Heart failure (HF) is a chronic disease that frequently causes quality of life (QoL) impairment. We aimed to evaluate whether fragility affects QoL perception in outpatients with HF across age strata. The Minnesota Living with Heart Failure Questionnaire (MLWHFQ) was used to assess QoL, and fragility was defined according to basic standardized geriatric scales. Predefined criteria for such scales were scores of Barthel index <90, Older Americans’ Resources and Services scale <10 in women and <6 in men, and Pfeiffer test >3 (±1 depending on educational grade) and ≥1 positive depression response on the abbreviated Geriatric Depression Scale. We evaluated 1,405 consecutive outpatients with HF (27.8% women, median age 69 years [twenty-fifth to seventy-fifth percentiles: 59 to 76 years]). Fragility, defined as at least 1 abnormal evaluation, was detected in 621 patients (44.2%). A positive depression response on the abbreviated Geriatric Depression Scale was the most prevalent (31.2%) component of fragility. We found a strong correlation between MLWHFQ score and the presence of fragility and all fragility components (all p <0.001). These associations prevailed in both younger (<75 years) and older patients (≥75 years; all p values <0.001 except for Pfeiffer test in younger patients [p = 0.007]). In multivariate regression analysis, QoL remained significantly associated with fragility after adjustment for age, gender, etiology of HF, left ventricular ejection fraction, New York Heart Association functional class, co-morbidities, and HF treatment, in both younger and older patients (p <0.001). In conclusion, MLWHFQ, a specific HF QoL questionnaire, is significantly influenced by fragility regardless of age.
Heart failure (HF) is a chronic disease with frequent hospital admissions and poor prognosis. In developed countries, 1% to 2% of the adult population has HF, and this prevalence rises to ≥10% in the population aged ≥70 years. In this scenario, fragility is often present among patients with HF; indeed, previous data report that even young patients with HF show a high degree of fragility. Moreover, the signs and symptoms of HF substantially impair patients’ quality of life (QoL). In elderly patients with HF, previous reports have shown that QoL is related to fragility. Whether fragility is a mediator of the effects of HF on QoL or HF-related fragility is a component of HF-related QoL are nonresolved questions. However, interactions among HF, fragility, and QoL are probably multiple and multidirectional. This study aimed to evaluate whether the relation between fragility and QoL is observed at all age strata in a large “real-life” cohort of ambulatory patients with HF.
Methods
We studied all consecutive outpatients who attended the HF clinic of a university hospital from August 2001 to November 2012. Referral criteria to the unit were HF irrespective of the origin (at least 1 HF hospitalization and/or reduced left ventricular ejection fraction [LVEF] of <40%), as a regular clinical practice standard. Most patients were referred to the clinic by cardiology and internal medicine departments, whereas fewer patients were referred by emergency department, short-stay unit, or other hospital departments. All patients provided written informed consent at the baseline visit to obtain analytical samples and to use their clinical data for research purposes. The investigation conforms to the principles outlined in the Declaration of Helsinki.
QoL was assessed with an HF-specific QoL questionnaire, the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) in its Spanish version, which has been widely used and prospectively validated. Consisting of 21 questions, the MLWHFQ evaluates the impact of HF on the physical, psychological, and social aspects of patients’ lives. Answers range from 0 (no limitation) to 5 (maximal limitation); thus, global scores are from 0 to 105, with higher scores reflecting worse QoL.
If necessary, depending on the patient’s reading and writing capabilities, an HF clinic nurse helped the patient to complete the questionnaire, neither altering the patient’s response nor compromising the patient’s independence in any case.
