Medical Therapy and Monitoring in Adult Congenital Heart Disease Heart Failure.

Heart failure (HF) in adult congenital heart disease (ACHD) is an increasingly common problem facing ACHD and advanced heart disease and transplant providers. Patients are highly nuanced, and therapies are poorly studied. Standard HF medications are often used in patients who are not targets of large clinical trials. HF management in this data-free zone requires focused, comprehensive team-based care and close follow-up and communication with patients.

Nonplatelet thromboxane generation is associated with impaired cardiovascular performance and mortality in heart failure.

Nonplatelet thromboxane generation, stimulated largely by oxidative stress, is a novel mortality risk factor in individuals with coronary artery disease. Though inversely associated with left ventricular ejection fraction (LVEF), a potential role in the pathobiology of heart failure (HF) remains poorly defined. Nonplatelet thromboxane generation and oxidative stress were assessed by measuring urine thromboxane-B2 metabolites (TXB2-M) and 8-isoPGF2α by ELISA in 105 subjects taking aspirin and undergoing right heart catheterization for evaluation of HF, valve disease, or after transplantation. Multivariable logistic regression and survival analyses were used to define associations of TXB2-M to invasive measures of cardiovascular performance and 4-year clinical outcomes. TXB2-M was elevated (>1,500 pg/mg creatinine) in 46% of subjects and correlated with HF severity by New York Heart Association (NYHA) functional class and brain natriuretic peptide level, modestly with LVEF, but not with HF etiology. There was no association of oxidative stress to HF type or etiology but a trend with NYHA functional class. Multiple invasive hemodynamic parameters independently associated with TXB2-M after adjustment for oxidative stress, age, sex, and race with pulmonary effective arterial elastance (Ea pulmonary), reflective of right ventricular afterload, being the most robust on hierarchical analysis. Similar to Ea pulmonary, elevated urinary TXB2-M is associated with increased risk of death (adjusted HR = 2.15, P = 0.037) and a combination of death, transplant, or mechanical support initiation (adjusted HR = 2.0, P = 0.042). Nonplatelet TXA2 thromboxane generation is independently associated with HF severity reflected by invasive measures of cardiovascular performance, particularly right ventricular afterload, and independently predicted long-term mortality risk.NEW & NOTEWORTHY Nonplatelet thromboxane generation in heart failure is independently associated with risk of death, transplant, or need for mechanical support. Measurement of urine thromboxane metabolites using a clinically available assay may be a useful surrogate for invasive measurement of cardiovascular hemodynamics and performance that could provide prognostic information and facilitate tailoring of therapy in patients with heart failure. Inhibiting thromboxane generation or its biological effects is a potential strategy for improving cardiovascular performance and outcomes in heart failure.

Contrast Ultrasound Assessment of Skeletal Muscle Recruitable Perfusion after Permanent Left Ventricular Assist Device Implantation: Implications for Functional Recovery.

