Efficient Measurement of Multiple Ventricular Assist Device Patient-reported Outcomes: Creation of a 20-item Profile from the MCS A-QOL Study

BACKGROUND

Patient-reported outcome (PRO) measures of distinct concepts are often put together into patient profile assessments. When brief, profile assessments can decrease respondent burden and increase measure completion rates. In this report, we describe creation of five self-reported 4-item short forms and the MCS A-QOL 20-item profile to assess PROs specific to adjustment and health-related quality of life (HRQOL) among patients who undergo left ventricular assist device (LVAD) implantation.

METHODS

Using a cross-sectional sample of patients (n=620) who underwent LVAD implantation at 12 U.S. sites or participated in the MyLVAD.com support group, we created five 4-item short forms: Satisfaction with Treatment, VAD Team Communication, Being Bothered by VAD Self-care and Limitations, Self-efficacy Regarding VAD self-care, and Stigma, which we combined into a 20-item Profile. Analyses included inter-correlations among measures, Cronbach's alpha (i.e., internal consistency reliability)/score-level-specific reliability, and construct validity.

RESULTS

The 620 patients were mean age=57 years, 78% male, 70% white, and 56% on destination therapy LVADs. Inter-correlations among the five 4-item measures were low to moderate (<0.50), indicating they are associated yet largely distinct, and correlations with calibrated measures and 6-item short forms were >0.76, indicating their ability to reflect full-item bank scores. Internal consistency reliability for the five 4-item short forms ranged from acceptable (≥0.70) to good (≥0.80). Construct validity was demonstrated for these measures.

CONCLUSIONS

Our five 4-item short forms are reliable and valid and may be used individually or together as a 20-item Profile to assess adjustment and HRQOL in patients who undergo LVAD implantation.

The Association of Unmet Palliative Care Needs and Physical Frailty With Clinical Outcomes: A Prospective Study of Adults With Heart Failure

BACKGROUND

People with heart failure, particularly those who are physically frail, experience complex needs that can be addressed by palliative care (PC). However, we have a limited understanding of how the intersection of unmet PC needs and physical frailty contributes to health-related quality of life (HRQOL) and risk for hospitalization or mortality.

OBJECTIVE

In this study, we sought to examine the association of unmet PC needs and physical frailty with clinical outcomes (baseline HRQOL and hospitalizations or mortality at 6 months).

METHODS

We recruited a convenience sample of community-dwelling persons with heart failure from an urban hospital system who were older than 50 years and hospitalized in the last year. We measured physical frailty using the FRAIL scale (nonfrail, 0-2; frail, 3-5), PC needs using the Integrated Palliative Outcome Scale (range, 0-58; higher scores indicating higher needs), and HRQOL using the Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores indicate higher HRQOL). We performed multivariable linear regression to test the relationships between physical frailty, PC needs, and HRQOL, and multivariable logistic regression for associations with all-cause 6-month hospitalization or mortality. We also performed an exploratory analysis of 4 PC needs/frailty groups (high PC needs/frail, high PC needs/nonfrail, low PC needs/frail, low PC needs/nonfrail) with outcomes.

RESULTS

In our overall sample (n = 298), mean (SD) age was 68 (9.8) years, 37% were women (n = 108), 28% identified as Black/African American (n = 84), and 65% had heart failure with preserved ejection fraction (n = 194). Mean PC needs score was 19.7, and frail participants (n = 130, 44%) had a significantly higher mean PC needs score than nonfrail participants (P < .001). Those with higher PC needs (Integrated Palliative Care Outcome Scale ≥ 20) had significantly worse HRQOL (P < .001) and increased odds of hospitalization or mortality (odds ratio, 2.5; P < .01) compared with those with lower PC needs, adjusting for covariates. Physically frail participants had significantly worse HRQOL (P < .001) and higher odds of hospitalization or mortality at 6 months (odds ratio, 2.6; P < .01) than nonfrail participants, adjusting for covariates. In an exploratory analysis, physically frail participants with high PC needs had the lowest HRQOL score, with an average score of 28.6 points lower (P < .001) and 4.6 times higher odds of hospitalization or mortality (95% confidence interval, 2.03-10.43; P < .001) than low-needs/nonfrail participants.

CONCLUSION

Higher unmet PC needs and physical frailty, separately and in combination, were associated with lower HRQOL and higher odds of hospitalization or mortality. Self-reported PC needs and physical frailty assessment in clinical settings may improve identification of patients at the highest risk for poor HRQOL and hospitalization or mortality amenable to PC intervention.

Incorporating reproductive system history data into cardiovascular nursing research to advance women's health

The lack of sex-specific variables, such as reproductive system history (RSH), in cardiovascular research studies is a missed opportunity to address the cardiovascular disease (CVD) burden, especially among women who face sex-specific risks of developing CVD. Collecting RSH data from women enrolled in research studies is an important step towards improving women's cardiovascular health. In this paper, we describe two approaches to collecting RSH in CVD research: extracting RSH from the medical record and participant self-report of RSH. We provide specific examples from our own research and address common data management and statistical analysis problems when dealing with RSH data in research.

