A single health status question had important prognostic value among outpatients with chronic heart failure

The Interaction Effect of Cardiac and Noncardiac Co-morbidities on Mortality Rates in Patients With Heart Failure

The prevalence of heart failure (HF) and co-morbidities are increasing. The prognostic impact of interaction between co-morbidity and HF remains unknown. The purpose of the present study was to examine if HF interacts with co-morbidity burden to increase mortality. We conducted a cohort study of all adult Danish patients (aged ≥18 years) with a hospital inpatient or outpatient clinic diagnosis of HF (n = 252,726) between 1995 and 2016. We matched each patient with up to 3 members of the general population without a history of HF (n = 744,372). Noncardiac co-morbidities were assessed using the Charlson co-morbidity index and were defined by 4 categories of co-morbidity: 0 (none), 1 (low), 2 to 3 (moderate), and ≥4 (severe). Cardiac co-morbidities were assessed individually. Among patients with HF with severe co-morbidity, 42% of the mortality rate during 30 days of follow-up was explained by the interaction with co-morbidity. The interaction effect was also substantial in patients with moderate (31%) and low co-morbidity burden (16%). During 31 to 365 days of follow-up, interaction effects were 1% for low co-morbidity, 8% for moderate co-morbidity, and 22% for severe co-morbidity. Beyond 1 year of follow-up, no interaction effect was observed. With the exception of cardiomyopathy, cardiac co-morbidities did not interact substantially with HF during the first year of follow-up. During longer follow-up, pulmonary hypertension, cardiomyopathy, and endocarditis showed interaction. In conclusion, noncardiac co-morbidities had biological interaction with HF that increased short-term mortality substantially beyond the individual effects of HF and co-morbidity.

Development of a one-item version of the Orofacial Esthetic Scale

OBJECTIVES

Orofacial appearance is increasingly recognized as an important dental patient-reported outcome making instrument development and refinement efforts to measure the outcome better necessary. The aim of this study was to derive a one-item version of the Orofacial Esthetic Scale (OES).

MATERIALS AND METHODS

OES data were collected from a consecutive sample of a total of 2113 adult English- or Spanish-speaking dental patients from HealthPartners dental clinic in Minnesota. Participants with missing data were excluded and analysis were performed using data from 2012 participants. Orofacial appearance was assessed with the English and the Spanish language version of the OES. Linear regression analysis was performed, with the OES item 8 ("Overall, how do you feel about the appearance of your face, your mouth, and your teeth?") as the predictor variable and the OES summary score as the criterion variable, to calculate the adjusted coefficients of determination (R²).

RESULTS

The value of adjusted R² was 0.83, indicating that the OES item 8 score explained about 83% of the variance of the OES summary score. The difference in R² scores between the two language groups was negligible.

CONCLUSION

The OES item 8 can be used for the one-item OES (OES-1). It is a psychometrically sound instrument for measuring orofacial appearance.

CLINICAL RELEVANCE

Due to its easy application and sufficient psychometric properties, the OES-1 can be used effectively as an alternative to longer OES instruments in all areas of dental practice and research.

Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Resting heart rate is a risk factor of adverse heart failure outcomes; however, studies have shown controversial results. This meta-analysis evaluates the association of resting heart rate with mortality and hospitalization and identifies factors influencing its effect.

METHODS AND RESULTS

We systematically searched electronic databases in February 2019 for studies published in 2005 or before that evaluated the resting heart rate as a primary predictor or covariate of multivariable models of mortality and/or hospitalization in adult ambulatory patients with heart failure. Random effects inverse variance meta-analyses were performed to calculate pooled hazard ratios. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess evidence quality. Sixty-two studies on 163,445 patients proved eligible. Median population heart rate was 74 bpm (interquartile range 72-76 bpm). A 10-bpm increase was significantly associated with increased risk of all-cause mortality (hazard ratio 1.10, 95% confidence interval 1.08-1.13, high quality). Overall, subgroup analyses related to patient characteristics showed no changes to the effect estimate; however, there was a strongly positive interaction with age showing increasing risk of all-cause mortality per 10 bpm increase in heart rate.

CONCLUSIONS

High-quality evidence demonstrates increasing resting heart rate is a significant predictor of all-cause mortality in ambulatory patients with heart failure on optimal medical therapy, with consistent effect across most patient factors and an increased risk trending with older age.

Self-reported health status and the associated risk of mortality in heart failure: The DANISH trial

OBJECTIVE

To examine the gradual association between self-reported health status and mortality in patients with heart failure (HF) as current research has focused on poor health status and increased risk of mortality.

