Terry A. Lennie

Triglycerides and Cardiovascular Disease A Scientific Statement From the American Heart Association

A long-standing association exists between elevated triglyceride levels and cardiovascular disease* (CVD).1,2 However, the extent to which triglycerides directly promote CVD or represent a biomarker of risk has been debated for 3 decades.3 To this end, 2 National Institutes of Health consensus conferences evaluated the evidentiary role of triglycerides in cardiovascular risk assessment and provided therapeutic recommendations for hypertriglyceridemic states.4,5 Since 1993, additional insights have been made vis-a-vis the atherogenicity of triglyceride-rich lipoproteins (TRLs; ie, chylomicrons and very low-density lipoproteins), genetic and metabolic regulators of triglyceride metabolism, and classification and treatment of hypertriglyceridemia. It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).6,7 In contrast, mean low-density lipoprotein cholesterol (LDL-C) levels have receded.7 Therefore, the purpose of this scientific statement is to update clinicians on the increasingly crucial role of triglycerides in the evaluation and management of CVD risk and highlight approaches aimed at minimizing the adverse public health–related consequences associated with hypertriglyceridemic states. This statement will complement recent American Heart Association scientific statements on childhood and adolescent obesity8 and dietary sugar intake9 by emphasizing effective lifestyle strategies designed to lower triglyceride levels and improve overall cardiometabolic health. It is not intended to serve as a specific guideline but will be of value to the Adult Treatment Panel IV (ATP IV) of the National Cholesterol Education Program, from which evidence-based guidelines will ensue. Topics to be addressed include epidemiology and CVD risk, ethnic and racial differences, metabolic determinants, genetic and family determinants, risk factor correlates, and effects related to nutrition, physical activity, and lipid medications. In the United States, the National Health and …

The Relationship among Young Adult College Students’ Depression, Anxiety, Stress, Demographics, Life Satisfaction, and Coping Styles

Recent research indicates that young adult college students experience increased levels of depression, anxiety, and stress. It is less clear what strategies college health care providers might use to assist students in decreasing these mental health concerns. In this paper, we examine the relative importance of coping style, life satisfaction, and selected demographics in predicting undergraduates’ depression, anxiety, and stress. A total of 508 full-time undergraduate students aged 18–24 years completed the study measures and a short demographics information questionnaire. Coping strategies and life satisfaction were assessed using the Brief COPE Inventory and an adapted version of the Brief Students’ Multidimensional Life Satisfaction Scale. Depression, anxiety, and stress were measured using the Depression Anxiety and Stress Scale-21 (DASS-21). Multiple regression analyses were used to examine the relative influence of each of the independent variables on depression, anxiety, and stress. Maladaptive coping was the main predictor of depression, anxiety, and stress. Adaptive coping was not a significant predictor of any of the three outcome variables. Reducing maladaptive coping behaviors may have the most positive impact on reducing depression, anxiety, and stress in this population.

Predictors of medication adherence using a multidimensional adherence model in patients with heart failure.

BACKGROUND Medication adherence in heart failure (HF) is a crucial but poorly understood phenomenon. The purpose of this study was to explore factors contributing to medication adherence in patients with HF by using the World Health Organizations multidimensional adherence model. METHODS AND RESULTS Patients (N = 134) with HF (70% were male, aged 61 +/- 12 years, 61% with New York Heart Association III/IV) were studied to determine the predictors of medication adherence derived from the multidimensional adherence model. Medication adherence was measured objectively using the medication event monitoring system for 3 months. Three indicators of adherence were assessed by the medication event monitoring system: 1) dose-count, the percentage of prescribed doses taken; 2) dose-days, the percentage of days the correct number of doses were taken; and 3) dose-time, the percentage of doses that were taken on schedule. Barriers to medication adherence, ethnicity, and perceived social support predicted dose-count (P < .001). New York Heart Association functional class, barriers to medication adherence, financial status, and perceived social support predicted dose-day (P < .001). Barriers to medication adherence and financial status predicted dose-time (P = .005). CONCLUSION A number of modifiable factors predicted medication adherence in patients with HF, providing specific targets for intervention.

