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Cognitive Impairment is Associated with Abnormal Cardiac Hemodynamics in Heart Failure with Preserved Ejection Fraction
S4 Journal of Cardiac Failure Vol. 25 No. 8S August 2019
Nursing New Investigator Award (Research/Clinical) 007 Cognitive Impairment is Associated with Abnormal Cardiac Hemodynamics in Heart Failure with Preserved Ejection Fraction Kenneth M. Faulkner1, Victoria Vaughan Dickson1, Jason Fletcher1, Stuart D. Katz2, Amil M. Shah3, Rebecca F. Gottesman4, Patricia Pat-Yue Chang5, Lucy Witt6, Gail D’Eramo Melkus1; 1New York University, New York, NY; 2NYU Langone Medical Center, New York, NY; 3Brigham and Women’s Hospital, Boston, MA; 4Johns Hopkins Medicine, Baltimore, MD; 5University of North Carolina, Chapel Hill, NC; 6 Emory University, Atlanta, GA Introduction: Cognitive impairment (CI) is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind CI in heart failure with preserved ejection fraction (HFpEF) has not been established. The purpose of this study was to evaluate associations between abnormal cardiac hemodynamics and CI in individuals with HFpEF. Hypothesis: Diastolic dysfunction, systolic dysfunction, and impaired ventricular vascular coupling will be associated with CI in HFpEF. Methods: This was a secondary analysis of data from the Atherosclerosis Risk in Communities Study. Individuals who completed in-person neurocognitive assessments at visit 5 were included. Individuals with stroke or dementia were excluded. Participants were classified as having HFpEF, heart failure with reduced ejection fraction (HFrEF), or no heart failure. Independent variables included echocardiographic measures of cardiac function and factors hypothesized to influence CI in HFpEF based on an extensive literature review. Dependent variables included scores on neurocognitive tests. Descriptive statistics were used to describe sample characteristics and identify significant differences among those with HFpEF, HFrEF, and no heart failure. Bivariate analysis identified predictors for multivariate models and evaluated collinearity. Multiple imputation by chained equations was conducted to account for missing values. Multiple linear regression identified independent predictors of CI. Results: Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. The effect of HFpEF on CI was small to moderate. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on one test of attention. No association between ventricular-vascular coupling and CI was identified. Older age, history of hypertension, and high numbers of depressive symptoms also were associated with CI. Conclusions: Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the need to screen individuals with HFpEF for CI. As CI is associated with worse outcomes, early identification and appropriate intervention has the potential to mitigate the effect of CI on outcomes, including mortality rates. The current study demonstrated an association between abnormal cardiac hemodynamics and CI. Although abnormal hemodynamics may contribute to CI in HFpEF, other factors may be involved. Future research should explore other mechanisms that contribute to CI in HFpEF.
or self-care behaviors. Discrepancies in understanding or an inability to accept the label of HF can make it difficult for patients to engage in self-care. Health care providers need to understand what HF means to patients before providing detailed information about the condition to make sure that patients can hear and accept information about HF.
