Use of the Living With Heart Failure questionnaire to ascertain patients' perspectives on improvement in quality of life versus risk of drug-induced death

Patient- and provider-related determinants of generic and specific health-related quality of life of patients with chronic systolic heart failure in primary care: a cross-sectional study

Background

Identifying the determinants of health-related quality of life (HRQOL) in patients with systolic heart failure (CHF) is rare in primary care; studies often lack a defined sample, a comprehensive set of variables and clear HRQOL outcomes. Our aim was to explore the impact of such a set of variables on generic and disease-specific HRQOL.

Methods

In a cross-sectional study, we evaluated data from 318 eligible patients. HRQOL measures used were the SF-36 (Physical/Mental Component Summary, PCS/MCS) and four domains of the KCCQ (Functional status, Quality of life, Self efficacy, Social limitation). Potential determinants (instruments) included socio-demographical variables (age, sex, socio-economic status: SES), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, multimorbidity (CIRS-G)), depression (PHQ-9), behavioural (EHFScBs and prescribing) and provider (e.g. list size of and number. of GPs in practice) variables. We performed linear (mixed) regression modelling accounting for clustering.

Results

Patients were predominantly male (71.4%), had a mean age of 69.0 (SD: 10.4) years, 12.9% had major depression, according to PHQ-9. Across the final regression models, eleven determinants explained 27% to 55% of variance (frequency across models, lowest/highest β): Depression (6×, -0.3/-0.7); age (4×, -0.1/-0.2); multimorbidity (4×, 0.1); list size (2×, -0.2); SES (2×, 0.1/0.2); and each of the following once: no. of GPs per practice, NYHA class, COPD, history of CABG surgery, aldosterone antagonist medication and Self-care (0.1/-0.2/-0.2/0.1/-0.1/-0.2).

Conclusions

HRQOL was determined by a variety of established individual variables. Additionally the presence of multimorbidity burden, behavioural (self-care) and provider determinants may influence clinicians in tailoring care to individual patients and highlight future research priorities.

Quality of life after aortic valve replacement

Understanding the quality of life after aortic valve replacement has become increasingly important. As aortic valve replacement numbers increase, more patients, physicians and families are affected by the subsequent quality of life. Quality of life information can inform the decision to perform aortic valve replacement and the selection of replacement valve. When reviewing quality of life results, it is important to realize that the findings are affected by the selection and quality of instruments, as many studies have not used valid or reliable instruments. Studies have shown that aortic valve replacement appears to significantly improve the quality of life of survivors, including those older than 70 years of age and even decades after the procedure, quality of life remains high. Studies have suggested that the elderly may gain as much quality of life benefit as younger patients. No consistent differences in resulting total quality of life have been observed between mechanical and bioprosthetic valves. Only one study showed some quality of life benefits of pulmonary autograft over mechanical valves. It is unclear whether minimally invasive aortic valve replacements confer better quality of life than standard aortic valve replacements. While existing quality of life studies have provided important information, more studies are needed especially as valve technology and operative techniques continue to improve. Future studies should endeavor to use validated general and disease-specific instruments and quantify the effects of demographics, preoperative clinical conditions and intraoperative variables on quality of life outcomes.

Improving outcomes for older adults with heart failure: a randomized trial using a theory-guided nursing intervention

Newly discharged older adults with heart failure continue to experience frequent hospital readmissions, lower quality of life, and decreased satisfaction with health services. A theory-guided intervention delivered by home health nurses via the telephone was studied using a randomized controlled trial to assess its feasibility and inform further studies. Findings generated a profile of older adults with heart failure, utilization by patients and nurses, operational issues, and preliminary data on intended outcomes. Implications for further study are presented.

Patients' self-assessed functional status in heart failure by New York Heart Association class: a prognostic predictor of hospitalizations, quality of life and death

Background

Clinician-assigned New York Heart Association (NYHA) class is an established predictor of outcomes in heart failure. This study aims to test whether patients' self-assessment of functional status by NYHA class predicts hospital admissions, quality of life, and mortality.

Methods and Results

This was an observational study within a randomized controlled trial. A total of 293 adult patients diagnosed with heart failure were recruited after an emergency admission at 3 acute hospitals in Norfolk, UK. Outcome measures included number of emergency admissions over 6 months, self-assessed quality of life measured with the Minnesota Living with Heart Failure questionnaire (MLHFQ) and EQ-5D at 6 months, and deaths up to 20 months' follow-up. Patients were grouped into 3 NYHA groups (I/II, III, and IV) based on patients' self-assigned NYHA class (SA-NYHA). A Poisson model indicated an increased readmission rate associated with higher SA-NYHA class (adjusted rate ratio 1.21; 95% CI 1.04–1.41; P = .02). Higher SA-NYHA class at baseline predicted worse quality of life at 6 months' follow-up (P = .002 for MLHFQ; P = .047 for EQ-5D), and was associated with higher mortality rate (adjusted hazard ratio 1.84; 95% CI 1.10–3.06; P = .02).

Conclusions

SA-NYHA class is predictive of hospitalization, quality of life, and mortality among patients with heart failure.

Quality of life and functional status in patients surviving 12 months after left ventricular assist device implantation

BACKGROUND

As left ventricular assist device (LVAD) support duration increases, quality of life (QoL) becomes a concern. We reviewed the QoL in patients on LVAD support for >or=1 year.

METHODS

We retrospectively reviewed our prospective database for patients supported >or=1 year by HeartMate pulsatile- (HM1) or continuous-flow (HM2) LVADs from 2000 to 2009. Transplant or death before 1 year merited exclusion. Metabolic equivalents of tasks (METs), the Minnesota Living with Heart Failure Questionnaire (MLHFQ), the 6-minute walk distance (6MWD), and New York Heart Association (NYHA) class were reviewed. Complications and re-admissions were assessed.

RESULTS

Thirty patients were supported for >or=1 year (7 HM1s, 23 HM2s). Mean support duration was 594 +/- 173 days. Mean QoL metrics/functional status indicators at 12 months were: 6MWD, 393 +/- 290 m; MET tolerance, 3.3 +/- 1; MLHFQ, 35 +/- 31; and NYHA, 1.4 +/- 0.6. Mean re-admissions/year was 2.9 +/- 2, with a duration of 13.8 +/- 21 days. Three patients were never re-admitted. Mean out-of-hospital time was 471 +/- 172 days (87.3% of days). Infectious complications led to 43% of re-admissions and occurred in the: drive-line (47%) at 442 +/- 236 days; blood (37%) at 472 +/- 257 days; and LVAD pocket (20%) at 550 +/- 202 days. Twenty-three patients (77%) required additional operations (1.7 +/- 1.8/year). The most common indication was drive-line infection, but ranged from ischemic bowel to defibrillator exchange. Eight required LVAD exchanges for mechanical (n = 4), electrical (n = 3), and thrombotic (n = 1) issues.

