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

Effects of an exercise adherence intervention on outcomes in patients with heart failure

The purpose of this study was to determine how an exercise adherence intervention affects the physiological, functional, and quality of life outcomes of patients with heart failure (HF). Sixteen HF patients were randomly assigned to an exercise-only group (n = 8) or to an exercise-with-adherence group (n = 8). Two of the 16 people died from nonexercise related causes during the study and were not included in the analysis. The intervention was tested over a 24-week period in which patients participated in a 12-week supervised exercise program (Phase 1) followed by 12 weeks of unsupervised home exercise (Phase 2). The intervention format was one of individualized graphic feedback on exercise goals and participation and problem-solving support by nurses. Results indicate that patients who received the intervention exercised more frequently and experienced improved outcomes during both phases. The adherence intervention may encourage HF patients to continue to exercise and thereby maintain the health benefits gained in both phases of an exercise program.

Pilot study of a Web-based compliance monitoring device for patients with congestive heart failure

BACKGROUND

Web-based home care monitoring systems can assess medication compliance, health status, quality of life, and physiologic parameters. They may help overcome some of the limitations associated with current congestive heart failure management models.

OBJECTIVES

This pilot study compared the effects of a self-care and medication compliance device, linked to a Web-based monitoring system, to the effects of usual care alone on compliance with recommended self-care behaviors; medication taking; quality of life; distance walked during a 6-minute walk test; and New York Heart Association Functional Class. We also assessed patient experiences living with the compliance device.

METHODS

We enrolled 18 patients with Functional Class II-III congestive heart failure in an urban VA Medical Center. The patients were randomized into 2 groups. Group A received usual care plus the compliance device. Group B (controls) received usual care only. Data were collected using the compliance device, the Heart Failure Self-Care Behavior Scale, pill counts, 6-minute walk test, and the Minnesota Living with Heart Failure Questionnaire at baseline and at 3 months follow-up.

RESULTS

At baseline and at 3 months, there were no differences between the compliance device group and the usual care group in self-care behaviors, pill counts, 6-minute walk-test distance, or Functional Class. However, quality of life improved significantly from baseline to 3-month follow-up (ANOVA, P =.006). This difference was due to an improvement in quality of life for the monitor group (P =.002) but not the usual care only group (P =.113). Patients in the compliance device group had a 94% medication compliance rate, 81% compliance with daily blood pressure monitoring, and 85% compliance with daily weight monitoring as compared to 51% for blood pressure monitoring and 79% for weight monitoring in the usual care group (P = NS).

CONCLUSION

These are promising pilot results that, if replicated in a larger sample, may significantly improve care and outcomes for patients with heart failure.

Gender differences in quality of life are minimal in patients with heart failure

BACKGROUND

Prior investigators have suggested that quality of life differs in men and women with heart failure, especially in the physical functioning domain. The purpose of this study was to compare quality of life in men and women with heart failure to determine if differences exist after controlling for functional status, age, and ejection fraction.

METHODS

Data from a sample of 640 men and women (50% each) matched on New York Heart Association functional classification and age were used for this secondary analysis. Scores on the Minnesota Living with Heart Failure Questionnaire were compared at baseline and 3 months after enrollment using multivariate techniques with ejection fraction controlled. Treatment group (intervention versus control) was controlled statistically at 3 months because the original data were drawn from experimental and quasi-experimental studies in which an improvement in quality of life had been a goal of the intervention. The sexes differed on marital status, so this variable was controlled in analyses as well.

RESULTS

In all analyses, quality of life was minimally worse in women compared with men (1-3 points at most). None of the differences reached statistical significance except for emotional quality of life at baseline (P =.03). By 3 months, both men and women reported significantly improved and comparable quality of life and there were no significant differences between them.

CONCLUSION

Quality of life is similar in men and women with heart failure when functional status, age, ejection fraction, and marital status differences are controlled.

