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Aims Management of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017. Methods and results The 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality. Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p p for interaction 0.026). Conclusion Despite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment. Graphical abstract Created with BioRender.com.

Management of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017.The 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality. Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p 0.001), compared to patients from the 2002-cohort. Comorbidity burden was comparable between both cohorts (mean of 3.9 comorbidities per patient) and substantially increased with age. Higher comorbidity burden was significantly associated with a comparable increased risk for HF hospitalization and all-cause mortality (HR 1.12 [1.02-1.22] and HR 1.18 [1.05-1.32]), in the 2002- and 2017-cohort respectively. When assessing individual comorbidities, obesity yielded a statistically higher prognostic effect on outcome in the 2017-cohort compared to the 2002-HF cohort (p for interaction 0.026).Despite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment. Created with BioRender.com.

BACKGROUND: Decreased appetite can contribute to malnutrition in patients with heart failure (HF). Little is known about the trajectory of appetite over time in patients with HF and the factors associated with decreased appetite after discharge from the hospital. OBJECTIVE: The aims of this study were to investigate changes in appetite over time and explore how fatigue, depressive symptoms, and quality of life are associated with decreased appetite. METHODS: Data from the multicenter randomized Coordinating study evaluating Outcomes of Advising and Counseling in Heart Failure were used. Logistic regression and mixed-effects logistic regression were used to investigate changes in appetite over time and to explore the relationship between appetite and fatigue, depressive symptoms, and quality of life. RESULTS: A total of 734 patients with HF (mean age, 69 years) were included. Decreased appetite was present at all follow-up measurements; however, decreased appetite was significantly lower at the 1-month (odds ratio [OR], 0.43; confidence interval [CI], 0.29-0.63), 6-month (OR, 0.31; CI, 0.20-0.47), 12-month (OR, 0.22; CI, 0.14-0.34), and 18-month (OR, 0.24; CI, 0.15-0.37) follow-ups compared with baseline. Decreased appetite was associated with fatigue (OR, 3.09; CI, 1.98-4.84), depressive symptoms (OR, 1.76; CI, 1.35-2.29), and low quality of life (OR, 1.01; CI, 1.01-1.02) across all measurement points adjusted for covariates. CONCLUSIONS: Appetite improved after discharge; however, at all time points, at least 22% of patients reported decreased appetite. Fatigue, depressive symptoms, and low quality of life are factors associated with decreased appetite. Decreased appetite is a long-standing problem in that it does not disappear spontaneously after an acute HF deterioration. Funding: Netherlands Heart FoundationNetherlands Heart Foundation [2000Z003]; Biosite France SAS; Jouy-en-Josas, France (brain natriuretic peptide); Roche Diagnostics Nederland BV, Venlo, the Netherlands; Novartis Pharma BV, Arnhem, the NetherlandsNetherlands Government

Aim According to guidelines, a prognosis should be discussed with all heart failure (HF) patients. However, many patients do not have these conversations with a healthcare provider. The aim of this study was to describe attitudes of cardiologists in Sweden and the Netherlands regarding this topic. Methods and results A survey was sent to 250 cardiologists in Sweden and the Netherlands with questions whether should the prognosis be discussed, what time should the prognosis be discussed, whom should discuss, what barriers were experienced and how difficult it is to discuss the prognosis (scale from 1-10). A total of 88 cardiologists participated in the study. Most cardiologists (82%) reported to discussing the prognosis with all HF patients; 47% at the time of diagnoses. The patients own cardiologist, another cardiologist, the HF nurse, or the general practitioner could discuss this with the patient. Important barriers were cognitive problems (69%) and a lack of time (64%). Cardiologists found it not very difficult to discuss the topic (mean score 4.2) with a significant difference between Swedish and Dutch cardiologist (4.7 vs. 3.7; P < 0.05). Conclusion Most cardiologists found it important to discuss the prognosis with HF patients although there are several barriers. Swedish cardiologists found it more difficult compared with their Dutch colleagues. A multidisciplinary approach seems important for improvement of discussing prognosis with HF patients. Funding Agencies|FORTE [201702227]

Background: Thirst is a distressing symptom and influences quality of life of patients with heart failure (HF). Knowledge about thirst in HF is insufficient; therefore, the aim of this study was to describe factors related to thirst, self-reported reasons for thirst, and interventions to relieve thirst in 3 different countries. Methods: A cross-sectional study was conducted in Sweden, the Netherlands, and Japan. Patients were recruited at the HF clinic or during HF hospitalization. Thirst was assessed by a visual analog scale (0-100); reasons for thirst and interventions to relieve thirst were assessed by an open-ended questionnaire. Patients were divided into low and high thirst based on the first and third tertiles of the visual analog scale. Results: Two hundred sixty-nine patients participated in the study (age, 72 +/- 12 years). Mean thirst intensity was 24 +/- 24, with a mean thirst of 53 +/- 15 in the highest tertile. No significant differences in thirst among the 3 countries were found. Multivariable logistic regression analysis showed that a higher dose of loop diuretics (odds ratio, 3.47; 95% confidence interval, 1.49-8.06) and fluid restriction (odds ratio, 2.21; 95% confidence interval, 1.08-4.32) were related to thirst. The most reported reasons for thirst were salty/spicy food (20%) and low fluid intake (18%). Most of the patients (56%) drank more in case of thirst; 20% only drank a little bit, probably related to a fluid restriction. Conclusions: Thirst in patients with HF was related to a higher dose of loop diuretics and fluid restriction. Healthcare providers should realize that it is important to assess thirst regularly and reconsider the need of a fluid restriction and the amount of loop diuretics in case of thirst.

