Health Status In Heart Failure Research Articles

Association of Medication Adherence and Health Status in Heart Failure With Reduced Ejection Fraction: Insights From the CHAMP-HF Registry.

The foundation for managing heart failure with reduced ejection fraction (HFrEF) is adherence to guideline-directed medical therapy. Finding an association between medication adherence and patients' health status (their symptoms, function, and quality of life) can be used to underscore its importance to patients. The association of self-reported medication adherence in US outpatients with HFrEF enrolled in the Change the Management of Patients with Heart Failure registry from 2015 to 2017 was compared with their health status at baseline and 12 months later. A secondary analysis of changes in adherence between baseline and 6 months with 6-month health status was also performed. Medication adherence was assessed with the self-reported 4-item Morisky-Green-Levine Medication Adherence Scale, with scores ≥1 classified as nonadherent. The primary health status outcome was the disease-specific 12-item Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS; range, 0-100; higher is better). Robust linear regression models adjusted for confounders were used. After excluding those who died (n=316) or did not provide 12-month KCCQ (n=1285), 3495 outpatients with HFrEF were included, of whom 1108 (31.7%) reported being nonadherent. Nonadherent participants were younger, had significantly worse baseline health status (-5.83-point difference; P<0.001), and showed less improvement at 12 months (-1.7-point difference in mean change; P=0.017) than adherent participants. Among nonadherent patients at baseline, those whose adherence improved trended toward greater 6-month health status improvements than those remaining nonadherent (fully adjusted difference of 2.52 points; P=0.054). In HFrEF, medication nonadherence was associated with worse health status and less improvement over the following year. Improvements in adherence were associated with better health status than remaining nonadherent, underscoring the importance of supporting adherence with guideline-directed medical therapy in patients with HFrEF.

Early Longitudinal Change in Heart Failure Health Status Following Initiation of Canagliflozin

Sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy improves health status in heart failure (HF). There is insufficient description regarding the timing, rate, and extent of the health status changes in heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) after initiation of SGLT2is. The authors sought to model the association of canagliflozin treatment with rates of change in HF symptom status in HFpEF and HFrEF. Study participants with HFrEF and HFpEF were treated with either canagliflozin 100mg or placebo for 12weeks. The Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) was assessed at baseline and at 2, 4, 6, and 12weeks. Longitudinal modeling assessed slope of KCCQ change across the study. Among 448 individuals with HF (181 with HFrEF and 267 with HFpEF), participants with HFpEF had lower baseline KCCQ-TSS scores than those with HFrEF (54 ± 21 vs 64 ± 20). Modeling demonstrated initial rapid improvement in KCCQ-TSS in both HF groups, with deceleration over the next 4 to 6weeks. The rate of change was greater among HFpEF participants (0.7 points/day; 95%CI: 0.3-1.1 points/day) than HFrEF participants (ΔKCCQ-TSS/day=0.5; 95%CI: 0.1-1.0 points/day) randomized to canagliflozin, but these differences were not statistically significant (0.2 points/day; 95%CI: -0.4 to 0.7 points/day; P = 056). After canagliflozin therapy, regardless of EF, modeling shows the KCCQ-TSS improves rapidly with the greatest improvements occurring within the first weeks of treatment. These results have implications for clinical use of SGLT2is and may be useful in the design of trials examining impact of these agents on health status in HF. (A Study on Impact of Canagliflozin on Health Status, Quality of Life, and Functional Status in HeartFailure [CHIEF-HF]; NCT04252287).

Nurse and Social Worker Palliative Telecare Team and Quality of Life in Patients With COPD, Heart Failure, or Interstitial Lung Disease

