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Exercise Factors Associated with 1-Year Mortality in Ambulatory Patients with Heart Failure
The 17th Annual Scientific Meeting
HFSA
S71
Clinical Care/Management Strategies 206 Exercise Factors Associated with 1-Year Mortality in Ambulatory Patients with Heart Failure Nancy M. Albert1, Harishida Patel2, Kristen Sethares3, Colin O’Rourke4, Jennifer Forney5, Jacqueline Gannuscio6, Rochelle Armola7, Diane Philip7, Barbara Riegel8, Sarah Fontana9, Eileen Hsich10; 1Cleveland Clinic, Cleveland, OH; 2Univ of Gothenburg, Gothenburg, Sweden; 3Univ of MA Dartmouth, North Dartmouth, MA; 4Cleveland Clinic, Cleveland, OH; 5Cleveland Clinic, Cleveland, OH; 6Wash DC VA Med Ctr, Washington, DC; 7ProMedica Toledo Hospital, Toledo, OH; 8 Univ of Pennsylvania, Philadelphia, PA; 9Hospitals of Univ of Pennsylvania, Philadelphia, PA; 10Cleveland Clinic, Cleveland, OH
Background: In prior research, no differences were found in 1-year mortality in pts with HF who participated in exercise interventions vs usual care. In HF-ACTION, over half of exercise pts were not fully adherent to the exercise intervention, even early into the trial. Understanding associations of exercise-related factors and 1year mortality might lead to new interventions that promote exercise adherence. Methods: Using a prospective, correlational design, out-pts with chronic HF from 6 clinics completed questionnaires on demographics, comorbidites, and factors thought to be important in exercise capability and adherence (fatigue, depression, functional status, knowledge about exercise expectations, value of exercise, barriers/benefits of exercise, and exercise self-efficacy). Investigators provided 1-year survival data. Cox proportional hazards models were used to test for significance of the effects of variables of interest on survival. P-values for estimates of comparisons of hazard within levels of categorical variables were from tests based on z-statistics. If more than 2 categories, multiple comparisons were made to test for differences in the hazard ratios between each pair of categories. Continuous variables were categorized using cut scores. Results: Of the cohort of 492 pts (mean (SD) age 63 (6 13.6) yrs; LVEF 34.9% (6 14.8%); BMI 29.3 (6 6.73) kg/ml/m2; 40.3% ; male, 64.8%; Caucasian, 76.2%; married, 58.9%; NYHA-FC III/IV, 30.9%) 21 (4.2%) died within 1 year after enrollment. Only 46% reported exercising at a moderate-vigorous level. Pt characteristics associated with mortality were older age (p50.037), no one to confide in (p50.046) and NYHA-FC (p50.001). Of exercise factors, mortality was reduced in pts with higher knowledge about exercise expectations (p50.019), higher value for being active (p50.002) and exercising (p50.007), longer 6MWT distance (p50.005), higher exercise self-efficacy (p50.033) and reports of exercising at a moderate-vigorous level compared with no-infrequent exercise patterns (p50.036). Conclusion: Among stable, out-pts with HF, many exercise-related factors were associated with 1-year mortality. Healthcare providers need to clearly communicate the value of exercise, explain details of moderate-vigorous exercise expectations and develop processes to increase self-efficacy for exercise to promote moderate-vigorous exercise behaviors and ongoing adherence to exercise.
Figure 1. Adjusted Kaplan-Meier survival analysis for males and female listed for HT. Results adjusted for age, weight, ABO blood group. Instropic and intra-aortic balloon pump support. ICD, wedge pressure 15 mm Hg and creatinine.
