Roger, Véronique L.

Background— Chronic disease can contribute to functional disability, which can degrade quality of life. However, the prevalence of functional disability and its association with outcomes among patients with heart failure requires further study. Methods and Results— Southeastern Minnesota residents with heart failure were enrolled from September 2003 through January 2012 into a cohort study with follow-up through December 2012. Difficulty with 9 activities of daily living (ADLs) was assessed by a questionnaire. Patients were divided into 3 categories of ADL difficulty (no/minimal, moderate, severe). The associations of ADL difficulty with mortality and hospitalization were assessed using Cox and Andersen-Gill models. Among 1128 patients (mean age, 74.7 years; 49.2% female), a majority (59.4%) reported difficulty with one or more ADLs at enrollment, with 272 (24.1%) and 146 (12.9%) experiencing moderate and severe difficulty, respectively. After a mean (SD) follow-up of 3.2 (2.4) years, 614 patients (54.4%) had died. Mortality increased with increasing ADL difficulty; the hazard ratio (95% confidence interval) for death was 1.49 (1.22–1.82) and 2.26 (1.79–2.86) for those with moderate and severe difficulty, respectively, compared to those with no/minimal difficulty ( P trend <0.001). Patients with moderate and severe difficulty were at an increased risk for all-cause and noncardiovascular hospitalization. In a second assessment, 17.7% of survivors reported more difficulty with ADLs and patients with persistently severe or worsening difficulty were at an increased risk for death (hazard ratio, 2.10; 95% confidence interval, 1.71–2.58; P <0.001) and hospitalization (hazard ratio, 1.51; 95% confidence interval, 1.31–1.74; P <0.001). Conclusions— Functional disability is common in patients with heart failure, can progress over time, and is associated with adverse prognosis.

Background— The prevalence and clinical significance of right ventricular (RV) systolic dysfunction (RVD) in patients with heart failure and preserved ejection fraction (HFpEF) are not well characterized. Methods and Results— Consecutive, prospectively identified HFpEF (Framingham HF criteria, ejection fraction ≥50%) patients (n=562) from Olmsted County, Minnesota, underwent echocardiography at HF diagnosis and follow-up for cause-specific mortality and HF hospitalization. RV function was categorized by tertiles of tricuspid annular plane systolic excursion and by semiquantitative (normal, mild RVD, or moderate to severe RVD) 2-dimensional assessment. Whether RVD was defined by semiquantitative assessment or tricuspid annular plane systolic excursion ≤15 mm, HFpEF patients with RVD were more likely to have atrial fibrillation, pacemakers, and chronic diuretic therapy. At echocardiography, patients with RVD had slightly lower left ventricular ejection fraction, worse diastolic dysfunction, lower blood pressure and cardiac output, higher pulmonary artery systolic pressure, and more severe RV enlargement and tricuspid valve regurgitation. After adjustment for age, sex, pulmonary artery systolic pressure, and comorbidities, the presence of any RVD by semiquantitative assessment was associated with higher all-cause (hazard ratio=1.35; 95% confidence interval, 1.03–1.77; P =0.03) and cardiovascular (hazard ratio=1.85; 95% confidence interval, 1.20–2.80; P =0.006) mortality and higher first (hazard ratio=1.99; 95% confidence interval, 1.35–2.90; P =0.0006) and multiple (hazard ratio=1.81; 95% confidence interval, 1.18–2.78; P =0.007) HF hospitalization rates. RVD defined by tricuspid annular plane systolic excursion values showed similar but weaker associations with mortality and HF hospitalizations. Conclusions— In the community, RVD is common in HFpEF patients, is associated with clinical and echocardiographic evidence of more advanced HF, and is predictive of poorer outcomes.

Background: To assess whether the individual housing-based socioeconomic status (SES) measure termed HOUSES was associated with post-myocardial infarction (MI) mortality. Methods: The study was designed as a population-based cohort study, which compared post-MI mortality among Olmsted County, Minnesota, USA, residents with different SES as measured by HOUSES using Cox proportional hazards models. Subjects’ addresses at index date of MI were geocoded to real property data to formulate HOUSES (a z-score for housing value, square footage, and numbers of bedrooms and bathrooms). Educational levels were used as a comparison for the HOUSES index. Results: 637 of the 696 eligible patients with MI (92%) were successfully geocoded to real property data. Post-MI survival rates were 60% (50–72), 78% (71–85), 72% (60–87), and 87% (81–93) at 2 years for patients in the first (the lowest SES), second, third, and fourth quartiles of HOUSES, respectively (p < 0.001). HOUSES was associated with post-MI all-cause mortality, controlling for all variables except age and comorbidity (p = 0.036) but was not significant after adjusting for age and comorbidity (p = 0.24). Conclusions: Although HOUSES is associated with post-MI mortality, the differential mortality rates by HOUSES were primarily accounted for by age and comorbid conditions. HOUSES may be useful for health disparities research concerning cardiovascular outcomes, especially in overcoming the paucity of conventional SES measures in commonly used datasets.