Fragility was assessed by a basic geriatric evaluation with 4 standardized geriatric scales: Barthel index evaluates dependence on basic activities of daily living (range, 0 to 100), Older Americans’ Resources and Services (OARS) scale (Instrumental Activities of Daily Living subscale of the Multidimensional Functional Assessment Questionnaire) evaluates autonomy in daily living instrumental activities (range, 0 to 14), Pfeiffer test (Short Portable Mental Status Questionnaire) evaluates cognitive function (range, 0 to 10), and to identify possible emotional problems, a Yesavage abbreviated Geriatric Depression Scale was used. Predefined criteria for abnormal results were scores of Barthel index <90, OARS scale <10 in women and <6 in men, and Pfeiffer test >3 (±1 depending on educational grade) and ≥1 positive depression response on abbreviated Geriatric Depression Scale. OARS scale score was considered differently for men and women because of the existence of marked cultural environmental differences, as has been recommended by other investigators. The presence of at least 1 abnormal evaluation identified fragile patients for the purpose of the study, as previously described.
Categorical variables are expressed as frequencies and percentages. Continuous variables are expressed as mean ± SD or median and twenty-fifth to seventy-fifth percentiles. Normal distribution was assessed by means of normal Q-Q plots. Statistical differences between groups were assessed using the chi-square test for categorical variables and Student t tests for continuous variables. Two multivariate regression models were created, one for evaluating the weight of each component of fragility (as dichotomous normal vs abnormal) in association with QoL and another for adjusting its relation for several important clinical variables (age, gender, etiology of HF, LVEF, New York Heart Association (NYHA) functional class, number of co-morbidities [hypertension, diabetes, atrial fibrillation, chronic obstructive pulmonary disease, peripheral vascular disease, renal failure, and anemia], and HF treatment). Statistical analyses were performed with SPSS 15 (SPSS Inc., Chicago, Illinois). A 2-sided p value of <0.05 was considered significant.
Results
We prospectively enrolled 1,405 consecutive patients with HF in the study (1,015 men and 390 women). Table 1 lists the demographic and clinical data of the patients at inclusion. Mean MLWHFQ score for the total studied population was 31.4 ± 18.9. Table 2 lists the prevalence of abnormal scores obtained with the standardized geriatric scales and the prevalence of fragility. The mean QoL score was 39.0 ± 18.9 for frail patients and 25.3 ± 17.1 for nonfrail patients (p <0.001). Figure 1 shows box plots of MLWHFQ scores for QoL assessment according to all standardized geriatric scales performed for fragility assessment; patients were placed into subgroups based on whether they had normal or abnormal results.
| Characteristics | Total Cohort (n = 1,405) |
|---|---|
| Age (yrs) | 66.7 ± 12.4 |
| Women | 390 (27.8) |
| Etiology of HF | |
| Coronary heart disease | 742 (52.8) |
| Idiopathic dilated cardiomyopathy | 171 (12.2) |
| Hypertensive cardiomyopathy | 134 (9.5) |
| Alcoholic cardiomyopathy | 75 (5.3) |
| Drug-related (medication) cardiomyopathy | 35 (2.5) |
| Valvular disease | 132 (9.4) |
| Other | 116 (8.3) |
| HF duration (mo) | 10 (2–48) |
| LVEF (%) | 33 ± 13 |
| NYHA functional class | |
| I | 63 (4.5) |
| II | 892 (63.5) |
| III | 426 (30.3) |
| IV | 24 (1.7) |
| Co-morbidities | |
| Hypertension | 855 (60.9) |
| Diabetes mellitus | 551 (39.2) |
| Chronic obstructive pulmonary disease | 257 (18.3) |
| Renal failure (creatinine clearance of <60 ml/min) | 766 (54.5) |
| Anemia (hemoglobin level of <12 g/dl) | 455 (32.4) |
| Peripheral vascular disease | 228 (16.2) |
| Atrial fibrillation | 253 (18.0) |
| Treatments | |
| ACEI/ARB | 1,056 (75.2) |
| β Blockers | 952 (67.8) |
| Loop diuretics | 1,073 (76.4) |
| Measurements | Total Cohort, n = 1,405 (%) |
|---|---|
| Abnormal Barthel index score | 286 (20.4) |
| Abnormal OARS scale score | 183 (13.0) |
| Abnormal Pfeiffer test score | 71 (5.1) |
| Depressive symptoms | 439 (31.2) |
| Fragility | 621 (44.2) |
We found a strong association between the MLWHFQ score and the presence of fragility and all components of fragility. This association was found in both patients aged <75 and ≥75 years ( Table 3 ). Focusing on patients with fragility, there were no differences in MLWHFQ score mean values according to age (p = 0.59). The same was observed when each abnormal individual component of fragility was analyzed.
