Karen Vuckovic

Effects of Exercise Interventions on Peripheral Vascular Endothelial Vasoreactivity in Patients with Heart Failure with Reduced Ejection Fraction

Changes in vascular function, such as endothelial dysfunction are linked to the progression of heart failure (HF) and poorer outcomes, such as increased hospitalisations. Exercise training may positively influence endothelial function in HF patients with reduced ejection fraction. The aim of this manuscript is to summarise HF studies evaluating the influence of exercise training on endothelial function as measured by flow mediated vasodilation as a primary outcome and to provide recommendations for future research studies designed to improve peripheral vascular function in HF. Databases were searched for studies published between 1995 and December 2011. Two reviewers determined eligibility and extracted information on study characteristics and quality, exercise interventions, and endothelial function. Eleven articles (N=318 HF participants with an ejection fraction <40%) were eligible for full review. Aerobic, resistance, or combined exercise training improved endothelium-dependent vasodilation as measured by ultrasound or plethysmography. There is less evidence supporting improvement in endothelium-independent function with exercise training. Sample sizes were small and predominantly male. Future research is needed to address the best mode and optimal dose of exercise for all patients with HF including women and subgroups with specific co-morbidities.

Defining the System: Contributors to Exercise Limitations in Heart Failure

One of the primary hallmarks of patients diagnosed with heart failure (HF) is a reduced tolerance to exercise and compromised functional capacity. This limitation stems from poor pumping capacity but also major changes in functioning of the vasculature, skeletal muscle, and respiratory systems. Advances in the understanding of the central and peripheral mechanisms of exercise intolerance during HF are critical for the future design of therapeutic modalities devised to improve outcomes. The interrelatedness between systems cannot be discounted. This review summarizes the current literature related to the pathophysiology of HF contributing to poor exercise tolerance, and potential mechanisms involved.

Systematic review of symptom clusters in cardiovascular disease.

Background: Although individual symptoms and symptom trajectories for various cardiovascular conditions have been reported, there is limited research identifying the symptom clusters that may provide a better understanding of patients’ experiences with heart disease. Aims: To summarize the state of the science in symptom cluster research for patients with acute coronary syndrome, myocardial infarction, coronary artery bypass surgery, and heart failure through systematic review and to provide direction for the translation of symptom cluster research into the clinical setting. Methods: Databases were searched for articles from January 2000 through to May 2015 using MESH terms “symptoms, symptom clusters, acute coronary syndrome (ACS), myocardial infarction (MI), coronary heart disease (CHD), ischemic heart disease (IHD), heart failure (HF), coronary artery bypass surgery (CABS), cluster analyses, and latent classes.” The search was limited to human studies, English language articles, and original articles investigating symptom clusters in individuals with heart disease. Fifteen studies meeting the criteria were included. Results: For patients with ACS and MI, younger persons were more likely to experience clusters with the most symptoms. Older adults were more likely to experience clusters with the lowest number of symptoms and more diffuse and milder symptom clusters that are less reflective of classic ACS presentations. For HF patients, symptom clusters frequently included physical and emotional/cognitive components; edema clustered in only three studies. Symptom expression was congruent across geographical regions and cultures. Conclusions: The findings demonstrated similarities in symptom clusters during ACS, MI, and HF, despite multiple methods and analyses. These results may help clinicians to prepare at-risk patients for proper treatment-seeking and symptom self-management behaviors.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

Background: Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences. Objective: The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS. Methods: A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured. Results: The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00–2.42), shoulder pain (OR, 1.76; CI, 1.13–2.73), and upper back pain (OR, 2.92; CI, 1.81–4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women. Conclusions: Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

Measurement of Dyspnea in Ambulatory African Americans With Heart Failure and a Preserved or Reduced Ejection Fraction

Background:Dyspnea is a burdensome and disabling heart failure (HF) symptom. Few studies examining dyspnea in HF have included African Americans (AAs), despite their developing HF at a younger age and having the highest mortality rates. Objective:The purpose of this cross-sectional study was to examine dyspnea in AA patients with HF and a preserved ejection fraction (HFpEF) compared with those with a reduced ejection fraction (HFrEF), before and after the 6-minute walk test (6MWT). Methods:A convenience sample of ambulatory AA patients (HFrEF, n = 26; HFpEF, n = 19) 50 years or older was recruited from an urban HF clinic. The Borg Scale and a visual analog scale (VAS) were used to measure dyspnea intensity before and after the 6MWT. Activity limitations related to dyspnea were described using the modified Medical Research Council Dyspnea Scale. Group comparisons were analyzed using repeated-measures analysis of variance and &khgr;2 tests. Convergent validity was determined between the Borg and VAS using Bland-Altman plots. Results:No significant differences were found in age, gender, and comorbidities between HF groups. Most HFpEF patients reported dyspnea at baseline (Borg, 63%; VAS, 73%) and after the 6MWT (Borg, 78%; VAS, 79%). In the HFrEF group, the prevalence of baseline dyspnea was greater when measured with the VAS (Borg, 34%; VAS, 80%) but was similar between instruments after the 6MWT (Borg, 64%; VAS, 77%). Both groups reported a similar change in dyspnea intensity during and after the 6MWT. The Bland-Altman plots indicated moderate agreement at each time point. Most patients described walking hurriedly or uphill as dyspnea-provoking on the Modified Respiratory Council Dyspnea Scale. Conclusions:The prevalence of dyspnea at baseline and after the 6MWT was high for both groups, but intensity varied with the dyspnea instrument used.

