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

Center- vs Home-Based Cardiac Rehabilitation in Patients With Heart Failure: EXIT-HF Randomized Controlled Trial

BACKGROUND

Despite being an evidence-based intervention, the implementation of cardiac rehabilitation (CR) is often unsatisfactory, especially among patients with heart failure (HF). Home-based CR can serve as an alternative to improve accessibility for patients unable to participate in center-based programs.

OBJECTIVES

The study sought to compare the clinical impact of center- vs home-based CR in HF patients.

METHODS

Single-center, parallel group, noninferiority trial, enrolling HF patients irrespective of ejection fraction. Patients were randomly allocated in a 1:1 ratio, then adjusted to a 1 center/2 home ratio during the COVID-19 pandemic, then adjusted to 12 weeks of a standard center-based (24 supervised exercise sessions) or home-based CR (4 supervised sessions plus 20 sessions at home, asynchronously monitored by telephone using wearable smartwatch data) program. The primary outcome was change in peak oxygen uptake (Vo2peak) at 12 weeks.

RESULTS

Of the 120 patients (age 62 ± 11 years, 66% men, mean left ventricular ejection fraction 36 ± 11%) who were randomized to center-based (n = 45) or home-based (n = 75) CR, 95 (79%) had complete Vo2peak data at the 12-week assessment: 34 (76%) in the center-based group and 61 (81%) in the home-based group. No significant between-group differences were found in Vo2peak change from baseline to week 12 (0.8 mL/kg/min [95% CI: 1.8 to -0.16 mL/kg/min]; P = 0.10). Additionally, no between-group differences were found for changes in the prespecified secondary outcomes: 6-minute walking distance, Minnesota Living with Heart Failure Questionnaire scores, disease-related biomarkers, and physical fitness. Exercise adherence to the CR program was similar between groups (home-based 84% vs center-based 81%).

CONCLUSIONS

In a contemporary well-treated HF population, home-based CR was noninferior to the center-based program, supporting the home-based approach as an effective and feasible alternative to the traditional center-based programs. (EXercise InTervention in Heart Failure [EXIT-HF]; NCT04334603).

Exercise training decreases the load and changes the content of circulating SDS-resistant protein aggregates in patients with heart failure with reduced ejection fraction

BACKGROUND

Heart failure (HF) often disrupts the protein quality control (PQC) system leading to protein aggregate accumulation. Evidence from tissue biopsies showed that exercise restores PQC system in HF; however, little is known about its effects on plasma proteostasis.

AIM

To determine the effects of exercise training on the load and composition of plasma SDS-resistant protein aggregates (SRA) in patients with HF with reduced ejection fraction (HFrEF).

METHODS

Eighteen patients with HFrEF (age: 63.4 ± 6.5 years; LVEF: 33.4 ± 11.6%) participated in a 12-week combined (aerobic plus resistance) exercise program (60 min/session, twice per week). The load and content of circulating SRA were assessed using D2D SDS-PAGE and mass spectrometry. Cardiorespiratory fitness, quality of life, and circulating levels of high-sensitive C-reactive protein, N-terminal pro-B-type natriuretic peptide (NT-proBNP), haptoglobin and ficolin-3, were also evaluated at baseline and after the exercise program.

RESULTS

The exercise program decreased the plasma SRA load (% SRA/total protein: 38.0 ± 8.9 to 36.1 ± 9.7%, p = 0.018; % SRA/soluble fraction: 64.3 ± 27.1 to 59.8 ± 27.7%, p = 0.003). Plasma SRA of HFrEF patients comprised 31 proteins, with α-2-macroglobulin and haptoglobin as the most abundant ones. The exercise training significantly increased haptoglobin plasma levels (1.03 ± 0.40 to 1.11 ± 0.46, p = 0.031), while decreasing its abundance in SRA (1.83 ± 0.54 × 1011 to 1.51 ± 0.59 × 1011, p = 0.049). Cardiorespiratory fitness [16.4(5.9) to 19.0(5.2) ml/kg/min, p = 0.002], quality of life, and circulating NT-proBNP [720.0(850.0) to 587.0(847.3) pg/mL, p = 0.048] levels, also improved after the exercise program.

CONCLUSION

Exercise training reduced the plasma SRA load and enhanced PQC, potentially via haptoglobin-mediated action, while improving cardiorespiratory fitness and quality of life of patients with HFrEF.

Burden of Heart Failure in Patients With Tricuspid Regurgitation and Effect of Transcatheter Repair on Different Subdimensions of Quality of Life

BACKGROUND

Right-sided heart failure (HF) due to severe tricuspid regurgitation (TR) is associated with reduced quality of life (QoL). Here, we analyzed the impact of TR on specific QoL dimensions and the effect of transcatheter tricuspid valve intervention (TTVI) on individual QoL items.

METHODS AND RESULTS

In this study, we included 174 patients with HF (49% women; median age, 79 years; 97% New York Heart Association ≥3) with baseline QoL assessment undergoing TTVI by transcatheter edge-to-edge-repair at our center between April 2016 and March 2022. QoL was assessed by the standardized Minnesota Living With HF Questionnaire. QoL change after TTVI and correlation to functional end points were analyzed. In addition, all QoL domains and the 21 individual items of the Minnesota Living With HF Questionnaire were analyzed. TTVI significantly reduced TR (TR ≥3: baseline 95%, 1-year-follow-up 7%; P<0.001). Total Minnesota Living with HF Questionnaire score improved from 37 (interquartile range, 26-50) points to 31 (interquartile range, 17-42) points (median follow-up-interval, 355 days; P<0.001). QoL improvement was associated with positive New York Heart Association class, 6-minute walking distance, and actigraphy changes (all P<0.05). The detailed analysis revealed that all items of the physical-related QoL dimension were impaired at baseline and strongly improved after TTVI. In contrast, the emotional and "social" Minnesota Living With HF Questionnaire dimensions were largely unaffected at baseline, yet specific items improved with TTVI.

CONCLUSIONS

In this single-center study, we delineate the QoL-associated disease burden of TR and identify specific QoL items that improved after TTVI. Our findings support TTVI in patients with reduced QoL and may add to the development of specific tools assessing the functional status of an increasing patient population undergoing TTVI.

Prognostic value of quality of life and functional status in patients with heart failure: a systematic review and meta-analysis

BACKGROUND

Functional health status is increasingly being recognized as a viable endpoint in heart failure (HF) trials. We sought to assess its prognostic impact and relationship with traditional clinical outcomes in patients with HF.

METHODS

MEDLINE and Cochrane central were searched up to January 2021 for post hoc analyses of trials or observational studies that assessed independent association between baseline health/functional status, and mortality and hospitalization in patients with HF across the range of left ventricular ejection fractions to evaluate the prognostic ability of NYHA class [II, III, IV], KCCQ, MLHFQ, and 6MWD. Hazard ratios (HR) with 95% confidence intervals were pooled.

RESULTS

Twenty-two studies were included. Relative to NYHA I, NYHA class II (HR 1.54 [1.16-2.04]; p < 0.01), NYHA class III (HR 2.08 [1.57-2.77]; p < 0.01), and NYHA class IV (HR 2.53 [1.25-5.12]; p = 0.01) were independently associated with increased risk of mortality. 6MWD (per 10 m) was associated with decreased mortality (HR 0.98 [0.98-0.99]; p < 0.01). A 5-point increase in KCCQ-OSS (HR 0.94 [0.91-0.96]; p < 0.01) was associated with decreased mortality. A high MLHFQ score (> 45) was significantly associated with increased mortality (HR 1.30 [1.14-1.47]; p < 0.01). NHYA class, 6MWD (per 10 m), KCCQ-OSS, and MLHFQ all significantly associated with all-cause mortality in patients with HF.

CONCLUSION

Identifying such patients with poor health status using functional health assessment can offer a complementary assessment of disease burden and trajectory which carries a strong prognostic value.

The Effectiveness of Lifestyle Interventions in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis

OBJECTIVES

To perform a network meta-analysis to determine the effectiveness of lifestyle interventions in exercise tolerance and quality of life (QoL) in people with HFpEF.

METHODS

Ten databases were searched for randomized controlled trials that evaluated a diet and/or exercise intervention in people with heart failure with preserved ejection fraction until May 2022. The co-primary outcomes were peak oxygen uptake (V̇O2peak) and Quality of Life as assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ). We synthesized data using network meta-analysis.