CONCLUSIONS

Although LVAD support is not without complications, patients spend the majority of time outside the hospital enjoying a good quality of life.

Improvement in health-related quality of life after hospitalization predicts event-free survival in patients with advanced heart failure

BACKGROUND

Health-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 RESULTS

We 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 x 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).

CONCLUSIONS

In 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.

Effects of aerobic or aerobic and resistance training on cardiorespiratory and skeletal muscle function in heart failure: a randomized controlled pilot trial

OBJECTIVE

To examined the effects of different training modalities on exercise capacity (Vo( 2peak)), systolic function, muscular strength and endurance and quality of life in heart failure patients.

DESIGN

Randomized controlled trial.

SETTING

Cardiac rehabilitation centre in Canada.

SUBJECTS

Forty-two individuals with heart failure (62 +/- 12 years; New York Heart Association (NYHA) classes I-III).

INTERVENTIONS

Aerobic training (n = 14), combined aerobic and resistance training (n = 15) or usual care (n = 13) three times per week for 12 weeks.

MAIN MEASURES

(1) Vo( 2peak) measured by symptom-limited graded exercise test on cycle ergometer; (2) systolic function assessed by two-dimensional echocardiography; (3) muscular strength and muscular endurance measured by one-repetition maximum procedure; and (4) quality of life assessed by questionnaires.

RESULTS

In the intention-to-treat analysis, neither aerobic nor combined aerobic and resistance training significantly improved Vo(2peak), systolic function or quality of life compared with usual care. However, combined aerobic and resistance training significantly improved upper extremity strength (40.7 (14.0)-48.5 (16.0) kg, P<0.05) and muscular endurance (5.7 (2.7)-11.6 (7.6) reps, P<0.05) compared with aerobic training or usual care. In compliant participants (exercise adherence 80%), Vo(2peak) increased in the aerobic group (16.9 (6.0)-19.0 (6.8), P= 0.026) and tended to increase in the combined training group (15.9 (5.0)-17.6 (5.6), P= 0.058) compared with usual care. Quality of life was improved in the aerobic group only.

CONCLUSIONS

Both aerobic and combined aerobic and resistance training are effective interventions to improve Vo(2peak) in compliant heart failure patients. Combined training may be more effective in improving muscle strength and endurance.

A randomized trial of the addition of home-based exercise to specialist heart failure nurse care: the Birmingham Rehabilitation Uptake Maximisation study for patients with Congestive Heart Failure (BRUM-CHF) study

AIMS

Supervised exercise can benefit selected patients with heart failure, however the effectiveness of home-based exercise remains uncertain. We aimed to assess the effectiveness of a home-based exercise programme in addition to specialist heart failure nurse care.

METHODS AND RESULTS

This was a randomized controlled trial of a home-based walking and resistance exercise programme plus specialist nurse care (n=84) compared with specialist nurse care alone (n=85) in a heart failure population in the West Midlands, UK.

PRIMARY OUTCOME

Minnesota Living with Heart Failure Questionnaire (MLwHFQ) at 6 and 12 months.

SECONDARY OUTCOMES

composite of death, hospital admission with heart failure or myocardial infarction; psychological well-being; generic quality of life (EQ-5D); exercise capacity. There was no statistically significant difference between groups in the MLwHFQ at 6 month (mean, 95% CI) (-2.53, -7.87 to 2.80) and 12 month (-0.55, -5.87 to 4.76) follow-up or secondary outcomes with the exception of a higher EQ-5D score (0.11, 0.04 to 0.18) at 6 months and lower Hospital Anxiety and Depression Scale score (-1.07, -2.00 to -0.14) at 12 months, in favour of the exercise group. At 6 months, the control group showed deterioration in physical activity, exercise capacity, and generic quality of life.

CONCLUSION

Home-based exercise training programmes may not be appropriate for community-based heart failure patients.

Factors associated with racial differences in myocardial infarction outcomes

BACKGROUND

Little information is available about factors associated with racial differences across a broad spectrum of post-myocardial infarction outcomes, including patients' symptoms and quality of life.

OBJECTIVE

To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences.

DESIGN

Prospective cohort study.

SETTING

10 hospitals in the United States.

PATIENTS

1849 patients who had myocardial infarction, 28% of whom were black.

MEASUREMENTS

Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire-assessed angina and quality of life.

RESULTS

Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, -0.6 [CI, -3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association.

LIMITATION

Residual confounding and missing data may have introduced bias.

CONCLUSION

Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes.

FUNDING

The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.

Effects of cardiac resynchronization therapy on long-term quality of life: an analysis from the CArdiac Resynchronisation-Heart Failure (CARE-HF) study

BACKGROUND

Cardiac resynchronization therapy (CRT) improves quality of life (QoL) when measured 3 to 6 months after implantation, but whether these effects are sustained is unknown. The CArdiac Resynchronisation-Heart Failure study is the only long-term randomized trial of CRT with repeated measures of QoL.

METHODS

Quality of life was measured at baseline and 3 months using generic European Quality of Life-5 Dimensions and disease-specific (Minnesota Living with Heart Failure) questionnaires and at 18 months and study-end using the latter instrument. Median follow-up was 29.6 (interquartile range 23.6-34.6) months.

RESULTS

At baseline, patients had a substantially impaired QoL (mean European Quality of Life-5 Dimensions score 0.60, 95% confidence interval [CI] 0.58-0.62) compared to an age-matched general population (0.78, 95% CI 0.76-0.80). Quality of life improved to a greater extent in patients assigned to CRT at each time point (P < .0001). By 18 months, the mean difference in disease-specific QoL score was 10.7 (95% CI 7.6-13.8) in favor of CRT, mostly due to improved physical functioning. Differences were sustained thereafter. Quality-adjusted life-years at 18 months increased by 0.13 (95% CI 0.07-0.182) and by 0.23 (95% CI 0.13-0.33) at study-end (both P < .0001). Little heterogeneity of effect across subgroups was observed.

CONCLUSION

Cardiac resynchronization therapy improves long-term QoL and survival in patients with moderate to severe heart failure. The effects appear sustained, and therefore, the gain in quality-adjusted life years with CRT should be even greater during longer term follow-up.

Diastolic heart failure: state of the science on best treatment practices

PURPOSE

The purpose of this article is to increase awareness among nurse practitioners (NPs) of the current state of the science on diastolic heart failure (DHF), the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines for DHF, and pathophysiology, diagnosis, and nonpharmacological and pharmacological management of DHF.

