Publications by authors named "Quin E Denfeld"

24 Publications

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Longitudinal Effects of Left Ventricular Assist Device Implantation on Global and Domain-Specific Cognitive Function.

J Cardiovasc Nurs 2020 Jun 22. Epub 2020 Jun 22.

Kenneth M. Faulkner, PhD, RN, ANP Postdoctoral Research Fellow, Boston College Connell School of Nursing, Chestnut Hill, Massachusetts; and Clinical Assistant Professor, Stony Brook University School of Nursing, New York. Christopher V. Chien, MD, FACC Clinical Assistant Professor of Medicine, University of North Carolina, Chapel Hill. Quin E. Denfeld, PhD, RN Assistant Professor, Oregon Health & Science University School of Nursing, Portland. Jill M. Gelow, MD, MPH Advanced Heart Failure and Transplant Cardiologist, Providence Health Institute, Portland, Oregon. Karen S. Lyons, PhD, FGSA Associate Professor, Boston College Connell School of Nursing, Chestnut Hill, Massachusetts. Kathleen L. Grady, PhD, MS, RN, FAHA, FHFSA, FAAN Professor of Cardiothoracic Surgery and Cardiac Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. James O. Mudd, MD Advanced Heart Disease and Transplant Cardiologist, Providence Spokane Heart Institute, Spokane, Washington. Christopher S. Lee, PhD, FAHA, FHFSA, FAAN Professor and Associate Dean for Research, Boston College Connell School of Nursing, Chestnut Hill, Massachusetts.

Background: Left ventricular assist devices (LVADs) are a common treatment of advanced heart failure, but cognitive dysfunction, which is common in heart failure, could limit the ability to perform postimplantation LVAD care. Implantation of an LVAD has been associated with improved cerebral perfusion and may improve cognitive function post implantation.

Objective: The aim of this study was to quantify longitudinal change in cognitive function after LVAD implantation.

Methods: A secondary analysis of data on 101 adults was completed to evaluate cognitive function before implantation and again at 1, 3, and 6 months post implantation of an LVAD. Latent growth curve modeling was conducted to characterize change over time. Serial versions of the Montreal Cognitive Assessment were used to measure overall (total) cognitive function and function in 6 cognitive domains.

Result: There was moderate, nonlinear improvement from preimplantation to 6 months post implantation in Montreal Cognitive Assessment total score (Hedges' g = 0.50) and in short-term memory (Hedges' g = 0.64). There also were small, nonlinear improvements in visuospatial ability, executive function, and attention from preimplantation to 6 months post implantation (Hedges' g = 0.20-0.28). The greatest improvements were observed in the first 3 months after implantation and were followed by smaller, sustained improvements or no additional significant change.

Conclusions: Implantation of an LVAD is associated with significant, nonlinear improvement in short-term memory and global cognitive function, with the most significant improvements occurring in the first 3 months after implantation. Clinicians should anticipate improvements in cognitive function after LVAD implantation and modify postimplantation education to maximize effectiveness of LVAD self-care.
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http://dx.doi.org/10.1097/JCN.0000000000000709DOI Listing
June 2020

Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis.

Int J Cardiol 2021 Feb 28. Epub 2021 Feb 28.

Oregon Health & Science University School of Nursing, 3455 S.W. U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA. Electronic address:

Objectives: This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF).

Background: The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood.

Methods: We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF.

Results: Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class.

Conclusions: In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.062DOI Listing
February 2021

Feasibility and potential benefits of partner-supported yoga on psychosocial and physical function among lung cancer patients.

Psychooncology 2021 Jan 16. Epub 2021 Jan 16.

Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA.

Objective: Patients with lung cancer experience significant declines in psychosocial and physical function during and after treatment that impact quality of life (QOL) and survival. Yoga is a potential strategy to mitigate functional decline among patients with lung cancer.

Methods: A single group 12-week pilot trial of low-moderate intensity yoga among patients with stage I-IV lung cancer and their partners (n = 46; 23 patient-partner dyads) during cancer treatment from two hospital systems. Feasibility, acceptability, descriptive statistics, and Cohen d effect sizes were calculated at 6 and 12-weeks for psychosocial and physical outcomes using validated questionnaires and assessments.

Results: At 6 and 12-weeks, retention was 65% and withdrawals were mainly due to disease progression. Among study completers (n = 26; 13 dyads) adherence was 80%. Comparing baseline to 12-week measurements, fatigue, depression symptoms, and sleep disturbance improved in 54% of participants for all three measures (Cohen's d = 0.40-0.53). QOL improved in 77% of participants (Cohen's d = 0.34). Upper and lower body flexibility, and lower body strength improved in 92%, 85% and 77% of participants, respectively (Cohen's d = 0.39-1.08). Six-minute walk test improved in 62% of participants an average of 32 meters (SD = 11.3; Cohen's d = 0.17). No serious adverse events were reported.

