Depressive symptoms are common in patients with heart failure (HF) and adversely affect mortality, morbidity, and health-related quality of life. Cognitive therapy (CT) has been proposed as a non-pharmacological treatment for depressive symptoms in patients with HF. However, there is currently little evidence to support use of CT in patients with HF. The purpose of this dissertation was to develop and test a brief, nurse-delivered CT intervention for the treatment of depressive symptoms in patients with HF. Prior to testing the intervention, preliminary work was conducted resulting in four manuscripts: 1) a review of the evidence for CT in treating depressive symptoms in patients with cardiovascular conditions, 2) a description of living with depressive symptoms in patients with HF and strategies that could be used to manage these symptoms, 3) a review of measures of negative thinking and the identification of a measure of negative thinking that can be used in patients with HF, and 4) an evaluation of the psychometric properties of this measure. Based on information from these manuscripts, a randomized, controlled pilot study was conducted to test the effects of a brief CT intervention on outcomes of hospitalized patients with HF who report depressive symptoms. Forty-two hospitalized patients with HF with mild-moderate depressive symptoms were randomized to a brief CT intervention focused on reducing negative thoughts with thought-stopping and affirmations, or to usual care control. Both groups experienced improvements in depressive symptoms, health-related quality of life, and negative thinking at one week and three months. However, the intervention group experienced longer cardiac event-free survival and fewer cardiovascular hospitalizations and emergency department visits at three months when compared to the control group. This dissertation has fulfilled an important gap in the evidence base for depression treatment in patients with HF by demonstrating that a nurse-delivered, brief CT intervention may improve cardiac event-free survival in patients with HF. This brief CT intervention is replicable, practical, can be delivered by acute care nurses, and may improve clinical outcomes in patients with HF. Additional research is needed to determine the effects of the intervention on long-term outcomes in patients with HF.

Individuals with cardiomyopathy are at higher risk to die from sudden cardiac arrest than those with non-failing (NF) hearts. This study examined the differences in electrical properties of failing and NF human hearts in terms of cardiac memory through explicit control of diastolic intervals in a sinusoidal fashion, restitution of action potential duration (APD) through standard and dynamic pacing protocols, maximum rate of depolarization and APD alternans. Recordings of transmembrane potentials were made in tissues extracted from patients with heart failure and one donor NF heart. Computational simulations were performed using the O’Hara Rudy model for generating surrogates of control data. Significant differences were seen between left ventricular (LV) tissue and NF LV tissue in tilt, and measures of memory in terms of area and thickness during the sinusoidal 400ms protocol. Minimum delay was also significantly higher in the failing LV during the sinusoidal 150ms protocol. Failing tissues showed a higher restitution slope and prolonged AP which is consistent with previous studies and is hypothesized to contribute to the increased susceptibility to unstable alternans. This study further explored how disease alters the electrical functioning of the heart and why these patients are at a higher risk of ventricular arrhythmia.

Introduction: Patient participation is important for improving outcomes and respecting selfdetermination and legal aspects in care. Heart failure is a chronic condition that puts high demands on self-care and patient participation. Patients often need advanced care due to deterioration of their heart failure symptoms, and one option is to provide care as home-care. There is limited knowledge of how patients with heart failure and their partners view participation in home-care. Aim: The overall aim of this thesis was to describe different perspectives of participation in structured heart failure home-care among patients with heart failure and their partners. Methods: All patients in this thesis received structured heart failure home-care, according to a model aiming to facilitate care, where safety, participation, and gaining knowledge about the illness and treatment, are in focus. Study I had a prospective pre-post longitudinal design including 100 patients with heart failure receiving home-care. Data was collected by selfadministered questionnaires. Study II had a descriptive design. Nineteen patients receiving home-care were interviewed, and data was analysed using qualitative content analysis. Study III had a descriptive and explorative design. Data was collected by video-recorded observations of 19 home visits and analysed by qualitative content analysis. Study IV had a parallel convergent mixed-method design including 15 partners of patients receiving structured home-care. Data was collected by interviews and self-administered questionnaires. Datasets were first analysed separately and then together. Results: Better self-care behaviour was significantly associated with all measured aspects of participation. Participation by received information increased significantly during the 12-month follow-up (I). Patients’ descriptions of participation included communication between patients and health care professionals, access to care, active involvement in care, a trustful relation with health care professionals, and options for decision-making(II). Observed care encounters revealed that participation was made possible by; (i) interaction, including exchange of care-related information, care-related reasoning, and collaboration, (ii) an enabling approach, including the patient expresses own wishes and shows an active interest, and the nurse is committed and invites to a dialogue (III). Partners scored fairly positive for their participation in care and they performed different levels of caregiving tasks. Descriptions of participation included; adapting to the caring needs and illness trajectory, mastering caregiving demands, interacting with care providers, and gaining knowledge to comprehend the health situation. The mixed-method results showed both convergent results and expanded knowledge (IV). Conclusions: Structured heart failure home-care facilitated participation both for patients and their partners. Patient participation with regard to received information improved significantly after receiving home-care. Aspects of patient participation were consistently associated with better self-care behaviour. Patients’ and partners’ descriptions revealed many aspects of participation, and observed home visits revealed how interaction and an enabling approach underpinned participation.

