis and then after multivariable adjustment for other known risk factors. Prolonged QRS duration increased univariable all-cause mortality (HR 1.71; 95% CI 1.33-2.19, P < .001) and after multivariable adjustment (HR 1.31; 95% CI 1.01-1.71, P = .04). The univariable effect size was larger in younger patients. In multivariable models, there was no significant interaction between prolonged QRS and age, hypertension, or coronary artery disease status.ConclusionsProlonged QRS duration (≥120 ms) on a predischarge ECG is an independent and consistent predictor of long-term mortality in hospitalized HFPSF patients.     

Medical Resource Use,Costs, and Quality of Life in Patients With Acute Decompensated Heart Failure: Findings From ASCEND-HF

BackgroundThe Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) randomly assigned 7,141 participants to nesiritide or placebo. Dyspnea improvement was more often reported in the nesiritide group, but there were no differences in 30-day all-cause mortality or heart failure readmission rates. We compared medical resource use, costs, and health utilities between the treatment groups.Methods and ResultsThere were no significant differences in inpatient days, procedures, and emergency department visits reported for the first 30 days or for readmissions to day 180. EQ-5D health utilities and visual analog scale ratings were similar at 24 hours, discharge, and 30 days. Billing data and regression models were used to generate inpatient costs. Mean length of stay from randomization to discharge was 8.5 days in the nesiritide group and 8.6 days in the placebo group (P = .33). Cumulative mean costs at 30 days were $16,922 (SD $16,191) for nesiritide and $16,063 (SD $15,572) for placebo (P = .03). At 180 days, cumulative costs were $25,590 (SD $30,344) for nesiritide and $25,339 (SD $29,613) for placebo (P = .58).ConclusionsThe addition of nesiritide contributed to higher short-term costs and did not significantly influence medical resource use or health utilities compared with standard care alone.