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Background: Clinicians and researchers often assume that symptom burden is associated with self-care management (SCM) in patients with heart failure (HF). However, that association is often not borne out in simple regression analyses and may be because another variable mediates the association. Fatalism is an appropriate candidate for mediation and is the belief that circumstances are predetermined without opportunity for control by individuals. Objective: Our objective was to determine whether fatalism mediated the relationship of symptom burden with SCM among adults with HF. Methods: We conducted a secondary analysis (N = 95) from a clinical trial. We used Self-care of HF Index to measure SCM, the Memorial Symptom Assessment Scale-HF for symptom burden, and the Cardiovascular Disease Fatalism Instrument to measure fatalism. We used the PROCESS macro to evaluate mediation. Results: Symptom burden was not directly associated with SCM (effect coefficient [C'] = 0.0805; 95% confidence interval, -0.048 to 0.209; P = . 217). There was, however, an indirect pathway between symptomburden and SCM through fatalism (ab = -0.040; 95% confidence interval, -0.097 to -0.002). Thosewith higher symptom burden were more fatalistic (a = 0.004, P = .015), and greater fatalism was associated with worse SCM (b = -9.132, P = .007). Conclusion: Symptom burden, not directly associated with SCM, is associated through the mediator of fatalism. Interventions to improve SCM should include strategies to mitigate fatalistic views. Self-care management interventions should focus on promoting internal locus of control or increasing perceptions of perceived control to decrease fatalism and improve engagement in self-care. [ABSTRACT FROM AUTHOR]

Aims Fatigue, a distressing symptom in patients with heart failure (HF), is associated with progress and health outcomes. Fatigue has been identified as having multidimensions, but a few studies have used a multidimensional fatigue scale. Many factors related to HF, including physical, psychological, and situational factors, may impact fatigue. However, there is limited knowledge about how these HF-related factors are associated with multidimensional fatigue in outpatients with HF in Japan. The aim of this study was to identify HF-related factors [physical; clinical characteristics, New York Heart Association (NYHA) functional class and physical function, psychological; depressive symptoms and anxiety, situational; health literacy and perceived control] associated with the five dimensions of fatigue in outpatients with HF. Methods and results Outpatients with HF (N = 165, mean age = 69.5 years, 78.8% male) completed the survey and physical assessment of gait speed. Fatigue was assessed using five dimensions of the Multidimensional Fatigue Inventory-20. Multiple linear regression analysis was conducted for each dimension of fatigue. General fatigue was predicted by age, NYHA, and perceived control. Physical fatigue was predicted by NYHA, depressive symptoms, and perceived control. Reduced activity was predicted by NYHA, gait speed, depressive symptoms, communicative health literacy, and critical health literacy. The reduced motivation was predicted by depressive symptoms and perceived control. Mental fatigue was predicted by depressive symptoms. Conclusion Different factors were significantly associated with each fatigue dimension. Further research is needed to alleviate fatigue in patients with HF. [ABSTRACT FROM AUTHOR]

Aims Eating a varied diet promotes adequate micronutrient intake. Poor appetite could decrease the desire to eat a varied diet leading to dietary micronutrient insufficiencies. The interrelationships among appetite, diet variety, and dietary micronutrient intake have not been investigated in patients with heart failure (HF). The purpose of the study was to determine whether the relationship between appetite and micronutrient insufficiency was mediated through diet variety. Methods and results A total of 238 patients with HF, mean age 61 ± 12.1; 68% male, and 45% NYHA class III/IV were included in this secondary analysis. Data collection consisted of a 4-day food diary and self-reported appetite on a 10-point visual analogue scale. Micronutrient insufficiency was defined as the total number of 17 minerals and vitamins that were insufficient in the diet. Diet variety was calculated as the number of 23 food types consumed over the 4 days. Mediation analysis, controlling for covariates age, gender, NYHA class, and body mass index showed that diet variety mediated the relationship between appetite and micronutrient insufficiencies [indirect effect = −0.0828, 95% confidence interval (CI): −0.1585 to −0.0150]. There was no direct effect of appetite on micronutrient insufficiency (c ´ = −0.1802; 95% CI = −0.3715 to.0111). Conclusions Diet variety played a previously unrecognized role in the relationship between appetite and dietary micronutrient intake in patients with HF. More research is needed to validate these associations in patients with HF. [ABSTRACT FROM AUTHOR]

Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan–Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance (p = 0.002), self-care management (p = 0.005), 30-day cardiac readmission (p = 0.003), and caregiver perceived control (p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients' 30-day cardiac readmissions, patient self-care, and caregiver perceived control. [ABSTRACT FROM AUTHOR]

Background: Antioxidant insufficiency, elevated inflammatory markers, and poor health-related quality of life (HRQOL) are prevalent in patients with heart failure (HF). Objective: The objective of this study was to examine the associations among dietary antioxidant intake, inflammatory markers, and HRQOL in patients with HF. Methods: This was a secondary analysis of 265 patients with HF who completed a 4-day food diary. We assessed intake of 10 antioxidants: alpha carotene, beta carotene, beta cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium. Antioxidant insufficiency was reflected by a measured level for each antioxidant that was below the estimate average requirement or lower than median for antioxidants without an estimate average requirement. Inflammatory markers including serum C-reactive protein, cytokines (interleukins 6 and 10), tumor necrosis factor-alpha, and soluble receptors (sTNFR1 and sTNFR2) were assessed with enzyme immunoassay. Health-related quality of life was measured using the Minnesota Living with Heart Failure at 12 months. Results: Dietary antioxidant insufficiency predicted C-reactive protein (β = 0.135, P =.032) and interleukin 10 (β = −.155, P =.027). Patients with higher antioxidant insufficiency had higher C-reactive protein and lower interleukin 10. Both antioxidant insufficiency (β = 0.13, P =.049) and higher C-reactive protein (β = 0.16, P =.019) were independently associated with poorer HRQOL while adjusting for covariates. Conclusions: Dietary antioxidant insufficiency was associated with increased markers of inflammation and poorer HRQOL. Improvement of diet quality among patients with HF may be a fruitful area of research for enhancing HRQOL. [ABSTRACT FROM AUTHOR]

