Diagnostic value of patterns of symptoms and signs of heart failure: application of latent class analysis with concomitant variables in a cross-sectional study

Characterizing High Risk Patients in Heart Failure: A Latent Class Analysis of Rehospitalization and Mortality

BACKGROUND

Patients with heart failure (HF) are typically classified based on left ventricular ejection fraction (LVEF). However, this may not optimally reflect distinct groups or predict risk. Therefore, alternative classification methods are needed.

OBJECTIVE

Our aim was to classify patients with HF based on sociodemographic and clinical data using latent class analysis, assess if latent classes pose varying risks of mortality and rehospitalization, and explore if these classes offer better risk stratification than LVEF or N-terminal prohormone of brain natriuretic peptide (NT-proBNP) alone.

METHODS

Data from 1045 patients were analyzed using latent class analysis to identify classes and assess mortality and rehospitalization risks. Kaplan-Meier curves with log-rank tests were used to compare mortality across latent classes, LVEF-based groups, and NT-proBNP-based groups.

RESULTS

Three latent classes were identified. Class 1 (48.8%) comprised middle-aged males with HF with reduced ejection fraction (HFrEF) and high NT-proBNP levels. Class 2 (26.1%) consisted of mainly older females with HF with preserved ejection fraction, high body mass index, hypertension, atrial fibrillation, and anemia. Class 3 (25.2%) included younger patients with HFrEF, high body mass index, and a high smoking rate. Class 1 and 2 had higher mortality risks ( P < .001) and longer rehospitalization durations ( P = .011) than class 3.

CONCLUSION

Latent class analysis categorized a heterogeneous group of patients with HF into homogeneous classes. These classes provide a close approximation of what could be observed in clinical practice and provide insight into patients at higher risk of mortality and rehospitalization.

Assessment of Bendopnea and Its Association With Clinical and Para-Clinical Findings in Systolic Heart Failure: A Cross-Sectional Study

Background and Aims

Bendopnea is a symptom found in patients with heart failure (HF) defined as shortness of breath when bending forward. The present study examined the correlation between bendopnea with other cardiac symptoms, echocardiographic findings, and cardiac function parameters.

Methods

This was a single-center prospective cross-sectional study of patients diagnosed with systolic HF. Medical history, bending tests, laboratory tests, electrocardiography (ECG), echocardiography, and 6-min walking test (6-MWT) were evaluated. Patients with reduced ejection fraction were followed to assess the 2-year outcomes for cardiovascular death and rehospitalization.

Results

A total of 80 patients were included in this study, of whom 54 (67.5%) were male. Bendopnea was present in 34 (42.5%) and their mean age was 62.44 years (compared to group without bendopnea, p = 0.869). Symptoms of HF such as dyspnea of exertion (DOE) and orthopnea were significantly related to the presence of bendopnea (p = 0.001, odds ratio (OR): 6.87, and p = 0.016, OR: 3.18, respectively). The bendopnea-positive group had a higher New York Heart Association (NYHA) class (p = 0.005). ECG results showed no significant difference between the two groups. The echocardiographic findings showed that the inferior vena cava (IVC) respiratory collapse was significantly lower in the bendopnea-positive group (p = 0.019, OR: 0.339, 95% CI:0.13-0.85). Moreover, they had a substantially lower performance in 6-MWT (387.39 vs. 325.58 m, p = 0.015). Neither rehospitalization nor death was related to bendopnea after a 2-year follow-up (p = 0.454).

Conclusion

Bendopnea was associated with several signs and symptoms of HF, including orthopnea, DOE, NYHA class, lower IVC collapse, and impaired functional capacity measured via 6-MWT. However, there was no association between bendopnea and ECG findings, ejection fraction, and NT-proBNP levels. Further studies with larger sample sizes are needed to assess the associations with long-term outcomes and confirm our findings.

Association of adverse childhood experiences with dietary patterns of school-age children: evidence from the birth cohort Generation XXI

BACKGROUND

Adverse Childhood Experiences (ACEs) have been associated with health-risk behaviors and several chronic diseases in adulthood. However, the relationship between exposure to ACEs and dietary patterns at school age is unknown.

OBJECTIVES

To investigate the association between ACEs and dietary patterns of 10-year-olds.

METHODS

The study included 5034 children from the Generation XXI cohort, recruited in 2005/2006 in Porto, Portugal. ACEs were assessed through a self-administered questionnaire covering the first 10 years (y) of life, quantified and grouped into 5 dimensions: "abuse," "school problems," "death/severe disease," "life changes," and "household dysfunction." Dietary patterns were identified by latent class analysis using data collected with a validated food frequency questionnaire. Five dietary patterns were studied: "low consumption," "energy-dense foods," "snacking," "intermediate consumption," and "healthier" (used as reference). Multinomial regression analyses were conducted, adjusted for the child's sex, household income, family structure, and mother's age [odds ratio (OR) and 99% confidence intervals (CIs)].

