Background: Caregiver support is considered necessary after heart transplant (HT) and left ventricular assist device (LVAD) for patients with end-stage heart failure (HF). Few studies have demonstrated how caregivers differ by gender and race, and whether that impacts therapy eligibility. Methods: We examined caregiver relationships among 674 patients (32% women, 55% Black) evaluated at Emory University from 2011 to 2017. Therapy readiness was assessed using the Stanford Integrated Assessment for Transplant (SIPAT). Evaluation outcome according to caregiver relationship was compared using χ2 analysis. Multivariable logistic regression determined the association between caregiver and eligibility according to gender and race. Results: Women and Black patients were less likely to have spouses as their support person (P <.001). Women were less likely to be considered eligible for advanced therapies (adjusted odds ratio [aOR].64, 95% confidence interval [CI].46–.89; P =.008), with Black women having lower eligibility than White women (aOR.28, 95% CI.11–.72; P =.008). Social support and SIPAT scores did not significantly influence eligibility by gender or race. Conclusion: Lack of caregiver support is considered a relative contraindication to advanced therapies. Type of caregiver in our cohort varied according to race and gender but did not explain differences in eligibility for advanced therapies.
Background
Despite the rising heart failure (HF) incidence and aging United States population, there are no validated prediction models for incident HF in the elderly population. We sought to develop a new prediction model for 5-year risk of incident HF among older persons.
Methods and Results
Proportional hazards models were used to assess independent predictors of incident HF, defined as hospitalization for new onset HF, in 2935 elderly participants without baseline HF enrolled in the Health ABC study (73.6±2.9 years, 47.9% males, 58.6% whites). A prediction equation was developed and internally validated by bootstrapping, allowing the development of a 5-year risk score. Incident HF developed in 258 (8.8%) participants during 6.5±1.8 years of follow-up. Independent predictors of incident HF included age, history of coronary disease and smoking, baseline systolic blood pressure and heart rate, serum glucose, creatinine, and albumin levels, and left ventricular hypertrophy. The Health ABC HF model had a c-statistic 0.73 in the derivation dataset, 0.72 by internal validation (optimism-corrected), and good calibration (goodness-of-fit χ2 6.24, p=0.621). A simple point score was created to predict incident HF risk into four risk groups corresponding to <5%, 5–10%, 10–20%, and >20% 5-yr risk. The actual 5-year incident HF rates in these groups were 2.9%, 5.7%, 13.3%, and 36.8% respectively.
Conclusion
The Health ABC HF prediction model uses common clinical variables to predict incident HF risk in the elderly, an approach that may be used to target and treat high-risk individuals.
Objective
Resistin is associated with inflammation and insulin resistance, and exerts direct effects on myocardial cells including hypertrophy and altered contraction. We investigated the association of serum resistin concentrations with risk for incident heart failure (HF) in humans.
Methods and Results
We studied 2902 older persons without prevalent HF (age, 73.6±2.9 years; 48.1% men; 58.8% white) enrolled in the Health ABC Study. Correlation between baseline serum resistin concentrations (20.3±10.0 ng/mL) and clinical variables, biochemistry panel, markers of inflammation and insulin resistance, adipocytokines, and measures of adiposity was weak (all rho<0.25). During a median follow-up of 9.4 years, 341 participants (11.8%) developed HF. Resistin was strongly associated with risk for incident HF in Cox proportional hazards models controlling for clinical variables, biomarkers, and measures of adiposity (HR, 1.15 per 10.0 ng/mL in adjusted model; 95%CI, 1.05–1.27; P=0.003). Results were comparable across sex, race, diabetes mellitus, and prevalent and incident coronary heart disease subgroups. In participants with available left ventricular ejection fraction at HF diagnosis (265 of 341; 77.7%), association of resistin with HF risk was comparable for cases with reduced vs. preserved ejection fraction.
Conclusions
Serum resistin concentrations are independently associated with risk for incident HF in older persons.
Background
Simultaneous adherence with multiple self-care instructions among heart failure (HF) patients is not well described.