009 Trends in Self-Management among Adults with Heart Failure from 2011 to 2016 Using the National Health and Nutrition Examination Surveys Soyoung Choi, JooYoung Seo; The Pennsylvania State University, University Park, PA Introduction: Heart failure (HF) affects patients’ quality of life as it progresses. Given the unpredictability of HF pathways and complex medical treatments, self-management of HF is demanding work for patients and family caregivers. Patients with HF, for instance, have to monitor symptoms, adhere to dietary recommendation (e.g., DASH diet) and medication regimens, and maintain regular physical activities; thus, discovering such characteristics in a scientific way is important. This study aims to shed light on changes in health-related characteristics and to investigate the self-management status of adults with HF. Methods: This study employed three public datasets provided by the National Health and Nutrition Examination Surveys undertaken between 2011 and 2016 at two-year intervals. The original surveys included a set of questions to measure the health and nutritional status of adults and children in the United States. Among the study cohort, 583 adults (ranging in age from 25 to 80) who self-reported the diagnosis of HF were filtered for this secondary data analysis (n=187 in 2011-2012, n=182 in 2013-2014, n=214 in 2015-2016). The selected variables for this report included as follows: laboratory data measuring physical health status; depression severity using patient health questionnaire (PHQ9); comorbidities; prescribed medications; dietary intakes; and physical activities. Results: The overall mean of the medications subjects were prescribed was 9.16 (SD=3.14). Figure 1 illustrates the heatmap for the patterns of comorbid disease. In dietary quality, the averages of sodium intake in each wave were 3093.45 (SD=1787.51), 3015.44 (SD=1567.25), and 3143.59 (SD=1629.42). While there were no significant differences (F=30.82, p=0.311), these values were higher than the AHA recommendation for maintaining sodium intake (less than 2,000mg/day). There were significant changes in the consumption of lowdensity lipoprotein (F=3.46, p=.033) and triglycerides (F=5.70, p =.004). The proportions of HF patients with moderate to severe depression were 17.11%, 21.98%, and 15.89% respectively. Lastly, subjects walked or bicycled approximately four days a week. However, the average minutes of sedentary activity a week ranged from 477.80 (SD=727.82) to 546.43 (SD=1150.56). Conclusion: Contrary to our expectations, the self-management among HF patients were not improved even if clinical guidelines for HF management had been updated periodically. Findings suggest that strategies and potential resources for improving self-management of HF should be further investigated.
008 What Does Heart Failure Mean to You? Solim Lee, Amy Ketcham, Brittany Koons, Julie Guerin, Barbara Riegel; University of Pennsylvania, Philadelphia, PA Introduction: Knowing how patients understand the meaning of heart failure (HF) is important for effective communication between health care providers and patients. This could help patients to engage in self-care based on a clear understanding of their conditions. The aim of this study was to explore the patients’ meaning of HF by asking patients, “What does heart failure mean to you?” Methods: We conducted a qualitative descriptive study. Adult patients with any type of HF were enrolled during hospitalization in the US. Participants were purposively selected using maximum variation sampling to ensure inclusion of patients from various age groups, gender, and different durations of HF. Patients with cognitive impairment (a Montreal Cognitive Assessment score below 22) or severe untreated mental illness were excluded. Openended 1:1 interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative inductive content analysis. Results: Twenty patients with HF (aged 36-84 years, 65% male, 65% White, 60% with some college education, 60% unemployed, 45% married) were enrolled. The duration of HF ranged from 4 months to 41 years (median 6 years). Most were NYHA class III (67%), and the median left ventricular ejection fraction was 30%. Four themes of what HF meant to patients emerged: (a) fearful label, (b) pathophysiological understanding, (c) limitations, and (d) adjustment. Under the theme ‘fearful label,’ two subthemes were identified: death sentence and scary label. The meaning of “failure” elicited fear and was associated with the belief, “I am going to die.” However, many patients defined HF based on its pathophysiology with two subthemes, insufficient pumping and its consequences into the theme “pathophysiological understanding.” In addition, many patients defined HF based on the limitations the diagnosis incurred in their lives. The subthemes limited life engagement, limited physical state, and emotional distress were identified. One of the main challenges was no longer being able to do what they want to do or used to be able to do. Finally, “adjustment” emerged with three subthemes: acceptance, adaptation, and life status change. For these patients, living with HF meant trying to accept it, learning how to deal with it, and making changes in their daily lives. Conclusions: The HF label itself might influence patients’ perception of their conditions
Figure 1. Comorbid disease patterns of adults with heart failure.
010 Give a Little, Get a Lot: The Power of IV Fluids in Heart Failure Jaclyn Lemoine1, Argyro Papafilippaki1, Amanda Pustelnikas1, Margaret Michaelian1, Andrew Halpert2, Joseph Carrozza Jr.1, Lana Tsao1; 1St. Elizabeth’s Medical Center, Boston, MA; 2Reprieve Cardiovascular, Milford, MA Introduction: Intravenous (IV) loop diuretics are the mainstay for treatment of acute decompensated heart failure (ADHF). Activation of the renin-angiotensin system with diuresis can result in intravascular volume depletion despite total volume overload.
