Till Örebro universitet

OBJECTIVE: To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care.

DESIGN: A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire.

SETTING: Three primary health care centres in Sweden.

SUBJECTS: Patients with a CHF diagnosis registered in their medical record.

MAIN OUTCOME MEASURES: Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9).

RESULTS: The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour.

CONCLUSION: Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

OBJECTIVE: To compare the level of exercise self-efficacy, symptoms, functional capacity and health status and investigate the association between these variables in patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). Additionally, to investigate how diagnosis, symptoms and patient characteristics are associated with exercise self-efficacy in these patient groups.

DESIGN: Cross-sectional study.

SETTING: Primary care.

SUBJECTS: Patients (n = 150) with COPD (n = 60), CHF (n = 60) and a double diagnosis (n = 30).

MAIN OUTCOME MEASURES: Swedish SCI Exercise Self-Efficacy score, modified Medical Research Council Dyspnea score (mMRC), fatigue score, pain severity score, Hospital Anxiety and Depression Scale, functional capacity measured as six-minute walking distance and health status measured by a Visual Analogue Scale.

RESULTS: Levels of exercise self-efficacy, health status and symptoms were alike for patients with COPD and patients with CHF. Functional capacity was similar after correction for age. Associations with exercise self-efficacy were found for slight dyspnea (mMRC = 1) (R -4.45; 95% CI -8.41- -0.50), moderate dyspnea (mMRC = 2) (-6.60;-10.68- -2.52), severe dyspnea (mMRC ≥ 3) (-9.94; -15.07- -4.80), fatigue (-0.87;-1.41- -0.32), moderate pain (-3.87;-7.52- -0.21) and severe pain (-5.32;-10.13- -0.52), symptoms of depression (-0.98;-1.42- -0.55) and anxiety (-0.65;-0,10- -0.32), after adjustment for diagnosis, sex and age.

CONCLUSION AND IMPLICATIONS: Patients with COPD or CHF have similar levels of exercise self-efficacy, symptoms, functional capacity and health status. More severe symptoms are associated with lower levels of exercise self-efficacy regardless of diagnosis, sex and age. When forming self-management groups with a focus on exercise self-efficacy, it seems more relevant to consider level of symptoms than the specific diagnosis of COPD or CHF.Key pointsExercise training is an important part of self-management in patients with COPD and chronic heart failure (CHF). High exercise self-efficacy is required for optimal exercise training.Patients with COPD and CHF have similar symptoms and similar levels of exercise self-efficacy, functional capacity and health status.Not the diagnosis, but symptoms of dyspnea, fatigue, pain, depression and anxiety are important factors influencing exercise self-efficacy and need to be addressed.When forming self-management groups with a focus on exercise self-efficacy, it seems more relevant to consider the level of symptoms than the specific diagnosis of COPD or CHF.

Purpose: The aim of this study was to examine the changing influence over time of comorbid heart disease on symptoms and health status in patients with COPD.

Patients and methods: This is a prospective cohort study of 495 COPD patients with a baseline in 2005 and follow-up in 2012. The study population was divided into three groups: patients without heart disease (no-HD), those diagnosed with heart disease during the study period (new-HD) and those with heart disease at baseline (HD). Symptoms were measured using the mMRC. Health status was measured using the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT; only available in 2012). Logistic regression with mMRC $2 and linear regression with CCQ and CAT scores in 2012 as dependent variables were performed unadjusted, adjusted for potential confounders, and additionally adjusted for baseline mMRC, respectively, CCQ scores.

Results: Mean mMRC worsened from 2005 to 2012 as follows: for the no-HD group from 1.8 (+/- 1.3) to 2.0 (+/- 1.4), (P=0.003), for new-HD from 2.2 (+/- 1.3) to 2.4 (+/- 1.4), (P=0.16), and for HD from 2.2 (+/- 1.3) to 2.5 (+/- 1.4), (P=0.03). In logistic regression adjusted for potential confounding factors, HD (OR 1.71; 95% CI: 1.03-2.86) was associated with mMRC $ 2. Health status worsened from mean CCQ as follows: for no-HD from 1.9 (+/- 1.2) to 2.1 (+/- 1.3) with (P=0.01), for new-HD from 2.3 (+/- 1.5) to 2.6 (+/- 1.6) with (P=0.07), and for HD from 2.4 (+/- 1.1) to 2.5 (+/- 1.2) with (P=0.57). In linear regression adjusted for potential confounders, HD (regression coefficient 0.12; 95% CI: 0.04-5.91) and new-HD (0.15; 0.89-5.92) were associated with higher CAT scores. In CCQ functional state domain, new-HD (0.14; 0.18-1.16) and HD (0.12; 0.04-0.92) were associated with higher scores. After additional correction for baseline mMRC and CCQ, no statistically significant associations were found.

Conclusion: Heart disease contributes to lower health status and higher symptom burden in COPD but does not accelerate the worsening over time.