Background Heart failure ( HF ) patients experience impaired functional status, diminished quality of life, high utilization of healthcare resources, and poor survival. Yet, the identification of patient‐centered factors that influence prognosis is lacking. Methods and Results We determined the association of 2 measures of self‐rated health with healthcare utilization and skilled nursing facility ( SNF ) admission in a community cohort of 417 HF patients prospectively enrolled between October 2007 and December 2010 from Olmsted County, MN . Patients completed a 12‐item Short Form Health Survey ( SF ‐12). Low self‐reported physical functioning was defined as a score ≤25 on the SF ‐12 physical component. The first question of the SF ‐12 was used as a measure of self‐rated general health. After 2 years, 1033 hospitalizations, 1407 emergency department ( ED ) visits, and 19,780 outpatient office visits were observed; 87 patients were admitted to a SNF . After adjustment for confounding factors, an increased risk of hospitalizations (1.52 [1.17 to 1.99]) and ED visits (1.48 [1.04 to 2.11]) was observed for those with low versus moderate‐high self‐reported physical functioning. Patients with poor and fair self‐rated general health also experienced an increased risk of hospitalizations (poor: 1.73 [1.29 to 2.32]; fair: 1.46 [1.14 to 1.87]) and ED visits (poor: 1.73 [1.16 to 2.56]; fair: 1.48 [1.13 to 1.93]) compared with good‐excellent self‐rated general health. No association between self‐reported physical functioning or self‐rated general health with outpatient visits and SNF admission was observed. Conclusion In community HF patients, self‐reported measures of physical functioning predict hospitalizations and ED visits, indicating that these patient‐reported measures may be useful in risk stratification and management in HF .

ObjectiveTo review the evidence on and estimate the risk of myocardial infarction and stroke in bipolar disorder.MethodA systematic search using MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and bibliographies (1946 – May, 2013) was conducted. Case‐control and cohort studies of bipolar disorder patients age 15 or older with myocardial infarction or stroke as outcomes were included. Two independent reviewers extracted data and assessed quality. Estimates of effect were summarized using random‐effects meta‐analysis.ResultsFive cohort studies including 13 115 911 participants (27 092 bipolar) were included. Due to the use of registers, different statistical methods, and inconsistent adjustment for confounders, there was significant methodological heterogeneity among studies. The exploratory meta‐analysis yielded no evidence for a significant increase in the risk of myocardial infarction: [relative risk (RR): 1.09, 95% CI 0.96–1.24, P = 0.20; I2 = 6%]. While there was evidence of significant study heterogeneity, the risk of stroke in bipolar disorder was significantly increased (RR 1.74, 95% CI 1.29–2.35; P = 0.0003; I2 = 83%).ConclusionThere may be a differential risk of myocardial infarction and stroke in patients with bipolar disorder. Confidence in these pooled estimates was limited by the small number of studies, significant heterogeneity and dissimilar methodological features.

Background— Little is known about the resuscitation preferences of patients with heart failure, how they may change over the course of the disease, and their association with mortality. Methods and Results— We enrolled consecutive Southeastern Minnesota residents with heart failure from October 2007 through September 2011 into a longitudinal study. Information on resuscitation preferences (Full Code or do-not-resuscitate [DNR]) was obtained from medical records through April 1, 2013. Of 608 patients enrolled, 237 died during follow-up. At enrollment, most patients (73.4%) were Full Code, whereas at death, most (78.5%) were DNR. The independent predictors of DNR status at enrollment were advanced age, chronic obstructive pulmonary disease, previous malignancy, and decreased mobility. Patients who were DNR were at increased risk of death (unadjusted hazard ratio, 2.03; 95% confidence interval, 1.48–2.73; P <0.001), but this risk did not persist after adjusting for age, comorbidity, and self-perceived general health (hazard ratio, 0.97; 95% confidence interval, 0.74–1.30; P =0.83). Of 481 patients who were Full Code during follow-up, 22 (4.6%) received cardiopulmonary resuscitation for an in-hospital cardiac arrest. Eight patients survived to hospital discharge; only 2 (9.1% of those receiving cardiopulmonary resuscitation) made a complete recovery and returned home. The median time from a final decision to be DNR until death was only 37 (7,70) days. Conclusions— The resuscitation preferences of patients with heart failure seem to be driven by the decline in clinical status that often accompanies advanced age and multimorbidity. Furthermore, these data suggest that electing DNR status does not independently affect a patient’s risk of death.

Heart failure (HF) has been singled out as an epidemic and is a staggering clinical and public health problem, associated with significant mortality, morbidity, and healthcare expenditures, particularly among those aged ≥65 years. The case mix of HF is changing over time with a growing proportion of cases presenting with preserved ejection fraction for which there is no specific treatment. Despite progress in reducing HF-related mortality, hospitalizations for HF remain frequent and rates of readmissions continue to rise. To prevent hospitalizations, a comprehensive characterization of predictors of readmission in patients with HF is imperative and must integrate the impact of multimorbidity related to coexisting conditions. New models of patient-centered care that draw on community-based resources to support HF patients with complex coexisting conditions are needed to decrease hospitalizations.