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Regular Monitoring of Lower Extremity Edema Predicts Cardiac Event-Free Survival in Patients with Heart Failure
The 15th Annual Scientific Meeting
HFSA
S5
Nursing Research Award 011 Regular Monitoring of Lower Extremity Edema Predicts Cardiac Event-Free Survival in Patients with Heart Failure Kyoung Suk Lee1, Terry A. Lennie1, Sandra B. Dunbar2, Susan J. Pressler3, Seongkum Heo4, Debra K. Moser1; 1College of Nursing, Univeristy of Kentucky, Lexington, KY; 2School of Nursing, Emory University, Atlanta, GA; 3School of Nursing, University of Michigan, Ann Arbor, MI; 4College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR Background: Regular symptom monitoring is a fundamental self-care component that most patients with heart failure (HF) rarely perform. Empirical evidence demonstrating the impact of regular symptom monitoring on outcomes is lacking. Purpose: To explore whether regular monitoring of lower extremity edema as a measure of symptom monitoring behaviors predict cardiac-event free survival in patients with HF. Methods: A total of 233 patients with HF (61 yrs, 34% female, 48% NYHA III/IV) participated. Adherence to regular symptom monitoring was assessed using a single item: How frequently do you check lower extremity swelling. Patients were considered adherent if they reported always monitor. To determine cardiac events (death, hospitalization, or emergency department visit due to cardiac reasons), patients were followed up a median of 365 days. Results: Less than half of the patients (42%) were adherent to monitoring of lower extremity edema. Cox regression analysis revealed that patients who were non-adherent to monitoring of lower extremity edema had a 1.9 times higher risk for cardiac event than patients who were adherent (95% CI 1.1-3.3) after adjusting for age, gender, living arrangement, comorbidity score, depressive symptom, body mass index, NYHA class, and HF etiology.
were significantly associated with HRQOL. The final overall model explained 66% of the variance in HRQOL; age contributed 4% (p 5 0.023), total symptom burden 14% (p 5 0.001), and comfort 7% of the variance. Conclusion: Consistent with previous research, older age is associated with better HRQOL; the needs of younger women with HFPSF warrant further study. Interventions reducing symptom burden and enhancing comfort for older women with HFPSF may improve HRQOL. Addressing life quality is congruent with a palliative approach in advanced chronic illness, an important complement to standard therapy in advanced and end-stage HF. Older women, a growing segment of our society, deserve no less in the last phase of their life journey.
013 “I Just Can’t Do It Anymore”: Patterns of Physical Activity and Cardiac Rehabilitation Referral in African Americans with Heart Failure Margaret M. McCarthy1, Alexandra Howe1, Judith Schipper2, Jaime Gonzalez3, Stuart Katz2, Victoria V. Dickson1; 1College of Nursing, New York University, New York, NY; 2Department of Medicine, New York University Langone Medical Center, New York, NY; 3Bellevue Hospital Heart Failure Program, Bellevue Hospital, New York, NY
Conclusion: This study highlights that fundamental importance of symptom monitoring to HF outcomes, and suggests that the process of checking for edema might increase patients’ awareness of bodily changes. Increased body awareness may lead patients with HF to take appropriate action in a timely manner.
Introduction: The purpose of this study was to describe patterns of physical activity (PA) and cardiac rehabilitation (CR) referral in African Americans with heart failure (HF) using a mixed methods approach. Methods: Guided by a naturalistic decisionmaking framework, qualitative data were obtained using a semi-structured interview guide. Standard and reliable instruments measured quantitative data about sociodemographics, physical functioning, and depression, and supplemented the qualitative findings. Thirty adults with HF were recruited from an urban HF clinic serving low-income minority individuals. Results: The mean age of the subjects was 60615 years; 40% were women. Mean BMI was 2966. The average duration of HF was 6.5611years; 66% were classified as NYHA Class III. Most (53%) reported being told to do “minimal exercise only” by their health care provider; 43% exercised less than 30 minutes in the last week. The mean Duke Activity Status Index (DASI) score of 16.8 in this sample represents ability to perform only moderate activity. Many (41%) had evidence of depression (PHQ-9 cut-off score $ 10). PHQ-9 was also negatively correlated (r5-.418; p5.02) with DASI scores; those with higher depression scores had lower levels of activity on the DASI. The qualitative data revealed an overarching theme of current PA as extremely limited by HF symptoms such as dyspnea, weakness and fatigue. Some patients appeared to have given up, while others were still trying to be active. A secondary theme reflected past PA (i.e. walking, sports, dancing) that individuals were unable to sustain. Barriers to PA included poor functional status, fear, and depressive symptoms. There was 82% concordance between quantitative and qualitative data on PA. When asked about referral to CR, 80% (n524) stated they were not referred. Conclusions: Despite strong evidence that PA is both safe and beneficial for HF patients and that CR is the standard of care, this ethnic minority sample was extremely limited in PA due to HF symptoms and lacked appropriate referrals to CR. Research to develop and test interventions that promote PA in vulnerable HF patients is needed. In addition, efforts to increase clinician adherence to treatment guidelines for PA and CR referral are indicated.
