German Competence Network Heart Failure Research Articles

Sex-related differences in self-efficacy of patients with heart failure: a pooled cross-sectional study of the German Competence Network Heart Failure.

To assess the level of self-efficacy in patients with heart failure (HF), and identify differences between important subgroups including sex, and to identify the determinants of high self-efficacy. This was a pooled cross-sectional analysis of 2,030 patients from four prospective studies conducted within the German Competence Network Heart Failure. We used the Self-efficacy Subscale and the Overall Summary Score (OSS) of the Kansas City Cardiomyopathy Questionnaire (KCCQ-23) to assess self-efficacy and health-related quality of life. The cut-off of 75 score points was used for the dichotomization into high (≥75) vs low (<75) self-efficacy. Depressive symptoms were measured by the Patient Health Questionnaire (PHQ-9). A total of 1,615 patients with HF provided complete self-efficacy scores: mean age 66.6±12.3 years, 431 (27%) women. Mean self-efficacy was 67.5±24.9, with 907 patients (56.2%) showing high self-efficacy and 708 patients (43.8%) showing low self-efficacy. Men had higher self-efficacy scores than women (68.7±24.5 vs. 64.2±26.0; p=0.001). Multivariable logistic regression identified KCCQ-OSS (OR per 5-point increase 1.08, 95%CI 1.04-1.12), female sex (OR 0.72, 95%CI 0.56-0.94), depressive symptoms (OR per 3-point increase in PHQ-9 0.90, 95%CI 0.83-0.98), and acute HF (0.46, 95% CI 0.34-0.62) as important predictors of high self-efficacy. In patients with HF, women seemed to exhibit lower self-efficacy than men. Health-related quality of life and psychological well-being were dominant determinants of self-efficacy. Future studies should investigate the role of self-efficacy as a therapeutic target for tailored and sex-specific nursing interventions.

Heart failure awareness: a cross-sectional study on misconceptions and educational opportunities

Abstract Heart failure (HF) is an increasing cause of cardiovascular morbidity and mortality. However, the lay public awareness about HF is shown to be inferior to the knowledge of myocardial infarction or stroke. The vast majority of HF patients lack basic comprehension of HF and self-care, which translates into suboptimal treatment outcomes. Therefore this study aimed to establish the present level of knowledge about HF of the lay public and to evaluate the effects of a single public lecture for the consideration of implementing further steps to raise public awareness. Design and methods: We performed a cross sectional survey study using an anonymous questionnaire designed by the German Competence Network Heart Failure (CNHF). Respondents were selected randomly and fulfilled the questionnaire free-willingly prior to and after a standardized lecture on HF. The CNHF questionnaire consisted of two sets of questions focusing on individual characteristics of the respondent and HF-related knowledge. The gathered data were verified by a standardized procedure in Wurzburg, Germany. Results: Among 1025 respondents 60% were females: 15% of the participants had occupational experience in the medical field. The majority (79%) of the study population had heard about HF previously. Typical complaints and symptoms of HF were correctly identified as ‘shortness of breath’ by 69%, ‘swelling of feet’ by 56%, ‘fatigue’ by 56%, and ‘weakness’ by 54% survey participants. The lecture resulted in 22% (from 26% to 48%) increase of correct identification of the combination all three HF symptoms (shortness of breath, swelling of feet and tiredness). The lecture significantly increased the proportion of correct answers for most of the questions. Particularly notable gains were observed in respondents without prior medical experience. Conclusion: The study population’s initial awareness of HF was insufficient. Standardized lecture improved the short-term knowledge about HF symptoms and nature of the disease. Regular educational activities increasing the HF awareness of general population and HF patients can increase the overall HF treatment success.

Prognostic impact of diastolic dysfunction in systolic heart failure-A cross-project analysis from the German Competence Network Heart Failure.

