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1.  Statins in the Treatment of Chronic Heart Failure: A Systematic Review 
PLoS Medicine  2006;3(8):e333.
Background
The efficacy of statin therapy in patients with established chronic heart failure (CHF) is a subject of much debate.
Methods and Findings
We conducted three systematic literature searches to assess the evidence supporting the prescription of statins in CHF. First, we investigated the participation of CHF patients in randomized placebo-controlled clinical trials designed to evaluate the efficacy of statins in reducing major cardiovascular events and mortality. Second, we assessed the association between serum cholesterol and outcome in CHF. Finally, we evaluated the ability of statin treatment to modify surrogate endpoint parameters in CHF.
Using validated search strategies, we systematically searched PubMed for our three queries. In addition, we searched the reference lists from eligible studies, used the “see related articles” feature for key publications in PubMed, consulted the Cochrane Library, and searched the ISI Web of Knowledge for papers citing key publications.
Search 1 resulted in the retrieval of 47 placebo-controlled clinical statin trials involving more than 100,000 patients. CHF patients had, however, been systematically excluded from these trials. Search 2 resulted in the retrieval of eight studies assessing the relationship between cholesterol levels and outcome in CHF patients. Lower serum cholesterol was consistently associated with increased mortality. Search 3 resulted in the retrieval of 18 studies on the efficacy of statin treatment in CHF. On the whole, these studies reported favorable outcomes for almost all surrogate endpoints.
Conclusions
Since CHF patients have been systematically excluded from randomized, controlled clinical cholesterol-lowering trials, the effect of statin therapy in these patients remains to be established. Currently, two large, randomized, placebo-controlled statin trials are under way to evaluate the efficacy of statin treatment in terms of reducing clinical endpoints in CHF patients in particular.
A systematic review found that patients with heart failure have been excluded from randomised controlled trials on the use of statins. Evidence from other studies on the effectiveness of statins for patients with heart failure is weak and conflicting.
Editors' Summary
Background.
When medical researchers test a drug—or some other treatment—for a particular medical condition, they often decide not to include in their study anyone who has, in addition to the disease they are interested in, certain other health problems. This is because including patients with two or more conditions can complicate the analysis of the results and make it hard to reach firm conclusions. However, excluding patients in this way can result in uncertainty as to whether treatments are effective for anyone who suffers from the disease in question, or just for people like those who took part in the research.
A great deal of research has been conducted with drugs known as statins, which lower cholesterol levels in the blood. (A raised level of cholesterol is known to be a major risk factor for cardiovascular disease, which causes heart attacks and strokes.) As a result of this research, statins have been accepted as effective and safe. They are now, in consequence, among the most commonly prescribed medicines. Heart failure, however, is not the same thing as a heart attack. It is the name given to the condition where the muscles of the heart have become weakened, most often as a result of aging, and the heart becomes gradually less efficient at pumping blood around the body. (Some people with heart failure live for many years, but 70% of those with the condition die within ten years.) It is common for people with cardiovascular disease also to have heart failure. Nevertheless, some researchers who have studied the effects of statins have made the decision not to include in their studies any patients with cardiovascular disease who, in addition, have heart failure.
Why Was This Study Done?
The researchers in this study were aware that patients with heart failure have often been excluded from statin trials. They felt it was important to assess the available evidence supporting the prescription of statins for such patients. Specifically, they wanted to find out the following: how often have patients with heart failure been included in statin trials, what evidence is available as to whether it is beneficial for patients with heart failure to have low cholesterol, and what evidence is there that prescribing statins helps these patients?
What Did the Researchers Do and Find?
They did not do any new work involving patients. Instead, they did a very thorough search for all relevant studies of good quality that had already been published and they reviewed the results. “Randomized clinical trials” (RCTs) are the most reliable type of medical research. The researchers found there had been 47 such trials (involving over 100,000 patients) on the use of statins for treating cardiovascular disease, but all these trials had excluded heart failure patients. They found eight studies (which were not RCTs) looking at cholesterol levels and heart failure. These studies found, perhaps surprisingly, that death rates were higher in those patients with heart failure who had low cholesterol. However, they also found 18 studies (again not RCTs) on the use of statins in patients with heart failure. These 18 studies seemed to suggest that statins were of benefit to the patients who received them.
What Do These Findings Mean?
The evidence for or against prescribing statins for people with heart failure is limited, conflicting, and unclear. Further research involving RTCs is necessary. (Two such trials are known to be in progress.)
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030333.
General information about statins is available from the Web site of Patient UK
The American Heart Association Web site is a good source of information about all types of heart disease, including heart attacks and heart failure
For a definition of randomized controlled trials see Wikipedia, a free online encyclopedia that anyone can edit
More detailed information about the quality of evidence from medical research may be found in the James Lind Library
doi:10.1371/journal.pmed.0030333
PMCID: PMC1551909  PMID: 16933967
2.  Improvement of primary care for patients with chronic heart failure: A study protocol for a cluster randomised trial comparing two strategies 
Background
Many patients with chronic heart failure (CHF), a common condition with high morbidity and mortality rates, receive treatment in primary care. To improve the management of CHF in primary care, we developed an implementation programme comprised of educational and organisational components, with support by a practice visitor and focus both on drug treatment and lifestyle advice, and on organisation of care within the practice and collaboration with other healthcare providers. Tailoring has been shown to improve the success of implementation programmes, but little is known about what would be best methods for tailoring, specifically with respect to CHF in primary care.
Methods/design
We describe the study protocol of a cluster randomised controlled trial to examine the effectiveness of tailoring a CHF implementation programme to general practices compared to a standardised way of delivering a programme. The study population will consist of 60 general practitioners (GPs) and the CHF patients they include. GPs are randomised in blocks of four, stratified according to practice size. With a tailored implementation programme GPs prioritise the issues that will form the bases of the support for the practice visits. These may comprise several issues, both educational and organizational.
