Quality of life in women with heart failure

What have we learned so far from the sex/gender issue in heart failure? An overview of current evidence

There are important differences in epidemiology, pathophysiology, HF patterns, prognosis, and treatment. Women have a higher incidence of HFpEF due to sex-specific factors (such as anthropometry, role of estrogens, pregnancy-related cardiomyopathies), increased incidence of comorbidities, and gender-specific conditions. Men instead present a predisposition to the development of HFrEF due to a higher incidence of coronary artery disease and myocardial infarction. However, there are still gaps in the management of women with HF. The poor inclusion of women in clinical trials may have contributed to a lesser understanding of disease behavior than in men. In addition, a full understanding of gender-specific factors that are studied in small populations is lacking in the literature, and only in recent years, studies have increased their focus on this issue. Understanding how society, family, and environment affect the prognosis of HF patients may help clinicians provide more appropriate levels of care. In this overview, we aimed at summarizing all the key available evidence regarding sex/gender differences in heart failure.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Cognitive Function Does Not Impact Self-reported Health-Related Quality of Life in Heart Failure Patients

BACKGROUND

Adults with heart failure (HF) often demonstrate impairment across multiple domains of cognitive functioning and report poor health-related quality of life (HRQoL). Previous researchers have found that cognitive deficits were generally not associated with HRQoL in a carefully evaluated sample. The exception was memory, which was only weakly associated with HRQoL. However, cognitive deficits interfere with self-care and disease self-management, which could be expected to affect HRQoL.

OBJECTIVE

We sought to verify this counterintuitive finding in a large well-characterized sample of HF patients using a well-validated neuropsychological battery.

METHODS

Participants were 302 adults (63% male) predominately white (72.5%) HF patients (68.7 ± 9.6 years) recruited from 2 medical centers. Self-reported HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire. Participants completed a neuropsychological battery examining attention, executive function, memory, and visuospatial functioning. Hierarchical multiple linear regression was used for analyses.

RESULTS

Mild global cognitive impairment was observed in 29.5% of the sample (Modified Mini-Mental State [3MS] Examination score <90). Controlling for gender, depression, HF severity, premorbid IQ, comorbidities, and education, only executive function predicted HRQoL, β = .17, P < .05. However, executive function accounted for only 0.6% of the variance in HRQoL.

CONCLUSION

Cognitive function generally did not predict HRQoL in HF patients. The correlates of HRQoL in HF do not appear to include mild cognitive impairment. Other factors may play a bigger role such as disease severity, age, and depressive symptoms. Future studies should investigate modifiable determinants of HRQoL in HF patients, toward the goal of finding interventions that preserve HRQoL during this chronic illness.

Measurement of Health-Related Quality of Life in Chronic Heart Failure, from a Nursing Perspective—a Review of the Literature

BACKGROUND

Living with chronic heart failure (CHF) is distressful and affects daily life. Because of the lack of a cure for CHF, there has been a progressive interest in using health-related quality of life (Hr-QoL) as an outcome measurement of the treatment in patients with CHF.

OBJECTIVE

The aim of this review was to describe the instruments/questionnaires used in different studies in the measurement of Hr-QoL in patients with CHF, and how they were put into operation as seen from a nursing perspective.

METHOD

MEDLINE and CINAHL databases were searched from January 1995 to June 2002, by using the keywords CHF, heart failure, QoL and Hr-QoL. A total of 33 articles were analysed.

RESULTS

Thirty-two different Hr-QoL questionnaires were found. Generic, disease-specific and battery approaches were different ways used to measure Hr-QoL. To assess/describe Hr-QoL, evaluate the impact of interventions and examine relations/predictors were three main objectives. However, different aspects of the concept Hr-QoL, influencing factors, how to implement the questionnaires and a lack of unified CHF criteria existed.

CONCLUSIONS

To create a guideline for the measurement of Hr-QoL in CHF patients is of great importance for nurses and might generate homogeneity in the measurement methods and promote the scientific approach in the nursing care process.

Fatigue and health-related quality of life in elderly patients with and without heart failure in primary healthcare

Background

Patients with heart failure (HF) in primary healthcare are in many respects not comparable to those in specialized care and the knowledge about different patient groups with and without HF is limited.

Aims

To compare fatigue and health-related quality of life (Hr-QoL) when adjusting for age, gender and social provision in patients with confirmed HF ( n=49) to a group of patients with symptoms indicating HF but without HF (NHF, n=59) and to an age-and sex-matched control-group ( n=40).

Method

A questionnaire including the Multidimensional Fatigue Inventory, the SF-36, and the Social Provisions Scale was used.

Results

The average age in all groups was 78 years. Patients in the HF and NHF groups reported worse physical QoL and more general and physical fatigue than the control group. HF patients had worse general health than the NHF group.

Conclusion

Elderly patients in primary healthcare with confirmed heart failure and patients with symptoms similar to heart failure perceived they had a significantly worse physical QoL and more general and physical fatigue than an age- and sex-matched control group. The similarities between the patient groups indicate the importance of the symptom experience for Hr-QoL.