Rapid contact with emergency medical services is imperative to save the lives of acute myocardial infarction patients. However, many patients turn to a telehealth advisory nurse instead, where the delivery of urgent and safe care largely depends on how the interaction in the call is established.The purpose of this study was to explore the interaction between tele-nurses and callers with an evolving myocardial infarction after contacting a national telehealth advisory service number as their first medical contact.Twenty men and 10 women (aged 46-89 years) were included. Authentic calls were analysed using inductive content analysis.One overall category, Movement towards directed level of care, labelled the whole interaction between the tele-nurse and the caller. Four categories conceptualised the different interactions: a distinct, reasoning, indecisive or irrational interaction. The interactions described how tele-nurses and callers assessed and elaborated on symptoms, context and actions. The interaction was pivotal for progress in the dialogue and affected the achievement of mutual understanding in the communicative process. An indecisive or irrational interaction could increase the risk of failing to recommend or call for acute care.The interaction in the communication could either lead or mislead the level of care directed in the call. This study adds new perspectives to the communicative process in the acute setting in order to identify a myocardial infarction and the level of urgency from both individuals experiencing myocardial infarction and professionals in the health system.

Purpose To examine profiles in patients with heart failure (HF) regarding their exercise motivation and self-efficacy. Patients & Methods The baseline data of patients with HF participating in the HF-Wii study were analysed. In total, 517 patients were divided into four groups based on their exercise motivation (exercise motivation index) and self-efficacy (exercise self-efficacy scale). To describe the differences in demographic and clinical variables between the groups, chi-square cross-tabulations and ANOVAs were conducted. Results The four groups were labelled as insecure avoiders (25%), laid-back strugglers (10%), conscientious self-doubters (42%) and determined achievers (22%). Patients’ profiles differ according to their motivations and self-efficacy towards exercise. Most patients were conscientious self-doubters (high motivation and low self-efficacy), and these patients had more comorbidities and lower exercise capacity compared to the other groups, which could decrease their confidence in exercising. However, only half of the patients who were determined achievers (high motivation and high self-efficacy) reached the recommended amount of physical activity per week. This indicates that motivation and self-efficacy are crucial determinants, but more factors are important for becoming more physically active. Conclusion Understanding patients’ motivations and self-efficacy are necessary in order to provide meaningful physical activity counselling and promotion.

Background: Patients’ self-care behaviour is still suboptimal in many heart failure (HF) patients and underlying mechanisms on how to improve self-care need to be studied. Aims: (1) To describe the trajectory of patients’ self-care behaviour over 1 year, (2) to clarify the relationship between the trajectory of self-care and clinical outcomes, and (3) to identify factors related to changes in self-care behaviour. Methods: In this secondary analysis of the COACH-2 study, 167 HF patients (mean age 73 years) were included. Self-care behaviour was assessed at baseline and after 12 months using the European Heart Failure Self-care Behaviour scale. The threshold score of ⩾70 was used to define good self-care behaviour. Results: Of all patients, 21% had persistent poor self-care behaviour, and 27% decreased from good to poor. Self-care improved from poor to good in 10%; 41% had a good self-care during both measurements. Patients who improved self-care had significantly higher perceived control than those with persistently good self-care at baseline. Patients who decreased their self-care had more all-cause hospitalisations (35%) and cardiovascular hospitalisations (26%) than patients with persistently good self-care (2.9%, p < 0.05). The prevalence of depression increased at 12 months in both patients having persistent poor self-care (0% to 21%) and decreasing self-care (4.4% to 22%, both p < 0.05). Conclusion: Perceived control is a positive factor to improve self-care, and a decrease in self-care is related to worse outcomes. Interventions to reduce psychological distress combined with self-care support could have a beneficial impact on patients decreasing or persistently poor self-care behaviour.

Background The aim of this study was to optimize a Question Prompt List which is designed to improve communication about the heart failure trajectory among patients, family members, and health care professionals. Methods Data were collected in a two-round Delphi survey and a cross-sectional survey, including patients with heart failure, their family members, and health care professionals working in heart failure care in Sweden and the Netherlands. Acceptability for and demand of the Question Prompt List were assessed. Results A total of 96 patients, 63 family members and 26 health care professionals participated in the study. Regarding acceptability, most of the original questions were found to be relevant by the participants for inclusion in the Question Prompt List but some cultural differences exist, which resulted in two versions of the list: a Swedish version including 33 questions and a Dutch version including 38 questions. Concerning demand, participants reported that they were interested in discussing the questions in the revised Question Prompt List with a physician or a nurse. Few patients and family members reported that they were worried by the questions in the Question Prompt List and hence did not want to discuss the questions. Conclusions This Question Prompt List has successfully been adapted into a Swedish version and a Dutch version and includes questions about the HF trajectory which patients, their families, and health care professionals perceived to be relevant for discussion in clinical practice. Overall, patients and family members were not worried about the content in the Question Prompt List and if used in accordance with patients’ and family members’ preferences, the Question Prompt List can help to improve communication about the heart failure trajectory.