The primary outcome measures are patient's experience of receiving structured primary care for CHF (PACIC, a questionnaire related to the Chronic Care Model), patients' health-related utilities (EQ-5D), and drugs prescriptions using the guideline adherence index. Patients being clustered in practices, multilevel regression analyses will be used to explore the effect of practice size and type of intervention programme. In addition we will examine both changes within groups and differences at follow-up between groups with respect to drug dosages and advice on lifestyle issues. Furthermore, in interviews the feasibility of the programme and goal attainment, organisational changes in CHF care, and formalised cooperation with other disciplines will be assessed.
Discussion
In the tailoring of the programme we will present the GPs a list with barriers; GPs will assess relevance and possibility to solve these barriers. The list is rigorously developed and tested in various projects. The factors for ordering the barriers are related to the innovation, the healthcare professional, the patient, and the context.
CHF patients do not form a homogeneous group. Subgroup analyses will be performed based on the distinction between systolic CHF and CHF with preserved left ventricular function (diastolic CHF).
Trial registration
ISRCTN: ISRCTN18812755
doi:10.1186/1748-5908-6-28
PMCID: PMC3072349  PMID: 21439047
3.  Guideline Compliance in Chronic Heart Failure Patients with Multiple Comorbid Diseases: Evaluation of an Individualised Multidisciplinary Model of Care 
PLoS ONE  2014;9(4):e93129.
Objective
To assess the impact of individualised, reconciled evidence-based recommendations (IRERs) and multidisciplinary care in patients with chronic heart failure (CHF) on clinical guideline compliance for CHF and common comorbid conditions.
Design and setting
A retrospective hospital clinical audit conducted between 1st July 2006 and February 2011.
Participants
A total of 255 patients with a diagnosis of CHF who attended the Multidisciplinary Ambulatory Consulting Services (MACS) clinics, at the Royal Adelaide Hospital, were included.
Main outcome measures
Compliance with Australian clinical guideline recommendations for CHF, atrial fibrillation, diabetes mellitus and ischaemic heart disease.
Results
Study participants had a median of eight medical conditions (IQR 6–10) and were on an average of 10 (±4) unique medications. Compliance with clinical guideline recommendations for pharmacological therapy for CHF, comorbid atrial fibrillation, diabetes or ischaemic heart disease was high, ranging from 86% for lipid lowering therapy to 98% anti-platelet agents. For all conditions, compliance with lifestyle recommendations was lower than pharmacological therapy, ranging from no podiatry reviews for CHF patients with comorbid diabetes to 75% for heart failure education. Concordance with many guideline recommendations was significantly associated if the patient had IRERs determined, a greater number of recommendations, more clinic visits or if patients participated in a heart failure program.
Conclusions
Despite the high number of comorbid conditions and resulting complexity of the management, high compliance to clinical guideline recommendations was associated with IRER determination in older patients with CHF. Importantly these recommendations need to be communicated to the patient’s general practitioner, regularly monitored and adjusted at clinic visits.
doi:10.1371/journal.pone.0093129
PMCID: PMC3979669  PMID: 24714369
4.  The Effect of Dementia on Medication Use and Adherence Among Medicare Beneficiaries With Chronic Heart Failure 
Background
Alzheimer disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease.
Objective
The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF.
Methods
This 2-year (1/1/2006–12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary measure of any EBM use and medication possession ratio among users.
Results
Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001).
Conclusions
EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.
doi:10.1016/j.amjopharm.2011.11.003
PMCID: PMC3296564  PMID: 22264854
dementia; heart failure; Medicare Part D; medication adherence
5.  Self-perceived symptoms and care needs of patients with severe to very severe chronic obstructive pulmonary disease, congestive heart failure or chronic renal failure and its consequences for their closest relatives: the research protocol 
Background
Recent research shows that the prevalence of patients with very severe chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic renal failure (CRF) continues to rise over the next years. Scientific studies concerning self-perceived symptoms and care needs in patients with severe to very severe COPD, CHF and CRF are scarce.
Consequently, it will be difficult to develop an optimal patient-centred palliative care program for patients with end-stage COPD, CHF or CRF. The present study has been designed to assess the symptoms, care needs, end-of-life care treatment preferences and communication needs of patients with severe to very severe COPD, CHF or CRF. Additionally, family distress and care giving burden of relatives of these patients will be assessed.
Methods/design
A cross-sectional comparative and prospective longitudinal study in patients with end-stage COPD, CHF or CRF has been designed. Patients will be recruited by their treating physician specialist. Patients and their closest relatives will be visited at baseline and every 4 months after baseline for a period of 12 months. The following outcomes will be assessed during home visits: self-perceived symptoms and care needs; daily physical functioning; general health status; end-of-life care treatment preferences; end-of-life care communication and care-giver burden of family caregivers. Additionally, end-of-life care communication and prognosis of survival will be assessed with the physician primarily responsible for the management of the chronic organ failure. Finally, if patients decease during the study period, the baseline preferences with regard to life-sustaining treatments will be compared with the real end-of-life care.
Discussion
To date, the symptoms, care needs, caregiver burden, end-of-life care treatment preferences and communication needs of patients with very severe COPD, CHF or CRF remain unknown. The present study will increase the knowledge about the self-perceived symptoms, care-needs, caregiver burden, end-of-life care treatment preferences and communication needs from the views of patients, their loved ones and their treating physician. This knowledge is necessary to optimize palliative care for patients with COPD, CHF or CRF. Here, the design of the present study has been described. A preliminary analysis of the possible strengths, weaknesses and clinical consequences is outlined.
doi:10.1186/1472-684X-7-5
PMCID: PMC2391145  PMID: 18460203
6.  Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals 
Jama  2012;307(10):1037-1045.