Many patients with chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) endure poor quality of life despite conventional therapy. Palliative care approaches may benefit this population prior to end of life. Determine the effect of a nurse and social worker palliative telecare team on quality of life in outpatients with COPD, HF, or ILD compared with usual care. Single-blind, 2-group, multisite randomized clinical trial with accrual between October 27, 2016, and April 2, 2020, in 2 Veterans Administration health care systems (Colorado and Washington), and including community-based outpatient clinics. Outpatients with COPD, HF, or ILD at high risk of hospitalization or death who reported poor quality of life participated. The intervention involved 6 phone calls with a nurse to help with symptom management and 6 phone calls with a social worker to provide psychosocial care. The nurse and social worker met weekly with a study primary care and palliative care physician and as needed, a pulmonologist, and cardiologist. Usual care included an educational handout developed for the study that outlined self-care for COPD, ILD, or HF. Patients in both groups received care at the discretion of their clinicians, which could include care from nurses and social workers, and specialists in cardiology, pulmonology, palliative care, and mental health. The primary outcome was difference in change in quality of life from baseline to 6 months between the intervention and usual care groups (FACT-G score range, 0-100, with higher scores indicating better quality of life, clinically meaningful change ≥4 points). Secondary quality-of-life outcomes at 6 months included disease-specific health status (Clinical COPD Questionnaire; Kansas City Cardiomyopathy Questionnaire-12), depression (Patient Health Questionnaire-8) and anxiety (Generalized Anxiety Disorder-7) symptoms. Among 306 randomized patients (mean [SD] age, 68.9 [7.7] years; 276 male [90.2%], 30 female [9.8%]; 245 White [80.1%]), 177 (57.8%) had COPD, 67 (21.9%) HF, 49 (16%) both COPD and HF, and 13 (4.2%) ILD. Baseline FACT-G scores were similar (intervention, 52.9; usual care, 52.7). FACT-G completion was 76% (intervention, 117 of 154; usual care, 116 of 152) at 6 months for both groups. Mean (SD) length of intervention was 115.1 (33.4) days and included a mean of 10.4 (3.3) intervention calls per patient. In the intervention group, 112 of 154 (73%) patients received the intervention as randomized. At 6 months, mean FACT-G score improved 6.0 points in the intervention group and 1.4 points in the usual care group (difference, 4.6 points [95% CI, 1.8-7.4]; P = .001; standardized mean difference, 0.41). The intervention also improved COPD health status (standardized mean difference, 0.44; P = .04), HF health status (standardized mean difference, 0.41; P = .01), depression (standardized mean difference, -0.50; P < .001), and anxiety (standardized mean difference, -0.51; P < .001) at 6 months. For adults with COPD, HF, or ILD who were at high risk of death and had poor quality of life, a nurse and social worker palliative telecare team produced clinically meaningful improvements in quality of life at 6 months compared with usual care. ClinicalTrials.gov Identifier: NCT02713347.

Health Status in Heart Failure and Cancer: Analysis of the Medicare Health Outcomes Survey 2016-2020

People with heart failure (HF) and cancer experience impaired physical and mental health status. However, health-related quality of life (HRQOL) has not been directly compared between these conditions in a contemporary population of older people. The authors sought to compare HRQOL in people with HF vs those with lung, colorectal, breast, and prostate cancers. The authors performed a pooled analysis of Medicare Health Outcomes Survey data from 2016 to 2020 in participants≥65 years of age with a self-reported history of HF or active treatment for lung, colon, breast, or prostate cancer. They used the Veterans RAND-12 physical component score (PCS) and mental component score (MCS), which range from 0-100 with a mean score of 50 (based on the U.S. general population) and an SD of 10. The authors used pairwise Student's t-tests to evaluate for differences in PCS and MCS between groups. Among participants with HF (n=71,025; 54% female, 16% Black), mean PCS was 29.5 and mean MCS 47.9. Mean PCS was lower in people with HF compared with lung (31.2; n=4,165), colorectal (35.6; n=4,270), breast (37.7; n=14,542), and prostate (39.6; n=17,670) cancer (all P< 0.001). Participants with HF had a significantly lower mean MCS than those with lung (31.2), colon (50.0), breast (52.0), and prostate (53.0) cancer (all P< 0.001). People with HF experience worse HRQOL than those with cancer actively receiving treatment. The pervasiveness of low HRQOL in HF underscores the need to implement evidence-based interventions that target physical and mental health status and scale multidisciplinary clinics.

Patient-Reported Versus Physician-Assessed Health Status in Heart Failure With Reduced and Preserved Ejection Fraction From ASIAN-HF Registry.