Objective To identify differences in psychosocial, behavioural and clinical outcomes between patients with heart failure (HF) with and without stroke. Design and participants A secondary analysis of 1023 patients with heart failure enrolled in the Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure. Setting Seventeen hospitals located across the Netherlands. Outcomes measures Depressive symptoms (Centre for Epidemiological Studies Depression Scale), quality of life (Minnesota Living with Heart Failure Questionnaire, Ladder of Life Scale), self-care (European Heart Failure Self-Care Behaviour Scale), adherence to HF management (modified version of the Heart Failure Compliance Questionnaire) and readmission for HF, cardiovascular-cause and all-cause hospitalisations at 18 months, and all-cause mortality at 18 months and 3 years. Results Compared with those without stroke, patients with HF with a stroke (10.3%; n=105) had twice the likelihood of severe depressive symptoms (OR 2.83, 95% CI 1.27 to 6.28, p=0.011; OR 2.24, 95% CI 1.03 to 4.88, p=0.043) at 12 and 18 months, poorer disease-specific and generic quality of life (OR 2.80, 95% CI 1.61 to 4.84, p

BACKGROUND: Thirst can be aggravated in patients with heart failure (HF), and optimization of HF medication can have positive impact on thirst. OBJECTIVES: The aims of this study were to describe changes in thirst intensity and to determine factors associated with high thirst intensity during optimization of HF medication. METHODS AND RESULTS: Patients with HF (N = 66) who were referred to an HF clinic for up-titration of HF medication were included. Data were collected during the first visit to the clinic and at the end of the treatment program. Data were dichotomized by the median visual analog scale score for thirst, dividing patients into 2 groups: low thirst intensity (0-20 mm) and high thirst intensity (>20 mm on a visual analog scale of 0-100 mm). In total, 67% of the patients reported a higher thirst intensity after the HF up-titration program. There was no difference in thirst intensity between the patients who reached target doses and those who did not. Plasma urea level (odds ratio, 1.33; 95% confidence interval, 1.07-1.65) and fluid restriction (odds ratio, 6.25; 95% confidence interval, 1.90-20.5) were independently associated with high thirst intensity in patients with HF. CONCLUSIONS: Thirst intensity increased in two-thirds of the patients during a time period of optimization of HF medication. Fluid restriction and plasma urea levels were associated with high thirst intensity. Funding agencies: Mats Klebergs Stiftelse; Lindhes Advokatbyra

Background: Vitamin D (Vit D) is suggested to play a role in the regulation of physical function as well as in depression. Since, Vit D deficiency is common in patients with heart failure (HF), this study aims to explore if Vit D levels are associated with depressive symptoms and if this association is mediated by the patients' physical function.Method: 506 HF patients (mean age 71, 38% women) were investigated. Depressive symptoms and physical function were measured with the Centre for Epidemiological Studies Depression Scale and the physical function scale from the RAND-36. Vit D was measured in blood samplesResults: At baseline there was no relationship between depressive symptoms and Vit D levels. However, at 18 months follow-up 29% of patients with Vit D 50 nmol/l (p Conclusion: In HF patients with Vit D 50 nmol/l. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Aim: It is still unclear whether telemonitoring reduces hospitalization and mortality in heart failure (HF) patients and whether adding an Information and Computing Technology-guided-disease-management-system (ICT-guided-DMS) improves clinical and patient reported outcomes or reduces healthcare costs. Methods: A multicenter randomized controlled trial was performed testing the effects of INnovative ICT-guided-DMS combined with Telemonitoring in OUtpatient clinics for Chronic HF patients (IN TOUCH) with in total 179 patients (mean age 69 years; 72% male; 77% in New York Heart Association Classification (NYHA) III-IV; mean left ventricular ejection fraction was 28%). Patients were randomized to ICT-guided-DMS or to ICT-guided-DMS + telemonitoring with a follow-up of nine months. The composite endpoint included mortality, HF-readmission and change in health-related quality of life (HR-QoL). Results: In total 177 patients were eligible for analyses. The mean score of the primary composite endpoint was -0.63 in ICT-guided-DMS vs. -0.73 in ICT-guided-DMS + telemonitoring (mean difference 0.1,95% CI: -0.67 +0.82, p = 0.39). All-cause mortality in ICT-guided-DMS was 12% versus 15% in ICT-guided-DMS + telemonitoring (p = 0.27); HF-readmission 28% vs. 27% p = 0.87; all-cause readmission was 49% vs. 51% (p = 0.78). HR-QoL improved in most patients and was equal in both groups. Incremental costs were 1360 in favor of ICT-guided-DMS. ICT-guided-DMS + telemonitoring had significantly fewer HF-outpatient-clinic visits (p < 0.01). Conclusion: ICT-guided-DMS + telemonitoring for the management of HF patients did not affect the primary and secondary endpoints. However, we did find a reduction in visits to the HF-outpatient clinic in this group suggesting that telemonitoring might be safe to use in reorganizing HF-care with relatively low costs. (C) 2015 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://cleativecommons.org/licenses/by-nc-nd/4.0/). Funding Agencies|Dutch Ministry of Health, Department of Pharmaceutical Affairs and Medical Technology (GMT)

Nana Waldréus,1 Misook L Chung,2 Martje HL van der Wal,3,4 Tiny Jaarsma5,6 1Department of Neurobiology, Division of Nursing, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; 2College of Nursing, University of Kentucky, Lexington,KY, USA; 3Department of Social and Welfare Studies, Division of Nursing Science, Faculty of Medical and Health Sciences, Linköping University, Linköping, Sweden; 4Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; 5Department of Social and Welfare Studies, Division of Nursing Science, Faculty of Medical and Health Sciences, Linköping University, Linköping, Sweden; 6Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia Background: Patients with heart failure (HF) can suffer from increased thirst intensity and distress. Trajectories of thirst intensity and distress from hospital to home are unclear. The aim of this study was to describe thirst intensity and distress trajectories in patients from the time of hospital admission to 4 weeks after discharge, and describe trajectories of thirst intensity and distress by patients’ characteristics (gender, age, body mass index [BMI], plasma urea, anxiety, and depression).Patients and methods: In this observational study, data were collected from patients with HF (n=30) at hospital admission, discharge, and at 2 and 4 weeks after discharge. Thirst intensity (visual analog scale, 100 mm) and distress (Thirst Distress Scale-HF, score 9–45) were used. Trajectories were examined using growth modeling.Results: Trajectory of the thirst intensity was significantly different, for patients with low and high thirst intensity levels (median cut-off 39 mm), from admission to 4 weeks follow up (thirst increased and decreased, respectively). Patients with high level of thirst distress (median score >22) at admission, having fluid restriction and women continued to have higher thirst distress over time. Patients feeling depressed had higher thirst intensity over time. There were no differences in the trajectories of thirst intensity and distress by age, BMI, plasma urea, and anxiety.Conclusion: Intensity and distress of thirst, having fluid restriction, and feeling depressed at the admission were critical in predicting the trajectory of thirst intensity and distress after discharge to home in patients with HF. Effective intervention relieving thirst should be provided before their discharge to home. Keywords: heart failure, thirst intensity, thirst distress, trajectories, fluid restriction