Aims Despite evidence-based recommendations for clinically stable patients with heart failure (HF) to engage in unsupervised exercise, the minimum cumulative dose of exercise per week associated with improvement in HF outcomes, especially in patients with poor functional capacity, has not been examined. We examined whether patients with HF and poor functional capacity who reported engagement in a guideline-recommended minimum weekly exercise had longer event-free survival than patients who did not exercise. Methods and results This analysis included 310 patients with HF who had completed the Duke Activity Status Index (DASI) and reported their level of engagement in exercise. Patients were grouped into good and poor functional capacity using a DASI cut-point of ≥19 and then further stratified based on their self-reported exercise level: high (≥60 min/week) and low (<60 min/week). Cox regression modelling was used to predict event-free survival for the four groups after adjusting for covariates. Patients (mean age = 61.6 ± 11.4 years, 30.3% female, 44.2% NYHA Classes III–IV) were followed for a median of 362 days. There were eight deaths and 108 all-cause hospitalizations. Patients with poor functional capacity who reported high exercise engagement had a 36% lower risk of all-cause hospitalization or mortality compared with patients with poor functional capacity who reported low exercise engagement (hazard ratio: 0.64, P = 0.028). Conclusion Self-reported engagement in a minimum of 60 min of exercise per week was associated with a significant improvement in event-free survival, even in patients with HF with low functional capacity. These results provide evidence that this dose of exercise is beneficial in patients with HF and poor functional capacity. [ABSTRACT FROM AUTHOR]

Background: African Americans are at the highest risk of developing heart failure (HF) compared with other races and are hospitalized at 7 to 8 times the rate of Whites. Poor overall self-care, low self-care confidence, and lower levels of perceived social support are factors related to increased risk for hospitalizations in HF. Yet, limited evidence is available regarding the factors that may differentially impact self-care confidence by race in patients with HF. Objective: The aim of this study was to examine to what extent race moderates the relationship between perceived social support and self-care confidence. Method: This is a secondary analysis of cross-sectional data from African American and White patients with HF in North America (n = 429). Patients completed the Multidimensional Scale of Perceived Social Support and the Self-Care Confidence Scale of the Self-Care of Heart Failure Index. A moderation analysis was conducted using hierarchal linear regression. Results: Sample mean age was 60.8 ± 11.5 years, 22.4% were African American, and 54.7% were in New York Heart Association class I or II. Moderation analyses yielded a significant interaction of perceived social support and race, showing White patients, not African Americans, have significantly different self-care confidence scores depending on level of social support: White, b = 0.224, 95% confidence interval [0.046–0.094], t = 5.65, and P <.001; African American, b = −0.776, 95% confidence interval [−0.049 to 0.060], t = 0.212, and P =.832. Conclusions: Our findings show a variable effect of perceived social support on self-care confidence as a function of race, suggesting the need for further research to develop and test interventions tailored to race and levels of social support in HF. [ABSTRACT FROM AUTHOR]

Background: Adherence to a low-sodium diet is essential to self-care of heart failure (HF). Genetic determinants of preference for high-sodium foods may impede adherence but have not been well-studied. Objective: Our purpose was to examine if TAS2R38 haplotype predicted salt taste sensitivity and dietary sodium intake among patients with HF. Method: This pilot study used baseline data from a large interventional randomized control trial to support adherence toa low-sodium diet in patients with HFand their family caregivers. Participants were tested for salt taste sensitivity and provided a 24-hour urinary sodium sample and a blood sample for DNA analysis at baseline. Fungiform papillae were counted. χ² Test and 1-way analysis of variance were used to compare haplotype groups. Linear regression was performed to examine predictors of salt taste sensitivity and 24-hour urinary sodium excretion, controlling for age, gender, ethnicity, smoking status, and fungiform papillae density. Results: There were 42 patients with HF and their family caregivers (age, 64.6 ± 13.4 years, 46.5% male, 97.7% white, and 90.7% nonsmoker). Pronine-alanine-valine homozygous haplotype predicted lower urinary sodium excretion (b = -1780.59, t41 = -2.18, P = .036), but genotype was not a significant predictor of salt taste sensitivity. Conclusions: The results of our study partially supported our hypothesis that PAV homozygous haplotype predicts 24-hour urinary sodium excretion. With our small sample size, more research is needed. Understanding genetic influences on taste can lead to development of educational interventions tailored to patients with HF and their family caregivers to better support dietary adherence. [ABSTRACT FROM AUTHOR]

Poor self-care is prevalent in patients with heart failure and adversely affects heart failure symptoms, hospitalization, and mortality. Adherence rates to different types of self-care vary in patients with heart failure. The purpose of this study was to examine factors associated with medication adherence, dietary sodium adherence, and symptom management in patients with heart failure. Data were collected using questionnaires, Medication Electronic Monitoring System, and 24-hour urine sodium output (N = 94). In logistic regression analysis, social support, education level, and race were associated with medication adherence (p =.002). Gender, race, perceived control, and depressive symptoms were associated with dietary sodium adherence (p =.030). Gender, education level, and depressive symptoms were associated with symptom management (p =.006). Different factors were associated with each type of self-care. Thus, clinicians need to manage each type of self-care by considering factors associated with it. [ABSTRACT FROM AUTHOR]

The aim was to determine whether 24-hour urine sodium excretion predicted event-free survival of patients with heart failure (HF) and diabetes mellitus (DM). Twenty-four hour urine sodium, as an indicator of dietary sodium, was collected from 107 patients with HF and comorbid DM. Patients were followed for a median period of 337 days to determine time to the first event of either all-cause hospitalization or cardiac-related mortality. There were 44 patients (41%) who had an event of death or hospitalization. Cox regression showed that higher urine sodium (>3.8 gm/day) was associated with 2.8 times greater risk for an event than lower urine sodium after controlling for age, gender, New York Heart Association class (I/II vs. III/IV), left ventricular ejection fraction, and body mass index. These data suggest that dietary sodium restriction may be beneficial for patients with HF and DM. [ABSTRACT FROM AUTHOR]