We aimed to assess if discordance between patient-reported Kansas City Cardiomyopathy Questionnaire (KCCQ)-overall summary (os) score and physician-assessed New York Heart Association (NYHA) class is common among patients with heart failure (HF) with reduced or preserved ejection fraction, and determine its association with outcomes. A total of 4818 patients with HF were classified according to KCCQ-os score (range 0-100, dichotomized by median value 71.9 into high [good] versus low [bad]) and NYHA class (I/II [good] or III/IV [bad]) as concordant good (low NYHA class, high KCCQ-os score), concordant bad (high NYHA class, low KCCQ-os score), discordant worse NYHA class (high NYHA class, high KCCQ-os score), and discordant worse KCCQ-os score (low NYHA class, low-KCCQ-os score). The composite of HF hospitalization or death at 1 year was compared across groups. There were 2070 (43.0%) concordant good, 1099 (22.8%) concordant bad, 331 (6.9%) discordant worse NYHA class, and 1318 (27.4%) discordant worse KCCQ-os score patients. Compared with concordant good, adverse outcomes were the highest in concordant bad (HR, 2.7 [95% CI, 2.2-3.5]) followed by discordant worse KCCQ-os score (HR, 1.8 [95% CI, 1.4-2.2]) and discordant worse NYHA class (HR, 1.5 [95% CI, 1.0-2.3]); with no modification by HF phenotype (preserved versus reduced ejection fraction, Pinteraction=0.52). At 6 months, 1403 (48%) experienced clinically significant improvement in KCCQ-os score (≥5 points increase over 6 months). Patients with improved KCCQ-os at 6 months (HR, 0.65 [95% CI, 0.47-0.92]) had better outcomes and the association was not modified by HF phenotype (Pinteraction=0.40). One-third of patients with HF had discordance between patient-reported and clinician-assessed health status, largely attributable to worse patient-reported outcomes. Such discordance, particularly in those with discordantly worse KCCQ, should alert physicians to an increased risk of HF hospitalization and death, and prompt further assessment for potential drivers of worse patient-reported outcomes relative to physicians' assessment.

Changes in cardiac biomarkers in association with alterations in cardiac structure and function, and health status in heart failure with reduced ejection fraction: the EVALUATE-HF trial.

N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac troponin T (cTnT) and soluble ST2 (sST2) provide complementary prognostic information in heart failure with reduced ejection fraction (HFrEF). We aimed to assess the association between changes in these markers with changes in cardiac structure, function and health status. Patients in the EVALUATE-HF trial (n=464) were randomized to sacubitril/valsartan or enalapril for 12 weeks, followed by 12-week open-label sacubitril/valsartan. Cardiac biomarkers, echocardiography, and Kansas City Cardiomyopathy Questionnaires (KCCQ) were completed at baseline, and after 12 and 24 weeks. A total of 410 patients (88%) had serial biomarker measurements available (mean age 67 ± 9 years, 75% male and 75% white). After 24 weeks of treatment, NT-proBNP, sST2 and cTnT decreased by median (Q1, Q3) -31% (-55%, +6%), -6% (-19%, +8%) and - 3% (-13%, +8%), respectively (all p < 0.001). Decreases in NT-proBNP were associated with reductions in cardiac volumes and improvements in systolic and diastolic function and health status. Decreases in cTnT were associated with reductions in left ventricular mass, but not with changes in left ventricular function or KCCQ. Decreases in sST2 were consistently associated with improvements in health status, but not with measures of cardiac structure or function. There was no effect modification from treatment on the associations investigated (p for interaction >0.05) CONCLUSION: In HFrEF, serial changes in NT-proBNP correlate with changes in several key measures of cardiac structure and health status. cTnT changes correlate with changes in left ventricular mass and sST2 with changes in health status. These data highlight possible complementary pathophysiologic implications of changes in NT-proBNP, cTnT and sST2. ClinicalTrials.gov Identifier: NCT02874794.