Physical activity is important for all heart failure (HF) patients to improve quality of life and physical function. Since adherence to physical activity is low and could differ between seasons, it is essential to explore factors related to change that may depend on seasonal changes. The purpose of this study was to describe the seasonal differences in physical activity and assess factors that influence these differences in a country with markedly different winter-to-summer weather conditions (in temperature, hours of daylight and snow fall).The study had a cross-sectional survey design. Outpatients with HF completed a questionnaire on physical activity, motivation and self-efficacy to exercise and HF symptom severity in the summer and the winter in a northern hemisphere country. We used analysis of variance to evaluate seasonal differences in physical activity, motivation, self-efficacy and HF symptom severity.Eighty-seven patients with HF (29% women, mean age 70 ± 9 years) were included and 35% performed less physical activity (METs) in the winter, compared to the summer. Increased symptom severity during the winter was associated with lower activity levels.One-third of the patients performed less physical activity during the winter compared to the summer, and this was associated with symptom severity. Decreased physical activity was not related with motivation and self-efficacy. This study emphasises the need for personalised physical activity programmes that also assess symptom severity and change in symptom severity depending between seasons.

Background: Patients with heart failure can experience thirst distress. However, there is no instrument to measure this in patients with heart failure. The aim of the present study was to develop the Thirst Distress Scale for patients with Heart Failure (TDS-HF) and to evaluate psychometric properties of the scale. Methods and results: The TDS-HF was developed to measure thirst distress in patients with heart failure. Face and content validity was confirmed using expert panels including patients and healthcare professionals. Data on the TDS-HF was collected from patients with heart failure at outpatient heart failure clinics and hospitals in Sweden, the Netherlands and Japan. Psychometric properties were evaluated using data from 256 heart failure patients (age 72±11 years). Concurrent validity of the scale was assessed using a thirst intensity visual analogue scale. Patients did not have any difficulties answering the questions, and time taken to answer the questions was about five minutes. Factor analysis of the scale showed one factor. After psychometric testing, one item was deleted. For the eight item TDS-HF, a single factor explained 61% of the variance and Cronbach’s alpha was 0.90. The eight item TDS-HF was significantly associated with the thirst intensity score ( r=0.55, pConclusion: The eight-item TDS-HF is valid and reliable for measuring thirst distress in patients with heart failure.

Background: Although several studies advise that discussions about prognosis and end-of-life care should be held throughout the whole heart failure (HF) trajectory, data is lacking on the prevalence and practice of such discussions in HF care. Objective: The study objective was to explore how often and why HF nurses in outpatient clinics discuss prognosis and end-of-life care in the context of patient education. Methods: This was a descriptive and comparative study. Participants were HF nurses from Swedish and Dutch HF outpatient clinics. Measurements were taken via a survey for both quantitative and qualitative data. Additional data was collected via open-ended questions and analyzed with content analysis. Results: Two hundred seventy-nine nurses registered 1809 patient conversations using a checklist. Prognosis and end-of-life care were among the least frequently discussed topics, whereas symptoms of HF was discussed most often. Prognosis was discussed with 687 patients (38%), and end-of-life care was discussed with 179 patients (10%). Prognosis and end-of-life care were discussed more frequently in The Netherlands than in Sweden (41% versus 34%, p < 0.001, 13% versus 4%, p < 0.001). The nurses did not always recognize prognosis and end-of-life care discussions as a part of their professional role. Conclusions: Currently, patient-nurse communication about prognosis and end-of-life care does not seem to be routine in patient education in HF clinics, and these discussions could be included more often. The reasons for nurses to discuss these topics were related to clinical routines, the patient's situation, and professional responsibilities. To improve future care, communication with patients needs to be further developed.

Background: In contrast to recommendations in recent guidelines, prognosis is not optimally discussed with patients with heart failure (HF). Reasons for not doing so can be related to both patient and provider characteristics. Purpose: The purpose of the study was to explore which patient- and nurse-related variables influence discussing prognosis with patients at an HF clinic. Method: Data from a previous survey on attitudes and clinical practice of HF nurses on discussing prognosis that was conducted in Sweden and the Netherlands were combined with data from a registration on topics that nurses discussed with their patients during a prespecified week at the HF clinic. Multivariable logistic regression analysis was performed to assess which variables are related to discussing prognosis. Results: A total of 275 HF nurses (mean age, 49 years) and data of 1633 patients with HF (mean age, 71 years) were included in the study. Prognosis was discussed with 42% of all patients during the visit at the HF clinic. Patients with whom prognosis was discussed were more often in New York Heart Association classes III to IV (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.44-2.26). Nurses discussing prognosis reported more knowledge on the topic (OR, 1.71; 95% CI, 1.36-2.16) and discussed more topics with the patient (OR, 1.27; 95% CI, 1.21-1.32). Dutch HF nurses were more likely to discuss prognosis compared with their Swedish colleagues (OR, 1.83; 95% CI, 1.43-2.33). Conclusions: Discussing prognosis with patients with HF by nurses at the HF clinic is related to the characteristics of patients and HF nurses. Future interventions to improve communications about prognosis therefore should have a broad approach.