Objectively Measured, but Not Self-Reported, Medication Adherence Independently Predicts Event-Free Survival in Patients With Heart Failure

OBJECTIVE Medication nonadherence is presumed to be related to poor clinical outcomes, yet this relationship rarely has been tested using objective adherence measures in patients with heart failure. Which objective indicators of medication adherence predict clinical outcomes are unknown. The study objective was to determine which indicators of medication adherence are predictors of event-free survival. METHODS Patients (N = 134) with heart failure (69% were male, aged 61 +/- 11 years, 61% with New York Heart Association class III/IV heart disease) were enrolled in this 6-month longitudinal study. Adherence was measured using two measures: 1) an objective measure, the Medication Event Monitoring System (MEMS); and 2) self-reported adherence (Medical Outcomes Studies Specific Adherence Scale). Three indicators of adherence were assessed by MEMS: 1) dose-count, percentage of prescribed doses taken; 2) dose-days, percentage of days correct number of doses taken; and 3) dose-time, percentage of doses taken on schedule. Events (emergency department visits, rehospitalization, and mortality) were obtained by patient/family interview and hospital databases. RESULTS In Cox regression, two of the three MEMS indicators, dose-count and dose-day, predicted event-free survival before and after controlling for age, gender, ejection fraction, New York Heart Association class, angiotensin-converting enzyme inhibitor use, and beta-blocker use (P = .004, P = .008, and P = .224, respectively). Self-report adherence did not predict outcomes (P = .402). CONCLUSION Dose-count and dose-day predicted event-free survival. Neither dose-time nor self-reported adherence predicted outcomes. Health care providers should assess specific behaviors related to medication taking rather than a global patient self-assessment of patient adherence.

Event-free survival in adults with heart failure who engage in self-care management.

BACKGROUND Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free. METHODS A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk. RESULTS The sample consisted of older (mean ± standard deviation=61.3 ± 11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364 ± 288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management. CONCLUSION Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.

Defining an evidence-based cutpoint for medication adherence in heart failure

BACKGROUND Despite the importance of medication adherence in heart failure, clinically relevant cutpoints for distinguishing the level of adherence associated with outcomes are unknown. OBJECTIVE The purpose of this study is to determine the cutpoint above which there is a positive relationship between level of medication adherence and event-free survival. METHODS This was a longitudinal study of 135 patients with heart failure. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System. Two indicators of adherence were assessed by the Medication Event Monitoring System (AARDEX, Union City, CA): (1) dose count, percentage of prescribed doses taken, and (2) dose days, percentage of days the correct number of doses was taken. Patients were followed up to 3.5 years to collect data on outcomes. A series of Kaplan-Meier plots with log-rank tests, Cox survival analyses, and receiver operating characteristic curves were assessed comparing event-free survival in patients divided at one-point incremental cutpoints. RESULTS Event-free survival was significantly better when the prescribed number of doses taken (dose count) or the correct dose (dose day) was > or =88%. This level was confirmed in a Cox regression model controlling for age, gender, ejection fraction, New York Heart Association, comorbidity, angiotensin-converting enzyme inhibitor use, and beta-blocker use. Receiver operating characteristic curves showed that adherence rates above 88% produced the optimal combination of sensitivity and specificity with respect to predicting better event-free survival. With 88% as the adherence cutpoint, the hazard ratio for time to first event for the nonadherent group was 2.2 by dose count (P = .021) and 3.2 by dose day (P = .002). CONCLUSION The results of this study provide clinicians and researchers with an evidence-based recommendation about the level of adherence needed to achieve optimal clinical outcomes.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft.

