Muna Hammash

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

Background Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure. Aims To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure. Methods A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS). Results Cronbach’s alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22–.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman’s rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t318 = −5.05, p < .001) supported construct validity. Conclusion The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

‘It could be worse … lot's worse!’ Why health-related quality of life is better in older compared with younger individuals with heart failure

BACKGROUND health-related quality of life (HRQOL) is markedly impaired in patients with heart failure (HF). Despite worse prognosis and physical status, older patients have better HRQOL than younger patients. OBJECTIVE to determine reasons for differences in HRQOL in older compared with younger HF patients. METHODS a mixed methods approach was used. HRQOL was assessed using the Minnesota Living with HF Questionnaire and compared among HF patients (n = 603) in four age groups (≤ 53, 54-62, 63-70 and ≥ 71 years). Socio-demographic/clinical and psychological factors related to HRQOL were determined in four groups using multiple regressions. Patients (n = 20) described their views of HRQOL during semi-structured interviews. RESULTS HRQOL was worse in the youngest group, and best in the two oldest groups. The youngest group reported higher levels of depression and anxiety than the oldest group. Anxiety, depression and functional capacity predicted HRQOL in all age groups. Qualitatively, patients in all age groups acknowledged the negative impact of HF on HRQOL; nonetheless older patients reported that their HRQOL exceeded their expectations for their age. Younger patients bemoaned the loss of activities and roles, and reported their HRQOL as poor. CONCLUSIONS better HRQOL among older HF patients is the result, in part, of better psychosocial status. The major factor driving better HRQOL among older patients is a change with advancing age in expectations about what constitutes good HRQOL.

Psychological Aspects of Heart Failure

Psychological conditions such as depression can have a greater impact on morbidity and mortality outcomes than traditional risk factors for these outcomes. Despite their importance, it is rare for clinicians to assess patients for these conditions and rarer still for them to consistently and adequately manage them. Illumination of the phenomena of comorbid psychological conditions in heart failure may increase awareness of the problem, resulting in improved assessment and management.

Beyond social support: Self-care confidence is key for adherence in patients with heart failure:

Background: Adherence to treatment is crucial to improve outcomes in patients with heart failure. Good social support is associated with better adherence, but the mechanism for this association has not been well-explored. Aims: The aim of this secondary analysis was to examine whether self-care confidence mediates the relationship between social support and treatment adherence in heart failure patients hospitalized with acute exacerbation. Methods: A total of 157 inpatients with heart failure (63.5±13 years, 73% New York Heart Association class III/IV) were recruited from two hospitals located in urban areas in the USA. Participants completed the Self-Care of Heart Failure Index, the Multidimensional Perceived Social Support Scale, and the Medical Outcomes Study Specific Adherence Scale. A series of regression models were used to determine the mediation relationship. Results: Controlling for marital status and hospital site, social support was associated with adherence (p=0.03). When self-confidence was included in the model, the effect of social support became non-significant, indicating full mediation of the relationship between social support and adherence by self-care confidence. The indirect effect (0.04) of social support on adherence through self-confidence was significant (95% confidence interval: 0.01–0.09). Conclusion: Heart failure self-care confidence mediated the relationship between social support and treatment adherence. Thus interventions targeting patients’ self-care confidence is essential to maximize patients’ treatment adherence.

Heart Rate Variability as a Predictor of Cardiac Dysrhythmias During Weaning From Mechanical Ventilation

BACKGROUND Weaning from mechanical ventilation to spontaneous breathing is associated with changes in the hemodynamic and autonomic nervous systems that are reflected by heart rate variability. Although cardiac dysrhythmias are an important manifestation of hemodynamic alterations, the impact of heart rate variability on the occurrence of dysrhythmias during weaning has not been specifically studied. OBJECTIVES To describe differences in heart rate variability spectral power and occurrence of cardiac dysrhythmias at baseline and during the initial trial of weaning from mechanical ventilation and to evaluate the impact of heart rate variability during weaning on occurrence of dysrhythmias. METHOD Continuous 3-lead electrocardiographic recordings were collected from 35 patients receiving mechanical ventilation for 24 hours at baseline and during the initial weaning trial. Heart rate variability was evaluated by using spectral power analysis. RESULTS Low-frequency power increased (P = .04) and high-frequency and very-low-frequency power did not change during weaning. The mean number of supraventricular ectopic beats per hour during weaning was higher than the mean at baseline (P < .001); the mean of ventricular ectopic beats did not change. Low-frequency power was a predictor of ventricular and supraventricular ectopic beats during weaning (P < .001). High-frequency power was predictive of ventricular and supraventricular (P = .02) ectopic beats during weaning. Very-low-frequency power was predictive of ventricular ectopic beats (P < .001) only. CONCLUSION Heart rate variability power spectra during weaning were predictive of dysrhythmias.

Implantable cardioverter defibrillator knowledge and end-of-life device deactivation: A cross-sectional survey

Background: End-of-life implantable cardioverter defibrillator deactivation discussions should commence before device implantation and be ongoing, yet many implantable cardioverter defibrillators remain active in patients’ last days. Aim: To examine associations among implantable cardioverter defibrillator knowledge, patient characteristics and attitudes to implantable cardioverter defibrillator deactivation. Design: Cross-sectional survey using the Experiences, Attitudes and Knowledge of End-of-Life Issues in Implantable Cardioverter Defibrillator Patients Questionnaire. Participants were classified as insufficient or sufficient implantable cardioverter defibrillator knowledge and the two groups were compared. Setting/participants: Implantable cardioverter defibrillator recipients (n = 270, mean age 61 ± 14 years; 73% male) were recruited from cardiology and implantable cardioverter defibrillator clinics attached to two tertiary hospitals in Melbourne, Australia, and two in Kentucky, the United States. Results: Participants with insufficient implantable cardioverter defibrillator knowledge (n = 77, 29%) were significantly older (mean age 66 vs 60 years, p = 0.001), less likely to be Caucasian (77% vs 87%, p = 0.047), less likely to have received implantable cardioverter defibrillator shocks (26% vs 40%, p = 0.031), and more likely to have indications of mild cognitive impairment (Montreal Cognitive Assessment score <24: 44% vs 16%, p < 0.001). Insufficient implantable cardioverter defibrillator knowledge was associated with attitudes suggesting unwillingness to discuss implantable cardioverter defibrillator deactivation, even during the last days towards end of life (p < 0.05). Conclusion: Implantable cardioverter defibrillator recipients, especially those who are older or have mild cognitive impairment, often have limited knowledge about implantable cardioverter defibrillator deactivation. This study identified several potential teachable moments throughout the patients’ treatment trajectory. An interdisciplinary approach is required to ensure that discussions about implantable cardioverter defibrillator deactivation issues are initiated at appropriate time points, with family members ideally also included.

Depressive Symptoms: Mediator of Event-Free Survival in Patients With Heart Failure.

Depressive symptoms and poor health perceptions are predictors of higher hospitalization and mortality rates (heart failure [HF]). However, the association between depressive symptoms and health perceptions as they affect event-free survival outcomes in patients with HF has not been studied. The purpose of this secondary analysis was to determine whether depressive symptoms mediate the relationship between health perceptions and event-free survival in patients with HF. A total of 458 HF patients (61.6 ± 12 years, 55% New York Heart Association Class III/IV) responded to one-item health perception question and completed the Patient Health Questionnaire–9. Event-free survival data were collected for up to 4 years. Multiple regression and Cox proportional hazards regression analysis showed that depressive symptoms mediated the relationship between health perceptions and event-free survival. Decreasing depressive symptoms is essential to improve event-free survival in patients with HF.