The Minnesota Living With Heart Failure Questionnaire: sensitivity to differences and responsiveness to intervention intensity in a clinical population

BACKGROUND

The Minnesota Living With Heart Failure Questionnaire (LHFQ) is a commonly used measure of health-related quality of life in persons with heart failure. Researchers have questioned whether LHFQ is sensitive to subtle differences and sufficiently responsive to clinical interventions because the instrument has demonstrated variable performance in clinical trials.

OBJECTIVES

A secondary analysis was conducted to assess the LHFQ for sensitivity to different clinical states and responsiveness to varying intensities of clinical intervention.

METHODS

A convenience sample of nine experimental or quasi-experimental studies from eight clinical sites in the United States yielded data from 1,136 patients with heart failure. Data in the studies had been collected at enrollment and one, three, and/or six months later. Data were analyzed using descriptive, univariate, and multivariate techniques.

RESULTS

Total and subscale scores on LHFQ were poorer in those with worse New York Heart Association functional class, although there was no difference in LHFQ scores between classes III and IV. No difference in LHFQ scores was found when patients were classified by ejection fraction. Scores improved significantly following hospital discharge, even in those in the control group. Changes in LHFQ scores were greatest in those receiving high intensity interventions.

CONCLUSIONS

The LHFQ is sensitive to major differences in symptom severity but may not be sensitive to subtle differences. It is responsive to high intensity interventions. Investigators are cautioned against using this instrument without first maximizing intervention power or without a control group for comparison.

Surrogate end points in heart failure

Because of the increasing number of pharmacologic strategies available for treatment of heart failure (HF), the time has come to reassess the adequacy of end points used to evaluate therapeutic efficacy. Interest in the use of surrogate end points in clinical studies is increasing. A surrogate end point is defined as a measurement that can substitute for a true end point for the purpose of comparing specific interventions or treatments in a clinical trial. A true end point is one that is of clinical importance to the patient (e.g., mortality or quality of life), whereas a surrogate end point is one biologically closer to the disease process (e.g., ejection fraction or left ventricular volume in HF). The prime motivation for the use of a surrogate end point concerns the possible reduction in sample size or trial duration. Such reductions have important cost implications and in some cases may influence trial feasibility. Another, perhaps more important, aspect of measuring surrogate end points is that they increase our understanding of the mechanism of action of drugs and thus may help physicians to take a more enlightened approach in managing their patients. In this article we have analyzed the possible potentials of the surrogate end points in clinical studies of patients with chronic HF. Other uses of possible surrogates are discussed, and the limitations in finding true surrogates are mentioned. At this time we conclude there is no well established surrogate in HF.

Correlates of health-related quality of life in patients with heart failure

BACKGROUND

The purpose of this study was to explore health-related quality of life (HRQOL) in patients with advanced heart failure undergoing heart transplantation evaluation. The overall aim of the study was to determine whether patients' demographic characteristics, functional status, neuroticism, social network, social support, spirituality, and time since symptom onset are related to the physical and mental components of a patient's HRQOL.

METHODS

A descriptive, correlational design was used. Patients (N = 61) were recruited from 2 university-affiliated, outpatient, heart failure programs. Data were collected from chart review, a 6-minute walk, and patient-completed instruments. HRQOL, including physical and mental health components, was assessed with use of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

Demographic characteristics, functional status, neuroticism, social network, social support, spirituality, and time since symptom onset explained 26% of the variability in the physical health component of HRQOL and 44% of the variability in the mental health component of HRQOL in patients with advanced heart failure. In analyzing the data for the most parsimonious model, New York Heart Association classification, 6-minute walk distance, and neuroticism explained 49% of the variability in the mental health component of HRQOL.

CONCLUSIONS

New York Heart Association classification, 6-minute walk distance, and neuroticism are related to the mental health component of HRQOL and can be easily included in the assessment of patients with heart failure who are undergoing heart transplantation evaluation. The findings of the current study require replication but may be used to identify patients with heart failure who are potentially at risk for reduced HRQOL.