Conclusions: Among patients with stage I-IV lung cancer including active treatment, a 12-week partner-supported yoga program is feasible, acceptable, and improved psychosocial and physical function. Low-intensity yoga may be a complimentary approach to reduce the effects of cancer treatment, however, more research is needed to determine the efficacy of partner-supported yoga to mitigate functional decline.
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http://dx.doi.org/10.1002/pon.5628DOI Listing
January 2021

Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis.

ESC Heart Fail 2020 Sep 21. Epub 2020 Sep 21.

Department of Clinical Nursing, Faculty of Health Sciences, Wroclaw Medical University, Bartla 5, Wroclaw, 51-618, Poland.

To estimate the risk of all-cause mortality and hospitalization in frail patients with chronic heart failure (HF), a systematic search and meta-analysis was carried out to identify all prospective cohort studies conducted among adults with HF where frailty was quantified and related to the primary endpoints of all-cause mortality and/or hospitalization. Twenty-nine studies reporting the link between frailty and all-cause mortality in 18 757 patients were available for the meta-analysis, along with 11 studies, with 13 525 patients, reporting the association between frailty and hospitalization. Frailty was a predictor of all-cause mortality and hospitalization with summary hazard ratios (HRs) of 1.48 [95% confidence interval (CI): 1.31-1.65, P < 0.001] and 1.40 (95% CI: 1.27-1.54, P < 0.001), respectively. Summary HRs for all-cause mortality among frail inpatients undergoing ventricular assist device implantation, inpatients hospitalized for HF, and outpatients were 1.46 (95% CI: 1.18-1.73, P < 0.001), 1.58 (95% CI: 0.94-2.22, P = not significant), and 1.53 (95% CI: 1.28-1.78, P < 0.001), respectively. Summary HRs for all-cause mortality and frailty based on Fried's phenotype were 1.48 (95% CI: 1.03-1.93, P < 0.001) and 1.42 (95% CI: 1.05-1.79, P < 0.001) for inpatients and outpatients, respectively, and based on other frailty measures were 1.42 (95% CI: 1.12-1.72, P < 0.001) and 1.60 (95% CI: 1.43-1.77, P < 0.001) for inpatients and outpatients, respectively. Across clinical contexts, frailty in chronic HF is associated with an average of 48% and 40% increase in the hazard of all-cause mortality and hospitalization, respectively. The relationship between frailty and all-cause mortality is similar across clinical settings and comparing measurement using Fried's phenotype or other measures.
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http://dx.doi.org/10.1002/ehf2.12827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754732PMC
September 2020

Identifying unique profiles of perceived dyspnea burden in heart failure.

Heart Lung 2020 Sep - Oct;49(5):488-494. Epub 2020 May 18.

William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Maloney Hall, Chestnut Hill, MA  02467, United States. Electronic address:

Background: Dyspnea is a common symptom of heart failure (HF) but dyspnea burden is highly variable.

Objectives: Identify distinct profiles of dyspnea burden and identify predictors of dyspnea symptom profile.

Methods: A secondary analysis of data from five studies completed at Oregon Health and Science University was conducted. The Heart Failure Somatic Perception Scale was used to measure dyspnea burden. Latent class mixture modeling identified distinct profiles of dyspnea burden in a sample of HF patients (n = 449). Backwards stepwise multinomial logistic regression identified predictors of latent profile membership.

Results: Four profiles of dyspnea burden were identified: no dyspnea/not bothered by dyspnea, mild dyspnea, moderate exertional dyspnea, and moderate exertional dyspnea with orthopnea and PND. Higher age was associated with greater likelihood of not being bothered by dyspnea than having moderate exertional dyspnea with orthopnea and PND. Higher NYHA class, anxiety, and depression were associated with greater likelihood of greater dyspnea burden.

Conclusions: Burden of dyspnea is highly variable among HF patients. Clinicians should account for the nuances of dyspnea and the activities that induce dyspnea when assessing HF patients.
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http://dx.doi.org/10.1016/j.hrtlng.2020.03.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483352PMC
March 2021

Cross-classification of physical and affective symptom clusters and 180-day event-free survival in moderate to advanced heart failure.

Heart Lung 2020 Mar - Apr;49(2):151-157. Epub 2019 Nov 18.

Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA.

Background: The relationship between physical and affective symptom clusters in heart failure (HF) is unclear.

Objectives: To identify associations between physical and affective symptom clusters in HF and to quantify outcomes and determinants of symptom subgroups.

Methods: This was a secondary analysis of data from two cohort studies among adults with HF. Physical and affective symptom clusters were compared using cross-classification modeling. Cox proportional hazards modeling and multinomial logistic regression were used to identify outcomes and determinants of symptom subgroups, respectively.

Results: In this young, mostly male sample (n = 274), physical and affective symptom clusters were cross-classified in a model with acceptable fit. Three symptom subgroups were identified: congruent-mild (69.3%), incongruent (13.9%), and congruent-severe (16.8%). Compared to the congruent-mild symptom group, the incongruent symptom group had significantly worse 180-day event-free survival.

Conclusion: Congruence between physical and affective symptom clusters should be considered when identifying patients at higher risk for poor outcomes.
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http://dx.doi.org/10.1016/j.hrtlng.2019.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7124999PMC
November 2020

Sympathetic Markers are Different Between Clinical Responders and Nonresponders After Left Ventricular Assist Device Implantation.