012
014
Comfort and Symptom Burden Associated with Health-Related Quality of Life in Older Women with Advanced Heart Failure and Preserved Systolic Function Bonita L. Huiskes1, J. Thomas Heywood2, Kathleen Dracup3; 1Azusa Pacific University, Azusa, CA; 2Scripps Clinic, La Jolla, CA; 3University of California San Francisco, San Francisco, CA
Is Cognitive Impairment Associated with Medication Adherence in Outpatients with Heart Failure? Lee Ann Hawkins, Shirley Kilian, T. Michael Kashner, Anthony Firek, Chistopher J. Firek, Elena V. Perez, Helme Silvet; Cardiology, VA Loma Linda Healthcare System, Loma Linda, CA
Introduction: Heart failure with preserved systolic function (HFPSF) accounts for approximately half of all heart failure (HF) patients, the majority of whom are older women. Little is known about this HF subgroup since they have been included in few HF clinical trials. Characteristics of those with advanced disease have not been welldescribed and factors influencing their health-related quality of life (HRQOL) have received little research attention. This descriptive, cross-sectional study examined multiple factors with potential impact on HRQOL: demographic, clinical, symptom, comfort, and functional capacity. Methods: The convenience sample of 60 women with HFPSF was recruited from two HF clinics. Subjects completed three questionnaires (Memorial Symptom Assessment Scale - HF [MSAS-HF], General Comfort Questionnaire [GCQ], Minnesota Living with Heart Failure Questionnaire [MLHFQ]) and a 6-Minute Walk Test (6MWT). Demographic and clinical characteristics were obtained from subject self-report and medical records. Data were analyzed using descriptive statistics and multiple linear regression. Results: The women (mean age 76.8 6 7.7 years) were NYHA Class III and had a mean number of co-morbidities of 4.7 6 1.6 and a mean number of symptoms of 13.2 6 6.4. Their average 6MWT distance was 201.4 6 117.1 meters. The mean MLHF total score was 42.3 6 21.8, indicating reduced quality of life. Using a multiple linear regression model to control for disease severity, clinical status, and functional capacity, younger age (p 5 0.023), greater comfort (p 5 0.002) and lower total symptom burden (p 5 0.001)
Introduction: Heart failure (HF) significantly impacts patients’ quality of life, morbidity and mortality, and represents a large expenditure for VA health care. Adherence to a structured medical regimen has been shown to improve clinical outcomes; however, compliance with medications is suboptimal in patients with HF. Cognitive impairment (CI) may affect medication adherence in patients with HF; yet neither the prevalence of CI nor its association to medication adherence has been evaluated in the VA population. Hypothesis: We hypothesized that CI is a prevalent condition in veteran outpatients with HF and is associated with medication adherence. Methods: The study was designed as a prospective cohort study in a single center (VA Loma Linda Healthcare System). Outpatients with HF but without previously diagnosed CI were enrolled. Patients were screened for CI by Saint Louis Mental Status (SLUMS) Examination. Demographic and clinical data, comorbidities, Geriatric Depression Scale (GDS), and laboratory data were collected at baseline. Medication adherence was determined by a 30-day pillcount of all medications. Results: 251 subjects were enrolled in the study. Mean age was 66 years with 99% being male and 73% Caucasian. More than half of the patients had diabetes (53%), hypertension (77%) and coronary artery disease (64%); 30% had history of depression. 59% of the patients were found to have cognitive impairment based on SLUMS Exam (Table 1). CI was significantly associated with age, race, education, depression (evaluated by GDS), blood pressure and Hemoglobin. 57% of patients
Figure 1. Cardiac Event -Free Survival by Adherence Levels of Symptom monitoring
HFSA
S5
Nursing Research Award 011 Regular Monitoring of Lower Extremity Edema Predicts Cardiac Event-Free Survival in Patients with Heart Failure Kyoung Suk Lee1, Terry A. Lennie1, Sandra B. Dunbar2, Susan J. Pressler3, Seongkum Heo4, Debra K. Moser1; 1College of Nursing, Univeristy of Kentucky, Lexington, KY; 2School of Nursing, Emory University, Atlanta, GA; 3School of Nursing, University of Michigan, Ann Arbor, MI; 4College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR Background: Regular symptom monitoring is a fundamental self-care component that most patients with heart failure (HF) rarely perform. Empirical evidence demonstrating the impact of regular symptom monitoring on outcomes is lacking. Purpose: To explore whether regular monitoring of lower extremity edema as a measure of symptom monitoring