Symptom Clusters and the Prediction of Hospitalization and Mortality in Patients with Heart Failure

S68 Journal of Cardiac Failure Vol. 20 No. 8S August 2014 targeting to modify patients’ psychological status may be useful for nutrition improvement.

Table 1. The agreement between sodium intake by food diary, self- report control fo sodium intake and residual sodium of 24-hour urine

24-hour urine Na (mmol/day)

Method/group Sodium intake assessed by food diary Adherent (!3g) Nonadherent ($3g) Self-reported control of sodium intake Adherent Nonadherent

Adherent (!200 mmol/day)

Nonadherent ($200 mmol/day)

52 (70.3%) 10 (13.5%)

52 (70.3%) 10 (13.5%)

174 Kappa

P

0.086

0.460

0.005

0.963

9 (12.2%) 3 (4.1%)

10 (13.5%) 2 (2.7%)

assessed by food dietary, self-report, and 24-hour urine are not consistent in patients with HF. For improving validity of study, it is imperative to determine a reliable instrument and carefully monitor during data collection when doing nutritional study.

173 Heart Failure Patients with More Anxiety Had More Total Energy, Protein, and Fat Dietary Intake Hui-Chu Yu1, Ming-Fen Tsai2, Ru Shang Jiang3, Tsuey-Yuan Huang2; 1National Taiwan University Hospital, Taipei, Taiwan; 2Chang Gung University of Science and Technology, Taoyuan, Taiwan; 3Chang Gung University of Science and Technology, Chiayi, Taiwan Introduction: Dietary intake adjustment is a useful treatment to improve disease outcomes in patients with heart failure (HF). The effects of psychosocial factors

Psychometric Validation of the Chinese Version of the Control Attitudes ScaleRevised in Taiwanese Heart Failure Patients Tsuey-Yuan Huang1, Ming-Fen Tsai1, Mei-Ling Yeh2, Ru Shang Jiang3, Debra K. Moser4; 1Chang Gung University of Science and Technology, Taoyuan, Taiwan; 2 National Taipei University of Nursing & Health Sciences, Taipei, Taiwan; 3Chang Gung University of Science and Technology, Chiayi, Taiwan; 4University of Kentucky, Lexington, KY Introduction: Perceived control is an important construct for heart failure (HF) patients that is related with better health outcomes. In Taiwan, none of instruments to measure perceived control have evidence of reliability and validity, thus limiting practical application of the construct in research and clinical practice. Hypothesis: The Chinese Version of the Control Attitudes Scale-Revised (Chinese CAS-R) is a valid and reliable instrument in Taiwanese HF patients. Methods: Chinese CAS-R was developed using translation/back-translation process and semantic equivalence; importantly, conceptual equivalence was also examined. Reliability was assessed using Cronbach’s alpha to determine internal consistency, and item homogeneity was assessed using item-total and inter-item correlations. Validity was examined by confirmatory factor analysis (CFA) and principal component analysis, and testing hypotheses about known associations. Results: The result of CFA revealed that the factor loadings of item 5 “No matter what I do, or how hard I try, I just can’t seem to get relief from my symptoms”, item 7 “Regarding my heart problems, I feel lots of control”, and item 8 “Regarding my heart problems, I feel helpless” were less than 0.30, so these items were deleted. In the CAS-R 5 item model, the model fit was adequate (i.e. GFI 5 0.932, NFI 5 0.888, CFI 5 0.895) as was the internal quality, with all factoring loadings greater than 0.50 and a Cronbach’s alpha of 0.793. Chinese CAS-R 5 item was associated with higher levels of maintenance of self-care (b 5 0.395, P ! 0.001), management of self-care (b 5 0.219, P ! 0.01), confidence of self-care (b 5 0.524, P ! 0.001), perceived social support (b 5 0.246, P ! 0.001), and depression (b 5 -0.125, P ! 0.05) respectively, after controlling for other relevant variables (i.e. age, gender, educated year, marital status, LVEF, NYHA class). Conclusion: This study provides evidence of the reliability and validity of the CAS-R 5 item as a measure of perceived control in Taiwanese HF patients.