BACKGROUND: In heart failure with reduced ejection fraction (HFrEF), abnormal regulation of skeletal muscle perfusion contributes to reduced exercise tolerance. The aim of this study was to test the hypothesis that improvement in functional status after permanent left ventricular assist device (LVAD) implantation in patients with HFrEF is related to improvement in muscle perfusion during work, which was measured using contrast-enhanced ultrasound (CEUS). METHODS: CEUS perfusion imaging of calf muscle at rest and during low-intensity plantar flexion exercise (20 W, 0.2 Hz) was performed in patients with HFrEF (n = 22) at baseline and 3 months after placement of permanent LVADs. Parametric analysis of CEUS data was used to quantify muscle microvascular blood flow (MBF), blood volume index, and red blood cell flux rate. For subjects alive at 3 months, comparisons were made between those with New York Heart Association functional class I or II (n = 13) versus III or IV (n = 7) status after LVAD. Subjects were followed for a median of 5.7 years for mortality. RESULTS: Echocardiographic data before and after LVAD placement and LVAD parameters were similar in subjects classified with New York Heart Association functional class I-II versus functional class III-IV after LVAD. Skeletal muscle MBF at rest and during exercise before LVAD implantation was also similar between groups. After LVAD placement, resting MBF remained similar between groups, but during exercise those with New York Heart Association functional class I or II had greater exercise MBF (111 ± 60 vs 52 ± 38 intensity units/sec, P = .03), MBF reserve (median, 4.45 [3.95 to 6.80] vs 2.22 [0.98 to 3.80]; P = .02), and percentage change in exercise MBF (median, 73% [-28% to 83%] vs -45% [-80% to 26%]; P = .03). During exercise, increases in MBF were attributable to faster microvascular flux rate, with little change in blood volume index, indicating impaired exercise-mediated microvascular recruitment. The only clinical or echocardiographic feature that correlated with post-LVAD exercise MBF was a history of diabetes mellitus. There was a trend toward better survival in patients who demonstrated improvement in muscle exercise MBF after LVAD placement (P = .05). CONCLUSIONS: CEUS perfusion imaging can quantify peripheral vascular responses to advanced therapies for HFrEF. After LVAD implantation, improvement in functional class is seen in patients with improvements in skeletal muscle exercise perfusion and flux rate, implicating a change in vasoactive substances that control resistance arteriolar tone.

Longitudinal Effects of Left Ventricular Assist Device Implantation on Global and Domain-Specific Cognitive Function.

BACKGROUND: Left ventricular assist devices (LVADs) are a common treatment of advanced heart failure, but cognitive dysfunction, which is common in heart failure, could limit the ability to perform postimplantation LVAD care. Implantation of an LVAD has been associated with improved cerebral perfusion and may improve cognitive function post implantation. OBJECTIVE: The aim of this study was to quantify longitudinal change in cognitive function after LVAD implantation. METHODS: A secondary analysis of data on 101 adults was completed to evaluate cognitive function before implantation and again at 1, 3, and 6 months post implantation of an LVAD. Latent growth curve modeling was conducted to characterize change over time. Serial versions of the Montreal Cognitive Assessment were used to measure overall (total) cognitive function and function in 6 cognitive domains. RESULT: There was moderate, nonlinear improvement from preimplantation to 6 months post implantation in Montreal Cognitive Assessment total score (Hedges' g = 0.50) and in short-term memory (Hedges' g = 0.64). There also were small, nonlinear improvements in visuospatial ability, executive function, and attention from preimplantation to 6 months post implantation (Hedges' g = 0.20-0.28). The greatest improvements were observed in the first 3 months after implantation and were followed by smaller, sustained improvements or no additional significant change. CONCLUSIONS: Implantation of an LVAD is associated with significant, nonlinear improvement in short-term memory and global cognitive function, with the most significant improvements occurring in the first 3 months after implantation. Clinicians should anticipate improvements in cognitive function after LVAD implantation and modify postimplantation education to maximize effectiveness of LVAD self-care.

Exploring gender differences in trajectories of clinical markers and symptoms after left ventricular assist device implantation.

AIMS: Despite well-known gender differences in heart failure, it is unknown if clinical markers and symptoms differ between women and men after left ventricular assist device (LVAD) implantation. Our aim was to examine gender differences in trajectories of clinical markers (echocardiographic markers and plasma biomarkers) and symptoms from pre- to post-LVAD implantation. METHODS AND RESULTS: This was a secondary analysis of data collected from a study of patients from pre- to 1, 3, and 6 months post-LVAD implantation. Data were collected on left ventricular internal end-diastolic diameter (LVIDd) and ejection fraction (LVEF), plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), and soluble suppressor of tumorigenicity (sST2). Physical and depressive symptoms were measured using the Heart Failure Somatic Perception Scale and Patient Health Questionnaire-9, respectively. Latent growth curve modelling was used to compare trajectories between women and men. The average age of the sample (n = 98) was 53.3 ± 13.8 years, and most were male (80.6%) and had non-ischaemic aetiology (65.3%). Pre-implantation, women had significantly narrower LVIDd (P < 0.001) and worse physical symptoms (P = 0.041) compared with men. Between pre- and 6 months post-implantation, women had an increase in plasma sST2 followed by a decrease, whereas men had an overall decrease (slope: P = 0.014; quadratic: P = 0.011). Between 1 and 6 months post-implantation, women had a significantly greater increase in LVEF (P = 0.045) but lesser decline in plasmoa NT-proBNP compared with men (P = 0.025). CONCLUSION: Trajectories of clinical markers differed somewhat between women and men, but trajectories of symptoms were similar, indicating some physiologic but not symptomatic gender differences in response to LVAD.

