Eun Kyeung Song

Three Gram Sodium Intake is Associated With Longer Event-Free Survival Only in Patients With Advanced Heart Failure

BACKGROUND There is limited evidence to support the recommendation that patients with heart failure (HF) restrict sodium intake. The purpose of this study was to compare differences in cardiac event-free survival between patients with sodium intake above and below 3 g. METHODS A total of 302 patients with HF (67% male, 62 ± 12 years, 54% New York Heart Association [NYHA] Class III/IV, ejection fraction 34 ± 14%) collected a 24-hour urine sodium (UNa) to indicate sodium intake. Patients were divided into 2 groups using a 3-g UNa cutpoint and stratified by NYHA Class (I/II vs. III/IV). Event-free survival for 12 months was determined by patient or family interviews and medical record review. Differences in cardiac event-free survival were determined by Kaplan-Meier survival curve with log-rank test and Cox hazard regression. RESULTS The Cox regression hazard ratio for 24-hour UNa ≥ 3 g in NYHA Class I/II was 0.44 (95% confidence interval [CI] = 0.20-0.97) and 2.54 (95% CI = 1.10-5.84) for NYHA III/IV after controlling for age, gender, HF etiology, body mass index, ejection fraction, and total comorbidity score. CONCLUSIONS These data suggest that 3 g dietary sodium restriction may be most appropriate for patients in NYHA functional Classes III and IV.

Symptom clusters predict event-free survival in patients with heart failure

Background:Physical symptoms are likely to occur in clusters that may be associated with adverse outcome in patients with heart failure (HF). Despite the importance of early recognition of worsening symptoms in HF management, the impact of physical symptoms on adverse outcome has not been explored in the context of symptom clusters. Purpose:The purposes of this study were to explore which physical symptom clusters occur in HF patients and to determine the impact of symptom clusters on event-free survival. Methods:A total of 421 patients (60% male; 62 [SD, 14] years; 72% New York Heart Association class II/III) completed the modified Memorial Symptom Assessment Scale-Heart Failure to measure physical symptoms during an index hospitalization in Seoul, Korea. Times to first event of cardiac rehospitalization and cardiac death were collected for 12 months after discharge and confirmed by review of hospital records. An agglomerative hierarchical clustering approach with Wards method was used to identify symptom clusters. Hierarchical Cox hazard regression was used to determine the impact of symptom clusters on cardiac rehospitalization and cardiac mortality. Results:Two distinct symptom clusters, the dyspneic and the weary symptom clusters, occurred in patients with HF. Shortness of breath, difficulty breathing when lying flat, and waking up breathless at night comprised the dyspneic symptom cluster. Lack of energy, lack of appetite, and difficulty sleeping comprised the weary symptom cluster. In hierarchical Cox hazard regression, elevated distress from the weary symptom cluster independently predicted cardiac rehospitalization (hazard ratio, 1.45; 95% confidence interval, 1.09-1.93), and increased distress from the dyspneic symptom cluster independently predicted cardiac mortality (hazard ratio, 2.00; 95% confidence interval, 1.16-3.34). Conclusion:The weary and the dyspneic symptom clusters predicted cardiac rehospitalization and cardiac mortality, respectively. Patient education for self-monitoring of symptoms should focus on symptom clusters rather than single symptom.

Adherence to a sodium-restricted diet is associated with lower symptom burden and longer cardiac event-free survival in patients with heart failure.

AIM To determine whether adherence to a sodium-restricted diet affects symptom burden and cardiac event-free survival in patients with heart failure. BACKGROUND The recommendation of an sodium-restricted diet is a standard component of HF management. Therefore, it is important to investigate whether adherence to sodium-restricted diet is actually associated with improvements in symptom burden and cardiac event-free survival. DESIGN A prospective cohort study. METHODS A total of 232 patients [71% male, 65 ± 10 years, 63% New York Heart Association (NYHA) class III/IV, ejection fraction (EF) 30 ± 9%] with HF received 24-hour urinary sodium excretion (24-hr UNa) assessments and were divided into two groups using a cut-off value of 3 g 24-hr UNa. Symptom burden, including the frequency and severity of heart failure symptoms, was assessed according to the modified Memorial Symptom Assessment Scale-Heart Failure with a higher score indicating a greater symptom burden. Cardiac event-free survival over a 12-month period was determined by reviewing medical records. RESULTS Patients with 24-hr UNa ≥ 3 g exhibited greater symptom burdens (β = 0·23, p < 0·001) in hierarchical linear regression analyses and shorter cardiac event-free survival [hazard ratio = 1·81, 95% confidence interval = 1·17-2·80) than patients with 24-hr UNa < 3 g in hierarchical Cox hazards regressions, after controlling for age, gender, HF aetiology, body mass index, NYHA class, EF, and total comorbidity score. CONCLUSIONS If sodium intake is limited to less than 3 g/day, symptom burden and clinical health outcomes can be improved in HF patients. RELEVANCE TO CLINICAL PRACTICE Health care providers need to help patients understand the rationale for an sodium-restricted diet to prevent worsening heart failure symptoms and unnecessary cardiac events. Continuous monitoring for dietary sodium intake as well as worsening heart failure symptoms should be emphasised in patient education.

