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Acute Heart Failure: Measuring The Diversity Of Health Related Quality Of Life Markers

Acute Heart Failure: Measuring The Diversity Of Health Related Quality Of Life Markers


A recent study investigated the impact of heart failure with reduced ejection fraction (HFrEF) on the health-related quality of life (HR-QoL) of patients and the inconsistencies that may arise when using different HR-QoL measurement tools. Conducted at a Taiwanese tertiary center’s Heart Failure Post-Acute-Care (HF-PAC) program, the study involved 134 hospitalized patients with acute decompensated HFrEF.


Participants completed three different HR-QoL questionnaires: the EuroQol-5 dimension (EQ-5D) questionnaire, the EQ-5D visual analogue scale (VAS), and the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Utility values were obtained from the EQ-5D questionnaire. The study found that there were significant variations in the scores obtained from these different tools, indicating potential inconsistencies in patient self-reports.


Noteworthy correlations were observed among the three tools, with the New York Heart Association functional class showing a notable association with all tool scores. Other associations included EQ-5D with coronary artery disease, mineralocorticoid receptor antagonists, and the 6-minute walk test; EQ-5D VAS with chronic kidney disease; and MLHFQ with age.


The study underscores the importance of using a range of HR-QoL measurement tools to capture diverse determinants and provide comprehensive patient-centered care. However, it suggests that recalibrating EQ-5D-derived utility scores may be necessary for a more precise assessment of HR-QoL in Taiwanese HFrEF patients, emphasizing the importance of tailoring assessments to individual patient needs within the HF-PAC program.


Heart failure (HF) signifies the heart’s incapacity to sufficiently pump blood to meet the body’s demands, a condition increasingly prevalent worldwide, notably among aging demographics. The symptoms of HF impose significant burdens and complexities in treatment strategies. Among its variants, heart failure with reduced ejection fraction (HFrEF), distinguished by notably decreased left ventricular ejection fraction (LVEF), presents distinct challenges in patient management and impacts health-related quality of life (HR-QoL) differently compared to other HF forms.


Effective management of HFrEF necessitates a thorough assessment of HR-QoL, facilitating tailored treatment plans aligned with each patient’s specific needs and objectives. This approach acknowledges that patients experiencing significant dyspnea may require different interventions from those primarily grappling with emotional distress. Furthermore, precise assessment tools help identify factors influencing HR-QoL, such as depression, anxiety, or social isolation, thereby potentially curbing disease progression and enhancing overall well-being.


In HF management, employing both disease-specific and generic HR-QoL questionnaires is crucial. For instance, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) delves into HF’s impact on daily life by addressing specific symptoms and concerns, while generic tools like the EuroQol-5 dimension (EQ-5D) offer a broader assessment of health dimensions, encompassing physical and mental well-being. Combining these questionnaires provides a comprehensive view of a patient’s HR-QoL, bridging specific disease impacts with overall health, thereby fostering patient-centered care.


Despite the common use of HR-QoL questionnaires, discrepancies often arise between questionnaire-derived results and patients’ self-reported HR-QoL (PSRQoL) in HF cases. This divergence stems from the subjective nature of PSRQoL, in contrast to the standardized format of HR-QoL questionnaires. Factors contributing to this disparity include variances in patient expectations, potential misunderstandings of questionnaire items, and social desirability bias influencing honest responses.


To address the diversity of HR-QoL measurement tools and the gap between these tools and PSRQoL in heart failure patients, particularly those with HFrEF, this study aims to assess the variability in HR-QoL measures within this specific group and explore determinants of HR-QoL within a Taiwanese context. By focusing on HFrEF patients, this research aims to provide valuable insights for a more nuanced and patient-centered care approach within this subset of the heart failure population.


This retrospective study, meticulously reviewed and sanctioned by the Institutional Review Board of Chi Mei Medical Center, meticulously adhered to the rigorous guidelines outlined for reporting observational studies as outlined in STROBE Statement. The investigation meticulously scrutinized patient cohorts drawn from the esteemed National Heart Failure Post-Acute-Care (HF-PAC) program, operational within a distinguished tertiary care facility located in the southern region of Taiwan. The study period spanned from October 2018 to March 2021, encapsulating a substantial timeframe for comprehensive data collection and analysis.


The HF-PAC program, renowned for its holistic and patient-centric approach, extends specialized care to individuals aged 18 and above, specifically those hospitalized due to acute decompensated HFrEF (Heart Failure with Reduced Ejection Fraction). Notably, patients exhibiting functional or cognitive impairments, dependence on mechanical respiratory support, or those in the advanced stages of renal disease were thoughtfully excluded from the program to ensure the homogeneity and integrity of the study cohort.


Data procurement involved a meticulous process, amalgamating information from electronic health records and conducting face-to-face interviews with skilled case managers. The comprehensive dataset encompassed a spectrum of parameters, including baseline demographics, cardiovascular medication profiles, heart failure staging, and detailed imaging reports. Additionally, the assessment of physical activity was conducted through the widely acknowledged 6-minute walk test (6MWT), categorized into distinct grades for comprehensive evaluation.


