Heart failure symptom clusters and quality of life Salyer, Jeanne; Flattery, Maureen; Lyon, Debra E.
Heart & lung,
September-October 2019, 2019 Sep - Oct, 2019-09-00, 20190901, Letnik:
48, Številka:
5
Journal Article
Recenzirano
Heart failure (HF) is a progressive symptomatic illness with reports suggesting that patients experience multiple symptoms. Symptom clusters constitute symptoms that co-occur, are related, and ...influence outcomes.
The specific aims of this study were to (1) examine prevalent symptoms experienced by persons with HF, (2) identify symptoms forming clusters, and (3) evaluate the impact of HF symptom clusters on quality of life (QOL).
117 participants (62% male; 50% black; age = 56) were recruited. Prevalent symptoms were evaluated; principle components analysis (PCA) was used to extract symptom clusters; regression analysis was used to evaluate factors influencing QOL, defined as life satisfaction.
Three symptom clusters–sickness behavior, discomforts of illness, and GI distress–were extracted. Sickness behavior significantly influenced QOL (β = −0.603 p = 0.0001), explaining 40% of the variance (F = 75.12; R2 = 0.404; p = 0.0001).
The Sickness Behavior cluster had a negative impact on QOL and suggests that incorporating an evaluation of these symptoms may facilitate identification and treatment of symptoms having an additive and detrimental influence on QOL. Studies to examine the stability of the clusters are warranted.
The changing epidemiology of cardiac allograft rejection has prompted many to question the yield of surveillance endomyocardial biopsy (EMB) in heart transplantation (HT) patients. We sought to ...determine the yield of EMB in the modern era.
We evaluated 2597 EMBs in 182 consecutive HT patients who survived to their first EMB. The EMBs were categorized as asymptomatic or clinically driven and were compared based on era of antiproliferative therapy use at our center (early azathioprine era: 1990-2000 vs modern mycophenolate era: 2000-2011).
In the modern era, patients had a higher prevalence of risk factors for developing rejection (≥ International Society of Heart and Lung Transplantation grade 2R); however, the frequency of rejection was decreased at all times (0-6 months: 60.2% vs 21.5%, P < 0.001, 6-12 months: 26.8% vs 1.8%, P < 0.001, 12-36 months: 32.3% vs 10.5%, P = 0.006). The yield of asymptomatic EMB decreased in the modern era between 0 and 6 months (10.9% vs 3.12%), 6 to 12 months (17% vs 0%), and years 2 to 3 (6.1% vs 1.5%). In the early era, the odds ratio of rejection during asymptomatic EMB compared to a clinically driven EMB was 0.47 (95% confidence interval, 0.31-0.71) and was decreased in the modern era (0.17 0.07-0.42, P = 0.04). The probability of detecting rejection on asymptomatic EMB was significantly reduced in the modern era, even after adjustment for tacrolimus and induction therapy (1% vs 8%, P < 0.001).
The clinical yield of surveillance EMB has decreased in the modern era. The EMB in asymptomatic patients longer than 6 months after HT warrants further scrutiny.
The psychosocial assessment of candidates for transplantation (PACT), developed to assess candidates for heart transplant, has not been routinely used to assess left ventricular assist device (LVAD) ...candidacy. We examined the efficacy of the PACT to assess psychosocial outcomes in LVAD patients.
We reviewed patients who received LVAD implants between June 2006 and April 2011 and retrospectively applied the PACT. We determined the accuracy of identifying social success with the PACT and revised domains to reflect criteria influencing social success for LVAD patients.
Forty-eight patients (72% men, 44% non-white, 50.4 years old) were divided into high-scoring and low-scoring groups. Nine patients with low PACT scores were falsely categorized as high-risk, whereas 4 with high scores had poor social outcomes. The score had a high positive-predictive value (0.86) but low negative-predictive value (0.31). The PACT was revised (modified mPACT) to measure indicators, such as social support and understanding of care requirements, identified to more closely affect LVAD outcome. The mPACT exhibited improved accuracy. A reclassification table was developed, and the net reclassification index was 0.32. The percentage of patients incorrectly classified for social risk decreased from 27% with the PACT to 8% with the mPACT. Patients with higher mPACT scores had decreased 30-day readmission rates (26% vs 67%, p = 0.045) after device implantation.
By emphasizing social support, psychologic health, lifestyle factors, and device understanding, the mPACT showed improved performance in risk-stratifying candidates for LVAD therapy. Prospective validation is warranted.
Aim
To identify symptom clusters in individuals with heart failure and evaluate the relationship of the identified clusters to functional status.
Background
Heart Failure is a global health problem ...affecting approximately 1–2% of the adult population in developed countries worldwide. Individuals with heart failure may experience as many as nine symptoms and may limit activities that worsen their symptoms or adjust the way they engage in activities.
Design
Cross‐sectional.
Methods
A convenience sample of individuals (n = 117) with a confirmed diagnosis of heart failure was recruited from an academic medical centre during 2011–2012. Prevalent heart failure symptoms and functional status outcomes (functional limitations and mobility) were evaluated. Factor analysis using the principal components method was used to extract symptom clusters. Regression analysis using a backwards stepwise model‐building approach was used to examine the effects of the symptom clusters, age and co‐morbidity on functional limitations and mobility.
Results
Three symptom clusters, sickness behaviour, discomforts of illness and gastrointestinal distress were extracted. When sickness behaviours and discomforts of illness were both present, functional limitations were more sensitive to sickness behaviours. Sickness behaviour and co‐morbidity were related to limited mobility.
Conclusions
Individuals with heart failure may be helped to improve their functional status by managing sickness behaviour and discomforts of illness symptoms. Identification of symptom clusters may lead to the development of interventions focusing on a cluster of heart failure symptoms.
Background Sustained maintenance on left ventricular assist device (LVAD) is associated with an increased frequency of severe infections. Although temporary changes in cellular immunity are seen ...immediately after implantation, the consequence of sustained LVAD treatment on immunity is unknown. Methods In vitro functional and phenotypic markers of T cell activation and 6 month clinical outcome were compared between patients with ≥6-month LVAD therapy and heart failure control patients. Results Recipients of LVADs had more infections (45.5% versus 0%; p < 0.05) and mortality (54% versus 16%; p < 0.05) than control patients. T-cell proliferative responses were lower among LVAD recipients than control patients when challenged with phytohemagglutinin (3.4 ± 4.7 versus 28.5 ± 19.6; p < 0.01), anti-CD3 (4.3 ± 4.5 versus 16.4 ± 17; p < 0.01), and staphylococcal enterotoxin B (7.2 ± 6.3 versus 26.1 ± 15.6; p = 0.002). Proliferative hyporesponsiveness among LVAD recipients was not caused by apoptosis (2.6% ± 2.7% versus 2.7% ± 2.1%; p = 0.94) or insufficient CD4+ cells (42.1% ± 11.3% versus 40.2% ± 7.5%; p = 0.71) relative to control patients. Instead, CD3+ cells from LVAD patients expressed less interleukin 2 (2.5% ± 1.5% versus 5.2% ± 3.1%; p = 0.03) and tumor necrosis factor-α (6.0% ± 3.5% versus 25.8% ± 8.7%; p < 0.001) and more interleukin 10 (5.8% ± 6.1% versus 2.6% ± 2.1%; p < 0.05). In addition, suppressive T-regulatory cells were more prevalent in LVAD patients than control patients (12.9% ± 3.2% versus 1.2% ± 1.1%; p < 0.001). Conclusions Cellular immunity is compromised among long-term LVAD recipients because of a downregulatory cytokine imbalance and emergence of suppressive T-regulatory cells.
PDF
