Heart Failure Symptomatology Research Articles

Caregiver subjective and physiological markers of stress and patient heart failure severity in family care dyads

Greater family caregiver exposure to uncontrolled patient symptoms is predictive of greater caregiver psychological and physiological stress in dementia and other chronic illnesses, but these phenomena have not been well-studied in heart failure (HF) – a disease with high symptom burden. The purpose of this study was to test the hypothesis that worse patient functional status (as reflected by increasing HF symptoms) would be associated with elevated psychological and physiological stress for the caregiver. This was a secondary analysis of data from 125 HF caregivers in the Caregiver Opportunities for Optimizing Lifestyle (COOL) study. Psychological stress was measured on four dimensions: care-related strain/burden (Oberst Caregiving Burden Scale), depression (Center for Epidemiological Studies Depression Scale), anxiety (State-Trait Anxiety Index), and general stress (Perceived Stress Scale). Physiological stress was measured by markers of HPA axis function (elevated cortisol awakening response [CAR]), endothelial dysfunction (increased PAI-1), and inflammation (increased IL-6, hsCRP). HF patient functional status was quantified by caregiver assessment of New York Heart Association (NYHA) Class. Generalized linear models were used to test associations between patient NYHA Class and stress (one model per indicator). NYHA Class (ordinal) was backwards difference coded in each model to examine caregiver stress in relation to increasing levels of HF severity. Caregivers were mostly female and in their mid-fifties, with a slight majority of the sample being African American and the patient’s spouse. Overall, patient functional status was associated with greater caregiver psychological and physiological stress. In terms of psychological stress, higher NYHA Class was significantly associated with greater caregiver anxiety and general stress, but not with caregiver burden or depression. In terms of physiological stress, higher NYHA Class was associated with elevated markers in all models (elevated CAR and higher IL-6, hsCRP, and PAI-1). Across models, most associations between NYHA Class and stress were present at relatively early stages of functional limitation (i.e. Class II), while others emerged when functional limitations became more severe. To inform timing and mechanisms for much-needed caregiver interventions, research is needed to determine which aspects of HF symptomatology are most stressful for caregivers across the HF trajectory.

Сердечная недостаточность: исторические аспекты изучения проблемы

The history of the issue of heart failure goes back many millennia. Thus, indirect evidence of the attentive attitude of ancient doctors is associated with Hippocrates, who described such phenomena as edema of the extremities and the accumulation of fluid in the cavities, changes in the characteristics of the heart, which obviously had a direct relationship to the symptomatology of heart failure. At the present stage, pathogenetic views have been significantly developed in heart failure. First of all, this concerns the properties of contractility and relaxation of the heart muscle as key in the pathogenesis of heart failure. So, it is now accepted to distinguish between clinical and pathophysiological concepts of systolic and diastolic dysfunction. In recent years, the development of cellular and molecular biology has contributed to a deeper penetration into the essence of the processes of myocardial trophism in heart failure. There has been a transition from the systemic organ to the cellular, molecular and even genetic levels of research on the problems of heart failure.

Abstract 229: Family Caregiver Stress and Patient Symptom Severity in Heart Failure

