Baseline Quality of Life as a Predictor of Mortality and Hospitalization in 5,025 Patients With Congestive Heart Failure

doi:10.1016/S0002-9149(96)00463-8

The American Journal of Cardiology

Volume 78, Issue 8, 15 October 1996, Pages 890-895

https://doi.org/10.1016/S0002-9149(96)00463-8 Get rights and content

Abstract

This study examined the independent relation of health-related quality of life (HRQL) to mortality and congestive heart failure (CHF)-related hospitalizations in patients with an ejection fraction of <0.35 followed for a mean of 36.5 months. A brief HRQL questionnaire was administered at baseline to patients randomized to placebo or enalapril in the Studies of Left Ventricular Dysfunction (SOLVD) trial. Participants had an ejection fraction of <0.35 and either symptomatic CHF (treatment trial, n = 2,465) or asymptomatic CHF (prevention trial, n = 2,560). Baseline assessment of HRQL predicted mortality and CHF-related hospitalizations in symptomatic and asymptomatic patients randomized to enalapril and placebo treatment. Domains that were the stronger univariate predictors of mortality and CHF-related hospitalizations were activities of daily living (relative risk [RR] for mortality: 1.163, p <0.000; for hospitalization: 1.215, p <0.000), general health (RR for mortality: 1.205, p <0.000; for hospitalization: 1.188, p <0.000), and social functioning (RR for mortality 1.098, p <0.000; for hospitalization: RR 1.156, p <0.000). In the multivariate model, activities of daily living (RR for mortality 1.41, p <0.000; for hospitalization: RR 1.43, p <0.002), general health (RR for mortality 1.21, p <0.000; for hospitalization RR 1.16, p <0.013) and heart failure symptoms (RR for mortality 1.02, p <0.025; for hospitalization RR 1.03, p <0.004) were found to be independent risk factors. HRQL independently predicted mortality and CHF-related hospitalizations after adjustment for ejection fraction, age, treatment, and New York Heart Association classification in patients with an ejection fraction of <0.35, randomized to enalapril and placebo treatment. HRQL provides additional clinical information regarding disease course and outcome that is not captured by traditional indexes of clinical status.

(Am J Cardiol 1996;78:890–895)

Section snippets

METHODS

Studies of left ventricular dysfunction trials: A description of the study design has been provided previously.4, 5, 6 Six thousand seven hundred ninety-seven subjects, aged 21 to 80 years, from 23 centers were randomized to receive double-blind enalapril (2.5 to 20 mg/day) or placebo to evaluate effects on patients with CHF (ejection fraction ≤ 0.35). Two thousand five hundred sixty-nine patients with CHF symptoms were enrolled in the treatment trial and 4,228 patients with no CHF symptoms

RESULTS

A summary of clinical characteristics of patients enrolled in the study are described in Table 2. The HRQL questionnaire was completed by 2,465 of the 2,569 patients (96%) enrolled in the treatment trial and the first 2,560 of the 4,228 patients (61%) enrolled in the prevention trial. Analysis of patient characteristics revealed that the groups randomized to enalapril and placebo within each trial were similar with respect to overall HRQL ratings.[3] Approximately 5% of questions on the HRQL

DISCUSSION

Baseline assessment of HRQL independently predicted mortality and CHF-related hospitalizations in symptomatic and asymptomatic patients randomized to enalapril or placebo treatment. The domains of ADL and general health, both in the univariate and multivariate analyses, predicted mortality and CHF-related hospitalizations. Quality-of-life indexes provided additional predictive value with respect to both mortality and CHF-related hospitalizations, above and beyond the predictive power of such

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Cited by (305)