Context
The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
Objective
To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.
Design, Setting, and Patients
The study population comprised adults (> 18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n=179 139), congestive heart failure (CHF) (n=92 377), hip fracture (n=90 046), or colon cancer (n=26 195) during 1998–2008, with follow-up to 1 year. The exposure measure was the index hospital’s end-of-life expenditure index for hospital, physician, and emergency department services.
Main Outcome Measures
The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.
Results
Patients’ baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89–0.98) for AMI, 0.81 (95% CI, 0.76–0.86) for CHF, 0.74 (95% CI, 0.68–0.80) for hip fracture, and 0.78 (95% CI, 0.66–0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Conclusion
Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
doi:10.1001/jama.2012.265
PMCID: PMC3339410  PMID: 22416099
7.  An Internet-Based Counseling Intervention With Email Reminders that Promotes Self-Care in Adults With Chronic Heart Failure: Randomized Controlled Trial Protocol 
JMIR Research Protocols  2014;3(1):e5.
Background
Chronic heart failure (CHF) is a public health priority. Its age-standardized prevalence has increased over the past decade. A major challenge for the management of CHF is to promote long-term adherence to self-care behaviors without overtaxing available health care resources. Counseling by multidisciplinary health care teams helps to improve adherence to self-care behaviors and to reduce the rate of death and hospitalization. In the absence of intervention, adherence to self-care is below recommended standards.
Objective
This trial aims to establish and evaluate a Canadian e-platform that will provide a core, standardized protocol of behavioral counseling and education to facilitate long-term adherence to self-care among patients with CHF.
Methods
Canadian e-Platform to Promote Behavioral Self-Management in Chronic Heart Failure (CHF-CePPORT) is a multi-site, double blind, randomized controlled trial with a 2 parallel-group (e-Counseling + Usual Care vs e-Info Control + Usual Care) by 3 assessments (baseline, 4-, and 12-month) design. We will identify subjects with New York Heart Association Class II or III systolic heart failure from collaborating CHF clinics and then recruit them (n=278) by phone. Subjects will be randomized in blocks within each site (Toronto, Montreal, and Vancouver). The primary outcome will be improved quality of life, defined as an increased number of subjects with an improvement of ≥5 points on the summary score of the Kansas City Cardiomyopathy Questionnaire. We will also assess the following secondary outcomes: (1) diet habits, depression, anxiety, smoking history, stress level, and readiness for change using self-report questionnaires, (2) physical activity level, current smoking status, and vagal-heart rate modulation by physiological tests, and (3) exercise capacity, prognostic indicators of cardiovascular functioning, and medication adherence through medical chart review. The primary outcome will be analyzed using generalized estimation equations with repeated measures on an intention-to-treat basis. Secondary outcomes will be analyzed using repeated-measures linear mixed models with a random effects intercept. All significant main effects or interactions in the statistical models will be followed up with post hoc contrasts using a Bonferroni correction with a 2-sided statistical significance criterion of P<.05.
Results
This 3.5-year, proof-of-principle trial will establish the e-infrastructure for a pan-Canadian e-platform for CHF that is comprised of a standardized, evidence-based protocol of e-Counseling.
Conclusions
CHF-CePPORT is designed to improve long-term adherence to self-care behaviors and quality of life among patients with CHF. It will demonstrate a distinct Canadian initiative to build capacity for preventive eHealth services for patients with CHF.
Trial Registration
ClinicalTrials.gov NCT01864369; http://clinicaltrials.gov/ct2/show/NCT01864369 (Archived by WebCite at http://www.webcitation.org/6Iiv6so7E).
doi:10.2196/resprot.2957
PMCID: PMC3936276  PMID: 24480783
e-counseling; chronic heart failure; lifestyle intervention; Internet-based intervention; quality of life
8.  Evaluation of a self-management programme for congestive heart failure patients: design of a randomised controlled trial 
Background
Congestive heart failure (CHF) has a substantial impact on care utilisation and quality of life. It is crucial for patients to cope with CHF adequately, if they are to live an acceptable life. Self-management may play an important role in this regard. Previous studies have shown the effectiveness of the 'Chronic Disease Self-Management Program' (CDSMP), a group-based cognitive behavioural programme for patients with various chronic conditions. However, the programme's effectiveness has not yet been studied specifically among CHF patients. This paper presents the design of a randomised controlled trial to evaluate the effects of the CDSMP on psychosocial attributes, health behaviour, quality of life, and health care utilisation of CHF patients.
Methods/Design
The programme is being evaluated in a two-group randomised controlled trial. Patients were eligible if they had been diagnosed with CHF and experienced slight to marked limitation of physical activity. They were selected from the Heart Failure and/or Cardiology Outpatient Clinics of six hospitals. Eligible patients underwent a baseline assessment and were subsequently allocated to the intervention or control group. Patients allocated to the intervention group were invited to attend the self-management programme consisting of six weekly sessions, led by a CHF nurse specialist and a CHF patient. Those allocated to the control group received care as usual. Follow-up measurements are being carried out immediately after the intervention period, and six and twelve months after the start of the intervention.
An effect evaluation and a process evaluation are being conducted. The primary outcomes of the effect evaluation are self-efficacy expectancies, perceived control, and cognitive symptom management. The secondary outcome measures are smoking and drinking behaviour, Body Mass Index (BMI), physical activity level, self-care behaviour, health-related quality of life, perceived autonomy, symptoms of anxiety and depression, and health care utilisation. The programme's feasibility is assessed by measuring compliance with the protocol, patients' attendance and adherence, and the opinions about the programme.