Ambient-pressure endstation of the Versatile Soft X-ray (VerSoX) beamline at Diamond Light Source.

The ambient-pressure endstation and branchline of the Versatile Soft X-ray (VerSoX) beamline B07 at Diamond Light Source serves a very diverse user community studying heterogeneous catalysts, pharmaceuticals and biomaterials under realistic conditions, liquids and ices, and novel electronic, photonic and battery materials. The instrument facilitates studies of the near-surface chemical composition, electronic and geometric structure of a variety of samples using X-ray photoelectron spectroscopy (XPS) and near-edge X-ray absorption fine-structure (NEXAFS) spectroscopy in the photon energy range from 170 eV to 2800 eV. The beamline provides a resolving power hν/Δ(hν) > 5000 at a photon flux > 1010 photons s-1 over most of its energy range. By operating the optical elements in a low-pressure oxygen atmosphere, carbon contamination can be almost completely eliminated, which makes the beamline particularly suitable for carbon K-edge NEXAFS. The endstation can be operated at pressures up to 100 mbar, whereby XPS can be routinely performed up to 30 mbar. A selection of typical data demonstrates the capability of the instrument to analyse details of the surface composition of solid samples under ambient-pressure conditions using XPS and NEXAFS. In addition, it offers a convenient way of analysing the gas phase through X-ray absorption spectroscopy. Short XPS spectra can be measured at a time scale of tens of seconds. The shortest data acquisition times for NEXAFS are around 0.5 s per data point.

Cross-classification of physical and affective symptom clusters and 180-day event-free survival in moderate to advanced heart failure.

BACKGROUND: The relationship between physical and affective symptom clusters in heart failure (HF) is unclear. OBJECTIVES: To identify associations between physical and affective symptom clusters in HF and to quantify outcomes and determinants of symptom subgroups. METHODS: This was a secondary analysis of data from two cohort studies among adults with HF. Physical and affective symptom clusters were compared using cross-classification modeling. Cox proportional hazards modeling and multinomial logistic regression were used to identify outcomes and determinants of symptom subgroups, respectively. RESULTS: In this young, mostly male sample (n = 274), physical and affective symptom clusters were cross-classified in a model with acceptable fit. Three symptom subgroups were identified: congruent-mild (69.3%), incongruent (13.9%), and congruent-severe (16.8%). Compared to the congruent-mild symptom group, the incongruent symptom group had significantly worse 180-day event-free survival. CONCLUSION: Congruence between physical and affective symptom clusters should be considered when identifying patients at higher risk for poor outcomes.

Hemostatic complications associated with ventricular assist devices.

Hemostatic complications are common in patients with ventricular assist devices. The pathophysiologic mechanisms that lead to dysregulated hemostasis involve complex interactions between device surface, sheer stress, and blood flow. These factors lead to various manifestations that require a thorough understanding of the interplay among platelets, coagulation factors, and red cells. In this article, we review the pathophysiology of hematologic complications (bleeding, acquired von Willebrand disease, heparin-induced thrombocytopenia, hemolysis, stroke and pump thrombosis), the clinical manifestations, and the management of each. We summarize the evidence available for management of these entities and provide a pragmatic clinical review.

The role of estrogen, immune function and aging in heart transplant outcomes.

