Comorbidity health pathways in heart failure patients: A sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry.
Comorbidity health pathways in heart failure patients: A sequences-of-regressions analysis using cross-sectional data from 10,575 patients in the Swedish Heart Failure Registry.
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DOI：
10.1371/journal.pmed.1002540
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发表时间：
2018-03
期刊：
影响因子：
15.8
通讯作者：
Stromberg A
中科院分区：
文献类型：
--
作者：
Lawson CA;Solis-Trapala I;Dahlstrom U;Mamas M;Jaarsma T;Kadam UT;Stromberg A
接受最佳治疗的心力衰竭（HF）患者通常有持续的症状和健康相关的生活质量差。合并症是常见的，但很少有人知道他们对这些因素的影响，指南驱动的HF护理仍然集中在心血管状态。对以下假设进行了检验：（i）合并症与HF患者更严重的症状和功能限制以及随后更差的患者评定健康状况相关，（ii）这些相关模式在选定的合并症之间存在差异。瑞典心力衰竭登记处（SHFR）是瑞典超过85%的医院或门诊就诊的HF患者的全国人口登记处。本研究纳入了10，575例在SHFR首次登记期间（2008年2月1日至2013年11月1日）记录的患者评定健康状况的HF患者。一个先验的健康模型和序列回归分析被用来测试合并症和患者报告的症状，功能限制，和患者评定的健康之间的关联。患者自评健康指标包括EuroQol-5维度（EQ-5D）问卷和EuroQol视觉模拟量表（EQ-VAS）。EQ-VAS评分范围为0（最差健康状况）至100（最佳健康状况）。从无合并症患者（平均EQ-VAS评分，66）到有心血管合并症患者（平均EQ-VAS评分，62）再到有非心血管合并症患者（平均EQ-VAS评分，59），患者自评健康状况逐渐下降。心血管合并症和患者自评健康之间的关系可以通过与焦虑或抑郁的相关性来解释（心房颤动，比值比[OR] 1.16，95% CI 1.06 ~ 1.27;缺血性心脏病[IHD]，OR 1.20，95% CI 1.09至1.32）和疼痛（IHD，OR 1.25，95% CI 1.14至1.38）。非心血管合并症与患者评定的健康之间的关系可以通过其与呼吸短促的关系来解释（糖尿病，OR 1.17，95% CI 1.03 ~ 1.32;慢性肾脏病[CKD，OR 1.23，95% CI 1.10 ~ 1.38;慢性阻塞性肺疾病[COPD]，OR 95% CI 1.84，1.62 - 2.10）和疲劳（糖尿病，OR 1.27，95% CI 1.13 - 1.42; CKD，OR 1.24，95% CI 1.12 - 1.38; COPD，OR 1.69，95% CI 1.50 - 1.91）。所有症状与患者评定的健康状况之间存在直接关联，通过功能限制存在间接关联。焦虑或抑郁与功能受限（OR 10.03，95%CI 5.16至19.50）和患者自评健康（EQ-VAS评分的平均差异，-18.68，95%CI-23.22至-14.14）的相关性最强。HF优化治疗不影响这些关联。该研究的主要局限性包括横断面设计和对其他人群的概括性不明确。需要进一步的前瞻性HF研究来测试这些关系的一致性及其对健康的影响。识别HF中不同的合并症健康途径可以为针对特定合并症和相关症状的个体化以人为本的护理提供证据。使用来自瑞典心力衰竭登记处的横截面数据，Claire Lawson及其同事检查了心力衰竭患者的合并症患者评定的健康途径心力衰竭是一种越来越常见的疾病，患者经常出现持续的症状和生活质量差，即使他们正在接受最好的心力衰竭治疗。大多数心力衰竭患者的健康状况主要是其他疾病，但心力衰竭治疗的重点是他们的心血管状态。人们对心力衰竭中不同合并症与生活质量之间的关系缺乏了解，这对于指导患者的个体化治疗计划非常重要。我们使用已建立的健康相关生活质量模型来开发和测试新的心力衰竭健康模型，该模型包括最常见的心力衰竭合并症。我们使用瑞典心力衰竭患者的国家登记册，通过检查患者报告的合并症、症状和功能限制之间的假定关系以及他们的整体健康经历来测试该模型。我们发现，非心血管合并症与心血管合并症相比，总体症状负担更高，症状更严重。心血管合并症的主要症状是疼痛和焦虑，而非心血管合并症的主要症状是呼吸急促和疲劳。心力衰竭优化治疗不影响这些症状、功能限制或生活质量。目前的心力衰竭指南侧重于改善心血管状态，以应对常见的心力衰竭症状（呼吸急促、疲劳和腿部肿胀）。我们的研究表明，对于一些患者来说，这些症状可能是由非心血管疾病（如糖尿病和肾脏疾病）引起的，而不是他们的心血管状态。我们发现，心血管合并症更可能与疼痛和焦虑有关，而不是呼吸急促或疲劳。为了改善与健康相关的生活质量，心力衰竭指南驱动的护理需要包括最常见的非心血管合并症的最佳管理以及疼痛和焦虑或抑郁的常规管理。为了提供个性化的患者护理，指南需要更好地将症状与患者的心血管和非心血管状态相结合。
Optimally treated heart failure (HF) patients often have persisting symptoms and poor health-related quality of life. Comorbidities are common, but little is known about their impact on these factors, and guideline-driven HF care remains focused on cardiovascular status. The following hypotheses were tested: (i) comorbidities are associated with more severe symptoms and functional limitations and subsequently worse patient-rated health in HF, and (ii) these patterns of association differ among selected comorbidities. The Swedish Heart Failure Registry (SHFR) is a national population-based register of HF patients admitted to >85% of hospitals in Sweden or attending outpatient clinics. This study included 10,575 HF patients with patient-rated health recorded during first registration in the SHFR (1 February 2008 to 1 November 2013). An a priori health model and sequences-of-regressions analysis were used to test associations among comorbidities and patient-reported symptoms, functional limitations, and patient-rated health. Patient-rated health measures included the EuroQol–5 dimension (EQ-5D) questionnaire and the EuroQol visual analogue scale (EQ-VAS). EQ-VAS score ranges from 0 (worst health) to 100 (best health). Patient-rated health declined progressively from patients with no comorbidities (mean EQ-VAS score, 66) to patients with cardiovascular comorbidities (mean EQ-VAS score, 62) to patients with non-cardiovascular comorbidities (mean EQ-VAS score, 59). The relationships among cardiovascular comorbidities and patient-rated health were explained by their associations with anxiety or depression (atrial fibrillation, odds ratio [OR] 1.16, 95% CI 1.06 to 1.27; ischemic heart disease [IHD], OR 1.20, 95% CI 1.09 to 1.32) and with pain (IHD, OR 1.25, 95% CI 1.14 to 1.38). Associations