Rebecca A. Gary

Family influences on heart failure self-care and outcomes.

Many patient education guidelines for teaching heart failure patients recommend inclusion of the family; however, family-focused interventions to promote self-care in heart failure are few. This article reviews the state of the science regarding family influences on heart failure self-care and outcomes. The literature and current studies suggest that family functioning, family support, problem solving, communication, self-efficacy, and caregiver burden are important areas to target for future research. In addition, heart failure patients without family and those who live alone and are socially isolated are highly vulnerable for poor self-care and should receive focused attention. Specific research questions based on existing science and gaps that need to be filled to support clinical practice are posed.

Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure

OBJECTIVE The purpose of this study is to compare the effectiveness of a combined 12-week home-based exercise (EX)/cognitive behavioral therapy (CBT) program (n=18) with CBT alone (n=19), EX alone (n=20), and with usual care (UC, n=17) in stable New York Heart Association Class II to III heart failure (HF) patients diagnosed with depression. METHODS Depressive symptom severity [Hamilton Rating Scale for Depression (HAM-D)], physical function [6-min walk test (6MWT)], and health-related quality of life (HRQOL) (Minnesota Living with Heart Failure Questionnaire) were evaluated at baseline (T1), after the 12-week intervention/control (T2), and following a 3-month telephone follow-up (T3). A repeated measures analysis of variance was used to determine group differences. Depression severity was dichotomized as minor (HAM-D, 11-14) and moderate-to-major depression (HAM-D, >/=15), and group intervention and control responses were also evaluated on that basis. RESULTS The greatest reduction in HAM-D scores over time occurred in the EX/CBT group (-10.4) followed by CBT (-9.6), EX (-7.3), and UC (-6.2), but none were statistically significant. The combined group showed a significant increase in 6-min walk distance at 24 weeks (F=13.5, P<.001). Among all groups with moderate-to-major depression, only those in CBT/EX had sustained lower HAM-D scores at 12 and 24 weeks, 6MWT distances were significantly greater at 12 (P=.018) and 24 (P=.013) weeks, and the greatest improvement in HRQOL also occurred. CONCLUSIONS Interventions designed to improve both physical and psychological symptoms may provide the best method for optimizing functioning and enhancing HRQOL in patients with HF.

A Trial of Family Partnership and Education Interventions in Heart Failure

BACKGROUND Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (Na) intake and medication adherence (MA). METHODS AND RESULTS HF patient and family member (FM) dyads (n = 117) were randomized to: usual care (UC), patient-FM education (PFE), or family partnership intervention (FPI). Dietary Na (3-day food record), urinary Na (24-hour urine), and MA (Medication Events Monitoring System) were measured at baseline (BL) before randomization, and at 4 and 8 months. FPI and PFE reduced urinary Na at 4 months, and FPI differed from UC at 8 months (P = .016). Dietary Na decreased from BL to 4 months, with both PFE (P = .04) and FPI (P = .018) lower than UC. The proportion of subjects adherent to Na intake (≤2,500 mg/d) was higher at 8 months in PFE and FPI than in UC (χ(2)(2) = 7.076; P = .029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention. CONCLUSIONS Dietary Na intake, but not MA, was improved by PFE and FPI compared with UC. The UC group was less likely to be adherent with dietary Na. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.

Development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test.

Background and Research Objective:Several heart failure (HF) knowledge tools have been developed and tested over the past decade; however, they vary in content, format, psychometric properties, and availability. This article details the development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test (A-HFKT) as a standardized instrument for both the research and clinical settings. Participants and Methods:Development and psychometric testing of the A-HFKT were undertaken with 116 New York Heart Association (NYHA) class II and III community-dwelling HF patients and their family members (FMs) participating in a family intervention study. Internal consistency, reliability, and content validity were examined. Construct validity was assessed by correlating education level, literacy, dietary sodium ingestion, medication adherence, and healthcare utilization with knowledge. Results:Content validity ratings on relevance and clarity ranged from 0.55 to 1.0, with 81% of the items rated from 0.88 to 1.0. Cronbach α values were .84 for patients, .75 for FMs, and .73 for combined results. Construct validity testing revealed a small but significant correlation between higher patient and FM knowledge on sodium restriction questions and lower ingested sodium, r = −0.17, P = .05 and r = −0.19, P = .04, respectively, and between patient knowledge and number of days that medications were taken correctly (diuretics: r = 0.173, P < .05, and angiotensin-converting enzyme: r = 0.223, P = .01). Finally, patients seeking emergency care or requiring hospitalization in the 4 months before study entry were found to have significantly lower FM knowledge using both t test and logistic regression modeling. Conclusions:The A-HFKT was revised using the content and construct validity data and is available for use with HF patients and FMs. The construct validity testing indicates that patient knowledge has a significant relationship to aspects of self-care. Furthermore, family knowledge may influence patient adherence with sodium restriction and healthcare utilization behavior.