Background: Impaired psychological state, such as anxiety and depressive symptoms, occurs in up to 40% of patients hospitalized for traumatic injury. These symptoms, in the acute period, may delay engagement in activity, such as ambulation, following injury. The purpose of this study was to determine whether baseline anxiety and depressive symptoms predicted delayed (>48 hr from admission) ambulation in patients hospitalized for major traumatic injury. Methods: Adults (n = 19) admitted for major trauma (Injury Severity Score [ISS] = 15) provided a baseline measure of anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS]). Logistic regression was used to determine the predictive power of baseline HADS Anxiety and HADS Depression subscale scores for delayed ambulation while controlling for ISS. Results: At baseline, anxiety was present in 32% of patients; 21% reported depressive symptoms. Baseline HADS Anxiety score did not predict the ambulation group. However, for each 1 point increase in baseline HADS Depression score, the likelihood of patients ambulating after 48 hr from admission increased by 67% (odds ratio = 1.67; 95% CI [1.02, 2.72]; p =.041). Conclusion: Worsening depressive symptoms were associated with delayed ambulation in the acute period following injury. Future, larger scale investigations are needed to further elucidate the relationship between psychological symptoms and the acute recovery period from trauma to better inform clinicians and guide development of interventions to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Trauma and management of injuries can result in reduction or loss of mobility, which can lead to skeletal muscle deconditioning and sustained disability. Prior investigators have examined changes in skeletal muscle due to injury and immobility separately. The muscular consequences of combined immobility and trauma have not been systematically investigated. Objective: The purpose of this study was to explore the association of time to first ambulation with skeletal muscle size and strength in patients after major trauma. Methods: Adults (N = 19) admitted for major trauma (Injury Severity Score [ISS] > 15) provided daily measures of muscle size (ultrasound) and strength (dynamometry) during hospitalization. Participants were grouped based on time to first ambulation. Repeated measures analysis of variance was used to compare muscle measures between the groups across 5 days while controlling for age and gender. Results: Participants were primarily male (63%) aged 40 ± 17 years with a mean ISS of 21 ± 4. Early ambulation was associated with a 10% increase from baseline in bicep size on Days 3 and 4 and a 15% increase from baseline on Day 5. There were no changes in rectus femoris size in either group. The early ambulation group was significantly stronger than the delayed ambulation group throughout the study in measures taken with the biceps (22%–37%) and quadriceps (26%–46%). Conclusion: Early ambulation following major trauma was associated with increased bicep size and greater muscle strength in the biceps and quadriceps muscles over time. [ABSTRACT FROM AUTHOR]

Background: To improve the health outcomes of survivors of stroke, it is critical that they are highly motivated to engage in rehabilitation activities. Despite the increasing prevalence of strokes among middle-aged adults, there is limited knowledge regarding factors that may affect survivors' motivation to engage in rehabilitation. Objective: The aim of this study was to examine the relationship among factors that predict the rehabilitation motivation of middle-aged survivors after a stroke through structural equation modeling. Methods: A total of 200 middle-aged (40--64 years) survivors of stroke from 9 rehabilitation hospitals in Korea completed questionnaires on depressive symptoms, self-efficacy, social support, and rehabilitation motivation. Information on clinical characteristics, including physical function (activities performed during daily life), was collected through the review of medical records. Structural equation modeling was used to construct a prediction model of rehabilitation motivation. Results: The average subject's age was 56.2 ± 6.6 years, and the mean time since the event of their stroke was 15.02 ± 8.95 months. Subjects' self-efficacy (being able to live everyday life) after their stroke (β = .500, P < .001) and the social support provided by family and medical personnel (β = .284, P < .010) directly affected their rehabilitation motivation. The bootstrapping method showed that depressive symptoms indirectly affected rehabilitation motivation through self-efficacy, as did physical function. Conclusions: In middle-aged survivors of stroke, self-efficacy and social support play a critical role in maintaining intrinsic motivation to engage in rehabilitation activities. Self-efficacy should be evaluated periodically and improved by encouraging individuals to achieve goals, emphasizing their self-regulation, especially among those who reported depressive symptoms and low physical function. [ABSTRACT FROM AUTHOR]

Self-care improves quality of life, and reduces exacerbations and mortality risk in people with chronic obstructive pulmonary disease (COPD). The purpose of this report is to describe the development and testing of the feasibility and acceptability of a digital, educational self-care intervention designed to improve self-care ability, adherence, knowledge, somatic symptoms, anxiety, and depressive symptoms. This pilot study was a quasi-experimental, repeated measures design. Self-care behaviors were identified, and educational modules were developed and built into a web-based platform. Twenty participants were enrolled to determine feasibility, acceptability, and preliminary efficacy. The intervention was deemed acceptable and feasible as evidenced by > 95% completion rates and high degree of participation. Overall, the intervention was well received and is feasible for future home-based interventions in those with COPD. Results included significant improvements in adherence and knowledge, and significant associations between self-care ability, adherence, and depressive symptoms. [ABSTRACT FROM AUTHOR]