From Novice to Expert: Confidence and Activity Status Determine Heart Failure Self-care Performance.

Background:In a previous, small, mixed-methods study, heart failure patients were described as novice, expert, or inconsistent in self-care. In that study, self-care types differed in experience, confidence, attitudes, and skill. Objectives:The aims of this study were to validate the novice-to-expert self-care typology and to identify determinants of the heart failure self-care types. Methods:A cross-sectional descriptive study was performed using data from 689 adults with heart failure (61 ± 2.5 years; 36% female, 50% New York Heart Association class III). Two-step likelihood cluster analysis was used to classify patients into groups using all items in the maintenance and management scales of the Self-care of Heart Failure Index. Multinomial regression was used to identify the determinants of each self-care cluster, testing the influence of age, gender, left ventricular ejection fraction, body mass index, depression, anxiety, hostility, perceived control, social support, activity status (Duke Activity Status Index), and self-care confidence. Results:Self-care behaviors clustered best into three types: novice (n = 185, 26.9%), expert (n = 229, 33.2%), and inconsistent (n = 275, 39.9%). The model predicting self-care cluster membership was significant (&khgr;2 = 88.67, p < .001); Duke Activity Status Index score and Self-care of Heart Failure Index confidence score were the only significant individual factors. Higher activity status increased the odds that patients would be inconsistent (odds ratio [OR] = 1.02-1.09) or novice (OR = 1.02-1.10) in self-care. Higher self-care confidence increased the odds of being an expert (OR = 1.05-1.09) or inconsistent (OR = 1.01-1.05) in self-care. Discussion:The three-level typology of heart failure self-care was confirmed. Patients who have fewer limitations to daily activities may not be driven adequately to engage in heart failure self-care and may need extra assistance in developing expertise.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

Background:Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable. Objective:The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival. Methods:A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or &khgr;2 test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event. Results:Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37). Conclusion:Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Depressive symptoms increase risk of rehospitalisation in heart failure patients with preserved systolic function

AIMS To examine the impact of depressive symptoms on rehospitalisation for heart failure exacerbation in patients with preserved systolic function. BACKGROUND Depressive symptoms associated with higher risk of rehospitalisation have been primarily demonstrated in heart failure patients with systolic dysfunction (ejection fraction <40%) and the factors influencing rehospitalisation of patients with preserved systolic function (ejection fraction > or =40%) remain unclear. DESIGN A prospective, descriptive study design was used. METHODS The following baseline data were collected from 165 patients with preserved systolic function during an index hospitalisation for heart failure in South Korea: age, gender, body mass index, New York Heart Association functional class, the ratio of mitral velocity to early diastolic velocity of the mitral annulus, comorbidities, history of prior admission and depressive symptoms. Patients were followed monthly for six months after discharge to collect date on all rehospitalisation for heart failure exacerbation. Hierarchical Cox proportional hazards regression was used to identify independent predictors of rehospitalisation. Kaplan-Meier survival curves with log-rank test were used to determine differences in time to rehospitalisation according to severity of depressive symptoms. RESULTS Almost half of the patients (48%) had moderate to severe depressive symptoms. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (hazard ratio = 1.06, 95% confidence interval = 1.02-1.10) and depressive symptoms (hazard ratio = 1.05, 95% confidence interval = 1.02-1.08) independently predicted rehospitalisation after controlling for other risk factors. Moderate and severe depressive symptoms were associated with both a higher rate and shorter time to rehospitalisation. CONCLUSIONS Moderate to severe depressive symptoms predict early rehospitalisation for heart failure exacerbations in patients with preserved systolic function. RELEVANCE TO CLINICAL PRACTICE Nurses should assess for depressive symptoms in patients with heart failure and refer those with depressive symptoms for treatment to improve outcomes.

Depressive Symptoms Affect the Relationship of N-Terminal Pro B-Type Natriuretic Peptide to Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND Both N-terminal pro B-type natriuretic peptide (NT-pro BNP) and depressive symptoms independently predict cardiac events in heart failure (HF) patients. However, the relationship among NT-pro BNP, depressive symptoms, and cardiac event is unknown. METHODS AND RESULTS Blood was drawn to measure NT-pro BNP and depressive symptoms were measured by the Patient Health Questionnaire 9 (PHQ-9) among 210 patients with HF. Data about cardiac event-free survival were collected for the average follow-up period of 397 days. Cox proportional hazards regression with survival curves were used to determine the relationship of NT-pro BNP and depressive symptoms to cardiac event-free survival. Higher NT-pro-BNP confers greater risk of cardiac events among those with depressive symptoms than those without depressive symptoms (P for the interaction = .029). Patients with NT-pro BNP > 581 pg/mL and total PHQ-9 score >/= 10 had a 5.5 times higher risk for cardiac events compared with patients with NT-pro BNP </= 581 pg/mL and total PHQ-9 score < 10 (P = .001). CONCLUSIONS The prognostic association of NT-pro BNP with cardiac event-free survival in patients with HF differed by the presence of depressive symptoms. Monitoring and treatment of depressive symptoms may be important for improving cardiac event-free survival in patients with HF.

