Marjan Motie

On-going palliative care enhances perceived control and patient activation and reduces symptom distress in patients with symptomatic heart failure: A pilot study

Introduction: There is a paucity of research about the impact of palliative care (PC) on perceived control (i.e. one’s perceived influence over outcomes or events in the environment) and activation (i.e. ability to self-manage) in patients with symptomatic heart failure (HF). Likewise, little is known about the association between perceived control, activation, and symptom distress in this patient population. We hypothesized that patients with advanced HF who received ongoing PC services (i.e. ≥2 PC consultations) vs no access or a single PC consultation would have greater improvements in perceived control and activation and greater reductions in symptom distress three months post-discharge for HF exacerbation. Methods: Forty-two patients (average age 53.9±8.0 years; predominantly male (72%), White (61%) and married (69%)) participated in the study. However, only 36 (85.7%) patients completed an outpatient PC consultation of which 29 (69%) patients returned for additional follow-up visits with the PC team. Data on perceived control, activation, and symptom distress were collected at baseline and three months. Parametric statistical models were applied to draw conclusions. Results: Findings showed that the patients who received ≥2 PC consultations had greater improvements in perceived control and activation than their counterparts; these increases were associated with greater reductions in symptom distress. Conclusion: Our findings suggest that on-going PC interventions enhance perceived control and activation in patients with advanced HF and open up the possibility of planning larger studies to assess the effect of PC on these variables as possible mediators to improvements in self-management and clinical outcomes.

Examining the effects of remote monitoring systems on activation, self-care, and quality of life in older patients with chronic heart failure

Background:The use of remote monitoring systems (RMSs) in healthcare has grown exponentially and has improved the accessibility to and ability of patients to engage in treatment intensification. However, research describing the effects of RMSs on activation, self-care, and quality of life (QOL) in older patients with heart failure (HF) is limited. Objective:The aim of this study was to compare the effects of a 3-month RMS intervention on activation, self-care, and QOL of older patients versus a reference group matched on age, gender, race, and functional status (ie, New York Heart Association classification) who received standard discharge instructions after an acute episode of HF exacerbation requiring hospitalization. Methods:A total of 21 patients (mean age, 72.7 ± 8.9 years; range, 58–83 years; 52.4% women) provided consent and were trained to measure their weight, blood pressure, and heart rate at home with an RMS device and transmit this information every day for 3 months to a centralized information system. The system gathered all data and dispatched alerts when certain clinical conditions were met. Results:The baseline sociodemographic and clinical characteristics of the 2 groups were comparable. Over time, participants in the RMS group showed greater improvements in activation, self-care, and QOL compared with their counterparts. Data showed moderately strong associations between increased activation, self-care, and QOL. Conclusion:Our preliminary data show that the use of an RMS is feasible and effective in promoting activation, self-care, and QOL. A larger-scale randomized clinical trial is warranted to show that the RMS is a new and effective method for improving clinical management of older adults with chronic HF.

Does preparedness planning improve attitudes and completion of advance directives in patients with symptomatic heart failure

BACKGROUND AND OBJECTIVE There is little evidence to support whether interventions that engage patients with symptomatic heart failure (HF) in preparedness planning impacts completion of advance directives (ADs). This study was conducted to assess the impact of a palliative care intervention on health perceptions, attitudes, receipt of information and knowledge of ADs, discussion of ADs with family and physicians, and completion of ADs in a cohort of patients with symptomatic HF. METHODS Thirty-six patients hospitalized for HF decompensation were recruited and referred for an outpatient consultation with a palliative care specialist in conjunction with their routine HF follow-up visit after discharge; telephone interviews to assess health status and attitudes toward ADs were conducted before and 3 months after the initial consultation using an adapted version of the Advance Directive Attitude Survey (ADAS). Information pertaining to medical history and ADs was verified through medical chart abstraction. RESULTS AND CONCLUSION The current study found support for enhancing attitudes and completion of ADs following a palliative care consultation in patients with symptomatic HF. Despite a significant increase in attitudes toward completion of ADs following the intervention, only 47% of the participants completed ADs. This finding suggests that although education and understanding of ADs is important and can result in more positive attitudes, it does not translate to completion of ADs in all patients.

Pro-HEART - a randomized clinical trial to test the effectiveness of a high protein diet targeting obese individuals with heart failure: rationale, design and baseline characteristics.