| Total Cohort (n = 1,405) | Age <75 yrs (n = 997) | Age ≥75 yrs (n = 408) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Yes | No | p | Yes | No | p | Yes | No | p | |
| Fragility | 39.0 ± 18.1 | 25.3 ± 17.1 | <0.001 | 38.7 ± 18.0 | 25.5 ± 17.7 | <0.001 | 39.5 ± 18.2 | 24.6 ± 14.7 | <0.001 |
| Abnormal Barthel index score | 42.6 ± 18.4 | 28.5 ± 17.8 | <0.001 | 42.6 ± 19.0 | 28.8 ± 18.3 | <0.001 | 42.6 ± 18.0 | 27.4 ± 16.1 | <0.001 |
| Abnormal OARS scale score | 45.6 ± 18.6 | 29.2 ± 17.9 | <0.001 | 47.7 ± 18.9 | 29.2 ± 18.3 | <0.001 | 44.2 ± 18.4 | 29.5 ± 16.7 | <0.001 |
| Abnormal Pfeiffer test score | 42.7 ± 18.1 | 30.8 ± 18.7 | <0.001 | 39.1 ± 17.3 | 30.3 ± 18.9 | 0.014 | 45.0 ± 18.3 | 32.1 ± 18.0 | <0.001 |
| Depressive symptoms | 39.6 ± 18.2 | 27.6 ± 17.9 | <0.001 | 38.9 ± 18.4 | 26.8 ± 18.0 | <0.001 | 41.2 ± 17.6 | 29.8 ± 17.6 | <0.001 |
In the multivariate regression analysis, the component of fragility with the greatest weight in association with QoL was depressive symptoms, followed by abnormal Barthel index score, as revealed by the standardized β values, whereas Pfeiffer test lost significance ( Table 4 ). When only patients aged ≥75 years were analyzed, an abnormal Barthel index score was the item with the greatest weight. When adjusting for several clinically relevant variables in the multivariate regression analysis, such as age, gender, etiology of HF, LVEF, NYHA functional class, number of co-morbidities, and HF treatment, QoL remained significantly associated with fragility for the total population and in patients aged <75 and ≥75 years ( Table 4 ). The weight of fragility in the QoL score was greater than other important clinical variables and was only exceeded by the NYHA functional class, according to standardized β values of multivariate regression ( Table 5 ). The NYHA functional class was the stronger determinant of QoL in multivariate analysis in both patients with (standardized β 0.387, p <0.001) and those without fragility (standardized β 0.285, p <0.001).
| Total Cohort | Age <75 yrs | Age ≥75 yrs | |||||||
|---|---|---|---|---|---|---|---|---|---|
| β (SE) | Standardized β | p | β (SE) | Standardized β | p | β (SE) | Standardized β | p | |
| Abnormal Barthel index score | 8.126 (1.474) | 0.174 | <0.001 | 6.680 (2.130) | 0.116 | 0.002 | 10.192 (2.042) | 0.272 | <0.001 |
| Abnormal OARS scale score | 7.726 (1.831) | 0.138 | <0.001 | 11.533 (2.862) | 0.158 | <0.001 | 5.444 (2.307) | 0.132 | 0.019 |
| Abnormal Pfeiffer test score | 0.963 (2.287) | 0.011 | 0.674 | −3.846 (3.723) | −0.034 | 0.302 | 4.333 (2.781) | 0.072 | 0.120 |
| Depressive symptoms | 9.904 (1.007) | 0.244 | <0.001 | 10.454 (1.226) | 0.255 | <0.001 | 8.157 (1.758) | 0.208 | <0.001 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