DATA SOURCES

The articles included in the review of the state of the science were retrieved by a search of PUBMED literature using the following key search terms: heart failure, diastolic heart failure, preserved systolic function, heart failure management, treatment of diastolic heart failure, treatment of diastolic dysfunction, and treatment of preserved systolic function. Current published guidelines from the ACC and AHA were reviewed to establish clinical recommendations for patients with DHF.

CONCLUSIONS

The state of the science and clinical recommendations for DHF are in the early stages compared to those for systolic heart failure (SHF). The need for more randomized clinical trials on nonpharmacological and pharmacological management and the development of standardized guidelines for DHF patients are clearly apparent.

IMPLICATIONS FOR PRACTICE

Both nonpharmacologic and pharmacologic management are effective and necessary to control the clinical signs and symptoms of DHF and improve overall quality of life. Successful tailoring of a treatment plan to suit each individual patient's needs and including the family are important for the NP to consider.

Acceptability and psychometric properties of the Minnesota Living With Heart Failure Questionnaire among patients undergoing heart valve surgery: validation and comparison with SF-36

BACKGROUND

Health-related quality of life (HQOL) enhancement is a major objective of valvular surgery (VS), but assessments have been limited primarily to generic measures that may not be optimally responsive to intervention. Disease-specific instruments have been used in heart failure (HF), commonly associated with valve disease, but have been neither validated nor routinely applied among patients undergoing VS.

METHODS AND RESULTS

We administered the Minnesota Living with Heart Failure (MLHFQ) and SF-36 questionnaires preoperatively (T(0)) to 50 patients undergoing VS and at 1 (T(1)) and 6 months (T(2)) after VS. Performance of MLHFQ was evaluated and compared with SF-36. MLHFQ completion rates were >98% (NS vs. SF-36); Cronbach's alpha was > or = 0.9 (total score, dimensions), supporting internal reliability. Confirmatory factor analysis verified good model fit for physical/emotional domain items (relative chi-squares < 3.0, critical ratios > 2.0, both instruments), supporting structural validity. Spearman coefficients correlating MLHFQ with parallel SF-36 domains were moderate to high (0.6-0.9; P < or = .001: T(0)-T(2)), supporting convergent validity. Baseline HQOL was poorest in patients with HF (P < or = .05 [both instruments]), supporting criterion validity. Responsiveness (proportional HQOL change scores: T(0) vs. T(2)) to VS was greater with MLHFQ vs. SF-36 (P < or = .002).

CONCLUSIONS

Among patients undergoing VS, the MLHFQ is highly acceptable and maintains good psychometric properties, comparing favorably with SF-36. These findings suggest its utility for measuring disease-specific HQOL changes after VS.

Evolving applications for patient-centered health status measures

Patient-centered health status measures-assessments of patients' symptoms, function, and quality of life-have matured substantially over the past 2 decades. Currently, valid, reliable, and sensitive disease-specific measures are available for quantifying the health status of patients with cardiovascular disease. This article briefly reviews the concept of health status measures, with a focus on their interpretation. It then discusses both the rationale and potential applications of health status measures in clinical care. Health status measures are not surrogate measures of outcome but rather highly meaningful outcomes of care. As such, they have important emerging roles as outcomes in clinical trials, as tools for monitoring patients in routine clinical care, as a mechanism for operationalizing and evaluating disease management programs, and as tools for quality assessment/improvement. Over time, it is expected that health status measures will also have an increasingly important role in patient-centered medical decision making. By becoming aware of the evolving roles of health status measures, clinicians can help to accelerate the realization of the Institute of Medicine's vision for a more transparent, evidence-based, patient-centered healthcare system.

Pain and quality of life in hospitalized patients with heart failure

The pain experience of patients with heart failure (HF) and its impact on their quality of life (QOL) has not been described in sufficient detail. This study sampled patients hospitalized with HF to describe the prevalence and severity of bodily pain; evaluate differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effect of selected demographic, disease-specific characteristics, bodily pain, and mental health on QOL. Two items from the Medical Outcomes Study--Short Form (SF-36) were used to measure pain, and one subscale of the SF-36 was used to evaluate mental health. The Minnesota Living With Heart Failure Questionnaire was used to measure QOL. Patients with HF (n=93) had a mean age of 75 years, were predominantly male (65%), and lived alone (47.3%). Lung diseases and diabetes were the most common comorbidities; 58% were categorized as New York Heart Association (NYHA) Class III, whereas 58% of the sample was diagnosed with HF in the past four years. Of note, 85% of the patients reported pain and 42.5% said that it was in the severe or very severe range. No demographic variables were associated with pain, whereas a higher number of chronic conditions were associated with pain. SF-36 mental health and pain scores, as well as NYHA class, explained 34.1% of the variance in QOL in patients with HF. These data suggest that pain is highly prevalent and has a significant impact on the QOL of patients with HF. However, additional research is warranted to determine the specific causes and characteristics of pain in these patients.

Long-term effects of a group-based high-intensity aerobic interval-training program in patients with chronic heart failure

Studies on the long-term effects of exercise training programs on functional capacity and the quality of life in patients with chronic heart failure (CHF) are sparse. The aim of this study was to evaluate the long-term effects of group-based, high-intensity interval training on functional capacity and the quality of life in 80 patients with stable CHF (mean age 70.1 +/- 7.9 years) in New York Heart Association classes II to IIIB. Patients were randomized to either an exercise group (n = 40) or a control group (n = 40). The mean ejection fractions at baseline were 31 +/- 8% in the exercise group and 31 +/- 1% in the control group. The exercise group exercised twice a week for 4 months in addition to 4 consultations with a CHF nurse. Six-minute walking distance, workload and exercise time on a cycle ergometer test, and the quality of life were measured at baseline and 4 and 12 months after enrollment. After 4 months, functional capacity (6-minute walking distance +58 vs -15 m, p <0.001) and the quality of life (Minnesota Living With Heart Failure Questionnaire score +10 vs -1 point, p <0.005) improved significantly in the exercise group compared with the control group. After 12 months, the improvements were still significant in the exercise group compared with the control group for all parameters (6-minute walking distance +41 vs -20 m, p <0.001; workload +10 vs -1 W, p = 0.001; exercise time +53 vs -6 seconds, p = 0.003; quality of life +10 vs -6 points, p = 0.003). In conclusion, the results support the implementation of a group-based aerobic interval training program to improve long-term effects on functional capacity and the quality of life in patients with CHF.