behaviors predict cardiac-event free survival in patients with HF. Methods: A total of 233 patients with HF (61 yrs, 34% female, 48% NYHA III/IV) participated. Adherence to regular symptom monitoring was assessed using a single item: How frequently do you check lower extremity swelling. Patients were considered adherent if they reported always monitor. To determine cardiac events (death, hospitalization, or emergency department visit due to cardiac reasons), patients were followed up a median of 365 days. Results: Less than half of the patients (42%) were adherent to monitoring of lower extremity edema. Cox regression analysis revealed that patients who were non-adherent to monitoring of lower extremity edema had a 1.9 times higher risk for cardiac event than patients who were adherent (95% CI 1.1-3.3) after adjusting for age, gender, living arrangement, comorbidity score, depressive symptom, body mass index, NYHA class, and HF etiology.
were significantly associated with HRQOL. The final overall model explained 66% of the variance in HRQOL; age contributed 4% (p 5 0.023), total symptom burden 14% (p 5 0.001), and comfort 7% of the variance. Conclusion: Consistent with previous research, older age is associated with better HRQOL; the needs of younger women with HFPSF warrant further study. Interventions reducing symptom burden and enhancing comfort for older women with HFPSF may improve HRQOL. Addressing life quality is congruent with a palliative approach in advanced chronic illness, an important complement to standard therapy in advanced and end-stage HF. Older women, a growing segment of our society, deserve no less in the last phase of their life journey.
013 “I Just Can’t Do It Anymore”: Patterns of Physical Activity and Cardiac Rehabilitation Referral in African Americans with Heart Failure Margaret M. McCarthy1, Alexandra Howe1, Judith Schipper2, Jaime Gonzalez3, Stuart Katz2, Victoria V. Dickson1; 1College of Nursing, New York University, New York, NY; 2Department of Medicine, New York University Langone Medical Center, New York, NY; 3Bellevue Hospital Heart Failure Program, Bellevue Hospital, New York, NY
Conclusion: This study highlights that fundamental importance of symptom monitoring to HF outcomes, and suggests that the process of checking for edema might increase patients’ awareness of bodily changes. Increased body awareness may lead patients with HF to take appropriate action in a timely manner.
Introduction: The purpose of this study was to describe patterns of physical activity (PA) and cardiac rehabilitation (CR) referral in African Americans with heart failure (HF) using a mixed methods approach. Methods: Guided by a naturalistic decisionmaking framework, qualitative data were obtained using a semi-structured interview guide. Standard and reliable instruments measured quantitative data about sociodemographics, physical functioning, and depression, and supplemented the qualitative findings. Thirty adults with HF were recruited from an urban HF clinic serving low-income minority individuals. Results: The mean age of the subjects was 60615 years; 40% were women. Mean BMI was 2966. The average duration of HF was 6.5611years; 66% were classified as NYHA Class III. Most (53%) reported being told to do “minimal exercise only” by their health care provider; 43% exercised less than 30 minutes in the last week. The mean Duke Activity Status Index (DASI) score of 16.8 in this sample represents ability to perform only moderate activity. Many (41%) had evidence of depression (PHQ-9 cut-off score $ 10). PHQ-9 was also negatively correlated (r5-.418; p5.02) with DASI scores; those with higher depression scores had lower levels of activity on the DASI. The qualitative data revealed an overarching theme of current PA as extremely limited by HF symptoms such as dyspnea, weakness and fatigue. Some patients appeared to have given up, while others were still trying to be active. A secondary theme reflected past PA (i.e. walking, sports, dancing) that individuals were unable to sustain. Barriers to PA included poor functional status, fear, and depressive symptoms. There was 82% concordance between quantitative and qualitative data on PA. When asked about referral to CR, 80% (n524) stated they were not referred. Conclusions: Despite strong evidence that PA is both safe and beneficial for HF patients and that CR is the standard of care, this ethnic minority sample was extremely limited in PA due to HF symptoms and lacked appropriate referrals to CR. Research to develop and test interventions that promote PA in vulnerable HF patients is needed. In addition, efforts to increase clinician adherence to treatment guidelines for PA and CR referral are indicated.