Fatigue in Chronic Heart Failure – Does Gender Make a Difference?

The primary aim of this study was to describe and compare the experience of fatigue in a group of elderly women and men with severe chronic heart failure. A sample of 158 patients (66 women and 92 men, with a mean age of 83 and 78 years, respectively) was invited to participate in a study on admission to a hospital outpatient heart failure clinic. A registered nurse interviewed patients using a modified version of the Fatigue Interview Schedule (FIS). Descriptions of the experiences of fatigue generally showed good agreement between men and women; however, some gender differences were found. Women expressed a clear role to fulfil because they were engaged in maintenance activities of their household. Although we still have only limited knowledge about the impact of gender on the experiences and coping strategies in disease and aging, it is important for care providers to consider gender differences when planning caring interventions.

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Factors and Interventions Influencing Health-Related Quality of Life in Patients with Heart Failure: A Review of the Literature

INTRODUCTION

Because of the lack of a cure for patients with chronic heart failure (HF), there has been a progressive interest in the use of health-related quality of life (Hr-QoL) as complementary end-point to mortality and morbidity.

AIM

The aim of this review was from a nursing perspective to describe Hr-QoL and the influencing factors of Hr-QoL, as well as to identify interventions aimed at influencing Hr-QoL in HF patients.

METHOD

Medline, Cinahl and PsycInfo databases were searched from 1995 to 2004. A total of 58 papers were included.

RESULTS

HF symptoms and activity status influence Hr-QoL negatively. However, several individual characteristics such as personality, gender and age must also be taken into consideration because different values might exist regarding what constitutes a good Hr-QoL. Nurse led interventions based on education, support and exercise can influence Hr-QoL positively. There is also a need of more studies about the effects of depression, sleep disturbances, support as well as education on Hr-QoL. There is also a need of exercise studies with larger sample sizes and older patients in higher NYHA classes.

CONCLUSION

Several individual factors impact Hr-QoL, therefore, must nursing interventions are individually adapted to the patient's resources.

Impact of Chronic Heart Failure on Elderly Persons' Daily Life: A Validation Study

BACKGROUND

Knowledge about how elderly persons perceive the impact of chronic heart failure (CHF) on daily life is important when planning nursing care. For this purpose, disease specific instruments are needed. However, few instruments have been developed or tested specifically on elderly persons.

AIM

To validate a Swedish version of the Minnesota Living with Heart Failure Questionnaire (LHFQ) on elderly persons with CHF, and use it to describe the impact of CHF on daily life in the same population.

METHODS

The sample comprised of 357 persons, aged between 65 and 99, diagnosed with CHF. A questionnaire including background data, the LHFQ and the SF-12 was used.

RESULTS

A factor analysis resulted in four dimensions: physical, emotional, treatment and pleasure. LHFQ showed convergent validity and ability to discriminate between known groups. Cronbach's alpha for the total scale was 0.94. Impairments in the physical dimension were most common, especially fatigue (88%) and shortness of breath (87%).

CONCLUSIONS

The LHFQ showed satisfying psychometric properties in an elderly Swedish population with CHF and can, with minor alterations, be recommended for research and clinical use. The impact of chronic heart failure on daily life was mostly physical, but other impairments were also common.

Predictors of memory performance among Taiwanese postmenopausal women with heart failure

BACKGROUND

There are no studies describing the nature of memory deficits among women with heart failure (HF).

OBJECTIVES

The aims of this study were to examine memory performance among Taiwanese women with HF compared with age- and education-matched healthy women, and to evaluate factors that explain memory performance in women with HF.

METHODS AND RESULTS

Seventy-six women with HF and 64 healthy women were recruited in Taiwan. Women completed working, verbal, and visual memory tests; HF severity was collected from the medical records. Women with HF performed significantly worse than healthy women on tests of working memory and verbal memory. Among women with HF, older age explained poorer working memory, and older age, higher HF severity, more comorbidities, and systolic HF explained poorer verbal memory. Menopausal symptoms were not associated with memory performance.

CONCLUSIONS

Results of the study validate findings of memory loss in HF patients from the United States and Europe in a culturally different sample of women. Working memory and verbal memory were worse in Taiwanese women with HF compared with healthy participants. Studies are needed to determine mechanisms of memory deficits in these women and develop interventions to improve memory.

Self-care confidence mediates the relationship between perceived social support and self-care maintenance in adults with heart failure

BACKGROUND

Social support may be associated with heart failure (HF) self-care; however, the mechanisms are not well understood. We examined the association between perceived support and self-care behaviors and whether self-care confidence mediates these relationships.

METHODS

Cross-sectional survey of HF patients seen in outpatient clinic settings. Our outcome (HF self-care maintenance and self-care management) and mediator (HF self-care confidence) variables were assessed with the Self-Care of Heart Failure Index. Perceived emotional/informational support was assessed with the Medical Outcomes Study social support survey. We performed regression analyses to examine associations between perceived support and HF self-care behaviors. Mediation analysis was performed according to the Baron and Kenny method.

