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The Mediating Role of Depression in Predictors of Instrumental Activities of Daily Living (IADL) Modification (Disability) in Persons with Heart Failure
S110 Journal of Cardiac Failure Vol. 15 No. 6S Suppl. 2009 60 admissions were associated with PAC placement. Segmented regression analysis reveals a decrease of approximately 1.03 PAC placements per month (p ! 0.0001). This effect was not modified by considering the intervention of publication of the ESCAPE trial in October, 2005 (level change 5 2.6, p 5 .66; trend change 5 .38, p 5 .11). Conclusions: Usage of the PAC at a high volume academic medical center is decreasing, confirming prior analyses. This trend was consistently observed during the time period considered and was not modified further by publication of the ESCAPE trial. Further analysis of our database will elucidate whether the general decrease in PAC use is also present in the subgroup of patients with severe, decompensated heart failure who may have been excluded from ESCAPE.
368 The Role of Questionnaire Scores and Laboratory Test Results in Identifying Hospitalizations and Deaths of Patients with Heart Failure Leonidas V. Athanasopoulos, Athanasios Dritsas, Dennis V. Cokkinos; 1st Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece Objectives: In patients (pts) with heart failure (HF), Minnesota Living with Heart Failure Questionnaire (MLHF) is used to measure quality of life and Specific Activity Questionnaire (SAQ) to assess activity capacity. Cardiopulmonary exercise testing (CPX), echocardiography and plasma levels of Brain Natriuretic Peptide (BNP) are also employed in their assessment. We compared the prognostic value of these modalities in identifying pts who will be hospitalized for HF deterioration or die from HF. Methods: Sixty-two pts with HF underwent a CPX on a treadmill and echocardiography test (LA, LVEF). Plasma N-terminal prohormone of BNP (NT-proBNP) was measured and all completed MLHF and SAQ. The pts were then followed-up for a mean period of 27 6 7 months for hospitalization for worsening HF and death from HF. Results: The mean 6 SD SAQ score was 6.8 6 1 and MLHF score 22.4 6 13. The mean LVEF was 30.8 6 6.8 % and LA was 47.9 6 7.3 mm. Peak VO2 was 19.6 6 5.5 ml/kgr/min, anaerobic threshold 16.5 6 4.5 ml/kgr/min and VE/VCO2 slope was 36.3 6 8. Median value and interquartile range of NT-proBNP was 495 (179 - 1247) pg/ml. Seven pts (11 %) were hospitalized for worsening HF and two pts (3 %) died due to HF. Areas under the ROC curves (AUC), sensitivity, specificity and criterion values are given in Table 1. When MLHF score was combined with NTproBNP the AUC increased to 0.885; p!0.001. Conclusions: VE/VCO2 slope showed the best discriminatory power; all remaining laboratory measures could also identify these pts well. Questionnaire scores had a very good discriminatory power, but lower compared to the laboratory measures. The combination of MLHF score with NT-proBNP, which are easily obtainable, has a prognostic value comparable to ergospirometric parameters.
generally poor (65.4 6 22.4). Age, gender, ethnicity, level of education, marital status, comorbid diabetes and hypertension, HF type and etiology, EF, and NYHA class were not significant determinants of self-care management individually or in combination. In contrast, comorbid renal disease (b53.3, 95%CI5.05-6.55, p5.047) and higher levels of self-care maintenance (b5.64, 95%CI5.31-.98, p!.001) were determinants of better self-care management, together explaining 19% of the variance self-care management (F58.21, p5.001). Conclusions: Comorbid renal disease is associated with better HF self-care management, indicating that patients with renal disease are better at recognizing HF signs and symptoms and engaging in treatment strategies. Level of engagement in self-care maintenance also is a significant determinant of HF symptom recognition and treatment, indicating that HF patients who are better at adhering to prescribed treatment and symptom monitoring also are better at recognizing and treating HF symptoms when they occur.