Psychometric testing of the MDASI-HF: a symptom assessment instrument for patients with cancer and concurrent heart failure

BACKGROUND

The debilitating symptoms of cancer and heart failure (HF) can adversely affect the patient's quality of life. This study evaluated the psychometric properties of the MD Anderson Symptom Inventory--Heart Failure (MDASI-HF), a 27-item self-report assessment instrument for patients with cancer and concurrent HF.

METHODS AND RESULTS

Psychometric testing used data from 156 patients (age 63.3 +/- 13.2 years, 56% male) with a diagnosis of cancer and HF receiving care in a major cancer center. Reliability of the MDASI-HF for the 13 symptoms (alpha = 0.89), 8 HF-specific items (alpha = 0.83), and interference items (alpha = 0.92) was high. Criterion-related validity with the Eastern Cooperative Oncology Group performance scale (r = 0.63) and the New York Heart Association classification (r = 0.65) were statistically significant, P = .01. Construct validity supported two constructs for the additional HF specific items: covert HF factor and overt HF factor.

CONCLUSION

The MDASI-HF is a valid and reliable instrument for symptom assessment in patients with cancer and HF. This instrument can be used to identify symptom occurrence and enhance the provider's understanding of the prevalence and severity of symptoms from the patient's perspective.

The enigma of quality of life in patients with heart failure

Current treatment goals in heart failure (HF) aim to improve both survival and quality of life (QoL) of patients. In this brief communication, we reviewed randomized controlled trials that assessed the impact of pharmacological treatment on QoL, and we discussed some methodological limitations of QoL assessment in HF. Studies that assessed QoL with a disease-specific questionnaire were included. We found that at present there is a paradox in HF treatment. Life prolonging therapies, such as angiotensin-converting-enzyme-inhibitors, and angiotensin receptor blockers improve modestly or only delay the progressive worsening of QoL in HF. Treatment with beta blockers does not affect QoL in any way. However, this neutral effect of beta blockers may also be due to some methodological limitations, such as the small number of patients included in beta blocker trials or the short duration of follow-up. Disease-specific questionnaires may also have some limitations, e.g. are not sensitive enough to detect small changes in QoL. On the other hand, therapies that significantly improve QoL in HF (e.g. inotropic agents) do not seem beneficial in relation to survival. We conclude that QoL in HF remains an open field, in which new therapies but also clarification of methodology is required. In the mean time, the use of life prolonging therapies appears as a safe measure to modestly improve or maintain QoL.

[Influence of cardiopathy etiology on responses to cardiac resynchronization therapy]

INTRODUCTION AND OBJECTIVES

Little is known about how responses to cardiac resynchronization therapy (CRT) are affected by the nature of the underlying cardiopathy. The aim of this study was to investigate how cardiopathy etiology influences the effect of CRT on reverse left ventricular remodeling.

METHODS

The study included 106 patients with left ventricular systolic dysfunction and left bundle branch block (LBBB) who were receiving CRT. Clinical and echocardiographic investigations were performed at baseline before implantation and at 6 and 12 month follow-up to determine left ventricular diameter, volume and systolic function, and to quantify mitral regurgitation.

RESULTS

During follow-up, it was observed that CRT reduced left ventricular volume and diameter, increased left ventricular ejection fraction (LVEF), and reduced mitral regurgitation severity irrespective of the etiology of the cardiopathy. In patients with ischemic dilated cardiomyopathy, LVEF increased by 34% and end-diastolic and end-systolic volumes decreased by 4% and 12%, respectively; in those with idiopathic dilated cardiomyopathy, LVEF increased by 38% and end-diastolic and end-systolic volumes decreased by 13% and 19%, respectively (P=NS for ischemic vs. non-ischemic disease). Nor were differences observed between the groups in clinical outcome: 74% of the ischemic group responded compared with 62% of the non-ischemic group (P=NS).

CONCLUSIONS

At 12-month follow-up, patients with left ventricular systolic dysfunction and LBBB treated by CRT showed clinical improvements and demonstrated reverse ventricular remodeling, irrespective of the etiology of their cardiopathy.

The use of cognitive behavioral therapy in the treatment of depression for individuals with CHF

Patients diagnosed with CHF have disproportionately high rates of depression. Research has demonstrated significant consequences of depression in patients with CHF including poor quality of life, worse medical adherence and increased health complications, health care utilization, and medical costs. Despite these consequences, the treatment of depression in patients with CHF has not been widely explored. In fact, a review of the literature demonstrates a clear gap when it comes to efficacious treatments of depression in patients afflicted with CHF. The present article introduces the empirically supported therapy 'cognitive behavioral therapy' (CBT) and provides information about the literature supporting the use of CBT in depressed patients. Finally, the present authors offer some practical suggestions for healthcare providers treating depressed patients with CHF.

Physical function and quality of life in older women with diastolic heart failure: effects of a progressive walking program on sleep patterns

This preliminary study tested the effects of a home-based walking intervention on total sleep time (TST), nocturnal awakenings, depressive symptoms, physical function, and quality of life (QOL) in older women with diastolic heart failure (DHF). Twenty-three women (mean age, 68+/-11 years) with New York Heart Association class II or III DHF were randomized to either a 12-week home-based walking intervention (n=13) or education-only program (control, n=10). No between-group differences were found in women in the intervention and control groups on any of the outcome variables. When outcomes were compared within each group at baseline and 12 weeks, intervention-group patients had improvement in TST (P<.01) and heart failure-related QOL (P<.05) and a trend for decreased depressive symptoms (P<.07). Women randomized to the control group had no change in any outcomes. These preliminary findings suggest that a progressive walking program may improve TST and QOL in older women with DHF. Findings from this study support the need for larger studies to evaluate the long-term benefits of a walking program on sleep patterns, QOL, and psychologic function in this population.

Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial

OBJECTIVE

To test whether a drug review and symptom self management and lifestyle advice intervention by community pharmacists could reduce hospital admissions or mortality in heart failure patients.

DESIGN

Randomised controlled trial.

SETTING

Home based intervention in heart failure patients.

PARTICIPANTS

293 patients diagnosed with heart failure were included (149 intervention, 144 control) after an emergency admission.

INTERVENTION

Two home visits by one of 17 community pharmacists within two and eight weeks of discharge. Pharmacists reviewed drugs and gave symptom self management and lifestyle advice. Controls received usual care.

MAIN OUTCOME MEASURES

The primary outcome was total hospital readmissions at six months. Secondary outcomes included mortality and quality of life (Minnesota living with heart failure questionnaire and EQ-5D).