RESULTS

We surveyed 150 HF patients (mean age 61 y; 51% female; 43% black). More emotional/informational support was associated with better self-care maintenance (β = 0.13; P = .04). More emotional/information support was associated with better self-care management in unadjusted (β = 0.23; P = .04), but not adjusted (β = 0.20, P = .10), analysis. Self-care confidence mediates the association between perceived support and self-care maintenance (percent change in β coefficient was 32%) and management (percent change in β coefficient was 20%).

CONCLUSION

Perceived emotional/informational support is associated with better self-care maintenance and possibly better self-care management. Greater self-care confidence is one mediating mechanism.

Perceived social support predicted quality of life in patients with heart failure, but the effect is mediated by depressive symptoms

PURPOSE

Depressive symptoms and inadequate social support are well-known independent predictors of increased mortality and morbidity in heart failure (HF). However, it is unclear how depressive symptoms and social support interact to influence quality of life. Thus, the purpose of this study was to determine the nature of the relationships (direct, mediator, and moderator) among depressive symptoms, social support, and quality of life in patients with HF.

METHODS

We performed a secondary data analysis that included 362 patients with HF who completed the measures of depressive symptoms (the Beck Depression Inventory-II), perceived social support (the Multidimensional Scale of Perceived Social Support), and quality of life (the Minnesota Living with Heart Failure Questionnaire) instruments. The direct, mediator, and moderator effects of both depressive symptoms and social support on quality of life were tested using multiple regressions and 2 × 2 ANCOVA.

RESULTS

Less social support and greater depressive symptoms independently predicted poorer quality of life. The relationship between social support and quality of life was mediated by depressive symptoms. Neither social support nor depressive symptoms moderated quality of life.

CONCLUSION

Promotion of social support will improve quality of life only when depressive symptoms are also effectively managed.

Gender differences in the influence of social support on one-year changes in functional status in older patients with heart failure

The purpose of this study was to determine the combined effects of gender and levels of social support on 1-year functional health outcomes in older persons diagnosed with heart failure (HF). Persons ≥ 65 years of age with an acute HF exacerbation (164 females; 271 males) were enrolled and followed for a year. Participants completed baseline and 12-month questionnaires containing clinical and demographic descriptive information and validated self-report measures of: (1) physical functioning (Medical Outcome Study [MOS] SF12 and Kansas City Cardiomyopathy Questionnaire [KCCQ]) and (2) social support (MOS- Social Support Survey). Women were more likely to be single, widowed or divorced, living alone and earning less annual income. At baseline, women reported significantly lower support and physical function scores. However, at 1 year there were no significant gender differences in the proportion of men or women who experienced clinically meaningful functional decline or death across the year of follow-up. In multivariable modeling, men with lower levels of social support were more likely to experience functional decline. This was not the case for women. Our findings suggest that gender-directed strategies to promote optimization of function for both men and women living with HF in their community are warranted.

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Social support and its association with health-related quality of life among older patients with chronic heart failure

BACKGROUND

Social support is generally known to influence health-related quality of life (HRQoL), but this association is not well explored among older patients with chronic heart failure.

AIMS

(1) To describe social support in older patients with chronic heart failure in relation to gender. (2) To investigate if age, gender, cohabitation, perceived financial situation, and disease severity are associated with social support. (3) To investigate if social support is associated with HRQoL after controlling for age, gender, and disease severity.

METHODS

Data were collected in a sample of 349 patients (≥ 65 years) with chronic heart failure. Patients' HRQoL was measured with the Minnesota Living with Heart Failure Questionnaire and the Short Form-12 Health Survey Questionnaire. The Interview Schedule for Social Interaction measured social support. Data were analysed with descriptive statistics, repeated-measure ANOVA, and multiple linear regression analyses with robust standard errors.

RESULTS

Social support was generally rated high, although being a man, living alone, perceiving a problematic financial situation, and high disease severity (NYHA) were associated with lower levels of social support. Age was not associated with social support. Social support was generally associated with HRQoL, in particular the emotional dimensions.

CONCLUSION

Taking social support into account when caring for older patients with heart failure can be of importance for improving or maintaining HRQoL.

Social status, health-related quality of life, and event-free survival in patients with heart failure

BACKGROUND

Social status may impact health-related quality of life (HRQOL), hospitalization, and mortality in patients with heart failure (HF).

PURPOSE

To determine if social status was associated with HRQOL and event-free survival.

HYPOTHESES

Higher social status (quality of perceived support, emotional support, marital status, and economic status) is related to better HRQOL and event-free survival after controlling covariates (New York Heart Association [NYHA] functional class, comorbidity status, and age).

METHODS

Patients (N = 147, 61 ± 11 years old, 70% male, 62% NYHA class III/IV) provided data on HRQOL (measured by the Minnesota Living with Heart Failure questionnaire) and social status. Event-free survival data were collected by medical record reviews and patient or family interviews. Hierarchical regression analysis and survival analysis were used to test the hypothesis.

RESULTS

Better quality of perceived support, better economic status, better functional status, older age, and less comorbidity were related to better HRQOL (R2 = .365, p = <.001). Only economic status predicted event-free survival.

CONCLUSION

Attention should be given to those who have lower social support to improve HRQOL and those who have lower economic status to improve event-free survival.