We investigated the modifying role and prognostic importance of diastolic dysfunction (DD) in patients with heart failure and systolic dysfunction (SD). The echocardiographic evaluation of diastolic function in patients with SD provides further prognostic information. From the German Competence Network Heart Failure, 1046 heart failure patients with reduced left ventricular ejection fraction (LVEF; <50%) were echocardiographically studied and followed for a median of 5 years. SD was subdivided into nonsevere (LVEF 36%-49%) and severe (LVEF ≤35%); DD was subdivided into nonsevere (E/E' <15) and severe (E/E' ≥15). In general, severe SD was associated with higher hazard ratios (HRs; 2-fold to 3.5-fold) for all endpoints (all-cause death, cardiac death, cardiovascular hospitalization, duration of hospitalization). Patients with severe SD had a 2.5-fold risk of death (95% confidence interval [CI]: 1.84-3.47, P < 0.001), and patients with severe DD showed a 1.8-fold risk (95% CI: 1.17-2.61, P = 0.004). Furthermore, we observed a strong interaction of SD and DD: concomitant severe DD in patients with moderate SD increased risk substantially (HR: 1.73, 95% CI: 1.16-2.6, P = 0.007); by contrast, in patients with severe SD, additional presence of severe DD added little or no risk (HR for interaction: 0.5-1.2). In heart failure patients with reduced LVEF, the evaluation of diastolic function provides additional prognostic information. Although severe SD generally increased the risk for all endpoints, the degree of DD and its impact as a prognostic marker for overall and cardiovascular mortality appeared of particular relevance in subjects with nonsevere SD.

Heart failure awareness survey in Germany: general knowledge on heart failure remains poor.

AimsPrevious studies demonstrated poor public awareness of heart failure (HF) compared with myocardial infarction and stroke. With respect to several activities to improve HF awareness in recent years, we present data on the development of HF awareness and information sources in Germany over 8 years.Methods and resultsIn 2007, 2012, and 2015, respectively, 2531, 359, and 171 respondents answered questions about causes, presentation, prognosis, and treatment of HF from a survey developed by the German Competence Network HF. Relationships between respondents' sociodemographic data and their HF knowledge were explored and changes in knowledge and use of information sources analysed. Sixty‐eight per cent of respondents knew HF as ‘weakness of the heart’. Seventy‐nine per cent knew shortness of breath, 74% reduced exercise tolerance, and 52% knew leg edema as symptoms. Only 40% knew all three symptoms. Although up to 34% of the respondents were directly or indirectly affected by HF, they demonstrated poor knowledge about severity and prognosis. Between 2007 and 2015, overall HF awareness has not changed; awareness about treatment has dropped significantly. Younger respondents used all media, especially internet, for information about health; older respondents preferred printed/verbal media and their physician.ConclusionsWe found rather insufficient public knowledge on HF etiology and symptoms but especially about management, severity, and prognosis, which is essential for good self‐care and adherence of patients. Heart failure awareness has not improved even though awareness campaigns were held over the years. It seems that especially older patients should be much more approached by their family physicians.

Influence of different aetiologies on clinical course and outcome in patients with dilated cardiomyopathy.

The clinical phenotype dilated cardiomyopathy is assumed to be the endstage of a multifactorial aetiopathogenetic pathophysiology which includes a not satisfactorily defined group of patients with inflammatory cardiomyopathy. Within the German Competence Network Heart Failure patients with heart failure due to dilated cardiomyopathy of viral/inflammatory (DCMi/v) and nonviral/noninflammatory (DCM) aetiology were enrolled. After 1 year 237 patients (180 male/57 female) were re-examined including complete clinical work-up. The association of different clinical courses with the time from initial diagnosis of heart failure (newly: ≤ 1 year; late: > 1 year) was investigated. After 1-year-follow-up New York Heart Association (NYHA) class (by -0.48 in newly diagnosed DCM and -0.82 in newly diagnosed DCMi/v in addition to -0.24 in late diagnosed DCM and -0.17 in late diagnosed DCMi/v) as well as left ventricular ejection fraction (+14% in newly diagnosed DCM and DCMi/v and +6% in later diagnosed DCM and DCMi/v) were significantly improved in all patients. In patients with early diagnosed dilated cardiomyopathy a strong improvement of NYHA class could be demonstrated. This study demonstrates for the first time a significant interaction between duration of disease, NYHA class and left ventricular ejection fraction in patients with DCM. Our results clearly demonstrate that in patients with DCM an early diagnosis within 1 year after occurrence of clinical signs is associated with a strong improvement in the clinical course, whereas late diagnosis results in a loss of change in clinical course and outcome.