208 Body Composition Analysis of Heart Failure Patients with and without Diabetes Using Bioelectrical Impedance Scale Sima D. Amin, Adrienne Clark, Preethi Srikanthan, Narineh Ohanian, Tatevik Krkasharian, Tamara Horwich; UCLA David Geffen School of Medicine, Los Angeles, CA Introduction: Diabetes is often associated with heart failure (HF). Adiposity, measured by body mass index (BMI) and waist circumference (WC), has been correlated with diabetes in non-HF patients. Bioelectrical impedance scale analysis (BIA) of body composition has rarely been used in comparing these populations. This study investigates the relationship between adiposity and diabetes in patients with chronic HF. Hypothesis: Insulin resistance may cause body composition to differ between diabetic and non-diabetic patients with HF. Lean body mass (LBM), adiposity and
207 Wait List Mortality Is Higher for Female Heart Transplant Candidates Alanna A. Morris1, Emir Veledar2, Robert T. Cole1, Divya Gupta1, Daniel B. Sims1, Wendy Book1, Andrew L. Smith1, Javed Butler1; 1Emory University, Atlanta, GA; 2 Emory University School of Public Health, Atlanta, GA
Introduction: Data from community-based heart failure (HF) trials have suggested better survival in women compared to men. However, little is known about gender differences in survival with end-stage HF. We sought to investigate gender differences in survival of patients with end-stage HF listed for heart transplantation (HT). Methods: We identified 38,036 subjects age $18 (23% female) in the Organ Procurement and Transplantation database listed for their first HT between 1985 and 2012. Wait list survival was censored on the day of removal from the wait list for death or being deemed too sick to transplant. Cox proportional regression models were used for multivariable analysis. Results: Compared to males, female HT candidates were younger (49613 vs. 53611 years, p!0.001), had a lower pulmonary capillary wedge pressure (2069 vs. 2269 mm Hg, p!0.001), and a lower creatinine (1.260.8 vs. 1.460.9 mg/dL, p!0.001). Females were less likely to have an implantable cardioverter-defibrillator (ICD) compared to males (43% vs. 48%, p! 0.001). The median number of days on the wait list was shorter for women than men (114 [31,362] vs. 141 [41,411] days, p!0.001). The unadjusted 1-year survival on the wait list was 78% for males and females (p50.2). After adjusting for age, weight, ABO blood group, inotropic and intra-aortic balloon pump support, ICD, wedge pressure $15 mm Hg and creatinine, female gender was associated with a higher risk of removal from the wait-list for death or being deemed too sick to transplant at 1 year (HR 1.14, 95% CI [1.04,1.24], p50.005). Conclusions: Compared to males, female HT candidates have a higher risk of 1-year morbidity/mortality on the waiting list. More investigation is needed to identify unique risk factors for death on the wait list in women.
Are (Years) Males (%) SBP (mmHg) DBP (mmHg) LVEF (%) BNP (pg/mL) Albumin (g/dL) Etiology Triglycerides (mg/dL) Total cholesterol (mg/dL) LDL (mg/dL) HDL (mg/dL) BMI (kg/m2) Body Fat Mass (kg) Percent Body Fat (%) WC (cm) LBM (kg) Dry Lean Mass (kg) LBM in Trunk (kg) LBM in Right (kg) LBM in Left Leg (kg) LBM in Left Arm (kg) LBM of Right Arm (kg) Beta-Blockers (%) Statin (%)
Diabetics N 5 76
Non-Diabetics N 5 221
57.41 6 11.61 83% 115.35 6 18.96 70.97 6 14.01 33.15 6 15.48 437.85 4.31 6 0.35 60% 148.24 6 82.76
54.85 6 14.94 70% 114.99 6 19.24 71.81 6 13.76 37.36 6 15.75 336.02 4.69 6 4.51 24% 118.13 6 60.78
0.127
149.70 6 45.50
159.65 6 45.22
0.151
80.31 6 41.57 40.85 6 12.92 30.04 6 6.55 30.59 6 14.85 32.76 6 9.25 104.63 6 16.11 59.16 6 11.85 15.53 6 3.19 59.66 6 12.51 19.83 6 4.85 20.11 6 6.99 7.69 6 2.05 7.66 6 2.08 96% 81%