Hintergrund: Bei etwa der Hälfte aller Patienten mit Herzinsuffizienz kann die Symptomatik auf eine Herzinsuffizienz bei erhaltener Ejektionsfraktion (HFPEF) zurückgeführt werden. Lange Zeit wurde der Herzinsuffizienz bei erhaltener Ejektionsfraktion eine bessere Prognose nachgesagt als der systolischen Herzinsuffizienz. Neuere Untersuchungen zeigen allerdings, dass die Prognose vergleichbar schlecht und gegenüber der Allgemeinbevölkerung deutlich herabgesetzt ist. Trotz großer klinischer Relevanz gibt es weder eine allgemeingültige Leitlinie zur Diagnostik der HFPEF noch eine überzeugende Therapie, die Morbidität und Mortalität reduziert. Auch ist bislang nicht geklärt, inwieweit sich demographische und klinische Faktoren auf die den Empfehlungen zugrunde liegenden Zielparameter auswirken. Ebenfalls ungeklärt ist, ob und wie diese krankheitstypischen, für die Diagnose wegweisenden Schlüsselparameter wie Leistungsfähigkeit, diastolische Funktion, neurohumorale Aktivierung und linksatriales und linksventrikuläres Remodeling auch unabhängig von demographischen und klinischen Faktoren untereinander assoziiert sind. Dieses ist von großem Interesse, da man die Parameter, anhand derer man eine Krankheit diagnostizieren und den Effekt einer Therapie messen will, gut kennen sollte und die Einflüsse, denen sie unterliegen, bekannt sein sollten. Material und Methoden: In der vorliegenden Arbeit werden Baselinedaten der Aldo-DHF-Studie präsentiert, die 422 ambulante Patienten mit einer symptomatischen Herzinsuffizienz bei erhaltener Ejektionsfraktion einschloss (mittleres Alter 67 Jahre, 48% männlich). Anhand dieser Daten wurden die Zusammenhänge zwischen zahlreichen demographischen und klinischen Charakteristika und Werten der Leistungsfähigkeit (peak VO 2), Werten der diastolischen Dysfunktion ( E/e‘), Höhe der neurohumoralen Aktivität (NT-proBNP) und Werten des kardialen Remodelings (linksatrialer Volumenindex und linksventrikulärer Massenindex) ermittelt sowie ihre Assoziation untereinander geprüft. Dazu wurden die Patienten nach ihrem jeweiligen NYHA-Stadium in zwei Gruppen unterteilt (NYHA-Stadium II, n= 363 Patienten; NYHA-Stadium III, n= 59 Patienten). Beziehungen zwischen Basischarakteristika und dem jeweiligen Zielparameter wurden zunächst mit einfacher Regression und anschließend mit multipler Regression untersucht. Beziehungen der Zielparameter untereinander wurden zum einen durch den Pearson-Korrelationskoeffizienten 5 Zusammenfassung 61 und zum anderen nach Adjustierung durch einen partiellen Korrelationskoeffizienten dargestellt. Ergebnisse: Wir stellten fest, dass das Alter der einzige Faktor ist, der sich auch unabhängig von demographischen und klinischen Faktoren signifikant negativ auf alle fünf untersuchten Schlüsselparameter auswirkt: die peak VO2 (p= < 0.001), das E/e‘ (p= 0,009), das NT-proBNP (p= < 0.001), den LAVI (p= 0.003) und den LVMI (p= 0.02). Die Leistungsfähigkeit (peak VO2) wird negativ durch ein weibliches Geschlecht (p= <0.001), chronotrope Inkompetenz (p= 0.002) und einzelne Begleiterkrankungen wie KHK (p= 0.002), DM (p= 0.05) und das Schlafapnoe-Syndrom(p= 0.02) beeinflusst. Außerdem wird die diastolische Funktion (E/e‘) durch weibliches Geschlecht (p= 0.008), durch einen höheren Pulsdruck (p= 0.04), eine niedrigere Ruheherzfrequenz (p= 0.03) und die Behandlung mit Betablockern (p= 0.001) herabgesetzt. Bei der Untersuchung des Zusammenhangs von Charakteristika des Patientenkollektivs und der neurohumoralen Aktivität zeigte sich, dass ein höherer BMI (p= 0.03) mit einem niedrigeren NT-proBNP-Spiegel assoziiert ist. Vorhofflimmern (p= < 0.001), eine niedrige Ruheherzfrequenz (p= 0.05), chronotrope Inkompetenz (p= 0.02), eine schlechte Nierenfunktion (p= 0.05), niedrige Hämoglobinspiegel (p= < 0.001), die Einnahme von Diuretika (p= 0.05) und Betablockern (p= < 0.001) sind hingegen mit einem erhöhten NT-proBNP-Spiegel assoziiert. Obgleich signifikant, korrelieren die peak VO2, E/e‘ und NT-proBNP unadjustiert lediglich moderat miteinander, während LAVI und LVMI gar nicht mit der Leistungsfähigkeit assoziiert sind. Nach Adjustierung entfällt die Signifikanz des zuvor genannten Zusammenhangs von peak VO2 mit E/e‘ und NT-proBNP. Das bedeutet, dass die Leistungsfähigkeit mit keinem der anderen Schüsselparameter in Zusammenhang steht, wenn man sie unabhängig von demographischen und anderen klinischen Faktoren betrachtet. Der Zusammenhang von E/e‘, NT-proBNP und LAVI sowie LVMI und LAVI bleibt auch nach Adjustierung bestehen. Patienten mit einem entsprechend den vorgegebenen Grenzwerten niedrigen NT-proBNP-Spiegel (NT-proBNP ≤ 220 ng/l) und niedrigen E/e‘-Werten (E/e‘ ≤ 15) hatten signifikant bessere peak VO2- und AT VO2-Werte als Patienten, bei denen auch nur einer dieser beiden Werte erhöht war. Schlussfolgerung: Wir untersuchten, welche demographischen und klinischen Faktoren mit der körperlichen Leistungsfähigkeit, der diastolischen Funktion, der neurohumoralen 5 Zusammenfassung 62 Aktivierung und dem linksatrialen sowie linksventrikulären Remodeling bei Patienten mit Herzinsuffizienz und erhaltener systolischer Funktion assoziiert sind. Besonders interessant war, dass die maximale Leistungsfähigkeit mit keinem der anderen diagnostischen Schlüsselparameter, unabhängig von demographischen und klinischen Faktoren, in Zusammenhang steht. Dennoch scheinen empfohlene Grenzwerte bei NT-proBNP und E/e‘ zur Diagnose einer HFPEF sinnvoll, da sie grundsätzlich Patienten mit einer niedrigeren peak VO2 selektieren. Die Herzinsuffizienz mit erhaltener EF ist ein multifaktoriell beeinflusstes klinisches Syndrom. Da die eingeschränkte Leistungsfähigkeit nicht unabhängig von anderen Faktoren mit den diagnostischen Parametern assoziiert ist, ist die individuelle Bewertung von Faktoren, die zu den Symptomen der Patienten beitragen, obligatorisch für die klinische Beurteilung und Therapie bei Patienten mit HFPEF.