The Association Between Regular Symptom Monitoring and Self-care Management in Patients With Heart Failure

Background:Symptom monitoring is considered the first step toward self-care management (actions to manage altered symptom status) to avert worsening heart failure (HF). However, empirical evidence demonstrating that symptom monitoring leads to adequate self-care management is lacking. We examined the relationship of adherence to regular symptom monitoring with adequate self-care management in HF patients. Methods and Results:A total of 311 HF patients (60 years, 35% women) were divided into 3 groups by adherence to 2 symptom monitoring behaviors (monitoring daily weights and lower extremity edema). Patients who were adherent to both symptom monitoring behaviors formed the adherent group (15.1%). Those adherent to either of the symptom monitoring behaviors formed the partially adherent group (28.9%). Those adherent to neither of the symptom monitoring behaviors formed the nonadherent group (56.0%). The adjusted odds of performing adequate self-care management were increased by 225% (95% confidence interval, 1.13–4.48) and 344% (95% confidence interval, 1.55–7.62) for the partially adherent and adherent symptom monitoring groups, respectively, compared with the nonadherent group. Conclusion:Adequacy of self-care management was predicted by adherence to symptom monitoring behaviors. This finding suggests that regular symptom monitoring facilitates performance of adequate self-care management, which may contribute to a decrease in preventable hospitalizations in HF.

Dietary sodium restriction below 2 g per day predicted shorter event-free survival in patients with mild heart failure.

Background: Despite a growing recognition that a strict low sodium diet may not be warranted in compensated heart failure (HF) patients, the link between sodium restriction below 2 g/day and health outcomes is unknown in patients at different levels of HF severity. Purpose: The purpose of this study was to compare differences in event-free survival among patients with <2 g/day, 2–3 g/day, or >3 g/day sodium intake stratified by New York Heart Association (NYHA) class. Method: A total of 244 patients with HF completed a four-day food diary to measure daily sodium intake. All-cause hospitalization or death for a median of 365 follow-up days and covariates on age, gender, etiology, body mass index, NYHA class, ejection fraction, total comorbidity score, the presence of ankle edema, and prescribed medications were determined by patient interview and medical record review. Hierarchical Cox hazard regression was used to address the purpose. Results: In NYHA class I/II (n=134), patients with <2 g/day sodium intake had a 3.7-times higher risk (p=0.025), while patients with >3 g/day sodium intake had a 0.4-times lower risk (p=0.047) for hospitalization or death than those with 2–3 g/day sodium intake after controlling for covariates. In NYHA class III/IV (n=110), >3 g/day sodium intake predicted shorter event-free survival (p=0.044), whereas there was no difference in survival curves between patients with <2 g/day and those with 2–3 g/day sodium intake. Conclusion: Sodium restriction below 2 g/day is not warranted in mild HF patients, whereas excessive sodium intake above 3 g/day may be harmful in moderate to severe HF patients.

Factors related to incidence of eye disorders in Korean patients at intensive care units.

AIMS The purpose of this study was to identify the incidence rate of eye disorders and further to identify factors related to incidence of eye disorders in intensive care unit patients. BACKGROUND Although the incidence of eye disorders in intensive care unit patients is very high, it is difficult to come to an accurate estimate of number of eye disorders in intensive care unit patients because eye disorders are often perceived to be minor problems. DESIGN A retrospective, descriptive survey design was used. METHOD The medical records of a total 235 patients with eye disorders were identified through a review of the medical records of 2,500 patients hospitalised in the intensive care units of Yonsei University Hospital, Seoul, Korea from January to December, 2004. To examine factors related to eye disorders, 522 patients without eye disorders from the cohort of 2,265 patients were randomly selected. Factors related to incidence of eye disorder were included in a multiple logistic regression model, after screening by the chi-squared test. RESULTS The incidence rate for eye disorders in the intensive care unit patients was 8.6%. From the multiple regression model, the following odds ratios (95% confidence intervals) of eye disorder were estimated; length of stay in intensive care unit of at least seven days: 2.8 (1.70-4.70); death: 2.5 (1.47-4.29); drowsy mental state: 2.2 (1.10-4.37); stupor mental state: 7.0 (3.20-15.45); coma mental state: 10.8 (3.47-33.74); no self-respiration: 1.9 (1.00-3.52); positive end expiratory pressure: 2.9 (1.66-4.92); sedatives: 4.2 (2.26-7.74); muscle relaxants: 2.3 (1.11-4.95). CONCLUSIONS Factors related to incidence of eye disorders in intensive care unit patients identified in this study support the need to pay attention to eye problems and eye care in intensive care unit patients. RELEVANCE TO CLINICAL PRACTICE An evidence-based eye care protocol should be provided as routine care to prevent eye complication, especially in critically ill patients with mechanical ventilators, positive end expiratory pressure, sedatives or muscle relaxants and for patients whose mental status is decreased.