RESULTS

Most children were exposed to ≥1 ACE (96%), and ∼27% had reported 6 or more ACEs throughout life. Those reporting 4-5 and ≥6 ACEs were more likely to follow the "Energy-dense foods" dietary pattern compared with those with no ACEs (OR: 2.41; 99% CI: 1.00, 5.77 and OR: 2.65; 99% CI: 1.10, 6.39, respectively). Children exposed to "abuse" in the first 10 y showed 28% higher odds of following the "low consumption" dietary pattern when compared to children with no reported ACEs and using the "healthier" dietary pattern as a reference (OR: 1.28; 99% CI: 1.00, 1.63).

CONCLUSIONS

Exposure to ACEs was associated with less healthy dietary patterns in school-aged children. Results suggest a cumulative effect of the adverse experiences resulting in a dietary pattern higher in energy-dense foods. Children with ACEs reported under the dimension of "abuse" seemed to have reduced food consumption.

Distinct Symptom Experience Among Subgroups of Patients With ESRD Receiving Maintenance Dialysis

CONTEXT

Patients with end-stage renal disease receiving dialysis experience multiple concurrent symptoms. A person-centered understanding of patients' symptom experiences may offer insights into individualized management.

OBJECTIVES

We identified subgroups of patients based on their symptom experiences and the characteristics that differentiated among these subgroups. Outcomes associated with these subgroups were evaluated.

METHODS

A total of 354 patients on dialysis were recruited at two regional hospitals in Hong Kong. While the Dialysis Symptom Index was adopted to assess symptoms, the Kidney Disease Quality of Life 36 and Karnofsky Performance Status Scale were used to evaluate the quality of life outcomes. Information on health care utilization and mortality were retrieved from medical records. Subgroups of patients were identified using latent class analysis based on the occurrence ratings. Differences in characteristics and outcomes were determined using Chi-squared test, analysis of variance, and Cox regression analysis.

RESULTS

Three latent classes were identified: low (37.8%), moderate physical-low psychological (29.7%), and moderate physical-high psychological (32.5%). Higher comorbidity burden and lower serum albumin levels differentiated between the low and moderate physical-low psychological classes. The moderate physical-high psychological class had the highest number of symptoms, poorest quality of life outcomes, and more unscheduled clinic visits. A shorter mean survival time (421 vs. 431 days) was also found.

CONCLUSION

Consistent with findings in other chronic conditions, subgroups of patients on dialysis have unique symptom experiences. Therefore, an individualized approach to symptom management is warranted. Our findings offer a phenotypic characterization for research on the underlying mechanisms for these symptom experiences.

Efficient selective screening for heart failure in elderly men and women from the community: A diagnostic individual participant data meta-analysis

Background Prevalence of undetected heart failure in older individuals is high in the community, with patients being at increased risk of morbidity and mortality due to the chronic and progressive nature of this complex syndrome. An essential, yet currently unavailable, strategy to pre-select candidates eligible for echocardiography to confirm or exclude heart failure would identify patients earlier, enable targeted interventions and prevent disease progression. The aim of this study was therefore to develop and validate such a model that can be implemented clinically. Methods and results Individual patient data from four primary care screening studies were analysed. From 1941 participants >60 years old, 462 were diagnosed with heart failure, according to criteria of the European Society of Cardiology heart failure guidelines. Prediction models were developed in each cohort followed by cross-validation, omitting each of the four cohorts in turn. The model consisted of five independent predictors; age, history of ischaemic heart disease, exercise-related shortness of breath, body mass index and a laterally displaced/broadened apex beat, with no significant interaction with sex. The c-statistic ranged from 0.70 (95% confidence interval (CI) 0.64-0.76) to 0.82 (95% CI 0.78-0.87) at cross-validation and the calibration was reasonable with Observed/Expected ratios ranging from 0.86 to 1.15. The clinical model improved with the addition of N-terminal pro B-type natriuretic peptide with the c-statistic increasing from 0.76 (95% CI 0.70-0.81) to 0.89 (95% CI 0.86-0.92) at cross-validation. Conclusion Easily obtainable patient characteristics can select older men and women from the community who are candidates for echocardiography to confirm or refute heart failure.

Association between dietary patterns and adiposity from 4 to 7 years of age

OBJECTIVE

The present study aimed to evaluate the association of 4-year-old children's dietary patterns with adiposity at 7 years, according to child's sex, using a conceptual model.