Serum potassium is routinely measured at admission for acute heart failure (AHF), but information on association with clinical variables and prognosis is limited. Potassium measurements at admission were available in 1,867 patients with AHF in the original cohort of 2,033 patients included in the Patients Hospitalized with acute heart failure and Volume Overload to Assess Treatment Effect on Congestion and Renal FuncTion trial. Patients were grouped according to low potassium (amp;lt;3.5 mEq/l), normal potassium (3.5 to 5.0 mEq/l), and high potassium (amp;gt;5.0 mEq/l) levels. Results were verified in a validation cohort of 1,023 patients. Mean age of patients was 71 +/- 11 years, and 66% were men. Low potassium was present in 115 patients (6%), normal potassium in 1,576 (84%), and high potassium in 176 (9%). Potassium levels increased during hospitalization (0.18 +/- 0.69 mEq/l). Patients with high potassium more often used angiotensin-converting enzyme inhibitors and mineralocorticoid receptor antagonists before admission, had impaired baseline renal function and a better diuretic response (p = 0.005), independent of mineralocorticoid receptor antagonist usage. During 180-day follow-up, a total of 330 patients (18%) died. Potassium levels at admission showed a univariate linear association with mortality (hazard ratio [log] 2.36, 95% confidence interval 1.07 to 5.23; p = 0.034) but not after multivariate adjustment. Changes of potassium levels during hospitalization or potassium levels at discharge were not associated with outcome after multivariate analysis. Results in the validation cohort were similar to the index cohort. In conclusion, high potassium levels at admission are associated with an impaired renal function but a better diuretic response. Changes in potassium levels are common, and overall levels increase during hospitalization. In conclusion, potassium levels at admission or its change during hospitalization are not associated with mortality after multivariate adjustment. (C) 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativeconunons.org/licenses/by/4.0/). Funding Agencies|NovaCardia; Merck Co., Inc.

This article refers to 'Which patients with heart failure should receive specialist palliative care?' by R.T. Campbell et al., published in this issue on pages 1338-1347.

In the last decades, the introduction of information and communication technology (ICT) in healthcare promised an improved quality of care while reducing workload and improving cost-effectiveness. This might be realised by the use of computer guided decision support systems and telemonitoring. This case study describes the process of care of a patient with chronic heart failure, who was treated with a computerised disease management system in combination with telemonitoring. With the help of these appliances, we think we were probably able to prevent at least two readmissions for heart failure in a period of 10 months.We also gained more insight into patient's behaviour with regards to compliance with the heart failure regimen at home. Frequent contact at distance and the online availability of physiological measurements at home facilitated patient tailored education and helped the patient to react adequately to symptoms of deterioration. Additionally, up-titration of heart failure medication was performed without contacting the patient at the outpatient clinic.

Background/aim: Fluid restriction has long been considered one of the cornerstones in self-care management of patients with heart failure. The aim of this discussion paper is to discuss fluid restriction in heart failure and propose advice about fluid intake in heart failure patients.Results: Although there have been seven randomised studies on fluid restriction in heart failure patients, the effect of fluid restriction on its own were only evaluated in two studies. In both studies, a stringent fluid restriction compared to a liberal fluid intake was not more beneficial with regard to clinical stability or body weight. In the other studies fluid restriction was part of a larger study intervention including, for example, individualised dietary recommendations and follow-up by telephone. Thus, the effect of fluid restriction on its own has been poorly evaluated.Conclusion: Fluid restriction should not be recommended to all heart failure patients. However, temporary fluid restriction can be considered in decompensated heart failure and/or patients with hyponatremia. Tailored fluid restriction based on body weight (30 ml/kg per day) seems to be most reasonable. To increase adherence to temporary fluid restriction, education, support and planned evaluations can be recommended.

Background: The clinical consequences of prehospital delay in heart failure (HF) patients are unknown. This study explores the relationship between prehospital delay of HF patients and length of hospital stay, plasma values of brain natriuretic peptides (BNP) as well as the association of delay with all-cause mortality, readmission for HF, or all-cause readmissions during short-(60 days) and long-term (18 months) follow-up.Methods: Data from 1023 hospitalized HF patients mean aged 71 years from the Coordinating study evaluating Outcomes of Advising and Counselling in HF study were analyzed.Results: Patients who delayed less than 1 day had significantly shorter stay in hospital (10 days vs. 11 days, P = 0.033). They also had significantly (P = 0.004) lower median plasma values of BNP (377 pg/mL) at discharge compared to patients who delayed >24 hours (492 pg/mL). Delay was not related to all-cause mortality and/or readmissions for HF.Conclusion: Although patients with a prehospital delay less than 1 day were more symptomatic on admission, they had a shorter hospital stay as well as lower plasma values of BNP at discharge. Delay was not associated hospital readmissions or mortality after discharge. (J Cardiac Fail 2012;18:202-207) Key Words: Heart failure, delay, outcome and process assessment.