Elderly women's experiences of support when living with congestive heart failure

Heart failure is a chronic syndrome that has physiological, psychological and social effects. The aim of the study was to illuminate the meanings of support as experienced by elderly women with chronic heart failure. Narrative interviews were conducted with five elderly women with chronic heart failure. A phenomenological hermeneutic method of interpretation was used. The meanings of support were experienced by the women out of two perspectives, that is, when support is present and when there is a lack of support. The findings were revealed in two themes: "Feeling confident means support" and "Feeling abandoned". The women do not wish to be a burden. They want to be independent as much as possible to defend their dignity. An important support to the women is that they are understood and confirmed in their illness. Supportive relations are most valuable, that is, a relationship that supports the women's independence. If there is no supportive relationship, they feel like a burden to others and they feel lonely; this loneliness creates suffering and counteracts wellbeing and health.

Marital status as an independent predictor of event-free survival of patients with heart failure

BACKGROUND

Depressive symptoms are a well-known predictor of mortality in patients with heart failure, and positive spousal support is associated with improved outcomes in these patients. However, in the context of depressive symptoms, the effect on survival of having a spouse is unknown.

OBJECTIVE

To determine the effect of marital status on event-free survival in patients with heart failure who did or did not have depressive symptoms.

METHODS

Depressive symptoms were assessed by using the Beck Depression Inventory-II in patients with heart failure who were followed-up for up to 4 years to collect data on mortality and hospitalizations. Patients were grouped according to the presence and absence of depressive symptoms by using the standard cutoff score of 14 on the Beck Depression Inventory-II. Kaplan-Meier and Cox regression analyses were used to compare event-free survival for married and nonmarried patients who were stratified according to the presence or absence of depressive symptoms.

RESULTS

Of 166 patients, 56% were married, and 33% had depressive symptoms. Levels of depressive symptoms were similar between married and nonmarried patients (10.9 vs 12.1; P = .39). Married patients experienced longer event-free survival than did nonmarried patients (P = .009), even with stratification according to depressive symptoms (P = .01).

CONCLUSIONS

Patients with a spouse had longer event-free survival than nonmarried patients did, even in the context of depressive symptoms.

Validation of Chinese Version of the Modified Pulmonary Functional Status and Dyspnea Questionnaire With Heart Failure Patients in Taiwan

Background Dyspnea is a distressing and functionally limiting symptom that patients with heart failure commonly experience. A valid instrument to quantify dyspnea for comparison of groups and for illness management is important.

Objective To validate the Chinese version of the Modified Pulmonary Functional Status and Dyspnea Questionnaire.

Methods The Chinese version was developed by using translation and back translation and was tested in Taiwan in 88 patients who had heart failure but no pulmonary disease or comorbid conditions limiting physical function. Data on a Taiwanese subsample (n=30) were compared with data on 30 patients in the United States matched by sex, age, and severity of disease to determine the equivalence of the Chinese and English versions. Construct validity was assessed by testing the hypothesis that health-related quality of life measured by using the Minnesota Living With Heart Failure Questionnaire is associated with the score on the dyspnea questionnaire. Reliability was assessed by using the Cronbach α and item-total correlations.

Results Equivalence between the US and Taiwanese samples was high, from 0.67 to 0.91 for each item of the questionnaire and for the total score. Satisfactory correlations between the Chinese dyspnea and the Minnesota questionnaires, especially in the physical dimension (r=0.71, P&lt;.001), provided support for the construct validity of the Chinese questionnaire. Reliability of the Chinese questionnaire was adequate (α=0.94).

Conclusions The Chinese Modified Pulmonary Functional Status and Dyspnea Questionnaire is a reliable and valid measure for dyspnea that can be used in Taiwanese patients with heart failure.

Cognitive impairment in heart failure: a systematic review of the literature

BACKGROUND

Heart failure (HF) and cognitive impairment are common medical conditions that are becoming increasingly prevalent in the aging Western population. They are associated with frequent hospitalisation and increased mortality, particularly when they occur simultaneously. Evidence from a number of studies suggests that HF is independently associated with impairment in various cognitive domains.

AIMS

This systematic literature review evaluates the relation between cognitive deterioration and heart failure.

METHODS

We searched electronic databases from 1966 to May 2006 for studies that investigated cognitive function in HF patients. Twenty-two controlled studies that met the inclusion criteria were selected for analysis. Study characteristics and data on global cognitive performance, memory scores, psychomotor speed and depression scores were extracted and analysed using the Cochrane Review Manager software.

RESULTS

Pooled analysis shows diminished neuropsychological performance in HF patients, as compared to control subjects. In a pooled sample of 2937 heart-failure patients and 14,848 control subjects, the odds ratio for cognitive impairment was 1.62 (95% confidence interval:1.48-1.79, p<0.0001) among subjects with HF.

CONCLUSION

This review confirms the relationship between HF and cognitive impairment, but it also stresses the need for additional systematic neuropsychological data and adequate neuro-imaging from representative populations of HF patients.