Background: Patientswith heart failure (HF) and their family caregivers usually consume similar diets, but there is a lack of evidence about diet quality of patients with HF and their family caregivers. Objective: The specific aim of this study was to compare diet quality of patients with HF with that of their family caregivers. Methods: In this cross-sectional study, 40 patients with HF and their 40 family caregivers completed a VioScreen Food Frequency Questionnaire from which Healthy Eating Index-2010 (HEI) diet quality scores (consisting of the total HEI score and 12 component scores) were calculated. Results: None of the 40 patient-caregiver dyads had a high diet quality score (ie, total HEI > 80), whereas 21%of participants had poor diet scores (ie, total HEI ≤ 50). There were no differences in total HEI scores (58.5 vs 59.4, P = .58) or the 12 component scores of the HEI within dyad members. Mean scores of 6 of the 12 components (ie, total fruit, greens and beans, total protein foods, seafood and plant proteins, fatty acids, empty calories) for both members of the HF dyad were lower than the national average. Interestingly, scores for the sodium component were similarly low in patients and caregivers (4.1 vs 3.4, P = .24), indicating high sodium intake. Conclusion: Both patients and caregivers consume poor-quality diets that are high in sodium. These findings suggest that nutrition interventions to improve diet quality for patients with HF need to be targeted at the family as a unit. [ABSTRACT FROM AUTHOR]

Background: In patients with heart failure (HF), good health-related quality of life (HRQOL) is as valuable as, or more valuable than, longer survival. However, HRQOL is remarkably poor, and HF symptoms are strongly associated with poor HRQOL. Yet, the multidimensional, modifiable predictors have been rarely examined. Objective: The aim of this study was to examine the baseline psychosocial, behavioral, and physical predictors of HF symptoms and HRQOL at 12 months and the mediator effect of HF symptoms in the relationship between depressive symptoms and HRQOL. Methods: We collected data from 94 patients with HF (mean ± SD age, 58 ± 14 years). Data included sample characteristics, depressive symptoms, perceived control, social support, New York Heart Association (NYHA) functional class, medication adherence, sodium intake, self-care management, and HF symptoms at baseline, as well as HF symptoms and HRQOL at 12 months. Multiple regression analyses were performed to address the purpose. Results: Baseline depressive symptoms (P < .001), medication adherence (P = .010), sodium intake (P = .032), and NYHA functional class (P = .040) significantly predicted 12-month HF symptoms, controlling for covariates (F = 7.363, R² = 47%, P < .001). Baseline medication adherence (P = .001), NYHA functional class (P < .001), and HF symptoms (P = .013) significantly predicted 12-month HRQOL (F = 10.701, R² = 59%, P < .001). Baseline HF symptoms fully mediated the relationship between baseline depressive symptoms and 12-monthHRQOL. Conclusion: Symptoms of HF and HRQOL could be improved by targeting multidimensional, modifiable predictors, such as self-care, depressive symptoms, and NYHA functional class. [ABSTRACT FROM AUTHOR]

Patients' perceptions of the causes and consequences of heart failure (HF) symptoms may impact effective self-management. The purpose of this study was to describe and explore patients' perceptions of HF symptom status and the causes and consequences on their daily lives in patients with HF. Descriptive and qualitative data were obtained from 20 patients using a semistructured interview guide. Data were analyzed using content analysis and descriptive statistics. Participants reported 15 symptoms (median = 4). Five themes were (a) multiple causes and multiple symptoms; (b) knowing some causes, but still unclear; (c) not being able to live life as previously did; (d) facing emotional distress due to HF symptoms; and (e) development of new priorities and lifestyles. The findings demonstrate that all participants perceived considerable difficulties living with HF symptoms. More comprehensive interventions need to be delivered to patients to manage multiple causes and symptoms effectively. [ABSTRACT FROM AUTHOR]

Background: Comorbid chronic obstructive pulmonary disease is found in approximately one-third of patients with heart failure. Survival in patients with chronic obstructive pulmonary disease generally decreases as lung function declines. However, the association between lung function, hospitalization and survival is less clear for patients with heart failure. Aim: The purpose of this study was to determine the predictive power of spirometry measures for event-free survival (combined all-cause hospitalization and/or mortality) in patients with heart failure. Methods: In this secondary analysis of data from three prospective, longitudinal studies, we selected patients with a confirmed diagnosis of heart failure who completed airflow limitation assessment using spirometry measures (n=137): forced vital capacity, forced expiratory volume/second, and forced expiratory volume/second/forced vital capacity. Cox proportional hazards modeling was used to determine the relationship between spirometry and all-cause hospitalization/mortality with and without adjusting for demographic and clinical covariates over a four-year follow-up period. Results: A majority (74%) exhibited some degree of airflow limitation (forced expiratory volume/second<80% predicted value) and 26 (19%) met the spirometric criterion for chronic obstructive pulmonary disease (forced expiratory volume/second/forced vital capacity⩽0.70). Cox proportional hazards regression models compared all-cause hospitalization/mortality between those with and without airflow limitation. Patients with airflow limitation were 2.2 times more likely to be hospitalized or die compared to those without airflow limitations (hazard ratio: 2.20, 95% confidence interval 1.06–4.53, p=0.03). Conclusion: Patients with comorbid heart failure and airflow limitation were at more than double the risk for an event. Spirometric measures may be useful to patients with heart failure, as tailored management of airflow limitation may impact event-free survival. [ABSTRACT FROM AUTHOR]

We hypothesized that risk factors for cardiovascular disease (CVD) would be associated with worse health perceptions in prison inmates. This study included 362 inmates recruited from four medium security prisons in Kentucky. Framingham Risk Score was used to estimate the risk of developing CVD within the next 10 years. A single item on self-rated health from the Medical Outcomes Survey–Short Form 36 was used to measure health perception. Multinomial logistic regression showed that for every 1-unit increase in Framingham Risk Score, inmates were 23% more likely to have rated their health as fair/poor and 11% more likely to rate their health as good rather than very good/excellent. These findings demonstrate that worse health perceptions may serve as a starting point for discussing cardiovascular risk factors and prevention with inmates. [ABSTRACT FROM AUTHOR]