Hjärtsvikt betraktas inte som en sjukdom. Det är ett kliniskt syndrom som uppstår som resultat av nedsatt hjärtmuskelfunktion där hjärtats pumpkraft avtar vilket leder till otillräcklig blodförsörjning till kroppens organ vid ett normalt fyllnadstryck. Personer som drabbas av hjärtsvikt har ökat i antal eftersom behandling av andra hjärtsjukdomar har förbättrats samt medellivslängden har ökat. Syftet med studien var att beskriva äldre patienters upplevelser av att leva med hjärtsvikt. Metoden som användes var en kvalitativ empirisk studie där datainsamlingsmetod var intervjuer och insamlade material analyserades med hjälp av kvalitativ innehållsanalys. I resultatet framkom fyra kategorier; upplevelser av symtom, känslomässiga reaktioner, behov av kunskap och behov av stöd. Känslan av välbefinnande påverkades av som resultat av belastningen med olika symptom, kombinerad med funktionshinder, förlust av självständighet, social isolering och existentiella frågor. Det var framförallt den minskade förmågan att utföra fysiska aktiviteter som hade den största påverkan på äldre patienters dagliga liv. Patienter hade inlärningsbehov och de upplevde osäkerhet när livet inte kunde kontrolleras. Stöd visade sig vara viktigt för patienters välbefinnande. Slutsatsen var att upplevelserna som patienter hade om hjärtsvikt är individuella; av den anledningen behövs en individuell vårdplan upprättas för att möta de verkliga och potentiella behov som patienter med hjärtsvikt har. / Heart failure is not considered a disease. It is a clinical syndrome that occurs as a result of impaired myocardial function in which the heart's pumping power decreases, leading to insufficient blood supply to the organs of the body at a normal filling pressure. People who suffer from heart failure have increased in number since the treatment of other cardiovascular diseases has improved and life expectancy has increased. The aim of the study was to describe older patients' experiences of living with heart failure. The method used was a qualitative empirical study using interviews as a data collection method, which was analyzed throughout qualitative content. The result shows four categories; symptoms experiences, emotional reactions, need for knowledge and the need for support. The feeling of well-being affected by the results of the load with different symptoms, combined with disability, loss of independence, social isolation, and existential issues. It was mainly the reduced ability to perform physical activities that had the greatest impact on older patient’s daily lives. Patients had learning needs and they experienced uncertainty when their lives could not be controlled. Support proved looks to be important for well-being of patients. The conclusion was that the experiences that patients had about heart failure are individual because we need to individualize the care plan and to meet the real and potential needs for patients with heart failure.

Ūminis širdies nepakankamumas yra vis dažniau sutinkama patologija, reikalaujanti didelių diagnostikos ir gydymo resursų, o šios patologijos baigčių prognozavimas išlieka mažai tyrinėtas. Tyrimui pasirinktas sergančių ligonių ūminiu miokardo infarktu, komplikuotu ūminiu širdies nepakankamumu, kontingentas. Darbe siekiama nustatyti hemodinamikos rodiklių ir biocheminių žymenų vertę prognozuojant ūminio miokardo infarkto sąlygoto širdies nepakankamumo eigos ypatumus, komplikacijų išsivystymo riziką, gydymo efektyvumą ir baigtis. Keliami uždaviniai nustatyti intervencinio gydymo metodų derinimo vertę ligoniams, sergantiems ūminio miokardo infarkto sąlygotu širdies nepakankamumu. Taip pat šiems ligoniams darbe numatyta įvertinti hemodinaminių oksigenacijos rodiklių pokyčius, jų kitimo dinamiką ir vertę prognozuojant gydymo baigtis; įvertinti invaziniais hemodinamikos tyrimo metodais nustatytų hemodinamikos rodiklių bei biocheminių žymenų pokyčių vertę prognozavimui. Taip pat siekiama nustatyti ligonių, sergančių ūminiu širdies nepakankamumu, sąlygotu ūminio miokardo infarkto, ribines hemodinaminių ir biocheminių žymenų vertes gydymo baigčių prognozavimui ir pagrįsti biocheminių žymenų bei nepertraukiamo hemodinamikos stebėjimo tikslingumą skirtingo lygio pagalbą teikiančiuose gydymo centruose, numatant ligonių tikslingą perkėlimą, savalaikiai numatant diagnozuojant būklės sunkumą, gyvybei grėsmingų komplikacijų kilimą, vertinant gydymo efektyvumą, prognozuojant gydymo baigtis. / Heart failure is a significant issue in the healthcare system, and