RESULTS

We identified 13 trials, including a total of 869 participants, and we incorporated 6 different interventions. Improvements in V̇O2peak compared to controls were seen for all exercise interventions (2.88 [95% CI: 1.36; 4.39] mL/kg/min) for high-intensity interval training (HIIT); 2.37 [95% CI: 1.02; 3.71] mL/kg/min for low-intensity exercise (LIT) combined with a hypocaloric diet; 2.05 [95% CI: 0.81; 3.29] mL/kg/min for moderate-intensity continuous training (MICT); 1.94 [95% CI: 0.59; 3.29] mL/kg/min for LIT; 1.85 [95% CI: 0.27; 3.44] mL/kg/min for MICT combined with resistance training) but not a hypocaloric diet alone (1.26 [95%CI: -0.08; 2.61] mL/kg/min). Only HIIT (-14.45 [95%CI: -24.81; -4.10] points) and LIT (95% CI: -11.05 [-20.55; -1.54] mL/kg/min) significantly improved MLHFQ scores. Network meta-analysis indicated that HIIT was the most effective intervention for improving both V̇O2peak (mean improvement 2.88 [95% CI: 1.36; 4.39] mL/kg/min, follow-up range, 4 weeks-3 years) and QoL (-14.45 [95% CI: -24.81; -4.10] points, follow-up range, 12-26 weeks) compared to usual care.

CONCLUSIONS

This network meta-analysis indicates that HIIT is the most effective lifestyle intervention studied to improve exercise capacity and QoL, with mean improvements exceeding the minimum clinically meaningful thresholds. HIIT is likely to be an underused management strategy in HFpEF, but further studies are needed to confirm long-term improvements in symptoms and clinical outcomes.

Telemedical Intervention and Its Effect on Quality of Life in Chronic Heart Failure Patients: The Results from the Telemedicine and e-Health Solution Pilot Program

(1) Background: Heart failure (HF) is not only a common cardiovascular disease with a poor prognosis. Its prevalence in developed countries equals 1-2% of the general population of adults, while in Poland HF, patients constitute 3.2% of the total population. Modern heart failure treatment should be focused not only on reducing the risk of death and the number of readmissions due to HF exacerbation but quality of life as well. Telemedicine has been suggested as a viable tool for enhancing HRQL. Therefore, we present the results of telemedical intervention in a group of HF patients and its effect on quality of life in chronic heart failure patients from a pilot study dedicated to reducing social inequalities in health through the use of telemedicine and e-health solutions. (2) Method: The project was a multicenter, open, non-controlled trial conducted by the University of Rzeszów, Poland. The data points were collected in the June 2023-December 2023 period from fourteen primary care units from five voivodeships, mostly considered social exclusion areas. A total of 52.7% of the patients recruited were Podkarpackie Voivodeship inhabitants. The result and discussion are presented based on the Chronic Heart Failure Questionnaire (CHFQ) and the EuroQol Visual Analogue Scale (EQVAS). (3) Results: During the program, a total of over 100,000 telemedicine examinations were conducted in the form of body weight measurement, heart rate, blood pressure tests, and 7-day Holter or 14-day event Holter assessment. Over the course of this study, coordinating the pilot program medical staff has ordered 570 changes in the patient's pharmacotherapy, confirming the positive impact on quality of life in the study group. (4) Conclusions: A comprehensive telemedical intervention can contribute to an improvement in the quality of life of patients with HF beyond what was achieved with the basic standard of care in the group of HF patients from the social exclusion region. It is now unclear if the result of the basic telemedical intervention would be constant after discontinuation of the mentioned pilot program.

Heart Failure Management in 2023: A Pharmacotherapy- and Lifestyle-Focused Comparison of Current International Guidelines

This review examines the pharmacotherapy and lifestyle recommendations of the most recent iterations of the Canadian Cardiovascular Society (CCS) / Canadian Heart Failure Society (CHFS), the European Society of Cardiology (ESC), and the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) heart failure (HF) guidelines, which all have been updated in response to therapeutic developments across the spectrum of left ventricular ejection fraction. Identified areas of unanimity across these guidelines include the following: recommending quadruple therapy for patients with HF with reduced ejection fraction (HFrEF; although no guideline proposed an ideal sequence of initiation); intravenous iron administration for patients with HFrEF and iron deficiency; and sodium restriction for patients with HF. Recent evidence regarding the harms of HFrEF medication withdrawal in patients with HF with improved ejection fraction has prompted subsequent guidelines to recommend against withdrawal. Due to the lower quality of evidence, there are disagreements regarding management of HF with preserved ejection fraction and uncertainty regarding management of HF with mildly reduced ejection fraction. Practical guidance is provided to clinicians navigating these challenging areas. In addition to these clinically focused comparisons, we describe opportunities for guideline improvement and harmonization. Specifically, these include opportunities regarding HFrEF sequencing, the need for timely updates, shared decision-making, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework adoption, and the creation of recommendations where high-quality evidence is lacking. Although these guidelines have broad agreement, key areas of controversy remain that may be addressed by emerging evidence and changes in guideline methodology.

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Evaluating depressive symptoms, BDNF Val66Met, and APOE-ε4 as moderators of response to computerized cognitive training in heart failure

BACKGROUND

Depressive symptoms, brain-derived neurotrophic factor (BDNF) Val66Met, and apolipoprotein (APOE)-ε4 may moderate response to computerized cognitive training (CCT) interventions among patients with heart failure (HF).

OBJECTIVES

The purpose of this study was to examine moderators of intervention response to CCT over 8 months among patients with HF enrolled in a 3-arm randomized controlled trial. Outcomes were memory, serum BDNF, working memory, instrumental activities of daily living (IADLs), and health-related quality of life (HRQL).

METHODS

256 patients with HF were randomized to CCT, computerized crossword puzzles active control, and usual care control groups for 8 weeks. Data were collected at enrollment, baseline, 10 weeks, and 4 and 8 months. Mixed effects models were computed to evaluate moderators.

RESULTS

As previously reported, there were no statistically significant group by time effects in outcomes among the 3 groups over 8 months. Tests of moderation indicated that depressive symptoms and presence of BDNF Val66Met and APOE-ε4 were not statistically significant moderators of intervention response in outcomes of delayed recall memory, serum BDNF, working memory, IADLs, and HRQL. In post hoc analysis evaluating baseline global cognitive function, gender, age, and HF severity as moderators, no significant effects were found. HF severity was imbalanced among groups (P = .049) which may have influenced results.

CONCLUSIONS

Studies are needed to elucidate biological mechanisms of cognitive dysfunction in HF and test novel interventions to improve memory, serum BDNF, working memory, IADLs and HRQL. Patients may need to be stratified or randomized by HF severity within intervention trials.

Decisional Needs and Patient Treatment Preferences for Heart Failure Medications: A Scoping Review

Background

Pharmacologic management of heart failure with reduced ejection fraction (HFrEF) involves several medications. Decision aids informed by patient decisional needs and treatment preferences could assist in making HFrEF medication choices; however, these are largely unknown.

Methods

We searched MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), without language restriction, for qualitative, quantitative, and mixed-method studies that included patients with HFrEF or clinicians providing HFrEF care, and reported data on decisional needs or treatment preferences applicable to HFrEF medications. We classified decisional needs using a modified version of the Ottawa Decision Support Framework (ODSF).

Results

From 3996 records, we included 16 reports describing 13 studies (n = 854). No study explicitly assessed ODSF decisional needs; however, 11 studies reported ODSF-classifiable data. Patients commonly reported having inadequate knowledge or information, and difficult decisional roles. No study systematically assessed treatment preferences, but 6 studies reported on attribute preferences. Reducing mortality and improving symptoms frequently were ranked as being important, whereas cost importance rankings varied, and adverse events generally were ranked as being less important.

Conclusion

This scoping review identified key decisional needs regarding HFrEF medications, notably inadequate knowledge or information, and difficult decisional roles, which can readily be addressed by decision aids. Future studies should systematically explore the full scope of ODSF-based decisional needs in patients with HFrEF, along with relative preferences among treatment attributes to further inform development of individualized decision aids.

Dietary Antioxidant Insufficiency Is Associated With Increased Inflammatory Markers and Poorer Health-Related Quality of Life in Patients With Heart Failure

BACKGROUND

Antioxidant insufficiency, elevated inflammatory markers, and poor health-related quality of life (HRQOL) are prevalent in patients with heart failure (HF).

OBJECTIVE

The objective of this study was to examine the associations among dietary antioxidant intake, inflammatory markers, and HRQOL in patients with HF.

