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Background: Adults with heart failure (HF) experience a constellation of symptoms; however, understanding of gender differences in HF symptoms remain elusive. The aim of this study was to determine whether there are gender differences in physical and depressive symptoms and symptom patterns in HF using 2 different analytic techniques. Methods: We performed a secondary analysis of combined data from 6 studies of adults with HF. Physical symptoms were measured with the HF Somatic Perception Scale, and depressive symptoms were measured with the Patient Health Questionnaire-9. First, we performed propensity matching with the nearest neighbor to examine the average treatment effect for HF Somatic Perception Scale and Patient Health Questionnaire-9 in the matched sample of women and men. Next, we used the entire data set in a latent class mixture model to determine patterns of symptoms. Finally, we calculated predictors of class membership with multinomial logistic regression. Results: The sample (n = 524, 86.5% systolic HF) was 37% women with a mean age of 58.3 ± 13.9 years and mean number of years with HF of 6.9 ± 6.9. Three hundred sixty-six participants were matched on propensity scores; there were no significant gender differences in symptom scores between matched women (n = 183) and men (n = 183). Among all 524 participants, 4 distinct latent classes of symptom patterns indicate that many patients with HF are fatigued, some have more depressive symptoms, and others have significantly more edema or cough. Gender did not predict membership to any symptom pattern. Conclusions: There were significant gender differences in sociodemographics, health behaviors, and clinical characteristics, but not HF symptoms or symptom patterns, using either analytic technique. [ABSTRACT FROM AUTHOR]

Aims: Physical frailty is highly prevalent and predictive of worse outcomes in heart failure (HF). Candidate biomarker analysis may help in understanding the mechanisms underlying physical frailty in HF. We aimed to identify candidate biomarkers associated with physical frailty in HF using a multimarker strategy of distinct pathophysiological processes. Methods and results: We collected data and plasma samples from 113 adults with New York Heart Association Functional Class I–IV HF. Physical frailty was measured with the Frailty Phenotype Criteria. Plasma biomarkers included: N-terminal pro-B-type natriuretic peptide, norepinephrine, dihydroxyphenylglycol, soluble tumour necrosis factor alpha receptor-1, adiponectin, insulin, glucose, insulin-like growth factor-1 (IGF-1), and myostatin. Comparative statistics and multivariate linear regression were used to test group differences and associations. The average age was 63.5 ± 15.7 years, half were women (48%), and most had a non-ischaemic aetiology of HF (73%). Physical frailty was identified in 42% and associated with female sex, higher body mass index and percent body fat, more comorbidities, and HF with preserved ejection fraction. Adjusting for Seattle HF Model projected survival score, comorbidities, body composition, and sex, physical frailty was associated with significantly lower plasma adiponectin [β ± standard error (SE) −0.28 ± 0.14, P = 0.047], IGF-1 (β ± SE −0.21 ± 0.10, P = 0.032), and myostatin (β ± SE −0.22 ± 0.09, P = 0.011). In sex-stratified analyses, IGF-1 and myostatin were significantly associated with physical frailty in men but not women. Conclusion: We identified biomarkers involved in adipose tissue and skeletal muscle development, maintenance, and function that were associated with physical frailty in HF. Graphical Abstract Graphical Abstract Abbreviations: HF, heart failure [ABSTRACT FROM AUTHOR]

Background and Objectives Increasingly, older adults and their families are expected to manage complex conditions with little support. In the case of heart failure (HF), symptom monitoring and management are critical in preventing acute exacerbations and poor clinical outcomes. The current study examined the role of dyadic confidence on engagement in HF care behaviors by patients and their spouses. Research Design and Methods A cross-sectional design was used to examine 60 couples living with HF. Three dyadic confidence variables were created to represent average level of confidence, gap in confidence, and direction of gap within each couple. A series of multilevel models were used to examine dyadic engagement in HF maintenance, management, and consulting behaviors and the role of dyadic confidence. Results Patients were significantly more engaged in HF maintenance behaviors than spouses; couples were more collaborative in their engagement in HF management and consulting behaviors. Average level of confidence in the dyad was significantly associated with patient engagement in all three HF behaviors. Spouse engagement was associated with more congruence in confidence and having higher levels of confidence than their partners with HF. Women were significantly more engaged in HF behaviors than men, regardless of role. Discussion and Implications The study employed a dyadic approach to HF care and a novel approach to confidence. Findings confirm the social nature of confidence and its important role in HF. Clinicians have opportunities to optimize patient outcomes by fostering greater collaboration within couples. [ABSTRACT FROM AUTHOR]