METHOD

This is a substudy of the DANISH (Defibrillator Implantation in Patients with Nonischemic Systolic HF) trial in which 1116 patients were randomized to receive or not receive an implantable cardioverter-defibrillator. Health status was assessed by a single question of the Short-Form 36. Patients were classified as having excellent/very good, good, fair (reference) or poor health status. We assessed the association between health status and mortality using multivariable Cox proportional hazard models.

RESULTS

Self-reported health status was completed by 943 (84%) patients at randomization with a median follow-up of 67 months and a health status distribution of; excellent/very good (n = 79, 8%), good (n = 369, 39%), fair (n = 409, 43%), and poor (n = 86, 9%). All-cause mortality (death events/ 100 person-years) occurred with gradual differences according to health status from excellent/ very good (2.14), good (3.74), fair (5.21) to poor health status (5.57). The gradual difference yielded a crude hazard ratio (HR) of 0.40, 95% CI 0.20-0.80 (adjusted HR 0.47 (95% CI 0.23-0.95) for excellent/ very good health status, HR 0.71, 95% CI 0.52-0.97 (adjusted HR 0.78 (95% CI 0.56-1.08) for good health status. Poor being worse than fair health status yielded a crude HR of 1.07, 95% CI 0.67-1.69.

CONCLUSION

Excellent/very good self-reported health status as assessed by a single question was associated with lower long-term mortality in patients with HF.

Ethnic differences in quality of life and its association with survival in patients with heart failure

Background

Optimizing quality of life (QoL) is a key priority in the management of heart failure (HF).

Hypothesis

To investigate ethnic differences in QoL and its association with 1‐year survival among patients with HF.

Methods

A prospective nationwide cohort (n = 1070, mean age: 62 years, 24.5% women) of Chinese (62.3%), Malay (26.7%) and Indian (10.9%) ethnicities from Singapore, QoL was assessed using the Minnesota Living with HF Questionnaire (MLHFQ) at baseline and 6 months. Patients were followed for all‐cause mortality.

Results

At baseline, Chinese had a lower (better) mean MLHFQ total score (29.1 ± 21.6) vs Malays (38.5 ± 23.9) and Indians (41.7 ± 24.5); P < .001. NYHA class was the strongest independent predictor of MLHFQ scores (12.7 increment for class III/IV vs I/II; P < .001). After multivariable adjustment (including NT‐proBNP levels, medications), ethnicity remained an independent predictor of QoL (P < .001). Crude 1‐year mortality in the overall cohort was 16.5%. A 10‐point increase of the physical component (of MLHFQ) was associated with a hazard (HR 1.22, 95% 1.03‐1.43) of 1‐year mortality (P = .018) in the overall cohort. An interaction between MLHFQ and ethnicity was found (P = .019), where poor MLHFQ score (per 10‐point increase) predicted higher adjusted mortality only in Chinese (total score: HR 1.18 [95% CI 1.07‐1.30]; physical: HR 1.44 [95% CI 1.17‐1.75]; emotional score: HR 1.45 [95% CI 1.05‐2.00]).

Conclusions

Ethnicity is an independent determinant of QoL in HF. Despite better baseline QoL in Chinese, QoL was more strongly related to survival in Chinese vs Malays and Indians. These findings have implications for HF trials that use patient‐reported outcomes as endpoints.

Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis

Aims

We sought to investigate the prognostic impact of co-morbid burden as defined by the Charlson Co-morbidity Index (CCI) in patients with a range of prevalent cardiovascular diseases.

Methods and results

We searched MEDLINE and EMBASE to identify studies that evaluated the impact of CCI on mortality in patients with cardiovascular disease. A random-effects meta-analysis was undertaken to evaluate the impact of CCI on mortality in patients with coronary heart disease (CHD), heart failure (HF), and cerebrovascular accident (CVA). A total of 11 studies of acute coronary syndrome (ACS), 2 stable coronary disease, 5 percutaneous coronary intervention (PCI), 13 HF, and 4 CVA met the inclusion criteria. An increase in CCI score per point was significantly associated with a greater risk of mortality in patients with ACS [pooled relative risk ratio (RR) 1.33; 95% CI 1.15-1.54], PCI (RR 1.21; 95% CI 1.12-1.31), stable coronary artery disease (RR 1.38; 95% CI 1.29-1.48), and HF (RR 1.21; 95% CI 1.13-1.29), but not CVA. A CCI score of >2 significantly increased the risk of mortality in ACS (RR 2.52; 95% CI 1.58-4.04), PCI (RR 3.36; 95% CI 2.14-5.29), HF (RR 1.76; 95% CI 1.65-1.87), and CVA (RR 3.80; 95% CI 1.20-12.01).