There is ample research to support the potential benefits of a high protein diet on clinical outcomes in overweight/obese, diabetic subjects. However, nutritional management of overweight/obese individuals with heart failure (HF) and type 2 diabetes mellitus (DM) or metabolic syndrome (MS) is poorly understood and few clinical guidelines related to nutritional approaches exist for this subgroup. This article describes the design, methods, and baseline characteristics of study participants enrolled in Pro-HEART, a randomized clinical trial to determine the short term and long term effects of a high protein diet (30% protein [~110 g/day], 40% carbohydrates [150 g/day], 30% fat [~50 g/day]) versus a standard protein diet (15% protein [~55 g/day], 55% carbohydrates [~200 g/day], 30% fat [~50 g/day]) on body weight and adiposity, cardiac structure and function, functional status, lipid profile, glycemic control, and quality of life. Between August, 2009 and May, 2013, 61 individuals agreed to participate in the study; 52 (85%) - mean age 58.2 ± 9.8 years; 15.4% Blacks; 57.7% Whites; 19.2% Hispanics; 7.7% Asians; 73.1% male; weight 112.0 ± 22.6 kg - were randomized to a 3-month intensive weight management program of either a high protein or standard protein diet; data were collected at baseline, 3 months, and 15 months. This study has the potential to reveal significant details about the role of macronutrients in weight management of overweight/obese individuals with HF and DM or MS.

Association between inflammatory biomarkers and adiposity in obese patients with heart failure and metabolic syndrome.

Obesity, type 2 diabetes mellitus (DM) and metabolic syndrome (MS) are common in patients with heart failure (HF). Studies investigating the association between known biomarkers and adiposity in patient populations are limited. The aim of the present study was to investigate the association between C-reactive protein (CRP) and leptin with adiposity in a sub-group of overweight/obese patients with HF, DM and/or MS. A total of 36 patients (mean age, 56.72±9.78 years; ranging between 27 and 76 years of age; 80.6% male; 52.8% Caucasian) were enrolled and their height, weight, waist circumference and body composition (e.g. percentage body fat and lean mass), as well as the levels of CRP and leptin, were assessed. The results demonstrated that there was a significant association between CRP and leptin, CRP and body mass index (BMI) and gender and percentage body fat (P<0.05, for all associations). Analysis of leptin and CRP levels revealed that patients in the highest BMI quartile (BMI, 40.3–61.2) had higher CRP levels (4.83 μg/ml vs. 3.03 μg/ml; P=0.033) and higher leptin levels (44.97 ng/ml vs. 24.64 ng/ml; P=0.042) compared with patients in the lower BMI quartile (BMI, 28.6–32.4). In conclusion, among obese patients with HF, DM and/or MS, an association between CRP and leptin was identified, providing further evidence that metabolic and inflammatory mechanisms are involved in these diseases. Future investigation to assess the potential impact of inflammation and adiposity, and the role of dietary interventions and weight loss on clinical outcomes in this population of chronically ill patients is warranted.

Relationships between Weight, Adiposity, Functional Status, and Left Ventricle Characteristics in Overweight and Obese Patients with Heart Failure

Aims This study was conducted to examine the relationship between adiposity and functional status (i.e. peak oxygen consumption [VO2max]), and left ventricular (LV) structural characteristics (i.e., LV ejection fraction [LVEF], LV end diastolic dimension [LVEDD], LV posterior wall thickness [LVPWT]) in heart failure (HF) patients with diabetes mellitus (DM), and/or metabolic syndrome (MS). We hypothesize that excess weight and body fat are significantly related to cardiac functional status. Methods and Results Ninety four patients’ clinical characteristics were analyzed at baseline to examine the relationships of interest. Results show that weight was correlated with fat and lean mass and LVEF (all p’s < 0.050). Novel findings from our data showed that weight, fat mass, and percent fat were inversely related to VO2max; weight, fat mass and lean mass were positively related with LVPWT. In a multivariate analysis, body mass index and fat mass accounted for 28.8% of the variance in VO2max, showing significantly higher predictive value than other covariates (P = 0.002). Conclusions Our findings show a possible relationship between body fat on functional status in this patient cohort and challenges existing research that supports that higher weight and increased fat are good in the setting of chronic HF (i.e. obesity paradox). Strategies to optimize weight and reduce adiposity warrants further investigation in this subgroup of patients.

Effect of weight loss on renal function in overweight and obese patients with heart failure

AIMS The effect of intentional weight loss on glomerular filtration rate (GFR) in overweight and obese patients with heart failure (HF), diabetes mellitus (DM) and/or metabolic syndrome (MS) has not been studied. The purpose of the present study is to assess the short term effects of intentional weight loss on renal function in this population. MATERIALS AND METHODS Fifty nine patients were recruited to participate in a 3-month intensive behavioral weight management intervention and received one of two standard structured energy-restricted meal plans (1200 or 1500kcal/day) based on their computed calorie deficit. Weight and renal function (serum creatinine, BUN and estimated glomerular filtration rate based on two formulas - Modification in Renal Disease Study (MDRD), and modified version of Cockcroft-Gault formula reported by Salazar Corcoran for obese patients (absolute and relative formulas) - were evaluated at baseline and at 3 months. RESULTS Participants had eGFR in the normal range at baseline and lost an average of 7.56±14.9 pounds (p<0.0001) over 3 months; however, there was no significant reduction in serum creatinine, BUN or eGFR. CONCLUSION This study provides evidence that intentional weight loss in overweight and obese patients with HF along with DM, and/or MS and normal baseline renal function does not adversely affect renal function overtime.