METHODS

This was a secondary analysis of 265 patients with HF who completed a 4-day food diary. We assessed intake of 10 antioxidants: alpha carotene, beta carotene, beta cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium. Antioxidant insufficiency was reflected by a measured level for each antioxidant that was below the estimate average requirement or lower than median for antioxidants without an estimate average requirement. Inflammatory markers including serum C-reactive protein, cytokines (interleukins 6 and 10), tumor necrosis factor-alpha, and soluble receptors (sTNFR1 and sTNFR2) were assessed with enzyme immunoassay. Health-related quality of life was measured using the Minnesota Living with Heart Failure at 12 months.

RESULTS

Dietary antioxidant insufficiency predicted C-reactive protein (β = 0.135, P = .032) and interleukin 10 (β = -.155, P = .027). Patients with higher antioxidant insufficiency had higher C-reactive protein and lower interleukin 10. Both antioxidant insufficiency (β = 0.13, P = .049) and higher C-reactive protein (β = 0.16, P = .019) were independently associated with poorer HRQOL while adjusting for covariates.

CONCLUSIONS

Dietary antioxidant insufficiency was associated with increased markers of inflammation and poorer HRQOL. Improvement of diet quality among patients with HF may be a fruitful area of research for enhancing HRQOL.

Exercise Training in Heart failure with Preserved and Reduced Ejection Fraction: A Systematic Review and Meta-Analysis

Background

While exercise training (ET) is an established tool in heart failure (HF), no research to date has analysed the efficacy of ET in both preserved (HFpEF) and reduced (HFrEF) ejection fraction phenotypes across the same clinically important parameters.

Methods

A comprehensive systematic search was performed to identify trials published between 1990 and May 2021. Controlled trials of adults reporting pre- and post-ET peak VO2, 6-min walk distance (6MWD), Minnesota Living with Heart Failure Questionnaire (MLHFQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) and left ventricular ejection fraction (LVEF) were considered. Parameters of cardiac diastolic function, brain natriuretic peptides (BNP)/N-terminal prohormone of BNP (NTproBNP) and follow-up hospitalisation and mortality data were also analysed.

Results

Ninety-three studies (11 HFpEF and 82 HFrEF) were included in the final analysis, with a pooled sample size of 11,081 participants. HFpEF analysis demonstrated significant improvements in peak VO2 (weighted mean difference: 2.333 ml·min^-1·kg^-1, P_fixed < 0.001), 6MWD (WMD: 35.396 m, P_fixed < 0.001), MLHFQ (WMD: − 10.932, P_random < 0.001), KCCQ (WMD: 3.709, P_fixed = 0.037) and E/e′ (WMD: − 1.709, [95% CI] = − 2.91–0.51, P_random = 0.005). HFrEF analysis demonstrated significant improvements in peak VO2 (WMD: 3.050 ml·min^-1·kg^-1, P_random < 0.001), 6MWD (WMD: 37.299 m, P_random < 0.001), MLHFQ (WMD: − 10.932, P_random < 0.001), LVEF (WMD: 2.677%, P_random = 0.002) and BNP/NTproBNP (SMD: − 1.349, P_random < 0.001). Outcome analysis was only performed in HFrEF, which found no significant changes in hospitalisation, all-cause mortality or composite end-points.

Conclusion

ET significantly improves exercise capacity and quality of life in both HFpEF and HFrEF patients. In HFpEF patients, ET significantly improved an important index of diastolic function, with significant improvements in LVEF and NTproBNP/BNP seen in HFrEF patients only. Such benefits did not translate into significantly reduced hospitalisation or mortality after short-term follow-up.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00464-5.

Transvenous phrenic nerve stimulation to treat central sleep apnoea in patients with heart failure may improve sleep, quality of life, and symptoms

BACKGROUND AND AIM

Sleep disorder breathing is an important non-cardiovascular comorbidity in patients with heart failure (HF). However, central sleep apnoea (CSA) remains poorly diagnosed and treated. This post-hoc analysis examined symptoms and quality of life in patients with CSA and HF following 12 months of transvenous phrenic nerve stimulation (TPNS) therapy.

METHODS AND RESULT

: Patients enrolled in remedē System Pivotal trial were invited to complete self-reported questionnaires. Symptoms and responses to three validated questionnaires were examined. Percentage of patients noting an impairment was calculated at baseline. At 12 months, % of patients experiencing improvement, no change, or worsening was calculated. Shifts from symptom presence at baseline to absence at 12 months was assessed for those symptoms experienced by ≥50% of patients at baseline. Seventy-five patients were included. Most frequently reported symptoms were fatigue and daytime sleepiness. Following 12 months of TPNS, a variety of subjective improvements were observed; 45% of patients indicating cessation of daytime sleepiness, 44% cessation of fatigue/weakness, and 52% no longer having difficulty falling/staying asleep. Specific questions related to tiredness/fatigue, motivation, and chance of dozing provided an insight into potential areas of improvement. Furthermore, at least 60% of patients reported resolution of insomnia/fragmented sleep and snoring on therapy.

CONCLUSION

Adult patients with CSA and HF experience distressing symptoms and limitations. TPNS was found to improve many of these. Awareness of key symptoms or limitations patients experience can be used to inform the development of a CSA-specific patient questionnaire to identify CSA sooner and aid treatment decisions.

Effects of educational intervention on mortality and patient-reported outcomes in individuals with heart failure: A randomized controlled trial

OBJECTIVE

To examine the effects of an educational intervention on patient-reported outcomes and all-cause mortality in heart failure (HF) patients METHODS: In this randomized controlled trial, we enrolled 122 hospitalized patients with HF. The intervention group (n = 60) received an individual nurse-led education session on HF self-management during hospitalization and three telephone calls after discharge. The control group (n = 62) received care as usual. Patient-reported outcomes were measured at baseline and at 3 and 6 months. Mortality status was determined using the National Death Records. Intervention effects were evaluated using the Cox proportional hazards regression model and linear mixed models.

RESULTS

During the follow-up (median: 568 days), 7 deaths (12%) in the intervention group and 15 deaths (24%) in the control group occurred (adjusted hazard ratio, 0.40; 95% confidence interval, 0.16-0.98; P = .046). From baseline to 3 and 6 months, the intervention group showed greater improvements in HF knowledge (difference=6.14, P = .03; difference=5.76, P = .02, respectively), self-care (difference=-6.08, P < .001; difference=-6.16, P < .001, respectively), and health-related quality of life (difference=-11.90, P = .01; difference=-14.57, P = .004, respectively) than the control group.

CONCLUSION

Educational intervention with telephone follow-up reduced all-cause mortality and improved patient-reported outcomes.

PRACTICE IMPLICATION

Educational intervention should be considered as part of routine care for HF patients.

Predictors and outcomes of quality of life in elderly patients with heart failure

Study objective

This study aims to identify predictors of health related quality of life (HRQoL) among patients with heart failure (HF) and assess whether HRQoL was a predictor of rehospitalisation and mortality, and if age influenced the findings.

Design

Observational cohort study.

Setting

Seven hospitals in the Northern Sydney Local Health District, Sydney, Australia.

Participants

Community dwelling patients who completed a Minnesota Living with HF questionnaire (MLHFQ) within 30 days of discharge after a HF hospitalisation.

Main outcome measure

Multivariable linear regression models were used to identify predictors of MLHFQ scores (higher score = worse HRQoL) and adjusted Cox regression models to assess the impact of MLHFQ scores on one-year rehospitalisation and mortality. Separate analyses were conducted for those aged ≤80 or >80 years.

Results

1911 patients of mean age 79 years (57 % aged >80 years) were included in this analysis. Among those aged ≤80 years; younger age, lower haemoglobin and presenting symptoms at hospitalisation of exertional dyspnoea, peripheral oedema and fatigue were predictors of worse post-discharge MLHFQ scores. In patients aged >80 years, living alone, chronic kidney disease, exertional dyspnoea and peripheral oedema were predictors of worse MLHFQ scores. Worse MLHFQ scores predicted one-year HF readmissions in those aged >80 years (HR 1.22, 95 % CI 1.07-1.37) but not those aged ≤80 years (HR 0.90 95 % CI 0.71-1.10).

Conclusions

In-hospital predictors can be identified for worse HRQoL post-discharge for HF. These vary according to age, and should be addressed prior to discharge.