Background: In chronic illness caregiving, greater family caregiver exposure to patient symptoms is predictive of greater caregiver psychological and physiological stress. Although heart failure (HF) carries high symptom burden, this phenomena is not well-studied in HF caregivers. Objective: To test the hypothesis that caregiver perception of patient HF symptoms is associated with elevated caregiver psychological and physiological stress. Methods: This was a secondary analysis of baseline data from 125 HF caregivers in the Caregiver Opportunities for Optimizing Lifestyle (COOL) study. Psychological stress was measured by caregiver report of care-related strain (Oberst Caregiving Burden Scale), depression (Center for Epidemiological Studies Depression), anxiety (State-Trait Anxiety Index), and general stress (Perceived Stress Scale). Physiological stress was quantified by markers of HPA axis dysfunction (elevated cortisol awakening response [CAR]), endothelial dysfunction (increased PAI-1), and inflammation (increased IL-6, hsCRP). HF symptoms were quantified by caregiver assessment of New York Heart Association (NYHA) Class, dichotomized as asymptomatic [Class I] versus symptomatic [Class II-IV]. Generalized linear models were used to test relationships between symptoms and stress (one model per indicator). IL-6, hsCRP, and PAI-1 were natural log transformed, and CAR was dichotomized based on a cutoff for elevated stress response (>75% increase). All models controlled for sociodemographic confounders (age, gender, race, education, caregiving relationship), with biomarker-specific confounders (comorbidity, adiposity, medications) added to physiological stress models. Results: Caregivers were mostly female (n=115, 92.0%), in their mid-fifties (55.4±11.5), African American (n=72, 57.6%), and the patient’s spouse (n=68, 54.4%) or adult child (n=30, 24.0%). One quarter perceived the patient to be asymptomatic (Class I: n=31, 24.8%; II: n=31, 24.8%; III: n=47, 37.6%; IV: n=15, 12.0%). Symptomatic HF was significantly associated with greater caregiver depression, anxiety, and general stress (β=4.0±1.9, p=0.04; β=3.9±1.4, p<0.01; and β=7.7±2.9, p<0.01, respectively), but not greater care-related strain (β=4.7±3.0, p=0.12). Symptomatic HF was also significantly associated with markers of HPA-axis dysfunction (elevated CAR: OR=3.1, 95% CI=1.0-9.7, p=0.05), endothelial dysfunction (PAI-1: β=0.39±0.16, p=0.01), and increased inflammation as measured by hsCRP (β=0.47±0.22, p=0.04), but not IL-6 (β=0.18±0.15, p=0.21). Conclusions: Overall, patient HF symptoms were associated with greater caregiver psychological and physiological stress. To inform timing and mechanisms for much-needed caregiver interventions, research is needed to determine which aspects of HF symptomatology are most stressful for caregivers across the HF trajectory.

Long-term outcome of hypertensive patients with heart failure with mid-range ejection fraction: The significance of blood pressure control.

Heart failure (HF) with mid-range ejection fraction (HFmrEF) is a newly suggested entity in HF. Since it has been inadequately addressed, there is an urgent need to determine the profile of HFmrEF patients and the optimal approach to their management. The present study aimed to assess the long-term clinical outcomes of hypertensive patients with HFmrEF and the impact of blood pressure (BP) on their mortality and cardiovascular outcome. We performed a retrospective observational study that included 121 hypertensive patients with HFmrEF and 149 hypertensives with heart failure and preserved ejection fraction (HFpEF). The median follow-up was 84months (22-122). Our analysis did not reveal any statistically significant difference between the two groups in total mortality (P=0.34) or cardiovascular mortality (P=0.54). The total mean survival time was 102.9months (100.5-110.1), while the mean survival time was 105.3months (80.4-90.2) in HFpEF and 97.6months (92.7-102.6) in HFmrEF. An office systolic BP>139mmHg and diastolic BP>89mmHg were significantly associated with both all-cause mortality (P=0.02 and P=0.013, respectively) and cardiovascular mortality (P=0.02 for both). In HFpEF patients, no significant association was found between outcome and office BP. HFpEF and HFmrEF have similar long-term outcomes. Suboptimal BP levels are a significant risk factor for an adverse outcome in HFmrEF. Our results emphasize the importance of good BP control in order to achieve better outcomes in hypertensives with impaired EF and HF symptomatology.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Left Ventricular Mass Change After Anthracycline Chemotherapy.

Myocardial atrophy and left ventricular (LV) mass reductions are associated with fatigue and exercise intolerance. The relationships between the receipt of anthracycline-based chemotherapy (Anth-bC) and changes in LV mass and heart failure (HF) symptomatology are unknown, as is their relationship to LV ejection fraction (LVEF), a widely used measurement performed in surveillance strategies designed to avert symptomatic HF associated with cancer treatment. We performed blinded, serial assessments of body weight, LVEF and mass, LV-arterial coupling, aortic stiffness, and Minnesota Living with Heart Failure Questionnaire measures before and 6 months after initiating Anth-bC (n=61) and non-Anth-bC (n=15), and in 24 cancer-free controls using paired t and χ2 tests and multivariable linear models. Participants averaged 51±12 years, and 70% were women. Cancer diagnoses included breast cancer (53%), hematologic malignancy (42%), and soft tissue sarcoma (5%). We observed a 5% decline in both LVEF (P<0.0001) and LV mass (P=0.03) in the setting of increased aortic stiffness and disrupted ventricular-arterial coupling in those receiving Anth-bC but not other groups (P=0.11-0.92). A worsening of the Minnesota Living with Heart Failure Questionnaire score in Anth-bC recipients was associated with myocardial mass declines (r=-0.27; P<0.01) but not with LVEF declines (r=0.11; P=0.45). Moreover, this finding was independent of LVEF changes and body weight. Early after Anth-bC, LV mass reductions associate with worsening HF symptomatology independent of LVEF. These data suggest an alternative mechanism whereby anthracyclines may contribute to HF symptomatology and raise the possibility that surveillance strategies during Anth-bC should also assess LV mass.