its prevalence in developed countries tends to increase due to the increasing proportion of the aging population. Acute heart failure as a complication of acute myocardial infarction is explored in the study. The aim of the study was to determine the value of hemodynamic indices and biochemical markers in the prognostication of the peculiarities of the course of acute heart failure, the risk of complications, and the effectiveness and outcomes of its treatment. The main objectives of the study were the following: to evaluate changes in hemodynamic oxygenation markers, and the dynamics and value of these changes in the prognostication of treatment outcomes in patients with acute heart failure depending on complications and therapeutic techniques;. to evaluate the value of the combination of interventional treatment techniques in patients with acute heart failure; to evaluate the prognostic value of hemodynamic markers identified via invasive hemodynamic examination techniques and changes in biochemical indices; to identify marginal values of hemodynamic and biochemical markers in the prognostication of treatment outcomes; to substantiate the expedience of and indications for biochemical markers and continuous monitoring of hemodynamics during the acute period of heart failure for timely detection of life-threatening complications, evaluation of treatment efficiency, and prognostication of outcomes.

Heart failure is the most common reason to hospitalization among persons over 65 years old. Self-care is an important part in the treatment of heart failure, but poor information and knowledge limits the ability of self-care and increases the risk of admission to hospital. The aim of the study was to investigate what information patients with heart failure describes that they receive from health care personal, how information is perceived, who provides the information, and on what occasions it is given. The aim was also to investigate whether patients' perception of knowledge about heart failure increased after hospitalization. The study is cross-sectional study with a descriptive design. A consecutive selection was used. A questionnaire was filled in by 28 participants. The study has shown that patients with heart failure largely experience information about heart failure inadequate. At firsthand the participants had been informed about swelling legs, dyspnea and increased weight. The information was highly described as comprehensible and individualized. Only one third of the participants described that they have been informed by a nurse. A few of the participants experienced increased knowledge about heart failure after the hospitalization. The information that is given to patients with heart failure is highly experienced as individualized and comprehensible but is given in insufficient extend, as the result demonstrate that many patients with heart failure completely lack information. A routine for heart failure caretaking that include information is required. / Hjärtsvikt är den vanligaste orsaken till inläggning på sjukhus hos personer över 65 år. Egenvård är en viktig del i behandlingen av hjärtsvikt, men bristande information och kunskap begränsar möjligheten till egenvård och därmed ökar risken för inläggning på sjukhus. Syftet med studien var att undersöka vilken information patienter med diagnosen hjärtsvikt beskriver att de får från vårdpersonal, på vilket sätt informationen upplevs, vem som ger informationen samt vid vilka tillfällen den ges. Syftet var också att undersöka om patientens upplevda kunskap om hjärtsvikt ökat efter vårdtillfället. Studien är en tvärsnittsstudie med deskriptiv design och genomförd som en enkätstudie med konsekutivt urval (N= 28). Studien visade att hjärtsviktpatienter i stor utsträckning upplever information om hjärtsvikt från vårdpersonal som otillräcklig. I första hand har deltagarna upplevt att de informerats om bensvullnad, andfåddhet, viktuppgång. Informationen upplevdes i hög grad lättförståelig och individuellt anpassad. Endast en tredjedel av deltagarna beskrev att de fått information av en sjuksköterska. Ett fåtal av deltagarna upplevde att kunskaperna om hjärtsvikt ökat efter vårdtillfället. Den information som ges till hjärtsviktspatienter upplevs till stor grad som individuellt anpassad och lättförståelig men informationen sker i bristande omfattning då resultatet visar att många patienter helt saknar information. Det behövs en rutin för omhändertagande av hjärtsviktspatienter som innefattar information.

