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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 < 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). 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. [GRAPHICS] ., Funding Agencies|Dutch Heart Foundation [2017-21, 2017-11, 2018-30, 2020B005, 2000Z003, 03-005-2021-T005]; leDucq Foundation (Cure PhosphoLambaN induced Cardiomyopathy (Cure-PLaN)); European Research Council (SECRETE-HF) [ERC CoG 818715]; Mandema-Stipendium of the Junior Scientific Masterclass of the University Medical Center Groningen [202010]

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

Aims This study aimed to explore factors related to non-adherence to exergaming in patients with heart failure. Methods and results Data from patients in the exergame group in the HF-Wii trial were used. Adherence to exergaming was defined as playing 80% or more of the recommended time. Data on adherence and reasons for not exergaming at all were collected during phone calls after 2, 4, 8, and 12 weeks. Logistic regression was performed between patients who were adherent and patients who were non-adherent. Secondly, a logistic regression was performed between patients who not exergamed at all and patients who were adherent to exergaming. Finally, we analysed the reasons for not exergaming at all with manifest content analysis. Almost half of the patients were adherent to exergaming. Patients who were adherent had lower social motivation [odds ratio (OR) 0.072; 95% confidence interval (CI) 0.054-0.095], fewer sleeping problems (OR 0.84; 95% CI 0.76-0.092), and higher exercise capacity (OR 1.003; 95% CI 1.001-1.005) compared with patients who were non-adherent. Patients who not exergamed at all had lower cognition (OR 1.18; 95% CI 1.06-1.31) and more often suffered from peripheral vascular disease (OR 3.74; 95% CI 1.01-13.83) compared with patients who were adherent to exergaming. Patients most often cited disease-specific barriers as a reason for not exergaming at all. Conclusions A thorough baseline assessment of physical function and cognition is needed before beginning an exergame intervention. It is important to offer the possibility to exergame with others, to be able to adapt the intensity of physical activity., Funding Agencies|Swedish National Science Council [K2013-69X-22302-01-3, 2016-01390]; Swedish National Science Council/the Swedish Research Council for Health, Working Life and Welfare, VR-FORTE [2014-4100]; Swedish Heart and Lung Association [Hjart-Lungfonden] [E085/12]; Swedish Heart and Lung Foundation (Hjart-Lungfonden) [20130340, 20160439]; Vardal Foundation (Vardalstiftelsen) [2014-0018]; Medical Research Council of Southeast SwedenUK Research & Innovation (UKRI)Medical Research Council UK (MRC) [FORSS 474681]

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.

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.

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 amp;gt; 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 amp;lt; 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 amp;lt; 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., Funding Agencies|Netherlands Heart Foundation (NHF)Netherlands Heart Foundation [2008B083]

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]

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, pamp;lt;0.001; OR 2.00, 95%CI 1.09 to 3.50, p=0.019) at 12 months, poorer self-care (OR 1.80, 95%CI 1.05 to 3.11, p=0.034; OR 2.87, 95%CI 1.61 to 5.11, pamp;lt;0.0011) and HF management adherence (OR 0.39, 95%CI 0.18 to 0.81, p=0.012; OR 0.35, 95%CI 0.17 to 0.72, p=0.004) at 12 and 18 months, higher rates of hospitalisations and mortality at 18 months and higher all-cause mortality (HR 1.43, 95%CI 1.07 to 1.91, p=0.016) at 3 years. Conclusions Patients with HF and stroke have worse psychosocial, behavioural and clinical outcomes, notably from 12 months, than those without stroke. To ameliorate these poor outcomes long-term, integrated disease management pathways are warranted., Funding Agencies|Netherlands Heart FoundationNetherlands Heart Foundation [2000Z003, D97.017]

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 amp;gt;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.

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 mu, Funding Agencies|NovaCardia; Merck Co., Inc.