Combined Aerobic and Resistance Exercise Program Improves Task Performance in Patients With Heart Failure

OBJECTIVES To assess the effects of a home-based aerobic and resistance training program on the physical function of adults with New York Heart Association (NYHA) class II and III patients and systolic heart failure (HF). DESIGN Randomized controlled trial. SETTING Home based. PARTICIPANTS Stable patients (N=24; mean age, 60 ± 10 y; left ventricular ejection fraction, 25% ± 9%; 50% white; 50% women) with New York Heart Association (NYHA) classes II and III (NYHA class III, 58%) systolic heart failure (HF). INTERVENTION A 12-week progressive home-based program of moderate-intensity aerobic and resistance exercise. Attention control wait list participants performed light stretching and flexibility exercises. MAIN OUTCOME MEASURES A 10-item performance-based physical function measure, the Continuous Scale Physical Functional Performance test (CS-PFP10), was the major outcome variable and included specific physical activities measured in time to complete a task, weight carried during a task, and distance walked. Other measures included muscle strength, HRQOL (Minnesota Living With Heart Failure Questionnaire, Epworth Sleepiness Scale), functional capacity (Duke Activity Status Index), and disease severity (brain natriuretic peptide) levels. RESULTS After the exercise intervention, 9 of 10 specific task activities were performed more rapidly, with increased weight carried by exercise participants compared with the attention control wait list group. Exercise participants also showed significant improvements in CS-PFP10 total score (P<.025), upper and lower muscle strength, and HRQOL (P<.001) compared with the attention control wait list group. Adherence rates were 83% and 99% for the aerobic and resistance training, respectively. CONCLUSIONS Patients with stable HF who participate in a moderate-intensity combined aerobic and resistance exercise program may improve performance of routine physical activities of daily living by using a home-based exercise approach. Performance-based measures such as the CS-PFP10 may provide additional insights into physical function in patients with HF that more commonly used exercise tests may not identify. Early detection of subtle changes that may signal declining physical function that are amenable to intervention potentially may slow further loss of function in this patient population.

The Importance of NLRP3 Inflammasome in Heart Failure

Patients with heart failure continue to suffer adverse health consequences despite advances in therapies over the past 2 decades. Identification of novel therapeutic targets that may attenuate disease progression is therefore needed. The inflammasome may play a central role in modulating chronic inflammation and in turn affecting heart failure progression. The inflammasome is a complex of intracellular interaction proteins that trigger maturation of proinflammatory cytokines interleukin-1β and interleukin-18 to initiate the inflammatory response. This response is amplified through production of tumor necrosis factor α and activation of inducible nitric oxide synthase. The purpose of this review is to discuss recent evidence implicating this inflammatory pathway in the pathophysiology of heart failure.

Diastolic heart failure

Diastolic heart failure (DHF) is estimated to occur in 40% to 50% of patients with heart failure. Evidence suggests that DHF is primarily a cardiogeriatric syndrome that increases from approximately 1% at age 50 years to 10% or more at 80 years. DHF is also more likely to occur in older women who are hypertensive or diabetic. Although survival is better in patients with DHF compared with systolic heart failure, mortality rates for patients with DHF are four times higher than those for healthy, community-dwelling older adults. The increase in DHF is anticipated to continue during the next several decades largely because of the aging of the population; increase in risk factors associated with hypertension, diabetes, and obesity; and ongoing technologic advances in the treatment of cardiovascular disease. Few clinical trials have evaluated therapy in this population, so evidence about the effectiveness of treatment strategies for DHF is limited. Future research should target novel interventions that specifically target patients with DHF who are typically older and female, and experience exertional intolerance and have a considerably reduced quality of life.

Evaluation of frailty in older adults with cardiovascular disease: incorporating physical performance measures.

Rapid growth in the numbers of older adults with cardiovascular disease (CVD) is raising awareness and concern of the impact that common geriatric syndromes such as frailty may have on clinical outcomes, health-related quality of life, and rising economic burden associated with healthcare. Increasingly, frailty is recognized to be a highly prevalent and important risk factor that is associated with adverse cardiovascular outcomes. A limitation of previous studies in patients with CVD has been the lack of a consistent definition and measures to evaluate frailty. In this review, building upon the work of Fried and colleagues, a definition of frailty is provided that is applicable for evaluating frailty in older adults with CVD. Simple, well-established performance-based measures widely used in comprehensive geriatric assessment are recommended that can be readily implemented by nurses in most practice settings. The limited studies conducted in older adults with CVD have shown physical performance measures to be highly predictive of clinical outcomes. Implications for practice and areas for future research are described for the growing numbers of elderly cardiac patients who are frail frailty and at risk for disability.