Sympathetic dysfunction is associated with worse fatigue and early and subtle symptoms in heart failure: an exploratory sex-stratified analysis

AIMS

Physical symptoms impact patients with heart failure (HF) despite treatment advancements; however, our understanding of the pathogenic mechanisms underlying HF symptoms remains limited, including sex differences therein. The objective of this study was to quantify associations between sympathetic markers [norepinephrine (NE) and 3,4-dihydroxyphenylglycol (DHPG)] and physical symptoms in patients with HF and to explore sex differences in these associations.

METHODS AND RESULTS

We performed a secondary analysis of combined data from two studies: outpatients with HF (n = 111), and patients prior to left ventricular assist device implantation (n = 38). Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) dyspnoea and early/subtle symptom subscales and the Functional Assessment in Chronic Illness Therapy Fatigue Scale (FACIT-F) to capture dyspnoea, early symptoms of decompensation, and fatigue. Norepinephrine and DHPG were measured with high-performance liquid chromatography with electrochemical detection. Multivariate linear regression was used to quantify associations between symptoms and sympathetic markers. The sample (n = 149) was 60.8 ± 15.7 years, 41% women, and 71% non-ischaemic aetiology. Increased plasma NE and NE:DHPG ratio were associated with worse FACIT-F scores (P = 0.043 and P = 0.013, respectively). Increased plasma NE:DHPG ratio was associated with worse HFSPS early/subtle symptoms (P = 0.025). In sex-stratified analyses, increased NE:DHPG ratio was associated with worse FACIT-F scores (P = 0.011) and HFSPS early/subtle scores (P = 0.022) among women but not men.

CONCLUSION

In patients with HF, sympathetic dysfunction is associated with worse fatigue and early/subtle physical symptoms with associations stronger in women than men.

Novel measures to assess ventricular assist device patient-reported outcomes: Findings from the MCS A-QOL study

BACKGROUND

Generic and heart failure-specific measures do not capture unique aspects of living with a ventricular assist device (VAD). Using state-of-the-science psychometric measurement methods, we developed a measurement system to assess post-ventricular assist device adjustment and health-related quality of life (HRQOL).

METHODS

Patients were recruited from 10/26/16-2/29/20 from 12 U.S. VAD programs. We created a dataset of participants (n = 620) enrolled before left (L)VAD implantation, with data at 3- or 6- months post-implantation (group1 [n = 154]), and participants enrolled after LVAD implantation, with data at one timepoint (group 2 [n = 466]). We constructed 5 item banks: 3 modified from existing measures and 2 new measures. Analyses included item response theory (IRT) modeling, differential item functioning tests for systematic measurement bias, and indicators of reliability and validity.

RESULTS

Of 620 participants, 56% (n = 345) were implanted as destination therapy, 51% (n = 316) were <12 months post-implantation, mean age = 57.3 years, 78% (n = 485) male, 70% (n = 433) White, 58% (n = 353) married/partnered, and 58% (n = 357) with >high school education. We developed 5 new VAD item banks/measures: 6-item VAD Team Communication; 12-item Self-efficacy Regarding VAD Self-care; 11-item Being Bothered by VAD Self-care and Limitations; 7-item Satisfaction with Treatment; and 11-item Stigma. Cronbach's alpha reliability ranged from good (≥0.80) to excellent (≥0.90) for item banks/measures. All measures, except VAD Team Communication, demonstrated at least moderate correlations (≥0.30) with construct validity indicators.

CONCLUSIONS

These measures meet IRT modeling assumptions and requirements; scores demonstrate reliability and validity. Use of these measures may assist VAD clinicians to inform patients about VADs as a treatment option and guide post-VAD interventions.

Guidelines on the use of sex and gender in cardiovascular research

In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.

PROMIS: Physical, Mental and Social Health Outcomes Improve From Before to Early After LVAD Implant: Findings From the Mechanical Circulatory Support: Measures of Adjustment and Quality of Life (MCS A-QOL) Study

Study participants (n = 272) completed 12 Patient-Reported Outcomes Measurement Information System (PROMIS) physical, mental and social health measures (questionnaires) prior to implantation of a left ventricular assist device (LVAD) and again at 3 and 6 months postimplant. All but 1 PROMIS measure demonstrated significant improvement from pre-implant to 3 months; there was little change between 3 and 6 months. Because PROMIS measures were developed in the general population, patients with an LVAD, their caregivers and their clinicians can interpret the meaning of PROMIS scores in relation to the general population, helping them to monitor a return to normalcy in everyday life.

Sex differences in the impact of physical frailty on outcomes in heart failure

BACKGROUND

Physical frailty is strongly related to adverse outcomes in heart failure (HF), and women are more likely to be physically frail than men; however, it is unknown if this sex difference affects outcomes.

OBJECTIVES

To determine if there are sex differences in the associations between physical frailty and health-related quality of life (HRQOL) and clinical outcomes in HF.