RESULTS

Primary outcome data were available for 291 participants (99%). 136 (91%) intervention patients received one or two visits. 134 admissions occurred in the intervention group compared with 112 in the control group (rate ratio=1.15, 95% confidence interval 0.89 to 1.48; P=0.28, Poisson model). 30 intervention patients died compared with 24 controls (hazard ratio=1.18, 0.69 to 2.03; P=0.54). Although EQ-5D scores favoured the intervention group, Minnesota living with heart failure questionnaire scores favoured controls; neither difference was statistically significant.

CONCLUSION

This community pharmacist intervention did not lead to reductions in hospital admissions in contrast to those found in trials of specialist nurse led interventions in heart failure. Given that heart failure accounts for 5% of hospital admissions, these results present a problem for policy makers who are faced with a shortage of specialist provision and have hoped that skilled community pharmacists could produce the same benefits.

TRIAL REGISTRATION NUMBER

ISRCTN59427925.

Predicting survival in heart failure

Despite advances in the therapy of cardiovascular disorders, heart failure remains a challenging disease with a dismal prognosis. A plethora of variables have been shown to be related to survival in patients with heart failure. These include heart failure etiology, clinical presentation, ventricular performance, exercise capacity, neurohormones and, more recently, inflammatory and necrosis markers. In this review we briefly list established predictive markers and discuss whether survival can accurately be predicted in this condition.

Effect of Darbepoetin Alfa on Exercise Tolerance in Anemic Patients With Symptomatic Chronic Heart Failure

OBJECTIVES

This study sought to investigate whether darbepoetin alfa, an erythropoiesis-stimulating protein (ESP), improves exercise capacity in patients with symptomatic chronic heart failure (CHF) and anemia.

BACKGROUND

Anemia is common in patients with CHF.

METHODS

In a multicenter, randomized, double-blind, placebo-controlled study, CHF patients with anemia (hemoglobin > or =9.0 to < or =12.0 g/dl) received subcutaneous placebo (n = 22) or darbepoetin alfa (n = 19) at a starting dose of 0.75 microg/kg every 2 weeks for 26 weeks. The primary end point was change in exercise tolerance from baseline to week 27 as measured by peak oxygen uptake (ml/min/kg body weight). Other end points included changes in absolute peak VO2 (ml/min), exercise duration, and health-related quality of life.

RESULTS

Differences (95% confidence interval) in mean changes from baseline to week 27 between treatment groups were 1.5 g/dl (0.5 to 2.4) for hemoglobin concentration (p = 0.005), 0.5 ml/kg/min (-0.7 to 1.7) for peak VO2 (p = 0.40), 45 ml/min (-35 to 127) for absolute peak VO2 (p = 0.27), and 108 s (-11 to 228) for exercise duration (p = 0.075). Patients receiving darbepoetin alfa compared with placebo had an improvement in self-reported Patient's Global Assessment of Change (79% vs. 41%, p = 0.01) but no significant differences in the Kansas City Cardiomyopathy and Minnesota Living with Heart Failure Questionnaire scores. Darbepoetin alfa was well tolerated.

CONCLUSIONS

In patients with symptomatic CHF and anemia, darbepoetin alfa increased and maintained hemoglobin concentrations and improved health-related quality of life. A trend toward increased exercise time but not peak VO2 was observed. (Impact of Darbepoetin Alfa on Exercise Tolerance and Left Ventricular Structure in Subjects With Symptomatic Congestive Heart Failure (CHF) and Anemia; http://clinicaltrials.gov/ct/show/NCT00117234?order = 1; NCT00117234).

Efficacy and Safety in Clinical Trials in Cardiovascular Disease

Mortality and morbid events are insensitive guides to the efficacy and safety of interventions in chronic cardiovascular disease (CVD). To enhance the ability to find new and effective long-term treatments, especially for the early stages of CVD, a revised strategy for clinical trials should emphasize efficacy on disease progression while monitoring symptoms and quality of life as guides to clinical benefit. Mortality, which is uncommon except in acute or advanced disease, provides at best a crude guide to net efficacy and safety. It must be monitored to support demonstrated efficacy on disease progression without adverse safety effects. This revised approach, made possible by our enhanced ability to monitor the progression of disease, should make it possible to study earlier disease and to improve cardiovascular health while reducing health care costs.

Effect of losartan and hydrochlorothiazide on exercise tolerance in exertional hypertension and left ventricular diastolic dysfunction

A randomized, double-blind study of 6 months of losartan 50 mg or hydrochlorothiazide (HCTZ) 12.5 mg was performed in 40 subjects with left ventricular diastolic dysfunction (mitral flow velocity E/A ratio < 1), exercise systolic blood pressure (BP) > 200 mm Hg, systolic BP at rest < 150 mm Hg, ejection fraction > 50%, and no ischemia. Before treatment, exercise systolic BP was 213 +/- 13 mm Hg (mean +/- SD) in the 19 patients randomized to losartan and 209 +/- 11 mm Hg in the 21 patients who received HCTZ. After 6 months, exercise systolic BP was similarly reduced in patients who received losartan (197 +/- 23 mm Hg, p < 0.01) and HCTZ (191 +/- 11 mm Hg, p < 0.01). With losartan, treadmill exercise time increased from 894 +/- 216 to 951 +/- 225 seconds (p = 0.011), and quality of life improved from 15 +/- 12 to 7 +/- 10 (p = 0.015) without a change in oxygen consumption (1,895 +/- 470 to 1,954 +/- 539 ml/min, p = 0.30). With HCTZ, exercise time (842 +/- 225 to 872 +/- 239 seconds, p = 0.32) and quality of life (19 +/- 21 vs 19 +/- 24, p = 0.43) did not change, whereas oxygen consumption decreased from 2,144 +/- 788 to 1,960 +/- 706 ml/min (p = 0.022). In conclusion, in patients with diastolic dysfunction and hypertensive responses to exercise, 6 months of losartan and HCTZ blunted systolic BP during exercise. Only losartan increased exercise tolerance and improved quality of life.

Home-based exercise improves functional performance and quality of life in women with diastolic heart failure

BACKGROUND

Diastolic heart failure (DHF) is common in older women. There have been no clinical trials that have identified therapies to improve symptoms in these patients. A total of 32 women with New York Heart Association class II and III DHF (left ventricular ejection fraction >45% and symptoms of dyspnea or fatigue) were randomized into a 12-week home-based, low-to-moderate intensity (40% and 60%, respectively) exercise and education program (intervention) or education only program (control). Methods and results The intervention group improved in the 6-minute walk test from 840 +/- 366 ft to 1043 +/- 317 ft versus 824 +/- 367 ft to 732 +/- 408 ft in the control group (P =.002). Quality of life also improved in the intervention group compared with the control group as measured by the Living with Heart Failure Questionnaire (41 +/- 26 to 24 +/- 18 vs 27 +/- 18 to 28 +/- 22 at 12 weeks, P =.002; 24 +/- 18 to 19 +/- 18 vs 28 +/- 22 to 32 +/- 27 at the 3-month follow-up, P =.014) and the Geriatric Depression Scale (6 +/- 4 to 4 +/- 4 vs 5 +/- 3 to 7 +/- 5 at 12 weeks, P =.012; 4 +/- 4 to 4 +/- 4 vs 7 +/- 5 to 7 +/- 5 at the 3-month follow-up, P =.009).