Effects of pimobendan on adverse cardiac events and physical activities in patients with mild to moderate chronic heart failure: the effects of pimobendan on chronic heart failure study (EPOCH study)

The long-term beneficial effects of pimobendan in the treatment of chronic heart failure (CHF) have not been established, so the present trial compared pimobendan (1.25 or 2.5mg twice daily) vs placebo in 306 patients with stable New York Heart Association class IIm or III CHF, and a radionuclide or echocardiographic left ventricular ejection fraction (LVEF) < or =45% despite optimal treatment with conventional therapy, for up to 52 weeks in a double-blind protocol. At the end of the 52 weeks of treatment, combined adverse cardiac events had occurred in 19 patients in the pimobendan group (15.9%) vs 33 patients in the placebo group (26.3%). The cumulative incidence of combined adverse cardiac events was 45% lower (95% confidence interval of hazard ratio: 0.31-0.97, log-rank test: p=0.035) in the pimobendan group than in the placebo group. Death and hospitalization for cardiac causes occurred in 12 patients in the pimobendan group (10.1%), vs 19 patients in the placebo group (15.3%), but without significant difference. Treatment with pimobendan also increased the mean Specific Activity Scale score from 4.39+/-0.12 at baseline to 4.68+/-0.15 at 52 weeks (p<0.05). In conclusion, long-term treatment with pimobendan significantly lowered morbidity and improved the physical activity of patients with mild to moderate CHF.

Long-term use of a left ventricular assist device for end-stage heart failure

BACKGROUND

Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated.

METHODS

We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure.

RESULTS

Kaplan-Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent (P=0.09), respectively. The frequency of serious adverse events in the device group was 2.35 (95 percent confidence interval, 1.86 to 2.95) times that in the medical-therapy group, with a predominance of infection, bleeding, and malfunction of the device. The quality of life was significantly improved at one year in the device group.

CONCLUSIONS

The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life. A left ventricular assist device is an acceptable alternative therapy in selected patients who are not candidates for cardiac transplantation.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Preferences for quality of life or survival expressed by patients with heart failure

BACKGROUND

As many patients with heart failure develop symptoms limiting daily life, newer therapies may be found to improve functional status without concomitant survival benefit. As some of these therapies may actually increase mortality, it is increasingly relevant to assess patients' preferences for survival vs improvement in symptoms.

METHODS

We enrolled 99 patients with advanced heart failure (ejection fraction 24 +/- 10, duration 6 +/- 5 years). Each patient completed time trade-off and standard gamble instruments, Minnesota Living with Heart Failure questionnaires and visual analog scales for dyspnea and overall health. Jugular venous pressure was assessed in all patients and peak oxygen consumption was measured during bicycle exercise in 60 patients.

RESULTS

Strong polarity of preference toward either survival or quality of life was expressed by 60% of patients. There was good correlation between time trade-off and standard gamble utility scores (r = 0.64), and between preference and functional class (r = 0.60). Higher jugular venous pressure and lower peak oxygen consumption were associated with poorer utility scores (p <.05). Higher dyspnea scores and worse Living with Heart Failure scores were also associated with preference to trade time or take risks for better health.

CONCLUSIONS

These findings suggest that heart failure patients express meaningful preferences about quality vs length of life. High jugular venous pressure, low peak oxygen consumption and poor Living with Heart Failure scores were related to low utility scores. These cannot be assumed, however, to predict the intensity of individual preference to trade nothing or virtually everything for better health.

Evaluation of 3 quality of life measurement tools in patients with chronic heart failure

OBJECTIVE

The objectives of this study are to (1) Address issues related to selecting a quality of life (QOL) measuring tool; and (2) Present data from a pilot test comparing 3 QOL tools (Medical Outcomes Study Short Form-36 [SF-36], the Minnesota Living with Heart Failure Questionnaire [LHFQ], and a visual analogue scale).

DESIGN

Descriptive comparative.