Reverse epidemiology in different stages of heart failure

BackgroundIn heart failure (HF), traditional cardiovascular risk factors (RF) as body mass index (BMI), total cholesterol (TC) and systolic blood pressure (SBP) are associated with better survival. It is unknown at which time point along the disease continuum the adverse impact of these RF ceases and may ‘start to reverse’. We analyzed the distribution of RF and their association with survival across HF stages. MethodsWe pooled data from four cohort studies from the German Competence Network HF. Employing ACC/AHA-criteria, patients were allocated to stage A (n=218), B (n=1324), C1 (i.e., New York Heart Association [NYHA] classes I & II; n=1134), and C2+D (NYHA III & IV; n=639). ResultsWith increasing HF severity median age increased (63/67/67/70years), whereas the proportion of females (56/52/37/35%), median BMI (26.1/28.8/27.7/26.6kg/m2), TC (212/204/191/172mg/dl), and SBP (140/148/130/120mmHg) decreased (P<0.001 for trend for all). In the total cohort, higher levels of all RF were associated with better survival, even after extensive adjustment for multiple confounders. If analyses were stratified, however, a higher RF burden predicted better survival only in clinically symptomatic patients: hazard ratio (HR) per +2kg/m2 BMI 0.91 (95% confidence interval 0.88; 0.95); per +10mg/dl TC 0.93 (0.92; 0.95); per +5mmHg SBP 0.94 (0.92; 0.95). ConclusionIn this well-characterized sample of patients representing the entire HF continuum, reverse associations were only consistently observed in symptomatic HF stages. Our data indicate that the phenomenon of a “reverse epidemiology” in HF is subject to significant selection bias in less advanced disease.

Economic burden of chronic heart failure with preserved vs. reduced ejection fraction - an analysis from the German Competence Network Heart Failure

Aim: Chronic heart failure (CHF) is currently one of the most prevalent cardiac diseases. The present analysis sought to estimate the one-year disease-related resource use and associated management costs of patients with CHF differentiated according to patients with preserved (HFpEF) and reduced ejection fraction (HFrEF). This differentiation could be used to describe patients as having systolic heart failure (HFrEF) and diastolic heart failure (HFpEF). Today, there is still paucity of data concerning cost of illness in heart failure according to these subgroups. Subject and Methods: 4,714 individuals with heart failure (mean age 64.5 years ± 13.2, 31.2% female, NYHA I-IV) were included from the German Competence Network Heart Failure. Patients with an ejection fraction (EF) of less than 50% were assigned to the HFrEF group (n = 3.530, mean age 63.7 years ± 13.2, 23.8% female, NYHA I-IV), whereas those with an EF≥50% constituted the HFpEF group (mean age 66.8 years ± 13.0, 53.3% female, NYHA I-IV). Disease-related resource use was assessed with regard to outpatient contacts to physicians, hospitalizations, rehabilitation stays, and drug utilization for a period of 12 months. Costs refer to the year 2011. Results: During one year, the entire patient population had on average 5.3 contacts to the general practitioner, 1.8 contacts to cardiologists and 0.7 hospital stays per year. The analysis showed that patients with HFrEF had a significant higher resource use compared to patients with HFpEF: The HFrEF group consulted the general practitioner with 6.1 contacts significantly more often in comparison to patients with HFpEF, who had on average 2.9 contacts to the GP (p < 0.001). A similar result was also seen in cardiologist contacts: the mean number of contacts was 2.2 in the HFrEF group and 0.7 in the HFpEF group (p < 0.001). In addition, the mean number of hospital stays was 0.9 for patients with HFrEF and 0.3 for patients with HFpEF (p < 0.001). Overall disease-related care costs per patient were calculated at 2,845 € per year, while the costs of the HFrEF group were 3.373 € and 1.271 € in the HFpEF group (p < 0.001). The largest component of total costs in the HFrEF group related to hospitalizations (2,481 €, 74%), while costs of rehabilitation (344 €, 10%), outpatient contacts (279 €, 8%), and medication (268 €, 8%) were considerably lower. The percentage distribution was nearly the same in the two subgroups of patients with HFrEF and HFpEF. Therefore, hospital admissions accounted for 74% of the total costs with 941 € in the HFpEF group, too. Costs for rehabilitation stays were 116 € (9% of the total costs) in the HFpEF group, while 9% of the total costs related to outpatient contacts (111 €), and 8% to drug utilization with 104 €. Conclusion: The present analysis demonstrates a high disease-related resource use of heart failure care. In particular, patients with reduced ejection fraction require increased resources compared to patients with preserved ejection fraction. Inpatient resources are the largest component in heart failure care, irrespective of underlying HFrEF or HFpEF. Hence, improved treatment strategies need to be developed to optimize care thus reducing hospitalization rates.