Discussion
A total number of 318 patients were included in the trial. At present, follow-up data are being collected. The results of the trial become clear after completion of the data collection in January 2007.
Trial Registration
Trialregister () ISRCTN88363287.
doi:10.1186/1472-6963-6-91
PMCID: PMC1569834  PMID: 16857049
9.  The experience of living with chronic heart failure: a narrative review of qualitative studies 
Background
Chronic heart failure (CHF) is the leading cause of all hospitalisations and readmissions in older people, accounting for a large proportion of developed countries' national health care expenditure. CHF can severely affect people's quality of life by reducing their independence and ability to undertake certain activities of daily living, as well as affecting their psychosocial and economic capacity. This paper reports the findings of a systematic narrative review of qualitative studies concerning people's experience of living with CHF, aiming to develop a wide-ranging understanding of what is known about the patient experience.
Methods
We searched eight relevant electronic databases using the terms based on the diagnosis of 'chronic heart failure', 'heart failure' and 'congestive heart failure' and qualitative methods, with restrictions to the years 1990-May 2008. We also used snowballing, hand searching and the expert knowledge of the research team to ensure all relevant papers were included in the review. Of 65 papers collected less than half (n = 30) were found relevant for this review. These papers were subsequently summarised and entered into QSR NVivo7 for data management and analysis.
Results
The review has identified the most prominent impacts of CHF on a person's everyday life including social isolation, living in fear and losing a sense of control. It has also identified common strategies through which patients with CHF manage their illness such as sharing experiences and burdens with others and being flexible to changing circumstances.
Finally, there are multiple factors that commonly impact on patients' self care and self-management in the disease trajectory including knowledge, understanding and health service encounters. These health service encounters encompass access, continuity and quality of care, co-morbid conditions, and personal relationships.
Conclusions
The core and sub-concepts identified within this study provide health professionals, service providers, policy makers and educators with broad insights into common elements of people's experiences of CHF and potential options for improving their health and wellbeing. Future studies should focus on building a comprehensive picture of CHF through examination of differences between genders, and differences within age groups, socioeconomic groups and cultural groups.
doi:10.1186/1472-6963-10-77
PMCID: PMC2851714  PMID: 20331904
10.  Case management for patients with chronic systolic heart failure in primary care: The HICMan exploratory randomised controlled trial 
Trials  2010;11:56.
Background
Chronic (systolic) heart failure (CHF) represents a clinical syndrome with high individual and societal burden of disease. Multifaceted interventions like case management are seen as promising ways of improving patient outcomes, but lack a robust evidence base, especially for primary care. The aim of the study was to explore the effectiveness of a new model of CHF case management conducted by doctors' assistants (DAs, equivalent to a nursing role) and supported by general practitioners (GPs).
Methods
This patient-randomised controlled trial (phase II) included 31 DAs and employing GPs from 29 small office-based practices in Germany. Patients with CHF received either case management (n = 99) consisting of telephone monitoring and home visits or usual care (n = 100) for 12 months. We obtained clinical data, health care utilisation data, and patient-reported data on generic and disease-specific quality of life (QoL, SF-36 and KCCQ), CHF self-care (EHFScBS) and on quality of care (PACIC-5A). To compare between groups at follow-up, we performed analyses of covariance and logistic regression models.
Results
Baseline measurement showed high guideline adherence to evidence-based pharmacotherapy and good patient self-care: Patients received angiotensin converting enzyme inhibitors (or angiotensin-2 receptor antagonists) in 93.8% and 95%, and betablockers in 72.2% and 84%, and received both in combination in 68% and 80% of cases respectively. EHFScBS scores (SD) were 25.4 (8.4) and 25.0 (7.1). KCCQ overall summary scores (SD) were 65.4 (22.6) and 64.7 (22.7). We found low hospital admission and mortality rates. EHFScBS scores (-3.6 [-5.7;-1.6]) and PACIC and 5A scores (both 0.5, [0.3;0.7/0.8]) improved in favour of CM but QoL scores showed no significant group differences (Physical/Mental SF-36 summary scores/KCCQ-os [95%CI]: -0.3 [-3.0;2.5]/-0.1 [-3.4;3.1]/1.7 [-3.0;6.4]).
Conclusions
In this sample, with little room for improvement regarding evidence-based pharmacotherapy and CHF self-care, case management showed no improved health outcomes or health care utilisation. However, case management significantly improved performance and key intermediate outcomes. Our study provides evidence for the feasibility of the case management model.
Trial registration number
ISRCTN30822978
doi:10.1186/1745-6215-11-56
PMCID: PMC2882359  PMID: 20478035
11.  Patient Preferences and Willingness-To-Pay for a Home or Clinic Based Program of Chronic Heart Failure Management: Findings from the Which? Trial 
PLoS ONE  2013;8(3):e58347.
Background
Beyond examining their overall cost-effectiveness and mechanisms of effect, it is important to understand patient preferences for the delivery of different modes of chronic heart failure management programs (CHF-MPs). We elicited patient preferences around the characteristics and willingness-to-pay (WTP) for a clinic or home-based CHF-MP.