OBJECTIVE This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. METHODS This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist. RESULTS The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms. CONCLUSIONS The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

Gender differences in and factors related to self-care behaviors: A cross-sectional, correlational study of patients with heart failure

BACKGROUND Although self-care may reduce exacerbations of heart failure, reported rates of effective self-care in patients with heart failure are low. Modifiable factors, including psychosocial status, knowledge, and physical factors, are thought to influence heart failure self-care, but little is known about their combined impact on self-care. OBJECTIVES The objective of this study was to identify factors related to self-care behaviors in patients with heart failure. DESIGN A cross-sectional, correlational study design was used. PARTICIPANTS AND SETTINGS One hundred twenty-two patients (77 men and 45 women, mean age 60+/-12 years old, 66% New York Heart Association functional class III/IV) were recruited from the outpatient clinics of an academic medical center and two community hospitals. METHODS Data on self-care behaviors (Self-Care of Heart Failure Index), depressive symptoms, perceived control, self-care confidence, knowledge, functional status, and social support were collected. Factors related to self-care were examined using hierarchical multiple regression. RESULTS Mean self-care behavior scores were less than 70 indicating the majority of men and women with HF did not consistently engage in self-care behaviors. Higher self-care confidence and perceived control and better heart failure management knowledge were associated with better self-care (r2=.25, p<.001). Higher perceived control and better knowledge were related to better self-care behaviors in men (r2=.18, p=.001), while higher self-care confidence and poorer functional status were related to better self-care behaviors in women (r2=.35, p<.001). CONCLUSION This study demonstrates the substantial impact of modifiable factors such as confidence in ones self-care abilities, perceived control, and knowledge on self-care behaviors. This study demonstrates that there are gender differences in factors affecting self-care, even though at baseline men and women have similar knowledge levels, physical, psychological, and behavioral status. Effective interventions focusing on modifiable factors and the unique characteristics of men and women should be provided to improve self-care behaviors in patients with heart failure.

Factors influencing medication adherence in patients with heart failure

BACKGROUND The purpose of this study was to explore factors influencing adherence to the prescribed medical regimen in patients with heart failure (HF). METHODS A convenience sample of 7 women and 9 men with HF participated in in-depth interviews. The interviews were audio-taped, transcribed, and checked for accuracy. Content analysis strategies were used to analyze the data. RESULTS The desire to be healthy was the primary motivator in the decision to take medications as prescribed. The process of making connections enhanced medication adherence. Participants connected knowledge of their illness and their symptoms with their medications effectiveness in decreasing these symptoms. Connections to a health care provider and family enhanced treatment adherence. Participants relied on environmental cues as reminders to take their medications, resulting in a habit of daily medication use. CONCLUSIONS Education that helps clients understand their illness, particular symptoms and how medications help them may be beneficial in promoting adherence. A positive working relationship with the health care provider may result in improved adherence.

Three Gram Sodium Intake is Associated With Longer Event-Free Survival Only in Patients With Advanced Heart Failure

BACKGROUND There is limited evidence to support the recommendation that patients with heart failure (HF) restrict sodium intake. The purpose of this study was to compare differences in cardiac event-free survival between patients with sodium intake above and below 3 g. METHODS A total of 302 patients with HF (67% male, 62 ± 12 years, 54% New York Heart Association [NYHA] Class III/IV, ejection fraction 34 ± 14%) collected a 24-hour urine sodium (UNa) to indicate sodium intake. Patients were divided into 2 groups using a 3-g UNa cutpoint and stratified by NYHA Class (I/II vs. III/IV). Event-free survival for 12 months was determined by patient or family interviews and medical record review. Differences in cardiac event-free survival were determined by Kaplan-Meier survival curve with log-rank test and Cox hazard regression. RESULTS The Cox regression hazard ratio for 24-hour UNa ≥ 3 g in NYHA Class I/II was 0.44 (95% confidence interval [CI] = 0.20-0.97) and 2.54 (95% CI = 1.10-5.84) for NYHA III/IV after controlling for age, gender, HF etiology, body mass index, ejection fraction, and total comorbidity score. CONCLUSIONS These data suggest that 3 g dietary sodium restriction may be most appropriate for patients in NYHA functional Classes III and IV.