Poor Medication Adherence Is Associated With Worse Health Status In Heart Failure With Reduced Ejection Fraction

<h3>Introduction</h3> Poor medication adherence is associated with increased hospitalization and mortality rates in patients with heart failure with reduced ejection fraction (HFrEF), but its association with health status is unknown. <h3>Methods</h3> CHAMP-HF is a multicenter observational study of outpatients with HFrEF (EF ≤40%). Medication adherence was assessed using the Morisky Medication Adherence Scale 4-Item<b>©</b> (MMAS-4) and any "yes" response was taken as a positive screen for non-adherence at enrollment. Health status was assessed by the Kansas City Cardiomyopathy Questionnaire Overall Summary score (KCCQ-OS) at baseline and 12-months. Robust linear regression was used to assess differences in health status at baseline, as well as change from baseline to 12 months. Models were serially adjusted for sociodemographic characteristics and comorbidities (Model 2), and HF medications (Model 3). <h3>Results</h3> Of 4,780 patients, 3,245 (67.9%) were classified as adherent and were more likely to be older (69 vs 65 years), white (75.1% vs 71.1%), more educated, and on fewer HF medications (3[2-4] vs 3[3-4]). They were also less likely to smoke (18.4% vs 23%) and have depression (24.9% vs 29%). Non-adherence to HF medications was associated with lower mean baseline KCCQ-OS (60.2 vs 66.8, p<0.001) that persisted after adjusting for baseline characteristics, comorbidities, and HF medications (Table 1A). Non-adherent patients also had a lower mean KCCQ-OS 12-months later (71.4 vs 77.1, p<0.001), with less improvement over 12-months in fully-adjusted analyses (Table 1B). <h3>Conclusions</h3> Poor medication adherence was associated with both worse baseline health status and less health status improvement over 12-months. Interventions that improve medication adherence should be tested to improve patients' health status.

Abstract 12934: The Association of Health Literacy With Health Status Outcomes in Heart Failure Patients

Background: Low health literacy (HL) is a known barrier to care and is associated with worse overall health status. The association of HL with disease-specific health status in heart failure (HF) patients is unknown. To address this gap we used data from Hopeful Heart , a randomized trial examining the impact of two 12-month treatment strategies in patients with HF and depression vs usual care. Methods: Health literacy was assessed at baseline via a brief screening tool previously validated in patients with HFrEF, classifying patients into adequate vs. low literacy. HF-specific health status was quantified with the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) at baseline, 3, 6, and 12 months. Using linear regression, we estimated the association of low HL with 12-month KCCQ-12 Summary Score, adjusting for treatment group, age, gender and LVEF. We also assessed the association of low HL with 12-month change in KCCQ-12, additionally adjusting for baseline score. Finally, we analyzed depression severity as a moderator in the interaction between HL and PROMIS-D depression score. Results: Among 756 patients, those with low HL (N=235, 31%) were similar in demographics (65±13 vs 64±13 years; 43% vs. 44% female; 24% vs. 28% non-White), but had less education (36% vs. 61% high school) and employment (10% vs. 19%) compared to those with adequate HL. Mean KCCQ-12 scores were consistently lower in participants with low HL at all time points (Figure). After adjusting for treatment group, age, sex, and LVEF, low HL was strongly associated with lower 12-month KCCQ-12 score (-9.5 points, CI [-13.7,-5.3]). After adjustment for baseline score, low HL remained associated with less improvement in KCCQ-12 (-5.9 points, CI [-9.7, -2.2]). Depressive symptoms did not moderate this association (interaction p=0.72). Conclusion: In patients with HF, low HL is associated with worse disease-specific health status and with poorer recovery in health status at 12-month follow up.

Impact of Sleep Apnea, Daytime Sleepiness, Comorbidities, and Depression on Patients' Heart Failure Health Status.

There is a gap in current research on common factors that impact patients with advanced heart failure (HF). The purpose of this secondary data analysis was to explore associations of those factors with three empirically verified measures of HF-related clinical, physical, and mental health status. Baseline data of 198 advanced systolic HF (EF < 40%) patients were analyzed. Patients were 61.6% male, with a mean age of 62.3 (SD = 13.2) years. The multivariable general linear modeling results indicated that patients who had poorer scores on HF-related clinical status were those who had sleep apnea (β = -6.6, p < .05), daytime sleepiness (β = -9.4, p < .01), four or more comorbidities (β = -11.8, p < .001), and depression (β = -18.7, p < .001). Depression was associated with all three measures of HF-related health status. These findings alert nurses to assess for sleep apnea and to use known screening measures for daytime sleepiness, depression, and comorbidities.