Fatigue and anaemia in patients with chronic heart failure

BACKGROUND

Fatigue is common in patients with chronic heart failure (CHF) and has great impact on functional ability and daily activity. Although anaemia is associated with fatigue, the relationship between fatigue and anaemia is unclear in CHF. The aim of this study was to describe the fatigue experience and its relationship to haemoglobin (Hb) concentration and to evaluate its effect on health-related quality of life in an unselected hospitalised CHF population.

METHODS

Ninety three consecutive patients hospitalised with a diagnosis of CHF, enrolled in the EuroHeart Failure Survey, completed the Multidimensional Fatigue Inventory Scale (MFI-20). New York Heart Association (NYHA) functional class, quality of life and haemoglobin were also assessed.

RESULTS

Anaemia (Hb < or = 125 g/L) was found in 31 (33%) patients. The perception of fatigue differed significantly between patients with CHF and healthy individuals. Anaemic patients reported significantly more fatigue compared to non-anaemic patients. Decreased haemoglobin and higher NYHA class explained 30% of the variance in General Fatigue. Perceived fatigue was also inversely related to global health and quality of life.

CONCLUSION

Our findings suggest that the subjective experience of fatigue in patients with CHF is associated with low haemoglobin concentration and reduced functional status after controlling for age and sex.

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

BACKGROUND

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

CONCLUSIONS

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

A conceptual model of cognitive deficits in chronic heart failure

PURPOSE

To describe a conceptual model to guide studies of cognitive deficits among patients with heart failure.

ORGANIZING FRAMEWORK

The conceptual framework of cognitive deficits in chronic heart failure is based on theoretical and empirical literature about (a) the pathophysiology of heart failure, (b) the pathophysiology of cognitive deficits, and (c) health-related quality of life. Other variables that may cause or contribute to cognitive deficits include age, the relative contributions of multiple comorbid conditions, hypertension, and depressive symptoms. Covariates that might influence cognitive deficits (medications, gender, and education) are also included in the model. The most prominent cognitive deficits are believed to occur in domains of attention, working memory, memory, learning, executive function, and psychomotor speed. The main outcome variable is health-related quality of life, which is believed to be influenced by circulatory insufficiency and cognitive deficits.

CONCLUSIONS

The conceptual model described in this paper is a framework for testing cognitive deficits that occur in heart failure. After validation through empirical testing, the model may be useful in developing interventions for patients with heart failure whose care is complicated by cognitive deficits.

Testing a published model of health-related quality of life in heart failure

BACKGROUND

Health-related quality of life (HRQOL) in patients with heart failure is compromised and associated with increased mortality and rehospitalization. Inadequate conceptualization of variables related to HRQOL has hampered clinicians' efforts to enhance HRQOL. The purpose of this study was to test the Wilson and Cleary model (WCM) of HRQOL in patients with heart failure.

METHODS AND RESULTS

Data from 293 patients with heart failure were analyzed to determine the best multivariate HRQOL model given variables derived from WCM. HRQOL was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Health perception, symptom status, and age predicted the total MLHFQ (P < .0001) and the emotional scale (P < .0001), and health perception, symptom status, New York Heart Association predicted the physical scale (P < .0001). Health perception was a mediator of the effect of symptom status on HRQOL. Functional status was not a mediator of the effect of symptom status on health perception.

CONCLUSION

The most influential variables associated with HRQOL were the subjective variables: health perception and symptom status. Objective variables proposed by WCM to drive the model were not significant predictors. Mediator effects hypothesized in the WCM were not fully demonstrated in this sample. Thus modification of the WCM is warranted.

Testing the psychometric properties of the Minnesota Living with Heart Failure questionnaire

BACKGROUND

Health-related quality of life (HRQOL) is an important outcome in patients with heart failure. One of the most commonly used instruments to measure HRQOL in this population is the Minnesota Living With Heart Failure Questionnaire (LHFQ). Although the psychometric properties of the LHFQ have been tested, the results do not definitively support the psychometric soundness of the instrument.

OBJECTIVE

To examine the psychometric properties of the LHFQ.

METHOD

Data from 638 patients with heart failure were used to assess the reliability, homogeneity, representativeness, discriminative ability, and construct validity of the LHFQ before and after deletion of 5 items that showed lack of representativeness and contributed to inadequate factor structure.

RESULTS

Cronbach's alphas for the LHFQ Total and subscales were greater than .80. Interitem correlation coefficients in 17 of the 21 items, item-total correlation coefficients in 20 items, and discriminative ability in all items were acceptable. The total and both subscales of the LHFQ differentiated New York Heart Association functional groups. The Physical subscale was moderately related to the physical measures (the Specific Activity Scale and symptom status), whereas the emotional subscale was weakly related to the measures. The results of item p level testing and factor analysis demonstrated that 7 items were consistently problematic and 5 items were recommended to be deleted. The results of the reliability, homogeneity, and construct validity after deletion of these items demonstrated that the psychometric properties of the LHFQ were improved as a result.

DISCUSSION

The initial results provided additional support for the reliability and substantial evidence for the validity of the LHFQ. However, the results of item and factor analyses did not fully support the psychometric soundness of several items. The psychometric properties of the LHFQ after deleting these items were improved. These results could provide researchers and clinicians a more useful measure of HRQOL.