Incidence rates and predictors of major and minor depression in patients with heart failure

AimsDepression is common in heart failure (HF) and associated with adverse outcomes. This study aimed to investigate incidence rates and predictors of depression in patients sampled from four subprojects of the German Competence Network Heart Failure. MethodsEight hundred thirty nine symptomatic HF patients free of depression at baseline underwent repeat depression screening (Patient Health Questionnaire, PHQ-9) after 12months. Ordered logistic regression analysis was employed to search for predictors of incident depression. ResultsIncident minor (major) depression was observed in 61 (7.3%) and 47 (5.6%) of the population. Depression was recurrent in 15 (25%) and 16 (34%), respectively. Multiple regression analysis revealed seven variables predicting minor or major depression: Previous depressive episode (odds ratio [OR] 4.04, 95% confidence interval [CI] 2.37–6.89, p≤0.001), previous resuscitation (OR 2.44, CI 1.23–4.81, p=0.010), current smoking (OR 2.06, CI 1.08–3.50, p=0.008), >4 visits/year to general practitioner (OR 1.67, CI 1.06–2.63, p=0.026), New York Heart Association class (OR 1.54/class, 95% CI 1.05–2.25, p=0.027), PHQ-9 baseline sum-score (OR 1.18/point, CI 1.11–1.27, p<0.001), and SF-36 physical functioning (OR 1.08/−5 points, CI 1.03–1.13, p=0.002). ConclusionsIn these HF patients initially free of depression annual incidence rates were high. Several independent predictors allowed identification of patients at particular risk. Although obtained in a selected cohort these findings call, in view of the grave prognosis of HF patients with comorbid depression, for regular depression screening and development of specific supportive strategies to improve patient care and outcomes in HF.

Implementation of pharmacotherapy guidelines in heart failure: experience from the German Competence Network Heart Failure

To evaluate the implementation of current pharmacotherapy guidelines of heart failure and to identify factors associated with high pharmacotherapy guideline adherence in heart failure patients. We pooled data from seven studies performed in the context of the German Competence Network Heart Failure selecting patients with chronic systolic heart failure and left ventricular ejection fraction (LVEF) <45% (n=2,682). The quality of pharmacotherapy was evaluated by calculating the guideline adherence indicator (GAI), which considers three (GAI-3) or five (GAI-5) of the recommended heart failure substance classes and accounts for respective contraindications. GAI-3 was categorized as perfect (GAI=100%: 71% of the cohort), medium (GAI=50-99%: 22%), and poor adherence (GAI <50%: 7%). In ordinal regression, the following factors were positively associated with perfect adherence: history of revascularization (odds ratio 1.59, 95% confidence interval 1.27-1.98), prior ICD implantation (2.29, 1.76-2.98), and LV ejection fraction <30% (1.45, 1.19-1.76), whereas age (per 10years; 0.82, 0.77-0.89), NYHA III/IV (0.15, 0.12-0.18), unknown duration of heart failure (0.69, 0.53-0.89), and antidepressant medication (0.61, 0.42-0.88) were negatively associated with perfect adherence. Better GAI-3 at baseline predicted favorable changes of LV ejection fraction and end-diastolic diameter after 1year. One-year mortality risk was closely related to GAI-3 in both groups of NYHA functional class I/II (excellent vs. poor GAI-3: 7.2 vs. 14.5%, log rank=0.004) and class III/IV (13.5 vs. 21.5%, log rank=0.005). This large pooled analysis showed that a high level of guideline adherence is achievable in the context of clinical studies. Those receiving and tolerating optimal pharmacotherapy experience a better prognosis. Nevertheless, the implementation of heart failure medication needs further improvement in female and elderly patients, especially those in NYHA functional class >II and patients with LVEF ≥30%.