Assessing Health Status in Heart Failure: A Better Way

The New York Heart Association (NYHA) system of functional classification, developed almost a century ago, has been widely accepted as a means of

Measuring health status and symptom burden using a web-based mHealth application in patients with heart failure.

Symptoms of heart failure markedly impair a patient's health status. The aim of this study was to identify predictors of health status in a sample of racially and ethnically diverse patients with heart failure using a web-based mobile health application, mi.Symptoms. We conducted a cross-sectional study at an urban academic medical center. Patients with heart failure self-reported symptoms using validated symptom instruments (e.g. patient-reported outcome measurement information system) by way of the mobile health application, mi.Symptoms. The primary study outcome was health status, measured with the Kansas City cardiomyopathy questionnaire clinical summary score. Data were analyzed using descriptive statistics and multiple linear regression. The mean age of the sample ( n=168) was 58.7 (±12.5) years, 37% were women, 36% were Black, 36% identified as Hispanic/Latino, 48% were classified as New York Heart Association class III, and 44% reported not having enough income to make ends meet. Predictors of better health status in heart failure included higher physical function ( β=0.89, p=0.001) and ability to participate in social roles and activities ( β=0.58, p=0.002), and predictors of poorer health status were New York Heart Association class IV ( β=-11.68, p=0.006) and dyspnea ( β=-0.77, p<0.001). The predictors accounted for 73% of the variance in health status. Patient-centered interventions should focus on modifiable risk factors that reduce dyspnea, improve functional status, and enhance engagement in social roles to improve the health status of patients with heart failure.

Abstract 16800: Sarcopenia in Advanced Systolic Heart Failure Patients Receiving Left Ventricular Assist Devices

Introduction: Sarcopenia is the age-related deterioration in skeletal muscle mass and function, which can be accelerated by chronic comorbidities. The prevalence in advanced systolic heart failure (HF) and impact on HF health status are currently uncertain. Sarcopenia diagnostic criteria from the Foundation for the National Institutes of Health (FNIH) and European Working Group on Sarcopenia in Older People (EWGSOP) have not been applied to HF cohorts. Hypothesis: We hypothesized that at the time of left ventricular assist device (LVAD) implantation systolic HF patients have prevalent sarcopenia, and that sarcopenia is associated with poorer nutritional and HF health status. Methods: We recruited 18 adults with systolic HF ±21 days from LVAD implantation. All underwent whole-body dual X-ray absorptiometry (DXA) to calculate appendicular lean mass (ALM). Subjects also underwent a 3-day food recall, Simplified Nutritional Appetite Questionnaire (SNAQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) for HF health status, handgrip strength and blood testing. Sarcopenia was defined by 2 ALM criteria: FNIH – males &lt;19.75kg, females &lt;15.02kg; EWGSOP – males &lt;7.26kg/m 2 , females &lt;5.5kg/m 2 . Linear regression determined relationships between appendicular lean mass and age, weight, handgrip strength, KCCQ summary score, SNAQ score, 24-hour protein intake, and key blood variables, without/with adjustment for sex and height. Results: Sarcopenia was diagnosed in 5 subjects (28%) by FNIH criteria and an additional 5 (10 total, 56%) by EWGSOP criteria (Figure). There were unadjusted associations between lower appendicular lean mass and lower handgrip strength; higher SNAQ score (higher malnutrition risk); lower sodium; and lower hemoglobin. After adjustment for sex and height, lower lean mass remained associated with lower hemoglobin. Lower appendicular lean mass was also independently associated with higher (more favorable) KCCQ scores. Conclusions: As many as half of advanced systolic HF patients meet standard DXA criteria for sarcopenia. Lower appendicular lean mass is independently associated with lower hemoglobin but does not appear to be associated with poorer HF status.

Telehealth Alerts and Nurse Response.