Background: Both heart failure symptoms and self-care are associated with patient outcomes. Although it is thought that symptoms drive self-care, there is limited evidence to support this assumption over time. Aims: To determine whether patterns of physical symptoms are significantly associated with heart failure self-care over time. Method: Latent mixture analysis was used to identify subgroups based on physical symptoms of dyspnea, sleepiness and edema (using the heart failure somatic perception and Epworth sleepiness scales). Growth modeling was used to determine if symptom subgroups were associated with self-care behaviors (using the self-care in heart failure index) over 6 months. Sociodemographic and clinical variables predicting the likelihood of subgroup membership were identified using logistic regression. Results: The sample (n=146) was on average 57 years old, 70% were men and 59% had class III/IV heart failure. Two symptom subgroups were identified (entropy 0.91): a high symptom group (n=24; 16%) with no significant change in symptoms over time (high sustained), and a low symptom group (n=122; 84%) with no significant change in symptoms over time (low sustained). The high sustained group was associated significantly with better self-care behaviors at baseline and over 6 months. Women (odds ratio (OR) 3.67, P=0.023) and patients with more depressive symptoms (OR 1.16, P=0.015) were more likely to be in the high sustained symptom group. Those treated with a renin–angiotensin–aldosterone system agent were less likely to be in the high symptom group (OR 0.17, P=0.015). Conclusion: Patients bothered more by symptoms are consistently more engaged in self-care behaviors over time. The results of this study support symptoms as an important driver of self-care behaviors. [ABSTRACT FROM AUTHOR]

Background: Physical symptoms and depression in heart failure (HF) are key drivers of health-related quality of life (HRQOL). Heart failure self-care behaviors are believed to influence how symptoms affect HRQOL. Objective: The goal of this study was to determine if HF self-care behaviors moderate the relationships between physical and depressive symptoms and HRQOL. Methods: In a cohort of adults with moderate to advanced HF, multivariate linear regression was used to evaluate the interaction between self-care behaviors (Self-care of HF index maintenance and management scales) and physical HF symptoms (HF Somatic Perception Scale) on emotional HRQOL (emotional dimension of Minnesota Living With HF Questionnaire). The interaction between self-care behaviors and depression (9-item Patient Health Questionnaire) was evaluated on physical HRQOL (physical dimension of Minnesota Living With HF Questionnaire). Results: The mean age of the sample (N = 202) was 57 T 13 years, 50% were women, and 61% had New York Heart Association class III or IV HF. Controlling for age, Seattle HF score, functional ability, and comorbidities, self-care maintenance and management moderated the relationship between physical HF symptoms and emotional HRQOL. Only self-care maintenance moderated the relationship between depression and physical HRQOL. Conclusion: In HF, HRQOL is dependent on both the severity of physical and depressive symptoms and the level of engagement in HF self-care behaviors. Future research should consider both self-care behaviors and symptomswhen examining patient HRQOL. [ABSTRACT FROM AUTHOR]

Background: Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD. Methods: The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD. Results: The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05). Conclusion: There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD. [ABSTRACT FROM AUTHOR]