Counsel the genotype, treat the phenotype

This editorial refers to 'Novel correlations between the genotype and the phenotype of hypertrophic and dilated cardiomyopathy: results from the German Competence Network Heart Failure' by S. Waldmuller et al., published in this issue on pages 1185-1192.

Novel correlations between the genotype and the phenotype of hypertrophic and dilated cardiomyopathy: results from the German Competence Network Heart Failure

Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) can both be due to mutations in the genes encoding β-myosin heavy chain (MYH7) or cardiac myosin-binding protein C (MYBPC3). The aim of the present study was to determine the prevalence and spectrum of mutations in both genes in German HCM and DCM patients and to establish novel genotype-to-phenotype correlations. Coding exons and intron flanks of the two genes MYH7 and MYBPC3 of 236 patients with HCM and 652 patients with DCM were sequenced by conventional and array-based means. Clinical records were established following standard protocols. Mutations were detected in 41 and 11% of the patients with HCM and DCM, respectively. Differences were observed in the frequency of splice site and frame-shift mutations in the gene MYBPC3, which occurred more frequently (P< 0.02, P< 0.001, respectively) in HCM than in DCM, suggesting that cardiac myosin-binding protein C haploinsufficiency predisposes to hypertrophy rather than to dilation. Additional novel genotype-to-phenotype correlations were found in HCM, among these a link between MYBPC3 mutations and a particularly large thickness of the interventricular septum (P= 0.04 vs. carriers of a mutation in MYH7). Interestingly, this correlation and a link between MYH7 mutations and a higher degree of mitral valve regurgitation held true for both HCM and DCM, indicating that the gene affected by a mutation may determine the magnitude of structural and functional alterations in both HCM and DCM. A large clinical-genetic study has unravelled novel genotype-to-phenotype correlations in HCM and DCM which warrant future investigation of both the underlying mechanisms and the prognostic use.

Resource use and costs in systolic heart failure according to disease severity: a pooled analysis from the German Competence Network Heart Failure

Aim Systolic chronic heart failure (CHF) is currently one of the most prevalent cardiac diseases. The present analysis sought to estimate the 1-year disease-related resource use and associated management costs of patients with CHF.

Resource utilization and costs in heart failure

Background: Chronic systolic heart failure (CHF) is currently one of the most prevalent cardiac diseases. The present analysis sought to estimate the one-year disease-related resource use and associated management costs of patients with CHF. Data and Methods: 2,710 individuals with systolic heart failure (mean age 62.9 years±13.6, 25.2% female) were included from the German Competence Network Heart Failure. Disease-related resource use was assessed with regard to outpatient contacts to physicians, hospitalizations including rehabilitation stays, and drug utilization. Results: During one year, patients had on average 6.1 contacts to their general practitioner, 1.7 contacts to cardiologists and 0.8 hospital stays per year. Overall, care costs per patient were calculated at 3,150€ per year. The largest component related to hospitalizations (2,328€, 74%), while costs of rehabilitation (294€, 9%), medication (290€, 9%) and outpatient contacts (238€, 8%) were considerably lower. Compared with 2,474€ in NYHA class I, there was a cost increase in NYHA II, III and IV of 14%, 48%, and 71% respectively. About 76% of this cost increases resulted from augmented hospital (inpatient) resource use. Conclusion: The present analysis demonstrates a high resource consumption of heart failure care. In particular, patients in higher NYHA classes require increased inpatient resources. Hence, improved treatment strategies need to be developed to optimize care thus reducing hospitalization rates.

Diuretic use in patients with systolic chronic heart failure: a German competence network heart failure experience

Diuretic use in patients with systolic chronic heart failure: a German competence network heart failure experience