Randomized Controlled Trial of a Cognitive Intervention to Improve Memory in Heart Failure

BACKGROUND

The objective of this 3-arm randomized controlled trial was to evaluate the efficacy of computerized cognitive training (CCT) in improving primary outcomes of delayed-recall memory and serum brain-derived neurotrophic factor (BDNF) levels; and the secondary outcomes were working memory, instrumental activities of daily living (IADLs) and health-related quality of life (HRQL) in patients with heart failure (HF).

METHODS AND RESULTS

Patients (n = 256) were randomly assigned to 8 weeks of CCT using BrainHQ, computerized crossword puzzles active control intervention, and usual care. All patients received weekly nurse-enhancement interventions. Data were collected at enrollment and baseline visits and at 10 weeks and 4 and 8 months. In mixed effects models, there were no statistically significant group or group-by-time differences in outcomes. There were statistically significant differences over time in all outcomes in all groups. Patients improved over time on measures of delayed-recall memory, working memory, IADLs, and HRQL and had decreased serum BDNF.

CONCLUSIONS

CCT did not improve outcomes compared with the active control intervention and usual care. Nurse-enhancement interventions may have led to improved outcomes over time. Future studies are needed to test nurse-enhancement interventions in combination with other cognitive interventions to improve memory in persons with HF.

Personalized pacing for diastolic dysfunction and heart failure with preserved ejection fraction: Design and rationale for the myPACE randomized controlled trial

Background

Patients with pacemakers and heart failure with preserved ejection fraction (HFpEF) or isolated diastolic dysfunction (DD) may benefit from a higher backup heart rate (HR) setting compared with the standard setting of 60 bpm.

Objective

The purpose of this study was to assess the effects of a personalized backup HR setting (myPACE group) compared with 60 bpm (control group).

Methods

In this prospective, blinded, randomized controlled study, pacemaker patients with DD or HFpEF and atrial pacing with intrinsic ventricular conduction or conduction system or biventricular pacing are randomized to the myPACE group or control group for 1 year. The primary outcome is the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores. Secondary endpoints include changes in N-terminal pro–brain natriuretic peptide levels, physical and emotional MLHFQ subscores, and pacemaker-detected atrial arrhythmia burden, patient activity levels, and thoracic impedance; hospitalization for heart failure, atrial fibrillation, cerebrovascular accident, or myocardial infarction; and loop diuretic or antiarrhythmic medication initiation or up-titration. A sample size of 118 subjects is expected to allow detection of a 5-point change in MLHFQ score in an intention-to-treat analysis and allow initial assessment of clinical outcomes and subgroup analyses.

Results

Enrollment began in July 2019. As of November 2020, 107 subjects have been enrolled. It is projected that the 1-year follow-up will be completed by December 2021.

Conclusion

Atrial pacing with intrinsic ventricular conduction or advanced ventricular pacing at a higher, personalized backup HR may be a therapeutic target for patients with isolated DD or HFpEF. The myPACE trial is designed to test this hypothesis.

Health-Related Quality of Life Is a Mediator of the Relationship Between Medication Adherence and Cardiac Event-Free Survival in Patients with Heart Failure

BACKGROUND

Health-related quality of life (HRQOL) is an important patient-reported outcome that is related to medication adherence, hospitalization and death. The nature of the relationships among medication adherence, HRQOL, and hospitalization and death is unknown. We sought to determine the relationships among medication adherence, HRQOL, and cardiac event-free survival in patients with heart failure.

METHODS AND RESULTS

We enrolled 218 patients with heart failure. Patients' medication adherence was measured objectively using the Medication Event Monitoring System. HRQOL was assessed using the Minnesota Living with Heart Failure Questionnaire. Patients were followed for up to 3.5 years to collect hospitalization and mortality data. Mediation analysis was used to determine the nature of the relationships among the variables. Patients with better medication adherence had better HRQOL (P = .014). Medication adherence and HRQOL were associated with cardiac event-free survival (both P < .05). Patients with medication nonadherence were 1.86 times more likely to experience a cardiac event than those with better medication adherence (P = .038). Medication adherence was not associated with cardiac event-free survival after entering HRQOL in the model (P = .118), indicating mediation by HRQOL of the relationship between medication adherence and cardiac event-free survival.

CONCLUSIONS

HRQOL mediated the relationship between medication adherence and cardiac event-free survival. It is important to assess medication adherence and HRQOL regularly and develop interventions to improve medication adherence and HRQOL to decrease hospitalization and mortality in patients with heart failure.

Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction

BACKGROUND

Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF.

SEARCH METHODS

We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies.  SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.

The prevalence of depression, stress and anxiety symptoms in patients with chronic heart failure

Background

Mental health illnesses are associated with frequent hospitalisation and an increased risk of all-cause mortality. Despite the high prevalence of depression in patients with chronic heart failure (CHF), there is a paucity of data on this subject from low and middle-income countries (LMIC). The aim of this study was to determine the prevalence of depression, anxiety, and stress symptoms in patients attending a dedicated CHF clinic.

Methods

A prospective study was conducted at an outpatient heart failure clinic in a tertiary academic centre. The study participants completed a Depression, Anxiety and Stress (DASS-21) questionnaire to screen for the presence and severity of depression, anxiety and stress symptoms. Furthermore, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) was completed and used to evaluate the impact of CHF on health-related quality of life (QoL). Descriptive statistics were used to describe patients' characteristics and logistic regression analysis to identify predictors of symptoms of depression.

Results

The study population comprised of 103 patients, predominantly female (62.1%) with a median age of 53 (interquartile range 38–61) years. Symptoms of depression were reported by 52.4%, with 11.6% reporting symptoms suggestive of extremely severe depression. Anxiety was diagnosed in 53.4% of patients and extremely severe anxiety was reported by 18.4% of patients. Fifty patients were classified as stressed, and only 7.7% had extremely severe stress. More than half of the patients (54.4%) were in New York Heart Association functional class I. The mean left ventricular ejection fraction in the entire cohort was 30% (SD =  ± 11.1%). In the multivariable logistic regression model, the MLHFQ score [odds ratio (OR) 1.04, 95% CI:1.02–1.06, p = 0.001] and the six-minute walk test [OR 0.99, 95% CI: 0.98–0.99, p = 0.014] were identified as independent predictors of depression.

Conclusion

Depression and anxiety symptoms were found in over half of patients attending the CHF clinic. We recommend that mental health screening should be routinely performed in patients with CHF. Prospective, adequately powered, multicentre studies from LMIC investigating the impact of depression, anxiety and stress on CHF outcomes such as health-related QoL, hospitalisation and mortality are required.

Patients With Irritable Bowel Syndrome Are Willing to Take Substantial Medication Risks for Symptom Relief

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder for which patients take significant risks to ameliorate symptoms. Unfortunately, there is no cure for IBS. We assessed the willingness of patients with IBS to take medication risks and the costs they would pay to improve symptoms.

METHODS

We mailed a survey on medication risk to patients with IBS who met the Rome IV criteria. The survey collected data on patient demographics, symptoms, medication use, prior medication-averse events, and pain catastrophization. A standard gamble evaluated respondents' willingness to take medication risks, and a willingness-to-pay set of questions quantified maximal spending on a hypothetical medication to treat IBS.

RESULTS

Among respondents (n = 215; 81.8% female; mean age, 57 y) the average duration of IBS symptoms was 17.7 years. Patients whose predominant symptom was severe diarrhea (diarrhea-predominant IBS) reported accepting a mean 10.2% ± 15.7% risk of sudden death for a 99% chance of cure. Pain catastrophizing scale scores were not associated with an increased likelihood of taking medication risks. Patients with IBS would be willing to pay an average amount of $73 per month (if annual income was <$75,000) and $197 per month (if annual income was >$75,000) for a medication that would resolve their pain.

CONCLUSIONS

In a survey of 215 patients with IBS, we found that patients with diarrhea-predominant IBS are willing to take extraordinary risks to improve their symptoms, whereas patients with IBS and pain catastrophization are not. Clinician understanding of patients' willingness to take medication risks might help them guide their patients through complex therapeutic options.

Exploring correlates of improved depression symptoms and quality of life following tai chi exercise for patients with heart failure

AIMS

Tai chi exercise has been shown in a prior randomized controlled trial to improve depression symptoms and quality of life (QoL) in patients with heart failure (HF), but correlates of these improvements are not well known. The purpose of this secondary analysis was to explore whether tai chi is associated with improvements in biopsychosocial and behavioural measures and whether such improvements are correlated with improved depression and QoL.