Background: To receive optimal treatment and care, it is essential that heart failure (HF) patients react adequately to worsening symptoms and contact a health care provider early. This specific "patient delay" is an important part of the total delay time. The purpose of this study was to assess patient delay and its associated variables in HF patients. less thanbrgreater than less thanbrgreater thanMethods and Results: In this cross-sectional study, data of 911 hospitalized HF patients from 17 Dutch hospitals (mean age 71 +/- 12 years; 62% male; left ventricular ejection fraction 34 +/- 15%) were analyzed. During the index hospitalization, patient delay and HF symptoms were assessed by interview. Patients completed questionnaires on depressive symptoms, knowledge and compliance. Clinical and demographic data were collected from medical charts and interviews by an independent data collector. Logistic regression analysis was performed to examine independent associations with patient delay. Median patient delay was 48 hours; 296 patients reported short delay (andlt;12 h) and 341 long delay (andgt;= 168 h). A history of myocardial infarction (MI) (odds ratio [OR] 0.49, 95% confidence interval [Cl] 0.34-0.71) or stroke (OR 0.43, 95% CI 0.24-0.76) was independently associated with short patient delay. Male gender, more HF knowledge, and more HF symptoms were associated with long patient delay. No differences were found between patients with and without a history of HF. less thanbrgreater than less thanbrgreater thanConclusions: Patients with a history of a life-threatening event (MI or stroke) had a shorter delay than patients without such an event. Patients without a life-threatening event might need to be educated on the recognition and need for appropriate action in a different way then those with an acute threatening previous experience.

Background: Because of the improvement of the pharmacological and non-pharmacological treatment in heart failure (HF) patients, the HF related therapeutic regimen is becoming more complicated. Non-compliance with this regimen can result in worsening HF symptoms, sometimes leading to hospitalisation. Aims: The aims of this systematic literature review are (1) to describe the consequences of noncompliance in HF patients; (2) to summarise the degree of compliance in the various aspects of the therapeutic regimen; and (3) to review interventions that are recommended to improve compliance in HF patients. Methods: A literature search of the MEDLINE and CINAHL database from 1988 to June 2003 was performed. Studies on compliance with life style recommendations according to the HF Guidelines of the European Society of Cardiology and the American Heart Association/American College of Cardiology were included. Conclusion: Noncompliance with medication and other lifestyle recommendations is a major problem in patients with HE Evidence based interventions to improve compliance in patients with HF are scarce. Interventions that can increase compliance and prevent HF related readmissions in order to improve the quality of life of patients with HF need to be developed and tested. (C) 2004 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

BACKGROUND:: Physical activity is the only nonpharmacological therapy that is proven to be effective in heart failure (HF) patients in reducing morbidity. To date, little is known about the levels of daily physical activity in HF patients and about related factors. OBJECTIVE:: The objectives of this study were to (a) describe performance-based daily physical activity in HF patients, (b) compare it with physical activity guidelines, and (c) identify related factors of daily physical activity. METHODS:: The daily physical activity of 68 HF patients was measured using an accelerometer (SenseWear) for 48 hours. Psychological characteristics (self-efficacy, motivation, and depression) were measured using questionnaires. To have an indication how to interpret daily physical activity levels of the study sample, time spent on moderate- to vigorous-intensity physical activities was compared with the 30-minute activity guideline. Steps per day was compared with the criteria for healthy adults, in the absence of HF-specific criteria. Linear regression analyses were used to identify related factors of daily physical activity. RESULTS:: Forty-four percent were active for less than 30 min/d, whereas 56% were active for more than 30 min/d. Fifty percent took fewer than 5000 steps per day, 35% took 5000 to 10 000 steps per day, and 15% took more than 10 000 steps per day. Linear regression models showed that New York Heart Association classification and self-efficacy were the most important factors explaining variance in daily physical activity. CONCLUSIONS:: The variance in daily physical activity in HF patients is considerable. Approximately half of the patients had a sedentary lifestyle. Higher New York Heart Association classification and lower self-efficacy are associated with less daily physical activity. These findings contribute to the understanding of daily physical activity behavior of HF patients and can help healthcare providers to promote daily physical activity in sedentary HF patients. PMID:23416939 DOI: 10.1097/JCN.0b013e318283ba14

Aims: Despite disparities in pathophysiology and disease manifestation between male and female patients with heart failure, studies focusing on sex differences in biomarkers are scarce. The purpose of this study was to assess sex-specific variation in clinical characteristics and biomarker levels to gain more understanding of the potential pathophysiological mechanisms underlying sex differences in heart failure. Methods and results: Baseline demographic and clinical characteristics, multiple biomarkers, and outcomes were compared between men and women in 567 patients. The mean age of the study group was 71 ± 11 years and 38% were female. Women were older, had a higher body mass index and left ventricular ejection fraction, more hypertension, and received more diuretic and antidepressant therapy, but less ACE-inhibitor therapy compared with men. After 3 years, all-cause mortality was lower in women than men (37.0 vs. 43.9%, multivariable hazard ratio = 0.64; 95% confidence interval 0.45–0.92, P = 0.016). Levels of biomarkers related to inflammation [C-reactive protein, pentraxin 3, growth differentiation factor 15 (GDF-15), and interleukin 6] and extracellular matrix remodelling (syndecan-1 and periostin) were significantly lower in women compared with men. N-terminal pro-brain natriuretic peptide, TNF-αR1a, and GDF-15 showed the strongest interaction between sex and mortality. Conclusion: Female heart failure patients have a distinct clinical presentation and better outcomes compared with male patients. The lower mortality was independent of differences in clinical characteristics, but differential sex associations between several biomarkers and mortality might partly explain the survival difference.

In the assessment of dyspnea one has to take into account both the patient’s own experience of the symptom and the clinicians observations of breathing rates, sounds and effort to get a complete picture. In addition, to choose appropriate treatment, the underlying cause of dyspnea needs to be assessed. While tools for clinical evaluation of heart failure have gained great interest in research and found a place in guidelines and clinical practice, the same cannot be said for instruments to assess patient self-reported dyspnea. To date, no specific dyspnea rating tool has been recommend over another. Reports from clinical practice are lacking and large; international studies in this field are warranted.