PSYCHOLOGICAL FACTORS ARE IMPORTANT CORRELATES OF DIETARY PATTERN IN OVERWEIGHT ADULTS

Introduction and Purpose:Abdominal obesity, the central distribution of adipose tissue, is a well-established cardiometabolic disease risk factor. The prevalence has steadily increased since 1988, and now more than 50% of adults have abdominal obesity. Psychological distress coupled with increased dietary energy density (ED) may contribute to abdominal obesity. Guided by the stress and coping model, this study examined the relationship between psychological factors (perceived stress and depressive symptoms) and dietary ED in overweight, working adults. The first hypothesis tested if psychological factors explained a significant amount of food and beverage ED variance above that accounted for by demographic factors. The second hypothesis tested if psychological factors explained a significant amount of food and nonalcoholic beverage ED variance above that accounted for by demographic factors. Post hoc analyses compared macronutrient composition and food group pattern between overweight, working adults with and without depressive symptoms. Methods:This descriptive, cross-sectional, correlation study was composed of 87 overweight, working adults (mean age, 41.3 [SD, 10.2] years; mean body mass index, 32.1 [SD, 6.1] kg/m2; 73.6% women; 50.6% African American). Participants completed the Beck Depression Inventory II and Perceived Stress Scale and weighed-3-day-food record analyzed for caloric intake (kilocalories) and weight (in grams) of consumed foods and beverages that were used to calculate ED (in kilocalories/gram). Height and weight were measured to calculate body mass index. Descriptive statistics, Mann-Whitney U test, and sequential regression modeling were used for data analysis. Results:Depressive symptoms were reported by 21.9% of participants and explained variance in food and beverage ED above that accounted for by African American race and reporting adequate caloric intake. Depressive symptoms explained variance in food and nonalcoholic beverage ED above that accounted for male sex, African American race, and reporting adequate caloric intake. Perceived stress and depressive symptoms were positively correlated; however, perceived stress was not a significant predictor of food and beverage ED. Conclusions:Depressive symptoms, potentially modifiable, were 4 times that found in the general population and independently predicted increased food and beverage ED. Further research is needed to determine if improvements in depressive symptoms alter dietary ED, potentially reducing cardiometabolic disease risk.

A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study.

Background: Recent guidelines for exercise in patients with heart failure (HF) recommended aerobic and resistance exercise as being safe and effective; however, the clinical and functional significance of these combined training modalities has not been established. In this pilot study, combined aerobic and resistance training was hypothesized to improve physical function, muscle strength, and health-related quality of life (HRQOL) compared with an attention control wait list (ACWL). Methods: The 10-item Continuous Scale Physical Functional Performance Test (CS-PFP10), which simulates common household chores; muscle strength (handgrip and knee extension); and HRQOL (Kansas City Cardiomyopathy Questionnaire) were evaluated at baseline (T1) and at 12 weeks (T2). The home-based moderate-intensity walking and resistance training program was performed 5 days a week. Results: Twenty-four New York Heart Association class II to III HF patients (mean [SD] age, 60 [10] years; mean [SD] left ventricular ejection fraction, 25% [9%]) were randomized to a combined aerobic and resistance exercise program or to an ACWL group. Of the total group, 58% were New York Heart Association class III HF patients, 50% were white, and 50% were female. The CS-PFP10 total scores were significantly increased in the exercise group, from 45 (18) to 56 (16). The Kansas City Cardiomyopathy Questionnaire overall summary score was significantly improved (P < .001) at T2 in the exercise intervention group compared with the ACWL group. Conclusions: Participants provided the home-based, combined aerobic and resistance exercise program had significantly improved physical function, muscle strength, symptom severity, and HRQOL compared with the ACWL group. The findings of this study must be interpreted cautiously owing to the limitations of a small sample, data collection from a single center, and differences between control and interventions groups at baseline. A combined aerobic and resistance exercise approach may improve physical function in stable HF patients, but further study in a larger, more diverse population is recommended. However, in this study, the CS-PFP10 instrument demonstrated its ability to identify functional health status in HF patients and thus warrants further testing in a larger sample for possible use in clinical practice.