Evaluation of Valtech’s transcatheter mitral valve repair device

ABSTRACTIntroduction: Functional mitral regurgitation is a debilitating condition, related to worsening of functional capacity and heart failure symptomatology. Cardioband (Valtech Cardio, Or Yehuda, Israel) is a novel technology designed for transcatheter repair of the mitral valve in the treatment of functional MR.Areas covered: A brief summary to direct the reader to important further reading, relevant websites; www.valtechcardio.com. An article about this device, relevant websites; www.ncbi.nlm.nih.gov/pubmed using search word ‘Cardioband’.Expert commentary: This device has been designed to be completely implantable percutaneously in a closed beating heart fashion. The adjustability features under the beating heart and guided by echocardiography allow to provide a tailored therapy to each particular mitral valve and regurgitation condition.

Predictors of depression in outpatients with heart failure: An observational study

BackgroundDepression is a common comorbidity of heart failure. Little is known about the influence of heart failure symptomatology and coping resources, such as social support and social problem-solving, on depression. ObjectiveTo examine whether individual and clinical characteristics, heart failure symptomatology, and the subcomponents of social support and social problem-solving increase the likelihood of depression in outpatients with heart failure. MethodsA secondary data analysis of a cross sectional study with 201 outpatients with heart failure was conducted. The following self-report questionnaires were used to collect data: the Heart Failure Symptom Survey, the Interpersonal Support Evaluation List-12, the Graven and Grant Social Network Survey, the Social Problem-Solving Inventory Revised-Short, and the Center for Epidemiological Studies – Depression scale. Descriptive statistics examined patient characteristics. Logistic regression explored predictors of depression from among individual and clinical characteristics, heart failure symptomatology, and subcomponents of social support (i.e., belonging, tangible, and appraisal support) and social problem-solving (i.e., positive and negative problem orientation; rational, impulsiveness/carelessness, and avoidance problem-solving styles). ResultsThe sample was primarily Caucasian (86.1%) male (62.6%) with an average age of 72.57 years. Individuals who were unmarried, experienced a higher symptom burden, and those who perceived less belonging support were more likely to be depressed. The subcomponents of social problem-solving did not influence depression. ConclusionsBelonging support was the most beneficial type of social support related to depression. Components of social problem-solving were not related to depression. Assessment of marital status, heart failure symptomatology, and perceived belonging support is needed to identify potential stressors and available social support in order to promote psychological adaptation.

The impact of digoxin on mortality in patients with chronic systolic heart failure: A propensity-matched cohort study

BackgroundPrior Studies showed mixed results in association of digoxin use with all-cause mortality (ACM). The aim of this analysis is to identify the impact of digoxin use on ACM in a contemporary heart failure (HF) cohort treated with guideline based therapy. MethodsWe included 2298 consecutive patients seen in an HF clinic between 2000 and 2015. Patients were considered to be a digoxin user if he/she received digoxin at any point during the enrollment period in the HF clinic. Patients were matched based on digoxin utility using propensity matching in 2–3:1 fashion. The primary outcome was ACM. ResultOf 2298 patients, 325 digoxin users were matched with 750 non-digoxin users. The Matched cohort did not have differences among demographics and clinical variables except for worse HF symptomatology and increased prevalence of atrial fibrillation. Overall, the prevalence of the use of guideline suggested therapies was 96%. After a median follow-up duration of 4years (IQR 2–6years), digoxin use was associated with increased ACM (21.8% versus 12.9%, unadjusted HR=1.81; 95% CI=1.33 to 2.45; p=0.001). This association remained significant after adjusting for the propensity score, atrial fibrillation, ejection fraction, and New York HF Class (HR=1.74; 95% CI=1.20 to 2.38; p<0.0001). ConclusionIn this analysis of well-treated HF patients, digoxin was associated with increased ACM. Further randomized controlled trials are needed to determine whether digoxin therapy should be used in well-treated HF patients. Until then, routine use of digoxin in clinical practice should be discouraged.