J Cardiovasc Nurs 2019 Jul/Aug;34(4):E1-E10

Quin E. Denfeld, PhD, RN Knight Cardiovascular Institute and Department of Physiology & Pharmacology, Oregon Health & Science University, Portland. Christopher S. Lee, PhD, RN, FAAN, FAHA, FHFSA William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts. William R. Woodward, PhD Department of Physiology & Pharmacology and Department of Neurology, Oregon Health & Science University, Portland. Shirin O. Hiatt, MS, RN, MPH School of Nursing, Oregon Health & Science University, Portland. James O. Mudd, MD Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Beth A. Habecker, PhD Knight Cardiovascular Institute and Department of Physiology & Pharmacology, Oregon Health & Science University, Portland.

Background: Clinical response to left ventricular assist devices (LVADs), as measured by health-related quality of life, varies among patients after implantation; however, it is unknown which pathophysiological mechanisms underlie differences in clinical response by health-related quality of life.

Objective: The purpose of this study was to compare changes in sympathetic markers (β-adrenergic receptor kinase-1 [βARK1], norepinephrine [NE], and 3,4-dihydroxyphenylglycol [DHPG]) between health-related quality of life clinical responders and nonresponders from pre- to post-LVAD implantation.

Methods: We performed a secondary analysis on a subset of data from a cohort study of patients from pre- to 1, 3, and 6 months after LVAD implantation. Clinical response was defined as an increase of 5 points or higher on the Kansas City Cardiomyopathy Questionnaire Clinical Summary score from pre- to 6 months post-LVAD implantation. We measured plasma βARK1 level with an enzyme-linked immunosorbent assay and plasma NE and DHPG levels with high-performance liquid chromatography with electrochemical detection. Latent growth curve modeling was used to compare the trajectories of markers between groups.

Results: The mean (SD) age of the sample (n = 39) was 52.9 (13.2) years, and most were male (74.4%) and received LVADs as bridge to transplantation (69.2%). Preimplantation plasma βARK1 levels were significantly higher in clinical responders (n = 19) than in nonresponders (n = 20) (P = .001), but change was similar after LVAD (P = .235). Preimplantation plasma DHPG levels were significantly lower in clinical responders than in nonresponders (P = .002), but the change was similar after LVAD (P = .881). There were no significant differences in plasma NE levels.

Conclusions: Preimplantation βARK1 and DHPG levels are differentiating factors between health-related quality of life clinical responders and nonresponders to LVAD, potentially signaling differing levels of sympathetic stimulation underlying clinical response.
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http://dx.doi.org/10.1097/JCN.0000000000000580DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527339PMC
October 2020

Heart Failure Symptom Biology in Response to Ventricular Assist Device Implantation.

J Cardiovasc Nurs 2019 Mar/Apr;34(2):174-182

Christopher S. Lee, PhD, RN, FAHA, FAAN, FHFSA Professor and Associate Dean for Research, Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts. James O. Mudd, MD Associate Professor, Oregon Health & Science University Knight Cardiovascular Institute, Portland. Karen S. Lyons, PhD, FGSA Associate Professor, Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts. Quin E. Denfeld, PhD, RN Assistant Professor, Oregon Health & Science University School of Nursing, Portland. Corrine Y. Jurgens, PhD, RN, FAHA, FAAN, FHFSA Associate Professor, Stony Brook University School of Nursing, New York. Bradley E. Aouizerat, MS, PhD Professor, New York University School of Dentistry, Department of Oral and Maxillofacial Surgery. Jill M. Gelow, MD, MPH Cardiologist, Providence Health, Portland, Oregon. Christopher V. Chien, MD Assistant Professor, University of North Carolina REX Healthcare, Raleigh. Emily Aarons Undergraduate Research Fellow, Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts. Kathleen L. Grady, PhD, RN, FAHA, FAAN, FHFSA Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF), particularly in response to left ventricular assist device (LVAD) implantation.

Objective: The aim of this study was to quantify the degree to which symptoms and biomarkers change in parallel from before implantation through the first 6 months after LVAD implantation in advanced HF.

Methods: This was a prospective cohort study of 101 patients receiving an LVAD for the management of advanced HF. Data on symptoms (dyspnea, early and subtle symptoms [HF Somatic Perception Scale], pain severity [Brief Pain Inventory], wake disturbance [Epworth Sleepiness Scale], depression [Patient Health Questionnaire], and anxiety [Brief Symptom Inventory]) and peripheral biomarkers of myocardial stretch, systemic inflammation, and hypervolumetric mechanical stress were measured before implantation with a commercially available LVAD and again at 30, 90, and 180 days after LVAD implantation. Latent growth curve and parallel process modeling were used to describe changes in symptoms and biomarkers and the degree to which they change in parallel in response to LVAD implantation.

Results: In response to LVAD implantation, changes in myocardial stretch were closely associated with changes in early and subtle physical symptoms as well as depression, and changes in hypervolumetric stress were closely associated with changes in pain severity and wake disturbances. Changes in systemic inflammation were not closely associated with changes in physical or affective symptoms in response to LVAD implantation.

