Kathleen Duncan

The effects of exercise training on fatigue and dyspnea in heart failure.

Background: Physiological benefits of exercise training for heart failure (HF) patients have been demonstrated, however little is known about the effects of training on the symptoms of fatigue and dyspnea. Aim: The purpose of this study was to examine HF symptoms of fatigue and dyspnea in response to a 24-week exercise training intervention. Methods: This pilot study was a randomized, two-group repeated measures design. Fifteen subjects in the intervention group completed a combination of aerobic and resistance training three times per week in a standard cardiac rehabilitation setting. The control group consisted of 6 subjects who were instructed not to begin any formal exercise program during the 24-week intervention. Results: Subjects (19 males and 2 females) had a mean age of 66.2 ± 10.2 years and mean ejection fraction (EF) of 28.4 ± 7.4%. Non-parametric Friedman Analysis of Variance by Ranks showed the exercise group significantly decreased sensory fatigue (Piper Fatigue Scale) over time (χ 2 = 6.49, p = .04) while the control group did not change (χ 2 = 0.93, p = .63). Dyspnea showed a non-significant decrease over time for the exercise group (χ 2 = 4.16, p = .13) while the control group showed a decrease from baseline to 12 weeks but an increase to above baseline values by week 24 (χ 2 = 0.18, p = .91). Conclusion: These results provide support for the beneficial effects of exercise training on symptoms of fatigue and dyspnea in HF patients. Larger studies to evaluate symptom response to exercise are needed.

Cluster analysis of symptom occurrence to identify subgroups of heart failure patients: a pilot study.

Background and Research Objective:The aim of this small-scale study was to explore the use of cluster analysis to identify subgroups of heart failure patients whose patterns of symptoms may help guide clinical management. The empirically derived clusters were compared on (1) demographics, (2) clinical characteristics, and (3) subscales of the Kansas City Cardiomyopathy Questionnaire. Subjects and Methods:A demographics questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the investigator-developed Heart Failure Symptom Survey were mailed to a random sample of 300 patients at a Midwestern outpatient heart failure clinic. Results and Conclusions:Of 139 respondents, 33 (24%) were female and 106 (76%) were male. The mean (SD) age was 70.6 (9.7) years, and all were white, except for a single African American female. Most subjects were married (84%) with a median level of high school education, and 5% were New York Heart Association classification I, 38% class II, 52% class III, and 5% class IV. Hierarchical cluster analysis was used to derive a 3-cluster solution based on the presence or absence of 14 symptoms. Cluster 1 patients had significantly lower incidence of symptoms and were more likely to be New York Heart Association class I or class II, with lower body mass index and higher education levels compared with patients in the other clusters. Both clusters 2 and 3 were more symptomatic than cluster 1. Compared with cluster 3, patients in cluster 2 reported more shortness of breath under circumstances other than activity, and the majority reported difficulty sleeping. They also tended to report greater symptom severity and impact on physical activity and enjoyment of life. Additional differences included comorbidities and percentage of subjects on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Examination of the clusters suggested clinical implications related to pharmacological management and raised questions concerning potential influences of duration of the heart failure condition, presence of sleep-disordered breathing, and impact of educational level on self-management behavior and symptom patterns.

Effects of Performance Feedback on Patient Pain Outcomes

The purpose of this study was to examine the effects of an individual feedback intervention provided to nurses on selected patient outcomes related to postoperative pain management. Individual performance feedback served as the intervention. Thirty orthopedic staff nurses received feedback information on their past performance of recommended pain management practices. Data were collected preintervention and postintervention on selected patient pain outcomes from the medical records of 240 patients who had undergone total knee arthroplasty. The patient outcome measures were mean 4-hour pain intensity ratings, mean highest pain intensity ratings, mean number of times pain ratings exceeded patients’ acceptable level of pain, mean administered morphine equivalents, and mean pain ratings on reassessment following analgesia administration. An improvement was noted in all pain outcomes following the feedback intervention. Results indicate that providing nurses with feedback on their past performance of pain management practices may contribute to decreased postoperative pain.