The Importance and Impact of Social Support on Outcomes in Patients With Heart Failure

As advances in medical treatment of heart failure (HF) become limited, other factors are being studied to improve outcomes. There is much evidence that supportive social relations have a major impact on health outcomes and that social support is essential for adjustment to illness. This article describes current research on the influence of social support on outcomes in patients with HF. A computerized literature search in Medline, CINAHL, and PsychLit was performed on each of the different outcomes in relation to social support, covering the period 1993 to 2003. Seventeen studies were found that investigated the relationship between social support and different outcome measures in HF. Four studies found clear relationships between social support and rehospitalizations and mortality; the relationship between quality of life and depression was less clear. Up to now, limited research has been done on the impact of social support on outcomes in patients with HF. The available studies suggest that social support has an impact on HF outcomes but further research is necessary before firm conclusions about the nature of these relationships can be reached.

Religious struggle: prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients

OBJECTIVES

For some people, diagnosis with a serious illness or other adverse life events can precipitate a period of religious struggle. While evidence of the harmful effects of religious struggle is accumulating, less is known about its prevalence or correlates. The aim of this study was to examine the prevalence and correlates of religious struggle in three groups of medical patients.

METHODS

Study participants included diabetic outpatients (N= 71), congestive heart failure outpatients (N = 70), and oncology inpatients (N = 97). Participants completed questionnaires which included several measures of religion, including religious struggle, emotional distress or well-being, and demographic characteristics.

RESULTS

Half of the total sample (52%) reported no religious struggle, while 15% reported moderate or high levels. In a multi-variate analysis, younger patients (p < 0.001) and CHF patients (p < 0.05) had higher levels of religious struggle. Those with higher levels of positive religious coping also reported higher levels of religious struggle (p < 0.01), while those who attended worship most frequently had lower levels of religious struggle (p < 0.05). Religious struggle was associated with higher levels of depressive symptoms and emotional distress in all three patient groups.

CONCLUSIONS

While further research is needed to help clarify the sources, additional correlates, and course of religious struggle, the findings in this study confirm the association between religious struggle and emotional distress in these three groups of medical patients. Clinicians should be attentive to signs of religious struggle. Where patient's responses indicate possible religious struggle, clinicians should consider referral to a trained, professional chaplain or pastoral counselor.

State of the Science for Cardiovascular Nursing Outcomes

The incidence of heart failure is increasing because of the progressive aging of the population and improved survival from cardiovascular disease. This article synthesizes the state of the science of nurse sensitive outcomes in heart failure treated medically or surgically and provides recommendations for building the science. Outcomes studied include mortality, morbidity, resource use, quality of life, symptoms, physical function, return to work, and self-care and compliance behavior. Gaps in the literature are identified and recommendations for future research are provided.

Sleep Difficulties, Daytime Sleepiness, and Health-related Quality of Life in Patients With Chronic Heart Failure

BACKGROUND

Normal sleep changes with age in duration, fragmentation, and depth. The prevalence of insomnia is high in the elderly general population. In patients with chronic heart failure (HF) objective sleep assessments have shown disturbances such as a shorter total duration of sleep, frequent arousals, and sleep stage changes.

OBJECTIVE

To describe self-assessed sleep difficulties, daytime sleepiness, and their relation to health-related quality of life (HRQOL) in men and women with HF, as well as to make a comparison to data from a norm population.

METHODS

Cross-sectional design including 223 patients with HF, New York Heart Association classification II-IV, assessed using the Uppsala Sleep Inventory-Chronic Heart Failure, the Epworth Sleepiness Scale, Medical Outcomes Study 36-Item Short Form Health Survey, and Minnesota Living With Heart Failure Questionnaire.

RESULTS

The most commonly reported sleep difficulties were initiating and maintaining sleep. The ratio of habitual sleep to the amount of estimated need for sleep was significantly shorter for women (P < .05), and the number of awakenings per night was significantly increased for men (P < .001). A total of 21% suffered from daytime sleepiness. Patients suffering from difficulties maintaining sleep, initiating sleep, and early morning awakenings reported significantly lower HRQOL in almost all dimensions of the SF-36 (P < .05-P < .001) compared to patients without sleeping difficulties, as well as to the normal population. The disease-specific Minnesota Living With Heart Failure Questionnaire showed significantly reduced (P < .05-P < .001) HRQOL as measured by the total and subscale scores for patients suffering from sleeping difficulties compared to patients without sleeping difficulties.

CONCLUSION

Patients with HF have a reduced HRQOL especially if difficulties maintaining sleep, initiating sleep, and early morning awakenings are involved.

Removing the boundaries: palliative care for patients with heart failure

AIM

This study aimed to explore the experiences of patients with severe heart failure and identify their needs for palliative care.

METHOD

A qualitative design was chosen. Semi-structured interviews were used for data collection and patients were interviewed in their homes. The sample consisted of 20 patients with a confirmed diagnosis of heart failure. Patients were between 60 and 83 years.

