Patient-reported and morbidity-mortality endpoints: can one have the best of both worlds?

Association Between Disease-specific Health-related Quality of Life and All-cause Mortality in Patients with Heart Failure: A Meta-analysis

BackgroundThe Kansas City Cardiomyopathy Questionnaire (KCCQ) is a measure of heart failure (HF) health status. Worse KCCQ scores are common in patients with chronic kidney disease (CKD), even without diagnosed heart failure (HF). Elevations in the cardiac biomarkers GDF‐15 (growth differentiation factor‐15), galectin‐3, sST2 (soluble suppression of tumorigenesis‐2), hsTnT (high‐sensitivity troponin T), and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) likely reflect subclinical HF in CKD. Whether cardiac biomarkers are associated with low KCCQ scores is not known.Methods and ResultsWe studied participants with CKD without HF in the multicenter prospective CRIC (Chronic Renal Insufficiency Cohort) Study. Outcomes included (1) low KCCQ score <75 at year 1 and (2) incident decline in KCCQ score to <75. We used multivariable logistic regression and Cox regression models to evaluate the associations between baseline cardiac biomarkers and cross‐sectional and longitudinal KCCQ scores. Among 2873 participants, GDF‐15 (adjusted odds ratio 1.42 per SD; 99% CI, 1.19–1.68) and galectin‐3 (1.28; 1.12–1.48) were significantly associated with KCCQ scores <75, whereas sST2, hsTnT, and NT‐proBNP were not significantly associated with KCCQ scores <75 after multivariable adjustment. Of the 2132 participants with KCCQ ≥75 at year 1, GDF‐15 (adjusted hazard ratio, 1.36 per SD; 99% CI, 1.12–1.65), hsTnT (1.20; 1.01–1.44), and NT‐proBNP (1.30; 1.08–1.56) were associated with incident decline in KCCQ to <75 after multivariable adjustment, whereas galectin‐3 and sST2 did not have significant associations with KCCQ decline.ConclusionsAmong participants with CKD without clinical HF, GDF‐15, galectin‐3, NT‐proBNP, and hsTnT were associated with low KCCQ either at baseline or during follow‐up. Our findings show that elevations in cardiac biomarkers reflect early symptomatic changes in HF health status in CKD patients.

Improvements in Health Status Associated with Medication Adjustments in Outpatients with HFrEF: Insights from the CHAMP-HF Registry

Quality of life and treatment preference for ventricular assist device therapy in ambulatory advanced heart failure: A report from the REVIVAL study

Background: Health-related quality of life (HRQL) is reduced in patients with heart failure with preserved ejection fraction (HFpEF). However, the extent to which HRQL outcomes are related to cardiac structure and function in patients with HFpEF is not well understood. Methods: We examined the association between baseline echocardiographic measures and longitudinal Kansas City Cardiomyopathy Questionnaire (KCCQ) measures in patients with HFpEF in the PARAGON-HF trial using longitudinal regression models adjusted for age, sex, baseline KCCQ score, randomization, and other important clinical confounders. Results: Among 1,094 patients with baseline KCCQ data at randomization and a baseline echocardiogram within 6 months of enrollment, the mean age was 74 years and 53% were women. Over 3 years, 78% completed KCCQ measures at baseline, 12, 24, and 36 months. Missing values for non-survivors (n=116) were imputed as zero to avoid survival bias. Posterior wall thickness, septal E/e’, and right ventricular (RV) end diastolic area were negatively associated with the KCCQ Overall Summary Score, and a similar pattern of associations was observed for the KCCQ Clinical Summary Score (Table). Pulmonary artery systolic pressure was additionally negatively associated with the KCCQ Total Symptom Score. Notably, left ventricular (LV) size, septal wall thickness, LV ejection fraction, LV strain, and left atrial size were not significantly associated with longitudinal changes in KCCQ. Conclusion: In patients with HFpEF, increased LV posterior wall thickness, elevated LV filling pressure, elevated pulmonary pressure, and RV enlargement - together suggestive of more advanced diastolic dysfunction - are associated with a decline in KCCQ scores and may influence future worsening of quality of life.