CONCLUSIONS

Women with DHF exhibit significant comorbidities and physical limitations. Home-based, low-to-moderate intensity exercise, in addition to education, is an effective strategy for improving the functional capacity and quality of life in women with DHF. Further study is needed to assess the long-term effect of exercise on clinical outcomes.

Acute and chronic oral magnesium supplementation: effects on endothelial function, exercise capacity, and quality of life in patients with symptomatic heart failure

Endothelial dysfunction is an important pathophysiologic mechanism in the progression of heart failure. The objective of the present study was to determine the effects of acute and chronic oral magnesium supplementation on endothelial function in patients with symptomatic heart failure. Twenty-two symptomatic chronic heart failure patients were randomized to receive 800 mg oral magnesium oxide daily or placebo for 3 months. Data collected included large and small arterial elasticity/compliance, hemodynamic parameters, exercise capacity, and quality-of-life score at baseline, 1 week, and 3 months. Patients who received magnesium had improved small arterial compliance at 3 months from baseline compared with placebo. This study suggests that chronic supplementation with oral magnesium is well tolerated and could improve endothelial function in symptomatic heart failure patients.

The effect of beta-blocker therapy on quality of life in heart failure patients: a systematic review and meta-analysis

PURPOSE

To assess the impact of beta-blocker therapy on quality of life (QoL) in chronic heart failure (CHF) patients receiving optimal standard medication.

METHODS

Randomised controlled trials (RCT) assessing QoL with a generic or disease specific instrument were identified by searching Medline, Embase, Pascal, Cochrane Controlled Trial database, and the bibliographies of the published articles. Studies published between 1985 and 2002 were included, regardless of language of publication. Cochrane Review Manager 4.2 software was used to analyse the data and standardised mean difference (SMD) was calculated to assess the effect on QoL.

RESULTS

A total of 9 trials involving 1954 patients fit into the inclusion criteria for the analysis. QoL improved more in the beta-blocker group compared to the control arm, but the SMD did not reach statistical significance (SMD, 0.07; 95%CI [-0.16, 0.02]; p = 0.13). Subgroup analysis, per type of beta-blocker and various treatment follow-up showed similar results.

CONCLUSIONS

In this meta-analysis there is evidence that beta-blocker therapy, on top of standard medication, does not impair QoL. Clinicians may add beta-blockers to standard therapy without concerns of impairing QoL in patients with CHF.

Predictors of the quality of life of older people with heart failure recruited from primary care

BACKGROUND

Current understanding of quality of life in heart failure is largely derived from clinical trials. Older people, women and those with co-morbidities are underrepresented in these. Little is known about factors predictive of quality of life amongst older people with heart failure recruited from community settings.

OBJECTIVE

To identify factors predictive of quality of life amongst older people recruited from community settings.

DESIGN

prospective questionnaire survey.

SETTING

General practice surgeries located in four areas of the UK: Bradford, Barnsley, East Devon and West Hampshire.

SUBJECTS

A total of 542 people aged >60 years with heart failure.

METHODS

Participants completed a postal questionnaire, which included a disease-specific measure (Kansas City Cardiomyopathy Questionnaire), a generic quality-of-life measure (SF-36) and sociodemographic information.

RESULTS

A multiple linear regression analysis identified the following factors as predictive of decreased quality of life: being female, being in New York Heart Association (NYHA) functional class III or IV, showing evidence of depression, being in socioeconomic groups III-V and experiencing two or more co-morbidities. Older age was associated with decreased quality of life, as measured by a generic health-related quality-of-life tool (the SF-36 mental and physical health functioning scales) but not by a disease-specific tool (the Kansas City Cardiomyopathy Questionnaire).

CONCLUSION

Findings from the study suggest that quality of life for older people with heart failure can be described as challenging and difficult, particularly for women, those in a high NYHA class, patients showing evidence of depression, patients in socioeconomic groups III-V, those experiencing two or more co-morbidities and the 'oldest old'. Such information can help clinicians working with older people identify those at risk of reduced quality of life and target interventions appropriately.

Clinical and analytical considerations in the study of health status in device trials for heart failure

BACKGROUND

Measures of health status (including symptoms, functional status, or quality of life) assess patients' experiences of their disease, and may therefore be used to quantify the benefits and risks of treatment. The aim of this article is to provide recommendations to regulatory agencies and research sponsors regarding the use of health status measures in medical device trials.

METHODS AND RESULTS

A workshop jointly planned by the Heart Failure Society of America and the US Food and Drug Administration was convened in October 2003 in Washington, DC. A Working Group to address health status measures initiated its collaboration at the workshop and continued its efforts throughout the next year. The Working Group recommended assessment of health status in all studies of heart failure therapy. Standardized instruments known to be valid, reliable, responsive to changes, and available in the languages of target populations should be used. Minimizing bias may be accomplished by using blinded, independent evaluators; collecting multiple health status measures; using valid statistical methods; and creating a health status resource bank.

CONCLUSION

Assessment of health status should be part of any device trial and should occur regardless of whether the device is intended as destination or bridging therapy. Health status endpoints should be chosen, collected, and analyzed with the same level of scientific rigor as traditional clinical endpoints. Regulatory agencies should require use of analytic methods that handle the complexity of health status data in addition to usual protocol protections.

The relationship between health perception and utility in heart failure patients in a clinical trial: results from an OVERTURE substudy

BACKGROUND

Cost-effectiveness analyses should be based on incremental years of life gained adjusted with a health status measure known as a utility. Measuring utilities for all subjects in a large-scale randomized trial, however, would be prohibitively cumbersome. We therefore sought to estimate utilities for all subjects from results obtained in a subset of patients.

METHODS AND RESULTS

We studied a subset of patients enrolled in a randomized trial of omapatrilat for the treatment of heart failure. Survey instruments (a time trade-off questionnaire, a visual analog scale [VAS] score of overall health perception, and the Duke Activity Status Index [DASI]) were administered to patients by mail and by telephone interviews. There was a significant (P <.0001) relationship between VAS score and utility described by the power function u=1-(1-v)q, where q=2.17 (95% CI 1.76 to 2.58). There was a significant positive correlation (r=.17, P <.04) between the DASI and utility, and a significant negative correlation (r=-.26, P <.001) between utility and New York Heart Association functional class.