Background: Vitamin C deficiency is prevalent in adults with heart failure (HF). Little is known about the relationship of dietary vitamin C deficiency with health outcomes in adults with HF. Objective: The study's aim was to determine the relationships of vitamin C deficiency measured at baseline with health-related quality of life (HRQOL) and cardiac event-free survival in patients with HF measured 1 year later. Method: A total of 251 patients with HF completed a 4-day food diary. Dietary vitamin C deficiency was defined as daily intake less than the estimated average requirement from the Institute of Medicine of 75 mg/d for men and 60 mg/d for women. Health-related quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire at 12 months. Patients were followed for a median of 1 year to determine time to the first event of cardiac-related hospitalization or death. Data were analyzed by hierarchical linear and Cox proportional hazards regressions. Results: One hundred patients (40%) had vitamin C deficiency. Dietary vitamin C deficiency was associated with poorer HRQOL at 12 months (β = 0.16, P = .02) after controlling for demographic and clinical variables. During the follow-up period, 59 patients (24%) had cardiac events. In Cox regression, vitamin C deficiency predicted shorter cardiac event-free survival after adjusting for the same covariates (hazards ratio, 1.95; 95% confidence interval, 1.08-3.51). Conclusion: Vitamin C deficiency was associated with poorer HRQOL and shorter cardiac event-free survival in patients with HF. The findings suggest that encouraging patients with HF to consume a diet rich in fruits/vegetables to prevent vitamin C deficiency may lead to better health outcomes. [ABSTRACT FROM AUTHOR]

Background: Heart failure is a chronic, burdensome condition with higher re-hospitalization rates in African Americans than Whites. Higher dietary antioxidant intake is associated with lower oxidative stress and improved endothelial function. Lower dietary antioxidant intake in African Americans may play a role in the re-hospitalization disparity between African American and White patients with heart failure. Objective: The objective of this study was to examine the associations among race, dietary antioxidant intake, and cardiac event-free survival in patients with heart failure. Methods: In a secondary analysis of 247 patients with heart failure who completed a four-day food diary, intake of alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein, zeaxanthin, lycopene, vitamins C and E, zinc, and selenium were assessed. Antioxidant deficiency was defined as intake below the estimated average requirement for antioxidants with an established estimated average requirement, or lower than the sample median for antioxidants without an established estimated average requirement. Patients were followed for a median of one year to determine time to first cardiac event (hospitalization or death). Survival analysis was used for data analysis. Results: African American patients had more dietary antioxidant deficiencies and a shorter cardiac event-free survival compared with Whites (p = .007 and p = .028, respectively). In Cox regression, race and antioxidant deficiency were associated with cardiac event-free survival before and after adjusting for covariates. Conclusion: African Americans with heart failure had more dietary antioxidant deficiencies and shorter cardiac event-free survival than Whites. This suggests that encouraging African American patients with heart failure to consume an antioxidant-rich diet may be beneficial in lengthening cardiac event-free survival. [ABSTRACT FROM AUTHOR]

Background: Depressive symptoms and vitamin D deficiency predict cardiac events in heart failure patients, but whether vitamin D supplements are associated with depressive symptoms and cardiac events in heart failure patients remains unknown. Purpose: The purpose of this study was to compare the association of vitamin D supplement use with depressive symptoms and cardiac events in heart failure patients with mild or moderate to severe depressive symptoms. Methods: A total of 177 heart failure patients with depressive symptoms (Patient Health Questionnaire-9 score ≥5) completed a three-day food diary to determine dietary vitamin D deficiency. Patients were split into four groups by dietary vitamin D adequacy versus deficiency and vitamin D supplement use versus non-use. The Patient Health Questionnaire-9 was used to reassess depressive symptoms at six months. Data on cardiac events for up to one year and vitamin D supplement use were obtained from patient interview and medical record review. Hierarchical linear and Cox regressions were used for data analysis. Results: Sixty-six patients (37.3%) had dietary vitamin D deficiency and 80 (45.2%) used vitamin D supplements. In patients with moderate to severe depressive symptoms, the group with dietary vitamin D deficiency and no supplements had the highest Patient Health Questionnaire-9 score at six months (β=0.542, p<0.001) and shortest cardiac event-free survival (p<0.001) among the four groups, the group with dietary vitamin D deficiency and no supplements didn’t have the highest Patient Health Questionnaire-9 score at six months and shortest cardiac event-free survival in patients with mild depressive symptoms. Conclusions: Vitamin D supplements predicted lower depressive symptoms and reduced cardiac events for patients with moderate to severe depressive symptoms. Vitamin D deficiency was associated with higher risk of shorter cardiac event-free survival in heart failure patients regardless of vitamin D supplementation. [ABSTRACT FROM AUTHOR]

Sodium intake in heart failure (HF) is a crucial but poorly understood phenomenon. Theoretical models promote understanding and provide a context for rational appraisal of complex situations. The purpose of this study was to determine which factors were associated with sodium intake in HF patients using theory of planned behavior (TPB). In this study, patients' (N = 244) attitudes, subjective norms, and perceived behavioral control (tenets of the TPB) were assessed using the Dietary Sodium Restriction Questionnaire. Sodium intake was estimated objectively by 24-hr urinary sodium excretion (UNa). The average UNa was 3,811 mg. Subjective norms, gender, and New York Heart Association functional class were associated with sodium intake (p < .001). Thus, it is important for health care providers to clearly express their approval of following low-sodium diet to their HF patients, and include significant others in interventions to help patients develop/maintain a positive subjective norm to decrease sodium intake and reduce HF exacerbations. [ABSTRACT FROM AUTHOR]

Sleep disturbance is common in patients with heart failure and their family caregivers. The purpose of this study was to determine whether sleep disturbances of patients and their spousal caregivers predicted their own and their partners' quality of life (QoL) in 78 heart failure patient-spousal caregiver dyads. Sleep disturbance was assessed using a composite score of four common sleep complaints. QoL was assessed by the physical and mental well-being subscales of the Short-Form 12 Health Survey. The multilevel dyadic actor-partner interdependence model analysis was used to determine the association between sleep disturbance and QoL. Each individual's sleep disturbance predicted their own poor physical and mental well-being while spousal caregivers' sleep disturbance predicted their partners' mental well-being. Results indicated that patients' mental well-being is sensitive to their spouses' sleep disturbance. Interventions targeting improving sleep and QoL may have to include both patients and spousal caregivers. [ABSTRACT FROM AUTHOR]