Unusual Heart Involvement of Wegener's Granulomatosis and Literature Review

&lt;p&gt;A female patient, 60 years of age, was presented to our hospital with chest pain and monomorphic ventricular tachycardia (VT). She was transferred to the Coronary Care Unit and amiodarone perfusion restored basal rhythm in atrial fibrillation. She has not sign of heart failure. A transtoracic echocardiogram (TTE) was performed and an one mitral mass was found at atrioventricular junction with displacement of the posterior mitral leaflet A transesophageal echocardiogram (TEE) demonstrated a mass at atrioventricular junction level with severe mitral regurgitation. Cardiac Magnetic Resonance (CMR) confirmed the mass and anterolateral papillary muscle was thickening and hypertrophied with hyperenhancement consistent with fibrosis. Moreover, T2-weighted imaging demonstrated hyperintense mass with respect to the surrounding myocardium in relation of inflammatory mass. She had saddle nose by destruction of the septum, bilateral hearing loss, sinusitis and scleritis and renal involvement as well. This patient was diagnosed of Wegener's Granulomatosis (WG) and she was treated with methylprednisolone during 3 days, continued with prednisolone and cyclophosphamide. An 8 days later echocardiogram did not find the mass. However, the patient developed symptomatology of heart failure and in the context of severe mitral regurgitation, mitral valve replacement was decided in multi-disciplinary Cardiology-Cardiothoracic meeting.&lt;/p&gt;

Cardiovascular prevention and rehabilitation for patients with ventricular assist device From exercise therapy to long-term therapy Part II: Long-term therapy

Over the years left ventricular assist devices (VADs) have become more durable and reliable, smaller, simpler, easier to implant and more comfortable. The extensive experience now acquired shows successful hospital discharge with VAD use. We are entering an era in which long-term mechanical circulatory support will play an increasing role in the approach to end-stage heart failure (HF); at the same time, the extension of VADs into destination therapy has revealed the limitations of our understanding of these populations. This second paper on cardiovascular prevention and rehabilitation for patients with left VADs will deal with the management of patients outside the highly specialized HF centers and surgical setting, with particular focus on postoperative patient management. Outpatient management of VAD patients is time-intensive, and a multidisciplinary approach is ideal in long-term care. Although the new devices have definite advantages over the older pumps, some challenges still remain, i.e. infection, stroke, device thrombosis, gastrointestinal bleeding, recurrent HF symptomatology with or without multisystem organ failure, and occurrence of ventricular arrhythmias.

Symptomatology and Coping Resources Predict Self-Care Behaviors in Middle to Older Age Patients with Heart Failure.

Background. Symptoms of heart failure (HF) and coping resources, such as social support and social problem-solving, may influence self-care behaviors. Research regarding the influence of HF symptomatology characteristics and components of social support and social problem-solving on self-care is limited. Objective. To identify predictors of HF self-care behaviors using characteristics of HF symptomatology, components of social support and social problem-solving, and demographic and clinical factors. Methods. Using a cross-sectional, correlational predictive design, a convenience sample (N = 201) of outpatients with HF answered self-report surveys. Multiple linear regression with stepwise variable selection was conducted. Results. Six predictors of HF self-care were identified: race, symptom frequency, symptom-related interference with enjoyment of life, New York Heart Association Class HF, rational problem-solving style, and social network (β = 34.265, R 2 = 0.19, P = 0.001). Conclusions. Assessing the influence of race on self-care behaviors in middle to older age patients with HF is important. Clinical assessment that focuses on symptom frequency, symptom-related interference with enjoyment of life, and HF Class might also impact self-care behaviors in this population. Rational problem-solving skills used and evaluation of the size of and satisfaction with one's social network may be appropriate when assessing self-care.