of non-cardiovascular comorbidities with patient-rated health were explained by their associations with shortness of breath (diabetes, OR 1.17, 95% CI 1.03 to 1.32; chronic kidney disease [CKD, OR 1.23, 95% CI 1.10 to 1.38; chronic obstructive pulmonary disease [COPD], OR 95% CI 1.84, 1.62 to 2.10) and with fatigue (diabetes, OR 1.27, 95% CI 1.13 to 1.42; CKD, OR 1.24, 95% CI 1.12 to 1.38; COPD, OR 1.69, 95% CI 1.50 to 1.91). There were direct associations between all symptoms and patient-rated health, and indirect associations via functional limitations. Anxiety or depression had the strongest association with functional limitations (OR 10.03, 95% CI 5.16 to 19.50) and patient-rated health (mean difference in EQ-VAS score, −18.68, 95% CI −23.22 to −14.14). HF optimizing therapies did not influence these associations. Key limitations of the study include the cross-sectional design and unclear generalisability to other populations. Further prospective HF studies are required to test the consistency of the relationships and their implications for health. Identification of distinct comorbidity health pathways in HF could provide the evidence for individualised person-centred care that targets specific comorbidities and associated symptoms. Using cross-sectional data from the Swedish Heart Failure Registry, Claire Lawson and colleagues examine the comorbidity patient-rated health pathways in heart failure patients Heart failure is an increasingly common condition, and patients often experience persistent symptoms and poor quality of life, even when they are receiving the best possible treatment for their heart failure. Most heart failure patients have other conditions that dominate their health experience, yet heart failure treatment focuses on their cardiovascular status. There is a lack of understanding about the relationships among different comorbidities and quality of life in heart failure, which are important to guide individualised treatment plans for patients. We used an established health-related quality of life model to develop and test a new heart failure health model that included the most common heart failure comorbidities. We tested this model by examining the postulated relationships among comorbidities, symptoms and functional limitations reported by patients, and their overall health experience, using a national register of heart failure patients in Sweden. We found that non-cardiovascular comorbidities were associated with much higher overall symptom burden and more severe symptoms than cardiovascular comorbidities. Predominant symptoms for cardiovascular comorbidities were pain and anxiety, whereas for non-cardiovascular comorbidities they were shortness of breath and fatigue. Heart failure optimising therapies did not influence these symptoms, functional limitations, or quality of life. Current guidelines in heart failure focus on improving cardiovascular status in response to common heart failure symptoms (shortness of breath, fatigue, and leg swelling). Our study shows that for some patients, these symptoms might be driven by non-cardiovascular conditions such as diabetes and renal disease, rather than their cardiovascular status. We found that cardiovascular comorbidities were more likely to be associated with pain and anxiety than shortness of breath or fatigue. To improve health-related quality of life, heart failure guideline-driven care needs to include optimal management of the most prevalent non-cardiovascular comorbidities and routine management of pain and anxiety or depression. To provide individualised patient care, guidelines need to better align symptoms with the cardiovascular and non-cardiovascular status of the patient.
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影响因子：
37.8
作者：
Shah SJ;Kitzman DW;Borlaug BA;van Heerebeek L;Zile MR;Kass DA;Paulus WJ
通讯作者：
Paulus WJ
影响因子：
3.5
作者：
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作者：
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通讯作者：
Enjuanes, Cristina
DOI：
10.1007/s11936-013-0249-2
发表时间：
2013-08-01
影响因子：
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作者：
Lewis, Eldrin F
通讯作者：
Lewis, Eldrin F