370 The Mediating Role of Depression in Predictors of Instrumental Activities of Daily Living (IADL) Modification (Disability) in Persons with Heart Failure Yaewon Seo1, Louise LaFramboise1, Ioana Dumitru1; 1College of Nursing, Univerisity of Nebraska Medical Center, Omaha, NE; 2College of Nursing, Univerisity of Nebraska Medical Center, Omaha, NE; 3Cardiology, Univerisity of Nebraska Medical Center, Omaha, NE Background: In heart failure (HF) patients, depression, a common co-morbidity, is related to functional impairments (fatigue & muscle weakness), and may accelerate further disability in instrumental activities of daily living (IADLs). Using the model of disability modified from Nagi (1991) and others, this study examined depression as a mediator for both fatigue and muscle weakness to disability (modification in IADLs) while considering the simultaneous effects of age, gender, and co-morbidities. Methods and Results: In a cross-sectional design, 48 men and 54 women over 21 years of age (M559.6 years) diagnosed with HF (NYHA Class II-IV) were recruited at an outpatient HF clinic. More than 80% of patients were categorized as a NYHA II. Participants moderately modified in IADLs (M52.08, SD51.68) and 40% were depressed ($ 14 on the Beck Depression Inventory II). The means of lower extremity muscle strength normalized by body weight and fatigue during the day of data collection were .86(kg) (SD5.25) and 4.02 (SD52.91), respectively. Path analysis with AmosÔ revealed that 41% of the variance in modification in IADLs was significantly explained by the overall model. All variables except for muscle strength had direct effects, with fatigue having the greatest direct effect. Fatigue and muscle strength had indirect effects through depression with age having an indirect effect through these variables on modification in IADLs. (see figure1)
Table 1. ROC analysis for identifying hospitalizations for HF deterioration and deaths from HF AUC p value VE/VCO2 slope Peak VO2 NT-proBNP AT LA LVEF MLHF score SAQ score
Criterion value
0.922 !0.001 O 39.5 0.895 !0.001 ! 15.6 ml/kgr/min 0.864 0.001 O 498.5 pg/ml 0.853 0.001 ! 12.6 ml/kgr/min 0.843 0.001 O 49.5 mm 0.805 0.004 ! 29% 0.771 0.01 O 23.33 0.743 0.02 ! 6.5
Sensitivity % Specificity % 89 89 89 89 89 78 78 67
86 87 77 88 66 71 70 77
369 Comorbid Renal Disease and Treatment Adherence Are Determinants of Symptom Recognition and Treatment in Patients with Symptomatic Heart Failure Christopher S. Lee, Barbara Riegel; Univ. of Pennsylvania School of Nursing, Philadelphia, PA Introduction: While several determinants of self-care maintenance (treatment adherence) have been identified in the heart failure (HF) population, the determinants of HF self-care management (symptom recognition and treatment) are largely unknown. Hypothesis: Sociodemographic and clinical data are useful as predictors of self-care management. Methods: Data from symptomatic, community-dwelling out-patients with HF enrolled in a prospective cohort study examining the impact of daytime sleepiness on HF self-care were used to test the hypothesis. Sociodemographic and clinical data were collected at enrolment. Self-care maintenance and management were measured with the Self-Care of Heart Failure index (SCHFI). SCHFI maintenance and management scales are standardized to range from 0-100 with higher scores indicating better self-care; SCHFI scores $70 are considered adequate. Multiple regression modeling was used to evaluate the influence of sociodemographic and clinical characteristics on self-care management. Results: The sample (n573) was in older adulthood (mean age 64 6 12 years), predominantly male (64.4%) and Caucasian (68.5%); half (49.3%) had diabetes mellitus, a majority (65.8%) had hypertension, and about 1/3rd of the sample (28.8%) had renal disease. The majority had systolic HF (60.3%) of ischemic origin (50.7%); the average EF was 35.1%618.7%, and the majority (64.4%) had NYHA class III HF. SCHFI maintenance scores were adequate (70.6 6 14.5) and self-care management scores were
Conclusion: Fatigue not only had a direct effect on depression, but fatigue and muscle strength were mediated by depression in predicting IADL modification (disability), suggesting interventions targeted to improve fatigue and muscle strength may improve depression and ultimately prevent disability in HF patients. Interventions specific to gender and co-morbidities also may be effective in preventing disability. Routine assessment of muscle strength and fatigue may identify HF patients at risk for depression and disability in HF patients.