Conclusions: These findings provide new insights into the many ways in which symptoms and biomarkers provide concordant or discordant information about LVAD response.
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http://dx.doi.org/10.1097/JCN.0000000000000552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481644PMC
May 2020

Comparative symptom biochemistry between moderate and advanced heart failure.

Heart Lung 2018 11 9;47(6):565-575. Epub 2018 Oct 9.

Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, United States.

Background: We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF).

Objectives: The purpose of this paper was to compare relationships between peripheral biomarkers of HF pathogenesis and physical symptoms between patients with advanced versus moderate HF.

Methods: This was a two-stage phenotype sampling cohort study wherein we examined patients with advanced HF undergoing ventricular assist device implantation in the first stage, and then patients with moderate HF (matched adults with HF not requiring device implantation) in the second stage. Linear modeling was used to compare relationships among biomarkers and physical symptoms between cohorts.

Results: Worse myocardial stress, systemic inflammation and endothelial dysfunction were associated with worse physical symptoms in moderate HF (n=48), but less physical symptom burden in advanced HF (n=48).

Conclusions: Where patients are in the HF trajectory needs to be taken into consideration when exploring biological underpinnings of physical HF symptoms.
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http://dx.doi.org/10.1016/j.hrtlng.2018.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530561PMC
November 2018

The Crossroads of Frailty and Heart Failure: What More Can We Learn?

J Card Fail 2018 11 6;24(11):733-734. Epub 2018 Oct 6.

Boston College William F. Connell School of Nursing, Chestnut Hill, Massachusetts.

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http://dx.doi.org/10.1016/j.cardfail.2018.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261512PMC
November 2018

Exploring the relationship between β-adrenergic receptor kinase-1 and physical symptoms in heart failure.

Heart Lung 2018 Jul - Aug;47(4):281-284. Epub 2018 May 24.

Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA.

Background: The relationship between physical heart failure (HF) symptoms and pathophysiological mechanisms is unclear.

Objective: To quantify the relationship between plasma β-adrenergic receptor kinase-1 (βARK1) and physical symptoms among adults with HF.

Methods: We performed a secondary analysis of data collected from two studies of adults with HF. Plasma βARK1 was quantified using an enzyme-linked immunosorbent assay. Physical symptoms were measured with the HF Somatic Perception Scale (HFSPS). Generalized linear modeling was used to quantify the relationship between βARK1 and HFSPS scores.

Results: The average age (n = 94) was 54.5 ± 13.1 years, 76.6% were male, and a majority (83.0%) had Class III or IV HF. βARK1 was significantly associated with HFSPS scores (β = 0.22 ± 0.10, p = 0.038), adjusting for other predictors of physical symptoms (model R = 0.250, F(7, 70) = 3.34, p = 0.004).

Conclusions: Higher βARK1 is associated with worse physical HF symptoms, pinpointing a potential pathophysiologic underpinning.
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http://dx.doi.org/10.1016/j.hrtlng.2018.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295114PMC
February 2019

Measurement of plasma norepinephrine and 3,4-dihydroxyphenylglycol: method development for a translational research study.

BMC Res Notes 2018 Apr 19;11(1):248. Epub 2018 Apr 19.

Department of Physiology & Pharmacology, Oregon Health & Science University, Portland, OR, USA.

Objective: Norepinephrine (NE), a sympathetic neurotransmitter, is often measured in plasma as an index of sympathetic activity. To better understand NE dynamics, it is important to measure its principal metabolite, 3,4-dihydroxyphenylglycol (DHPG), concurrently. Our aim was to present a method, developed in the course of a translational research study, to measure NE and DHPG in human plasma using high performance liquid chromatography with electrochemical detection (HPLC-ED).

Results: After pre-purifying plasma samples by alumina extraction, we used HPLC-ED to separate and quantify NE and DHPG. In order to remove uric acid, which co-eluted with DHPG, a sodium bicarbonate wash was added to the alumina extraction procedure, and we oxidized the column eluates followed by reduction because catechols are reversibly oxidized whereas uric acid is irreversibly oxidized. Average recoveries of plasma NE and DHPG were 35.3 ± 1.0% and 16.3 ± 1.1%, respectively, and there was no detectable uric acid. Our estimated detection limits for NE and DHPG were approximately 85 pg/mL (0.5 pmol/mL) and 165 pg/mL (0.9 pmol/mL), respectively. The measurement of NE and DHPG in human plasma has wide applicability; thus, we describe a method to quantify plasma NE and DHPG in a laboratory setting as a useful tool for translational and clinical research.
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http://dx.doi.org/10.1186/s13104-018-3352-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909231PMC
April 2018

Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices.