Nursing New Investigator Award (Research/Clinical) 007 Cognitive Impairment is Associated with Abnormal Cardiac Hemodynamics in Heart Failure with Preserved Ejection Fraction Kenneth M. Faulkner1, Victoria Vaughan Dickson1, Jason Fletcher1, Stuart D. Katz2, Amil M. Shah3, Rebecca F. Gottesman4, Patricia Pat-Yue Chang5, Lucy Witt6, Gail D’Eramo Melkus1; 1New York University, New York, NY; 2NYU Langone Medical Center, New York, NY; 3Brigham and Women’s Hospital, Boston, MA; 4Johns Hopkins Medicine, Baltimore, MD; 5University of North Carolina, Chapel Hill, NC; 6 Emory University, Atlanta, GA Introduction: Cognitive impairment (CI) is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind CI in heart failure with preserved ejection fraction (HFpEF) has not been established. The purpose of this study was to evaluate associations between abnormal cardiac hemodynamics and CI in individuals with HFpEF. Hypothesis: Diastolic dysfunction, systolic dysfunction, and impaired ventricular vascular coupling will be associated with CI in HFpEF. Methods: This was a secondary analysis of data from the Atherosclerosis Risk in Communities Study. Individuals who completed in-person neurocognitive assessments at visit 5 were included. Individuals with stroke or dementia were excluded. Participants were classified as having HFpEF, heart failure with reduced ejection fraction (HFrEF), or no heart failure. Independent variables included echocardiographic measures of cardiac function and factors hypothesized to influence CI in HFpEF based on an extensive literature review. Dependent variables included scores on neurocognitive tests. Descriptive statistics were used to describe sample characteristics and identify significant differences among those with HFpEF, HFrEF, and no heart failure. Bivariate analysis identified predictors for multivariate models and evaluated collinearity. Multiple imputation by chained equations was conducted to account for missing values. Multiple linear regression identified independent predictors of CI. Results: Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. The effect of HFpEF on CI was small to moderate. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on one test of attention. No association between ventricular-vascular coupling and CI was identified. Older age, history of hypertension, and high numbers of depressive symptoms also were associated with CI. Conclusions: Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the need to screen individuals with HFpEF for CI. As CI is associated with worse outcomes, early identification and appropriate intervention has the potential to mitigate the effect of CI on outcomes, including mortality rates. The current study demonstrated an association between abnormal cardiac hemodynamics and CI. Although abnormal hemodynamics may contribute to CI in HFpEF, other factors may be involved. Future research should explore other mechanisms that contribute to CI in HFpEF.
or self-care behaviors. Discrepancies in understanding or an inability to accept the label of HF can make it difficult for patients to engage in self-care. Health care providers need to understand what HF means to patients before providing detailed information about the condition to make sure that patients can hear and accept information about HF.