SETTING

A Southern university-affiliated tertiary medical center outpatient heart failure clinic.

PATIENTS

Thirty adults, randomly selected from those treated in a multidisciplinary, nurse practitioner-managed heart failure clinic.

RESULTS

Significant correlations were found among the global or broader measures of QOL (visual analog scale and LHFQ Total score) and the component scores (LHFQ Emotional, LHFQ Physical, SF-36 Mental [MCS], and SF-36 Physical [PCS]), with the only exception being that of the LHFQ Total and the SF-36 PCS. Mental and physical components of QOL were not related within the SF-36 or between the SF-36 PCS and the LHFQ Emotional score. However, the emotional and physical scores were highly and significantly related within the LHFQ and between the SF-36 MCS and the LHFQ Physical score.

CONCLUSIONS

The SF-36 was better able to differentiate physical and emotional aspects of QOL in this sample. The LHFQ subscales may be less useful in QOL assessment than the total score.

Inotropic therapy for heart failure: an evidence-based approach

BACKGROUND

Agents that increase cardiac contractility (positive inotropes) have beneficial hemodynamic effects in patients with acute and chronic heart failure but have frequently led to increased mortality when given on a long-term basis. Despite this fact, inotropes remain commonly used in the management of heart failure.

METHODS

We reviewed the available data on short- and long-term inotrope use in heart failure, emphasizing high-quality evidence on the basis of randomized trials that were powered to address clinical end points.

RESULTS

Available data suggest that long-term inotropic therapy has a negative impact on survival in patients with heart failure, regardless of the agent used. The data that inotropic therapy improves quality of life are mixed. High-quality randomized evidence is lacking for the use of inotropes for other heart failure indications, such as for acute decompensations or as a "bridge to transplant."

CONCLUSIONS

On the basis of the available evidence, the routine use of inotropes as heart failure therapy is not indicated in either the acute or chronic setting. Potentially appropriate uses of inotropes include as temporary treatment of diuretic-refractory acute heart failure decompensations or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Inotropes also may be appropriate as a palliative measure in patients with truly end-stage heart failure. A model of heart failure pathophysiologic features that combines an understanding of both hemodynamic and neurohormonal factors will be required to best develop and evaluate novel treatments for advanced heart failure.

The underreporting of results and possible mechanisms of 'negative' drug trials in patients with chronic heart failure

Large drug trials have become very important to determine which drugs should be used in the treatment of patients with chronic heart failure (CHF). When these trials showed "positive" results, publication of the data soon followed, leading to a substantial impact on prescription patterns. In the case of "negative" results, many times they were not published, or were reported as an abstract or as short paper disclosing only the main findings. In this article we will discuss some of these trials that were conducted in the last 10 years, since we believe they may provide insight into the pathophysiology and treatment options in CHF.

A health perception score predicts cardiac events in patients with heart failure: results from the IMPRESS trial

BACKGROUND

New York Heart Association (NYHA) class and treadmill exercise test variables are widely used for estimating prognosis and measuring the outcomes of treatment in patients with heart failure, but they do not take patients' perceptions into account.

METHODS AND RESULTS

Five hundred forty-five patients enrolled in a multicenter 24-week comparison of the effects of omapatrilat and lisinopril on functional capacity in patients with heart failure reported a visual analog scale (VAS) score of their overall health perception at week 12 of the study. A total of 27 first events, defined as death or worsening heart failure (hospitalization, emergency room visit, or study discontinuation), occurred in the subsequent 12 weeks. The mean (+/-SD) health perception scores were 0.43 +/- 0.31 and 0.68 +/- 0.20 in patients with and without events, respectively (P =.0006). The risk ratio (RR) for an event associated with a decile change in the health perception score was 0.74 (95% confidence interval [CI], 0.61-0.88; P =.001). The RR was unaltered by adjustment for demographic variables, treadmill time, and NYHA functional class. Although the week 12 NYHA functional class was predictive of events (RR = 2.1; 95% CI, 1.2-4.6; P =.04), treadmill time was not (RR = 0.87; 95% CI, 0.73-1.03; P = 0.11).