Of paramount importance was the consideration of various factors influencing quality of life (QoL) among HFrEF patients. This encompassed demographic variables, HF-associated comorbidities such as hypertension, coronary artery disease (CAD), diabetes, and chronic kidney disease (CKD), as well as the utilization of guideline-directed medical therapies. Functional capacity indicators, including New York Heart Association functional class (NYHA Fc), left ventricular ejection fraction (LVEF), and 6MWT results, were meticulously analyzed to gain insights into the patients’ clinical status and QoL determinants.


The measurement of QoL was conducted with precision, employing standardized instruments such as EQ-5D and MLHFQ questionnaires, as mandated by the HF-PAC program. The EQ-5D scores were transformed into utility values, offering a nuanced reflection of life quality and utility. Conversely, the MLHFQ scores delved into the multifaceted aspects of physical, emotional, and social dimensions of HR-QoL in HF patients. To facilitate comparative analyses and enhance interpretability, utility scores were uniformly adjusted to align with the scale of EQ-5D VAS scores.


Statistical analyses were conducted with meticulous attention to detail, encompassing comprehensive reporting of patients’ information, HR-QoL measures, and utility scores. Parameters were expressed using appropriate statistical descriptors, including means, standard deviations, medians, interquartile ranges, and percentages. Furthermore, Pearson’s correlations were meticulously employed to ascertain the relationships between HR-QoL questionnaires, while multivariate regression analyses were conducted to unravel the determinants of QoL variations. Sensitivity analyses, inclusive of outlier exclusion and stepwise regression methodologies, were rigorously undertaken to bolster the robustness of the findings. Moreover, subgroup analyses were meticulously performed to elucidate the association between determinants and individual dimensions of QoL assessment tools.


The statistical analyses were conducted with the aid of the esteemed Statistical Package for Social Sciences (SPSS) Version 22.0, ensuring the integrity and reliability of the findings. Notably, statistical significance was duly recognized at a threshold of P < 0.05 for two-tailed analyses, underscoring the significance of the reported associations and findings.


In this study, 134 patients were analyzed, predominantly male (70.1%) and with a significant portion being current smokers (38.1%). The average age was 62.2 years, with an average Left Ventricular Ejection Fraction (LVEF) of 29.2%. The majority had comorbidities like hypertension, coronary artery disease (CAD), diabetes, chronic kidney disease (CKD), hyperlipidemia, and atrial fibrillation. Guideline-directed medical therapy was commonly prescribed, with ARNIs or ACE-Is/ARBs being the most frequent (85.8%). However, SGLT2is were less frequently prescribed (20.1%).


Health-related quality of life (HR-QoL) was assessed using EQ-5D and MLHFQ tools. EQ-5D scores indicated moderate impairment, particularly in pain and anxiety/depression dimensions, while MLHFQ scores highlighted physical aspects as most affected. Correlations between these tools suggested consistent assessment of HR-QoL aspects. NYHA Fc was consistently associated with all HR-QoL measurements, with EQ-5D showing sensitivity to CAD, MRAs, and the 6-minute walk test. Subgroup analyses revealed associations between CAD, MRAs, and 6MWT with specific HR-QoL dimensions, while NYHA Fc and age were associated with various components of MLHFQ. Additionally, CKD emerged as a significant determinant of EQ-5D VAS scores. These findings underscore the multifaceted nature of HR-QoL assessment in heart failure patients, highlighting the importance of considering various demographic and clinical factors in clinical management.


This research employed three distinct measurement instruments to evaluate the Health-Related Quality of Life (HR-QoL) among patients with Heart Failure with Reduced Ejection Fraction (HFrEF) in a specific regional population. Notably, each tool exhibited sensitivity to certain aspects of the patients’ condition, such as the New York Heart Association Functional Classification (NYHA Fc), coronary artery disease (CAD), mineralocorticoid receptor antagonists (MRAs), and the 6-minute walk test (6MWT). These findings underscore the importance of utilizing multiple measurement tools to gain a comprehensive understanding of patient health status, aiding in the customization of patient-centered interventions.


An intriguing observation was the disparity between the EQ-5D-derived utility scores and the Patient Self-Reported Quality of Life (PSRQoL) scores, indicating a potential discrepancy in accurately measuring HR-QoL among Taiwanese HFrEF patients. This highlights the necessity of recalibrating EQ-5D utility scores to better align with the patient’s actual HR-QoL, thus enhancing the applicability of this measurement tool.


Furthermore, the study shed light on the significant influence of emotional factors, such as pain and anxiety/depression, on HR-QoL in HFrEF patients, emphasizing the need for integrated mental health support in their care. Additionally, factors such as age, NYHA Fc, 6MWT, CAD, CKD, and MRAs were identified as significantly associated with HR-QoL scores, providing valuable insights for clinicians to tailor interventions effectively.


Despite its contributions, the study has certain limitations, including its cross-sectional design, sample composition, and potential variations in the psychometric properties of the utilized questionnaires across different cultural contexts. Future research should address these limitations and further explore the intricate interplay of factors affecting HR-QoL in HFrEF patients.


In conclusion, this study underscores the importance of employing multiple HR-QoL measurement tools and tailoring interventions based on individual patient needs. It highlights the necessity of recalibrating EQ-5D utility scores and integrating patient perspectives into decision-making processes to enhance patient-centered care within the HF-PAC programme in Taiwan.

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