Conclusion

Increasing co-morbid burden as defined by CCI is associated with a significant increase in risk of mortality in patients with underlying CHD, HF, and CVA. CCI provides a simple way of predicting adverse outcomes in patients with cardiovascular disease and should be incorporated into decision-making processes when counselling patients.

Health-related quality of life and long-term morbidity and mortality in patients hospitalised with systolic heart failure

Background

Health-related quality of life has been shown to impact prognosis in chronic heart failure, however with limited long-term follow-up. We analysed data spanning 8–12 years to assess the impact of health-related quality of life using the Nottingham Health Profile on first hospitalisation and mortality, for cardiovascular and all causes.

Methods

We included 208 patients aged ≥60 years with New York Heart Association class II–IV and left ventricular systolic dysfunction hospitalised in Stockholm during 1996–99. Data on hospital admissions, discharge diagnoses and date and cause of death were collected from administrative databases and medical records until 2007. Cox proportional hazard models were employed to analyse the time to event for mortality and hospitalisations.

Results

Mean age was 76 years, 58% were male and mean ejection fraction was 34%. Median survival was 4.6 years (range 6 days–11.9 years); 148 patients died. All-cause and cardiovascular mortality were determined by physical mobility (by Nottingham Health Profile), age, gender, diuretic dose and haemoglobin level. Glomerular filtration rate was significant for all-cause mortality, while atrioventricular plane displacement was predictive of cardiovascular mortality. Median time to first all-cause and cardiovascular hospitalisation was 5.7 and 11.2 months, respectively. Time to first all-cause hospitalisation was determined by physical mobility, emotional reactions, age, gender and haemoglobin level, while only physical mobility and diuretic dose predicted time to first cardiovascular hospitalisation.

Conclusions

In conclusion, in patients with systolic chronic heart failure, physical mobility as part of health-related quality of life is an independent prognostic marker for cardiovascular and all-cause readmissions and mortality over 12 years.

Quality of life and survival in patients with heart failure

AIMS

To examine whether self-rated disease-specific and generic quality of life predicts long-term mortality, independent of brain natriuretic peptide (BNP) levels, and to explore factors related to low quality of life in a well-defined heart failure (HF) population.

METHODS AND RESULTS

A cohort of 661 patients (62% male; age 71 years; left ventricular ejection fraction 34%) was followed prospectively for 3 years. Quality of life questionnaires (Ladder of Life, RAND36, and Minnesota Living with Heart Failure Questionnaire) and BNP levels were assessed at discharge after a hospital admission for HF. Three-year mortality was 42%. After adjustment for demographic variables, clinical variables, and BNP levels, poor quality of life scores predicted higher mortality; per 10 units on the physical functioning [hazard ratio (HR) 1.08, 95% confidence interval (CI) 1.02-1.14] and general health (HR 1.08, 95% CI 1.01-1.16) dimensions of the RAND36. Patients with low scores on these dimensions were more likely to be in New York Heart Association class III-IV, diagnosed with co-morbidities, have suffered longer from HF, have lower estimated glomerular filtration rates, and have fewer beta-blocker prescriptions.

CONCLUSION

Quality of life was independently related to survival in a cohort of hospitalized patients with HF.

TRIAL REGISTRATION

NCT 98675639.

Additive prognostic value of subjective assessment with respect to clinical cardiological data in patients with chronic heart failure

BACKGROUND

Health-related quality of life tools that better reflect the unique subjective perception of heart failure (HF) are needed for patients with this disorder. The aim of this study was to explore whether subjective satisfaction of HF patients about daily life may provide additional prognostic information with respect to clinical cardiological data.

METHODS

One hundred and seventy-eight patients (age 51 ± 9 years) with moderate to severe HF [New York Heart Association (NYHA) class 2.0 ± 0.7; left ventricular ejection fraction (LVEF) 29 ± 8%] in stable clinical condition underwent a standard clinical evaluation and compiled the Satisfaction Profile (SAT-P) questionnaire focusing on subjective satisfaction with daily life. Cox regression analysis was used to assess whether SAT-P factors (psychological functioning, physical functioning, work, sleep/eating/leisure, social functioning) had any prognostic value.