CONCLUSIONS

A patient-reported measure of perceived health predicts events in patients with heart failure.

Choice-matching preference reversals in health outcome assessments

BACKGROUND

Health outcome utility assessments generally assume procedural invariance. Preference reversals violating procedural invariance occur in economic scenarios when the assessment process shifts from a choice to a fill-in-the-blank task.

PURPOSE

To determine if similar reversals occur in utility assessments.

METHODS

One hundred thirty-six volunteer subjects completed 6 preference assessments of 4 personal health scenarios. Patients responded to otherwise identical tasks using either choice or fill-in-the-blank processes in a randomized crossover design. The authors determined the percentage of subjects preferring, or inferred to prefer, a given choice.

RESULTS

Preference reversals occurred in all assessment scenarios.

CONCLUSIONS

These preference reversals are a potential source of confusion for utility assessment and informed consent. They could be manipulated to achieve ends other than the best interest of patients. Anchoring or the prominence hypothesis may explain these findings.

Quality of life in patients with heart failure: do gender differences exist?

OBJECTIVE

The purpose of this study was to evaluate gender differences in quality of life (QOL) in a large sample of age-matched and ejection fraction (EF)-matched patients with heart failure.

DESIGN

Matched comparisons of secondary data were used.

SETTING

The setting consisted of multicenter Studies of Left Ventricular Dysfunction trials.

SAMPLE

The sample included 1382 patients (691 men and 691 women) who were age-matched and EF-matched.

OUTCOME MEASURES

Global QOL and the QOL dimensions of physical function, emotional distress, social health, and general health were measured using the Ladder of Life, items from the Profile of Mood States Inventory, the Functional Status Questionnaire, the beta-Blocker Heart Attack Trial instrument, and an item from the RAND Medical Outcomes Study instrument.

RESULTS

Women had significantly worse general life satisfaction, physical function, and social and general health scores than men. There were no significant differences found between gender groups for current life situation or emotional distress. After controlling for New York Heart Association classification, women still had significantly worse ratings for intermediate activities of daily living (a sub-dimension of physical functioning) and social activity.

CONCLUSIONS

Despite controlling for age, EF, and New York Heart Association classification, women had worse QOL ratings than did men for intermediate activities of daily living and social activity. Research should focus on identifying why differences exist and developing measures to improve QOL, particularly physical functioning, in women with heart failure.

Rational use of inotropic therapy in heart failure

Despite their theoretic appeal, agents that increase cardiac contractility (positive inotropes) have consistently been shown to increase mortality when given chronically to patients with heart failure. The routine use of inotropes as heart failure therapy in either the acute or the chronic setting is not supported by the available data. Some appropriate uses of inotropes are as temporary treatment of diuretic-refractory acute heart failure decompensations, or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Although controversial, the use of inotropes as a palliative measure in the small subset of patients with truly end-stage heart failure may be appropriate. An understanding of the appropriate goals of therapy is important for both patients and physicians if rational decisions about the use of inotropes are to be made.

Diastolic dysfunction as a cause of exercise intolerance

Tachycardia accompanying exercise shortens the duration of diastole, reducing the time available for the left ventricular (LV) filling. Thus, the LV must fill more rapidly for the stroke volume to increase (or even be maintained) during exercise. Normally, this is accomplished without requiring an excessive increase in left atrial (LA) pressure by an acceleration of LV relaxation and a fall in LV early diastolic pressure during exercise. This response is lost following the development of heart failure due to systolic dysfunction, both in experimental animals and in patients. In fact, in such situations, LV relaxation slows and LV early diastolic pressure increases due to exercise. Thus, any diastolic dysfunction present at rest in CHF during systolic dysfunction is exacerbated during exercise. Similarly, patients with primary diastolic dysfunction heart failure with preserved systolic function may not be able to augment LV filling rates without an abnormal increase in LA pressure. Thus, diastolic dysfunction may contribute to exercise intolerance, both in systolic dysfunction and primary diastolic dysfunction. Acute studies suggest that treatment with angiotensin II receptor blockers or verapamil may improve exercise tolerance in some patients with primary diastolic dysfunction.