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/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: 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 samples Results: 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 at baseline had depressive symptoms compared 19% of those with Vit D levels >50 nmol/l (p < 0.05). Only in patients with Vit D < 50 nmol/l, Vit D correlated significantly to physical function and depressive symptoms (r = .29, p < 0.001 and r = .20, p < 0.01). In structural equation modelling an indirect association between Vit D and depressive symptoms was found, mediated by physical function (B = 0.20). This association was only found in patients with Vit D levels <50 nmol/l. Conclusion: In HF patients with Vit D < 50 nmol/l, Vit D is associated to depressive symptoms during follow-up and this association is mediated by physical function. This relationship is not found in patients with Vitamin D level >50 nmol/l. (C) 2016 Elsevier Ireland Ltd. All rights reserved., Funding Agencies|Netherlands Heart Foundation [2000Z003]

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: Thirst is often increased in patients with heart failure (HF) and can cause distress during the course of the condition. The aim of the present study was to describe the trajectory of thirst during an 18-month period and to identify variables associated with persistent thirst in patients with HF. Methods and Results: Data were collected from 649 patients with HF with the use of the Revised Heart Failure Compliance Scale at 1, 6, 12, and 18 months after a period of hospital treatment for worsening HF. Thirst trajectory was described for the 4 follow-up visits and logistic regression analysis was used to identify factors independently associated with persistent thirst. In total, 33% (n = 212) of the patients reported thirst on greater than= 1 occasions and 34% (n = 46) continued to have thirst at every follow-up visit. Nineteen percent (n = 121) of the patients had persistent thirst. Patients with persistent thirst were more often younger and male and had more HF symptoms. Higher body mass index and serum urea also increased the risk of persistent thirst. Conclusions: Patients with HF who were thirsty at the 1-month follow-up were more often also thirsty at subsequent visits. Assessment of thirst is warranted in clinical practice because one-fifth of patients suffer from persistent thirst.

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 sed

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, Funding Agencies|Dutch Ministry of Health, department of Pharmaceutical Affairs and Medical Technology (GMT)

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, P<.01) between years of using the internet and R&T was found. In both groups KM was associated with the constructs B&T (B=.55, P=<.01) and R&T (B=.50, P=<.01). Conclusions Both cardiologists and HF-nurses perceived barriers in working with a CDSS in all of the examined constructs. KM has a strong positive correlation with perceived barriers, indicating that increasing knowledge about CDSSs can decrease their barriers., Funding Agencies|Dutch Government of health, section pharmaceuticals and medical technology (GMT)

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. less thanbrgreater than less thanbrgreater thanBaseline 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 0.450.92, 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-R1a, and GDF-15 showed the strongest interaction between sex and mortality. less thanbrgreater than less thanbrgreater thanFemale 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., Funding Agencies|Netherlands Heart Foundation|2000Z003|Biosite France SAS, Jouy-en-Josas, France||Roche Diagnostics Nederland BV, Venlo, the Netherlands||Novartis PharmaBV, Arnhem, the Netherlands||Dutch Heart Foundation|2006T37|European Commission|FP7-242209-BIOSTAT-CHF

The aim of this study was to examine long-term compliance with nonpharmacologic treatment of patients with heart failure (HF) and its associated variables. Data from 648 hospitalized patients with HF (mean age 69 +/- 12 years, 38% women, mean left ventricular ejection fraction 33 +/- 14%) were analyzed. Compliance was assessed by means of self-report at baseline and 1, 6, 12, and 18 months after discharge. Patients completed questionnaires on depressive symptoms, HF knowledge, and physical functioning at baseline. Logistic regression analyses were performed to examine independent associations with low long-term compliance. From baseline to 18-month follow-up, long-term compliance with diet and fluid restriction ranged from 77% to 91% and from 72% to 89%, respectively. In contrast, compliance with daily weighing (34% to 85%) and exercise (48% to 64%) was lower. Patients who were in New York Heart Association functional class II were more often noncompliant with fluid restriction (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.25 to 3.08). A lower level of knowledge on HF was independently associated with low compliance with fluid restriction (OR 0.78, 95% CI 0.71 to 0.86) and daily weighing (OR 0.86, 95% CI 0.79 to 0.94). Educational support improved compliance with these recommendations. Female gender (OR 1.91, 95% CI 1.26 to 2.90), left ventricular ejection fraction andgt;= 40% (OR 1.55, 95% CI 1.03 to 2.34), a history of stroke (OR 3.55, 95% CI 1.54 to 8.16), and less physical functioning (OR 0.99, 95% CI 0.98 to 0.99) were associated with low compliance with exercise. In conclusion, long-term compliance with exercise and daily weighing was lower than long-term compliance with advice on diet and fluid restriction. Although knowledge on HF and being offered educational support positively affected compliance with weighing and fluid restriction, these variables were not related to compliance with exercise. Therefore, new approaches to help patients with HF stay, Funding Agencies|Netherlands Heart Foundation, The Hague, The Netherlands|2000Z003

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 10months. 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: 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: 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: 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.

