Date Published: March 27, 2018
Publisher: Public Library of Science
Author(s): Claire A. Lawson, Ivonne Solis-Trapala, Ulf Dahlstrom, Mamas Mamas, Tiny Jaarsma, Umesh T. Kadam, Anna Stromberg, Carolyn S. P. Lam
Abstract: BackgroundOptimally treated heart failure (HF) patients often have persisting symptoms and poor health-related quality of life. Comorbidities are common, but little is known about their impact on these factors, and guideline-driven HF care remains focused on cardiovascular status. The following hypotheses were tested: (i) comorbidities are associated with more severe symptoms and functional limitations and subsequently worse patient-rated health in HF, and (ii) these patterns of association differ among selected comorbidities.Methods and findingsThe Swedish Heart Failure Registry (SHFR) is a national population-based register of HF patients admitted to >85% of hospitals in Sweden or attending outpatient clinics. This study included 10,575 HF patients with patient-rated health recorded during first registration in the SHFR (1 February 2008 to 1 November 2013). An a priori health model and sequences-of-regressions analysis were used to test associations among comorbidities and patient-reported symptoms, functional limitations, and patient-rated health. Patient-rated health measures included the EuroQol–5 dimension (EQ-5D) questionnaire and the EuroQol visual analogue scale (EQ-VAS). EQ-VAS score ranges from 0 (worst health) to 100 (best health). Patient-rated health declined progressively from patients with no comorbidities (mean EQ-VAS score, 66) to patients with cardiovascular comorbidities (mean EQ-VAS score, 62) to patients with non-cardiovascular comorbidities (mean EQ-VAS score, 59). The relationships among cardiovascular comorbidities and patient-rated health were explained by their associations with anxiety or depression (atrial fibrillation, odds ratio [OR] 1.16, 95% CI 1.06 to 1.27; ischemic heart disease [IHD], OR 1.20, 95% CI 1.09 to 1.32) and with pain (IHD, OR 1.25, 95% CI 1.14 to 1.38). Associations of non-cardiovascular comorbidities with patient-rated health were explained by their associations with shortness of breath (diabetes, OR 1.17, 95% CI 1.03 to 1.32; chronic kidney disease [CKD, OR 1.23, 95% CI 1.10 to 1.38; chronic obstructive pulmonary disease [COPD], OR 95% CI 1.84, 1.62 to 2.10) and with fatigue (diabetes, OR 1.27, 95% CI 1.13 to 1.42; CKD, OR 1.24, 95% CI 1.12 to 1.38; COPD, OR 1.69, 95% CI 1.50 to 1.91). There were direct associations between all symptoms and patient-rated health, and indirect associations via functional limitations. Anxiety or depression had the strongest association with functional limitations (OR 10.03, 95% CI 5.16 to 19.50) and patient-rated health (mean difference in EQ-VAS score, −18.68, 95% CI −23.22 to −14.14). HF optimizing therapies did not influence these associations. Key limitations of the study include the cross-sectional design and unclear generalisability to other populations. Further prospective HF studies are required to test the consistency of the relationships and their implications for health.ConclusionsIdentification of distinct comorbidity health pathways in HF could provide the evidence for individualised person-centred care that targets specific comorbidities and associated symptoms.
Partial Text: Heart failure (HF) is a complex clinical syndrome of multiple symptoms, functional impairments, and poor health-related quality of life (HRQoL). With modern therapies, HF patients are now living longer but with a potentially higher symptom burden  that can be worse compared to people with other chronic diseases including cancer . Inadequate symptom control and poor HRQoL are significant drivers of hospitalisations, readmissions, and death in HF [3,4].
Our study used an a priori evidence-informed health model to investigate the potential pathways linking comorbidities with patient-reported symptoms, functional limitations, and patient-rated health in a large population-based registry of over 10,000 patients. The importance of elucidating these pathways for clinical management is the potential to improve HF prognosis by tailoring interventions to an individual patient’s risk, pathology, and health. Uniquely, by using sequences of regressions to separate out direct and indirect associations, we found that the potential pathways to HF patient health are different for cardiovascular compared to non-cardiovascular comorbidities and among specific comorbid diseases. Importantly, with minor exception, HF optimising therapies were not associated with symptoms, functional limitations, or patient-rated health. These key findings provide the evidence for a step-change in understanding and testing mechanisms between HF and overall patient-rated health and for developing precision medicine that targets specific comorbidities and associated symptoms.