RESULTS

Patients reported difficulties in walking, extreme fatigue and problems managing daily activities. Having to rely on family, friends and neighbours was common, causing feelings of being a burden, loneliness and isolation. Patients talked about dying as well as their fears and frustrations in living with heart failure. Barriers to accessing information and social services were identified. None of these patients had been referred to specialist palliative care services.

CONCLUSIONS

Patients' experiences were similar to those of patients living with advanced cancer and yet they received little support. Comprehensive routine assessment of the palliative care needs of patients living with severe heart failure is recommended.

Hospice as an alternative model of care for older patients with end-stage heart failure

The end of life for patients with end-stage heart failure is often characterized by pain, shortness of breath, and diminished quality of life, indicating a lack of adequate care necessary for patients to experience a good death. The vast majority of those who die from heart failure are 65 or older and potentially eligible for the Medicare Hospice Benefit. Yet, only about 10% of patients with end-stage heart failure actually enroll in hospice programs. Lack of enrollment into hospice has been attributed to a variety of factors including a lack of understanding of the availability of hospice as an option for those with heart failure. While improving models of care for patients with heart failure has been of great interest during the last two decades, little is known about the benefits of hospice as a model for care in patients with end-stage heart failure. Nursing must participate in research that explores options of either improving current models of care or developing new and improved models of care for patients with heart failure.

Relationship of Age and Sex to Health-Related Quality of Life in Patients With Heart Failure

• Background Although health-related quality of life is diminished among patients with chronic heart failure, few investigators have examined interactions of age and sex with health-related quality of life longitudinally.

• Objectives To examine differences in health-related quality of life among 4 groups of patients with heart failure on the basis of age (&lt;65 years and &gt;65 years) and sex and to evaluate relationships of age and sex to changes in health-related quality of life during 6 months.

• Methods Patients from 2 outpatient clinics in an urban county hospital were interviewed at baseline and 26 weeks later. Health-related quality of life was measured by using the Minnesota Living With Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire.

• Results A total of 165 patients (52% women; mean age, 57.6 years) completed interviews at baseline and 26 weeks later. At baseline, patients younger than 65 years had poorer health-related quality of life scores on total scales and some subscales than did older patients. Women had poorer scores than did men on some scales, particularly the emotional subscales. At 26 weeks, patients younger than 65 had poorer total health-related quality of life on 1 scale than did patients 65 and older, and women had poorer scores than did men on 1 total scale. With demographic and clinical factors controlled for, women younger than 65 had improvements in health-related quality of life on some scales.

• Conclusions Women younger than 65 years had relatively poorer initial health-related quality of life that improved after 26 weeks.

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

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

Cognitive deficits in patients with heart failure: a review of the literature

PURPOSE

Chronic heart failure (HF) and cognitive impairments (CI) are common problems in the elderly. Both are associated with increased mortality and disability, decreased quality of life, and increased health care costs. While these conditions may occur by chance in the same individual, there is increasing evidence that HF is independently associated with CI. The purpose of this article is to review and critique the literature addressing the prevalence, type, and severity of CI in HF patients, the clinical factors associated with CI, and the potential pathophysiology underlying the development of CI, and to recommend priority areas for future research.

RESULTS

Memory and attention deficits are the most frequently occurring CI in this patient population, followed by slowed motor response times and difficulties in problem solving. Prevalence rates range from 30% to 80% depending upon the age of the patients and the characteristics of the sample being studied. Most patients have mild impairments, although as many as one fourth may have moderate to severe CI. The relationship between left ventricular ejection fraction and cognition is inconsistent and may be nonlinear. The pathophysiology underlying the development of CI in HF patients may be related to both cerebral infarction and cerebral hypoperfusion either alone or in combination.

CONCLUSIONS

The current literature is limited by studies with sometimes small or nonrepresentative samples, few matched control studies, and lack of longitudinal data that could indicate the conditions that favor the development of CI over time. Future research needs to focus on (1) determining the types, frequency, and severity of impairments in cognitive functioning among a representative sample of HF patients, (2) explicating the pathological mechanisms and the clinical factors that underlie the development of cognitive deficits, and (3) identifying the ways CI influences quality of life. Interventions can then be developed to prevent or delay the occurrence of CI or to minimize their effect on patient self-management and quality of life.

Facilitators and barriers to heart failure self-care

Self-care of heart failure (HF) is difficult to master, but the reasons why remain unclear. The purpose of this study was to explore how HF influences patients' lives, assess how they perform self-care, and determine how their life situation facilitates or impedes HF self-care. Qualitative data were obtained from 26 individuals with chronic HF. Data were gathered using structured interviews and analyzed using content analysis. Physical limitations, debilitating symptoms, difficulties coping with treatment, lack of knowledge, distressed emotions, multiple comorbidities, and personal struggles were common. Self-care involved the recognition of symptoms, but atypical symptoms such as faintness were rarely attributed to HF. Patients discussed their successes and failures in following dietary, exercise, and medication recommendations. Some adaptation strategies were practical and some involved internal resources. Many patients accepted support from others, but some withdrew. With the number of barriers these patients face, it is not surprising that self-care of HF is typically poor and that readmission rates continue to be high. Recommendations are provided for a stepped approach to patient education and counseling that uses these findings in practice.