Changing health related quality of life and outcomes in heart failure by age, sex and subtype
2023, eClinicalMedicine
There are calls to integrate serial recordings of health related quality of life (HRQoL) into routine care, clinical trials and prognosis. Little is known about the relationship between change in HRQoL and outcomes in heart failure (HF) patients by age, sex and HF subtype.
From the Swedish Heart Failure Registry (SwedeHF; 2008–2019), patients were categorised by reduced (<40%, HFrEF), mildly-reduced (40–49%, HFmrEF) and preserved (≥50%, HFpEF) ejection fraction. HRQoL was measured using Euro-QoL-5D visual analogue scale (EQ5D-vas), collected at baseline and 1-year. Baseline EQ5D-vas scores were categorised by: “best” (76–100), “good” (51–75), “bad” (26–50), and “worst” (0–25). Change in EQ5D-vas was categorised as ‘no significant change’ (<5 points increase/decrease); some worsening (5–9 points decrease); considerable worsening (≥10 points decrease); some improvement (5–9 points increase); considerable improvement (≥10 points increase). Associations with admission and death were estimated and interactions with patient sub-groups tested.
Among 23,553 patients (median age 74 [66–81] years, 8000 [34%] female), baseline EQ5D-vas was worse in older patients, women, and those with HFpEF compared to their respective counterparts. Compared to patients with the “best” EQ5D-vas, the adjusted associations for admission for those with “good”, “bad” and “worst” EQ5D-vas were, respectively: HR 1.09 (1.04, 1.14), 1.27 (1.21, 1.33) and 1.39 (1.28, 1.51). Compared to no significant change in EQ5D-vas, the adjusted estimates for admission following some improvement, considerable improvement, some worsening and considerable worsening were, respectively: HR 0.91 (0.82, 1.01), 0.75 (0.70, 0.81), 1.04 (0.92, 1.16) and 1.25 (1.16, 1.35). Results were similar amongst groups and for HF admission and death.
Change in HRQoL was an independent indicator of risk of admission and death in people with all HF subtypes, irrespective of age and sex.
NIHR.
Patient-Reported Status and Heart Failure Outcomes in Asia by Sex, Ethnicity, and Socioeconomic Status
2023, JACC: Asia
In heart failure (HF), symptoms and health-related quality of life (HRQoL) are known to vary among different HF subgroups, but evidence on the association between changing HRQoL and outcomes has not been evaluated.
The authors sought to investigate the relationship between changing symptoms, signs, and HRQoL and outcomes by sex, ethnicity, and socioeconomic status (SES).
Using the ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) Registry, we investigated associations between the 6-month change in a “global” symptoms and signs score (GSSS), Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS), and visual analogue scale (VAS) and 1-year mortality or HF hospitalization.
In 6,549 patients (mean age: 62 ± 13 years], 29% female, 27% HF with preserved ejection fraction), women and those in low SES groups had higher symptom burden but lower signs and similar KCCQ-OS to their respective counterparts. Malay patients had the highest GSSS (3.9) and lowest KCCQ-OS (58.5), and Thai/Filipino/others (2.6) and Chinese patients (2.7) had the lowest GSSS scores and the highest KCCQ-OS (73.1 and 74.6, respectively). Compared to no change, worsening of GSSS (>1-point increase), KCCQ-OS (≥10-point decrease) and VAS (>1-point decrease) were associated with higher risk of HF admission/death (adjusted HR: 2.95 [95% CI: 2.14-4.06], 1.93 [95% CI: 1.26-2.94], and 2.30 [95% CI: 1.51-3.52], respectively). Conversely, the same degrees of improvement in GSSS, KCCQ-OS, and VAS were associated with reduced rates (HR: 0.35 [95% CI: 0.25-0.49], 0.25 [95% CI: 0.16-0.40], and 0.64 [95% CI: 0.40-1.00], respectively). Results were consistent across all sex, ethnicity, and SES groups (interaction P > 0.05).
Serial measures of patient-reported symptoms and HRQoL are significant and consistent predictors of outcomes among different groups with HF and provide the potential for a patient-centered and pragmatic approach to risk stratification.
Study of the factors contributing to poor quality of life in chronic heart failure with reduced ejection fraction
2021, Annales de Cardiologie et d'Angeiologie
La prévalence de l'insuffisance cardiaque ne cesse d'augmenter. L'amélioration de la qualité de vie chez les patients porteurs de cette maladie est l'un des objectifs incontournables dans son traitement. La qualité de vie des patients insuffisants cardiaque reste peu étudiée en Tunisie. L'objectif de notre étude était de mesurer la qualité de vie et de déterminer les facteurs auxquels elle est liée.
Dans cette étude prospective, nous avons inclus les patients en insuffisance cardiaque suivis dans le service de cardiologie de l'hôpital Habib Thameur sur une période de quatre mois, avec comme critère de sélection majeur, une fraction d’éjection systolique gauche (FEVG) inférieure ou égale à 45 %. L’étude a porté sur l’évaluation de la qualité de vie au moyen du questionnaire spécifique de Minnesota. La relation entre la qualité de vie et les différents paramètres recueillis a été étudiée en analyse univariée puis en régression logistique binaire.
Dans un échantillon total de 100 patients, l’âge moyen était de 62,7±12,8 ans. Nos patients étaient majoritairement de sexe masculin (77 %), de classe fonctionnelle NYHA III à IV (61 %), avec en moyenne 2,5±1,5 comorbidités et une FEVG de 36 %. En matière de qualité de vie, nous avons eu autant de patients avec une qualité de vie altérée que de patients avec une bonne qualité de vie selon le score de Minnesota. Avec des moyennes de 45 ± 28,3 pour le score total (médiane 41,5), pour le sous-score physique (médiane 17,5) et pour le sous-score émotionnel (médiane 11,25). Les facteurs dépendant de la mauvaise qualité de vie en analyse univariée étaient l'inactivité professionnelle, l'hypertension artérielle, l'insuffisance rénale, l'anémie, le régime hyposodé, l'inactivité physique, la classe fonctionnelle NYHA avancée et les QRS large. En régression logistique binaire, les facteurs associés à une mauvaise qualité de vie étaient: les classes fonctionnelles NYHA avancées et l'insuffisance rénale.
Cette étude a montré que les classes avancées NYHA et l'insuffisance rénale sont des facteurs de mauvaise qualité de vie indépendamment de la sévérité de la maladie chez les insuffisants cardiaques chroniques.