CONCLUSION

There is a significant relationship between the relatively easily obtainable health perception score by VAS with the more complex utility by time tradeoff for a subset of patients in a multicenter randomized clinical trial. This relationship may be helpful in examining the cost-effectiveness of new treatments for heart failure.

The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study

AIMS

To assess the quality of life of patients with heart failure, due to left ventricular dysfunction (NYHA class III or IV), taking optimal medical therapy using baseline quality of life assessments from the CArdiac REsynchronisation in Heart Failure (CARE-HF) trial, and to evaluate the appropriateness of using the EQ-5D in patients with heart failure.

METHODS AND RESULTS

The quality of life of patients enrolled in CARE-HF was evaluated using the EQ-5D and Minnesota Living with Heart Failure Questionnaire. Response rates for the instruments were >90% and statistical modelling revealed an association between EQ-5D and Minnesota Living with Heart Failure scores. Heart failure is shown to have an important impact on all aspects of quality of life, but particularly on patients' mobility and usual activities, and leads to significant reductions in comparison with a representative sample of the UK population.

CONCLUSIONS

The impact of heart failure varies amongst patients but the overall burden of disease appears to be comparable to other chronic conditions such as motor neurone or Parkinson's disease. The EQ-5D appears to be an acceptable valid measure for use in patients with heart failure although further evidence of the responsiveness of this measure in such patients is required.

Effect of Valsartan on Quality of Life When Added to Usual Therapy for Heart Failure: Results From The Valsartan Heart Failure Trial

BACKGROUND

The effect on quality of life (QOL) of valsartan administered in addition to prescribed background heart failure therapy was assessed as a secondary endpoint in the Valsartan Heart Failure Trial (Val-HeFT).

METHODS AND RESULTS

QOL was assessed in 3010 patients receiving either valsartan (160 mg twice daily) or placebo in addition to prescribed background therapy (beta-blockers or angiotensin-converting enzyme inhibitors), using the Minnesota Living with Heart Failure (MLWHF) questionnaire. Treatment differences were compared at intervals to 36 months after randomization and at endpoint (last observation) using analysis of covariance and repeated measures mixed-effects, and at endpoint using a Mantel-Haenszel chi-squared test. Scores lower than baseline were indicative of improved QOL. Valsartan had a significant beneficial effect on the least-square mean change in overall MLWHF score from baseline to study endpoint (+/- standard error) (average followup 23.0 months) compared with placebo (0.19 +/- 0.47 versus 1.94 +/- 0.48; P = .005 respectively). The placebo group was characterized by a deterioration in QOL as the trial progressed. More patients on valsartan reported a clinically meaningful improvement in MLWHF score (a decrease of > or =5 points) than on placebo (34.0% versus 30.2%).

CONCLUSION

Valsartan compared to placebo added to prescribed therapy slows progressive worsening of QOL in patients with heart failure.

The effect of cardiac resynchronization on morbidity and mortality in heart failure

BACKGROUND

Cardiac resynchronization reduces symptoms and improves left ventricular function in many patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. We evaluated its effects on morbidity and mortality.

METHODS

Patients with New York Heart Association class III or IV heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony who were receiving standard pharmacologic therapy were randomly assigned to receive medical therapy alone or with cardiac resynchronization. The primary end point was the time to death from any cause or an unplanned hospitalization for a major cardiovascular event. The principal secondary end point was death from any cause.

RESULTS

A total of 813 patients were enrolled and followed for a mean of 29.4 months. The primary end point was reached by 159 patients in the cardiac-resynchronization group, as compared with 224 patients in the medical-therapy group (39 percent vs. 55 percent; hazard ratio, 0.63; 95 percent confidence interval, 0.51 to 0.77; P<0.001). There were 82 deaths in the cardiac-resynchronization group, as compared with 120 in the medical-therapy group (20 percent vs. 30 percent; hazard ratio 0.64; 95 percent confidence interval, 0.48 to 0.85; P<0.002). As compared with medical therapy, cardiac resynchronization reduced the interventricular mechanical delay, the end-systolic volume index, and the area of the mitral regurgitant jet; increased the left ventricular ejection fraction; and improved symptoms and the quality of life (P<0.01 for all comparisons).

CONCLUSIONS

In patients with heart failure and cardiac dyssynchrony, cardiac resynchronization improves symptoms and the quality of life and reduces complications and the risk of death. These benefits are in addition to those afforded by standard pharmacologic therapy. The implantation of a cardiac-resynchronization device should routinely be considered in such patients.

Consensus statement: Palliative and supportive care in advanced heart failure

BACKGROUND

A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure."

EVIDENCE

Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews.

CONCLUSIONS

The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.

Effect of candesartan and verapamil on exercise tolerance in diastolic dysfunction

Diastolic dysfunction may be exacerbated by increased systolic blood pressure (SBP) during exercise. Ang II may contribute to this process. We performed a randomized, double-blind, crossover study of two weeks of candesartan (16 mg) and verapamil (SR 160 mg). The 21 subjects were 64 +/- 10 years old with ejection fraction greater than 50%, no ischemia, mitral flow velocity E/A less than 1, normal resting SBP (< 150 mm Hg), and SBP greater than 200 mm Hg during exercise. Exercise tolerance was assessed using a Modified Bruce Protocol at baseline and after each two-week treatment period, separated by a two-week washout period. Quality of life (QOL) was assessed using the Minnesota Living with Heart Failure questionnaire. During exercise, Ang II levels increased from 29 +/- 18 to 33 +/- 18 pg/ml (P < 0.05). SBP during exercise was 213 +/- 9 mm Hg at baseline and similarly reduced by candesartan (198 +/- 18, P < 0.01) and verapamil (197 +/- 14, P < 0.01). With candesartan, exercise time increased from 793 +/- 182 seconds to 845 +/- 163 seconds (P < 0.05), and QOL improved from 11 +/- 14 to 5 +/- 6 (P < 0.05). In contrast, verapamil did not significantly improve exercise time or QOL. In patients with mild diastolic dysfunction at rest and a hypertensive response to exercise, both Ang II receptor blockade and verapamil blunted the hypertensive response to exercise. Ang II blockade increased exercise tolerance and improved QOL.