Depressive symptoms and poor health perceptions are predictors of higher hospitalization and mortality rates (heart failure [HF]). However, the association between depressive symptoms and health perceptions as they affect event-free survival outcomes in patients with HF has not been studied. The purpose of this secondary analysis was to determine whether depressive symptoms mediate the relationship between health perceptions and event-free survival in patients with HF. A total of 458 HF patients (61.6 ± 12 years, 55% New York Heart Association Class III/IV) responded to one-item health perception question and completed the Patient Health Questionnaire-9. Event-free survival data were collected for up to 4 years. Multiple regression and Cox proportional hazards regression analysis showed that depressive symptoms mediated the relationship between health perceptions and event-free survival. Decreasing depressive symptoms is essential to improve event-free survival in patients with HF. [ABSTRACT FROM AUTHOR]

Although following a low-sodium diet (LSD) for heart failure (HF) has been recommended for decades, little is known about factors related to long-term patient adherence. The purposes of this study were to (a) compare sodium intake and factors affecting adherence in a long-term adherent group and in a non-adherent group and (b) examine predictors of membership in the long-term adherent group. Patients with HF (N = 74) collected 24-hr urine samples and completed the Dietary Sodium Restriction Questionnaire and the Patient Health Questionnaire-9. Long-term adherence was determined using the Stage of Dietary Behavior Change Scale. The long-term adherent group had lower sodium intake (3,086 mg vs. 4,135 mg, p = .01) and perceived more benefits from LSD than the non-adherent group. Only positive attitudes toward LSD predicted membership in the long-term adherence group (odds ratio [OR] = 1.18, p = .005). Interventions focused on enhancing positive perceptions of the benefits of an LSD may improve long-term dietary adherence in patients with HF. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine associations among bone mineral density, osteopenia/osteoporosis, body mass index (BMI), and body composition in patients with heart failure (HF). A total of 119 patients (age = 61 ± 12 years, 65% male) underwent dual-energy X-ray absorptiometry scans to determine bone mineral density and body composition. In multivariable linear regressions, BMI, relative skeletal muscle index (RSMI), and mineral-free lean mass were positively associated with total body bone mineral density. Mineral-free lean mass was most strongly associated with bone mineral density (β = .398). In multivariable logistic regressions, higher BMI, RSMI, and mineral-free lean mass were associated with lower odds for osteopenia/osteoporosis. Fat mass was not associated with total body bone mineral density or osteopenia/osteoporosis. These results suggest that muscle mass may be the important component of body mass associated with bone mineral density in patients with HF. [ABSTRACT FROM AUTHOR]

Aims: To describe correlations and agreement between salivary and serum B-type natriuretic peptide (BNP), C-reactive protein (CRP), interleukin (IL)-6, and IL-10 and determine which biomarkers predict worse functional class in patients with heart failure (HF). Methods: Serum and saliva were collected from 75 hospitalized patients with HF (57 ± 12 years, 43% female, New York Heart Association [NYHA] Classes I [4%], II [43%], and III [53%]). Oral inflammation was rated as good, fair, or poor. Spearman’s ρ and Bland–Altman were used to determine correlations and agreement of the salivary and serum forms of each biomarker. Logistic regressions were used to determine which biomarkers predicted worse NYHA functional class, controlling for depression, body mass index, smoking, and oral inflammation. Results: Median biomarker concentrations were as follows: BNP (serum 361 pg/ml, saliva 9 pg/ml), CRP (serum 13 ng/ml, saliva 25.6 ng/ml), IL-6 (serum 19.3 pg/ml, saliva 10.5 pg/ml), and IL-10 (serum 64.1 pg/ml, saliva 4.7 pg/ml). There was a moderate-to-strong correlation for serum–salivary CRP, weak correlation for serum–salivary IL-6, and no correlations for serum–salivary BNP and IL-10. The Bland–Altman test showed good salivary–serum agreement for all biomarkers, but as serum concentrations rose, salivary measures underestimated serum levels. Visible oral inflammation was the only predictor of worse NYHA class. [ABSTRACT FROM AUTHOR]

Background: Depressive symptoms hinder heart failure patients' engagement in self-care. As social support helps improve self-care and decrease depressive symptoms, it is possible that social support buffers the negative impact of depressive symptoms on self-care. Objective: The purpose of this study is to examine the effect of living arrangements as an indicator of social support on the relationship between depressive symptoms and self-care in heart failure patients. Methods: Stable heart failure patients (N = 206) completed the Patient Health Questionnaire-9 to measure depressive symptoms. Self-care (maintenance, management, and confidence) was measured with the Self-Care of Heart Failure Index. Path analyses were used to examine associations among depressive symptoms and the self-care constructs by living arrangements. Results: Depressive symptoms had a direct effect on self-care maintenance and management (standardized β = -0.362 and -0.351, respectively), but not on self-care confidence in patients living alone. Depressive symptoms had no direct or indirect effect on any of the 3 self-care constructs in patients living with someone. Conclusions: Depressive symptoms had negative effects on self-care in patients living alone, but were not related to self-care in patients living with someone. Our results suggest that negative effects of depressive symptoms on self-care are buffered by social support. [ABSTRACT FROM AUTHOR]

