Social isolation and depression predict 12-month outcomes in the "waiting for a new heart study"

Social Isolation and Implementation of Advanced Care Planning Among Hospitalized Patients With Heart Failure

Background

The implementation of advance care planning (ACP) in heart failure management is insufficient. Social isolation (SI) could be a barrier to ACP initiation, albeit the relationship between SI and patients' preference for ACP or end‐of‐life care remains unknown.

Methods and Results

We conducted a questionnaire survey, including assessments of SI using the 6‐item Lubben Social Network Scale as well as patients' perspectives on ACP and end‐of‐life care. Of the 160 patients approached by our multidisciplinary heart failure team during admission, 120 patients (75.0%) completed the survey (median age, 73.0 years; men, 74.2%). A Cox proportional hazard model was constructed to elucidate the short‐term (180‐day) prognostic impact of SI. Overall, 28.3% of participants were at high risk for SI (6‐item Lubben Social Network Scale score <12). High‐risk patients had more negative attitudes toward ACP than those without (61.8% versus 80.2%; P =0.035). The actual performance of ACP conversation in patients with and without high risk were 20.6% and 30.2%, respectively. Regarding preference in end‐of‐life care, “Saying what one wants to tell loved ones” (73.5% versus 90.6%; P =0.016) and “Spending enough time with family” (58.8% versus 77.9%; P =0.035) were less important in high‐risk patients. High risk for SI was associated with higher 180‐day risk‐adjusted all‐cause mortality (hazard ratio, 7.89 [95% CI, 1.53–40.75]).

Conclusions

In hospitalized patients with heart failure, high risk for SI was frequently observed. High‐risk patients were associated with a negative attitude toward ACP, despite higher mortality. Further research is required to establish an ideal approach to provide ACP in socially vulnerable patients.

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up

We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND

Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.

METHODS

A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs).

RESULTS

In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010).

CONCLUSIONS

The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Role of Depression and Social Isolation at Time of Waitlisting for Survival 8 Years After Heart Transplantation

Background

We evaluated depression and social isolation assessed at time of waitlisting as predictors of survival in heart transplant (HTx) recipients.

Methods and Results

Between 2005 and 2006, 318 adult HTx candidates were enrolled in the Waiting for a New Heart Study, and 164 received transplantation. Patients were followed until February 2013. Psychosocial characteristics were assessed by questionnaires. Eurotransplant provided medical data at waitlisting, transplantation dates, and donor characteristics; hospitals reported medical data at HTx and date of death after HTx. During a median follow‐up of 70 months (<1–93 months post‐HTx), 56 (38%) of 148 transplanted patients with complete data died. Depression scores were unrelated to social isolation, and neither correlated with disease severity. Higher depression scores increased the risk of dying (hazard ratio=1.07, 95% confidence interval, 1.01, 1.15, P=0.032), which was moderated by social isolation scores (significant interaction term; hazard ratio = 0.985, 95% confidence interval, 0.973, 0.998; P=0.022). These findings were maintained in multivariate models controlling for covariates (P values 0.020–0.039). Actuarial 1‐year/5‐year survival was best for patients with low depression who were not socially isolated at waitlisting (86% after 1 year, 79% after 5 years). Survival of those who were either depressed, or socially isolated or both, was lower, especially 5 years posttransplant (56%, 60%, and 62%, respectively).

Conclusions

Low depression in conjunction with social integration at time of waitlisting is related to enhanced chances for survival after HTx. Both factors should be considered for inclusion in standardized assessments and interventions for HTx candidates.

Illness, normality and identity: the experience of heart transplant as a young adult

PURPOSE

End stage heart failure and transplant present great opportunities and challenges for patients of all ages. However, young adulthood may present additional specific challenges associated with the development of identity, career and romantic relationships. Despite recognition of greater mortality rates in young adults, consideration of the experience of transplant during this life stage has been largely overlooked in the literature. The aim of this study was to explore the experience of heart transplant in young adults.