Preferences for treatment outcomes in patients with heart failure: symptoms versus survival

BACKGROUND

Patient preferences for congestive heart failure therapy outcomes may vary depending on the goals of improving symptoms versus survival, but this has not been extensively investigated. Our objective was to analyze patient preferences for congestive heart failure therapy outcomes based on the goals of symptom versus survival improvement.

METHODS AND RESULTS

This was a prospective, full-profile conjoint analysis study of individual preferences for congestive heart failure treatment outcomes. Conjoint analysis was based on ratings of 16 treatment-outcome profiles, each consisting of 4 attributes (tiredness, shortness of breath, depression, and survival) varied across 4 severity levels. Part-worths (utilities) and importance weights were calculated for each attribute to determine their relative contribution to the full-profile rating decision using standard full-profile conjoint analysis techniques. Fifty-one patients with congestive heart failure from our medical center (University of Pennsylvania Medical Center, Philadelphia, PA) and 47 age-, gender-, and race-matched control subjects were studied. Part-worths and importance weights were significantly different for shortness of breath and depression between patients and control subjects. Symptom-sensitive (n = 33) and survival-sensitive (n = 17) treatment outcome preference segments were identified within the patient group. Importance weights for symptom-sensitive versus survival-sensitive patients were as follows: tiredness 0.30+/-0.10 versus 0.16+/-0.09 (P < .01); shortness of breath 0.26+/-0.08 versus 0.21+/-0.08 (P = .07); depression 0.26+/-0.09 versus 0.19+/-0.09 (P = .01); and survival 0.18+/-0.07 versus 0.43+/-0.11 (P < .01). There were no significant predictors of which treatment outcome preference segment a patient belonged. Control subjects did not display similar preference segmentation.

CONCLUSIONS

Symptomatic congestive heart-failure patients were clustered into symptom-sensitive and survival-sensitive segments in a manner suggesting that treatment outcomes of improved symptoms were of greater importance to the majority than longer survival. A full understanding of these individual preferences may have important implications for the design of therapy for heart-failure patients.

Predictors of quality of life in women with heart failure. SOLVD Investigators. Studies of Left Ventricular Dysfunction

BACKGROUND

Two and one half million women have heart failure (HF). Yet little is known about quality of life (QOL) in this population and the factors influencing it. Given the importance of QOL as an outcome of care, we conducted a study to evaluate predictors of QOL in women with HF.

METHODS

Using baseline QOL data collected in the Studies of Left Ventricular Dysfunction (SOLVD) trials, we studied predictors of QOL in 691 women with HF. Univariate, bivariate, and multiple regression analyses were used. Potential predictors included age, education, tobacco use, social isolation, life stresses, comorbidity index, New York Heart Association (NYHA) class, HF symptoms, etiology, and medications. We measured global QOL and QOL dimensions of physical function, emotional distress, and social and general health.

RESULTS

Women were older (61+/-10.5 years), predominantly Caucasian (75%), and their mean ejection fraction was 0.27 (+/-6.51). Variables with the strongest relationship to QOL included dyspnea, NYHA class, and life stresses. As dyspnea, life stresses, and NYHA class increased, QOL decreased. Additionally, smoking behavior and vasodilator use was associated with decreased QOL. Heart failure etiology of ischemic origin was associated with decreased social life satisfaction, and use of digitalis was predictive of increased social life satisfaction. Finally, increasing age was related to an increase in general life satisfaction.

CONCLUSION

Symptom amelioration, which may improve functional ability, has the greatest potential for increasing QOL in women with HF. Programs to increase physical activity in women with HF should be developed and tested. Finally, clinicians may need to optimize HF medications in women.