Background: Health disparities are related to race/ethnicity, financial status and poor self-care behaviors, but the relationships between these factors remain unknown. Objective: To explore the relationships between race/ethnicity, financial status and cardiac event-free survival, and the reasons for any disparities in patients with heart failure (HF). Methods: We collected demographic data (e.g., race/ethnicity and financial status), clinical data (e.g., medication regimen) and self-care behaviors (by the Self-Care of Heart Failure Index) in 173 HF patients at baseline. Patients were grouped by race/ethnicity (African–American and Caucasian) and financial status (higher if they reported having “enough or more than enough to make ends meet” and lower if they “did not have enough to make ends meet”). Chi-square tests, t-tests and survival analyses were used to explore the relationships between race/ethnicity, financial status, self-care and survival. Results: African–American race/ethnicity and poor financial status were associated with poor outcomes (p < 0.005) when controlling for covariates. HF patients with lower financial status reported engaging in fewer self-care maintenance behaviors than those with higher financial status. African–American HF patients trended to report engaging in fewer self-care maintenance behaviors than Caucasian HF patients. African–Americans with lower financial status had a four- to six-times higher risk of experiencing cardiac events compared to patients who were Caucasian with higher financial status before and after controlling for covariates. Conclusions: African–American HF patients and those with lower financial status had worse outcomes and reported fewer self-care maintenance behaviors. Interventions promoting self-care may decrease the disparity in outcomes and should be tailored to African–Americans and those with lower financial status. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to describe how to develop a theory-based tailored dietary intervention (TADI) and test its feasibility and acceptability in patients with heart failure (HF). Methods: The development team consisted of experts in HF, nutrition, and clinical trials. Four patients with HF and 3 additional experts reviewed intervention materials and provided feedback. The 5-session TADI was developed from this feedback and tested in 5 patients with HF (50% women; mean age, 55 years). Participation and intervention completion rates were collected for feasibility test. In addition, data on dietary adherence and the factors affecting dietary adherence were collected at baseline and after the Intervention for feasibility test. Data on patient acceptability were collected at the end of sessions. Results: Sixty percent of patients we approached expressed interest in this study. Five patients completed all of the sessions and follow-up data collection. Mean dietary sodium consumption decreased from 2.38 to 1.30 g/d. Among the factors affecting dietary adherence, skills showed the greatest increase. Patient acceptability scores for sessions 1, 2, 3, and 4 were 98%, 97%, 100%, and 100% of 100%, respectively. Conclusion: The TADI is ready for testing in larger sample studies to manage sodium intake. [ABSTRACT FROM AUTHOR]

Background/Objectives: Heart failure (HF) is a condition of chronic exacerbations and injury resulting from an intricate relationship between biochemical and biological mechanisms. Inflammation can be a significant contributor in the pathophysiology of HF. Antioxidants may slow the progression of HF because of their ability to inhibit damaging inflammatory processes. The purpose of this study was to test a dietary intervention in patients with HF to assess the impact of lycopene on biomarkers of inflammation. Subjects/Methods: Forty participants with HF were randomly assigned to 1 of 2 groups: lycopene intervention and usual care. The lycopene intervention group received 29.4 mg of lycopene intake per day by drinking an 11.5 oz serving of V8 100% vegetable juice for 30 days. We obtained serum lycopene, uric acid, C-reactive protein (CRP), and b-type natriuretic peptide to determine the impact of the intervention. Results: Plasma lycopene levels increased in the intervention group compared with the usual care group (0.51 pmol/L to 0.76 pmol/L, P = .002; 0.56 pmol/L to 0.58 pmol/L). C-reactive protein levels decreased significantly in the intervention group in women and but not in men (P = .04). The preintervention CRP level for women was 5.9 ± 3.7 mg/dL and for men was 2.2 ± 2.1 mg/dL. The postintervention CRP level for women was 4.5 ± 3.6 mg/dL and for men was 2.4 ± 2.1 mg/dL. Conclusions: These findings suggest that the antioxidants in a 30-day intervention of V8 juice affect CRP levels in a sample of female patients with HF. [ABSTRACT FROM AUTHOR]

Problem Understanding young adults' anxiety requires applying a multidimensional approach to assess the psychosocial, behavioral, and cognitive aspects of this phenomenon. Methods A hypothesized model of the relationships among coping style, thinking style, life satisfaction, social support, and selected demographics and anxiety among college students was tested using path analysis. A total of 257 undergraduate students aged 18-24 years completed an online survey. The independent variables were measured using the Multidimensional Scale of Perceived Social Support, the Brief Students' Multidimensional Life Satisfaction Scale, the Brief COPE Inventory, the Positive Automatic Thoughts Questionnaire, and the Cognition Checklist-Anxiety. The outcome, anxiety, was measured using the Anxiety subscale of the 21-item Depression Anxiety and Stress Scale. Findings Only negative thinking and maladaptive coping had a direct relationship with anxiety. Negative thinking was the strongest predictor of both maladaptive coping and anxiety. Conclusion These findings suggest that helping undergraduates manage their anxiety by reducing their negative thinking is critical. Designing and testing interventions to decrease negative thinking in college students is recommended for future research. [ABSTRACT FROM AUTHOR]

Purpose In rural communities that experience high rates of cardiovascular disease (CVD) morbidity and mortality, family history education may enhance risk awareness and support engagement in healthy behaviors but could also engender fatalism. This study was conducted to assess if the relationship between family history and adherence to healthy lifestyle behaviors is moderated by fatalism. Methods Baseline data were obtained from 1,027 adult participants in the HeartHealth in Rural Kentucky study. Multiple linear regression was used to determine whether fatalism moderated the relationship between high-risk family history of CVD and adherence to healthy lifestyle behaviors, controlling for sociodemographic variables and CVD risk factors. The relationship between family history and healthy behaviors was assessed for subgroups of participants divided according to the upper and lower quartiles of fatalism score. Findings The relationship between high-risk family history of CVD and adherence to healthy behaviors was moderated by fatalism. Among those with the highest quartile of fatalism scores, high-risk family history predicted greater adherence to healthy behaviors, while among those in the lowest quartile, and among those with the middle 50% of fatalism scores, there was no association between family history and healthy behavior scores. Conclusions Family history education can provide people at increased risk for CVD important information to guide health practices. This may be particularly relevant for those with a high degree of fatalistic thinking. In rural communities with limited health resources, family history education, combined with assessment of fatalism, may support better targeted interventions to enhance engagement in healthy behaviors. [ABSTRACT FROM AUTHOR]