371 Knowledge, Attitudes, and Beliefs about Hypertension Vary by Ethnicity Randy Wexler1, Christopher Taylor2, Jonathon Scott2, Adam Pleister3, Craig Michael3, Feldman David3; 1Family Medicine, The Ohio State University, Columbus, OH; 2 Medical Dietetics, The Ohio State University, Columbus, OH; 3Internal Medicine, Division of Cardiology, The Ohio State University, Columbus, OH Purpose: To identify patient knowledge, attitudes, and beliefs about hypertension. Methods: An IRB approved survey was administered to hypertensive patients within a metropolitan Primary Care Network (n5310), which assessed knowledge about
368 The Role of Questionnaire Scores and Laboratory Test Results in Identifying Hospitalizations and Deaths of Patients with Heart Failure Leonidas V. Athanasopoulos, Athanasios Dritsas, Dennis V. Cokkinos; 1st Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece Objectives: In patients (pts) with heart failure (HF), Minnesota Living with Heart Failure Questionnaire (MLHF) is used to measure quality of life and Specific Activity Questionnaire (SAQ) to assess activity capacity. Cardiopulmonary exercise testing (CPX), echocardiography and plasma levels of Brain Natriuretic Peptide (BNP) are also employed in their assessment. We compared the prognostic value of these modalities in identifying pts who will be hospitalized for HF deterioration or die from HF. Methods: Sixty-two pts with HF underwent a CPX on a treadmill and echocardiography test (LA, LVEF). Plasma N-terminal prohormone of BNP (NT-proBNP) was measured and all completed MLHF and SAQ. The pts were then followed-up for a mean period of 27 6 7 months for hospitalization for worsening HF and death from HF. Results: The mean 6 SD SAQ score was 6.8 6 1 and MLHF score 22.4 6 13. The mean LVEF was 30.8 6 6.8 % and LA was 47.9 6 7.3 mm. Peak VO2 was 19.6 6 5.5 ml/kgr/min, anaerobic threshold 16.5 6 4.5 ml/kgr/min and VE/VCO2 slope was 36.3 6 8. Median value and interquartile range of NT-proBNP was 495 (179 - 1247) pg/ml. Seven pts (11 %) were hospitalized for worsening HF and two pts (3 %) died due to HF. Areas under the ROC curves (AUC), sensitivity, specificity and criterion values are given in Table 1. When MLHF score was combined with NTproBNP the AUC increased to 0.885; p!0.001. Conclusions: VE/VCO2 slope showed the best discriminatory power; all remaining laboratory measures could also identify these pts well. Questionnaire scores had a very good discriminatory power, but lower compared to the laboratory measures. The combination of MLHF score with NT-proBNP, which are easily obtainable, has a prognostic value comparable to ergospirometric parameters.
generally poor (65.4 6 22.4). Age, gender, ethnicity, level of education, marital status, comorbid diabetes and hypertension, HF type and etiology, EF, and NYHA class were not significant determinants of self-care management individually or in combination. In contrast, comorbid renal disease (b53.3, 95%CI5.05-6.55, p5.047) and higher levels of self-care maintenance (b5.64, 95%CI5.31-.98, p!.001) were determinants of better self-care management, together explaining 19% of the variance self-care management (F58.21, p5.001). Conclusions: Comorbid renal disease is associated with better HF self-care management, indicating that patients with renal disease are better at recognizing HF signs and symptoms and engaging in treatment strategies. Level of engagement in self-care maintenance also is a significant determinant of HF symptom recognition and treatment, indicating that HF patients who are better at adhering to prescribed treatment and symptom monitoring also are better at recognizing and treating HF symptoms when they occur.
