Cognitive deficits and health-related quality of life in chronic heart failure.

BACKGROUND: Patients with chronic heart failure (HF) have cognitive deficits in memory, psychomotor speed, and executive function and poor health-related quality of life (HRQL), but the association between cognitive deficits and HRQL is unknown. OBJECTIVES: The objectives of this study were to (1) evaluate the relationship between HF severity, age, comorbidities, and cognitive deficits and HRQL among patients with chronic HF and (2) examine whether cognitive deficits mediated the relationship between HF severity and HRQL. DESIGN AND SAMPLE: This study was part of a larger explanatory study; 249 patients with HF completed face-to-face interviews. METHODS: Measures of HF severity, comorbidity (multiple comorbid conditions, hypertension, and depressive symptoms), cognitive function (domains of language, working memory, memory, psychomotor speed, and executive function), and HRQL were obtained. Clinical variables were abstracted from patients' records. Statistical analyses were conducted using descriptive statistics, Pearson correlation coefficients, and multiple linear regression analyses. RESULTS: Overall, the HRQL of patients was moderately poor. Heart failure severity, age, depressive symptoms, and total recall memory explained 55% of the variance in HRQL, but the contribution of memory was minimal (1%). Patients with more severe HF, younger age, and more depressive symptoms had poorer HRQL. Other cognitive function variables, multiple comorbidity, and hypertension were not significant explanatory variables for HRQL. Cognitive deficits did not mediate the relationship between HF severity and HRQL. CONCLUSIONS: Novel interventions targeted at improving HRQL continue to be urgently needed, particularly among younger patients and patients with depressive symptoms. Measures of HRQL are not sufficient as outcomes when investigating cognitive deficits in HF. Investigators need to include outcome measures of patients' actual abilities to perform daily activities and HF self-care.

Cognitive deficits in chronic heart failure.

BACKGROUND: Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF. OBJECTIVES: : The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits. METHODS: A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF. RESULTS: Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample. DISCUSSION: HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.

Research in patients with heart failure: challenges in recruitment.

BACKGROUND: Published studies of patients with heart failure may not include details about the challenges in the recruitment process. OBJECTIVES: To describe the recruitment process during the first 18 months of a study being conducted to evaluate cognitive deficits in patients with chronic heart failure. METHODS: Details of the recruitment process are described for 2 clinic sites. RESULTS: A total of 4,027 echocardiograms were screened at site 1 to evaluate eligibility. Of the 161 patients eligible, 61 (38%) were invited to participate, and 29 of the 61 (48%) completed the study. At site 2, four hundred thirty-seven medical records of patients were screened, resulting in 163 eligible patients (37%). The staff invited 70 of the 163 patients (43%) to participate, and 52 of the 70 (74%) completed the study. The refusal rate was 23% at site 1 and 21% at site 2. CONCLUSIONS: Successful recruitment in studies involving patients with heart failure often requires screening of a large group of patients.

Therapeutic plasma exchange performed in parallel with extra corporeal membrane oxygenation for antibody mediated rejection after heart transplantation.

We report on the feasibility, safety, and efficacy of performing therapeutic plasmapheresis (TPE) in parallel with extracorporeal membrane oxygenation (ECMO) to alleviate antibody mediated rejection (AMR) after heart transplantation. Two pediatric and one adult patient presented with severe congestive heart failure and respiratory distress after heart transplantation and required ECMO support. TPE was initiated to treat AMR while patients remained on ECMO. Each patient received three to five procedures either every day or every other day. One equivalent total plasma volume (TPV) was processed for each procedure (patient TPV + ECMO extracorporeal TPV). A total of 13 TPE procedures were performed with 12 procedures completed without complications or adverse events; one procedure was terminated before completion because of cardiac arrhythmia. Anti-HLA antibody titers decreased after TPE in all three patients. Ventricular function improved and ECMO was discontinued in 2 of 3 patients. Performing large volume TPE with a processed volume up to 2.5 times the patient's TPV is well tolerated in both pediatric (< or = 10 kg) and adult patients. TPE in parallel with ECMO is feasible, safe, and may be measurably effective at reducing anti-HLA antibodies and should be considered as part of the treatment for patients with early AMR after heart transplantation.

A conceptual model of cognitive deficits in chronic heart failure.

PURPOSE: To describe a conceptual model to guide studies of cognitive deficits among patients with heart failure. ORGANIZING FRAMEWORK: The conceptual framework of cognitive deficits in chronic heart failure is based on theoretical and empirical literature about (a) the pathophysiology of heart failure, (b) the pathophysiology of cognitive deficits, and (c) health-related quality of life. Other variables that may cause or contribute to cognitive deficits include age, the relative contributions of multiple comorbid conditions, hypertension, and depressive symptoms. Covariates that might influence cognitive deficits (medications, gender, and education) are also included in the model. The most prominent cognitive deficits are believed to occur in domains of attention, working memory, memory, learning, executive function, and psychomotor speed. The main outcome variable is health-related quality of life, which is believed to be influenced by circulatory insufficiency and cognitive deficits. CONCLUSIONS: The conceptual model described in this paper is a framework for testing cognitive deficits that occur in heart failure. After validation through empirical testing, the model may be useful in developing interventions for patients with heart failure whose care is complicated by cognitive deficits.