Background: Weaning from mechanical ventilation to spontaneous breathing is associated with changes in the hemodynamic and autonomic nervous systems that are reflected by heart rate variability. Although cardiac dysrhythmias are an important manifestation of hemodynamic alterations, the impact of heart rate variability on the occurrence of dysrhythmias during weaning has not been specifically studied. Objectives: To describe differences in heart rate variability spectral power and occurrence of cardiac dysrhythmias at baseline and during the initial trial of weaning from mechanical ventilation and to evaluate the impact of heart rate variability during weaning on occurrence of dysrhythmias. Method: Continuous 3-lead electrocardiographic recordings were collected from 35 patients receiving mechanical ventilation for 24 hours at baseline and during the initial weaning trial. Heart rate variability was evaluated by using spectral power analysis. Results: Low-frequency power increased (P= .04) and high-frequency and very-low-frequency power did not change during weaning. The mean number of supraventricular ectopic beats per hour during weaning was higher than the mean at baseline (P< .001); the mean of ventricular ectopic beats did not change. Low-frequency power was a predictor of ventricular and supraventricular ectopic beats during weaning (P< .001). High-frequency power was predictive of ventricular and supraventricular (P= .02) ectopic beats during weaning. Very-low-frequency power was predictive of ventricular ectopic beats (P< .001) only. Conclusion: Heart rate variability power spectra during weaning were predictive of dysrhythmias. [ABSTRACT FROM AUTHOR]

Background: health-related quality of life (HRQOL) is markedly impaired in patients with heart failure (HF). Despite worse prognosis and physical status, older patients have better HRQOL than younger patients.Objective: to determine reasons for differences in HRQOL in older compared with younger HF patients.Methods: a mixed methods approach was used. HRQOL was assessed using the Minnesota Living with HF Questionnaire and compared among HF patients (n = 603) in four age groups (≤53, 54–62, 63–70 and ≥71 years). Socio-demographic/clinical and psychological factors related to HRQOL were determined in four groups using multiple regressions. Patients (n = 20) described their views of HRQOL during semi-structured interviews.Results: HRQOL was worse in the youngest group, and best in the two oldest groups. The youngest group reported higher levels of depression and anxiety than the oldest group. Anxiety, depression and functional capacity predicted HRQOL in all age groups. Qualitatively, patients in all age groups acknowledged the negative impact of HF on HRQOL; nonetheless older patients reported that their HRQOL exceeded their expectations for their age. Younger patients bemoaned the loss of activities and roles, and reported their HRQOL as poor.Conclusions: better HRQOL among older HF patients is the result, in part, of better psychosocial status. The major factor driving better HRQOL among older patients is a change with advancing age in expectations about what constitutes good HRQOL. [ABSTRACT FROM AUTHOR]

For a majority of patients with advanced heart failure, there is a need for complementary, non-pharmacologic interventions that could be easily implemented by health care providers to provide palliative care. Three major pathologic pathways underlying heart failure symptoms have been identified: fluid overload, inflammation, and oxidative stress. Prior research has demonstrated that three nutrients-sodium, omega-3 fatty acids, and lycopene-can alter these pathologic pathways. Therefore, the purposes of this study are to test the effects of a 6-month nutrition intervention of dietary sodium reduction combined with supplementation of lycopene and omega-3 fatty acids on heart failure symptoms, health-related quality of life, and time to heart failure rehospitalization or all-cause death. The aims of this double blind-placebo controlled study are (1) to determine the effects of a 6-month nutrition intervention on symptom burden (edema, shortness of air, and fatigue) and health-related quality of life at 3 and 6 months, and time to heart failure rehospitalization or all-cause death over 12 months from baseline; (2) compare dietary sodium intake, inflammation, and markers of oxidative stress between the nutrition intervention group and a placebo group at 3 and 6 months; and (3) compare body weight, serum lycopene, and erythrocyte omega-3 index between the nutrition intervention group and a placebo group at 3 and 6 months. A total of 175 patients with advanced heart failure will be randomized to either the nutrition intervention or placebo group. © 2013 Wiley Periodicals, Inc. Res Nurs Health 36:120-145, 2013 [ABSTRACT FROM AUTHOR]

mckinley s., fien m., riegel b., meischke h., aburuz m.e., lennie t.a. & moser d.k. (2012) Complications after acute coronary syndrome are reduced by perceived control of cardiac illness. Journal of Advanced Nursing 68(10), 2320-2330. Abstract Aims. To investigate the relationship between anxiety, perceived control and rate of in-hospital complications after acute coronary syndrome. Background. Anxiety may be associated with higher risk of complications following acute myocardial infarction; perceived control may moderate this relationship. Design. Prospective observational study. Methods. Patients enrolled in a trial investigating delay in seeking treatment for acute coronary syndrome had anxiety measured at enrolment and 3 months using the Brief Symptom Inventory anxiety subscale. The acute coronary syndrome hospital presentations investigated occurred between 2001-2006. Patients with anxiety scores greater than the population norm at both time points were categorized as persistently anxious. Perceived control was measured at enrolment using the Control Attitudes Scale-Revised. Data were collected from the medical record on in-hospital complications in patients presenting with acute coronary syndrome within 2 years of enrolment. Chi-square and t-tests were used for univariate analyses and multiple logistic regression to identify independent predictors of complications. Results. Patients ( n = 171) were 64% men with mean age 69 years. Ischaemic or arrhythmic complications occurred in 26 patients (15%) with no difference in complication rates between those persistently anxious and others. Important univariate predictors of in-hospital complications were lower perceived control, diagnosis of acute myocardial infarction, heart failure and higher pulse rate on admission. Low perceived control and diagnosis of acute myocardial infarction were independent predictors of in-hospital complications in the multiple logistic regression. Conclusion. Perceived control, but not persistent anxiety, prior to acute coronary syndrome was an important predictor of in-hospital complications after acute coronary syndrome. Interventions to increase cardiac patients' perceived control of their cardiac illness may reduce in-hospital complications after acute coronary syndrome. [ABSTRACT FROM AUTHOR]