METHODS

We conducted a prospective study of adults with HF. Physical frailty was assessed using the Frailty Phenotype Criteria. HRQOL was assessed using the Minnesota Living with HF Questionnaire. One-year clinical events (all-cause death or cardiovascular hospitalization or emergency department visit) were ascertained. We used generalized linear modeling to quantify associations between physical frailty and HRQOL, and Cox proportional hazards modeling to quantify associations between physical frailty and clinical events, adjusting for Seattle HF Model scores.

RESULTS

The sample (n = 115) was 63.5 ± 15.7 years old and 49% women. Physical frailty was associated with significantly worse total HRQOL among women (p = 0.005) but not men (p = 0.141). Physical frailty was associated with worse physical HRQOL among both women (p < 0.001) and men (p = 0.043). There was a 46% higher clinical event risk for every one-point increase in physical frailty score among men (p = 0.047) but not women (p = 0.361).

CONCLUSIONS

Physical frailty is associated with worse overall HRQOL among women and higher clinical event risk among men, indicating a need to better understand contributors to sex-specific health differences associated with physical frailty in HF.

Are Physical and Depressive Symptoms Different Between Women and Men With Heart Failure?: An Exploration Using Two Analytic Techniques

BACKGROUND

Adults with heart failure (HF) experience a constellation of symptoms; however, understanding of gender differences in HF symptoms remain elusive. The aim of this study was to determine whether there are gender differences in physical and depressive symptoms and symptom patterns in HF using 2 different analytic techniques.

METHODS

We performed a secondary analysis of combined data from 6 studies of adults with HF. Physical symptoms were measured with the HF Somatic Perception Scale, and depressive symptoms were measured with the Patient Health Questionnaire-9. First, we performed propensity matching with the nearest neighbor to examine the average treatment effect for HF Somatic Perception Scale and Patient Health Questionnaire-9 in the matched sample of women and men. Next, we used the entire data set in a latent class mixture model to determine patterns of symptoms. Finally, we calculated predictors of class membership with multinomial logistic regression.

RESULTS

The sample (n = 524, 86.5% systolic HF) was 37% women with a mean age of 58.3 ± 13.9 years and mean number of years with HF of 6.9 ± 6.9. Three hundred sixty-six participants were matched on propensity scores; there were no significant gender differences in symptom scores between matched women (n = 183) and men (n = 183). Among all 524 participants, 4 distinct latent classes of symptom patterns indicate that many patients with HF are fatigued, some have more depressive symptoms, and others have significantly more edema or cough. Gender did not predict membership to any symptom pattern.

CONCLUSIONS

There were significant gender differences in sociodemographics, health behaviors, and clinical characteristics, but not HF symptoms or symptom patterns, using either analytic technique.

Referral Order Placement Decreases Time to Transfer to Adult Congenital Heart Disease Care

Pediatric patients with moderate and great complexity congenital heart disease (CHD) may benefit from coordinated transfer to adult congenital heart disease (ACHD) centers to reduce the risk of complications; however, there are a variety of transfer practices. We examined the impact of referral order placement at the last pediatric cardiology visit on time to transfer to an ACHD center. We analyzed data collected from pediatric patients with moderate and great complexity CHD who were eligible to transfer to our tertiary center's accredited ACHD center. We examined transfer outcomes and time-to-transfer between those with a referral order placed at the last pediatric cardiology visit and those without using Cox proportional hazards modeling. The sample (n = 65) was 44.6% female and mean age at study start was 19.5 years (± 2.2). Referral orders were placed for 32.3% of patients at the last pediatric cardiology visit. Those who had a referral order placed at the last visit had significantly higher number of successful transfers to the ACHD center compared to those who did not (95% vs 25%, p < 0.001). In a Cox regression model, placement of a referral order at the last pediatric cardiology visit was associated significantly with a sooner time to transfer (HR 6.0; 95% CI 2.2-16.2, p > 0.001), adjusting for age, sex, complexity, living location, and pediatric cardiology visit location. Placement of a referral order at the last pediatric cardiology visit may improve transfer occurrence and time to transfer to accredited ACHD centers.

Survival analysis 101: an easy start guide to analysing time-to-event data

Survival analysis, also called time-to-event analysis, is a common approach to handling event data in cardiovascular nursing and health-related research. Survival analysis is used to describe, explain, and/or predict the occurrence and timing of events. There is a specific language used and methods designed to handle the unique nature of event data. In this methods paper, we provide an 'easy start guide' to using survival analysis by (i) providing a step-by-step guide and (ii) applying the steps with example data. Specifically, we analyse cardiovascular event data over 6 months in a sample of patients with heart failure.

Candidate biomarkers of physical frailty in heart failure: an exploratory cross-sectional study

AIMS

Physical frailty is highly prevalent and predictive of worse outcomes in heart failure (HF). Candidate biomarker analysis may help in understanding the mechanisms underlying physical frailty in HF. We aimed to identify candidate biomarkers associated with physical frailty in HF using a multimarker strategy of distinct pathophysiological processes.