Purpose. To examine the outcome of a 6-month treatment with carvedilol or metoprolol on peak and submaximal exercise performance and ventilatory efficiency in patients with heart failure (HF). / Methods. 27 patients with HF were randomized to receive either metoprolol or carvedilol for 6 months and compared with 12 healthy controls. Maximal exercise capacity was assessed at baseline and after 6 months with a symptom limited incremental treadmill protocol (RAMP). Submaximal exercise was determined to be the portion of exercise below a respiratory exchange ratio of 1.0. Peak heart rate (HR), oxygen uptake (VO2), and ventilatory equivalent for O2 and CO2 were recorded. The slopes of the VE vs. VCO2, VE vs. VO2 and VE/VCO2 vs. VO2 relationships were calculated for each subject from submaximal values. / Results. Resting HR decreased to similar extent in both treatment groups. There were no other significant changes in resting hemodynamics or ventricular function. Peak VO2 and HR decreased significantly in both treatment groups. Peak VE/VCO2 and submaximal VCO 2 vs. VE slope were not changed significantly after therapy. / Conclusion. beta-blocker treatment with either metoprolol or carvedilol does not decrease the slope of the VCO2 vs. VE relationship. The present observations may suggest that the exaggerated ventilatory response of patients with moderate HF is not mediated by beta-adrenergic receptors.

Population aging in Canada is associated with a rising burden of heart failure (HF), a condition associated with substantial morbidity, mortality and health service use. HF management involves pharmacotherapy, exercise, dietary restrictions and symptom monitoring. First-line combination pharmacotherapy for HF consists of an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) in conjunction with a β-adrenergic receptor blocker (β-blocker). This combination therapy can reduce mortality, improve symptoms and reduce health service use. However, evidence about the benefits of these therapies has been derived from randomized controlled trials in younger patients from acute care and specialty clinic settings. Little work has explored outcomes among older individuals and those in the community setting. In purposely studying an older cohort of individuals with HF, the goals of this research were three-fold: to comprehensively describe their sociodemographic, clinical and service use characteristics; to describe rates of usage of first-line HF pharmacotherapy and correlates of non-use; and to examine the outcomes of mortality, long-term care (LTC) admission, long-stay hospitalization, admission, new cognitive decline and new functional decline as well as predictors of these outcomes. To achieve these aims, this work made use of the extensive data available through the Resident Assessment Instrument – Home Care (RAI-HC) database in Ontario. The RAI-HC is mandated for use in Ontario to assess all long-stay home care clients (those expected to receive home care service for at least 60 days). This assessment contains over 300 items about sociodemographic and clinical characteristics, diagnoses, service use and geriatric conditions, such as functional abilities and cognition. The study samples included long-stay home care clients older than 65 years of age. The descriptive analyses (N=264,030) demonstrated that older home care clients with HF are a more complex group than home care clients without HF, with more comorbidity and higher use of medications and health care services. From the analyses examining pharmacotherapy use (N=176,860), rates of use of first-line pharmacotherapy were low, with only 30% of clients with HF receiving recommended combination first-line therapies, a similar proportion receiving no therapies and the remainder receiving at least one therapy. The multivariate analyses revealed that hypertension and diabetes mellitus diagnoses affect first-line therapy use. Regardless of clinical subgroup, use of these therapies was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Longitudinal analyses were done using Cox proportional hazards regression modeling (N=9,283) in which individuals were followed for nine months after each RAI-HC assessment. Results from these analyses showed that female gender and living alone reduced the risk of all outcomes except LTC admission, while age over 85 years generally increased the risk of all examined outcomes. Comprehensive clinical indicators, the Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale and Method for Assigning Priority Level (MAPLe) algorithm, increased the risk of all outcomes except new cognitive decline. ACE inhibitor use was protective of LTC admission and functional decline, but not mortality, long-stay hospitalizations or cognitive decline. The complexity of older individuals with HF could impair self-care abilities and points to the need for initiatives to help such individuals manage their care at home with appropriate support and services. The low rates of use of first-line pharmacotherapy among older home care clients with HF highlights the need for better understanding of which factors affect prescribing practices. Better evidence, that is more applicable to older individuals with HF, is needed about the therapeutic benefits of first-line therapies to help enhance the evidence base and improve patient care.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.