Methods
Patient-reported adherence to eight recommendations related to exercise, alcohol, medications, smoking, diet, weight, and symptoms was assessed among 308 HF patients using the Medical Outcomes Study Specific Adherence Scale questionnaire (0=‘never’, 5=‘always’; maximum score=40). A baseline cumulative score of ≥32/40 (average ≥80%) defined good adherence. Clinical events (death/transplantation/ventricular assist device), resource utilization, functional capacity (6-minute walk distance), and health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were compared among patients with and without good adherence.
Results
Mean follow-up 2.0±1.0 years. Adherence ranged from 26.3% (exercise) to 89.9% (medications). A cumulative score indicating good adherence was reported by 35.7%, whereas good adherence with every behavior was reported by 9.1% of patients. Good adherence was associated with fewer hospitalizations (all-cause 87.8 vs. 107.6; P=0.018; HF 29.6 vs. 43.8; P=0.007), and hospitalized days (all-cause 422 vs. 465; P=0.015; HF 228 vs. 282; P<0.001) per 100 person-years; and better health status (KCCQ overall score 70.1±24.6 vs. 63.8±22.8; P=0.011). Adherence was not associated with clinical events or functional capacity.
Conclusions
Patient-reported adherence with HF self-care recommendations is alarmingly low and selective. Good adherence was associated with lower resource utilization and better health status.
Objectives:
We investigated sex-based differences in eligibility for and outcomes after receipt of advanced heart failure (HF) therapies.
Background:
Although women are more likely to die from HF than men, registry data suggest that women are less likely to receive heart transplant (HT) or left ventricular assist device (LVAD) for largely unknown reasons.
Methods:
We performed a single-center, retrospective cohort study of patients evaluated for advanced HF therapies from 2012 to 2016. Logistic regression was used to determine the association of sex with eligibility for HT/LVAD. Competing risks and Kaplan-Meier analysis were used to examine survival.
Results:
Of 569 patients (31% women) evaluated, 223 (39.2%) were listed for HT and 81 (14.2%) received destination (DT) LVAD. Women were less likely to be listed for HT (adjusted odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21 – 0.61; P<0.0001), based on allosensitization (P<0.0001) and obesity (P=0.02). Women were more likely to receive DT LVAD (adjusted OR 2.29, 95% CI 1.23 – 4.29; P=0.01). Survival was similar between men and women regardless of whether they received HT, DT LVAD, or were ineligible for therapy.
Conclusion:
Women are less likely to be HT candidates, but more likely to receive DT LVAD.
Background
Race- and gender- specific epidemiology of incident heart failure (HF) in a contemporary elderly cohort is not well described.
Methods
We studied 2934 participants without HF enrolled in the Health ABC Study (age 73.6±2.9 years, 47.9% men, 58.6% white, 41.4% black) and assessed incidence of HF, population attributable risk (PAR) of independent risk factors for HF, and outcomes of incident HF.
Results
During a median follow-up of 7.1 years, 258 (8.8%) participants developed HF (13.6/1000 person-years). Men and blacks were more likely to develop HF. No significant sex-based differences were observed in risk factors. Coronary heart disease (whites: PAR 23.9%, blacks: PAR 29.5%) and uncontrolled blood pressure (whites: PAR 21.3%, blacks: PAR 30.1%) carried the highest PAR in both races. In blacks, 6 out of 8 risk factors assessed (coronary heart disease, uncontrolled blood pressure, left ventricular hypertrophy, reduced glomerular filtration rate, smoking, and increased heart rate) had >5% higher PAR compared to whites, leading to a higher overall proportion of HF attributable to modifiable risk factors in blacks vs. whites (67.8% vs. 48.9%). Participants who developed HF had a higher annual mortality (18.0% vs. 2.7%). No racial difference in survival after HF was noted; however, rehospitalization rates were higher in blacks (62.1 vs. 30.3/100 person-years, P<.001).
Conclusions
Incident HF is common in the elderly; a large proportion of HF risk was attributed to modifiable risk factors. Racial differences in risk factors for HF and in hospitalization rates after HF need to be accounted for prevention and treatment efforts.