METHODS AND RESULTS

We collected data and plasma samples from 113 adults with New York Heart Association Functional Class I-IV HF. Physical frailty was measured with the Frailty Phenotype Criteria. Plasma biomarkers included: N-terminal pro-B-type natriuretic peptide, norepinephrine, dihydroxyphenylglycol, soluble tumour necrosis factor alpha receptor-1, adiponectin, insulin, glucose, insulin-like growth factor-1 (IGF-1), and myostatin. Comparative statistics and multivariate linear regression were used to test group differences and associations. The average age was 63.5 ± 15.7 years, half were women (48%), and most had a non-ischaemic aetiology of HF (73%). Physical frailty was identified in 42% and associated with female sex, higher body mass index and percent body fat, more comorbidities, and HF with preserved ejection fraction. Adjusting for Seattle HF Model projected survival score, comorbidities, body composition, and sex, physical frailty was associated with significantly lower plasma adiponectin [β ± standard error (SE) -0.28 ± 0.14, P = 0.047], IGF-1 (β ± SE -0.21 ± 0.10, P = 0.032), and myostatin (β ± SE -0.22 ± 0.09, P = 0.011). In sex-stratified analyses, IGF-1 and myostatin were significantly associated with physical frailty in men but not women.

CONCLUSION

We identified biomarkers involved in adipose tissue and skeletal muscle development, maintenance, and function that were associated with physical frailty in HF.

Frequency and Predictors of Falls Among Adults With Heart Failure: A Prospective Study

OBJECTIVE

Adults with heart failure (HF) may be at high risk for falling due to age, comorbidities and frailty; however, few studies have examined falls in HF. The purpose of this study was to quantify the frequency and predictors of falls over 1 year among adults with HF.

METHODS

We conducted a prospective study of adults with New York Heart Association (NYHA) functional class I-IV HF. After baseline assessment of physical frailty and clinical characteristics, participants self-reported falls every 3 months during 1 year. Comparative statistics were used to identify baseline differences between those who fell vs those who did not. A stepwise negative binomial regression model was used to identify predictors of fall rate over 1 year.

RESULTS

The sample (n = 111) was 63.4 ± 15.7 years old, 48% were women, 28% had HF with preserved ejection fraction, and 41% were frail. Over 1 year, 43 (39%) of participants reported at least 1 fall and 28 (25%) of participants reported 2+ falls. Among those who fell, 29 (67%) reported injurious falls. Those who fell had significantly higher body mass indexes and were more likely to have NYHA class III/IV, type 2 diabetes and HF with preserved ejection fraction and to meet slowness and physical exhaustion criteria than those who did not fall. The fall rate was elevated among those with type 2 diabetes and those meeting the slowness and physical exhaustion criteria for physical frailty.

CONCLUSIONS

Nearly 40% of adults with HF experienced a fall within 1 year. Screening for comorbidities, slowness and exhaustion may help to identify those at risk for a fall.

Validity and reliability of the left ventricular assist device self-care behaviour scale

BACKGROUND

Adequate self-care behaviour is essential for patients with a left ventricular assist device (LVAD) to prevent complications, prolong life, and optimise quality of life. However, there were no valid and reliable measurements available to assess self-care behaviour among patients with LVAD. We have previously developed the 33-item LVAD self-care behaviour scale.

OBJECTIVES

To evaluate psychometric properties of the 33-item LVAD self-care behaviour scale.

METHODS AND RESULTS

Data on 127 patients with a LVAD in Israel, Japan, and the USA were analysed (mean age 51±14.3, 81% male). Exploratory factor analysis extracted three factors, and 13 items were excluded from the scale. Internal consistency assessed by Cronbach's alpha was acceptable for the total scale (α = 0.80) and the three subscales: Factor 1: Monitoring (α = 0.81), Factor 2: Heart failure self-care (α = 0.67), and Factor 3: LVAD self-care (α = 0.63). The 20-item version of the LVAD self-care behaviour scale had sufficient convergent validity with another scale that assessed self-care related to the driveline of LVAD (r = 0.47, p<0.001). Test-retest reliability was adequate (intraclass correlation coefficient = 0.58).

CONCLUSIONS

The 20-item version of the LVAD self-care behaviour scale showed adequate validity and reliability. The scale is ready for use in clinical practice and research. Additional testing might further optimise the scale.

Validity of Patient-Reported Outcomes Measurement Information System Physical, Mental, and Social Health Measures After Left Ventricular Assist Device Implantation and Implications for Patient Care

BACKGROUND

A better understanding is needed of the burdens and benefits of left ventricular assist device (LVAD) implantation on patients' physical, mental, and social well-being. The purpose of this report was to evaluate the validity of Patient-Reported Outcomes Measurement Information System (PROMIS) measures for LVAD patients and to estimate clinically important score differences likely to have implications for patient treatment or care.

METHODS

Adults from 12 sites across all US geographic regions completed PROMIS measures ≥3 months post-LVAD implantation. Other patient-reported outcomes (eg, Kansas City Cardiomyopathy Questionnaire-12 item), clinician ratings, performance tests, and clinical adverse events were used as validity indicators. Criterion and construct validity and clinically important differences were estimated with Pearson correlations, ANOVA methods, and Cohen d effect sizes.