Low-to-Moderate Alcohol Intake and Health Status in Heart Failure Patients

Introduction: Sarcopenia is the age-related deterioration in skeletal muscle mass and function, which can be accelerated by chronic comorbidities. The prevalence in advanced systolic heart failure (HF) and impact on HF health status are currently uncertain. Sarcopenia diagnostic criteria from the Foundation for the National Institutes of Health (FNIH) and European Working Group on Sarcopenia in Older People (EWGSOP) have not been applied to HF cohorts. Hypothesis: We hypothesized that at the time of left ventricular assist device (LVAD) implantation systolic HF patients have prevalent sarcopenia, and that sarcopenia is associated with poorer nutritional and HF health status. Methods: We recruited 18 adults with systolic HF ±21 days from LVAD implantation. All underwent whole-body dual X-ray absorptiometry (DXA) to calculate appendicular lean mass (ALM). Subjects also underwent a 3-day food recall, Simplified Nutritional Appetite Questionnaire (SNAQ), Kansas City Cardiomyopathy Questionnaire (KCCQ) for HF health status, handgrip strength and blood testing. Sarcopenia was defined by 2 ALM criteria: FNIH – males &lt;19.75kg, females &lt;15.02kg; EWGSOP – males &lt;7.26kg/m 2 , females &lt;5.5kg/m 2 . Linear regression determined relationships between appendicular lean mass and age, weight, handgrip strength, KCCQ summary score, SNAQ score, 24-hour protein intake, and key blood variables, without/with adjustment for sex and height. Results: Sarcopenia was diagnosed in 5 subjects (28%) by FNIH criteria and an additional 5 (10 total, 56%) by EWGSOP criteria (Figure). There were unadjusted associations between lower appendicular lean mass and lower handgrip strength; higher SNAQ score (higher malnutrition risk); lower sodium; and lower hemoglobin. After adjustment for sex and height, lower lean mass remained associated with lower hemoglobin. Lower appendicular lean mass was also independently associated with higher (more favorable) KCCQ scores. Conclusions: As many as half of advanced systolic HF patients meet standard DXA criteria for sarcopenia. Lower appendicular lean mass is independently associated with lower hemoglobin but does not appear to be associated with poorer HF status.

This systematic review evaluates the effectiveness of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in assessing quality of life improvements among patients with heart failure (HF) undergoing various forms of exercise training rehabilitation, including telemedicine and in-person modalities, across all stages of HF, irrespective of ejection fraction (EF) and clinical status. The aim was to collate evidence from studies employing the KCCQ as a measure of quality of life (QoL). A comprehensive search strategy was implemented across PubMed, Scopus, and Embase databases, adhering to the PRISMA guidelines, including literature up until October 2023. Inclusion criteria encompassed studies on patients diagnosed with HF undergoing exercise training rehabilitation assessed by KCCQ. Nine articles met the inclusion criteria, involving a total of 3905 patients from various global locations and conducted between 2012 and 2022. Results indicated significant heterogeneity in exercise interventions and patient characteristics. Notably, high-intensity interval training (HIIT) showed a marked improvement in KCCQ scores (from 68.0 to 80.0) compared to moderate continuous training (MCT) and control groups, underscoring its potential for enhancing QoL. Additionally, a significant improvement in the 6-min walking test (6MWT) outcomes was observed, with an average increase of 106 m (95% CI: 60, 152) in one study, reflecting physical capacity enhancements. However, the difference in KCCQ scores between intervention and control groups was not statistically significant in several studies. In conclusion, the KCCQ's effectiveness is highlighted by its ability to detect clinically meaningful improvements in QoL across diverse exercise modalities, including HIIT and MCT, tailored to the specific needs of HF populations. The consistent correlation between KCCQ score improvements and enhanced physical outcomes, such as the 6MWT, supports its reliability in capturing the nuanced benefits of exercise interventions on patient well-being.

Background: In patients with permanent atrial fibrillation, hypertension and diabetes frequently coexist and contribute to adverse cardiovascular outcomes. Beyond traditional clinical outcomes, health-related quality of life has become an essential measure of disease burden. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a validated patient-reported outcome instrument widely used in cardiovascular populations, but its role in hypertensive diabetics has not been systematically explored. This study aimed to evaluate the impact of diabetes on patient-reported quality of life in hypertensive individuals with permanent atrial fibrillation and identify clinical determinants of impaired health status. Methods: We conducted a retrospective study on hypertensive patients with permanent atrial fibrillation hospitalized between January 2021 and December 2023 at the County Emergency Clinical Hospital of Timișoara. Patients completed the KCCQ during admission and were stratified into hypertension without diabetes (HTN-only, n = 89) and hypertension with type 2 diabetes (HTN + DM, n = 109). Demographic, laboratory, and echocardiographic data were analyzed. The primary outcome was the difference in KCCQ scores between groups. Multivariable regression identified independent predictors of quality of life, and logistic regression with ROC analysis evaluated predictors of low KCCQ (<50). Results: Among 198 patients (109 with diabetes, 89 without), mean KCCQ was lower in HTN + DM versus HTN-only patients (50.9 ± 11.3 vs. 54.9 ± 14.4, p = 0.034). Diabetic patients had worse renal function, higher uric acid, and greater inflammatory burden. KCCQ correlated positively with eGFR (r = 0.43, p < 0.001) and negatively with creatinine, urea, neutrophil percentage, left atrial volume, and age. In multivariable analysis, diabetes was not an independent predictor, whereas reduced eGFR, higher neutrophils, larger atrial volume, and HFrEF were significant determinants. Logistic regression for low KCCQ showed good discrimination (AUC 0.78, 95% CI: 0.72–0.84). Conclusions: Diabetes worsens health-related quality of life in hypertensive patients with permanent atrial fibrillation primarily through renal dysfunction, inflammation, and cardiac remodeling. Targeting these pathways may improve both outcomes and patient-perceived health.