AIMS: The aim of this prospective study was to investigate the association between compliance with non-pharmacological recommendations (diet, fluid restriction, weighing, exercise) and outcome in patients with heart failure (HF). METHODS AND RESULTS: In total 830 patients after an HF hospitalization participated in the study (age 70 +/- 11; left ventricular ejection fraction 34%). Compliance was measured 1 month after discharge; patients were followed for 18 months. Primary outcomes were the composite of death or HF readmission and the number of unfavourable days. Cox regression analysis was used to determine the association between primary outcome and compliance. Adjustments were made for those variables that were identified as confounders in the association between compliance and outcome. Patients who were non-compliant with at least one of the recommendations had a higher risk of mortality or HF readmission (HR 1.40; P = 0.01). Non-compliance with exercise was associated with an increased risk for mortality or HF readmission (HR 1.48; P < 0.01), while non-compliance with daily weighing was associated with an increased risk of mortality (HR 1.57; P = 0.02). Non-compliance (overall) and non-compliance with exercise were both associated with a higher risk for HF readmission [HR 1.38; P < 0.05(overall) and HR 1.55; P < 0.01(exercise)]. Patients who were overall non-compliant or with weighing and exercise had more unfavourable days than compliant patients. CONCLUSION: Non-compliance with non-pharmacological recommendations in HF patients is associated with adverse outcome.

BACKGROUND: Noncompliance with pharmacological and nonpharmacological recommendations is a problem in many heart failure (HF) patients, leading to worse symptoms and readmission. Although knowledge is available regarding factors related to compliance with HF regimens, little is known about patients' perspectives. We investigated patients' reasons and motivations for compliance with HF regimens from their perspective, and we studied how patients manage these recommendations in daily life. The health belief model was used as a framework for this study. METHODS: A qualitative descriptive study was used, and 15 HF patients were interviewed about reasons for compliance, barriers to compliance, interventions that helped them comply with medications, sodium restriction, fluid restriction, and daily weighing. RESULTS: The most commonly reported reasons for compliance included fear of hospitalization and HF symptoms. Barriers to compliance were mainly related to the negative aspects of a regimen, e.g., taste of the food and thirst. Most patients tried to make their lifestyle changes part of the daily routine. Several problems and misunderstandings with the regimen were evident. Patients themselves offered many tips that helped them comply with the regimen. CONCLUSIONS: To improve compliance in HF patients, patient-tailored interventions must be targeted at specific problems and patients' beliefs regarding the regimen, and aim at implementing the regimen into daily life. Healthcare providers need to emphasize the benefits of compliance, motivate patients to comply, and focus on individual barriers to compliance, knowledge deficits, and misunderstandings regarding the regimen. More specific advice about medications and diet is needed. Group interventions, including tips patients themselves provide, might also be useful in helping patients implement the HF regimen in their daily lives.

BACKGROUND: As a result of the improvement of pharmacological and non-pharmacological treatment of heart failure patients, the heart failure regimen is becoming more complicated, especially for elderly patients with co-morbid diseases. Non-adherence to this regimen is a problem in many heart failure patients, leading to worsening symptoms, rehospitalization and decreased quality of life. AIM: This paper gives an overview of literature on adherence to pharmacological and non-pharmacological treatment in elderly heart failure patients. The paper addresses the definition of adherence and the extent and significance of the problem of non-adherence in elderly heart failure patients. Factors contributing to non-adherence, focused on the elderly are outlined and finally interventions to improve adherence in this elderly heart failure patient group are described. CONCLUSION: Non-adherence to medication and lifestyle recommendations is a major problem in elderly heart failure patients. Five dimensions that affect adherence are described consisting of social and economic factors, factors related to the health care system, to the condition of the patient, the therapy and factors related to the patient. Since non-adherences is a multidimensional problem, interventions need to be directed to all factors that are related to adherence in elderly heart failure patients. A multidisciplinary approach in a heart failure team is crucial to improve adherence in this vulnerable patient group. Effectiveness of interventions to improve adherence in elderly heart failure patients needs to be further tested.