RESULTS

Participants' (n=648) mean age was 58 years, and the majority were men (78%), non-Hispanic White people (68%), with dilated cardiomyopathy (55%), long-term implantation strategy (57%), and New York Heart Association classes I and II (54%). Most correlations between validity indicators and PROMIS measures were medium to large (≥0.3; p<0.01). Most validity analyses demonstrated medium-to-large effect sizes (≥0.5) and clinically important differences in mean PROMIS scores (up to 14.8 points). Ranges of minimally important differences for 4 PROMIS measures were as follows: fatigue (3-5 points), physical function (2-3), ability to participate in social roles and activities (3), and satisfaction with social roles and activities (3-5).

CONCLUSIONS

The findings provide convincing evidence for the relevance and validity of PROMIS physical, mental, and social health measures in patients from early-to-late post-LVAD implantation. Findings may inform shared decision-making when patients consider treatment options. Patients with an LVAD, their caregivers, and their clinicians should find it useful to interpret the meaning of their PROMIS scores in relation to the general population, that is, PROMIS may help to monitor a return to normalcy in everyday life.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Geriatric Cardiology: Coming of Age

Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD care to older adults challenging. In this review, we first describe the history of geriatric cardiology, an orientation that acknowledges the unique needs of older adults with CVD. Then, we introduce 5 essential principles for meeting the needs of older adults with CVD: 1) recognize and consider the potential impact of multicomplexity; 2) evaluate and integrate constructs of cognition into decision-making; 3) evaluate and integrate physical function into decision-making; 4) incorporate social environmental factors into management decisions; and 5) elicit patient priorities and health goals and align with care plan. Finally, we review future steps to maximize care provision to this growing population.

Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

Patterns and predictors of dyspnoea following left ventricular assist device implantation

AIMS

Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation.

METHODS AND RESULTS

This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement.

CONCLUSION

Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.

Background and Design of the Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure (BIOMES-HF) Study

BACKGROUND

Symptoms, which often cluster together, are a significant problem in heart failure (HF). There is considerable heterogeneity in symptom burden, particularly in the vulnerable transition period after a hospitalization for HF, and the biological underpinnings of symptom during transitions are unclear. The purpose of this paper is to describe the background and design of a study that addresses these knowledge gaps, entitled "Biological and Physiological Mechanisms of Symptom Clusters in Heart Failure" (BIOMES-HF).

STUDY DESIGN AND METHODS

BIOMES-HF is a prospective gender- and age-balanced longitudinal study of 240 adults during the 6-month transition period after a HF hospitalization. The aims are to: 1) identify clusters of change in physical symptoms, 2) quantify longitudinal associations between biomarkers and physical symptoms, and 3) quantify longitudinal associations between physical frailty and physical symptoms among adults with heart failure. We will measure multiple symptoms, biomarkers, and physical frailty at discharge and then at 1 week and 1, 3, and 6 months post-hospitalization. We will use growth mixture modeling and longitudinal mediation modeling to examine changes in symptoms, biomarkers, and physical frailty post-HF hospitalization and associations therein.

CONCLUSIONS

This innovative study will advance HF symptom science by utilizing a multi-biomarker panel and the physical frailty phenotype to capture the multifaceted nature of HF. Using advanced quantitative modeling, we will characterize heterogeneity and identify potential mechanisms of symptoms in HF. As a result, this research will pinpoint amenable targets for intervention to provide better, individualized treatment to improve symptom burden in HF.

BRIEF LAY SUMMARY

Adults with heart failure may have significant symptom burden. This study is designed to shed light on our understanding of the role of biological and physiological mechanisms in explaining heart failure symptoms, particularly groups of co-occurring symptoms, over time. We will explore how symptoms, biomarkers, and physical frailty changes after a heart failure hospitalization. The knowledge generated from this study will be used to guide the management and self-care for adults with heart failure.

A Primer on Incorporating Sex as a Biological Variable into the Conduct and Reporting of Basic and Clinical Research Studies

The recent move to require sex as a biological variable (SABV), which includes gender, into the reporting of research published by the American Journal of Physiology - Heart and Circulatory Physiology follows a growing, and much-needed, trend by journals. Understandably, there is concern over how to do this without adding considerable work, especially if one's primary research focus is not on elucidating sex/gender differences. The purpose of this article is to provide additional guidance and examples on how to incorporate SABV into the conduct and reporting of basic and clinical research. Using examples from our research, which includes both studies focused and not focused on sex/gender differences, we offer suggestions for how to incorporate SABV into basic and clinical research studies.

Characterizing Sex Differences in Physical Frailty Phenotypes in Heart Failure

BACKGROUND

Although women with heart failure (HF) are potentially more likely to be physically frail compared with men with HF, the underlying contributors to this sex difference are poorly understood. The purpose of this study was to characterize sex differences in physical frailty phenotypes in HF.

METHODS

We prospectively enrolled adults with class I-IV HF. Physical frailty was measured with the frailty phenotype criteria. Symptoms of dyspnea, sleep-related impairment, pain interference, depression, and anxiety were assessed. Body composition was measured using dual-energy x-ray absorptiometry. Simple comparative statistics and stepwise regression modeling were used.