J Cardiovasc Nurs 2018 Mar/Apr;33(2):144-151

Christopher S. Lee, PhD, RN, FAHA, FAAN, FHFSA Carol A. Lindeman Distinguished Professor, School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Christopher V. Chien, MD Assistant Professor, REX Healthcare, University of North Carolina, Raleigh. Shirin O. Hiatt, MPH, MS, RN Project Coordinator, School of Nursing, Oregon Health & Science University, Portland. Julie T. Bidwell, PhD, RN Post-doctoral Fellow, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. Quin E. Denfeld, PhD, RN Post-doctoral Fellow, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Kathleen L. Grady, PhD, RN, FAHA, FAAN, FHFSA Professor, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. James O. Mudd, MD Associate Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland.

Background: Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD.

Methods: The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD.

Results: The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05).

Conclusion: There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.
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http://dx.doi.org/10.1097/JCN.0000000000000430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173804PMC
July 2019

Identifying a Relationship Between Physical Frailty and Heart Failure Symptoms.

J Cardiovasc Nurs 2018 Jan/Feb;33(1):E1-E7

Quin E. Denfeld, PhD, RN Post-Doctoral Fellow, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Kerri Winters-Stone, PhD, FACSM Elnora E. Thompson Distinguished Professor, Research Professor, School of Nursing and Knight Cancer Institute, Oregon Health & Science University, Portland. James O. Mudd, MD Associate Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Shirin O. Hiatt, MS, MPH, RN Research Associate, School of Nursing, Oregon Health & Science University, Portland. Christopher S. Lee, PhD, RN, FAHA, FAAN, FHFSA Carol A. Lindeman Distinguished Professor, Associate Professor, Knight Cardiovascular Institute and School of Nursing, Oregon Health & Science University, Portland.

Background: Heart failure (HF) is a complex clinical syndrome associated with significant symptom burden; however, our understanding of the relationship between symptoms and physical frailty in HF is limited.

Objective: The aim of this study was to quantify associations between symptoms and physical frailty in adults with HF.

Methods: A sample of adults with symptomatic HF were enrolled in a cross-sectional study. Physical symptoms were measured with the HF Somatic Perception Scale-Dyspnea subscale, the Epworth Sleepiness Scale, and the Brief Pain Inventory short form. Affective symptoms were measured with the Patient Health Questionnaire-9 and the Brief Symptom Inventory-Anxiety scale. Physical frailty was assessed according to the Frailty Phenotype Criteria: shrinking, weakness, slowness, physical exhaustion, and low physical activity. Comparative statistics and generalized linear modeling were used to quantify associations between symptoms and physical frailty, controlling for Seattle HF Model projected 1-year survival.

Results: The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were male, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physically frail participants had more than twice the level of dyspnea (P < .001), 75% worse wake disturbances (P < .001), and 76% worse depressive symptoms (P = .003) compared with those who were not physically frail. There were no differences in pain or anxiety.

Conclusions: Physically frail adults with HF have considerably worse dyspnea, wake disturbances, and depression. Targeting physical frailty may help identify and improve physical and affective symptoms in HF.
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http://dx.doi.org/10.1097/JCN.0000000000000408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617768PMC
August 2018

The prevalence of frailty in heart failure: A systematic review and meta-analysis.

Int J Cardiol 2017 Jun 10;236:283-289. Epub 2017 Feb 10.

Oregon Health & Science University Knight Cardiovascular Institute, Portland, OR, USA; Oregon Health & Science University School of Nursing, Portland, OR, USA.

Background: There is a growing interest in the intersection of heart failure (HF) and frailty; however, estimates of the prevalence of frailty in HF vary widely. The purpose of this paper was to quantitatively synthesize published literature on the prevalence of frailty in HF and to examine the relationship between study characteristics (i.e. age and functional class) and the prevalence of frailty in HF.

Methods: The prevalence of frailty in HF, divided into Physical Frailty and Multidimensional Frailty measures, was synthesized across published studies using a random-effects meta-analysis of proportions approach. Meta-regression was performed to examine the influence of age and functional class (at the level of the study) on the prevalence of frailty.

Results: A total of 26 studies involving 6896 patients with HF were included in this meta-analysis. Despite considerable differences across studies, the overall estimated prevalence of frailty in HF was 44.5% (95% confidence interval, 36.2%-52.8%; z=10.54; p<0.001). The prevalence was slightly lower among studies using Physical Frailty measures (42.9%, z=9.05; p<0.001) and slightly higher among studies using Multidimensional Frailty measures (47.4%, z=5.66; p<0.001). There were no significant relationships between study age or functional class and prevalence of frailty.

Conclusions: Frailty affects almost half of patients with HF and is not necessarily a function of age or functional classification. Future work should focus on standardizing the measurement of frailty and on broadening the view of frailty beyond a strictly geriatric syndrome in HF.
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http://dx.doi.org/10.1016/j.ijcard.2017.01.153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392144PMC
June 2017

Frequency of and Significance of Physical Frailty in Patients With Heart Failure.

Am J Cardiol 2017 04 25;119(8):1243-1249. Epub 2017 Jan 25.

Oregon Health and Science University Knight Cardiovascular Institute, Portland, Oregon; Oregon Health and Science University School of Nursing, Portland, Oregon.