012
014
Comfort and Symptom Burden Associated with Health-Related Quality of Life in Older Women with Advanced Heart Failure and Preserved Systolic Function Bonita L. Huiskes1, J. Thomas Heywood2, Kathleen Dracup3; 1Azusa Pacific University, Azusa, CA; 2Scripps Clinic, La Jolla, CA; 3University of California San Francisco, San Francisco, CA
Is Cognitive Impairment Associated with Medication Adherence in Outpatients with Heart Failure? Lee Ann Hawkins, Shirley Kilian, T. Michael Kashner, Anthony Firek, Chistopher J. Firek, Elena V. Perez, Helme Silvet; Cardiology, VA Loma Linda Healthcare System, Loma Linda, CA
Introduction: Heart failure with preserved systolic function (HFPSF) accounts for approximately half of all heart failure (HF) patients, the majority of whom are older women. Little is known about this HF subgroup since they have been included in few HF clinical trials. Characteristics of those with advanced disease have not been welldescribed and factors influencing their health-related quality of life (HRQOL) have received little research attention. This descriptive, cross-sectional study examined multiple factors with potential impact on HRQOL: demographic, clinical, symptom, comfort, and functional capacity. Methods: The convenience sample of 60 women with HFPSF was recruited from two HF clinics. Subjects completed three questionnaires (Memorial Symptom Assessment Scale - HF [MSAS-HF], General Comfort Questionnaire [GCQ], Minnesota Living with Heart Failure Questionnaire [MLHFQ]) and a 6-Minute Walk Test (6MWT). Demographic and clinical characteristics were obtained from subject self-report and medical records. Data were analyzed using descriptive statistics and multiple linear regression. Results: The women (mean age 76.8 6 7.7 years) were NYHA Class III and had a mean number of co-morbidities of 4.7 6 1.6 and a mean number of symptoms of 13.2 6 6.4. Their average 6MWT distance was 201.4 6 117.1 meters. The mean MLHF total score was 42.3 6 21.8, indicating reduced quality of life. Using a multiple linear regression model to control for disease severity, clinical status, and functional capacity, younger age (p 5 0.023), greater comfort (p 5 0.002) and lower total symptom burden (p 5 0.001)
Introduction: Heart failure (HF) significantly impacts patients’ quality of life, morbidity and mortality, and represents a large expenditure for VA health care. Adherence to a structured medical regimen has been shown to improve clinical outcomes; however, compliance with medications is suboptimal in patients with HF. Cognitive impairment (CI) may affect medication adherence in patients with HF; yet neither the prevalence of CI nor its association to medication adherence has been evaluated in the VA population. Hypothesis: We hypothesized that CI is a prevalent condition in veteran outpatients with HF and is associated with medication adherence. Methods: The study was designed as a prospective cohort study in a single center (VA Loma Linda Healthcare System). Outpatients with HF but without previously diagnosed CI were enrolled. Patients were screened for CI by Saint Louis Mental Status (SLUMS) Examination. Demographic and clinical data, comorbidities, Geriatric Depression Scale (GDS), and laboratory data were collected at baseline. Medication adherence was determined by a 30-day pillcount of all medications. Results: 251 subjects were enrolled in the study. Mean age was 66 years with 99% being male and 73% Caucasian. More than half of the patients had diabetes (53%), hypertension (77%) and coronary artery disease (64%); 30% had history of depression. 59% of the patients were found to have cognitive impairment based on SLUMS Exam (Table 1). CI was significantly associated with age, race, education, depression (evaluated by GDS), blood pressure and Hemoglobin. 57% of patients
Figure 1. Cardiac Event -Free Survival by Adherence Levels of Symptom monitoring