DESIGN

Prospective cohort study. Diet was assessed using an FFQ. Age- and sex-specific BMI standard deviation scores (Z-scores) were defined according to the WHO. Fat mass percentage (FM%), fat mass index (FMI) and waist-to-height ratio (WHtR) were also considered, converted into Z-scores using sex-specific means and standard deviations of the current sample. Dietary patterns were identified by latent class analysis and their association with adiposity was estimated by linear regression models.

SETTING

Population-based birth cohort Generation XXI (Porto, Portugal, 2005-2006).

SUBJECTS

Children (n 3473) evaluated at both 4 and 7 years of age.

RESULTS

Three dietary patterns were identified: high in energy-dense foods (EDF); low in foods typically consumed at main meals and intermediate in snacks (Snacking); and higher in vegetables and fish and lower in EDF (Healthier, reference). The EDF dietary pattern at 4 years of age was positively associated with later BMI only in girls (β=0·075, 95 % CI 0·009, 0·140, P-interaction=0·046). The EDF dietary pattern was also associated with other adiposity indicators only in girls (FMI: β=0·071, 95 % CI 0·000, 0·142; WHtR: β=0·094, 95 % CI 0·023, 0·164). Snacking was not significantly associated with any marker of adiposity in either girls or boys.

CONCLUSIONS

Although dietary patterns and adiposity persisted across the two ages in both sexes, EDF at 4 years of age increased adiposity at 7 years of age only in girls.

Association of maternal characteristics and behaviours with 4-year-old children's dietary patterns

This study examined the association of family and maternal characteristics with preschool children's dietary patterns. Trained interviewers evaluated subsample 3422 mothers and children enrolled in the population-based birth cohort Generation XXI (Porto, Portugal, 2005-2006). Maternal characteristics and behaviours (exercise, smoking habits, diet and child-feeding practices) and family characteristics were evaluated. Maternal diet was classified by a dietary score, and children's dietary patterns were identified by latent class analysis. Odds ratios (OR) and confidence intervals (95% CI) were estimated by multinomial regression models. The analysis was based on a framework with four conceptual levels: maternal socio-economic position (SEP) at 12 years, maternal socio-economic and demographic characteristics at child's delivery, family characteristics and maternal behaviours at child's 4 years. Three dietary patterns were identified in children: high in energy-dense foods (EDF); low in foods typically consumed at main meals and intermediate in snacks (Snacking); higher in healthy foods; and lower in unhealthy ones (Healthier, reference). Lower maternal SEP had an overall effect on children's diet (low vs. high SEP; EDF, OR = 1.76, 95% CI: 1.42-2.18; Snacking, OR = 1.73, 95% CI: 1.27-2.35), while maternal education was directly associated with it (≤9 vs. >12 schooling years, EDF, OR = 2.19, 95% CI: 1.70-2.81; Snacking, OR = 2.22, 95% CI: 1.82-3.55). Children whose mothers had worse dietary score were significantly more likely to follow unhealthier patterns (first vs. fourth quartile; EDF, OR = 9.94, 95% CI: 7.35-13.44, P-trend < 0.001; Snacking, OR = 4.21, 95% CI: 2.94-6.05, P-trend < 0.001). Maternal diet was the key factor associated with children's diet, above and beyond socio-economic and demographic characteristics, accounting for one-third of the determination coefficient of the fully adjusted model. At preschool age, interventions should give a particular focus on maternal diet and low SEP groups.

Self-Reported Side Effects and Adherence to Antiretroviral Therapy in HIV-Infected Pregnant Women under Option B+: A Prospective Study

Background

Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy.

Methods

We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes.

Results

Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses.

Conclusion

These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.

Dietary patterns and asthma prevalence, incidence and control

BACKGROUND

The increased asthma prevalence in westernized societies has been suggested to be related to environment exposures and lifestyle changes, particularly diet. We aimed to explore the association between dietary patterns and asthma prevalence, incidence and control in a nationally representative population.

METHODS

Data from 32,644 adults, 53% female, from the 4th Portuguese National Health Survey were analysed. Prevalence of asthma was 5.3%; 'current asthma', defined by asthma symptoms within previous year, 3.5%; 'current medicated asthma' defined by use of asthma medication within previous year, 3.0%; 'current severe asthma' defined by emergency visit because of asthma within previous year, 1.4%; and 'incident asthma', 0.2%. Dietary patterns (DP) were identified by latent trait models based on dietary intake. Unconditional logistic regression models were performed to analyse association between DP and asthma. Age, gender, education, family income, proxy reporting information, smoking, body mass index and physical activity level were analysed as confounders.