Methodology/Principal Findings
A Discrete Choice Experiment was completed by a sub-set of patients (n = 91) enrolled in the WHICH? trial comparing home versus clinic-based CHF-MP. Participants provided 5 choices between hypothetical clinic and home-based programs varying by frequency of nurse consultations, nurse continuity, patient costs, and availability of telephone or education support. Participants (aged 71±13 yrs, 72.5% male, 25.3% NYHA class III/IV) displayed two distinct preference classes. A latent class model of the choice data indicated 56% of participants preferred clinic delivery, access to group CHF education classes, and lower cost programs (p<0.05). The remainder preferred home-based CHF-MPs, monthly rather than weekly visits, and access to a phone advice service (p<0.05). Continuity of nurse contact was consistently important. No significant association was observed between program preference and participant allocation in the parent trial. WTP was estimated from the model and a dichotomous bidding technique. For those preferring clinic, estimated WTP was ≈AU$9-20 per visit; however for those preferring home-based programs, WTP varied widely (AU$15-105).
Conclusions/Significance
Patient preferences for CHF-MPs were dichotomised between a home-based model which is more likely to suit older patients, those who live alone, and those with a lower household income; and a clinic-based model which is more likely to suit those who are more socially active and wealthier. To optimise the delivery of CHF-MPs, health care services should consider their patients’ preferences when designing CHF-MPs.
doi:10.1371/journal.pone.0058347
PMCID: PMC3591337  PMID: 23505491
12.  Prescribing Data in General Practice Demonstration (PDGPD) project - a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension 
Background
Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner’s drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.
Methods
A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a “control” for the other two groups.
De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.
Discussion
This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.
doi:10.1186/1472-6963-12-273
PMCID: PMC3515472  PMID: 22913571
13.  Improvement of primary care for patients with chronic heart failure: a pilot study 
Background
Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.
Methods
An observational study was performed in 19 general practices in the south-eastern part of the Netherlands, evaluation involving 15 general practitioners and 77 CHF patients. The programme for improvement comprised educational and organizational components and was delivered by a trained practice visitor to the practices. The evaluation was based on case registration forms completed by health professionals and telephone interviews.
Results
Management relating to diet and physical exercise seemed to have improved as eight patients were referred to dieticians and five to physiotherapists. The seasonal influenza vaccination rate increased from 94% to 97% (75/77). No impact on smoking was observed. Pharmaceutical treatment was adjusted according to guideline recommendations in 12% of the patients (9/77); 7 patients started recommended medication and 2 patients received dosage adjustments. General practitioners perceived the programme to be feasible. Clinical task delegation to nurses and assistants increased in some practices, but collaboration with other healthcare providers remained limited.
Conclusions
The improvement programme proved to have moderate impact on patient care. Its effectiveness should be tested in a larger rigorous evaluation study using modifications based on the pilot experiences.
doi:10.1186/1472-6963-10-8
PMCID: PMC2820039  PMID: 20064198
14.  A story of maladies, misconceptions and mishaps: effective management of heart failure 
Social science & medicine (1982)  2004;58(3):631-643.
Congestive heart failure (CHF) is a common chronic disease with effective therapy, yet interventions to improve outcomes have met with limited success. Though problems in self-management are suspected causes for deterioration, few efforts have been made to understand how self-management could be improved to enhance the lives of affected patients. We conducted semi-structured interviews of 19 patients with CHF treated at an urban United States hospital to elucidate their knowledge and beliefs about CHF and to understand what underlies their self-care routines. A comparison of the themes generated from these interviews with the common-sense model for self-management of illness threats, clarifies how patients’ perceptions and understanding of CHF affected their behaviors. Patients had an acute model of CHF. They did not connect chronic symptoms with a chronic disease, CHF, and did not recognize that these symptoms worsened over time from their baseline of moderate, chronic distress, to a severe state that required urgent care. As a consequence, they often did not manage symptoms on a routine basis and did not, therefore, prevent or minimize exacerbations. When they worsened, many patients reported barriers to reaching their physicians and most reported seeking care primarily in an emergency room.
These in depth responses elucidate how the interplay between acute and chronic models of a chronic illness effect self-management behaviors. These factors play a previously not understood role in patient’s efforts to understand and manage the ever-present but symptomatically variable chronic illness that is CHF. These new concepts illustrate the tools that may be needed to effectively manage this serious and disabling illness, and suggest possible ways to enhance the self-management process and ultimately improve patients’ lives.
PMCID: PMC4301306  PMID: 14652059
Heart failure; Self-management; Patient beliefs
15.  Protective roles of erythropoiesis-stimulating proteins in chronic heart failure with anemia 
Anemia is a common comorbidity in patients with chronic heart failure (CHF) and is frequently treated with erythropoiesis-stimulating proteins (ESPs). Previous studies, however, have been relatively short in duration and have not provided conclusive data on the safety or clinical efficacy of ESP treatment. The aim of this study was to explore the safety and therapeutic effects of ESPs in patients with anemia and CHF. A systematic literature search in EMBASE and MEDLINE from their inception to July 2013 was performed, and clinical studies that evaluated the effects of ESPs among patients with CHF were identified. Randomized clinical trials comparing the effects of ESP treatment with those of placebo treatment or usual care regimes in anemic patients with CHF were included. Nine randomized, controlled trials were identified, comprising 750 patients with CHF and anemia receiving ESP treatment for between three months and one year. ESP treatment had a significantly lower risk of CHF hospitalization [relative risk (RR), 0.47; 95% confidence interval (CI), 0.32–0.70; P=0.0002] and a moderate reduction in mortality risk (RR, 0.68; 95% CI, 0.38–1.19; P=0.18). Treatment with ESPs in patients with symptomatic CHF and anemia resulted in significant improvements in hemoglobin, hematocrit and brain natriuretic peptide levels, as well as exercise capacity, renal function, New York Heart Association class and left ventricular ejection fraction. In conclusion, this study found that treatment with ESPs exerts beneficial effects against CHF and is not associated with a higher mortality rate or adverse effects. These outcomes support the instigation of a trial evaluating the treatment of anemia with ESPs in patients with chronic CHF.
doi:10.3892/etm.2014.1845
PMCID: PMC4113650  PMID: 25120615
anemia; chronic heart failure; erythropoiesis-stimulating proteins; hospitalization; mortality
16.  Factors related to time to admission to specialized multidisciplinary clinics in patients with congestive heart failure 
The Canadian Journal of Cardiology  2009;25(10):e347-e352.