The 2018 Revised United Network for Organ Sharing Heart Allocation System (HAS) was proposed to reclassify status 1A candidates into groups of decreasing acuity; however, it does not take into account factors such as body mass index (BMI) and blood group which influence waitlist (WL) outcomes. We sought to validate patient prioritization in the new HAS at our center. We retrospectively evaluated patients listed for heart transplantation (n = 214) at Emory University Hospital from 2011 to 2017. Patients were reclassified into the 6-tier HAS. Multistate modeling and competing risk analysis were used to compare outcomes of transplantation and WL death/deterioration between new tiers. Additionally, a stratified sensitivity analysis by BMI and blood group was performed. Compared with tier 4 patients, there was progressively increasing hazard of WL death/deterioration in tier 3 (HR: 2.52, 95% CI: 1.37-4.63, P =.003) and tier 2 (HR: 5.03, 95% CI: 1.99-12.70, P <.001), without a difference in transplantation outcome. When stratified by BMI and blood group, this hierarchical association was not valid in patients with BMI ≥30 kg/m2 and non-O blood groups in our cohort. Therefore, the 2018 HAS accurately prioritizes the sickest patients in our cohort. Factors such as BMI and blood group influence this relationship and iterate that the system can be further refined.
Objectives
To evaluate the association between inflammation and heart failure (HF) risk in older adults.
Background
Inflammation is associated with HF risk factors and also directly affects myocardial function.
Methods
The association of baseline serum concentrations of interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and C-reactive protein (CRP) with incident HF was assessed with Cox models among 2610 older persons without prevalent HF enrolled in the Health ABC Study (age, 73.6±2.9 years; 48.3% men; 59.6% white).
Results
During follow-up (median, 9.4 years), 311 participants (11.9%) developed HF. In models controlling for clinical characteristics, ankle-arm index, and incident coronary heart disease, doubling of IL-6, TNF-α, and CRP concentrations was associated with 29% (95% CI, 13 to 47%; P<.001), 46% (95% CI, 17 to 84%; P=.001), and 9% (95% CI, -1 to 24%; P=.087) increase in HF risk, respectively. In models including all three markers, IL-6 and TNF- α, but not CRP, remained significant. These associations were similar across sex and race and persisted in models accounting for death as a competing event. Post-HF ejection fraction was available in 239 (76.8%) cases; inflammatory markers had stronger association with HF with preserved ejection fraction. Repeat IL-6 and CRP determinations at 1-year follow-up did not provide incremental information. Addition of IL-6 to the clinical Health ABC HF model improved model discrimination (C index from 0.717 to 0.734; P=.001) and fit (decreased Bayes information criterion by 17.8; P<.001).
Conclusions
Inflammatory markers are associated with HF risk among older adults and may improve HF risk stratification.
A shared understanding of medical conditions between patients and their health care providers may improve self-care and outcomes. In this study, the concordance between responses to a medical history self-report (MHSR) form and the corresponding provider documentation in electronic health records (EHRs) of 19 select co-morbidities and habits in 230 patients with heart failure were evaluated. Overall concordance was assessed using the κ statistic, and crude, positive, and negative agreement were determined for each condition. Concordance between MHSR and EHR varied widely for cardiovascular conditions (κ = 0.37 to 0.96), noncardiovascular conditions (κ = 0.06 to 1.00), and habits (κ = 0.26 to 0.69). Less than 80% crude agreement was seen for history of arrhythmias (72%), dyslipidemia (74%), and hypertension (79%) among cardiovascular conditions and lung disease (70%) and peripheral arterial disease (78%) for noncardiovascular conditions. Perfect agreement was observed for only 1 of the 19 conditions (human immunodeficiency virus status). Negative agreement >80% was more frequent than >80% positive agreement for a condition (15 of 19 [79%] vs 8 of 19 [42%], respectively, p = 0.02). Only 20% of patients had concordant MSHRs and EHRs for all 7 cardiovascular conditions; in 40% of patients, concordance was observed for ≤5 conditions. For noncardiovascular conditions, only 28% of MSHR-EHR pairs agreed for all 9 conditions; 37% agreed for ≤7 conditions. Cumulatively, 39% of the pairs matched for ≤15 of 19 conditions. In conclusion, there is significant variation in the perceptions of patients with heart failure compared to providers’ records of co-morbidities and habits. The root causes of this variation and its impact on outcomes need further study.