RESULTS

Two of the five identified DP were associated with asthma: 'high fat, sugar and salt' DP (positively correlated with pastry, chocolate and sweet desserts, candies, salty snacks, chips, fruit juices, soft drinks and alcoholic beverages consumption at snacks) was associated with asthma prevalence (OR = 1.13, 95% CI = 1.03, 1.24) and current severe asthma (OR = 1.23, 95% CI = 1.03, 1.48), while 'fish, fruit and vegetables' DP (positively correlated with fish, vegetables and fruit intake at meals) was negatively associated with current (OR = 0.84, 95% CI = 0.73, 0.98), and current medicated asthma (OR = 0.84, 95% CI = 0.72, 0.98), after adjustment for confounders.

CONCLUSION & CLINICAL RELEVANCE

Our results suggest a protective association between 'fish, vegetables and fruit' DP and current asthma and current medicated asthma, and a detrimental association between 'high fat, sugar and salt' DP and severe asthma prevalence, further supporting the rational for diet and lifestyle intervention studies in asthma based on whole dietary patterns and physical activity.

Obesity increases the prevalence and the incidence of asthma and worsens asthma severity

BACKGROUND & AIMS

We aimed to explore the association between obesity and asthma prevalence, incidence and severity.

METHODS

The study included 32,644 adults, 52.6% female, from a representative sample of the 4th Portuguese National Health Survey. The following asthma definitions were used: ever asthma (ever medical doctor asthma diagnosis), current asthma (asthma within the last 12 months), current persistent asthma (required asthma medication within the last 12 months), current severe asthma (attending an emergency department because of asthma within the last 12 months), and incident asthma (asthma diagnosis within the last 12 months). Body mass index was calculated based on self-reported weight and height and categorised according to WHO classification. Logistic regression models adjusted for confounders were performed.

RESULTS

Prevalence of ever asthma was 5.3%, current asthma 3.5%, current persistent asthma 3.0%, current severe asthma 1.4%, and incident asthma 0.2%. Prevalence of obesity was 16%, overweight 37.6%, normal weight 44.6% and underweight 0.2%. Being overweight, obesity class I and II, and obesity class III were associated with an OR (95% CI) with ever asthma 1.22 (1.21-1.24), 1.39 (1.36-1.41), 3.24 (3.08-3.40) respectively; current asthma 1.16 (1.14-1.18), 1.86 (1.82-1.90), 4.73 (4.49-4.98) respectively; current persistent asthma 1.08 (1.06-1.10), 2.06 (2.01-2.10), 5.24 (4.96-5.53), and current severe asthma 1.36 (1.32-1.40), 1.50 (1.45-1.55) and 3.70 (3.46-3.95), respectively. Considering the incidence of asthma, obesity more than quadrupled the odds (OR = 4.46, 95% CI 4.30, 4.62).

CONCLUSION

Obesity is associated in a dose dependent way with an increase of prevalent and incident asthma, and it seems to increase the odds of a more persistent and severe asthma phenotype independently of socio-demographic determinants, physical activity, and dietary patterns. Our results provide rational for future lifestyle intervention studies for weight reduction in the obesity-asthma phenotype.

Socioeconomic position early in adolescence and mode of delivery later in life: findings from a Portuguese birth cohort

Objective

This study assessed the influence of socioeconomic position at 12 years of age (SEP-12) on the variability in cesarean rates later in life.

Methods

As part of the Portuguese Generation XXI birth cohort we evaluated 7358 women with a singleton pregnancy who delivered at five Portuguese public hospitals serving the region of Porto (April/2005–September/2006). Based on the twelve items that described socioeconomic circumstances at age 12, a latent class analysis was used to classify women’s SEP-12 as high, intermediate and low. Multiple Poisson regression was used to estimate adjusted risk ratio (RR) and respective 95% confidence interval (95% CI).

Results

The cesarean rates in high, intermediate and low SEP-12 were, respectively, 40.9%, 37.5% and 40.5% (p = 0.100) among primiparous women; 14.2%, 11.6% and 15.5% (p = 0.04) among multiparous women with no previous cesarean and 78.6%, 72.2% and 70.0% (p = 0.08) among women with a previous cesarean. A low to moderate association between SEP-12 and cesarean rates was observed among multiparous women with a previous cesarean, illustrating that women from higher SEP-12 were more likely to have a surgical delivery (RR = 1.12;95%CI:1.01–1.24 comparing high with low SEP-12 and RR = 1.03:95%CI:0.94–1.14 comparing intermediate with low SEP-12) not explained by potential mediating factors. No such association was found either in primiparous or in multiparous women without a previous cesarean.

Conclusions

The association between SEP-12 and cesarean rates suggests the effect of past socioeconomic context on the decision concerning the mode of delivery, but only among women who experienced a previous cesarean. Accordingly, it appears that early-life socioeconomic circumstances drive cesarean rates but the effect can be modified by lived experiences concerning childbirth.