RESULTS

The average age of the sample (n=115) was 63.6±15.7 years, 49% were women, and 73% had nonischemic cause. Forty-three percent of the sample was physically frail. Women had a 4.6 times greater odds of being physically frail compared with men, adjusting for covariates (odds ratio=4.63 [95% CI, 1.81-11.84], P=0.001). Both physically frail men and women were characterized by more type 2 diabetes, higher comorbidity burden, and worse dyspnea symptoms. Physically frail women had significantly worse symptoms compared with non-physically frail women but no difference in body composition characteristics. Physically frail men had significantly lower appendicular muscle mass, higher percent fat, lower hemoglobin, and more depressive symptoms compared with non-physically frail men.

CONCLUSIONS

Women are significantly more likely to be physically frail compared with men in HF. Physical frailty in both women and men is characterized by comorbidities and worse symptoms; physical frailty in men is characterized by worse physiological characteristics.

Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis

OBJECTIVES

This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF).

BACKGROUND

The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood.

METHODS

We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF.

RESULTS

Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I2 = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class.

CONCLUSIONS

In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.

Exploring gender differences in trajectories of clinical markers and symptoms after left ventricular assist device implantation

AIMS

Despite well-known gender differences in heart failure, it is unknown if clinical markers and symptoms differ between women and men after left ventricular assist device (LVAD) implantation. Our aim was to examine gender differences in trajectories of clinical markers (echocardiographic markers and plasma biomarkers) and symptoms from pre- to post-LVAD implantation.

METHODS AND RESULTS

This was a secondary analysis of data collected from a study of patients from pre- to 1, 3, and 6 months post-LVAD implantation. Data were collected on left ventricular internal end-diastolic diameter (LVIDd) and ejection fraction (LVEF), plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), and soluble suppressor of tumorigenicity (sST2). Physical and depressive symptoms were measured using the Heart Failure Somatic Perception Scale and Patient Health Questionnaire-9, respectively. Latent growth curve modelling was used to compare trajectories between women and men. The average age of the sample (n = 98) was 53.3 ± 13.8 years, and most were male (80.6%) and had non-ischaemic aetiology (65.3%). Pre-implantation, women had significantly narrower LVIDd (P < 0.001) and worse physical symptoms (P = 0.041) compared with men. Between pre- and 6 months post-implantation, women had an increase in plasma sST2 followed by a decrease, whereas men had an overall decrease (slope: P = 0.014; quadratic: P = 0.011). Between 1 and 6 months post-implantation, women had a significantly greater increase in LVEF (P = 0.045) but lesser decline in plasmoa NT-proBNP compared with men (P = 0.025).

CONCLUSION

Trajectories of clinical markers differed somewhat between women and men, but trajectories of symptoms were similar, indicating some physiologic but not symptomatic gender differences in response to LVAD.

Feasibility and potential benefits of partner-supported yoga on psychosocial and physical function among lung cancer patients

OBJECTIVE

Patients with lung cancer experience significant declines in psychosocial and physical function during and after treatment that impact quality of life (QOL) and survival. Yoga is a potential strategy to mitigate functional decline among patients with lung cancer.

METHODS

A single group 12-week pilot trial of low-moderate intensity yoga among patients with stage I-IV lung cancer and their partners (n = 46; 23 patient-partner dyads) during cancer treatment from two hospital systems. Feasibility, acceptability, descriptive statistics, and Cohen d effect sizes were calculated at 6 and 12-weeks for psychosocial and physical outcomes using validated questionnaires and assessments.

RESULTS

At 6 and 12-weeks, retention was 65% and withdrawals were mainly due to disease progression. Among study completers (n = 26; 13 dyads) adherence was 80%. Comparing baseline to 12-week measurements, fatigue, depression symptoms, and sleep disturbance improved in 54% of participants for all three measures (Cohen's d = 0.40-0.53). QOL improved in 77% of participants (Cohen's d = 0.34). Upper and lower body flexibility, and lower body strength improved in 92%, 85% and 77% of participants, respectively (Cohen's d = 0.39-1.08). Six-minute walk test improved in 62% of participants an average of 32 meters (SD = 11.3; Cohen's d = 0.17). No serious adverse events were reported.

CONCLUSIONS

Among patients with stage I-IV lung cancer including active treatment, a 12-week partner-supported yoga program is feasible, acceptable, and improved psychosocial and physical function. Low-intensity yoga may be a complimentary approach to reduce the effects of cancer treatment, however, more research is needed to determine the efficacy of partner-supported yoga to mitigate functional decline.

Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis

To estimate the risk of all-cause mortality and hospitalization in frail patients with chronic heart failure (HF), a systematic search and meta-analysis was carried out to identify all prospective cohort studies conducted among adults with HF where frailty was quantified and related to the primary endpoints of all-cause mortality and/or hospitalization. Twenty-nine studies reporting the link between frailty and all-cause mortality in 18 757 patients were available for the meta-analysis, along with 11 studies, with 13 525 patients, reporting the association between frailty and hospitalization. Frailty was a predictor of all-cause mortality and hospitalization with summary hazard ratios (HRs) of 1.48 [95% confidence interval (CI): 1.31-1.65, P < 0.001] and 1.40 (95% CI: 1.27-1.54, P < 0.001), respectively. Summary HRs for all-cause mortality among frail inpatients undergoing ventricular assist device implantation, inpatients hospitalized for HF, and outpatients were 1.46 (95% CI: 1.18-1.73, P < 0.001), 1.58 (95% CI: 0.94-2.22, P = not significant), and 1.53 (95% CI: 1.28-1.78, P < 0.001), respectively. Summary HRs for all-cause mortality and frailty based on Fried's phenotype were 1.48 (95% CI: 1.03-1.93, P < 0.001) and 1.42 (95% CI: 1.05-1.79, P < 0.001) for inpatients and outpatients, respectively, and based on other frailty measures were 1.42 (95% CI: 1.12-1.72, P < 0.001) and 1.60 (95% CI: 1.43-1.77, P < 0.001) for inpatients and outpatients, respectively. Across clinical contexts, frailty in chronic HF is associated with an average of 48% and 40% increase in the hazard of all-cause mortality and hospitalization, respectively. The relationship between frailty and all-cause mortality is similar across clinical settings and comparing measurement using Fried's phenotype or other measures.

Identifying unique profiles of perceived dyspnea burden in heart failure

BACKGROUND

Dyspnea is a common symptom of heart failure (HF) but dyspnea burden is highly variable.

OBJECTIVES

Identify distinct profiles of dyspnea burden and identify predictors of dyspnea symptom profile.

METHODS

A secondary analysis of data from five studies completed at Oregon Health and Science University was conducted. The Heart Failure Somatic Perception Scale was used to measure dyspnea burden. Latent class mixture modeling identified distinct profiles of dyspnea burden in a sample of HF patients (n = 449). Backwards stepwise multinomial logistic regression identified predictors of latent profile membership.

RESULTS

Four profiles of dyspnea burden were identified: no dyspnea/not bothered by dyspnea, mild dyspnea, moderate exertional dyspnea, and moderate exertional dyspnea with orthopnea and PND. Higher age was associated with greater likelihood of not being bothered by dyspnea than having moderate exertional dyspnea with orthopnea and PND. Higher NYHA class, anxiety, and depression were associated with greater likelihood of greater dyspnea burden.

CONCLUSIONS

Burden of dyspnea is highly variable among HF patients. Clinicians should account for the nuances of dyspnea and the activities that induce dyspnea when assessing HF patients.

Cross-classification of physical and affective symptom clusters and 180-day event-free survival in moderate to advanced heart failure

BACKGROUND

The relationship between physical and affective symptom clusters in heart failure (HF) is unclear.

OBJECTIVES

To identify associations between physical and affective symptom clusters in HF and to quantify outcomes and determinants of symptom subgroups.

METHODS

This was a secondary analysis of data from two cohort studies among adults with HF. Physical and affective symptom clusters were compared using cross-classification modeling. Cox proportional hazards modeling and multinomial logistic regression were used to identify outcomes and determinants of symptom subgroups, respectively.

RESULTS

In this young, mostly male sample (n = 274), physical and affective symptom clusters were cross-classified in a model with acceptable fit. Three symptom subgroups were identified: congruent-mild (69.3%), incongruent (13.9%), and congruent-severe (16.8%). Compared to the congruent-mild symptom group, the incongruent symptom group had significantly worse 180-day event-free survival.

CONCLUSION

Congruence between physical and affective symptom clusters should be considered when identifying patients at higher risk for poor outcomes.

Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices

BACKGROUND

Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD.

METHODS

The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD.

RESULTS

The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05).

CONCLUSION

There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.

Exploring the relationship between β-adrenergic receptor kinase-1 and physical symptoms in heart failure

BACKGROUND

The relationship between physical heart failure (HF) symptoms and pathophysiological mechanisms is unclear.

OBJECTIVE

To quantify the relationship between plasma β-adrenergic receptor kinase-1 (βARK1) and physical symptoms among adults with HF.

METHODS

We performed a secondary analysis of data collected from two studies of adults with HF. Plasma βARK1 was quantified using an enzyme-linked immunosorbent assay. Physical symptoms were measured with the HF Somatic Perception Scale (HFSPS). Generalized linear modeling was used to quantify the relationship between βARK1 and HFSPS scores.

RESULTS

The average age (n = 94) was 54.5 ± 13.1 years, 76.6% were male, and a majority (83.0%) had Class III or IV HF. βARK1 was significantly associated with HFSPS scores (β = 0.22 ± 0.10, p = 0.038), adjusting for other predictors of physical symptoms (model R² = 0.250, F(7, 70) = 3.34, p = 0.004).

CONCLUSIONS

Higher βARK1 is associated with worse physical HF symptoms, pinpointing a potential pathophysiologic underpinning.

Measurement of plasma norepinephrine and 3,4-dihydroxyphenylglycol: method development for a translational research study

Objective

Norepinephrine (NE), a sympathetic neurotransmitter, is often measured in plasma as an index of sympathetic activity. To better understand NE dynamics, it is important to measure its principal metabolite, 3,4-dihydroxyphenylglycol (DHPG), concurrently. Our aim was to present a method, developed in the course of a translational research study, to measure NE and DHPG in human plasma using high performance liquid chromatography with electrochemical detection (HPLC-ED).