BACKGROUND: Aging and loss of estrogen suppress immune function, potentially improving survival after orthotopic heart transplant (OHT). The effect of female aging on OHT outcomes is unknown. METHODS: Between 1995 and 2015, 41,299 adult OHT recipients (24.3% women) were studied using a retrospective multi-institutional cohort. Patients were stratified by age and gender into premenopausal (18-39 years), perimenopausal (40-49 years), and postmenopausal (≥50 years) groups. Kaplan-Meier survival analyses and risk-adjusted models examined gender differences across groups at one, five, and ten years. RESULTS: Kaplan-Meier survival was equivalent for postmenopausal women and men, and lower for premenopausal women than men at all time points (p ≤ 0.05). Postmenopausal women had higher risk-adjusted five-year survival than premenopausal women (AOR 1.61, 95% CI 1.15-2.25, p = 0.006). CONCLUSIONS: Premenopausal women have lower unadjusted survival than men after OHT. Post-menopausal women have significantly better five-year survival than pre-menopausal women. Menopause may contribute to improved survival after OHT.

Sympathetic Markers are Different Between Clinical Responders and Nonresponders After Left Ventricular Assist Device Implantation.

BACKGROUND: Clinical response to left ventricular assist devices (LVADs), as measured by health-related quality of life, varies among patients after implantation; however, it is unknown which pathophysiological mechanisms underlie differences in clinical response by health-related quality of life. OBJECTIVE: The purpose of this study was to compare changes in sympathetic markers (ß-adrenergic receptor kinase-1 [ßARK1], norepinephrine [NE], and 3,4-dihydroxyphenylglycol [DHPG]) between health-related quality of life clinical responders and nonresponders from pre- to post-LVAD implantation. METHODS: We performed a secondary analysis on a subset of data from a cohort study of patients from pre- to 1, 3, and 6 months after LVAD implantation. Clinical response was defined as an increase of 5 points or higher on the Kansas City Cardiomyopathy Questionnaire Clinical Summary score from pre- to 6 months post-LVAD implantation. We measured plasma ßARK1 level with an enzyme-linked immunosorbent assay and plasma NE and DHPG levels with high-performance liquid chromatography with electrochemical detection. Latent growth curve modeling was used to compare the trajectories of markers between groups. RESULTS: The mean (SD) age of the sample (n = 39) was 52.9 (13.2) years, and most were male (74.4%) and received LVADs as bridge to transplantation (69.2%). Preimplantation plasma ßARK1 levels were significantly higher in clinical responders (n = 19) than in nonresponders (n = 20) (P = .001), but change was similar after LVAD (P = .235). Preimplantation plasma DHPG levels were significantly lower in clinical responders than in nonresponders (P = .002), but the change was similar after LVAD (P = .881). There were no significant differences in plasma NE levels. CONCLUSIONS: Preimplantation ßARK1 and DHPG levels are differentiating factors between health-related quality of life clinical responders and nonresponders to LVAD, potentially signaling differing levels of sympathetic stimulation underlying clinical response.

HCMV trimer- and pentamer-specific antibodies synergize for virus neutralization but do not correlate with congenital transmission.

Human cytomegalovirus (HCMV) causes substantial disease in transplant patients and harms the development of the nervous system in babies infected in utero. Thus, there is a major focus on developing safe and effective HCMV vaccines. Evidence has been presented that a major target of neutralizing antibodies (NAbs) is the HCMV pentamer glycoprotein gH/gL/UL128-131. In some studies, most of the NAbs in animal or human sera were found to recognize the pentamer, which mediates HCMV entry into endothelial and epithelial cells. It was also reported that pentamer-specific antibodies correlate with protection against transmission from mothers to babies. One problem with the studies on pentamer-specific NAbs to date has been that the studies did not compare the pentamer to the other major form of gH/gL, the gH/gL/gO trimer, which is essential for entry into all cell types. Here, we demonstrate that both trimer and pentamer NAbs are frequently found in human transplant patients' and pregnant mothers' sera. Depletion of human sera with trimer caused reductions in NAbs similar to that observed following depletion with the pentamer. The trimer- and pentamer-specific antibodies acted in a synergistic fashion to neutralize HCMV and also to prevent virus cell-to-cell spread. Importantly, there was no correlation between the titers of trimer- and pentamer-specific NAbs and transmission of HCMV from mothers to babies. Therefore, both the trimer and pentamer are important targets of NAbs. Nevertheless, these antibodies do not protect against transmission of HCMV from mothers to babies.

