European Journal of Cardiovascular Nursing

Symptom perception in heart failure has been identified as crucial for effective self-care that is a modifiable factor related to decreased hospital readmission and improved survival.

To review systematically the heart failure symptom perception literature and synthesise knowledge on definition, description, factors and instruments.

We conducted a scoping review including studies reporting patient-reported symptom perception in adults with heart failure. Structured searches were conducted in Medline, PubMed, Embase, CINAHL, PsychINFO, Web of Science, Cochrane, JBI and grey literature. Two authors independently reviewed references for eligibility. Data were charted in tables and results narratively summarised.

The search yielded 3057 references, of which 106 were included. The definition of heart failure symptom perception comprised body listening, monitoring signs, recognising, interpreting and labelling symptoms, and furthermore awareness of and assigning meaning to the change. Symptom monitoring, recognition and interpretation were identified as challenging. Symptom perception facilitators include prior heart failure hospitalisation, heart failure self-care maintenance, symptom perception confidence, illness uncertainty and social support. Barriers include knowledge deficits, symptom clusters and lack of tools/materials. Factors with inconsistent impact on symptom perception include age, sex, education, experiences of living with heart failure, comorbidities, cognitive impairment, depression and symptom progression. One instrument measuring all dimensions of heart failure symptom perception was identified.

Heart failure symptom perception definition and description have been elucidated. Several factors facilitating or hampering symptom perception are known. Further research is needed to determine a risk profile for poor symptom perception – which can then be taken into consideration when supporting heart failure self-care.

Heart failure is one of the most common reasons for hospitalization among older adults and negatively influences person-reported outcomes of patients and their care partners. Moreover, the majority of heart failure research examines patients and care partners separately, ignoring the interdependent nature of the heart failure dyad.

The aim of this study was to examine the interpersonal factors associated with depressive symptoms of heart failure patients and spouse care partners, patient hospitalizations over the last 12 months and care strain.

A descriptive, cross-sectional design was used to examine 60 community-dwelling adults with heart failure and their spouse care partners. Multilevel modeling controlled for the interdependent nature of the dyadic data.

Patients had significantly worse depressive symptoms than their spouse care partners. More patient concealment (i.e. hiding concerns/worries) and worse relationship quality were significantly associated with greater depressive symptoms for patients, but not spouse care partners. Better relationship quality (reported by spouse care partners) was significantly associated with lower levels of care strain, whereas better relationship quality (reported by patients) was significantly associated with worse care strain. Patients who had one or more hospitalizations over the past 12 months were significantly more likely to report higher levels of concealment; relationship quality was not associated with patient hospitalizations.

Findings highlight the interdependent nature of heart failure and the complexity of the interpersonal context. Greater focus on how the heart failure dyad navigates illness as a unit over time is needed to design and tailor innovative lines of clinical intervention to optimize dyadic and individual health.

Depressive symptoms are prevalent and cause poor health outcomes in patients with heart failure. Studies show that the physical symptoms of heart failure are associated with depressive symptoms. However, little is known about the underlying mechanisms of this relationship.

The purpose of our study was to examine the associations between physical symptoms, illness perceptions, coping strategies and depressive symptoms and to test the multiple mediation effects of illness perceptions and coping strategies on the relationship between physical symptoms and depressive symptoms in patients with heart failure.

Physical symptoms, illness perceptions, coping strategies and depressive symptoms were assessed using self-reported questionnaires among 302 patients (64.2±11.9 years, 54% male) with heart failure in a tertiary general hospital. A serial multiple mediation model was tested using the PROCESS macro for SPSS.

Depressive symptoms were positively correlated with physical symptoms (r=0.487, p<0.01), illness perceptions (r=0.499, p<0.01) and acceptance–resignation coping (r=0.580, p<0.01). The relationship between physical symptoms and depressive symptoms was mediated by illness perceptions (indirect effect: 0.036, confidence interval (0.014, 0.059)) and by acceptance-resignation (indirect effect: 0.034, confidence interval (0.019, 0.053)), respectively, and by these two in serial (indirect effect: 0.021, confidence interval (0.013, 0.033)).

Patients with heart failure who have more physical symptoms are vulnerable to the development of depression. Healthcare providers should implement interventions focused on changing illness perceptions and reducing acceptance–resignation coping to relieve depressive symptoms.

Risk factor control is essential in limiting the progression of coronary heart disease, but the necessary active patient involvement is often difficult to realise, especially in patients suffering psychosocial risk factors (e.g. distress). Blended collaborative care has been shown as an effective treatment addition, in which a (non-physician) care manager supports patients in implementing and sustaining lifestyle changes, follows-up on patients, and integrates care across providers, targeting both, somatic and psychosocial risk factors.

The aim of this study was to test the feasibility, acceptance and effect of a six-month blended collaborative care intervention in Germany.

For our randomised controlled pilot study with a crossover design we recruited coronary heart disease patients with ⩾1 insufficiently controlled cardiac risk factors and randomised them to either immediate blended collaborative care intervention (immediate intervention group, n=20) or waiting control (waiting control group, n=20).