Results

After pre-purifying plasma samples by alumina extraction, we used HPLC-ED to separate and quantify NE and DHPG. In order to remove uric acid, which co-eluted with DHPG, a sodium bicarbonate wash was added to the alumina extraction procedure, and we oxidized the column eluates followed by reduction because catechols are reversibly oxidized whereas uric acid is irreversibly oxidized. Average recoveries of plasma NE and DHPG were 35.3 ± 1.0% and 16.3 ± 1.1%, respectively, and there was no detectable uric acid. Our estimated detection limits for NE and DHPG were approximately 85 pg/mL (0.5 pmol/mL) and 165 pg/mL (0.9 pmol/mL), respectively. The measurement of NE and DHPG in human plasma has wide applicability; thus, we describe a method to quantify plasma NE and DHPG in a laboratory setting as a useful tool for translational and clinical research.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3352-3) contains supplementary material, which is available to authorized users.

Frequency of and Significance of Physical Frailty in Patients With Heart Failure

Physical frailty is an important prognostic indicator in heart failure (HF); however, few studies have examined the relation between physical frailty and invasive hemodynamics among adults with HF. The purpose of this study was to characterize physical frailty in HF in relation to invasive hemodynamics. We enrolled 49 patients with New York Heart Association class II to IV HF when participants were scheduled for a right-sided cardiac heart catheterization procedure. Physical frailty was measured according to the "frailty phenotype": shrinking, weakness, slowness, physical exhaustion, and low physical activity. Markers of invasive hemodynamics were derived from a formal review of right-sided cardiac catheterization tracings, and projected survival was calculated using the Seattle HF model. The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were men, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physical frailty was identified in 24 participants (49%) and was associated with worse Seattle HF model 1-year projected survival (p = 0.007). After adjusting for projected survival, physically frail participants had lower cardiac index (by both thermodilution and the Fick equation) and higher heart rates compared with those not physically frail (all p <0.05). In conclusion, physical frailty is highly prevalent in patients with HF and is associated with low-output HF.

The prevalence of frailty in heart failure: A systematic review and meta-analysis

BACKGROUND

There is a growing interest in the intersection of heart failure (HF) and frailty; however, estimates of the prevalence of frailty in HF vary widely. The purpose of this paper was to quantitatively synthesize published literature on the prevalence of frailty in HF and to examine the relationship between study characteristics (i.e. age and functional class) and the prevalence of frailty in HF.

METHODS

The prevalence of frailty in HF, divided into Physical Frailty and Multidimensional Frailty measures, was synthesized across published studies using a random-effects meta-analysis of proportions approach. Meta-regression was performed to examine the influence of age and functional class (at the level of the study) on the prevalence of frailty.

RESULTS

A total of 26 studies involving 6896 patients with HF were included in this meta-analysis. Despite considerable differences across studies, the overall estimated prevalence of frailty in HF was 44.5% (95% confidence interval, 36.2%-52.8%; z=10.54; p<0.001). The prevalence was slightly lower among studies using Physical Frailty measures (42.9%, z=9.05; p<0.001) and slightly higher among studies using Multidimensional Frailty measures (47.4%, z=5.66; p<0.001). There were no significant relationships between study age or functional class and prevalence of frailty.

CONCLUSIONS

Frailty affects almost half of patients with HF and is not necessarily a function of age or functional classification. Future work should focus on standardizing the measurement of frailty and on broadening the view of frailty beyond a strictly geriatric syndrome in HF.

Comorbidity profiles and inpatient outcomes during hospitalization for heart failure: an analysis of the U.S. Nationwide inpatient sample

BACKGROUND

Treatment of heart failure (HF) is particularly complex in the presence of comorbidities. We sought to identify and associate comorbidity profiles with inpatient outcomes during HF hospitalizations.

METHODS

Latent mixture modeling was used to identify common profiles of comorbidities during adult hospitalizations for HF from the 2009 Nationwide Inpatient Sample (n = 192,327).

RESULTS

Most discharges were characterized by "common" comorbidities. A "lifestyle" profile was characterized by a high prevalence of uncomplicated diabetes, hypertension, chronic pulmonary disorders and obesity. A "renal" profile had the highest prevalence of renal disease, complicated diabetes, and fluid and electrolyte imbalances. A "neurovascular" profile represented the highest prevalence of cerebrovascular disease, paralysis, myocardial infarction and peripheral vascular disease. Relative to the common profile, the lifestyle profile was associated with a 15% longer length of stay (LOS) and 12% greater cost, the renal profile was associated with a 30% higher risk of death, 27% longer LOS and 24% greater cost, and the neurovascular profile was associated with a 45% higher risk of death, 34% longer LOS and 37% greater cost (all p < 0.001).

CONCLUSIONS

Comorbidity profiles are helpful in identifying adults at higher risk of death, longer length of stay, and accumulating greater costs during hospitalizations for HF.