Device-detected congestion is associated with worse patient-reported outcomes in heart failure.

BACKGROUND: Congestion is a common cause of symptoms in heart failure (HF). Yet, intrathoracic impedance, an objective marker of cardiopulmonary congestion, has not been examined in relation to HF symptoms. OBJECTIVE: To determine whether device-detected cardiopulmonary congestion is a predictor of physical and psychological symptoms and health-related quality of life (HRQOL) in adults with HF over 3 months. METHODS: Multivariate generalized linear modeling was used to quantify the association of cardiopulmonary congestion (Optivol® Index exceeding 60 Ω threshold) with HRQOL (12-item Kansas City Cardiomyopathy Questionnaire) and both physical symptoms (Functional Assessment of Chronic Illness Therapy-Fatigue Scale; HF Somatic Perception Scale Dyspnea and Early & Subtle Symptoms subscales) and affective symptoms (9-item Patient Health Questionnaire; 6-item Patient-Reported Outcomes Measurement Information System Anxiety Scale). RESULTS: The mean age of the sample (n = 49) was 62years old, 39% were women, and 63% had NYHA class III/IV HF. Participants who experienced threshold crossings in the previous 90days reported on average, 130% higher dyspnea (p = 0.017; confidence interval (CI) 10.2%, 437%), 40% higher early & subtle symptoms (p = 0.029; CI 3.4%, 89.7%), 106% higher depressive symptoms (p = 0.003; CI 19.1%, 257%) and 40% higher anxiety (p = 0.028; CI 3.7%, 89.1%). Threshold crossings in the previous 90days were also significantly associated with a clinically meaningful decrease in HRQOL (ß = -16.16 ±â€¯6.32; p = 0.01). CONCLUSIONS: Intrathoracic impedance measured with the Optivol Index can provide additional information regarding the patient experience of hallmark physical and psychological HF symptoms and HRQOL over 3months.

Heart Failure Symptom Biology in Response to Ventricular Assist Device Implantation.

BACKGROUND: We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF), particularly in response to left ventricular assist device (LVAD) implantation. OBJECTIVE: The aim of this study was to quantify the degree to which symptoms and biomarkers change in parallel from before implantation through the first 6 months after LVAD implantation in advanced HF. METHODS: This was a prospective cohort study of 101 patients receiving an LVAD for the management of advanced HF. Data on symptoms (dyspnea, early and subtle symptoms [HF Somatic Perception Scale], pain severity [Brief Pain Inventory], wake disturbance [Epworth Sleepiness Scale], depression [Patient Health Questionnaire], and anxiety [Brief Symptom Inventory]) and peripheral biomarkers of myocardial stretch, systemic inflammation, and hypervolumetric mechanical stress were measured before implantation with a commercially available LVAD and again at 30, 90, and 180 days after LVAD implantation. Latent growth curve and parallel process modeling were used to describe changes in symptoms and biomarkers and the degree to which they change in parallel in response to LVAD implantation. RESULTS: In response to LVAD implantation, changes in myocardial stretch were closely associated with changes in early and subtle physical symptoms as well as depression, and changes in hypervolumetric stress were closely associated with changes in pain severity and wake disturbances. Changes in systemic inflammation were not closely associated with changes in physical or affective symptoms in response to LVAD implantation. CONCLUSIONS: These findings provide new insights into the many ways in which symptoms and biomarkers provide concordant or discordant information about LVAD response.

Comparative symptom biochemistry between moderate and advanced heart failure.

