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Author Notes:

Julie T. Bidwell, PhD, RN, Betty Irene Moore School of Nursing, 2570 48th Street, Sacramento, CA 95817, United States of America.+1 (916) 703-3706. Email: jtbidwell@ucdavis.edu

The authors declare no conflicts of interest.


Research Funding:

This work was supported by the National Institutes of Health/National Institute of Nursing Research [grant numbers P01NR011587 (Corwin, Dunbar), UL1TR000454 (D. Stephens), and T32NR012715 (Dunbar, Bidwell)], and the Atlanta Veterans Administration Medical Center. Cortisol Assay services were provided by the Biomarkers Core Laboratory at the Yerkes National Primate Research Center, supported by the Yerkes National Primate Research Center Base Grant 2P51RR000165-51.

Dr. Bidwell is supported by the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR001860 and linked award KL2 TR001859). The content is solely the responsibility of the authors and does not necessarily represent the official views of NINR or the Veterans Administration.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Endocrinology & Metabolism
  • Neurosciences
  • Psychiatry
  • Neurosciences & Neurology
  • Heart failure
  • Caregivers
  • Symptoms
  • Stress
  • psychological
  • physiological
  • LIFE

Caregiver subjective and physiological markers of stress and patient heart failure severity in family care dyads


Journal Title:



Volume 133


, Pages 105399-105399

Type of Work:

Article | Post-print: After Peer Review


Greater family caregiver exposure to uncontrolled patient symptoms is predictive of greater caregiver psychological and physiological stress in dementia and other chronic illnesses, but these phenomena have not been well-studied in heart failure (HF) – a disease with high symptom burden. The purpose of this study was to test the hypothesis that worse patient functional status (as reflected by increasing HF symptoms) would be associated with elevated psychological and physiological stress for the caregiver. This was a secondary analysis of data from 125 HF caregivers in the Caregiver Opportunities for Optimizing Lifestyle (COOL) study. Psychological stress was measured on four dimensions: care-related strain/burden (Oberst Caregiving Burden Scale), depression (Center for Epidemiological Studies Depression Scale), anxiety (State-Trait Anxiety Index), and general stress (Perceived Stress Scale). Physiological stress was measured by markers of HPA axis function (elevated cortisol awakening response [CAR]), endothelial dysfunction (increased PAI-1), and inflammation (increased IL-6, hsCRP). HF patient functional status was quantified by caregiver assessment of New York Heart Association (NYHA) Class. Generalized linear models were used to test associations between patient NYHA Class and stress (one model per indicator). NYHA Class (ordinal) was backwards difference coded in each model to examine caregiver stress in relation to increasing levels of HF severity. Caregivers were mostly female and in their mid-fifties, with a slight majority of the sample being African American and the patient's spouse. Overall, patient functional status was associated with greater caregiver psychological and physiological stress. In terms of psychological stress, higher NYHA Class was significantly associated with greater caregiver anxiety and general stress, but not with caregiver burden or depression. In terms of physiological stress, higher NYHA Class was associated with elevated markers in all models (elevated CAR and higher IL-6, hsCRP, and PAI-1). Across models, most associations between NYHA Class and stress were present at relatively early stages of functional limitation (i.e. Class II), while others emerged when functional limitations became more severe. To inform timing and mechanisms for much-needed caregiver interventions, research is needed to determine which aspects of HF symptomatology are most stressful for caregivers across the HF trajectory.

Copyright information:

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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