Physical frailty is an important prognostic indicator in heart failure (HF); however, few studies have examined the relation between physical frailty and invasive hemodynamics among adults with HF. The purpose of this study was to characterize physical frailty in HF in relation to invasive hemodynamics. We enrolled 49 patients with New York Heart Association class II to IV HF when participants were scheduled for a right-sided cardiac heart catheterization procedure. Physical frailty was measured according to the "frailty phenotype": shrinking, weakness, slowness, physical exhaustion, and low physical activity. Markers of invasive hemodynamics were derived from a formal review of right-sided cardiac catheterization tracings, and projected survival was calculated using the Seattle HF model. The mean age of the sample (n = 49) was 57.4 ± 9.7 years, 67% were men, 92% had New York Heart Association class III/IV HF, and 67% had nonischemic HF. Physical frailty was identified in 24 participants (49%) and was associated with worse Seattle HF model 1-year projected survival (p = 0.007). After adjusting for projected survival, physically frail participants had lower cardiac index (by both thermodilution and the Fick equation) and higher heart rates compared with those not physically frail (all p <0.05). In conclusion, physical frailty is highly prevalent in patients with HF and is associated with low-output HF.
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http://dx.doi.org/10.1016/j.amjcard.2016.12.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366261PMC
April 2017

Gender-Specific Physical Symptom Biology in Heart Failure.

J Cardiovasc Nurs 2015 Nov-Dec;30(6):517-21

Christopher S. Lee, PhD, RN, FAHA Associate Professor, School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Shirin O. Hiatt, MPH, MS, RN Research Project Coordinator, School of Nursing, Oregon Health & Science University, Portland. Quin E. Denfeld, BSN, RN PhD Student, School of Nursing, Oregon Health & Science University, Portland. Christopher V. Chien, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. James O. Mudd, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland.

Background: There are several gender differences that may help explain the link between biology and symptoms in heart failure (HF).

Objective: The aim of this study was to examine gender-specific relationships between objective measures of HF severity and physical symptoms.

Methods: Detailed clinical data, including left ventricular ejection fraction and left ventricular internal end-diastolic diameter, and HF-specific physical symptoms were collected as part of a prospective cohort study. Gender interaction terms were tested in linear regression models of physical symptoms.

Results: The sample (101 women and 101 men) averaged 57 years of age and most participants (60%) had class III/IV HF. Larger left ventricle size was associated with better physical symptoms for women and worse physical symptoms for men.

Conclusion: Decreased ventricular compliance may result in worse physical HF symptoms for women and dilation of the ventricle may be a greater progenitor of symptoms for men with HF.
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http://dx.doi.org/10.1097/JCN.0000000000000191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400191PMC
August 2016

Symptom-Hemodynamic Mismatch and Heart Failure Event Risk.

J Cardiovasc Nurs 2015 Sep-Oct;30(5):394-402

Christopher S. Lee, PhD, RN, FAHA Associate Professor, School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Shirin O. Hiatt, MPH, MS, RN Research Project Coordinator, School of Nursing, Oregon Health & Science University, Portland. Quin E. Denfeld, BSN, RN PhD Student and Research Associate, School of Nursing, Oregon Health & Science University, Portland. James O. Mudd, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Christopher Chien, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland.

Background: Heart failure (HF) is a heterogeneous condition of both symptoms and hemodynamics.

Objective: The goals of this study were to identify distinct profiles among integrated data on physical and psychological symptoms and hemodynamics and quantify differences in 180-day event risk among observed profiles.

Methods: A secondary analysis of data collected during 2 prospective cohort studies by a single group of investigators was performed. Latent class mixture modeling was used to identify distinct symptom-hemodynamic profiles. Cox proportional hazards modeling was used to quantify difference in event risk (HF emergency visit, hospitalization, or death) among profiles.

Results: The mean age (n = 291) was 57 ± 13 years, 38% were female, and 61% had class III/IV HF. Three distinct symptom-hemodynamic profiles were identified: 17.9% of patients had concordant symptoms and hemodynamics (ie, moderate physical and psychological symptoms matched the comparatively good hemodynamic profile), 17.9% had severe symptoms and average hemodynamics, and 64.2% had poor hemodynamics and mild symptoms. Compared with those in the concordant profile, both profiles of symptom-hemodynamic mismatch were associated with a markedly increased event risk (severe symptoms hazards ratio, 3.38; P = .033; poor hemodynamics hazards ratio, 3.48; P = .016).

Conclusions: A minority of adults with HF have concordant symptoms and hemodynamics. Either profile of symptom-hemodynamic mismatch in HF is associated with a greater risk of healthcare utilization for HF or death.
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http://dx.doi.org/10.1097/JCN.0000000000000175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4281513PMC
May 2016

Physical and psychological symptom biomechanics in moderate to advanced heart failure.

J Cardiovasc Nurs 2015 Jul-Aug;30(4):346-50

Quin E. Denfeld, BSN, RN PhD Student, School of Nursing, Oregon Health & Science University, Portland. James O. Mudd, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Christopher Chien, MD Assistant Professor, Knight Cardiovascular Institute, Oregon Health & Science University, Portland. Shirin O. Hiatt, MPH, MS, RN Research Associate, School of Nursing, Oregon Health & Science University, Portland. Christopher S. Lee, PhD, RN, FAHA Assistant Professor, School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland.