Table 1 (174). Criterion-related validity: Regression results testing the relationship between CAS-R 5-item and established measures

Outcome Predictor CAS-R 5-item Age in year Male gender Education year Have partner/single LV ejection fraction NYHA class III/IV Valid sample size R2

SC Maintenance .395*** .149 .025 -.023 .145* .006 .041 192 20%

SC Management

SC Confidence

.219** .135 .102 -.103 .015 -.041 .110 192 10.2%

.524*** .069 .021 -.043 .058 -.022 .048 192 27.3%

HRQOL -.081 -.132* .019 .109 -.082 -.034 .3 15*** 304 16.4%

Depression -.125* -.157* .049 .026 -.133* .015 .211*** 334 11.9%

Anxiety -.022 -.153* .103 .069 -.051 -.022 .254*** 334 11.5%

PSS .246*** -0.18 .084 -.034 .129* -.047 -.094 334 10.5%

Note: CAS-R 5 Control Attitudes Scale-Revised, LV5left Ventricle; NYHA5New York Heart Association; SC5Self Care; HRQOL5Health Related Quality of Life; PSS5Perceived Social Support; Values in the cells are standardized regression coefficient; *p !.05, **p ! .01, *** p ! .001. including depression, anxiety, perceived control, and social support on dietary intake across HF patients were investigated in the current study. Hypothesis: Psychological status may affect HF patients’ dietary intake style. Method: Crossectional and correctional study was used in the current study. Patients with HF were recruited from outpatient clinics in Taiwan. Psychosocial factors were depression, anxiety, perceived control, and perceived social support. These factors were measured using the Brief Symptom Inventory, Revised Control Attitudes Scale, and Multidimensional Scale of Social Support Scale, respectively. Four-day food diaries were analyzed using Dietary Analysis Profession Edition 2011 (E-Kitchen Cooperation). To examine the association of anxiety with dietary intakes (energy, total fat, total carbohydrate, total protein, and sodium), hierarchical linear regression analysis was performed with the presence of personal information (gender and age) and disease severity (length since diagnosis, LVEF, NYHA class). Results: The cohort included 80 patients and their characteristics were as the followings: 66.3% male, mean (SD) age 60.1 (616.7) years; LVEF 42.6 (6 16.7) %; 31% NYHA class III/IV; length since diagnosis 2.3 (63.5) years; and BMI 26.6 (6 5.8). After adjusting for patient’s personal information and disease severity, anxiety was positively associated with energy (b 5 .26, p ! .05), total fat (b 5 .31, p ! .01) and total protein (b 5 .26, p ! .05), respectively. The unique variance explained due to anxiety was 6% (of total 21%) for energy, 8% (of total 22%) for total fat and 6% (of total 19%), respectively. However, anxiety was not associated with both total carbohydrate and sodium. Conclusions: Heart failure patients with more anxiety had more total energy, protein, and fat dietary intake. Interventions

175 Symptom Clusters and the Prediction of Hospitalization and Mortality in Patients with Heart Failure Tsuey-Yuan Huang1, Ming-Fen Tsai1, Ru Shang Jiang2, Mei-Ling Yeh3, Debra K. Moser4; 1Chang Gung University of Science and Technology, Taoyuan, Taiwan; 2 Chang Gung University of Science and Technology, Chiayi, Taiwan; 3National Taipei University of Nursing & Health Sciences, Taipei, Taiwan; 4University of Kentucky, Lexington, KY

Background: Heart failure (HF) patients have multiple distressing symptoms that are associated with poor outcomes. These symptoms do not occur in isolation from each other, but likely occur as discrete clusters that may prove helpful to clinicians trying to counsel patients about symptom monitoring and management. Defining common symptom clusters and determining the association of these symptom clusters with outcomes may improve patient management. Specific Aims: To define symptom clusters and their association with event-free survival (cardiac hospitalization or all-caused death) in HF patients. Methods: Patients were recruited from outpatient HF clinics. Physical symptoms (dyspnea, fatigue, edema, sleeplessness, anorexia, and poor memory) were measured by the modified Pulmonary Function Status and Dyspnea Questionnaire (PFSDQ-M) and Minnesota Living with Heart Failure Questionnaire (MLHFQ). A two-stage cluster analysis was conducted to identify