BACKGROUND: We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF). OBJECTIVES: The purpose of this paper was to compare relationships between peripheral biomarkers of HF pathogenesis and physical symptoms between patients with advanced versus moderate HF. METHODS: This was a two-stage phenotype sampling cohort study wherein we examined patients with advanced HF undergoing ventricular assist device implantation in the first stage, and then patients with moderate HF (matched adults with HF not requiring device implantation) in the second stage. Linear modeling was used to compare relationships among biomarkers and physical symptoms between cohorts. RESULTS: Worse myocardial stress, systemic inflammation and endothelial dysfunction were associated with worse physical symptoms in moderate HF (n=48), but less physical symptom burden in advanced HF (n=48). CONCLUSIONS: Where patients are in the HF trajectory needs to be taken into consideration when exploring biological underpinnings of physical HF symptoms.

Safe delivery of lung stereotactic body radiation therapy in a patient with a left ventricular assist device and implantable cardioverter defibrillator.

This is the first case to discuss the safe delivery of stereotactic body radiation therapy to a left lower lobe lung nodule in a patient with a third generation left ventricular assist device (Heartware®) and implantable cardioverter defibrillator.

The Spectroscopy Village at Diamond Light Source.

This manuscript presents the current status and technical details of the Spectroscopy Village at Diamond Light Source. The Village is formed of four beamlines: I18, B18, I20-Scanning and I20-EDE. The village provides the UK community with local access to a hard X-ray microprobe, a quick-scanning multi-purpose XAS beamline, a high-intensity beamline for X-ray absorption spectroscopy of dilute samples and X-ray emission spectroscopy, and an energy-dispersive extended X-ray absorption fine-structure beamline. The optics of B18, I20-scanning and I20-EDE are detailed; moreover, recent developments on the four beamlines, including new detector hardware and changes in acquisition software, are described.

Exploring the relationship between ß-adrenergic receptor kinase-1 and physical symptoms in heart failure.

BACKGROUND: The relationship between physical heart failure (HF) symptoms and pathophysiological mechanisms is unclear. OBJECTIVE: To quantify the relationship between plasma ß-adrenergic receptor kinase-1 (ßARK1) and physical symptoms among adults with HF. METHODS: We performed a secondary analysis of data collected from two studies of adults with HF. Plasma ßARK1 was quantified using an enzyme-linked immunosorbent assay. Physical symptoms were measured with the HF Somatic Perception Scale (HFSPS). Generalized linear modeling was used to quantify the relationship between ßARK1 and HFSPS scores. RESULTS: The average age (n = 94) was 54.5 ± 13.1 years, 76.6% were male, and a majority (83.0%) had Class III or IV HF. ßARK1 was significantly associated with HFSPS scores (ß = 0.22 ± 0.10, p = 0.038), adjusting for other predictors of physical symptoms (model R2 = 0.250, F(7, 70) = 3.34, p = 0.004). CONCLUSIONS: Higher ßARK1 is associated with worse physical HF symptoms, pinpointing a potential pathophysiologic underpinning.

Patient and Caregiver Determinants of Patient Quality of Life and Caregiver Strain in Left Ventricular Assist Device Therapy.