Background: There is a common dissociation between objective measures and patient symptomatology in heart failure (HF).

Objective: The aim of this study was to explore the relationship between cardiac biomechanics and physical and psychological symptoms in adults with moderate to advanced HF.

Methods: We performed a secondary analysis of data from 2 studies of symptoms among adults with HF. Stepwise regression modeling was performed to examine the influence of cardiac biomechanics (left ventricular internal diastolic diameter, right atrial pressure [RAP], and cardiac index) on symptoms.

Results: The average age of the sample (n = 273) was 57 ± 16 years, 61% were men, and 61% had class III or IV HF. Left ventricular internal diastolic diameter (β = 4.22 ± 1.63, P = .011), RAP (β = 0.71 ± 0.28, P = .013), and cardiac index (β = 7.11 ± 3.19, P = .028) were significantly associated with physical symptoms. Left ventricular internal diastolic diameter (β = 0.10 ± 0.05, P = .038) and RAP (β = 0.03 ± 0.01, P = .039) were significantly associated with anxiety. There were no significant biomechanical determinants of depression.

Conclusion: Cardiac biomechanics were related to physical symptoms and anxiety, providing preliminary evidence of the biological underpinnings of symptomatology among adults with HF.
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http://dx.doi.org/10.1097/JCN.0000000000000171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263019PMC
March 2016

Comorbidity profiles and inpatient outcomes during hospitalization for heart failure: an analysis of the U.S. Nationwide inpatient sample.

BMC Cardiovasc Disord 2014 Jun 5;14:73. Epub 2014 Jun 5.

Oregon Health & Science University School of Nursing and Knight Cardiovascular Institute, 3455 SW US Veterans Hospital Road, Portland, OR 97239-2941, USA.

Background: Treatment of heart failure (HF) is particularly complex in the presence of comorbidities. We sought to identify and associate comorbidity profiles with inpatient outcomes during HF hospitalizations.

Methods: Latent mixture modeling was used to identify common profiles of comorbidities during adult hospitalizations for HF from the 2009 Nationwide Inpatient Sample (n = 192,327).

Results: Most discharges were characterized by "common" comorbidities. A "lifestyle" profile was characterized by a high prevalence of uncomplicated diabetes, hypertension, chronic pulmonary disorders and obesity. A "renal" profile had the highest prevalence of renal disease, complicated diabetes, and fluid and electrolyte imbalances. A "neurovascular" profile represented the highest prevalence of cerebrovascular disease, paralysis, myocardial infarction and peripheral vascular disease. Relative to the common profile, the lifestyle profile was associated with a 15% longer length of stay (LOS) and 12% greater cost, the renal profile was associated with a 30% higher risk of death, 27% longer LOS and 24% greater cost, and the neurovascular profile was associated with a 45% higher risk of death, 34% longer LOS and 37% greater cost (all p < 0.001).

Conclusions: Comorbidity profiles are helpful in identifying adults at higher risk of death, longer length of stay, and accumulating greater costs during hospitalizations for HF.
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http://dx.doi.org/10.1186/1471-2261-14-73DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057902PMC
June 2014

Background and design of the profiling biobehavioral responses to mechanical support in advanced heart failure study.

J Cardiovasc Nurs 2014 Sep-Oct;29(5):405-15

Christopher S. Lee, PhD, RN, FAHA Associate Professor, Schools of Nursing and Medicine, Oregon Health & Science University, Portland. James O. Mudd, MD Assistant Professor, Director of Heart Failure/Transplant Cardiology, School of Medicine, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, School of Medicine, Oregon Health & Science University, Portland. Thuan Nguyen, MD, PhD Assistant Professor, School of Medicine, Oregon Health & Science University, Portland. Shirin O. Hiatt, MPH, MS, RN Research Project Director, School of Nursing, Oregon Health & Science University, Portland. Jennifer K. Green, MS Research Associate, School of Nursing, Oregon Health & Science University, Portland. Quin E. Denfeld, BSN, RN, CCRN Research Associate, School of Nursing, Oregon Health & Science University, Portland. Julie T. Bidwell, BSN, RN Research Associate, School of Nursing, Oregon Health & Science University, Portland. Kathleen L. Grady, PhD, APN, FAHA, FAAN Associate Professor, Administrative Director, Center for Heart Failure, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Background: Unexplained heterogeneity in response to ventricular assist device (VAD) implantation for the management of advanced heart failure impedes our ability to predict favorable outcomes, provide adequate patient and family education, and personalize monitoring and symptom management strategies. The purpose of this article was to describe the background and the design of a study entitled "Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure" (PREMISE).