RESULTS

Forty-six cardiac deaths occurred during a median of 30 months. Patients who died had higher NYHA class, more depressed left ventricular function, reduced systolic blood pressure (SBP), increased heart rate (HR), and worse biochemistry (all p < 0.05). Among the SAT-P factors, only physical functioning (PF) was significantly reduced in the patients who died (p = 0.003). Using the best subset selection procedure, resistance to physical fatigue (RPF) was selected from among the items of the PF factor. RPF showed independent predictive value when entered into a prognostic model including NYHA class, LVEF, SBP, and HR with an adjusted hazard ratio of 0.86 per 10 units increase (95% CI 0.75-0.98, p = 0.02).

CONCLUSIONS

Patients' dissatisfaction with physical functioning is associated with reduced long-term survival, after adjustment for known risk factors in HF. Given its user-friendly structure, simplicity, and significant prognostic value, the RPF score may represent a useful instrument in clinical practice.

Improved perceived general health is observed with prosthodontic treatment

OBJECTIVES

Prosthodontic treatment affects not only oral health, but also general health. However, whether prosthodontic patients actually perceive a change in their general health has not been well studied. This study aims to compare self-reported general-health status in patients before and after prosthodontic treatment.

METHODS

Self-reported general-health status was measured using a single-item questionnaire in a consecutive sample of 500 prosthodontic patients. Responses were recorded using a five-point scale ranging from "poor" to "excellent."

RESULTS

After treatment, patients' self-reported general-health status was slightly but statistically significantly improved. Perceived general health improved in 2.3% of patients treated with fixed partial dentures, in 11.3% of patients treated with removable partial dentures, and in 4.1% of patients treated with complete dentures. Changes in self-reported general-health status were not related to age or gender.

CONCLUSION

Prosthodontic treatment appears to have a positive effect on perceived general health.

Health-related quality of life and long-term mortality in patients treated with percutaneous coronary intervention

BACKGROUND

Health status has become increasingly important as an outcome measure in patients with cardiovascular disease. Poor patient-rated health status has been shown to predict mortality in patients with coronary artery disease and heart failure. In patients treated with percutaneous coronary intervention (PCI), we examined whether poor health status predicts 6-year mortality and whether a decline in health status is associated with adverse clinical outcome.

METHODS

Consecutive patients (N = 872) treated with PCI as part of the RESEARCH registry, completed the 36-item Short-Form Health Survey (SF-36) at 1 and 12 months post-PCI.

RESULTS

The SF-36 domains physical functioning (hazard ratio [HR] 2.59, 95% CI 1.61-4.16), social functioning (HR 2.76, 95% CI 1.74-4.37), role limitations due to physical functioning (HR 2.45, CI 1.52-3.92), mental health (HR 2.12, 95% CI 1.35-3.31), vitality (HR 1.73, 95% CI 1.09-2.74), bodily pain (HR 2.25, 95% CI 1.43-3.54), and general health (HR 2.46, 95% CI 1.57-3.87) were associated with 6-year mortality. A decline in health status was not related with higher 6-year mortality.

CONCLUSIONS

Health status domains as measured with the SF-36 predicted death at 6-year follow-up in PCI patients treated with drug-eluting stenting, independent of demographic and clinical characteristics. In contrast, a decline in health status between 1 and 12 months post index procedure, as measured with the SF-36, was not associated with 6-year mortality in PCI patients treated with drug-eluting stenting.

Psychological distress and mortality in systolic heart failure

BACKGROUND

Depression, anxiety, and type D ("distressed") personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure.

METHOD AND RESULTS

Consecutive outpatients with chronic heart failure (n=641; 74.3% men; mean age, 66.6+/-10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality. After a mean follow-up of 37.6+/-15.6 months, 123 deaths (76 due to cardiac cause) were recorded. Cumulative hazard functions for elevated anxiety/depression symptoms differed marginally for all-cause (P=0.06), but not cardiac, mortality (P=0.43); type D personality was associated with neither all-cause mortality (P=0.63) nor cardiac mortality (P=0.87). In multivariable analyses, neither elevated anxiety/depression symptoms nor type D personality was associated with all-cause mortality (hazard ratio [HR]=1.18; 95% CI, 0.76 to 1.84; P=0.45 and HR=1.09; 95% CI, 0.67 to 1.77; P=0.73, respectively) or cardiac mortality (HR=1.13; 95% CI, 0.63 to 2.04; P=0.65 and HR=1.16; 95% CI, 0.62 to 2.18; P=0.67). In secondary analyses, a 1-point increase in anxiety/depression (range, 0 to 16) was associated with an 8% increase in risk for all-cause mortality (HR=1.08; 95% CI, 1.01 to 1.15; P=0.02).