009 Trends in Self-Management among Adults with Heart Failure from 2011 to 2016 Using the National Health and Nutrition Examination Surveys Soyoung Choi, JooYoung Seo; The Pennsylvania State University, University Park, PA Introduction: Heart failure (HF) affects patients’ quality of life as it progresses. Given the unpredictability of HF pathways and complex medical treatments, self-management of HF is demanding work for patients and family caregivers. Patients with HF, for instance, have to monitor symptoms, adhere to dietary recommendation (e.g., DASH diet) and medication regimens, and maintain regular physical activities; thus, discovering such characteristics in a scientific way is important. This study aims to shed light on changes in health-related characteristics and to investigate the self-management status of adults with HF. Methods: This study employed three public datasets provided by the National Health and Nutrition Examination Surveys undertaken between 2011 and 2016 at two-year intervals. The original surveys included a set of questions to measure the health and nutritional status of adults and children in the United States. Among the study cohort, 583 adults (ranging in age from 25 to 80) who self-reported the diagnosis of HF were filtered for this secondary data analysis (n=187 in 2011-2012, n=182 in 2013-2014, n=214 in 2015-2016). The selected variables for this report included as follows: laboratory data measuring physical health status; depression severity using patient health questionnaire (PHQ9); comorbidities; prescribed medications; dietary intakes; and physical activities. Results: The overall mean of the medications subjects were prescribed was 9.16 (SD=3.14). Figure 1 illustrates the heatmap for the patterns of comorbid disease. In dietary quality, the averages of sodium intake in each wave were 3093.45 (SD=1787.51), 3015.44 (SD=1567.25), and 3143.59 (SD=1629.42). While there were no significant differences (F=30.82, p=0.311), these values were higher than the AHA recommendation for maintaining sodium intake (less than 2,000mg/day). There were significant changes in the consumption of lowdensity lipoprotein (F=3.46, p=.033) and triglycerides (F=5.70, p =.004). The proportions of HF patients with moderate to severe depression were 17.11%, 21.98%, and 15.89% respectively. Lastly, subjects walked or bicycled approximately four days a week. However, the average minutes of sedentary activity a week ranged from 477.80 (SD=727.82) to 546.43 (SD=1150.56). Conclusion: Contrary to our expectations, the self-management among HF patients were not improved even if clinical guidelines for HF management had been updated periodically. Findings suggest that strategies and potential resources for improving self-management of HF should be further investigated.
008 What Does Heart Failure Mean to You? Solim Lee, Amy Ketcham, Brittany Koons, Julie Guerin, Barbara Riegel; University of Pennsylvania, Philadelphia, PA Introduction: Knowing how patients understand the meaning of heart failure (HF) is important for effective communication between health care providers and patients. This could help patients to engage in self-care based on a clear understanding of their conditions. The aim of this study was to explore the patients’ meaning of HF by asking patients, “What does heart failure mean to you?” Methods: We conducted a qualitative descriptive study. Adult patients with any type of HF were enrolled during hospitalization in the US. Participants were purposively selected using maximum variation sampling to ensure inclusion of patients from various age groups, gender, and different durations of HF. Patients with cognitive impairment (a Montreal Cognitive Assessment score below 22) or severe untreated mental illness were excluded. Openended 1:1 interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative inductive content analysis. Results: Twenty patients with HF (aged 36-84 years, 65% male, 65% White, 60% with some college education, 60% unemployed, 45% married) were enrolled. The duration of HF ranged from 4 months to 41 years (median 6 years). Most were NYHA class III (67%), and the median left ventricular ejection fraction was 30%. Four themes of what HF meant to patients emerged: (a) fearful label, (b) pathophysiological understanding, (c) limitations, and (d) adjustment. Under the theme ‘fearful label,’ two subthemes were identified: death sentence and scary label. The meaning of “failure” elicited fear and was associated with the belief, “I am going to die.” However, many patients defined HF based on its pathophysiology with two subthemes, insufficient pumping and its consequences into the theme “pathophysiological understanding.” In addition, many patients defined HF based on the limitations the diagnosis incurred in their lives. The subthemes limited life engagement, limited physical state, and emotional distress were identified. One of the main challenges was no longer being able to do what they want to do or used to be able to do. Finally, “adjustment” emerged with three subthemes: acceptance, adaptation, and life status change. For these patients, living with HF meant trying to accept it, learning how to deal with it, and making changes in their daily lives. Conclusions: The HF label itself might influence patients’ perception of their conditions
Figure 1. Comorbid disease patterns of adults with heart failure.
010 Give a Little, Get a Lot: The Power of IV Fluids in Heart Failure Jaclyn Lemoine1, Argyro Papafilippaki1, Amanda Pustelnikas1, Margaret Michaelian1, Andrew Halpert2, Joseph Carrozza Jr.1, Lana Tsao1; 1St. Elizabeth’s Medical Center, Boston, MA; 2Reprieve Cardiovascular, Milford, MA Introduction: Intravenous (IV) loop diuretics are the mainstay for treatment of acute decompensated heart failure (ADHF). Activation of the renin-angiotensin system with diuresis can result in intravascular volume depletion despite total volume overload.