The 18th Annual Scientific Meeting



HFSA

S69

177 Improved Patient Identification for ICD/CRT Using Automated EMR/Analytics Guliz Kozdag1, Kaelin E. DeMuth1, Alisha Aggarwal1, Sergio Pinski1, Gian Novaro1, Viviana Navas1, Andrew Boyle1, W.H. Wilson Tang2, Michael Shen1; 1Cleveland Clinic Florida, Weston, FL; 2Cleveland Clinic Foundation, Cleveland, OH

Figure 1. Kaplan-Meier Survival among 3 Groups Stratified by Symptom Cluster Symptoms. subgroups of patients based on their perceived severity of the six symptoms. KaplanMeier survival curve and log-rank test were used to assess whether symptom clusters were associated with event-free survival during 12-month follow-up. Results: Two hundred fifty-seven patients (mean age 61.2612.3 yrs; 75% male; 41% NYHA III/ IV) participated. Three symptom clusters were identified (Figure 1) Based on the severity of symptoms these clusters were called the non-severe symptom cluster (all symptoms were rated with low severity), the typical severity symptom cluster (dyspnea and fatigue severity were high, edema severity low, and other symptom severity moderates), and an atypical severity symptom cluster (low severity of dyspnea and fatigue, high severity of edema, and moderate severity of other symptoms). Symptom clusters were associated with event-free survival (p 5 0.017). Post hoc comparison showed that prognosis was best in the non-severe symptom cluster compared to the typical symptom (p !.001) and non-typical symptom clusters (p! .001), which did not differ. Conclusions: Prognostically important symptom clusters are identifiable in patients with HF. Both patients and clinicians can use this information to improve their surveillance and management of symptoms.

176 Reduced Intrathoracic Impedance Correlates with Poor Renal Function in Heart Failure Patients Jaimie Manlucu1, Vinod Sharma2, Jodi Koehler3, Lorne Gula1, Eduardo Warman3, Raymond Yee1, George Wells4, Anthony Tang1; 1London Health Sciences Centre, London, ON, Canada; 2Medtronic Inc., Minneapolis, MN; 3Medtronic Inc, Minneapolis, MN; 4University of Ottawa, Ottawa, ON, Canada Reduction in Intrathoracic Impedance Reflects Deterioration in Renal Function in Heart Failure Patients Introduction: Heart failure (HF) exacerbations accompanied by a significant deterioration in renal function are associated with a poor prognosis. Early recognition of impending decompensation may help improve outcomes. We sought to evaluate the relationship between intrathoracic impedance and renal function in patients enrolled in the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT). Methods: Patients enrolled in the RAFT trial with at least 1 same day measurement of glomerular filtration rate (GFR) and intrathoracic impedance performed at least 60 days post-implant were eligible. Intrathoracic impedance measurements were performed through each patient’s device using Optivol software (Medtronic). Patient data was classified according to severity of renal impairment as estimated by the GFR. A generalized estimating equation (GEE) was used to adjust for multiple observations in a patient. Results: Optivol and GFR data from 1108 patients (83% male) with an average age of 6669 years were included. Among them, 195 (18%) had a history of renal disease, 967 (87%) were NYHA functional class II, and 825 patients (74%) had a CRT-D device. The mean left ventricular ejection fraction was 2365%. A total of 4403 same day measurements of GFR and Optivol were analyzed, with a mean follow up period of 23 (615) months. The majority of patients had at least mild to moderately impaired renal function (GFR !90mL/min/1.73 m2) for 76% of the total days analyzed. Patients with severe renal impairment (GFR !30 mL/min/1.73 m2) had the lowest impedance (68.8 ohms (95% CI [66.9-70.8]) and highest proportion of days with a Fluid Index O60ohm-days (p!0.05), suggestive of higher levels of pulmonary congestion than patients with less renal impairment. Overall, both impedance and OptiVol fluid index values seemed to improve in parallel with renal function (p!0.001). Conclusion: Device estimates of intrathoracic impedance correlate well with the severity of renal impairment in patients with mild to moderate heart failure. Further studies are required to explore its potential role in the proactive management of HF patients and titration of medical therapy.