METHODS AND RESULTS

Participants were n = 100 adults with chronic systolic HF (mean age = 67.4, SD = 12.0; 64% male; 96% White; New York Heart Association class = 1-3) randomized to a 12 week tai chi exercise intervention or health education control. Constructs of interest included social support, exercise self-efficacy, activity engagement, sense of coherence, and inflammatory biomarkers. Tai chi was associated with increased everyday activity engagement compared with the health education group (P < 0.05), but there were no group differences in social support or sense of coherence. Among tai chi participants, improved self-efficacy was correlated with QoL (r = 31, P = 0.05), and there was a trend toward improved depression symptoms and social support (r = -0.22, P = 0.13). Among all participants, controlling for intervention group, improved sense of coherence, and inflammation (C-reactive protein) were associated with improved depression symptoms, and improved self-efficacy, sense of coherence, and frequency of activity engagement were associated with improved QoL.

CONCLUSIONS

Tai chi exercise promotes inter-related psychosocial improvements for patients with HF. A range of biopsychosocial and behavioural variables are relevant to mood management in patients with HF.

Building a Heart Failure Clinic: A Practical Guide from the Heart Failure Society of America

Heart failure (HF) remains a leading cause of mortality and morbidity and a primary driver of health care resource use in the United States. As such, there continues to be much interest in the development and refinement of HF clinics that manage patients with HF in a guideline-directed, technology-enabled, and coordinated approach. Optimization of resource use and maintenance of collaboration with other providers are also important themes when considering implementation of HF clinics. Through this document, the Heart Failure Society of America aims to provide a contemporary, practical guide to creating and sustaining a HF clinic. The guide discusses (1) patient care considerations for delivering guideline-directed and patient-centered care, and (2) operational considerations including development of a HF clinic business plan, setting goals, leadership support, triggers for patient referral and patient follow-up, patient population served, optimal clinic staffing models, relationships with subspecialists, and continuous quality improvement. This document was developed to empower providers and clinicians who wish to build and sustain community-based, successful HF clinics.

Change of Health-Related Quality of Life Over Time and Its Association With Patient Outcomes in Patients With Heart Failure

Background Improving health-related quality of life is an important goal in the management of patients with heart failure (HF). Defining health-related quality of life changes over time in patients with HF with preserved (HFpEF) or reduced ejection fraction and showing their association with other important clinical events could support the use of health-related quality of life as a measure of quantifying HF care. Methods and Results In the Alberta HEART (Heart Failure Aetiology and Analysis Team) cohort (n=621), patients were categorized into 4 subgroups: healthy controls (n=98), at risk (n=163), HFpEF (n=191), and HF with reduced ejection fraction (n=169). The change of the Kansas City Cardiomyopathy Questionnaire (KCCQ), EuroQOL 5 dimensions, and Functional Assessment of Cancer Therapy-Anemia over 12 months, and its association with a composite of death or rehospitalization within 3 years were assessed. At baseline, the KCCQ overall summary score was 73 (interquartile range, 53-86) in HFpEF and 78 (interquartile range, 56-90) in HF with reduced ejection fraction (P=0.22). Overall, 30.5% of patients with HF experienced ≥5-point improvements and 32.4% had ≥5-point worsening in KCCQ overall summary score at 12 months, which did not differ between HFpEF and HF with reduced ejection fraction (P=0.23). Clinical events were higher in patients with HF who had a decline in KCCQ over 12 months as compared with those with stable KCCQ scores (70.2% versus 52.0%, P=0.012). The results were similar for the Functional Assessment of Cancer Therapy-Anemia and EuroQOL 5 dimensions. Conclusions In patients with HF, the KCCQ quantified clinically meaningful changes over time, which were associated with important clinical outcomes in patients with HFpEF. Given the observed variability and prognostication in different patient trajectories, health-related quality of life measures could be valuable for quantifying the quality of care in healthcare systems.

Dietary Vitamin C Deficiency Is Associated With Health-Related Quality of Life and Cardiac Event-free Survival in Adults With Heart Failure

BACKGROUND

Vitamin C deficiency is prevalent in adults with heart failure (HF). Little is known about the relationship of dietary vitamin C deficiency with health outcomes in adults with HF.

OBJECTIVE

The study's aim was to determine the relationships of vitamin C deficiency measured at baseline with health-related quality of life (HRQOL) and cardiac event-free survival in patients with HF measured 1 year later.

METHOD

A total of 251 patients with HF completed a 4-day food diary. Dietary vitamin C deficiency was defined as daily intake less than the estimated average requirement from the Institute of Medicine of 75 mg/d for men and 60 mg/d for women. Health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire at 12 months. Patients were followed for a median of 1 year to determine time to the first event of cardiac-related hospitalization or death. Data were analyzed by hierarchical linear and Cox proportional hazards regressions.

RESULTS

One hundred patients (40%) had vitamin C deficiency. Dietary vitamin C deficiency was associated with poorer HRQOL at 12 months (β = 0.16, P = .02) after controlling for demographic and clinical variables. During the follow-up period, 59 patients (24%) had cardiac events. In Cox regression, vitamin C deficiency predicted shorter cardiac event-free survival after adjusting for the same covariates (hazards ratio, 1.95; 95% confidence interval, 1.08-3.51).

CONCLUSION

Vitamin C deficiency was associated with poorer HRQOL and shorter cardiac event-free survival in patients with HF. The findings suggest that encouraging patients with HF to consume a diet rich in fruits/vegetables to prevent vitamin C deficiency may lead to better health outcomes.

Decision regret in implantable cardioverter-defibrillator recipients : A cross-sectional analysis on patients that regret their decision after ICD implantation

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) are designed to deliver therapy in the event of malignant ventricular arrhythmias. Despite their benefits, some ICD recipients regret their decision on device implantation.

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, and consequences of recipients that regretted their decision after implantation.

METHODS

A questionnaire-based cross-sectional survey of consecutive ICD recipients examined during a routine outpatient follow-up visit was conducted. Their level of depression and anxiety was assessed with the hospital anxiety and depression scale (HADS). Quality of life (QOL) was assessed using the Minnesota living with heart failure questionnaire.

RESULTS

Of 434 ICD recipients invited to the study, 423 (97.5%) agreed and completed the survey, 349 (83%) had a primary prevention indication, and 339 (80%) ischemic cardiomyopathy. A total of 41 recipients (9.7%) regretted their decision to undergo ICD implantation. These patients were: (1) younger (63 versus 69 years), (2) more frequently in New York Heart Association (NYHA) ≥2 functional class (63% versus 22%), (3) had higher education levels (more than high-school: 76% versus 60%), (4) felt that preoperative information was lacking (22% versus 4%), (5) had more complications in the perioperative period (15% versus 3%), (6) felt less safe after ICD implantation (54% versus 5%), and (7) considered more frequently ICD deactivation during near end-of-life situations (54% versus 29%). Mean QOL and HADS scores were significantly worse in these patients (36 versus 30 and 12 versus 8.8 points, respectively; p < 0.01 for all).

CONCLUSION

Almost 10% of ICD recipients regretted their decision after implantation. Predictors included younger age, higher education levels, complicated perioperative period, and lack of preoperative information.

Disability and quality of life in heart failure patients: a cross-sectional study

BACKGROUND

Although both hospitalization and mortality due to heart failure (HF) have been widely studied, less is known about the impact of HF on disability and quality of life.

AIM

To assess the degree of disability and quality of life in HF patients attended at family medicine centres.

DESIGN AND SETTING

Cross-sectional study of a cohort of HF patients attended at family medicine centres.

METHODS

Disability was assessed with the WHODAS 2 questionnaire, which provides a global and six domain scores that is understanding and communication, getting around, self-care, getting along with people, life activities and participation in society. Quality of life was assessed with the Minnesota Living with Heart Failure Questionnaire, which furnishes a global and two domain scores, physical and emotional.

RESULTS

A breakdown of the results showed that 28% of patients had moderate disability and 16.7% had severe disability, with the most important areas affected being: life activities, 8.9% extreme disability and 30.3% severe disability; getting around, 34.6% severe disability and 2% extreme disability; and participation in society, 53.3% moderate-severe disability. Quality of life was mildly affected. New York Heart Association (NYHA) Functional Classification and sex were the major determinants of disability and quality of life. Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists were associated with better scores in the "getting around" and "life activity" domains.

CONCLUSION

HF patients in primary care show an important degree of disability and an acceptable quality of life.