Background: Preventing hospitalization and improving event-free survival are primary goals of heart failure (HF) treatment according to current European Society of Cardiology guidelines; however, substantial uncertainty remains in our ability to predict risk and improve outcomes. Although caregivers often assist patients to manage their HF, little is known about their influence on clinical outcomes. Aims: To quantify the influence of patient and caregiver characteristics on patient clinical event risk in HF. Methods: This was a secondary analysis of data using a sample of Italian adults with HF and their informal caregivers (n = 183 patient–caregiver dyads). HF patients were followed over 12 months for the following clinical events: hospitalization for HF, emergency room visit for HF or all-cause mortality. Influence of baseline caregiver- and patient-level factors (patient and caregiver age; dyad relationship type; patient New York Heart Association (NYHA) Class, cognition, and comorbidities; and caregiver strain, mental health status, and contributions to HF self-care) on patient risk of death or hospitalization/emergency room use was quantified using Cox proportional hazards regression. Results: Over the course of follow up, 32.8% of patients died, 19.7% were hospitalized for HF and 10.4% visited the emergency room. Higher caregiver strain, better caregiver mental health status and greater caregiver contributions to HF self-care maintenance were associated with significantly better event-free survival. Worse patient functional class and greater caregiver contributions to patient self-care management were associated with significantly worse patient event-free survival. Conclusion: Considering caregiving factors together with patient factors significantly increases our understanding of patient clinical event risk in HF. [ABSTRACT FROM AUTHOR]

ABSTRACT Over half a million Americans are affected by cirrhosis, the cause of end-stage liver disease (ESLD). Little is known about how symptom burden changes over time in adults with ESLD and their informal caregivers, which limits our ability to develop palliative care interventions that can optimize symptom management and quality of life in different patient-caregiver dyads. The purpose of this article is to describe the background and design of a prospective, longitudinal descriptive study, 'Symptom Burden in End-Stage Liver Disease Patient-Caregiver Dyads,' which is currently in progress. The study is designed to (i) identify trajectories of change in physical and psychological symptom burden in adults with ESLD; (ii) identify trajectories of change in physical and psychological symptom burden in caregivers of adults with ESLD; and (iii) determine predictors of types of patient-caregiver dyads that would benefit from tailored palliative care interventions. We aim for a final sample of 200 patients and 200 caregivers who will be followed over 12 months. Integrated multilevel and latent growth mixture modeling will be used to identify trajectories of change in symptom burden, linking those changes to clinical events, and quality of life outcomes and characterizing types of patient-caregiver dyads based on patient-, caregiver-, and dyad-level factors. Challenges we have encountered include unexpected attrition of study participants, participants not returning their baseline questionnaires, and hiring and training of research staff. The study will lay the foundation for future research and innovation in ESLD, end-of-life and palliative care, and caregiving. [ABSTRACT FROM AUTHOR]

Background: Caregivers are thought to play a major role in helping patients first appraise and then respond to heart failure (HF) symptoms. Aims: The aims of this study were to: (a) characterise distinct patterns of HF patient-caregiver dyads with respect to symptom appraisal; and (b) link dyadic symptom appraisal to contributions to self-care and caregiver strain. Methods and results: A cross-sectional dyadic descriptive design was used to capture patient and caregiver appraisal of patient HF symptoms (i.e. dyspnoea, fatigue, pain and anxiety). Contributions to self-care were measured using patient and caregiver versions of the Self-Care of Heart Failure Index and the European Heart Failure Self-care Behaviour Scale. Caregiver strain was measured using the Multidimensional Caregiver Strain Index. Multilevel and latent class mixture modelling (LCMM) were used to examine distinct patterns of symptom appraisal. Two patterns of dyadic symptom appraisal were identified: one pattern (n = 24; 38.7%) wherein caregivers appraised patients' symptoms as being significantly worse than did the patient (labelled as 'Caregiver > Patient'); and a second pattern (n = 38; 61.3%) wherein patients appraised their symptoms similar to or worse than that as perceived by their caregiver (labelled as 'Patient ≥ Caregiver'). Dyads in the Caregiver > Patient pattern of symptom appraisal reported much better contributions to self-care (symptom response behaviours only), but also greater caregiver strain, compared with dyads in the Patient ≥ Caregiver pattern. Greater patient depression and older caregiver age were significant determinants of fitting the Patient ≥ Caregiver pattern. Conclusion: Differences in how HF patients and caregivers appraise symptoms together must be taken into consideration when examining contributions to HF care and caregiver outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Heart failure patients vary considerably in their self-care management behaviors (i.e. recognizing and responding to symptoms). The goal of this study was to identify unique patterns of change in heart failure self-care management and quantify associations between self-care management and quality of life (HRQOL) over time. Methods: A prospective cohort study among adults with symptomatic heart failure was designed to measure changes in self-care management (Self-care of Heart Failure Index) and HRQOL (Kansas City Cardiomyopathy Questionnaire) over six months. Growth mixture modeling was used to identify unique trajectories of change in self-care management. Results: The mean age (n=146) was 57 years, 70% were male, and 41% had class II heart failure. Two trajectories of self-care management were identified (entropy = 0.88). The larger trajectory (73.3%) was characterized by a significant decline in self-care management over time and no change in HRQOL. The smaller trajectory (26.7%) was characterized by marked improvements in self-care management and HRQOL. Changes in heart failure self-care management occurred in the absence of change in routine self-care maintenance behaviors, functional classification, and physical and psychological symptoms. Patients with greater physical symptoms at enrollment (odds ratio (OR) =1.04, p=0.037), larger left ventricles (OR=1.50, p=0.044), and ischemic heart failure (OR=3.84, p=0.014) were more likely to have the declining trajectory of self-care management. Higher levels of depression at enrollment were associated with reduced odds of having a decline in self-care management over time (OR=0.85, p<0.001). Conclusions: There are unique and clinically-relevant trajectories of change in heart failure self-care management that are associated with differences in HRQOL. [ABSTRACT FROM AUTHOR]

Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patient's care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 ( SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 ( SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Background: Heart failure (HF) is a heterogeneous condition of both symptoms and hemodynamics. Objective: The goals of this study were to identify distinct profiles among integrated data on physical and psychological symptoms and hemodynamics and quantify differences in 180-day event risk among observed profiles. Methods: A secondary analysis of data collected during 2 prospective cohort studies by a single group of investigators was performed. Latent class mixture modeling was used to identify distinct symptom-hemodynamic profiles. Cox proportional hazards modeling was used to quantify difference in event risk (HF emergency visit, hospitalization, or death) among profiles. Results: The mean age (n = 291) was 57 ± 13 years, 38% were female, and 61% had class III/IV HF. Three distinct symptom-hemodynamic profiles were identified: 17.9% of patients had concordant symptoms and hemodynamics (ie, moderate physical and psychological symptoms matched the comparatively good hemodynamic profile), 17.9% had severe symptoms and average hemodynamics, and 64.2% had poor hemodynamics and mild symptoms. Compared with those in the concordant profile, both profiles of symptom-hemodynamic mismatch were associated with a markedly increased event risk (severe symptoms hazards ratio, 3.38; P = .033; poor hemodynamics hazards ratio, 3.48; P = .016). Conclusions: A minority of adults with HF have concordant symptoms and hemodynamics. Either profile of symptom-hemodynamic mismatch in HF is associated with a greater risk of healthcare utilization for HF or death. [ABSTRACT FROM AUTHOR]

Background: There is a common dissociation between objective measures and patient symptomatology in heart failure (HF). Objective: The aim of this study was to explore the relationship between cardiac biomechanics and physical and psychological symptoms in adults with moderate to advanced HF. Methods: We performed a secondary analysis of data from 2 studies of symptoms among adults with HF. Stepwise regression modeling was performed to examine the influence of cardiac biomechanics (left ventricular internal diastolic diameter, right atrial pressure [RAP], and cardiac index) on symptoms. Results: The average age of the sample (n = 273) was 57 T 16 years, 61% were men, and 61% had class III or IV HF. Left ventricular internal diastolic diameter (" = 4.22 T 1.63, P = .011), RAP (" = 0.71 T 0.28, P = .013), and cardiac index (" = 7.11 T 3.19, P = .028) were significantly associated with physical symptoms. Left ventricular internal diastolic diameter (" = 0.10 T 0.05, P = .038) and RAP (" = 0.03 T 0.01, P = .039) were significantly associated with anxiety. There were no significant biomechanical determinants of depression. Conclusion: Cardiac biomechanics were related to physical symptoms and anxiety, providing preliminary evidence of the biological underpinnings of symptomatology among adults with HF. [ABSTRACT FROM AUTHOR]