BACKGROUND:
Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF.
OBJECTIVES:
To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics.
METHODS:
Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients.
RESULTS:
A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF.
CONCLUSION:
There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.
PMCID: PMC2782508  PMID: 19812808
Congestive heart failure; Multidisciplinary heart failure clinics; Referral
17.  Consultation with cardiologists for persons with new-onset chronic heart failure: A population-based study 
The Canadian Journal of Cardiology  2009;25(12):690-694.
BACKGROUND:
It is recommended that persons recently diagnosed with heart failure consult with a specialist in heart failure.
OBJECTIVES:
To determine whether patients who were diagnosed with new-onset chronic heart failure (CHF) by a noncardiologist consulted with a cardiologist, and identify the factors associated with delayed consultation.
METHODS:
Physician reimbursement administrative data were obtained for all adults with suspected new-onset CHF in the year 2000 in Quebec, defined operationally as a physician visit for CHF (based on the International Classification of Diseases, 9th Revision diagnostic codes), with no previous physician visit code for CHF in the preceding three years. Among those first diagnosed by a noncardiologist, Cox regression modelling was used to identify patient and physician characteristics associated with time to cardiology consultation.
RESULTS:
Of the 13,523 persons coded as having incident CHF, 54.9% consulted a cardiologist within the next 2.5 to 3.5 years, and 67.4% were seen by an internist or cardiologist. Older patients, women, and those with lower comorbidity and socioeconomic status had significantly longer times to cardiology consultation.
CONCLUSION:
The data suggest that many patients with suspected new-onset CHF do not receive prompt cardiology care, as stipulated by current recommendations. Equity of access for women and those with lower socioeconomic status appears to be problematic.
PMCID: PMC2807830  PMID: 19960128
Congestive heart failure; Health policy; Referral to cardiologists
18.  Detection of calf muscle alterations in patients with chronic heart failure by 31P magnetic resonance spectroscopy: Impaired adaptation to continuous exercise 
Previous studies suggested that alteration of systemic skeletal muscle metabolism is a major determinant of exercise tolerance in patients with chronic heart failure (CHF). The authors examined calf muscle metabolism during continuous exercise of the foot in patients with CHF compared with normal subjects using 31P magnetic resonance spectroscopy. The subjects were patients with New York Heart Association class II CHF who had previously suffered New York Heart Association class IV heart failure. Plantarflexion of the foot was repeated for 8 min 40 s at a rate of one contraction per second against a 2 kg load inside the magnet. At rest, during exercise (divided into the first one-half [EX1] and the latter one-half [EX2]) and at recovery, 31P magnetic resonance spectroscopy data sets were acquired every 4 min 20 s. At rest, the phosphocreatine to hexamethylphosphoric triamide (PCr:HMPT) and the inorganic phosphate (Pi) to PCr ratios in the CHF group were not different from those in the normal group. During EX1 in the normal group, PCr levels decreased and Pi levels increased. Although exercise continued, these changes improved during EX2, suggesting there was an adaptation to exercise. The degree of change in the PCr:HMPT ratio during EX1 in the CHF group was not significantly different from that during EX1 in the normal group; however, the improvement during EX2 in the CHF group was impaired. The Pi:PCr ratio of EX1 to EX2 in the CHF group was significantly greater than that in the normal group (0.74±0.22 versus 0.19±0.05, respectively, P<0.005). Thus, in CHF, adaptation to continuous exercise may be impaired by alteration of skeletal muscle metabolism and this alteration may worsen exercise capacity.
PMCID: PMC2716221  PMID: 19641660
Calf muscle; Exercise tolerance; Heart failure; 31P magnetic resonance spectroscopy
19.  The role of nurses in the management of heart failure 
Heart  2005;91(Suppl 2):ii39-ii42.
Care provided by specialist nurses has been shown to improve outcomes for patients with chronic heart failure (CHF), significantly reducing the number of unplanned readmissions, length of hospital stay, hospital costs, and mortality. Most patients develop CHF as a result of coronary artery disease. Once cardiac damage has occurred, the risk of developing heart failure can be reduced by providing appropriate treatment at appropriate dosages. While cardiac rehabilitation clinics provide an opportunity to check drug usage, their prime focus is on optimising patients' physical well being following a heart attack. In addition, evidence suggests that general practitioners are frequently reluctant to initiate appropriate treatments and to up-titrate drug dosages even for patients with diagnosed heart failure. Therefore, to ensure that these patients are not left on starting doses of medications many hospitals are now setting up nurse led post-myocardial infarction (MI) clinics. The Omada programme is a secondary care based, nurse led model of care set up in 1999 to improve the management of CHF by providing appropriate patient education within a nurse led clinic setting, optimising evidence based medication and fostering partnership between health professionals in both primary and secondary care. The model of care is highly applicable to the post-MI setting, where it can ensure that patients receive better care at an earlier stage.