Parenteral Inotropic Therapy in the Home

This article provides an evidence-based overview of heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment with intravenous inotropic medications in the home. Inotropic infusions in the home setting require advanced care planning, symptom management, and knowledge about ambulatory pumps and devices. These medications can be safely used throughout the continuum of care as pediatric/adult bridges from transplant to hospice care. Nurses who recognize advanced HF symptomatology and use prognostic/risk-stratification models will be better prepared to facilitate this advanced care planning, thus supporting optimal treatment outcomes. The ultimate goal of care for heart failure therapy in the home is to integrate pharmacotherapeutic knowledge of treatment advances with comfort measures and to provide them to patients concurrently and in a seamless process.

Circulation: Cardiovascular Interventions Editors’ Picks

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

Supraventricular tachycardia causing heart failure

Supraventricular tachycardia (SVT) causing heart failure is an important cause of tachycardia-induced cardiomyopathy. Advances in anti-arrhythmic drugs to achieve either rate or rhythm control, curative ablative therapy directed at the underlying tachycardia mechanism to restore sinus rhythm, and atrioventricular junction ablation with permanent pacemaker placement for better rate control have improved the outcome of SVT management and subsequently improved the heart failure symptomatology and in some cases reversed remodeling of the cardiac dysfunction. The aim of this review is to provide the reader with clinical presentation as well as the common SVTs causing heart failure, pathophysiology of SVT causing heart failure, evaluation and management of SVT causing heart failure, and prognosis of SVT causing heart failure.

Role of Left Ventricular Stiffness in Heart Failure With Normal Ejection Fraction

Increased left ventricular stiffness is a distinct finding in patients who have heart failure with normal ejection fraction (HFNEF). To elucidate how diastolic dysfunction contributes to heart failure symptomatology during exercise, we conducted a study using an invasive pressure-volume loop approach and measured cardiac function at rest and during atrial pacing and handgrip exercise. Patients with HFNEF (n=70) and patients without heart failure symptoms (n=20) were enrolled. Pressure-volume loops were measured with a conductance catheter during basal conditions, handgrip exercise, and atrial pacing with 120 bpm to analyze diastolic and systolic left ventricular function. During transient preload reduction, the diastolic stiffness constant was measured directly. Diastolic function with increased stiffness was significantly impaired in patients with HFNEF during basal conditions. This was associated with increased end-diastolic pressures during handgrip exercise and with decreased stroke volume and a leftward shift of pressure-volume loops during atrial pacing. Increased left ventricular stiffness contributed to increased end-diastolic pressure during handgrip exercise and decreased stroke volume during atrial pacing in patients with HFNEF. These data suggest that left ventricular stiffness modulates cardiac function in HFNEF patients and suggests that diastolic dysfunction with increased stiffness is a target for treating HFNEF.

Drugs that interrupt the renin-angiotensin system should be among the preferred initial drugs to treat hypertension.

The goal of antihypertensive therapy is to provide effective treatment that can be sustained lifelong, while lowering elevated blood pressure and preventing hypertensive end-organ damage and mortality. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II antagonists (AIIAs) control blood pressure as well as other available classes of antihypertensive drugs. The ACE inhibitors have been demonstrated to reduce the incidence of stroke, reverse left ventricular hypertrophy, and improve congestive heart failure symptomatology and mortality to a similar degree as diuretics and beta-adrenergic blockers. ACE inhibitors reduce postmyocardial infarction recurrence, improve congestive heart failure symptomatology and mortality, and slow the progression of glomerular renal disease. The AIIAs reverse left ventricular hypertrophy. Several of these agents have been shown to improve congestive heart failure symptomology and mortality, to reduce the occurrence of early atherosclerotic vascular disease, and to slow the progression of renal failure in type 2 diabetes mellitus nephropathy. One AIIA has reduced the incidence of end-stage renal disease in non-insulin-dependence diabetes mellitus nephropathy over 3 years. Ideally, antihypertensive therapy should maintain or improve the patients quality of life without creating side effects or adverse laboratory effects. Among the available nine classes of antihypertensive drugs, ACE inhibitors and the AIIAs come close to meeting the description of an ideal drug. AIIAs and ACE inhibitors, two classes of antihypertensive drugs that reduce the activity of the renin-angiotensin II system, should be among the preferred first-step drugs for the treatment of hypertension.