Background: The benefits of ICD/CRT are well established in clinical trials. However, clinical registries continued to observe variable and at times hazardous therapy adoption rates. Identification of these patients is challenging in healthcare organizations due to lack of tracking systems, imperfect physician communication, and loss to follow-up. There is no established approach for automated identification and referral using EMRs (electronic medical records)/analytics for this population in real world practice. Methods: All patients with EF # 35% from non-invasive cardiac imaging were identified and screened as device candidates based on clinical history, EF, and QRS duration according to current guidelines using an automated analytic algorithm applied to standard EMR data. The clinical trajectory of patients identified by the automated algorithm was then ascertained via manual chart review by 2 physicians independently. Results: Among the 1,911 patients diagnosed as cardiomyopathy or heart failure in 2013, 254 patients were deemed eligible for ICD or CRT based on the automated algorithm. Detailed chart review revealed that 94 (37%) had already received ICD/CRT, 39 (15%) were not indicated for ICD/CRT and 23 (9%) deceased within the year. Of the remaining 98 actionable subjects (39% of the population), 11 (11%) evaluated and pending for device implantation, 11 (11%) waiting for revaluation, 54 subjects (55%) had seen a specialist but had no firm plans for device implant nor documented contraindication, and 22 (23%) did not have any specialist referral for evaluation for ICD/CRT. Conclusion: We found that among patients eligible for device implant identified via an automated algorithm, over 1/3 lack documentation of device consideration after specialist referral and 23% had not been referred to specialist. These findings highlight the potential value of an automated EMR/analytics tools to identify and track patients for consideration of guideline-directed ICD/CRT therapy. Further studies are warranted to determine if prospective use of these tools to influence physician behavior may lead to more appropriate rates of device implantation, and ultimately improved outcomes. Table.

Designations for ICD/CRT: Referral Implanted Reevaluating Lost follow-up Not Referred ICD CRT TOTAL

54 40 94

10 1 11

42 12 54

16 6 22

178 Changing the Trajectory of the “Frequent Flyer”: Use of the Intensive Heart Failure Clinic in Patients Identified with Two Heart Failure Admissions Within a Two Month Period Shervin Golbari1, Sharon Mack2, Catherine C. Fallick2; 1MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH; 2MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH Background: Decreased readmissions in heart failure (HF) patients improve outcome, quality of life and costs to society. Multi-disciplinary HF programs achieve these goals, however not all facilities have the resources available for this level of patient care. Methods: 16 patients (pts) with reduced ejection fraction (EF), admitted twice for HF over a two month period, were prospectively enrolled into the Intensive Heart Failure Clinic (IHFC), a pilot program employing intensive care by a cardiologist and a nurse practitioner within a more traditional academic HF program. Baseline Population: Pts had a mean EF of 22 6 9, 37% were African-American (AA), 75% had an ischemic etiology, 38% had Diabetes Mellitus and 81% had hypertension. On initiation, mean blood urea nitrogen and creatinine were 26 and 1.4 mg/dl respectively. Pts had mean body mass index of 30. At time of entry, 100% of patients were on Beta-Blockers (BB), 88% were on Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blocker and 37% were on Hydralazine (67% of AA pts and 20% of non-AA pts). Results: Pts were followed for a mean of 293 days 6 221. Pts required an average of 5 and 6 follow-ups by the Cardiologist and Nurse Practitioner respectively, and an average of 6 telephone calls. Number of admissions in these patients averaged 4.3 6 2.7 in the year prior to entry into the program and 1.8 6 1.8 admissions after entry (p 50.05). 25% were readmitted within 30 days,31% within 90 days and 30% of pts were not readmitted. Mean hospital time to readmission was 104 6 78 days. New York Heart Association class improved from a mean of 3 6 0.6 to 2.2 6 0.8 (p !0.005). B-type Natriuretic Peptide (BNP) decreased from 1654 6 1450 pg/ml to 804 6 891 pg/ml (p # 0.03). Degree of tricuspid regurgitation decreased (p 50.05) despite lack of improvement in EF or Mitral regurgitation. There was no change in guideline based therapy, however hydralazine use increased from 37 to 69%, the increase derived from initiation of medication in