Background: Treating hypertrophic cardiomyopathy (HCM) aims to improve health status. Given the importance of accurately assessing health status and the limitations of the New York Heart Association (NYHA) Class, the Kansas City Cardiomyopathy Questionnaire (KCCQ) has gained interest. Thus, frameworks for interpreting the KCCQ in the context of the NYHA are needed. Methods: EXPLORER-HCM (NCT03470545) randomized patients with NYHA class II-III HCM to mavacamten or placebo and collected the NYHA and KCCQ. We pooled subjects for analyses who had KCCQ scores and NYHA class at baseline and 30-weeks. KCCQ scores, stratified by class at baseline, 30 weeks, and by change in class were reported as means±standard deviations. We generated two unadjusted models predicting the probability of NYHA class attribution for a given KCCQ-Overall Summary Score (OSS) at 30 weeks and for change in NYHA class by changes in KCCQ-OSS. Results: Of 196 participants, mean age was 57.9±12.2 years, 120 (61.2%) were male, and the baseline mean LVOT gradient was 51.5±30 mm Hg. Mean KCCQ scores by NYHA classes at baseline and 30 weeks are included in Table 1. Figure 1 maps the probability of NYHA Class by KCCQ. KCCQ-OSS Scores &lt;40 mapped to Class III, scores from 40-85 mapped to Class II, and &gt;85 mapped to Class I. Reductions of &gt;25 points on the KCCQ-OSS aligned with worsening class and increases by &gt;8 points on the KCCQ-OSS reflected improvement in class. Conclusion: NYHA Class is concordant with KCCQ, but there is variability in health status within class and changes in class. These analyses may help clinicians interpret both cross-sectional and changes in KCCQ scores for patients with obstructive HCM.

Background: Heart failure (HF) is a common, chronic clinical syndrome with appreciable impact on both prognosis and lifestyle of patients. Two main aims of management include preventing disease progression and improving quality of life (QoL). Not much work has been done in this area in Sub-Saharan Africa and most of the available disease specific instruments were developed using the Caucasian population. Aim: We therefore evaluated the QoL of stable HF patients attending the cardiology clinic of the Lagos University Teaching Hospital using a disease specific instrument, Kansas City Cardiomyopathy Questionnaire (KCCQ) and a generic one, the WHOQOL- BREF. Method: Consenting, stable HF patient were recruited from the cardiology clinic of the Lagos University Teaching Hospital. Relevant clinical data and echocardiographic parameters were retrieved from their clinical notes and the subjects filled out the questionnaires, the KCCQ and the WHOQOL-BREF. The QoL and four main domains in the WHOQOL- BREF were compared with scores on the KCCQ for relationships. Result: Data set of 190 patients was analysed. There were 91 (47.9%) males and 99 (52.1%) females with a mean age 51.90 ± 13.21 yrs. Only 52 (27.4%) had college education and 143 (75.2%) had very poor personal resources. About 104 (54.7%) were paying their medical bills themselves. The mean QoL score using the KCCQ score was 59.61 ± 23.80. With The KCCQ, 6.9% felt their QoL was poor and 20% felt it was fair while 11.6% and 20.5% felt their QoL was poor and fair respectively with the WHOQOL-BREF. There was positive correlation, p