Optimising outcomes in end-stage heart failure: differences in therapeutic responses between diverse ethnic groups

Clinical and pathophysiological differences between Japanese and Caucasian patients are observed in many aspects of heart disease. Indeed, data derived from studies in one population cannot be automatically extrapolated to the other. The therapeutic goal of heart failure has recently been aimed at improving mortality in Western societies. The long-term use of an inotropic agent in the energy-starved failing heart has been expected to increase myocardial energy use and accelerate the disease process. However, this may not be the case in the Japanese population in whom mortality is relatively low. Therefore, vesnarinone therapy could be justified, since it allows optimal care in terms of an improved quality of life. Nevertheless, re-analysis of the findings of the Vesnarinone Trial (VEST) emphasised again the reasons for the precautions relating to vesnarinone use: (i) vesnarinone was associated with increased death, usually occurring within 7 months of initiation of the drug; (ii) the mortality rate was higher in patients receiving concomitant digoxin, which necessitated close monitoring of renal function; (iii) the mortality rate also increased in patients with severe bradycardia, indicating the importance of regular ECG monitoring; and (iv) improvements in cardiac function and symptoms by the drug may result in sudden death, particularly in patients with severe heart failure. Such patients should be closely monitored by a physician.

Adjunctive effects of exercise training in heart failure patients receiving maximum pharmacologic therapy

The purpose of this pilot study was to test the adjunctive effects of a 12-week exercise training intervention vs. standard pharmacologic therapy on quality of life, functional status, and mood in heart failure patients. A randomized, two-group repeated measures design was used to test outcomes at baseline and 12 weeks in 23 subjects (ejection fraction <or=40%, standard pharmacologic therapy [diuretics, angiotensin-converting enzyme inhibitors, b blockers, and digoxin] and no change in medical therapy for 30 days). The exercise group had significantly higher adjusted means on the role physical, role emotional, and mental functioning subscales of the Medical Outcomes Study 36-item Short-Form Health Survey compared with the control group. Confusion/bewilderment (Profile of Mood States subscale) adjusted mean scores were significantly lower for the exercise group, indicating better mood compared with the control group. Exercise training provided adjunctive benefit in terms of role and mental functioning for these heart failure patients.

Congestive heart failure patients' perceptions of quality of life: the integration of physical and psychosocial factors

Congestive heart failure (CHF) lowers survival and worsens the quality of life (QOL) of over four million older Americans. Both clinicians and standardized instruments used to assess the QOL of patients with CHF focus primarily on physical symptoms rather than capturing the full range of psychosocial concerns. The purpose of this study was to gather descriptions of the components of QOL as understood by patients living with CHF. Focus groups were conducted with patients with known CHF, New York Heart Association (NYHA) class I-IV, and left ventricular fraction of <40%. Focus groups were audiotaped, transcribed, and reviewed for common and recurrent themes using the methods of constant comparisons. We conducted three focus groups (n = 15) stratified by NYHA stage with male patients ranging in age from 47-82 years of age. Five patients were classified with NYHA stage III/IV and ten with NYHA stage I/II. Thirty attributes of QOL were identified which fell into five broad domains: symptoms, role loss, affective response, coping, and social support. Expectedly, patients reported the importance of physical symptoms; however, participants also identified concern for family, the uncertainty of prognosis, and cognitive function as dimensions of QOL. Changes in patients' lives attributed to CHF were not always considered deficiencies; rather, methods of coping with CHF were identified as important attributes representing possible opportunities for personal growth. Clinicians must understand the full range of concerns affecting the QOL of their older patients with CHF. The findings suggest that psychosocial aspects and patient uncertainty about their prognosis are important components of QOL among CHF patients.

Psychosocial factors and their association with clinical outcomes in patients with heart failure: why clinicians do not seem to care

Poor quality of life, social isolation, depression and anxiety all have been linked to increased risk of rehospitalization and mortality in patients with heart failure. Yet, despite evidence of their importance to outcomes in heart failure patients, psychosocial factors are assessed and treated infrequently in clinical practice. Potential reasons for this include: (1) inadequate dissemination of research about the link between psychosocial factors and outcomes; (2) insufficient training in heart-mind interactions that precludes clinicians from taking advantage of what is known; (3) perceived problems with interventions or with the science of heart-mind interactions that interfere with acceptance of what is known; (4) concerns about how to measure psychosocial factors in clinical practice; and (5) lack of curiosity from clinicians about the role of psychosocial factors in their patients. In this article, each of these possible explanations is explored and recommendations suggested.

Fluid restriction in heart failure patients: is it useful? The design of a prospective, randomised study

Thirst is a common and troublesome symptom for patients with moderate to severe heart failure. The pharmacological and non-pharmacological treatment as well as the nature of the disease itself causes increased thirst. There is no evidence in the literature about the usefulness of fluid restriction for heart failure patients. Formerly, when very little pharmacological treatment was available, fluid restriction was one of the few interventional options but nowadays when the pharmacological treatment has improved, its importance may be questioned. This article describes the design of an ongoing study with the aim to determine if an individualised and less restrictive fluid prescription can improve the quality of life, cardiac function and exercise capacity, and decrease in hospital admissions and thirst. This study will be performed as a two-group, 1:1 randomised cross-over study. In group 1, the patients are instructed to comply with a maximum fluid intake of 1.5 l. This is a standard treatment today. In group 2, the patients are recommended to intake a fluid, based on the physiological need of 30 ml/kg body weight/24 h, and are allowed to increase the fluid intake to a maximum of 35 ml/kg body weight/24 h. After 16 weeks, the patients will cross over to the other intervention strategy and continue for another 16 weeks.

Use of health-related quality of life in prescribing research. Part 1: why evaluate health-related quality of life?

Clinicians, regulatory authorities, and pharmaceutical companies increasingly recognize the importance of assessing the patient's perspective on the impact of disease and its treatment on their health-related quality of life (HRQoL). This article describes the importance of assessing HRQoL, particularly in patients with chronic disease, provides examples of the different types of instrument available for measuring HRQoL and considers how such assessment can aid medical-decision making. In addition we consider the potential role of HRQoL assessment in routine clinical practice, and its use in licensing and health technology appraisal.

Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure

Hispanics are a growing ethnic minority in the United States and one at significant risk for heart failure. Health-related quality of life (HRQL) is poor in individuals with heart failure, especially during and immediately following hospitalization. No prior research into the HRQL of Hispanics with heart failure was located. A sample of 80 individuals with heart failure, evenly divided by primary language and matched on functional status using the New York Heart Association classification system and age, was studied for 6 months following hospital discharge. Data on HRQL were collected using Spanish and English versions of the Minnesota Living with Heart Failure Questionnaire. Scores improved over time in both groups but significantly more so in the Hispanics when compared to the non-Hispanics. Group differences in HRQL could not be explained by demographics, clinical characteristics, treatment received, perceived support, or instrument response characteristics. Further exploration of this naturally occurring phenomenon may provide insight into how HRQL can be improved in the general heart failure population.