Quality‐of‐Life Scores, Not New York Heart Association Classification, Predict Symptomatic Improvement among Patients with Acute Decompensated Heart Failure

Background:

Literature on measurement of symptomatic improvement in ADHF admitted to telemetry is sparse. Visual analog scales (VASs) are valid measures of dyspnea in ADHF. Because dyspnea is a complex psychobiologic phenomenon and the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) is a global measure of quality of life, we hypothesized that worse quality‐of‐life (QOL) scores would be associated with slower symptomatic improvement.

Methods:

MLWHFQ was administered to dyspneic patients with B‐type natriuretic peptide (BNP) levels > 100 pg/mL and a diagnosis of ADHF in the emergency department. Patients with rapid atrial fibrillation (AF) were excluded because rate‐related transient left ventricular dysfunction may occur and symptomatic improvement may occur with rate control alone. Hemodialysis patients, patients with sepsis, non‐English speakers, patients with acute coronary syndromes, and patients with dementia were also excluded. A visual analog scale (VAS) scored dyspnea (0‐10 cm); word anchors at 10 cm represent “unbearable” dyspnea, at 7 “very bad” dyspnea, at 4 “moderate” dyspnea, and at 0 “no” dyspnea. The VAS was shown in the emergency department close to the time of presentation and then daily. Patients were classified as slow responders (VAS score > 4: moderate or worse on rest dyspnea, orthopnea, or nocturnal dyspnea scales by day 2) or rapid responders (score < 4: mild or better on all 3 by day 2). Charlson Comorbidity Index (CCI) scores were extracted. A regression model adjusting for age, sex, ejection fraction (EF), comorbidity, and creatinine clearance was created.

Results:

Mean age of 113 enrollees was 65 ± 15 years, mean EF was 36% ± 19%, and 50% were male. Mean BNP was 973 ± 849 pg/mL. Fifty‐one patients were classified as rapid responders (RRs) and 62 as slow responders (SRs). Mean QOL scores were 42 ± 23 (95% Cl: 35–48) for RRs and 56 ± 21 (95% Cl 51–61) for SRs (P = 0.0004). Age, sex, comorbidity scores, NYHA classification grouping percentages, EF, and creatinine clearance did not differ significantly between the 2 groups. Higher QOL scores correlated with slower improvement with an odds ratio of 10.5 (95% Cl: 10.2–10.7) per 10‐point increase in QOL scores in favor of slow improvement (P < 0.0001). The influence of comorbidity was not significant. NYHA class did not predict symptomatic improvement (P = 0.055). Patients with VAS rest dyspnea scores on day 2 > 4 had higher MLWHFQ scores (61 ± 20, 95% Cl 54–67) than those with scores < 3 (43 ± 23, 95% Cl 38–49), P = 0.0001. Orthopnea scores had a similar trend (P = 0.0002). NYHA classification was a weaker predictor of improvement in rest dyspnea (P = 0.02) or orthopnea (P = 0.01) alone.

Conclusions:

Among patients with ADHF without rapid atrial fibrillation, higher MLWHFQ scores predict slower symptomatic improvement. Comorbidity does not contribute significantly to rapidity of symptomatic improvement. NYHA class is a less robust predictor of improvement in dyspnea and does not predict overall symptomatic improvement. Quality‐of‐life scores may have an important role in randomization strategies in trials of therapy of ADHF in the emergency department.

Author Disclosure:

V. Sharma, SUNY Downstate, Biosite provided material support; N, Rojas, none; E, Ko, none; P. Khullar, none; R. Amipara, none; S. Zehtabchi, none; R. Latif, none; R. Birkhahn, Methodist Hospital of Brooklyn, Biosite provided material support.