Background Impaired health status as measured by standardized tools such as Kansas City Cardiomyopathy Questionnaire (KCCQ), Duke Activity Status Index (DASI) and six-minute walk test (6MWT) has been shown to predict hospitalization and mortality in patients with chronic heart failure. However, prognostic implications of these measurements in response to guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) remained to be elucidated. Purpose We hypothesized that impaired health status were predictive of persistently elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) after 6 and 12 months of therapeutic optimization in HFrEF. Methods Data on the GUIDE-IT trial that included protocolized HFrEF drug titration were analyzed. Patients who did not have NT-proBNP at 12 months were excluded. KCCQ overall and clinical summary scores, and DASI scores at baseline and 6 months were calculated. Six-minute walk test (6MWT) distance at baseline were also available. Response to medical therapy was defined as having NT-proBNP at 12 months of less than 1,000 pg/mL. Median value of each measurement was used as a cutoff. Multivariate logistic regression analysis was used to determine independent associations between different QOL scores and NT-proBNP response after adjustment for age, comorbidities, baseline EF, NYHA functional class, and NT-proBNP. Results There were 193 (43%) responders. Compared with those who responded to the medical therapy, non-responders were older, and more likely to have comorbidities including coronary artery disease, stroke, PAD, AF, hypertension, COPD, DM, CKD, and dyslipidemia, as well as lower EF, NHYA functional class and higher baseline NT-proBNP. After adjustment for baseline characteristics, lower KCCQ (either overall or summary) scores at baseline and 6 months, and lower DASI scores at 6 months (but not baseline) were independently associated with lower likelihood of response to GDMT (Table). In contrast, baseline 6MWT distance did not predict non-response to GDMT after adjustments. Conclusions Only impaired baseline KCCQ scores were predictive of persistently elevated NT-proBNP, while lower KCCQ and DASI scores at 6 month were predictive of persistently elevated NT-proBNP. Funding Acknowledgement Type of funding sources: None. Health Status Score below Median and ORs

Grouping comorbidities can better reflect the intrinsic relationships among complications. We aimed to explore the relationships between comorbidity groups and dynamic changes in health-related quality of life (HRQoL) in patients with chronic heart failure (CHF). A total of 1533 patients with CHF were included. Demographic and clinical variables were recorded during hospitalization. HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and at 3 and 12 months. Latent class analysis was used to identify comorbidity groups among patients with CHF. This method identifies latent subgroups by analyzing patterns in their comorbidities. Repeated-measures analysis of variance (ANOVA) was used to assess the relationships between comorbidity groups and dynamic changes in KCCQ scores. Three comorbidity clusters were identified: the young/valvular heart disease (VHD) group, the elderly/coronary heart disease (CHD) group, and the high-comorbidity burden group. The young group had a relatively lower comorbidity burden and the best HRQoL, followed by the elderly/CHD group, while the high-comorbidity burden group showed the worst HRQoL. The overall summary scores, clinical summary scores, social limitations, physical limitations, and self-efficacy were significantly highest in the high-comorbidity burden group. In addition, at 3 months the symptom scores had decreased in all three groups. Repeated-measures ANOVA showed that the comorbidity groups were significantly associated with dynamic changes in HRQoL through time and group effects. There were significant differences in the baseline characteristics and dynamic changes of HRQoL among different comorbidity clusters. Patients in the high-comorbidity burden group performed the worst in terms of quality of life, but the improvement was the most significant.

AimsHeart failure (HF) is a complex clinical syndrome with multiple comorbidities. Cognitive impairment, stress, anxiety, depression, and lower quality of life are prevalent in HF. Herein, we explore the interplay between these parameters and study their value to predict major adverse cardiovascular events (MACEs) and health‐related quality of life (HrQoL) in patients with HF with reduced ejection fraction using guideline recommended assessment tools.Methods and resultsWe conducted a longitudinal study using a sample of 65 patients from two hospitals. A battery of tests was applied to assess cognition [Montreal Cognitive Assessment (MoCA)], stress (Perceived Stress Scale‐10), anxiety, and depression (Hospital Anxiety and Depression Scale) at baseline. MACEs were registered using clinical records. HrQoL was estimated using the Kansas City Cardiomyopathy Questionnaire (KCCQ). A descriptive statistical analysis was conducted, and multiple linear and Cox regression models conducted to determine the predictive value of neurocognitive parameters and HrQoL in MACE. Both MoCA [hazard ratio = 0.906 (0.829–0.990); P = 0.029] and KCCQ scores were predictors of MACE, but not of overall mortality. Anxiety, depression, and stress scores did not predict MACE. However, anxiety (β = −0.326; P = 0.012) and depression levels (β = −0.309; P = 0.014) were independent predictors of the KCCQ score.ConclusionsThe MoCA score and HrQoL were predictors of MACE‐free survival. Anxiety and depression were good predictors of HrQoL, but not of MACE‐free survival.

Effect of family nursing therapeutic conversations on health-related quality of life, self-care and depression among outpatients with heart failure: A randomized multi-centre trial