The 6-min walk test: is it an effective method for evaluating heart failure therapies?

The 6-min walk (6MW) is a self-paced test for measuring functional capacity. Lower 6MW distances have been associated with adverse outcomes in patients with heart failure. The purpose of this article is to describe the history of the 6MW test and to evaluate its reliability, validity, and predictive value as well as the responsiveness of the test to therapies. In the literature we reviewed, reliability was affected by several factors including learning effects and protocol deviations. The 6MW distance was moderately correlated with peak oxygen consumption derived from cardiopulmonary exercise stress testing. In some studies the 6MW distance was predictive of hospitalization and mortality. In pharmacological and cardiac resynchronization trials the 6MW distance did not consistently detect clinical improvements. Despite limitations, the 6MW test is a viable alternative to stress testing for objectively evaluating functional capacity in some settings. We provide recommendations for using the 6MW test in future studies.

Improving the Heart Failure Readmission Rate at an Urban Medical Center

Background: Heart failure (HF) is a chronic health condition that affects over 5 million people annually. It is the most common cause of 30-day readmissions with nearly 90% of these readmissions being unplanned. CMS requires hospitals to publicly report 30 day readmission rates for HF with the goal of improving accountability. In 2006, this hospitals 30-day readmission rate was 27% as compared to the national average of 24%. Purpose: To analyze the impact of several quality improvement interventions on 30-day readmission rates for HF at this urban medical center. Intervention: The following interdisciplinary interventions were implemented in the third quarter of 2009: (1) improved nursing discharge education regarding heart failure (ie. sodium restricted diet, medication adherence, daily weight); (2) a detailed medication list was given to patients; (3) patients received an appointment within 2 weeks with an advanced practice nurse (APN) specializing in heart failure; (4) HF patients received their medications prior to discharge; (5) all patients received a follow-up phone call by an APN within 7-10 days of discharge; (6) the hospital billing personnel analyzed patients charts to ensure that HF admissions were being coded appropriately. Methods: Patients were included if their initial admission was coded DRG 428 as their primary diagnosis and were readmitted within 30 days with any diagnosis. Data was summarized into 7, 14, and 30 day readmission rates. Rates were compared prior to the intervention and after. Pearson chi square was used to compare the two groups. Conclusion: At one year, the 30-day readmission rate decreased from 27.1% to 18.2% (p = 0.000) the 14 day readmission rate decreased from 15.1% to 9.1% (p=.003) and the 7 day readmission rate decreased from 8.8% to 5.5% (p=.038). Overall, patients were 1.6 times less likely to be readmitted for HF after the intervention. Recommendations: Hospitals can implement tailored interdisciplinary interventions to decrease their readmission rates. Sustainability of these process improvements will be critical to maintaining a high level of care for HF patients.

Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department

Background: It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions. Aims: Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis. Methods: A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis. Results: The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS. Conclusions: Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.

What's the Risk? Older Women Report Fewer Symptoms for Suspected Acute Coronary Syndrome than Younger Women

Abstract The purpose of the study was to determine whether older (≥65 years) and younger (<65 years) women presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome (ACS) varied on risk factors, comorbid conditions, functional status, and symptoms that have implications for emergent cardiac care. Women admitted to five EDs were enrolled. The ACS Symptom Checklist was used to measure symptoms. Comorbid conditions and functional status were measured with the Charlson Comorbidity Index and Duke Activity Status Index. Logistic regression models were used to evaluate symptom differences in older and younger women adjusting for ACS diagnosis, functional status, body mass index (BMI), and comorbid conditions. Analyses were stratified by age, and interaction of symptom by age was tested. Four hundred women were enrolled. Mean age was 61.3 years (range 21–98). Older women (n = 163) were more likely to have hypertension, hypercholesterolemia, never smoked, lower BMI, more comorbid conditions, and lower functional status. Younger women (n = 237) were more likely to be members of minority groups, be college-educated, and have a non-ACS discharge diagnosis. Younger women had higher odds of experiencing chest discomfort, chest pain, chest pressure, shortness of breath, nausea, sweating, and palpitations. Lack of chest symptoms and shortness of breath (key symptoms triggering a decision to seek emergency care) may cause older women to delay seeking treatment, placing them at risk for poorer outcomes. Younger African American women may require more comprehensive risk reduction strategies and symptom management.

American association of heart failure nurses (AAHFN) position statement on patient access to healthcare

Heart failure (HF) in the United States is at an epidemic level with an increasing incidence as the population ages and technology advances.1 Although a diagnosis of HF is marked by frequent hospitalizations, increased mortality and loss of quality-adjusted life years, advances in evidenced-based therapies and quality of care have significantly improved outcomes for patients. All patients with HF regardless of their age, geographic location or socioeconomic circumstances should have the opportunity to receive high level quality care and comprehensive individualized patient education. Patients who are educated and engaged in their care are more likely to have positive outcomes such as fewer hospitalizations and improved quality of life.2,3 Often nurses help the patient, family and caregiver to manage the complexities of HF care and the transition from hospital to home.