The increasing prevalence and poor prognosis associated with chronic heart failure (CHF) have made the improvement of quality of life (QoL) one of the main goals in the treatment of CHF patients. Since little is known about the QoL in Tunisian patients with heart failure (HF), the current study was performed to assess QoL in a sample of Tunisian patients hospitalized with HF and to identify factors related to QoL.
In this prospective study, we evaluated patients with CHF attending the cardiology department of Habib Thameur University Hospital in a four-month period. Echocardiography was performed and patients with left ventricular ejection fraction of 45% or less were selected. QoL assessment was performed with a disease-specific instrument: the Minnesota Living with Heart Failure Questionnaire (MLHFQ) in a sample of 100 selected patients. Relationships between health-related QoL and the studied variables were examined with bivariate correlations and binary logistic regression analysis.
In the total sample (n = 100), mean age was 62.7 years. The majority were male (77%), married (76%), with a mean of 2.5 comorbidities, and in a New York Heart Association (NYHA) functional class III to IV (61%). Mean LVEF was 36%. Half of the patients had poor QoL on the total MLHFQ scale (median = 41.5) as well as on its physical (median = 17.5) and emotional (median = 11.25) domains. In univariate analysis, the following variables were related to poor QoL with p < 0.005: not being employed, suffering from hypertension, renal failure, anemia, being under a low-salt diet, having no regular physical activity, having the physical symptoms of HF, higher NYHA class and longer QRS duration. In multiple regression analysis, the main independent predictors of poor QoL on the total scale were higher NYHA functional class and renal dysfunction,. The data provided no evidence of an association between LVEF and QoL.
This study has found that higher NHYA functional class and chronic kidney disease are risk factors for impaired QoL, independently of disease severity among patients with heart failure.
Health-Related Quality of Life Is a Mediator of the Relationship Between Medication Adherence and Cardiac Event-Free Survival in Patients with Heart Failure
2021, Journal of Cardiac Failure
Health-related quality of life (HRQOL) is an important patient-reported outcome that is related to medication adherence, hospitalization and death. The nature of the relationships among medication adherence, HRQOL, and hospitalization and death is unknown. We sought to determine the relationships among medication adherence, HRQOL, and cardiac event-free survival in patients with heart failure.
We enrolled 218 patients with heart failure. Patients’ medication adherence was measured objectively using the Medication Event Monitoring System. HRQOL was assessed using the Minnesota Living with Heart Failure Questionnaire. Patients were followed for up to 3.5 years to collect hospitalization and mortality data. Mediation analysis was used to determine the nature of the relationships among the variables. Patients with better medication adherence had better HRQOL (P = .014). Medication adherence and HRQOL were associated with cardiac event-free survival (both P < .05). Patients with medication nonadherence were 1.86 times more likely to experience a cardiac event than those with better medication adherence (P = .038). Medication adherence was not associated with cardiac event-free survival after entering HRQOL in the model (P = .118), indicating mediation by HRQOL of the relationship between medication adherence and cardiac event-free survival.
HRQOL mediated the relationship between medication adherence and cardiac event-free survival. It is important to assess medication adherence and HRQOL regularly and develop interventions to improve medication adherence and HRQOL to decrease hospitalization and mortality in patients with heart failure.
Correlation between medication regimen complexity and quality of life in patients with heart failure
2020, Research in Social and Administrative Pharmacy
To determine if a correlation exists between the medication regimen complexity index (MRCI) and quality of life (QoL) in patients with heart failure (HF) assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).
Retrospective chart review from July 2012 through June 2018 identified patients for inclusion who completed an MLHFQ. Baseline and, if available, follow-up MLHFQ scores were collected. The medication list documented on the date of the MLHFQ was used to calculate the MRCI.
Patients with a documented MLHFQ score were included (n = 72) in the primary analysis. No correlation existed between baseline MRCI and MLHFQ (r = 0.07; p = 0.55). A secondary analysis of correlation between change in MRCI and MLHFQ was conducted for patients (n = 30) with a follow-up MLHFQ score. A moderate, negative correlation (r = −0.47; p = 0.009) existed between change in MRCI and MLHFQ from baseline to follow-up.
No significant correlation between MRCI and MLHFQ scores were found at baseline. Patients with follow-up MLHFQ scores demonstrated improvements in QoL, despite increasingly complex medication regimens. Medication regimen complexity alone is likely an insufficient marker for predicting QoL in patients with HF.
Associations between pre-, post-, and peri-operative variables and health resource use following surgery for head and neck cancer
2019, Oral Oncology
We examined associations between pre-, post-, and peri-operative variables and health resource use in head and neck cancer patients.
Patients (N = 183) who were seen for a pre-surgical consult between January 2012 and December 2014 completed surveys that assessed medical history, a patient-reported outcome measure (PROM) of dysphagia, and quality of life (QOL). After surgery, peri-operative (e.g., tracheostomy, feeding tube) and post-operative (e.g., complications) variables were abstracted from patients’ medical records.
Multivariate regression models using backward elimination showed that pre-surgical University of Washington Quality of Life (UW-QOL) Inventory and M.D. Anderson Dysphagia Inventory (MDADI) composite scores, documented surgical complications, and having a tracheostomy, were all significant predictors of hospital length of stay, explaining 57% of the total variance (F(5, 160) = 18.71, p < .001). Male gender, psychiatric history, and lower pre-surgical MDADI scores significantly predicted thirty-day unplanned readmissions (30dUR). Pre-surgical MDADI composite scores also significantly predicted emergencey department (ED) visits within 30 days of initial hospital discharge (p = .02).
Assessment of PROMs and QOL in the pre-surgical setting may assist providers in identifying patients at risk for prolonged LOS and increased health resource use after hospital discharge.