A self-directed adherence management program for patients with heart failure completing combined aerobic and resistance exercise training

This study measured the impact of the Exercise Adherence Management Program (EAMP) provided to 20 patients with heart failure (HF) who participated in a combined resistance and aerobic exercise training program during two 12-week phases. The EAMP included strategies designed to support exercise self-efficacy and adherence. Results indicate that an improvement in exercise self-efficacy occurred during the study period, whereas exercise adherence declined during the unsupervised phase. The highest rated adherence strategy for helpfulness and self-efficacy was group sessions. The study supports the use of adherence strategies based on self-efficacy in exercise programs for patients with HF.

Psychological responses and adherence to exercise in heart failure.

Purpose: The purpose of this study was to describe psychological effects and exercise adherence during a multicomponent exercise training intervention. Methods: A sample of 42 patients with heart failure were randomized into an exercise (INV) group (n = 22) and an attention control (AC) group (n = 20). The exercise protocol included two 12‐week phases, a structured phase and a self‐managed phase. The psychological responses assessed were mood states and exercise self‐efficacy. To meet the second purpose of the study, the exercise group was dichotomized based on the number of sessions completed to create two adherence subgroups. Findings: Results indicate self‐efficacy improved for the INV group and was maintained during the self‐management phase. The adherence subgroups demonstrated different patterns for weekly exercise. Depression and confusion scores improved for the high‐adherence group in contrast to worsening for the low‐adherence group. Conclusions: Results suggest a need for further study of the psychological responses of exercise adherence for patients with heart failure. Clinical Relevance: The study indicates the importance of continuous assessment of exercise participation and longer term adherence support for patients with heart failure.

Relationship of resting B-type natriuretic peptide level to cardiac work and total physical work capacity in heart failure patients.

PURPOSE Plasma B-type natriuretic peptide (BNP) levels obtained at rest have been previously shown to be correlated with the global functional capacity measures of peak oxygen uptake (&OV0312;O2peak) and the minute ventilation/carbon dioxide (VE/&OV0312;CO2) slope. The purpose of this study was to assess the relationship of the plasma BNP level to the rate-pressure product (RPP) as an indicator of central or cardiac work capacity. METHODS Twenty-two subjects (12 men), mean age 57 ± 12 years, diagnosed with heart failure (8 ischemic/14 nonischemic) were recruited. All subjects were stable on optimal medical therapy for at least 1 month. Blood samples for BNP level analysis were obtained at rest. Subjects underwent a symptom-limited treadmill exercise test using a ramping protocol while &OV0312;O2, heart rate (HR), and blood pressure (BP) were monitored. Correlation analyses were conducted to assess the relationship of BNP level to RPP level, &OV0312;O2peak, VE/&OV0312;CO2 slope, end-tidal CO2 pressure (PETCO2), and left ventricular ejection fraction (LVEF). RESULTS Resting BNP levels were significantly correlated with RPP levels (r = −0.69). The BNP level and the RPP level were correlated with &OV0312;O2peak (r = −0.63 and r = 0.66, respectively) and VE/&OV0312;CO2 slope (r = 0.53 and r = −0.54, respectively). The RPP level but not the BNP level was correlated with PETCO2 (r = 0.57). Neither BNP nor RPP levels were well correlated with LVEF (r = −0.26 and r = 0.14, respectively). DISCUSSION The results of this study suggest that resting plasma BNP level may be a useful clinical measure for evaluating both global functional capacity and myocardial specific work capacity in individuals with heart failure.

Patient-Selected Strategies for Post Cardiac Rehabilitation Exercise Adherence in Heart Failure

Purpose The aim of this study was to evaluate the use of patient-selected exercise adherence strategies following cardiac rehabilitation (CR). Design Twenty patients with heart failure (HF) were recruited and randomly assigned to the intervention or control group at completion of CR. Methods The intervention included the use of six adherence strategies (logs, graphs, pedometers, phone follow-up, education, and a letter from CR staff), which were provided for 6 weeks post CR and during home-based exercise. After 6 weeks, the intervention group selected strategies to continue, and only those were provided for the last 6 weeks. At 12 weeks, patients were retested. Findings Patients with HF demonstrated improvement in distance walked and less HF symptoms and adhered to exercise at levels recommended during CR. Conclusion Inclusion of patient-selected adherence strategies supports continued exercise and helps to sustain physiological improvements. Clinical Relevance Results from this study have implications for CR programs serving HF patients and provide insight into adherence strategies.