CONCLUSIONS

Neither elevated anxiety/depression symptoms nor type D personality was associated with an increased risk for all-cause or cardiac mortality. Future studies with adequate power and a longer follow-up duration are needed to further elucidate the role of psychological distress in chronic heart failure.

Defining an evidence-based cutpoint for medication adherence in heart failure

BACKGROUND

Despite the importance of medication adherence in heart failure, clinically relevant cutpoints for distinguishing the level of adherence associated with outcomes are unknown.

OBJECTIVE

The purpose of this study is to determine the cutpoint above which there is a positive relationship between level of medication adherence and event-free survival.

METHODS

This was a longitudinal study of 135 patients with heart failure. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System. Two indicators of adherence were assessed by the Medication Event Monitoring System (AARDEX, Union City, CA): (1) dose count, percentage of prescribed doses taken, and (2) dose days, percentage of days the correct number of doses was taken. Patients were followed up to 3.5 years to collect data on outcomes. A series of Kaplan-Meier plots with log-rank tests, Cox survival analyses, and receiver operating characteristic curves were assessed comparing event-free survival in patients divided at one-point incremental cutpoints.

RESULTS

Event-free survival was significantly better when the prescribed number of doses taken (dose count) or the correct dose (dose day) was > or =88%. This level was confirmed in a Cox regression model controlling for age, gender, ejection fraction, New York Heart Association, comorbidity, angiotensin-converting enzyme inhibitor use, and beta-blocker use. Receiver operating characteristic curves showed that adherence rates above 88% produced the optimal combination of sensitivity and specificity with respect to predicting better event-free survival. With 88% as the adherence cutpoint, the hazard ratio for time to first event for the nonadherent group was 2.2 by dose count (P = .021) and 3.2 by dose day (P = .002).

CONCLUSION

The results of this study provide clinicians and researchers with an evidence-based recommendation about the level of adherence needed to achieve optimal clinical outcomes.

Health status as a risk factor in cardiovascular disease: a systematic review of current evidence

BACKGROUND

Patient-perceived health status is receiving increased recognition as a patient-centered outcome in chronic heart failure (CHF) and coronary artery disease (CAD), but poor health status is also associated with adverse prognosis. In this systematic review, we examined current evidence on the influence of health status on prognosis in CHF and CAD.

METHODS

We conducted a search of PubMed using a set of a priori-defined search terms, the Web of Science for newly cited articles, and the reference lists of eligible articles, resulting in 34 articles.

RESULTS

Poor physical health status was a significant predictor for adverse health outcomes in patients with CHF and CAD. In CHF, poor physical health status seemed to be a stronger predictor of hospitalization than mortality. Little evidence was found that poor mental health status is associated with adverse prognosis in CHF and CAD. A disease-specific measure was a better predictor in CHF, but not in CAD. The majority of studies adjusted for an objective measure of disease severity. Neither the index event nor time to follow-up appeared to influence the predictive value of health status.

CONCLUSIONS

Poor physical health status is associated with adverse CAD and CHF prognosis. Heterogeneity across studies makes definitive conclusions difficult as to which components of health status may be detrimental to patients' health, and how health status as a potential risk factor should be assessed, monitored, and intervened upon in clinical practice.

Impact of provider self-management education, patient self-efficacy, and health status on patient adherence in heart failure in a Veterans Administration population

To address the need for more information on predictors of adherence to heart failure (HF) self-management regimens, this study analyzed surveys completed by 259 HF patients receiving care at 2 Veterans Affairs hospitals in 2003. Linear multivariable regression models were used to examine general health status, HF-specific health status (Kansas City Cardiomyopathy Questionnaire) self-management education, and self-efficacy as predictors of self-reported adherence to salt intake and exercise regimens. Self-management education was provided most often for salt restriction (87%) followed by exercise (78%). In multivariable regression analyses, education about salt restriction (P=.01), weight reduction (P=.0004), self-efficacy (P=.03), and health status (P=.003) were significantly associated with patient-reported adherence to salt restriction. In a similar model, self-efficacy (P=.006) and health status (P< or = .0001), but not exercise education, were significantly associated with patient-reported exercise adherence. Findings suggest that provider interventions may lead to improved adherence with HF self-management and thus improvements in patients' health.