Losartan improves exercise tolerance in patients with diastolic dysfunction and a hypertensive response to exercise

OBJECTIVES

The aim of the study was to test the hypothesis that angiotensin II (Ang II) blockade would improve exercise tolerance in patients with diastolic dysfunction and a marked increase in systolic blood pressure (SBP) during exercise.

BACKGROUND

Diastolic dysfunction may be exacerbated during exercise, especially if there is a marked increase in SBP. Angiotensin II may contribute to the hypertensive response to exercise and impair diastolic performance.

METHODS

We performed a randomized, double-blind, placebo-controlled, crossover study of two weeks of losartan (50 mg q.d.) on exercise tolerance and quality of life. The subjects were 20 patients, mean age 64 +/- 10 years with normal left ventricular systolic function (EF >50%), no ischemia on stress echocardiogram, mitral flow velocity E/A <1, normal resting SBP (<150 mm Hg), and a hypertensive response to exercise (SBP >200 mm Hg). Exercise echocardiograms (Modified Bruce Protocol) and the Minnesota Living With Heart Failure questionnaire were administered at baseline, and after each two-week treatment period, separated by a two-week washout period.

RESULTS

Resting blood pressure (BP) was unaltered by placebo or losartan. During control, patients were able to exercise for 11.3 +/- 2.5 (mean +/- SD) min, with a peak exercise SBP of 226 +/- 24 mm Hg. After two weeks of losartan, baseline BP was unaltered, but peak SBP during exercise decreased to 193 +/- 27 mm Hg (p < 0.05 vs. baseline and placebo), and exercise time increased to 12.3 +/- 2.6 min (p < 0.05 vs. baseline and placebo). With placebo, there was no improvement in exercise duration (11.0 +/- 2.0 min) or peak exercise SBP (217 +/- 26 mm Hg). Quality of life improved with losartan (18 +/- 22, p < 0.05) compared to placebo (22 +/- 26).

CONCLUSIONS

In patients with Doppler evidence of diastolic dysfunction at rest and a hypertensive response to exercise, Ang II receptor blockade blunts the hypertensive response to exercise, increases exercise tolerance and improves quality of life.

A dose-dependent increase in mortality with vesnarinone among patients with severe heart failure. Vesnarinone Trial Investigators

BACKGROUND

Vesnarinone, an inotropic drug, was shown in a short-term placebo-controlled trial to improve survival markedly in patients with severe heart failure when given at a dose of 60 mg per day, but there was a trend toward an adverse effect on survival when the dose was 120 mg per day. In a longer-term study, we evaluated the effects of daily doses of 60 mg or 30 mg of vesnarinone, as compared with placebo, on mortality and morbidity.

METHODS

We enrolled 3833 patients who had symptoms of New York Heart Association class III or IV heart failure and a left ventricular ejection fraction of 30 percent or less despite optimal treatment. The mean follow-up was 286 days.

RESULTS

There were significantly fewer deaths in the placebo group (242 deaths, or 18.9 percent) than in the 60-mg vesnarinone group (292 deaths, or 22.9 percent) and longer survival (P=0.02). The increase in mortality with vesnarinone was attributed to an increase in sudden death, presumed to be due to arrhythmia. The quality of life had improved significantly more in the 60-mg vesnarinone group than in the placebo group at 8 weeks (P<0.001) and 16 weeks (P=0.003) after randomization. Trends in mortality and in measures of the quality of life in the 30-mg vesnarinone group were similar to those in the 60-mg group but not significantly different from those in the placebo group. Agranulocytosis occurred in 1.2 percent of the patients given 60 mg of vesnarinone per day and 0.2 percent of those given 30 mg of vesnarinone.

CONCLUSIONS

Vesnarinone is associated with a dose-dependent increase in mortality among patients with severe heart failure, an increase that is probably related to an increase in deaths due to arrhythmia. A short-term benefit in terms of the quality of life raises issues about the appropriate therapeutic goal in treating heart failure.