370 The Mediating Role of Depression in Predictors of Instrumental Activities of Daily Living (IADL) Modification (Disability) in Persons with Heart Failure Yaewon Seo1, Louise LaFramboise1, Ioana Dumitru1; 1College of Nursing, Univerisity of Nebraska Medical Center, Omaha, NE; 2College of Nursing, Univerisity of Nebraska Medical Center, Omaha, NE; 3Cardiology, Univerisity of Nebraska Medical Center, Omaha, NE Background: In heart failure (HF) patients, depression, a common co-morbidity, is related to functional impairments (fatigue & muscle weakness), and may accelerate further disability in instrumental activities of daily living (IADLs). Using the model of disability modified from Nagi (1991) and others, this study examined depression as a mediator for both fatigue and muscle weakness to disability (modification in IADLs) while considering the simultaneous effects of age, gender, and co-morbidities. Methods and Results: In a cross-sectional design, 48 men and 54 women over 21 years of age (M559.6 years) diagnosed with HF (NYHA Class II-IV) were recruited at an outpatient HF clinic. More than 80% of patients were categorized as a NYHA II. Participants moderately modified in IADLs (M52.08, SD51.68) and 40% were depressed ($ 14 on the Beck Depression Inventory II). The means of lower extremity muscle strength normalized by body weight and fatigue during the day of data collection were .86(kg) (SD5.25) and 4.02 (SD52.91), respectively. Path analysis with AmosÔ revealed that 41% of the variance in modification in IADLs was significantly explained by the overall model. All variables except for muscle strength had direct effects, with fatigue having the greatest direct effect. Fatigue and muscle strength had indirect effects through depression with age having an indirect effect through these variables on modification in IADLs. (see figure1)
Table 1. ROC analysis for identifying hospitalizations for HF deterioration and deaths from HF AUC p value VE/VCO2 slope Peak VO2 NT-proBNP AT LA LVEF MLHF score SAQ score
Criterion value
0.922 !0.001 O 39.5 0.895 !0.001 ! 15.6 ml/kgr/min 0.864 0.001 O 498.5 pg/ml 0.853 0.001 ! 12.6 ml/kgr/min 0.843 0.001 O 49.5 mm 0.805 0.004 ! 29% 0.771 0.01 O 23.33 0.743 0.02 ! 6.5
Sensitivity % Specificity % 89 89 89 89 89 78 78 67
86 87 77 88 66 71 70 77
369 Comorbid Renal Disease and Treatment Adherence Are Determinants of Symptom Recognition and Treatment in Patients with Symptomatic Heart Failure Christopher S. Lee, Barbara Riegel; Univ. of Pennsylvania School of Nursing, Philadelphia, PA Introduction: While several determinants of self-care maintenance (treatment adherence) have been identified in the heart failure (HF) population, the determinants of HF self-care management (symptom recognition and treatment) are largely unknown. Hypothesis: Sociodemographic and clinical data are useful as predictors of self-care management. Methods: Data from symptomatic, community-dwelling out-patients with HF enrolled in a prospective cohort study examining the impact of daytime sleepiness on HF self-care were used to test the hypothesis. Sociodemographic and clinical data were collected at enrolment. Self-care maintenance and management were measured with the Self-Care of Heart Failure index (SCHFI). SCHFI maintenance and management scales are standardized to range from 0-100 with higher scores indicating better self-care; SCHFI scores $70 are considered adequate. Multiple regression modeling was used to evaluate the influence of sociodemographic and clinical characteristics on self-care management. Results: The sample (n573) was in older adulthood (mean age 64 6 12 years), predominantly male (64.4%) and Caucasian (68.5%); half (49.3%) had diabetes mellitus, a majority (65.8%) had hypertension, and about 1/3rd of the sample (28.8%) had renal disease. The majority had systolic HF (60.3%) of ischemic origin (50.7%); the average EF was 35.1%618.7%, and the majority (64.4%) had NYHA class III HF. SCHFI maintenance scores were adequate (70.6 6 14.5) and self-care management scores were
Conclusion: Fatigue not only had a direct effect on depression, but fatigue and muscle strength were mediated by depression in predicting IADL modification (disability), suggesting interventions targeted to improve fatigue and muscle strength may improve depression and ultimately prevent disability in HF patients. Interventions specific to gender and co-morbidities also may be effective in preventing disability. Routine assessment of muscle strength and fatigue may identify HF patients at risk for depression and disability in HF patients.
371 Knowledge, Attitudes, and Beliefs about Hypertension Vary by Ethnicity Randy Wexler1, Christopher Taylor2, Jonathon Scott2, Adam Pleister3, Craig Michael3, Feldman David3; 1Family Medicine, The Ohio State University, Columbus, OH; 2 Medical Dietetics, The Ohio State University, Columbus, OH; 3Internal Medicine, Division of Cardiology, The Ohio State University, Columbus, OH Purpose: To identify patient knowledge, attitudes, and beliefs about hypertension. Methods: An IRB approved survey was administered to hypertensive patients within a metropolitan Primary Care Network (n5310), which assessed knowledge about