doi:10.1136/hrt.2005.062117
PMCID: PMC1876347  PMID: 15831611
20.  Cardiac Resynchroniztion Therapy In Heart Failure: Recent Advances And New Insights 
Newer non-pharmacological therapies for heart failure are being evaluated for patients of congestive heart failure (CHF). Mechanical support with left ventricular assist devices and heart transplantation are reserved for the minority of patients who have severely decompensated heart failure. Despite these therapeutic advances, it is generally accepted that current therapies do not adequately address the clinical need of patients with heart failure, and additional strategies are being developed. Cardiac resynchronization therapy (CRT) is a new modality that involves synchronization of ventricular contraction and has shown a lot of promise in managing symptomatic patients of CHF who are on optimal medical therapy and have interventricular conduction delay (IVCD). It has improved exercise tolerance and NYHA functional class in such patients in sinus rhythm and a recent meta-analysis has also shown mortality benefits in CHF. Recently benefits of CRT have also been observed in CHF patients who do not have wide QRS complexes on electrocardiogram (EKG). It has also been shown to benefit drug refractory angina in CHF. Recent studies have also focused on the combined use of CRT and implantable cardioverter defibrillator (ICD) and it has shown encouraging results. Our aim in this descriptive review is to define practice guidelines and to improve clinicians' knowledge of the available published clinical evidence, concentrating on few randomized controlled trials.
PMCID: PMC1502045  PMID: 16943911
21.  Medication adherence, self-care behaviour and knowledge on heart failure in urban South Africa: the Heart of Soweto study 
Background
There is a paucity of data on treatment adherence in patients with chronic heart failure (CHF) in Africa.
Methods
We examined the pattern of treatment adherence, self-care behaviour and treatment knowledge in 200 consecutive patients with CHF attending the Chris Hani Baragwanath Hospital, Soweto, South Africa via a combination of questionnaire (100%, n = 200) and pill count (41%, n = 82).
Results
Mean age was 56 ± 14 years, 157 were black African (79%) and 109 (55%) were male. CHF-specific treatment included loop diuretics (93%), beta-blockers (84%), ACE inhibitors (74%), spironolactone (64%) and cardiac glycosides (24%); mean number of medications was 6 ± 2. Overall, 71% (58 of 82) adhered to their prescribed CHF regimen and individual medication adherence ranged from 64 to 79%. Behavioural adherence varied from 2.5 to 98%. Patient treatment knowledge was poor; 56% could not name medication effects or side effects. However, an average knowledge score of 69% was achieved on 10 questions concerning CHF management.
Conclusion
As in other regions of the world, non-adherence to complex CHF treatment is a substantial problem in Soweto. Our data confirm the need for a dedicated CHF management programme to optimise CHF-related outcomes in a low-resource environment.
PMCID: PMC3721814  PMID: 20532432
medication adherence; self-care behaviour; knowledge; heart failure; Africa
22.  An intervention to promote physical activity and self-management in people with stable chronic heart failure The Home-Heart-Walk study: study protocol for a randomized controlled trial 
Trials  2011;12:63.
Background
Chronic heart failure (CHF) is a chronic debilitating condition with economic consequences, mostly because of frequent hospitalisations. Physical activity and adequate self-management capacity are important risk reduction strategies in the management of CHF. The Home-Heart-Walk is a self-monitoring intervention. This model of intervention has adapted the 6-minute walk test as a home-based activity that is self-administered and can be used for monitoring physical functional capacity in people with CHF. The aim of the Home-Heart-Walk program is to promote adherence to physical activity recommendations and improving self-management in people with CHF.
Methods/Design
A randomised controlled trial is being conducted in English speaking people with CHF in four hospitals in Sydney, Australia. Individuals diagnosed with CHF, in New York Heart Association Functional Class II or III, with a previous admission to hospital for CHF are eligible to participate. Based on a previous CHF study and a loss to follow-up of 10%, 166 participants are required to be able to detect a 12-point difference in the study primary endpoint (SF-36 physical function domain).
All enrolled participant receive an information session with a cardiovascular nurse. This information session covers key self-management components of CHF: daily weight; diet (salt reduction); medication adherence; and physical activity. Participants are randomised to either intervention or control group through the study randomisation centre after baseline questionnaires and assessment are completed. For people in the intervention group, the research nurse also explains the weekly Home-Heart-Walk protocol. All participants receive monthly phone calls from a research coordinator for six months, and outcome measures are conducted at one, three and six months. The primary outcome of the trial is the physical functioning domain of quality of life, measured by the physical functioning subscale of the Medical Outcome Study Short Form -36. Secondary outcomes include physical functional capacity measured by the standard six minute walk test, self-management capacity, health related quality of life measured by Medical Outcome Study Short Form -36 and Minnesota Living With Heart Failure Questionnaire, self-efficacy and self-care behaviour.
Discussion
A self-monitoring intervention that can improve individual's exercise self-efficacy, self-management capacity could have potential significance in improving the management of people with chronic heart failure in community settings.
Trial Registration
Australian New Zealand Clinical Trial Registry 12609000437268
doi:10.1186/1745-6215-12-63
PMCID: PMC3061924  PMID: 21366927
23.  Inverse Association of N-Terminal Pro-B-Type Natriuretic Peptide with Metabolic Syndrome in Patients with Congestive Heart Failure 
PLoS ONE  2013;8(11):e79096.
Background
Metabolic syndrome has been shown to be associated with lower levels of plasma N-terminal pro-B-type natriuretic peptide (Nt-proBNP) in the general population. We sought to elucidate the relationship between Nt-proBNP and components of metabolic syndrome in patients with congestive heart failure (CHF).
Methods
Fasting blood samples were obtained from 93 patients in our institution. Plasma levels of Nt-proBNP and other biochemical data were measured. The New York Heart Association (NYHA) classification system (I-IV) was used to define the functional capacity of CHF. Metabolic syndrome and its components were defined using diagnostic criteria from the International Diabetes Federation.