Phantom shocks in implantable cardioverter-defibrillator recipients: impact of education level, anxiety, and depression

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are designed to deliver shocks in the event of ventricular arrhythmias. Some ICD recipients experience the sensation of ICD discharge in the absence of an actual discharge (phantom shock, PS).

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, and consequences of PS in ICD recipients.

MATERIALS AND METHODS

Consecutive ICD recipients were examined during a routine outpatient follow-up (FU) visit. Subjects completed a written survey; their level of depression and anxiety was assessed with the hospital anxiety and depression scale (HADS). Quality of life (QOL) was assessed using the Minnesota living with heart failure questionnaire.

RESULTS

Of 434 patients invited to the study, 423 (97.5%) ICD recipients agreed to and completed the survey; 349 (83%) had a primary prevention indication and 339 (80%) ischemic cardiomyopathy. A total of 27 patients (6.4%) reported a PS during a mean FU of 64 ± 44 months (5.4% in the primary prevention group and 10.8% in the secondary prevention group; p = 0.11). PS were related to higher education (≥bachelor's degree 41% versus 20%; p = 0.03), and more frequent in patients receiving adequate shocks during FU (34% versus 0.5%; p < 0.001). HADS score levels were higher following PS (15 ± 6 versus 8.8 ± 7.4; p < 0.001). The majority of patients reporting PS felt that the information provided to them prior to ICD placement was insufficient (22.2% versus 5.0%), that they needed psychological support after ICD implantation (26% versus 3%), and considered ICD deactivation in near end-of-life situations (59% versus 29%; p < 0.001 for all).

CONCLUSIONS

PS occur in 6.4% of all ICD recipients and are related to higher education and to patients that experienced adequate shocks during FU.

Exercise Rehabilitation Improves Cardiac Volumes and Functional Capacity in Patients With Endomyocardial Fibrosis: A RANDOMIZED CONTROLLED TRIAL

PURPOSE

Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy associated with low functional capacity and high mortality rates. Exercise training has been proved to be a nonpharmacological treatment of cardiovascular diseases. Therefore, the purpose of this study was to determine the effects of exercise rehabilitation in EMF patients.

METHODS

Twenty-two EMF patients, functional classes II and III (New York Heart Association [NYHA]), were randomized to the control (C-EMF) or exercise rehabilitation (Rehab-EMF) group. Patients in the Rehab-EMF group underwent 4 mo of exercise rehabilitation, whereas patients in the C-EMF group were instructed to maintain their usual daily routine. Peak oxygen uptake ((Equation is included in full-text article.)O2), cardiac function, and quality of life were evaluated. All assessments were performed at baseline and after 4 mo.

RESULTS

After 4 mo of rehabilitation, peak (Equation is included in full-text article.)O2 increased in the Rehab-EMF group (17.4 ± 3.0 to 19.7 ± 4.4 mL/kg/min, P < .001), whereas the C-EMF group showed no difference (15.3 ± 3.0 to 15.0 ± 2.0 mL/kg/min, P = .87). Also, post-intervention, peak (Equation is included in full-text article.)O2 in the Rehab-EMF group was greater than that in the C-EMF group (P < .001). Furthermore, the Rehab-EMF group, when compared to the C-EMF group, showed an increase in left ventricular end-diastolic volume (102.1 ± 64.6 to 136.2 ± 75.8 mL vs 114.4 ± 55.0 to 100.4 ± 49.9 mL, P < .001, respectively) and decrease in left atrial diastolic volume (69.0 ± 33.0 to 34.9 ± 15.0 mL vs 44.6 ± 21.0 to 45.6 ± 23.0 mL, P < .001, respectively). Quality-of-life scores also improved in the Rehab-EMF group, whereas the C-EMF group showed no change (45 ± 23 to 27 ± 15 vs 47 ± 15 to 45 ± 17, P < .001, respectively).

CONCLUSION

Exercise rehabilitation is a nonpharmacological intervention that improves functional capacity, cardiac volumes, and quality of life in EMF patients after endocardial resection surgery. In addition, exercise rehabilitation should be prescribed to EMF patients to improve their clinical condition.

Tackling Patient-Reported Outcomes in Atrial Fibrillation and Heart Failure: Identifying Disease-Specific Symptoms?

Atrial fibrillation (AF) and heart failure (HF) both significantly affect morbidity and mortality and also account for high symptom burden and impaired health-related quality of life (hrQoL). Several well-designed and broadly implemented patient-reported outcome instruments are available for both AF and HF and can easily measure hrQoL in each disease process. A better understanding of the diverse phenotypes of AF and HF, as well as the heterogeneous treatment effects of disease-specific interventions, is necessary to further disentangle the complex relationship between symptoms of AF and HF.

A systematic review of recent cardiac rehabilitation meta-analyses in patients with coronary heart disease or heart failure

Aim: The aim of the project was to conduct a systematic review of meta-analyses of supervised, home-based or telemedicine-based exercise cardiac rehabilitation (CR) published between July 2011 and April 2018. Materials & methods: Evidence on mortality, hospitalization, peak VO₂, exercise capacity, muscle strength and health-related quality of life in patients with coronary heart disease or heart failure referred to CR was obtained by searching six electronic databases. Results: Of the 127 point estimates identified in the 30 CR meta-analyses identified (mortality, n = 12; hospitalization, n = 11; VO₂, n = 40; exercise capacity, n = 20; strength, n = 18; health-related quality of life, n = 26), 60% were statistically significant and 35% clinically important. Conclusion: The statistical data are sufficiently robust to promote strategies to improve referral to and participation in CR although evidence for clinical importance needs to be further investigated.

Disease management interventions for heart failure

BACKGROUND

Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012.

OBJECTIVES

To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness.

MAIN RESULTS

We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective.

AUTHORS' CONCLUSIONS

We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome.

Might Massage Or Guided Meditation Provide “Means to A Better End”? Primary Outcomes from An Efficacy Trial with Patientsatthe end of Life

This article reports findings from a randomized controlled trial of massage and guided meditation with patients at the end of life. Using data from 167 randomized patients, the authors considered patient outcomes through 10 weeks post-enrolment, as well as next-of-kin ratings of the quality of the final week of life for 106 patients who died during study participation. Multiple regression models demonstrated no significant treatment effects of either massage or guided meditation, delivered up to twice a week, when compared with outcomes of an active control group that received visits from hospice-trained volunteers on a schedule similar to that of the active treatment arms. The authors discuss the implications of their findings for integration of these complementary and alternative medicine therapies into standard hospice care.

Electrically guided versus imaging-guided implant of the left ventricular lead in cardiac resynchronization therapy: a study protocol for a double-blinded randomized controlled clinical trial (ElectroCRT)

BACKGROUND

Cardiac resynchronization therapy (CRT) is an established treatment in patients with heart failure and prolonged QRS duration where a biventricular pacemaker is implanted to achieve faster activation and more synchronous contraction of the left ventricle (LV). Despite the convincing effect of CRT, 30-40% of patients do not respond. Among the most important correctable causes of non-response to CRT is non-optimal LV lead position.

METHODS

We will enroll 122 patients in this patient-blinded and assessor-blinded, randomized, clinical trial aiming to investigate if implanting the LV lead guided by electrical mapping towards the latest LV activation as compared with imaging-guided implantation, causes an excess increase in left ventricular (LV) ejection fraction (LVEF). The patients are randomly assigned to either the intervention group: preceded by cardiac computed tomography of the cardiac venous anatomy, the LV lead is placed according to the latest LV activation in the coronary sinus (CS) branches identified by systematic electrical mapping of the CS at implantation and post-implant optimization of the interventricular pacing delay; or patients are assigned to the control group: placement of the LV lead guided by cardiac imaging. The LV lead is targeted towards the latest mechanical LV activation as identified by echocardiography and outside myocardial scar as identified by myocardial perfusion (MP) imaging. The primary endpoint is change in LVEF at 6-month follow up (6MFU) as compared with baseline measured by two-dimensional echocardiography. Secondary endpoints include relative percentage reduction in LV end-systolic volume, all-cause mortality, hospitalization for heart failure, and a clinical combined endpoint of response to CRT at 6MFU defined as the patient being alive, not hospitalized for heart failure, and experiencing improvement in NYHA functional class or/and > 10% increase in 6-minute walk test.