Social support and health-related quality of life in chronic heart failure patients

OBJECTIVES

Objectives of this study were to: (1) describe perceived social support during a baseline hospitalization and 12 months later among heart failure patients; (2) examine differences in social support as a function of gender and age (less than 65 and 65 years or older); and (3) examine social support as a predictor of health-related quality of life.

BACKGROUND

Social support is a predictor of well-being and mortality, but little is known about support patterns among heart failure patients and how they influence quality of life.

METHODS

The sample included 227 hospitalized patients with heart failure who completed the Social Support Survey and the Chronic Heart Failure Questionnaire at baseline; 147 patients completed these questionnaires again 12 months after baseline.

RESULTS

Mean baseline and 12-month total support scores were 56 and 53, respectively, with a score of 76 indicating the most positive perceptions of support. The ANOVA indicated significant interactions of gender by age for total (F = 5.04; p = 0.03) and emotional/informational support (F = 4.87; p = 0.03) and for positive social interactions (F = 4.43; p = 0.04), with men under age 65 perceiving less support than men aged 65 and older and women in either age group. Baseline support did not predict 12-month health-related quality of life, but changes in social support significantly predicted changes in health-related quality of life (R2 = 0.14).

CONCLUSIONS

Overall, perceptions of support were moderate to high, but there was wide variation in perceptions over time. Men under age 65 reported less support than other groups of patients. Importantly, changes in social support were significant predictors of changes in health-related quality of life.

Health-related quality of life and sense of coherence among elderly patients with severe chronic heart failure in comparison with healthy controls

OBJECTIVE

To describe health-related quality of life (QoL) and sense of coherence (SOC) in a group of elderly people with moderate to severe chronic heart failure and to make comparisons with a healthy sex- and age-matched control group.

METHODS

Patients (n = 94), with a mean age of 81 years, hospitalized for chronic heart failure with New York Heart Association functional classification III to IV were age- and sex-matched to a healthy control group. The instruments used were the 36-Item Short Form Health Survey (SF-36) and SOC.

RESULTS

The patients had lower levels of health-related QoL scores (SF-36) but high and similar scores of SOC compared with the controls. There were, however, significant positive correlations between the SOC scores and the emotional dimensions in the SF-36 instrument.

CONCLUSION

The findings from this study indicate that old age and severe chronic heart failure were associated with limited functional abilities and impaired health-related QoL but also with internal resources such as SOC.

Heart failure in women

Heart failure affects more than 5 million Americans. Each year, about 400,000 individuals develop heart failure, making it the nation's most rapidly growing cardiac problem. Almost one third of these individuals have New York Heart Association Functional Class III or IV heart failure and are faced with progressive clinical deterioration and frequent hospital admissions. These figures will continue to escalate as the population ages. The success of interventional procedures and pharmacologic therapies in the management of coronary artery disease has enabled this population to survive acute events, at the same time creating a population with chronic disease. Common etiologies of heart failure in women include coronary artery disease, myocardial infarction, and valvular disease. However, women are at especially high risk for developing heart failure due to diastolic dysfunction associated with hypertension and diabetes. Heart failure in women is best managed across the care continuum, incorporating pharmacologic agents, interventional procedures when appropriate, dietary restrictions, self-monitoring, and psychosocial support. Much of the recent literature has focused on women and heart disease. This emphasis is partly due to public misconception about women's health problems and the growing body of research distinguishing gender differences. Significant advances in therapy have been made to improve the quality and span of life for people with heart disease. Despite therapeutic advances, however, women have high mortality rates from heart disease, including heart failure due to ischemic causes. In fact, women with heart failure present differently than men and have different etiologies and treatment options. As we learn more about women and heart disease, the distinguishing differences unfold and become helpful in establishing a plan of care.

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

OBJECTIVE

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

DESIGN

Matched comparisons of secondary data were used.

SETTING

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

SAMPLE

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Self-care strategies for symptom management in patients with chronic heart failure

BACKGROUND

The troublesome symptoms experienced by patients with chronic heart failure are associated with diminished quality of life, frequent hospitalizations, and mortality.

OBJECTIVES

To describe the symptoms experienced by patients with heart failure, to detail the self-care strategies used by these patients in managing their symptoms, and to categorize the self-care strategies.

METHODS

Six focus groups were used with 23 patients who had heart failure, along with six focus groups with 18 family members of the patients. Data analysis was performed by transcription of audiotape recordings of the group sessions and review of field notes.

RESULTS

The patients reported a large number of troublesome symptoms, many consistent with past empirical findings, but some not reported in previous studies. Self-care strategies to manage the symptoms clustered into 11 categories.

CONCLUSIONS

Results from this study provided direction for future studies to (a) identify the prevalence, severity, and etiologies of the commonly reported symptoms, particularly cognitive impairment, loss of balance, and depression; (b) evaluate the emotions reported by women with heart failure; and (c) test the strategies as part of an intervention program to improve symptom management in patients with heart failure.