BACKGROUND: Compliance with medication, diet, and monitoring symptoms is a problem in heart failure (HF) patients. Noncompliance can lead to worsening symptoms and is associated with personal beliefs about compliance. To intervene effectively, knowledge of factors related to patients' beliefs about compliance is needed. OBJECTIVES: The aims of this study are to: (1) gain insight into patients' beliefs about compliance; (2) examine the association of demographic variables and depressive symptoms to beliefs; (3) assess compliance with medication, diet, and daily weighing; and (4) examine the association of compliance to patients' beliefs. METHODS: Nine hundred fifty-four HF patients completed questionnaires on beliefs about medication and diet; 297 patients also completed a questionnaire on beliefs about symptom monitoring. Most important barriers and benefits were assessed as well as differences in beliefs between subgroups and the association between compliance and beliefs. RESULTS: The most important barriers were diuresis during the night (57%), the taste of food (51%), and limited ability to go out (33%). A barrier related to failure to weigh daily was forgetfulness (26%). Patients with depressive symptoms and patients with a low level of HF knowledge experienced more barriers to compliance with the HF regimen. Self-reported compliance with medication was almost 99%, compliance with diet 77%, and with daily weighing 33%. CONCLUSIONS AND IMPLICATIONS: In order to improve compliance, it is important that interventions should be directed to those patients who experience more barriers to compliance, such as patients with depressive symptoms and patients with a low level of knowledge on the HF regimen. Improvement of knowledge, therefore, will remain an important issue in HF management programs.

AIMS: Non-compliance in patients with heart failure (HF) contributes to worsening HF symptoms and may lead to hospitalization. Several smaller studies have examined compliance in HF, but all were limited as they only studied either the individual components of compliance and its related factors or several aspects of compliance without studying the related factors. The aims of this study were to examine all dimensions of compliance and its related factors in one HF population. METHODS AND RESULTS: Data were collected in a cohort of 501 HF patients. Clinical and demographic data were assessed and patients completed questionnaires on compliance, beliefs, knowledge, and self-care behaviour. Overall compliance was 72% in this older HF population. Compliance with medication and appointment keeping was high (>90%). In contrast, compliance with diet (83%), fluid restriction (73%), exercise (39%), and weighing (35%) was markedly lower. Compliance was related to knowledge (OR=5.67; CI 2.87-11.19), beliefs (OR=1.78; CI 1.18-2.69), and depressive symptoms (OR=0.53; CI 0.35-0.78). CONCLUSION: Although some aspects of compliance had an acceptable level, compliance with weighing and exercise were low. In order to improve compliance, an increase of knowledge and a change of patient's beliefs by education and counselling are recommended. Extra attention should be paid to patients with depressive symptoms.

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 non-compliance 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: Non-compliance with medication and other lifestyle recommendations is a major problem in patients with HF. 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.

BACKGROUND: Heart failure (HF) knowledge as well as compliance are considered to be underlying mechanisms of the effects of HF management programs. However, there are no valid and reliable measurement instruments available which measures knowledge of HF patients. AIM: To develop a reliable and valid instrument, which measures the knowledge, patients have on their disease and the HF-related health care regimen. METHODS: The HF knowledge scale was developed in 3 phases; (1) concept analysis and first construction, (2) revision of items and (3) testing for validity and reliability. RESULTS: The Dutch HF knowledge scale is a 15-item, self-administered questionnaire that covers items concerning HF knowledge in general, knowledge on HF treatment (including diet and fluid restriction) and HF symptoms and symptom recognition. Face validity as well as content and construct validity was tested in HF patients in 19 hospitals in the Netherlands. The scale was able to differentiate between HF patients with high and low level of HF knowledge. Cronbach's alpha of the knowledge scale in this population (n=902) was .62. CONCLUSION: The instrument is a valid and reliable scale that can be used in research to gain insight in the effect of education and counselling of HF patients. After additional testing, the instrument seems to be a valid and reliable scale to be used in clinical practice to measure HF knowledge.

BACKGROUND: 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. AIMS: 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. METHODS: 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. RESULTS: The study started in January 2002 and results are expected at the end of 2005. CONCLUSIONS: 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.