May 2, 2008 Researchers compared 60 heart failure outpatients to 30 outpatients with advanced cancer being treated at Johns Hopkins Hospital or Bayview Medical Center. Researchers found that heart failure outpatients suffer many of the same symptoms as advanced cancer patients and may need the same level of supportive or palliative care.
Heart failure outpatients have similar numbers of symptoms and levels of depression and spiritual well-being as patients with advanced lung and pancreatic cancer, researchers reported at the American Heart Association's 9th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.
In their study, researchers from the University of Colorado Denver School of Medicine also found that heart failure patients with "poor" health status had greater symptoms and depression and worse spiritual well-being than patients with advanced cancer.
The study compared 60 ambulatory heart failure patients to 30 outpatients with advanced cancer being treated at Johns Hopkins Hospital or Bayview Medical Center in Baltimore, Md. Those with heart failure were outpatients, able to attend clinics and complete questionnaires.
"There has been a lot of attention on improving the quality of life and reducing suffering in cancer patients, but less on patients with heart failure," said David Bekelman, M.D., M.P.H., lead author of the study. "Heart failure patients, particularly those with poor health status, need the option of palliative care."
Palliative care -- care devoted to improving quality of life and reducing suffering for patients with severe, life-threatening illnesses and their families -- is often used to help advanced cancer patients.
Disease and death in chronic heart failure is high, with the average survival of 1.6 years after a hospitalization. Heart failure can have a major impact on a patient's health status, contributing to symptom burden, functional limitations, and in turn depression, researchers said.
Researchers used the Memorial Symptom Assessment Scale-Short Form to assess symptom burden; Geriatric Depression Scale-Short Form for depression; Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale for spiritual well-being; and Kansas City Cardiomyopathy Questionnaire (KCCQ) for heart failure severity.
Researchers found no statistical difference among heart failure and cancer patients in measured physical symptoms, depression scores and spiritual well-being. The study also compared the same three parameters in heart failure patients with different ejection fractions. Ejection fraction is a common measure of heart function. Symptoms, depression and spiritual well-being were similar among heart failure patients with ejection fractions above and below 30, showing that while ejection fraction is a useful marker of heart failure severity, it did not correlate with quality of life domains.
However, heart failure patients with worse health status had a statistically greater number of physical symptoms (13.2 versus 8.6), higher depression scores (6.7 vs. 3.2) and lower spiritual well-being (29 vs. 38.9) than the cancer patients -- even after adjusting for age, gender, marital status, education and income.
"The main finding was that patients with heart failure have a similar burden of symptoms, depression and low levels of spiritual well-being as advanced cancer patients," said Bekelman, assistant professor of medicine at the University of Colorado Denver School of Medicine. "Advanced cancer patients are often quite sick and need care focused on quality of life in addition to care focused on the disease. We don't usually think about providing similar care to outpatients with heart failure."
"Patients with heart failure who are not at the end of life have palliative care needs," Bekelman said. "But palliative care has been markedly under-used in heart failure patients."
When researchers compared heart failure patients who had scores 50 or lower on the 100-point KCCQ (indicating poor health status) to the cancer patients, the heart failure patients had a statistically higher rate of symptoms and depression and a worse score on spiritual well-being.
Little research-based evidence exists to guide practitioners on which heart failure patients may benefit from palliative care. The study showed that KCCQ scores of under 50 can help identify patients who may benefit, Bekelman said.
"Heart failure patients' symptoms such as shortness of breath, fatigue, pain, constipation and dry mouth can be improved with medical management," he said. "Depression, which is common in patients with heart failure, can be treated with medications and counseling. Persistent symptoms can also contribute to depression, and treating persistent symptoms can help improve mood."
"Clinicians should not underestimate the importance of using supportive communication and empathy with heart failure patients to reduce both symptoms and depression," Bekelman said.
It may be helpful for physicians to get a chaplain or clergy member involved in the patient's care to improve spiritual well-being, Bekelman said, noting that other approaches used to improve spiritual well-being in cancer patients, such as dignity therapy and meaning-centered psychotherapy, should also be evaluated for heart failure patients.
Co-authors are: John S. Rumsfeld, M.D., Ph.D.; Edward P. Havranek, M.D.; Traci E. Yamashita, M.S.; Evelyn Hunt, M.D.; and Jean S. Kutner, M.D., M.S.P.H.
The study was funded by the Johns Hopkins Center for Complementary and Alternative Medicine; the Johns Hopkins General Clinical Research Center; and the National Center for Complimentary and Alternative Medicine, NIH.
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