Participation rate in the intervention phase was 67% (n=40), and participants reported high satisfaction (M=1.63, standard deviation=0.69; scale 1 (very high) to 5 (very low)). The number of risk factors decreased significantly from baseline to six months in the immediate intervention group (t(60)=3.07, p=0.003), but not in the waiting control group t(60)=−0.29, p=0.77). Similarly, at the end of their intervention following the six-month waiting period, the waiting control group also showed a significant reduction of risk factors (t(60)=3.88, p<0.001).

This study shows that blended collaborative care can be a feasible, accepted and effective addition to standard medical care in the secondary prevention of coronary heart disease in the German healthcare system.

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=−0.205, p=0.001) and arrival by ambulance (β=−0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Given the importance of improving health for patients with heart failure, the present study examined the temporal associations between eHealth literacy, insomnia, psychological distress, medication adherence, quality of life and cardiac events among older patients with heart failure.

With a longitudinal design older patients with echocardiography verified heart failure (N=468; 50.4% New York Heart Association class II, mean age 69.3±7.3 years; 238 men) in need of cardiac care at seven Iranian university outpatient clinics went through clinical examinations and completed the following questionnaires at baseline: eHealth literacy scale (eHEALS, assessing eHealth literacy); 5-item medication adherence report scale (MARS-5, assessing medication adherence); Minnesota living with heart failure questionnaire (MLHFQ, assessing quality of life); insomnia severity index (ISI, assessing insomnia); and hospital anxiety and depression scale (HADS, assessing psychological distress). All the patients completed the ISI and HADS again 3 months later; and the MARS-5 6 months later. Also, their cardiac events were collected 18 months later. Three mediation models were then conducted.

eHealth literacy had direct and indirect effects (through insomnia and psychological distress) on medication adherence and quality of life. Moreover, eHealth literacy had protecting effects on cardiac events (hazard ratio (HR) 0.53; 95% confidence interval (CI) 0.37, 0.65) through the mediators of insomnia (HR 0.19; 95% CI 0.15, 0.26), psychological distress (HR 0.08; 95% CI 0.05, 0.12) and medication adherence (HR 0.05; 95% CI 0.04, 0.08).

As eHealth literacy was a protector for patients with heart failure, healthcare providers may plan effective programmes to improve eHealth literacy for the population. Additional benefits of improving eHealth literacy in heart failure may be decreased insomnia and psychological distress, improved quality of life, as well as decreased cardiovascular events.

Low confidence to exercise is a barrier to engaging in exercise in heart failure patients. Participating in low to moderate intensity exercise, such as the six-minute walk test, may increase exercise confidence.

To compare the effects of a six-minute walk test with an educational control condition on exercise confidence in heart failure patients.

This was a prospective, quasi-experimental design whereby consecutive adult patients attending an out-patient heart failure clinic completed the Exercise Confidence Scale prior to and following involvement in the six-minute walk test or an educational control condition.

Using a matched pairs, mixed model design (n=60; 87% male; M_age=58.87±13.16), we identified a significantly greater improvement in Total exercise confidence (F(1,54)=4.63, p=0.036, partial η²⁼0.079) and Running confidence (F(1,57)=4.21, p=0. 045, partial η²⁼0.069) following the six-minute walk test compared to the educational control condition. These benefits were also observed after adjustment for age, gender, functional class and depression.

Heart failure patients who completed a six-minute walk test reported greater improvement in exercise confidence than those who read an educational booklet for 10 min. The findings suggest that the six-minute walk test may be used as a clinical tool to improve exercise confidence. Future research should test these results under randomized conditions and examine whether improvements in exercise confidence translate to greater engagement in exercise behavior.

Malnutrition in elderly patients is one of the important issues in an aging society. We aimed to investigate the prevalence and prognostic impact of malnutrition assessed using the geriatric nutritional risk index in very elderly patients hospitalized owing to heart failure.

We enrolled 213 consecutive patients aged ⩾80 years who were hospitalized with heart failure. The mean age was 87.2 ± 4.9 years, and 43.7% of them were male. The nutritional status on admission was evaluated using the geriatric nutritional risk index, which was calculated as follows: 14.89 × serum albumin (g/dL) + 41.7 × body mass index/22. The patients were divided into two groups, a low geriatric nutritional risk index group (<92) with malnutrition risk and a high geriatric nutritional risk index group (⩾92) without malnutrition risk.

The mean geriatric nutritional risk index of all patients was 90.7 ± 10.6, and 108 patients (50.7%) had low geriatric nutritional risk index. During the 540-day follow-up, the all-cause mortality was significantly higher in the low geriatric nutritional risk index group than in the high geriatric nutritional risk index group (35.7% vs. 12.9%, p < 0.001). The Cox proportional-hazards regression analysis revealed that low geriatric nutritional risk index was an independent predictor of mortality (hazard ratio, 2.28; 95% confidence interval, 1.15–4.49; p = 0.02).

Low geriatric nutritional risk index on admission was common and was associated with poor prognosis in patients aged ⩾80 years who were hospitalized owing to heart failure.