Background Clinical Decision Support Systems (CDSSs) can support guideline adherence in heart failure (HF) patients. However, the use of CDSSs is limited and barriers in working with CDSSs have been described as a major obstacle. It is unknown if barriers to CDSSs are present and differ between HF nurses and cardiologists. Therefore the aims of this study are; 1. Explore the type and number of perceived barriers of HF nurses and cardiologists to use a CDSS in the treatment of HF patients. 2. Explore possible differences in perceived barriers between two groups. 3. Assess the relevance and influence of knowledge management (KM) on Responsibility/Trust (R&T) and Barriers/Threats (B&T). Methods A questionnaire was developed including; B&T, R&T, and KM. For analyses, descriptive techniques, 2-tailed Pearson correlation tests, and multiple regression analyses were performed. Results The response- rate of 220 questionnaires was 74%. Barriers were found for cardiologists and HF nurses in all the constructs. Sixty-five percent did not want to be dependent on a CDSS. Nevertheless thirty-six percent of HF nurses and 50% of cardiologists stated that a CDSS can optimize HF medication. No relationship between constructs and age; gender; years of work experience; general computer experience and email/internet were observed. In the group of HF nurses a positive correlation (r .33, PFunding Agencies|Dutch Government of health, section pharmaceuticals and medical technology (GMT)

Background: Although telemonitoring is increasingly used in heart failure care, data on expectations, experiences, and organizational implications concerning telemonitoring are rarely addressed, and the optimal profile of patients who can benefit from telemonitoring has yet to be defined. less thanbrgreater than less thanbrgreater thanObjective: To assess the actual status of use of telemonitoring and to describe the expectations, experiences, and organizational aspects involved in working with telemonitoring in heart failure in the Netherlands. less thanbrgreater than less thanbrgreater thanMethods: In collaboration with the Netherlands Organization for Applied Scientific Research (TNO), a 19-item survey was sent to all outpatient heart failure clinics in the Netherlands, addressed to cardiologists and heart failure nurses working in the clinics. less thanbrgreater than less thanbrgreater thanResults: Of the 109 heart failure clinics who received a survey, 86 clinics responded (79%). In total, 31 out of 86 (36%) heart failure clinics were using telemonitoring and 12 heart failure clinics (14%) planned to use telemonitoring within one year. The number of heart failure patients receiving telemonitoring generally varied between 10 and 50; although in two clinics more than 75 patients used telemonitoring. The main goals for using telemonitoring are "monitoring physical condition", "monitoring signs of deterioration" (n=39, 91%), "monitoring treatment" (n=32, 74%), "adjusting medication" (n=24, 56%), and "educating patients" (n=33, 77%). Most patients using telemonitoring were in the New York Heart Association (NYHA) functional classes II (n=19, 61%) and III (n=27, 87%) and were offered the use of the telemonitoring system "as long as needed" or without a time limit. However, the expectations of the use of telemonitoring were not met after implementation. Eight of the 11 items about expectations versus experiences were significantly decreased (Pandlt;.001). Health care professionals experienced the most changes related to the use of telemonitoring in their work, in particular with respect to "keeping up with current development" (before 7.2, after 6.8, P=.15), "being innovative" (before 7.0, after 6.1, P=.003), and "better guideline adherence" (before 6.3, after 5.3, P=.005). Strikingly, 20 out of 31 heart failure clinics stated that they were considering using a different telemonitoring system than the system used at the time. less thanbrgreater than less thanbrgreater thanConclusions: One third of all heart failure clinics surveyed were using telemonitoring as part of their care without any transparent, predefined criteria of user requirements. Prior expectations of telemonitoring were not reflected in actual experiences, possibly leading to disappointment. (J Med Internet Res 2013;15(1):e4) doi:10.2196/jmir.2161 Funding Agencies|Dutch Ministry of Health, department of Pharmaceutical Affairs and Medical Technology (GMT)

Background: In the last decades, the introduction of information and communications technology (ICT) in healthcare promised an improved quality of care while reducing work load, and resulting in a more cost-effective system. These goals might be realised by the use of computerised disease management systems (DMS) and telemedicine (TM). Aim: This case study describes the potential of a computerised disease management system in combination with telemonitoring in a patient with chronic heart failure (HF) who was frequently readmitted to the hospital. Methods: During a period of 10 months we followed and treated a male patient (age, 50, LVEF 29%) after five HF hospitalisations within six months. Therefore we used an ICT-guided DMS, in combination with TM. Predefined ranges of weight, blood pressure and heart rate were formulated. In case of serious deviated measures at home, the HF nurse was immediately informed by SMS and E-mail. With an interactive system (health monitor) the patient answered questions about his condition, including HF symptoms. In case of slight deviation of the predefined ranges, without an increase of HF symptoms, the patient gets an automatic generated advice on actions that must be taken.

Background: Chronic heart failure (HF) is a rapidly increasing epidemic with high mortality and high morbidity, leading to increasing healthcare costs. Although guidelines for the management of HF are clear, the quality of care for HF patients can still be improved. Disease management systems implemented in smart ICT solutions and telemedicine are expected to improve quality of care and to reduce costs. Aim: To investigate the effect of information and communications technology (ICT) guided disease management (DM) and telemedicine (TM) on the quality and efficiency of care in patients with HF after a hospitalisation for HF. Methods: The IN TOUCH study (innovative ICT guided disease management combined with telemonitoring in outpatient clinics for chronic heart failure patients) is a multicentre study in which 10 Dutch hospitals are participating. Patients are randomised to DM alone (n=75) or DM with TM (n=150). Total follow-up will be nine months. Primary endpoint of the study is a composite score of: (1) death from any cause during the follow-up of the study, (2) first re-admission for HF, and (3) change in quality of life compared to baseline, assessed by the Minnesota living with heart failure questionnaire.