Health monitoring within a telehealth program is a strategy to efficiently care for older adults with heart failure (HF). Limited description is identified in the literature for the extent participant submissions trigger an alert or monitoring nurses transfer telehealth alert-range data to the medical record. The aim was to describe the initial 90 days of participant submissions measuring within alert range and nurse response to alerts with documentation to the medical record. Review of telehealth and medical records of 187 older veterans with HF participating at one Veterans Administration Care Coordination Home Telehealth program led to reporting the proportion of participant telehealth submissions measuring within alert range and nurse response to alert-range data. Less than 2.5% of self-rated health status and nearly one-quarter of physiologic submissions measured within alert range. Timely nurse response averaged 28.7% and increased when submissions for vital signs, weight, or medication alerted for consecutive days. Neither alert nor nurse response data were significantly associated with characteristic measures. Clinical relevance of alert-range telehealth data is uncertain partly due to frequent alerts triggered by physiologic submissions, few health status changes noted by the participant or the monitoring nurse, and the nonsignificant association between the proportion of alerts or nurse response, respectively, with demographic or clinical baseline measures. Future studies are needed to identify telehealth program measures that decrease alerting data not associated with clinical worsening and increase recognition-of-change in HF health status by the participant and monitoring nurse.

Association of Functional and Health Status Measures in Heart Failure

A wide variety of instruments have been used to assess the functional capabilities and health status of patients with chronic heart failure (HF), but it is not known how well these tests are correlated with one another, nor which one has the best association with measured exercise capacity. Forty-one patients with HF were assessed with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing, the Duke Activity Status Index (DASI), the Veterans Specific Activity Questionnaire (VSAQ), the Kansas City Cardiomyopathy Questionnaire (KCCQ), and 6-minute walk distance. Pretest clinical variables, including age, resting pulmonary function tests (forced expiratory volume in 1 s and forced vital capacity), and ejection fraction (EF) were also considered. The association between performance on these functional tools, clinical variables, and exercise test responses including peak VO2 and the VO2 at the ventilatory threshold, was determined. Peak oxygen uptake (VO2) was significantly related to VO2 at the ventilatory threshold (r = 0.76, P < .001) and estimated METs from treadmill speed and grade (r = 0.72, P < .001), but had only a modest association with 6-minute walk performance (r = 0.49, P < .01). The functional questionnaires had modest associations with peak VO2 (r = 0.37, P < .05 and r = 0.26, NS for the VSAQ and DASI, respectively). Of the components of the KCCQ, peak VO2 was significantly related only to quality of life score (r = 0.46, P < .05). Six-minute walk performance was significantly related to KCCQ physical limitation (r = 0.53, P < .01) and clinical summary (r = 0.44, P < .05) scores. Among pretest variables, only age and EF were significantly related to peak VO2 (r = -0.58, and 0.46, respectively, P < .01). Multivariately, age and KCCQ quality of life score were the only significant predictors of peak VO2, accounting for 72% of the variance in peak VO2. Commonly used functional measures, symptom tools, and quality of life assessments for patients with HF are poorly correlated with one another and are only modestly associated with exercise test responses. These findings suggest that exercise test responses, non-exercise test estimates of physical function, and quality of life indices reflect different facets of health status in HF and one should not be considered a surrogate for another.

Assessing HF Health Status with the KCCQ

Assessing the health status of heart failure (HF) patients is challenging, despite the predictive value of several clinical and laboratory

Testing Videotape Education for Heart Failure

This pilot study tested a videotape intervention designed to improve patient self-management of heart failure (HF). Content of the video series (produced professionally under a federal grant) is based on national, scientifically validated guidelines for HF home management. Outcomes tested were HF knowledge, symptom reporting, and functional status. Participants were 10 newly diagnosed HF patients (mean age 67). After viewing the tapes, data indicated participants had a clinically relevant improvement in HF knowledge, and improved or maintained HF health status. None were rehospitalized during the 60-day follow-up period. One patient contacted his/her physician to report weight gain, as prompted by the videotapes. The cost data indicated that patients paid $177 out of pocket monthly for medications and all were low income. These results indicate the need for further testing of the videotape as a potentially cost-effective method of teaching about HF self-management and daily home self-monitoring.