DISCUSSION

We assume an absolute increase in LVEF of 12% in the intervention group versus 8% in the control group. If an excess increase in LVEF can be achieved by LV lead implantation guided by electrical mapping, this study supports the conduct of larger trials investigating the impact of this strategy for LV-lead implantation on clinical outcomes in patients treated with CRT.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02346097 . Registered on 12 January 2015. Patients were enrolled between 16 February 2015 and 13 December 2017.

Baduanjin exercise for patients with ischemic heart failure on phase-II cardiac rehabilitation (BEAR trial): study protocol for a prospective randomized controlled trial

Background

Preliminary evidence based on clinical observations suggests that meditative exercise may offer potential benefits for patients with chronic heart failure (CHF). Cardiac rehabilitation (CR), as a class-IA indication in clinical practice guidelines, has been established as an effective strategy to improve quality of life and prognosis of CHF patients. Baduanjin exercise is an important component of traditional Chinese Qigong exercises. However, its benefits for CHF have not been rigorously tested. We sought to investigate whether Baduanjin, as an adjunct to standard care, improves cardiopulmonary function, exercise tolerance, and quality of life in patients with CHF caused by coronary artery disease (CAD).

Methods/design

In this randomized controlled trial, 120 patients will be randomly allocated in a 1:1 ratio to Baduanjin exercise combined with conventional exercise of CR (Baduanjin exercise group) or conventional exercise of CR alone (conventional exercise group). In addition to conventional physical activity, participants in the Baduanjin exercise group will participate in a 45-min Baduanjin exercise training session twice a week, for 12 weeks. The primary outcome is walking distance in the 6-min Walk Test (6MWT), and the secondary outcomes are peak oxygen uptake (VO₂ peak), ventilatory anerobic threshold (VAT), The minute ventilation to carbon dioxide production relationship (VE/VCO₂ slope), left ventricular end-diastolic volume index (LVEDVi), left ventricular ejection fraction (LVEF), quality of life assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), amino-terminal pro-brain natriuretic peptide (NT-proBNP), hs-CRP, heart rate variability (HRV), New York Heart Association (NYHA) classification, and major adverse cardiovascular events.

Discussion

This is the first trial to evaluate the effects of a Baduanjin exercise-based CR program on cardiopulmonary function and exercise tolerance in ischemic CHF patients. If successful, it will prove the value of Baduanjin exercise in improving cardiopulmonary function and exercise tolerance in patients with ischemic heart failure on phase-II CR, and may further develop a Chinese Qigong exercise-based CR framework.

Trial registration

ClinicalTrials.gov, ID: NCT03229681. Registered retrospectively on 23 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2759-4) contains supplementary material, which is available to authorized users.

Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction

BACKGROUND

Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required.

OBJECTIVES

To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions.

SELECTION CRITERIA

We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data.

MAIN RESULTS

37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction.

AUTHORS' CONCLUSIONS

There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.

Comparing Measures to Assess Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction

OBJECTIVES

This study sought to compare the performance of 2 health-related quality of life (HRQOL) questionnaires in patients with heart failure with preserved ejection fraction (HFpEF).

BACKGROUND

The ability to accurately assess HRQOL over time is important in the care of patients with heart failure. The validity and reliability of HRQOL tools including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) has not been fully determined or compared in patients with HFpEF.

METHODS

Among patients with stable chronic HFpEF enrolled in the NEAT (Nitrate Effect on Activity Tolerance in Heart Failure) trial (n = 110), the study evaluated and compared reliability, validity, and responsiveness to change of the MLHFQ and KCCQ at baseline, 6 weeks, and 12 weeks.

RESULTS

Internal consistency was good and comparable for MLHFQ and KCCQ domains measuring similar aspects of HRQOL at baseline including the MLHFQ physical (Cronbach's α = 0.93) compared with the KCCQ clinical summary (α = 0.91), and the MLHFQ emotional (α = 0.92) compared with the KCCQ quality of life (α = 0.87). Correlations with New York Heart Association functional class (Spearman rho; r_s= -0.37 vs. 0.30) and 6-min walk test (6MWT) (r_s = 0.38 vs. -0.23) at baseline were slightly stronger for the KCCQ overall summary score than for the MLHFQ total score. The MLHFQ was more responsive to change in 6MWT based on responsiveness statistics.

CONCLUSIONS

These data suggest that both the MLHFQ and KCCQ are reliable and valid tools to assess HRQOL in HFpEF. The KCCQ was more strongly correlated with baseline functional status parameters, while the MLHFQ was more responsive to improvement in 6MWT.

Exercise training in heart failure

Exercise training (ET) in heart failure (HF) has long been established as an important part of HF care. ET is known to improve quality of life and functional capacity in a number of ways. Despite its proposed benefits, evidence supporting its routine inclusion in standard rehabilitation programme is at times conflicting, partly because of the significant heterogeneity present in available randomised controlled trials. There is lack of evidence with regard to the duration of the overall benefit, the optimal exercise regimen and whether certain types of HF aetiologies benefit more than others. The aim of this review is to provide an update to date literature review of the positive and negative evidence surrounding ET in HF, while proposing an efficient novel in-hospital exercise-based rehabilitation programme for patients with HF in addition to a pre-existing HF clinic.

Effect of an exercise-based cardiac rehabilitation program "Baduanjin Eight-Silken-Movements with self-efficacy building" for heart failure (BESMILE-HF study): study protocol for a randomized controlled trial

BACKGROUND

Exercise-based cardiac rehabilitation is a beneficial therapy for patients with chronic heart failure. The delivery of exercise-based cardiac rehabilitation should adopt an evidence-based approach, as well as be culturally appropriate and sensitive to individual needs and preferences. The Baduanjin Eight-Silken-Movements with Self-efficacy Building for Heart Failure (BESMILE-HF) program is the first to apply a traditional Chinese exercise, Baduanjin, as the core component in an exercise-based cardiac rehabilitation program. This trial aims to assess the efficacy, safety, and acceptability of the addition of the BESMILE-HF program to usual medications for patients with chronic heart failure.

METHODS/DESIGN

The BESMILE-HF study is a mixed-design study. It includes a two-group, parallel, randomized controlled trial with 200 chronic heart failure patients, as well as a qualitative component. Patients will be randomized into either an intervention group receiving the 12-week BESMILE-HF program plus usual medications, or a control group receiving only usual medications. The primary outcomes are peak oxygen consumption assessed using a cardiopulmonary exercise test, and disease-specific quality of life using the Minnesota Living with Heart Failure Questionnaire. The secondary outcomes are: exercise performance, exercise self-efficacy, general quality of life, dyspnea and fatigue, depression, cardiac function, prognostic and inflammatory indicator levels, hospitalization, use of medications, and major adverse cardiac events. Assessments will be carried out at baseline, and at the 4th week, 8th week, and 12th week. The qualitative component will include a semi-structure interview describing patients' experiences with the intervention.

DISCUSSION

This study can provide evidence for how to deliver a contextually adapted exercise-based cardiac rehabilitation program with the potential to be scaled up throughout China.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03180320 . Registered on 2 June 2017.

Heart Failure Symptoms Profile Associated With Depressive Symptoms

Heart failure (HF) symptoms are known to influence depressive symptoms, yet a symptom profile has not been identified. HF symptoms relative to symptom experience (frequency, severity, interference with physical activity and enjoyment of life) associated with depressive symptoms were examined. Data from three HF studies (N = 308) which used the Heart Failure Symptom Survey were included in this cross-sectional secondary analysis. Supervised classification for and identification of symptoms most associated with depressive symptoms were accomplished using random forest algorithms via conditional inference trees. The HF symptom profile associated with depressive symptoms across all four symptom experience domains included fatigue, dizziness, and forgetfulness/difficulty concentrating. Abdominal bloating, worsening cough, and difficulty sleeping were also important, but did not consistently rank in the top 5 for symptom importance relative to all symptom experience domains. Symptom profiling may enhance early identification of patients at risk for depressive symptoms and inform symptom management interventions.

Correlates of Exercise Self-efficacy in a Randomized Trial of Mind-Body Exercise in Patients With Chronic Heart Failure

PURPOSE

Exercise self-efficacy is one of the strongest predictors of physical activity behavior. Prior literature suggests that tai chi, a mind-body exercise, may increase self-efficacy; however, this is not extensively studied. Little is known about the factors associated with development of exercise self-efficacy in a population with heart failure.