Background Although the value of telemonitoring in heart failure patients is increasingly studied, little is known about the value of the separate components of telehealth: ICT guided disease management and telemonitoring. The aim of this study is to investigate the value of telemonitoring added to ICT guided disease management (DM) on the quality and efficiency of care in patients with chronic heart failure (CHF) after a hospitalisation. Methods/Design The study is divided in two arms; a control arm (DM) and an intervention arm (DM+TM) in 10 hospitals in the Netherlands. In total 220 patients will be included after worsening of CHF (DM: N = 90, DM+TM: N = 130). Total follow-up will be 9 months. Data will be collected at inclusion and then after 2 weeks, 4.5 and 9 months. The primary endpoint of this study is a composite score of: 1: death from any cause during the follow-up of the study, 2: first readmission for HF and 3: change in quality of life compared to baseline, assessed by the Minnesota Living with Heart failure Questionnaire. The study has started in December 2009 and results are expected in 2012. Conclusions The IN TOUCH study is the first to investigate the effect of telemonitoring on top of ICT guided DM on the quality and efficiency of care in patients with worsening HF and will use a composite score as its primary endpoint. Trial registration Netherlands Trial Register (NTR): NTR1898

Background: Noncompliance with diet and fluid restriction is a problem in patients with heart failure (HF). In recent studies, a relationship between compliance with sodium and fluid restriction and knowledge and beliefs regarding compliance was found. In these studies, however, compliance was primarily measured by interview or questionnaire. Objectives: To examine the relationship between compliance with sodium and fluid restriction measured with a nutrition diary and knowledge, beliefs, and other relevant variables in HF patients. Methods: Eighty-four HF patients completed a nutrition diary for 3 days. Patients also completed questionnaires on knowledge, beliefs regarding compliance, and depressive symptoms. Differences in relevant variables between compliant and noncompliant patients were assessed. Results: Compliance with sodium and fluid restriction was 79% and 72%. Although not statistically significant, a higher percentage of patients were compliant with the less stringent restrictions compared with the more stringent restrictions, and in addition, more noncompliant patients perceived difficulty following the regimen compared with their compliant counterparts. In contrast with other studies, no significant differences in knowledge, beliefs, and relevant demographic and clinical variables were found between compliant and noncompliant patients. Conclusion: Perceived difficulty and the amount of the prescribed restriction seem to be relevant concepts that play a role in compliance with sodium and fluid restriction in HF and need to be explored in future research.

Heart failure (HF) disease management programs are widely implemented, but data about their effect on outcome have been inconsistent.The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) was a multicenter, randomized, controlled trial in which 1023 patients were enrolled after hospitalization because of HF. Patients were assigned to 1 of 3 groups: a control group (follow-up by a cardiologist) and 2 intervention groups with additional basic or intensive support by a nurse specializing in management of patients with HF. Patients were studied for 18 months. Primary end points were time to death or rehospitalization because of HF and the number of days lost to death or hospitalization.Mean patient age was 71 years; 38% were women; and 50% of patients had mild HF and 50% had moderate to severe HF. During the study, 411 patients (40%) were readmitted because of HF or died from any cause: 42% in the control group, and 41% and 38% in the basic and intensive support groups, respectively (hazard ratio, 0.96 and 0.93, respectively; P = .73 and P = .52, respectively). The number of days lost to death or hospitalization was 39 960 in the control group, 33 731 days for the basic intervention group (P = .81), and 34 268 for the intensive support group (P = .49). All-cause mortality occurred in 29% of patients in the control group, and there was a trend toward lower mortality in the intervention groups combined (hazard ratio, 0.85; 95% confidence interval, 0.66-1.08; P = .18). There were slightly more hospitalizations in the 2 intervention groups (basic intervention group, P = .89; and intensive support group, P = .60).Neither moderate nor intensive disease management by a nurse specializing in management of patients with HF reduced the combined end points of death and hospitalization because of HF compared with standard follow-up. There was a nonsignificant, potentially relevant reduction in mortality, accompanied by a slight increase in the number of short hospitalizations in both intervention groups. Clinical Trial Registry http://trialregister.nl Identifier: NCT 98675639.

While there are data to support the use of comprehensive non-pharmacological intervention programs in patients with heart failure (HF), other studies have not confirmed these positive findings. Substantial differences in the type and intensity of disease management programs make it impossible to draw definitive conclusions about the effectiveness, optimal timing and frequency of interventions.1. To determine the effectiveness of two interventions (basic support vs. intensive support) compared to 'care as usual' in HF patients, on time to first major event (HF readmission or death), quality of life and costs. 2. To investigate the role of underlying mechanisms (knowledge, beliefs, self-care behaviour, compliance) on the effectiveness of the two interventions.This is a randomised controlled trial in which 1050 patients with heart failure will be randomised into three treatment arms: care as usual, basic education and support or intensive education and support. Outcomes of this study are; time to first major event (HF hospitalisation or death), quality of life (Minnesota Living with HF Questionnaire, RAND36 and Ladder of Life) and costs. Data will be collected during initial admission and then 1, 6, 12, and 18 months after discharge. In addition, data on knowledge, beliefs, self-care behaviour and compliance will be collected.The study started in January 2002 and results are expected at the end of 2005.This study will help health care providers in future to make rational and informed choices about which components of a HF management program should be expanded and which components can possibly be deleted.