93.54 6 34.52 46.22 6 19.61 27.78 6 5.85 26.19 6 13.07 30.11 6 9.92 97.71 6 15.42 57.35 6 12.17 15.16 6 3.25 57.22 6 12.39 19.79 6 6.06 19.23 6 4.49 7.17 6 2.04 7.29 6 2.08 87% 58%
P Value
0.890 0.658 0.065 0.329 0.293 2.414E-06 0.147
0.031 0.011 0.009 0.023 0.036 0.003 0.254 0.397 0.143 0.958 0.407 0.072 0.178 0.006 3.99E-05
HFSA
S71
Clinical Care/Management Strategies 206 Exercise Factors Associated with 1-Year Mortality in Ambulatory Patients with Heart Failure Nancy M. Albert1, Harishida Patel2, Kristen Sethares3, Colin O’Rourke4, Jennifer Forney5, Jacqueline Gannuscio6, Rochelle Armola7, Diane Philip7, Barbara Riegel8, Sarah Fontana9, Eileen Hsich10; 1Cleveland Clinic, Cleveland, OH; 2Univ of Gothenburg, Gothenburg, Sweden; 3Univ of MA Dartmouth, North Dartmouth, MA; 4Cleveland Clinic, Cleveland, OH; 5Cleveland Clinic, Cleveland, OH; 6Wash DC VA Med Ctr, Washington, DC; 7ProMedica Toledo Hospital, Toledo, OH; 8 Univ of Pennsylvania, Philadelphia, PA; 9Hospitals of Univ of Pennsylvania, Philadelphia, PA; 10Cleveland Clinic, Cleveland, OH
Background: In prior research, no differences were found in 1-year mortality in pts with HF who participated in exercise interventions vs usual care. In HF-ACTION, over half of exercise pts were not fully adherent to the exercise intervention, even early into the trial. Understanding associations of exercise-related factors and 1year mortality might lead to new interventions that promote exercise adherence. Methods: Using a prospective, correlational design, out-pts with chronic HF from 6 clinics completed questionnaires on demographics, comorbidites, and factors thought to be important in exercise capability and adherence (fatigue, depression, functional status, knowledge about exercise expectations, value of exercise, barriers/benefits of exercise, and exercise self-efficacy). Investigators provided 1-year survival data. Cox proportional hazards models were used to test for significance of the effects of variables of interest on survival. P-values for estimates of comparisons of hazard within levels of categorical variables were from tests based on z-statistics. If more than 2 categories, multiple comparisons were made to test for differences in the hazard ratios between each pair of categories. Continuous variables were categorized using cut scores. Results: Of the cohort of 492 pts (mean (SD) age 63 (6 13.6) yrs; LVEF 34.9% (6 14.8%); BMI 29.3 (6 6.73) kg/ml/m2; 40.3% ; male, 64.8%; Caucasian, 76.2%; married, 58.9%; NYHA-FC III/IV, 30.9%) 21 (4.2%) died within 1 year after enrollment. Only 46% reported exercising at a moderate-vigorous level. Pt characteristics associated with mortality were older age (p50.037), no one to confide in (p50.046) and NYHA-FC (p50.001). Of exercise factors, mortality was reduced in pts with higher knowledge about exercise expectations (p50.019), higher value for being active (p50.002) and exercising (p50.007), longer 6MWT distance (p50.005), higher exercise self-efficacy (p50.033) and reports of exercising at a moderate-vigorous level compared with no-infrequent exercise patterns (p50.036). Conclusion: Among stable, out-pts with HF, many exercise-related factors were associated with 1-year mortality. Healthcare providers need to clearly communicate the value of exercise, explain details of moderate-vigorous exercise expectations and develop processes to increase self-efficacy for exercise to promote moderate-vigorous exercise behaviors and ongoing adherence to exercise.
Figure 1. Adjusted Kaplan-Meier survival analysis for males and female listed for HT. Results adjusted for age, weight, ABO blood group. Instropic and intra-aortic balloon pump support. ICD, wedge pressure 15 mm Hg and creatinine.