METHOD

Interviews were conducted with nine participants across three transplant services in the United Kingdom and the data subject to interpretative phenomenological analysis.

RESULTS

Analysis identified three themes. "Separating from illness" and "working toward normality" involved limiting the influence of illness on identity, as well as reengaging with typical functioning in young adulthood. "Integrating transplant into identity" involved acknowledging the influence of living with a shortened life expectancy.

CONCLUSIONS

The need for support that recognizes specific challenges of transplant as a young adult is discussed (e.g. the development of age specific end of life pathways, improved communication between transplant recipients, their families and teams), including consideration of the impact of societal discourses (e.g. gift of life) which provided additional challenges for patients. IMPLICATIONS FOR REHABILITATION Heart transplant presents specific challenges according to the recipient's life stage. The needs of young adult recipients should be considered. Transplant professionals should consider providing opportunities for peer support and addressing the identities and values of young adult transplant recipients during rehabilitation.

The Paradox of Waiting for Heart Transplant: Between Control and Fate

OBJECTIVES

Understanding a patient's perspective has received increased attention. Awaiting heart transplant remains a great challenge, not only for patients and their families but also for health professionals. This particular challenge has multiple aspects, the most important being the psychological one. Understanding candidates for heart transplant is vital for all caregivers. In this study, our aim was to present the individual's experience of awaiting heart transplant.

MATERIALS AND METHODS

Structured interviews and the Pictorial Representation of Illness and Self Measure, Hospital Anxiety and Depression Scale, the Illness Cognition Questionnaire, and the Illness Perception Questionnaire-Revised measurements were performed in 2 male patients (60 and 61 years old) who were on heart transplant wait list.

RESULTS

The patients expressed their concerns and perceived severe consequences of heart disease. They also demonstrated the importance of significant others and hope. The results suggest the existence of realistic cognitive pictures of the disease. The patients revealed high sense of control along with the awareness of being dependent on fate. The lack of severe anxiety and depressive symptoms along with high perceived benefits' scores suggest the existence of an adaptation process.

CONCLUSIONS

Awaiting heart transplant appears to be a multidimensional phenomenon. The paradoxic configuration of a high sense of control along with the awareness of being dependent on fate was apparent. Significant others and hope seem to be of great importance. The Pictorial Representation of Illness and Self Measure allows a better understanding of a patient's perspective and allows the patient to share personal views. The individual approach provides opportunities that go far beyond routine clinical assessment.

Is it time for a cardiac allocation score? First results from the Eurotransplant pilot study on a survival benefit-based heart allocation

BACKGROUND

Patients awaiting heart transplantation in Eurotransplant are prioritized by waiting time and medical urgency. To reduce mortality, the introduction of post-transplant survival in an allocation model based on the concept of survival benefit might be more appropriate. The aim of this study was to assess the prognostic accuracy of the heart failure survival score (HFSS), the Seattle heart failure model (SHFM), the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) model, and the index for mortality prediction after cardiac transplantation (IMPACT) score for predicting mortality.

METHODS

The HFSS, SHFM, the adapted SHFM, and the INTERMACS model were evaluated for predicting waiting list mortality among heart transplant candidates, and the IMPACT score was tested for predicting post-transplant mortality in separate Cox regression models. Included were the 448 adult heart transplant candidates listed for an urgent status between October 2010 and June 2011 in Eurotransplant. A cardiac allocation score (CAS) was calculated based on the estimated survival times as predicted by the scores. All analyses were performed for the total cohort and separately for ventricular assist device (VAD) and non-VAD patients.

RESULTS

Mortality on the waiting list could significantly be predicted in the non-VAD cohort by HFSS (p = 0.005) and SHFM (p < 0.0001) and after transplant by IMPACT (p < 0.0001). None of the tested scores could predict mortality among VAD-supported patients.

CONCLUSIONS

In non-VAD patients, the HFSS, SHFM, and IMPACT provide accurate risk stratification. Further studies will reveal whether these models should be considered as the basis for a new heart allocation policy in Eurotransplant.

Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation

PURPOSE OF REVIEW

Given that the prevalence of psychiatric disorders in transplant candidates and recipients is substantially higher than in the general population, and that linkages between psychiatric disorders and medical outcomes for nontransplant-related diseases have been established, it is important to determine whether psychiatric disorders predict posttransplant medical outcomes.

RECENT FINDINGS

Most research has focused on the association between depression (both pretransplant and posttransplant) and posttransplant mortality. Some research has examined transplant-related morbidity outcomes, such as graft rejection, posttransplant malignancies, and infection. However, methodological limitations make it difficult to compare existing studies in this literature directly. Overall, the studies presented in this review indicate that psychiatric distress occurring in the early transplant aftermath bears a stronger relationship to morbidity and mortality outcomes than psychiatric distress occurring before transplant.

SUMMARY

The literature on the impact of psychiatric conditions on the morbidity and mortality of solid organ transplant recipients remains inconclusive. More research is needed in order to investigate these associations among a broader range of psychiatric predictors, morbidity outcomes, and recipient populations. Until evidence suggests otherwise, we recommend frequent monitoring of psychiatric symptoms during the first year after transplantation to aid in early identification and treatment during this critical period of adjustment.

Preparation and Support of Patients through the Transplant Process: Understanding the Recipients' Perspectives

Preparation for heart transplant commonly includes booklets, instructional videos, personalized teaching sessions, and mentorship. This paper explores heart transplant recipients' thoughts on their preparation and support through the transplant process. Twenty-five interviews were audio-/videotaped capturing voice and body language and transcribed verbatim. Coding addressed language, bodily gesture, volume, and tone in keeping with our visual methodology. Recipients reported that only someone who had a transplant truly understands the experience. As participants face illness and life-altering experiences, maintaining a positive attitude and hope is essential to coping well. Healthcare professionals provide ongoing care and reassurance about recipients' medical status. Mentors, family members, and close friends play vital roles in supporting recipients. Participants reported that only heart transplant recipients understood the experience, the hope, and ultimately the suffering associated with living with another persons' heart. Attention needs to be focused not solely on the use of teaching modalities, but also on the development of innovative support networks. This will promote patient and caregiver engagement in self-management. Enhancing clinicians' knowledge of the existential aspects of transplantation will provide them with a nuanced understanding of the patients' experience, which will ultimately enhance their ability to better prepare and support patients and their caregivers.

Beyond rose colored glasses: the adaptive role of depressive and anxious symptoms among individuals with heart failure who were evaluated for transplantation

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.

Patients' sex and emotional support as predictors of death and clinical deterioration in the waiting for a new heart study: results from the 1-year follow-up

CONTEXT

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

OBJECTIVE

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

DESIGN, SETTING, AND PARTICIPANTS

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs. low support]) were assessed at the time of wait-listing. Main Outcomes-Time until death/delisting due to deteriorated tealth, considering competing outcomes (e.g., transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models.

RESULTS

By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs. 8.6%) and being a past or current smoker (80.4% vs. 56.9%). More women than men had low vocational level (93.1% vs. 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04-5.12; P = .04); low emotional support further tended to increase the risk for this outcome (P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04-4.82; P = .04).

CONCLUSION

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.

Patients' Sex and Emotional Support as Predictors of Death and Clinical Deterioration in the Waiting for a New Heart Study: Results from the 1-Year Follow-up

Context

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

Objective

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

Design, Setting, and Participants

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs low support]) were assessed at the time of wait-listing.

Main Outcomes

Time until death/delisting due to deteriorated health, considering competing outcomes (eg, transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models. Results—By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs 8.6%) and being a past or current smoker (80.4% vs 56.9%). More women than men had low vocational level (93.1% vs 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04–5.12; P = .04); low emotional support further tended to increase the risk for this outcome ( P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04–4.82; P = .04).

Conclusion

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.