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^*: A complete list of the SOLVD investigators may be found in Bangdiwala SI, Weiner DH, Bourassa MG, Friesinger GC II, Ghali JK, Yusuf S, for the SOLVD Investigators. Studies of Left Ventricular Dysfunction (SOLVD) Registry: rationale, design, methods and description of baseline characteristics. Am J Cardiol 1992;70:347–353.

^*a: A complete list of the SOLVD investigators may be found in Bangdiwala SI, Weiner DH, Bourassa MG, Friesinger GC II, Ghali JK, Yusuf S, for the SOLVD Investigators. Studies of Left Ventricular Dysfunction (SOLVD) Registry: rationale, design, methods and description of baseline characteristics. Am J Cardiol 1992;70:347–353.

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Baseline Quality of Life as a Predictor of Mortality and Hospitalization in 5,025 Patients With Congestive Heart Failure

Abstract

Section snippets

METHODS

RESULTS

DISCUSSION

Quality of life in patients with advanced heart failure

J Heart Lung Transplant

Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure

N Engl J Med

Studies of Left Ventricular Dysfunction (SOLVD)—rationale, design and methods: two trials that evaluate the effect of enalapril in patients with reduced ejection fraction

Am J Cardiol

Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions

N Engl J Med

The functional status questionnaire: reliability and validity when used in primary care

J Gen Intern Med

The MOS short form general health survey: reliability and validity in a patient population

Med Care

Social relationships and health

Science