Study Design And Methods: PREMISE is a prospective cohort study designed to (1) identify common and distinct trajectories of change in physical and psychological symptom burden; (2) characterize common trajectories of change in serum biomarkers of myocardial stress, systemic inflammation, and endothelial dysfunction; and (3) quantify associations between symptoms and biomarkers of pathogenesis in adults undergoing VAD implantation. Latent growth mixture modeling, including parallel process and cross-classification modeling, will be used to address the study aims and will entail identifying trajectories, quantifying associations between trajectories and both clinical and quality-of-life outcomes, and identifying predictors of favorable symptom and biomarker responses to VAD implantation.

Conclusions: Research findings from the PREMISE study will be used to enhance shared patient and provider decision making and to shape a much-needed new breed of interventions and clinical management strategies that are tailored to differential symptom and pathogenic responses to VAD implantation.
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http://dx.doi.org/10.1097/JCN.0b013e318299fa09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885612PMC
October 2015

Physical and psychological symptom profiling and event-free survival in adults with moderate to advanced heart failure.

J Cardiovasc Nurs 2014 Jul;29(4):315-23

Christopher S. Lee, PhD, RN, FAHA Assistant Professor, School of Nursing, Oregon Health & Science University, Portland. Jill M. Gelow, MD, MPH Assistant Professor, School of Medicine, Oregon Health & Science University, Portland. Quin E. Denfeld, BSN, RN PhD Student, School of Nursing, Oregon Health & Science University, Portland. James O. Mudd, MD Assistant Professor, School of Medicine, Oregon Health & Science University, Portland. Donna Burgess, RN, BSN Heart Failure Nurse, Oregon Health & Science University Hospital, Portland. Jennifer K. Green, MS Research Associate, School of Nursing, Oregon Health & Science University, Portland. Shirin O. Hiatt, MPH, MS, RN Research Associate, School of Nursing, Oregon Health & Science University, Portland. Corrine Y. Jurgens, PhD, RN, FAHA Associate Dean for Research, Associate Professor, School of Nursing, Stony Brook University, New York.

Unlabelled: : Heart failure (HF) is a heterogeneous symptomatic disorder. The goal of this study was to identify and link common profiles of physical and psychological symptoms to 1-year event-free survival in adults with moderate to advanced HF.

Methods: Multiple valid, reliable, and domain-specific measures were used to assess physical and psychological symptoms. Latent class mixture modeling was used to identify distinct symptom profiles. Associations between observed symptom profiles and 1-year event-free survival were quantified using Cox proportional hazards modeling.

Results: The mean age of the participants (n = 202) was 57 ± 13 years, 50% were men, and 60% had class III/IV HF. Three distinct profiles, mild (41.7%), moderate (30.2%), and severe (28.1%), that captured a gradient of both physical and psychological symptom burden were identified (P < .001 for all comparisons). Controlling for the Seattle HF Score, adults with the moderate symptom profile were 82% more likely (hazard ratio, 1.82; 95% confidence interval, 1.07-3.11; P = .028) and adults with the severe symptom profile were more than twice as likely (hazard ratio, 2.06; 95% confidence interval, 1.21-3.52; P = .001) to have a clinical event within 1 year than patients with the mild symptom profile.

Conclusions: Profiling patterns among physical and psychological symptoms identifies HF patient subgroups with significantly worse 1-year event-free survival independent of prognostication based on objective clinical HF data.
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http://dx.doi.org/10.1097/JCN.0b013e318285968aDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762955PMC
July 2014

Precision and accuracy: comparison of point-of-care and laboratory glucose concentrations in cardiothoracic surgery patients.

J Cardiovasc Nurs 2011 Nov-Dec;26(6):512-8

Cardiac and Surgical Intensive Care Unit at Oregon Health & Science University, Portland, Oregon 97239, USA.

Background: There have been variable results on the practice of tight glycemic control, and studies have demonstrated that point-of-care (POC) glucometers have variable accuracy.

Objective: The purpose of this study was to determine the difference between blood glucose concentrations obtained from POC glucometers as compared with laboratory results in cardiothoracic surgery (CTS) patients.

Methods: This was a descriptive study on a convenience sample of 46 CTS patients. A single sample of arterial blood was collected and analyzed at the bedside with the POC glucometer and in the laboratory to obtain a serum glucose concentration and hematocrit (Hct). A paired t test was used to compare the mean differences along with Spearman ρ correlation to examine the relationship between difference scores and Hct.

Results: The POC glucose was significantly higher than the laboratory result (t = 8.5, P < .001) with a mean of 12.3 (SD, 9.8) mg/dL. Spearman ρ correlation between the difference scores and Hct was -0.43, P = .003. Using a tercile split, groups with Hct of less than 26% (n = 16) and greater than 29% (n = 15) were identified. The unpaired t test on the mean difference scores of these 2 groups was t = -2.7, P < .01, with an overall mean difference 8.6 mg/dL (95% confidence interval, -15 to -2.2). The mean difference was 16.3 in the low-Hct group and 7.8 in the high-Hct group.

Conclusions: Point-of-care glucometer results differ significantly from laboratory glucose concentrations, with the difference widening as the Hct decreases. This raises the concern about using POC devices to provide tight glycemic control in CTS patients.
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http://dx.doi.org/10.1097/JCN.0b013e31820a7bf4DOI Listing
February 2012