BACKGROUND: Although current guidelines emphasize the importance of social support to the success of left ventricular assist device (LVAD) therapy, few studies examine the influence of the caregiver on patient outcomes or quantify the impact of LVAD caregiving on caregiver outcomes. The purpose of this analysis was to identify patient and caregiver determinants of patient quality of life (QOL) and caregiver strain in response to LVAD therapy. METHODS AND RESULTS: Data on patients receiving LVAD therapy and their caregivers (n=50 dyads) were prospectively collected pre-implantation and 1, 3, and 6 months post-implantation. Growth curve modeling was used to describe change in patient QOL (Kansas City Cardiomyopathy Questionnaire) and caregiver strain (Multidimensional Caregiver Strain Index). Patient QOL improved most in the first month (ß=23.22±3.76, P<0.001), followed by gradual gains over 6 months (ß=1.90±0.64, P<0.01). Caregivers experienced worsening of strain in the first month (ß=4.30±1.42, P<0.01), followed by gradual resolution to pre-implantation levels by 6 months (ß=-0.71±0.23, P<0.01). Worse pre-implantation patient symptoms were associated with greater improvement in patient QOL (ß=0.53±0.19, P<0.01) but worsening caregiver strain (ß=0.15±0.07, P=0.04). Better relationship quality was associated with greater improvement in patient QOL (ß=14.39±5.85, P=0.01) and less pre-implantation caregiver strain (ß=-9.31±2.28, P<0.001). Nonspousal caregivers experienced less pre-implantation strain (ß=-8.60±3.10, P=0.01), and patients with nonspousal caregivers had less improvement in QOL (ß=-3.70±1.62, P=0.02). CONCLUSIONS: A combination of patient and caregiver characteristics predicts patient and caregiver response to LVAD therapy. Including caregiver factors in future studies may be helpful in developing interventions that improve patient and caregiver outcomes, together.

Patterns of heart failure symptoms are associated with self-care behaviors over 6 months.

BACKGROUND: Both heart failure symptoms and self-care are associated with patient outcomes. Although it is thought that symptoms drive self-care, there is limited evidence to support this assumption over time. AIMS: To determine whether patterns of physical symptoms are significantly associated with heart failure self-care over time. METHOD: Latent mixture analysis was used to identify subgroups based on physical symptoms of dyspnea, sleepiness and edema (using the heart failure somatic perception and Epworth sleepiness scales). Growth modeling was used to determine if symptom subgroups were associated with self-care behaviors (using the self-care in heart failure index) over 6 months. Sociodemographic and clinical variables predicting the likelihood of subgroup membership were identified using logistic regression. RESULTS: The sample ( n=146) was on average 57 years old, 70% were men and 59% had class III/IV heart failure. Two symptom subgroups were identified (entropy 0.91): a high symptom group ( n=24; 16%) with no significant change in symptoms over time (high sustained), and a low symptom group ( n=122; 84%) with no significant change in symptoms over time (low sustained). The high sustained group was associated significantly with better self-care behaviors at baseline and over 6 months. Women (odds ratio (OR) 3.67, P=0.023) and patients with more depressive symptoms (OR 1.16, P=0.015) were more likely to be in the high sustained symptom group. Those treated with a renin-angiotensin-aldosterone system agent were less likely to be in the high symptom group (OR 0.17, P=0.015). CONCLUSION: Patients bothered more by symptoms are consistently more engaged in self-care behaviors over time. The results of this study support symptoms as an important driver of self-care behaviors.

The Role of Dyadic Confidence on Engagement in Heart Failure Care Behaviors.

Background and Objectives: Increasingly, older adults and their families are expected to manage complex conditions with little support. In the case of heart failure (HF), symptom monitoring and management are critical in preventing acute exacerbations and poor clinical outcomes. The current study examined the role of dyadic confidence on engagement in HF care behaviors by patients and their spouses. Research Design and Methods: A cross-sectional design was used to examine 60 couples living with HF. Three dyadic confidence variables were created to represent average level of confidence, gap in confidence, and direction of gap within each couple. A series of multilevel models were used to examine dyadic engagement in HF maintenance, management, and consulting behaviors and the role of dyadic confidence. Results: Patients were significantly more engaged in HF maintenance behaviors than spouses; couples were more collaborative in their engagement in HF management and consulting behaviors. Average level of confidence in the dyad was significantly associated with patient engagement in all three HF behaviors. Spouse engagement was associated with more congruence in confidence and having higher levels of confidence than their partners with HF. Women were significantly more engaged in HF behaviors than men, regardless of role. Discussion and Implications: The study employed a dyadic approach to HF care and a novel approach to confidence. Findings confirm the social nature of confidence and its important role in HF. Clinicians have opportunities to optimize patient outcomes by fostering greater collaboration within couples.