Survival differences between heart failure in general practices and in hospitals

Effectiveness and cost effectiveness of palliative care interventions in people with chronic heart failure and their caregivers: a systematic review

BACKGROUND

Chronic heart failure is a common condition, and its prevalence is expected to rise significantly over the next two decades. Research demonstrates the increasing multidimensional needs of patients and caregivers. However, access to palliative care services for this population has remained poor. This systematic review was to provide an evidence synthesis of the effectiveness and cost-effectiveness of palliative care interventions for people with chronic heart failure and their caregivers.

METHODS

Relevant publications were identified via electronic searches of MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL and HMIC from inception to June 2019. Grey literature databases, reference list, and citations of key review articles were also searched. Quality was assessed using the Revised Cochrane Risk of Bias Tool.

RESULTS

Of the 2083 records, 18 studies were identified including 17 having randomised controlled trial (RCT) designs and one mixed methods study with an RCT component. There was significant heterogeneity in study settings, control groups, interventions delivered, and outcome measures used. The most commonly assessed outcome measures were functional status (n = 9), psychological symptoms (n = 9), disease-specific quality of life (n = 9), and physical symptom control (n = 8). The outcome measures with the greatest evidence for benefit included general and disease-specific quality of life, psychological symptom control, satisfaction with care, physical symptom control, medical utilisation, and caregiver burden. Moreover, the methodological quality of these studies was mixed, with only four having an overall low risk of bias and the remaining studies either demonstrating high risk of bias (n = 10) or showing some concerns (n = 4) due to small sample sizes and poor retention. Only two studies reported on economic costs. Both found statistically significant results showing the intervention group to be more cost effective than the control group, but the quality of both studies was at high risk of bias.

CONCLUSIONS

This review supports the role of palliative care interventions in patients with chronic heart failure and their caregivers across various outcomes, particularly quality of life and psychological wellbeing. Due to the highly heterogeneous nature of palliative care interventions, it is not possible to provide definitive recommendations as to what guise palliative care interventions should take to best support the complex care of this population. Considerable future research, particularly focusing on quality of care after death and the caregiver population, is warranted.

Plasma von Willebrand factor and soluble E-selectin levels in stable outpatients with systolic heart failure: The Frederiksberg heart failure study

BACKGROUND

Endothelial dysfunction is a well-established aspect of the pathophysiology of patients with systolic heart failure. We have previously reported that patients who have had multiple current or previous hospital admissions for decompensated heart failure have consistently shown abnormal levels of plasma von Willebrand factor (vWf, an index of endothelial damage/dysfunction) and soluble E-selectin (E-sel, an index of endothelial activation), as well as other indices of endothelial perturbation.

METHODS

To investigate if endothelial abnormalities extend to CHF outpatients who have only been recently diagnosed or have relatively mild or few, stable symptoms (at baseline), given the better prognosis in these patients, we performed a cross-sectional analysis of CHF patients, where vWf and E-sel levels (as indices of endothelial perturbation) were measured (ELISA) and related to left ventricular ejection fraction (LVEF), exercise capacity (6-min walk test) and N-terminal pro-Brain Natiuretic Peptide (NT-proBNP).

RESULTS

There were no statistically significant differences in vWf and E-sel levels amongst patients with systolic heart failure compared to controls. Plasma NT-proBNP levels in patients with CHF were significantly elevated compared to controls (p<0.0001). Among the patients with CHF, higher NT-proBNP levels correlated with poorer LVEF [Spearman r=-0.244, p<0.004] and shorter 6-min walk distance [Spearman r=-0.226, p=0.045] but not NYHA class. Plasma vWf or E-sel levels did not correlate with LVEF, 6-min walk test or NYHA class. NT-proBNP levels correlated weakly with E-sel [Spearman r=-0.211, p=0.015] but not vWf.

CONCLUSION

The present observation suggests that stable CHF outpatients with few symptoms may in fact have less severe endothelial perturbation, as reflected by plasma indices such as vWf and E-selectin. There was limited association of endothelial indices to LVEF, exercise capacity, NYHA class and NT-proBNP levels.

Life expectancy of elderly and very elderly patients with chronic heart failure

INTRODUCTION

The survival of patients with chronic heart failure is typically reported as a comparison of different groups of patients using the hazard ratio from a Cox proportional hazards analysis. The absolute survival is generally neglected. Furthermore, attention is often focused on relatively young patients although chronic heart failure largely affects older patients. The present study was undertaken to determine the life expectancy (a measure of absolute survival) of older patients with chronic heart failure.

METHODS

Patients >75 years with chronic heart failure caused by impaired left ventricular systolic function who attended an outpatient clinic were included in the study. Follow-up commenced on August 1, 1993, and continued until September 30, 2005, when vital status was ascertained. Mean survival time was calculated as a measure of life expectancy.

RESULTS

There were 210 patients included in the study. Male patients of mean age 80 years had a life expectancy of 3.9 years (95% CI 3.2-4.5), compared with that of 7 years for men in the general population of the same age. For female patients of mean age 80 years, the life expectancy was 4.5 years (95% CI 3.6-5.7), compared with 8.5 years for the general population of women of the same age.

CONCLUSION

The presence of chronic heart failure in older patients results in an approximately 50% reduction in life expectancy.

Expressed emotion, adaptation, and patient survival among couples coping with chronic heart failure

Previous research (J. C. Coyne et al., 2001) that showed that marital functioning predicted mortality among patients with chronic heart failure (CHF) led to an examination of whether expressed emotion (EE) captured negative marital influences on patient survival. The authors assessed EE using 5-min speech samples obtained from patients (137 men and 47 women) and their spouses. Prevalence of EE was low, and patient and spouse EE were unrelated. Spouse EE was not associated with survival, after the authors controlled for severity of illness. Among patient EE variables, high EE status predicted survival, but in the opposite direction of what was anticipated. Overall, relations between EE and self-report measures of adaptation were weak and inconsistent. Despite the strength of findings concerning EE and psychiatric outcomes, EE does not show promise in predicting adaptation to CHF, and researchers and clinicians should instead seek to identify positive marital factors that may promote patient survival.