Results
Forty-nine patients (52.7%) had CHF. There was a positive correlation between plasma Nt-proBNP levels and NYHA functional capacity in CHF patients. Plasma Nt-proBNP levels increased significantly with each increasing NYHA class of the disease. The prevalence of metabolic syndrome in CHF patients was higher than that in patients without CHF. Most importantly, we found that plasma Nt-proBNP levels were lower in CHF patients with metabolic syndrome attributable to inverse relationships between plasma Nt-proBNP and body mass index (β = −0.297), plasma triglyceride (β = −0.286) and homeostasis model assessment of insulin resistance (HOMA-IR; β = −0.346). Fasting glucose to insulin ratio (FGIR, an insulin sensitivity index) was positively associated with plasma Nt-proBNP levels (β = 0.491), and was the independent predictor of plasma Nt-proBNP levels in CHF patients.
Conclusions
Plasma Nt-proBNP levels are inversely associated with metabolic syndrome in CHF patients. Reduced plasma Nt-proBNP levels in CHF patients may lead to impaired lipolysis and metabolic function, and may contribute to the development of metabolic syndrome in CHF patients.
doi:10.1371/journal.pone.0079096
PMCID: PMC3827135  PMID: 24265747
24.  Failure to consult for symptoms of heart failure in patients with a type‐D personality 
Heart  2007;93(7):814-818.
Background
Self‐management and adequate consultation behaviour are essential for the successful treatment of chronic heart failure (CHF). Patients with a type‐D personality, characterised by high social inhibition and negative affectivity, may delay medical consultation despite increased symptom levels and may be at an increased risk for adverse clinical outcomes.
Aim
To examine whether type‐D personality predicts poor self‐management and failure to consult for evident cardiac symptoms in patients with CHF.
Design/methods/patients
178 outpatients with CHF (aged ⩽80 years) completed the type‐D Personality Scale at baseline, and the Health Complaints Scale (symptoms) and European Heart Failure Self‐care Behaviour Scale (self‐management) at 2 months of follow‐up. Medical information was obtained from the patients' medical records.
Results
At follow‐up, patients with a type‐D personality experienced more cardiac symptoms (OR 6.4; 95% CI 2.5 to 16.3, p<0.001) and more often appraised these symptoms as worrisome (OR 2.9; 95% CI 1.3 to 6.6, p<0.01) compared with patients with a non‐type‐D personality. Paradoxically, patients with a type‐D personality were less likely to report these symptoms to their cardiologist/nurse, as indicated by an increased risk for inadequate consultation behaviour (OR 2.7; 95% CI 1.2 to 6.0, p<0.05), adjusting for demographics, CHF severity/aetiology, time since diagnosis and medication. Accordingly, of 61 patients with CHF who failed to consult for evident cardiac symptoms, 43% had a type‐D personality (n = 26). Of the remaining 108 patients with CHF, only 14% (n = 16) had a type‐D personality.
Conclusion
Patients with CHF with a type‐D personality display inadequate self‐management. Failure to consult for increased symptom levels may partially explain the adverse effect of type‐D personality on cardiac prognosis.
doi:10.1136/hrt.2006.102822
PMCID: PMC1994460  PMID: 17344329
25.  Neuroticism personality trait is associated with Quality of Life in patients with Chronic Heart Failure 
World Journal of Cardiology  2014;6(10):1113-1121.
AIM: To evaluate Quality of life (QoL) in chronic heart failure (CHF) in relation to Neuroticism personality trait and CHF severity.
METHODS: Thirty six consecutive, outpatients with Chronic Heart Failure (6 females and 30 males, mean age: 54 ± 12 years), with a left ventricular ejection fraction ≤ 45% at optimal medical treatment at the time of inclusion, were asked to answer the Kansas City Cardiomyopathy Questionnaire (KCCQ) for Quality of Life assessment and the NEO Five-Factor Personality Inventory for personality assessment. All patients underwent a symptom limited cardiopulmonary exercise testing on a cycle-ergometer, in order to access CHF severity. A multivariate linear regression analysis using simultaneous entry of predictors was performed to examine which of the CHF variables and of the personality variables were correlated independently to QoL scores in the two summary scales of the KCCQ, namely the Overall Summary Scale and the Clinical Summary Scale.
RESULTS: The Neuroticism personality trait score had a significant inverse correlation with the Clinical Summary Score and Overall Summary Score of the KCCQ (r = -0.621, P < 0.05 and r = -0.543, P < 0.001, respectively). KCCQ summary scales did not show significant correlations with the personality traits of Extraversion, Openness, Conscientiousness and Agreeableness. Multivariate linear regression analysis using simultaneous entry of predictors was also conducted to determine the best linear combination of statistically significant univariate predictors such as Neuroticism, VE/VCO2 slope and VO2 peak, for predicting KCCQ Clinical Summary Score. The results show Neuroticism (β = -0.37, P < 0.05), VE/VCO2 slope (β = -0.31, P < 0.05) and VO2 peak (β = 0.37, P < 0.05) to be independent predictors of QoL. In multivariate regression analysis Neuroticism (b = -0.37, P < 0.05), the slope of ventilatory equivalent for carbon dioxide output during exercise, (VE/VCO2 slope) (b = -0.31, P < 0.05) and peak oxygen uptake (VO2 peak), (b = 0.37, P < 0.05) were independent predictors of QoL (adjusted R2 = 0.64; F = 18.89, P < 0.001).
CONCLUSION: Neuroticism is independently associated with QoL in CHF. QoL in CHF is not only determined by disease severity but also by the Neuroticism personality trait.
doi:10.4330/wjc.v6.i10.1113
PMCID: PMC4209438  PMID: 25349656
Chronic heart failure; Five-Factor Personality Inventory; Kansas City Cardiomyopathy Questionnaire; Quality of Life

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