METHODS

We utilized data from a randomized controlled trial of 12 weeks of group tai chi classes versus education in patients with chronic heart failure (n = 100). Multivariable linear regression was used to explore possible correlates of change in exercise self-efficacy in the entire sample and in the subgroup who received tai chi (n = 50). Covariates included baseline quality of life, social support, functional parameters, physical activity, serum biomarkers, sociodemographics, and clinical heart failure parameters.

RESULTS

Baseline 6-minute walk (β=-0.0003, SE = 0.0001, P = .02) and fatigue score (β= 0.03, SE = 0.01, P = .004) were significantly associated with change in self-efficacy, with those in the lowest tertile for 6-minute walk and higher tertiles for fatigue score experiencing the greatest change. Intervention group assignment was highly significant, with self-efficacy significantly improved in the tai chi group compared to the education control over 12 weeks (β= 0.39, SE = 0.11, P < .001). In the tai chi group alone, lower baseline oxygen uptake (β=-0.05, SE = 0.01, P = .001), decreased mood (β=-0.01, SE = 0.003, P = .004), and higher catecholamine level (epinephrine β= 0.003, SE = 0.001, P = .005) were significantly associated with improvements in self-efficacy.

CONCLUSIONS

In this exploratory analysis, our initial findings support the concept that interventions like tai chi may be beneficial in improving exercise self-efficacy, especially in patients with heart failure who are deconditioned, with lower functional status and mood.

Combined Exercise and Inspiratory Muscle Training in Patients With Heart Failure: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

Studies have reported the benefits of exercise and inspiratory muscle training (IMT) in patients with heart failure (HF); however, there is no meta-analysis on the effects of the combination of exercise and IMT in patients with HF. The objective of this study was to determine whether combined exercise/IMT was more effective than conventional exercise on exercise capacity, respiratory muscle strength, and quality of life in patients with HF.

METHODS

This is a systematic review and meta-analysis. We searched MEDLINE, LILACS, CINAHL, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials (from the earliest date available to April 2015) for randomized controlled trials, examining effects of combined exercise/IMT versus conventional exercise on exercise capacity, respiratory muscle strength, and quality of life measurements in patients with HF. Two reviewers selected studies independently. Weighted mean differences and 95% CIs were calculated.

RESULTS

Three studies met the study criteria. Combined exercise/IMT resulted in improvement in maximal inspiratory pressure weighted mean differences (20.89 cm H2O; 95% CI, 14.0-27.78) and Minnesota Living with Heart Failure Questionnaire weighted mean differences (4.43; 95% CI, 0.72-8.14). Nonsignificant difference was observed in peak (Equation is included in full-text article.)O2 for participants in the combined exercise/IMT group compared with the conventional exercise group. No serious adverse events were reported.

CONCLUSIONS

Combined exercise/IMT may improve maximal inspiratory pressure and quality of life in patients with HF and should be considered for inclusion in cardiac rehabilitation programs.

Impact of a Telehealth Program With Voice Recognition Technology in Patients With Chronic Heart Failure: Feasibility Study

Background

Despite the advances in the diagnosis and treatment of heart failure (HF), the current hospital-oriented framework for HF management does not appear to be sufficient to maintain the stability of HF patients in the long term. The importance of self-care management is increasingly being emphasized as a promising long-term treatment strategy for patients with chronic HF.

Objective

The objective of this study was to evaluate whether a new information communication technology (ICT)–based telehealth program with voice recognition technology could improve clinical or laboratory outcomes in HF patients.

Methods

In this prospective single-arm pilot study, we recruited 31 consecutive patients with chronic HF who were referred to our institute. An ICT-based telehealth program with voice recognition technology was developed and used by patients with HF for 12 weeks. Patients were educated on the use of this program via mobile phone, landline, or the Internet for the purpose of improving communication and data collection. Using these systems, we collected comprehensive data elements related to the risk of HF self-care management such as weight, diet, exercise, medication adherence, overall symptom change, and home blood pressure. The study endpoints were the changes observed in urine sodium concentration (uNa), Minnesota Living with Heart Failure (MLHFQ) scores, 6-min walk test, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) as surrogate markers for appropriate HF management.

Results

Among the 31 enrolled patients, 27 (87%) patients completed the study, and 10 (10/27, 37%) showed good adherence to ICT-based telehealth program with voice recognition technology, which was defined as the use of the program for 100 times or more during the study period. Nearly three-fourths of the patients had been hospitalized at least once because of HF before the enrollment (20/27, 74%); 14 patients had 1, 2 patients had 2, and 4 patients had 3 or more previous HF hospitalizations. In the total study population, there was no significant interval change in laboratory and functional outcome variables after 12 weeks of ICT-based telehealth program. In patients with good adherence to ICT-based telehealth program, there was a significant improvement in the mean uNa (103.1 to 78.1; P=.01) but not in those without (85.4 to 96.9; P=.49). Similarly, a marginal improvement in MLHFQ scores was only observed in patients with good adherence (27.5 to 21.4; P=.08) but not in their counterparts (19.0 to 19.7; P=.73). The mean 6-min walk distance and NT-proBNP were not significantly increased in patients regardless of their adherence.

Conclusions

Short-term application of ICT-based telehealth program with voice recognition technology showed the potential to improve uNa values and MLHFQ scores in HF patients, suggesting that better control of sodium intake and greater quality of life can be achieved by this program.

The Home-Heart-Walk study, a self-administered walk test on perceived physical functioning, and self-care behaviour in people with stable chronic heart failure: A randomized controlled trial

BACKGROUND

Adherence to self-care recommendations is associated with improved patient outcomes and improved quality of life for people living with heart failure. The Home-Heart-Walk (HHW) is an intervention to promote physical activity adapting the elements of a six minute walk test, a reliable and valid measure. This adaptation was designed to support self-monitoring of physical functioning and promote the self-care of people with heart failure. The primary outcome of the Home-Heart-Walk was perceived physical functioning and the secondary outcomes were six-minute walk test distance, health related quality of life, self-care behaviour, self-efficacy and physical activity level.

METHODS

A multicentre randomized controlled trial. Participants ( N=132) were recruited from three academic hospitals in Sydney, Australia. Participants were randomized to either the Home-Heart-Walk group or the control group. Perceived physical functioning, health related quality of life, self-care behaviour, exercise self-efficacy and physical activity level were measured at baseline and at three- and six-month follow-up.

RESULTS

After adjusting for baseline scores, there were no statistically significant between-group differences in perceived physical functioning, six-minute walk test distance, health related quality of life and exercise self-efficacy at follow-up. The intervention group had improvement in self-care behaviour ( F(1,129) = 4.75, p = 0.031) and physical activity level ( U = 1713, z = -2.12, p = 0.034) at the six-month follow-up compared with the control group.

CONCLUSION

The Home-Heart-Walk did not improve the perceived physical functioning of the intervention group. Although the feasibility and acceptability of this strategy to support self-monitoring and improve self-care behaviour was demonstrated, self-reported adherence was unreliable; newer technologies may offer better assessment of adherence.

The reliability and validity of Chinese version of SF36 v2 in aging patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF), a major public health problem worldwide, seriously limits health-related quality of life (HRQOL). How to evaluate HRQOL in older patients with CHF remains a problem.

AIM

To evaluate the reliability and validity of the Chinese version of the Medical Outcomes Study Short Form version 2 (SF-36v2) in CHF patients.

METHODS

From September 2012 to June 2014, we assessed QOL using the SF-36v2 in 171 aging participants with CHF in four cardiology departments. Convergent and discriminant validity, factorial validity, sensitivity among different NYHA classes and between different age groups, and reliability were determined using standard measurement methods.

RESULTS

A total of 150 participants completed a structured questionnaire including general information and the Chinese SF-36v2; 132 questionnaires were considered valid, while 21 patients refused to take part. 25 of the 50 participants invited to complete the 2-week test-retest questionnaires returned completed questionnaires. The internal consistency reliability (Cronbach's α) of the total SF-36v2 was 0.92 (range 0.74-0.93). All hypothesized item-subscale correlations showed satisfactory convergent and discriminant validity. Sensitivity was measured in different NYHA classes and age groups. Comparison of different NYHA classes showed statistical significance, but there was no significant difference between age groups.

DISCUSSION

We confirmed the SF-36v2 as a valid instrument for evaluating HRQOL Chinese CHF patients. Both reliability and validity were strongly satisfactory, but there was divergence in understanding subscales such as "social functioning" because of differing cultural background.

CONCLUSIONS

The reliability, validity, and sensitivity of SF-36v2 in aging patients with CHF were acceptable.