208 Body Composition Analysis of Heart Failure Patients with and without Diabetes Using Bioelectrical Impedance Scale Sima D. Amin, Adrienne Clark, Preethi Srikanthan, Narineh Ohanian, Tatevik Krkasharian, Tamara Horwich; UCLA David Geffen School of Medicine, Los Angeles, CA Introduction: Diabetes is often associated with heart failure (HF). Adiposity, measured by body mass index (BMI) and waist circumference (WC), has been correlated with diabetes in non-HF patients. Bioelectrical impedance scale analysis (BIA) of body composition has rarely been used in comparing these populations. This study investigates the relationship between adiposity and diabetes in patients with chronic HF. Hypothesis: Insulin resistance may cause body composition to differ between diabetic and non-diabetic patients with HF. Lean body mass (LBM), adiposity and
207 Wait List Mortality Is Higher for Female Heart Transplant Candidates Alanna A. Morris1, Emir Veledar2, Robert T. Cole1, Divya Gupta1, Daniel B. Sims1, Wendy Book1, Andrew L. Smith1, Javed Butler1; 1Emory University, Atlanta, GA; 2 Emory University School of Public Health, Atlanta, GA
Introduction: Data from community-based heart failure (HF) trials have suggested better survival in women compared to men. However, little is known about gender differences in survival with end-stage HF. We sought to investigate gender differences in survival of patients with end-stage HF listed for heart transplantation (HT). Methods: We identified 38,036 subjects age $18 (23% female) in the Organ Procurement and Transplantation database listed for their first HT between 1985 and 2012. Wait list survival was censored on the day of removal from the wait list for death or being deemed too sick to transplant. Cox proportional regression models were used for multivariable analysis. Results: Compared to males, female HT candidates were younger (49613 vs. 53611 years, p!0.001), had a lower pulmonary capillary wedge pressure (2069 vs. 2269 mm Hg, p!0.001), and a lower creatinine (1.260.8 vs. 1.460.9 mg/dL, p!0.001). Females were less likely to have an implantable cardioverter-defibrillator (ICD) compared to males (43% vs. 48%, p! 0.001). The median number of days on the wait list was shorter for women than men (114 [31,362] vs. 141 [41,411] days, p!0.001). The unadjusted 1-year survival on the wait list was 78% for males and females (p50.2). After adjusting for age, weight, ABO blood group, inotropic and intra-aortic balloon pump support, ICD, wedge pressure $15 mm Hg and creatinine, female gender was associated with a higher risk of removal from the wait-list for death or being deemed too sick to transplant at 1 year (HR 1.14, 95% CI [1.04,1.24], p50.005). Conclusions: Compared to males, female HT candidates have a higher risk of 1-year morbidity/mortality on the waiting list. More investigation is needed to identify unique risk factors for death on the wait list in women.
Are (Years) Males (%) SBP (mmHg) DBP (mmHg) LVEF (%) BNP (pg/mL) Albumin (g/dL) Etiology Triglycerides (mg/dL) Total cholesterol (mg/dL) LDL (mg/dL) HDL (mg/dL) BMI (kg/m2) Body Fat Mass (kg) Percent Body Fat (%) WC (cm) LBM (kg) Dry Lean Mass (kg) LBM in Trunk (kg) LBM in Right (kg) LBM in Left Leg (kg) LBM in Left Arm (kg) LBM of Right Arm (kg) Beta-Blockers (%) Statin (%)
Diabetics N 5 76
Non-Diabetics N 5 221
57.41 6 11.61 83% 115.35 6 18.96 70.97 6 14.01 33.15 6 15.48 437.85 4.31 6 0.35 60% 148.24 6 82.76
54.85 6 14.94 70% 114.99 6 19.24 71.81 6 13.76 37.36 6 15.75 336.02 4.69 6 4.51 24% 118.13 6 60.78
0.127
149.70 6 45.50
159.65 6 45.22
0.151
80.31 6 41.57 40.85 6 12.92 30.04 6 6.55 30.59 6 14.85 32.76 6 9.25 104.63 6 16.11 59.16 6 11.85 15.53 6 3.19 59.66 6 12.51 19.83 6 4.85 20.11 6 6.99 7.69 6 2.05 7.66 6 2.08 96% 81%
93.54 6 34.52 46.22 6 19.61 27.78 6 5.85 26.19 6 13.07 30.11 6 9.92 97.71 6 15.42 57.35 6 12.17 15.16 6 3.25 57.22 6 12.39 19.79 6 6.06 19.23 6 4.49 7.17 6 2.04 7.29 6 2.08 87% 58%
P Value
0.890 0.658 0.065 0.329 0.293 2.414E-06 0.147
0.031 0.011 0.009 0.023 0.036 0.003 0.254 0.397 0.143 0.958 0.407 0.072 0.178 0.006 3.99E-05