BACKGROUND:Adherence to heart failure therapy is important in reducing morbidity and mortality over the course of the disease process. The aim of this study was to examine factors associated with non-adherence to warfarin in chronic heart failure patients. METHODS:Eighty patients receiving warfarin therapy in 2002 were included. Adherence was defined as maintenance of international normalized ratio (INR) between 2 and 3.5 and keeping scheduled appointments for INR checks at least 75% of the time. Clinical variables examined included age, gender, race, insurance, left ventricular ejection fraction (LVEF), etiology, New York heart association (NYHA) class, comorbidities, smoking, and alcohol use. RESULTS:Of 80 patients studied, 59 were male with mean age ( +/- standard deviation) 52 +/- 13 years, 24 had ischemic etiology with mean LVEF of 24% +/- 9%. Non-adherence was associated with tobacco use, odds ratio of 6.5 (p <0.01). Ischemic etiology was associated with adherence, odds ratio of 4.5 (p <0.01). Non-adherent patients were more likely to be insured with Medicare/Medicaid (p = 0.04) and have better NYHA class (p = 0.04). Adherence positively correlated with older age and lower LVEF, and negatively correlated with number of hospitalizations (p<0.01 for all). In a multiple regression model, patients with improvement in LVEF had decreased adherence over the year (p<0.01). CONCLUSIONS:The profile of heart failure patients who demonstrated non-adherence to warfarin therapy included younger age, nonischemic etiology, better NYHA class, smoking, insurance with Medicare/Medicaid and improved LVEF over the study. Measures targeting these patients may result in improved adherence to other pharmacologic treatments of heart failure.

Objective: To assess levels of and factors associated with depression and negative affect 5 years after heart transplant (HT). Participants: 370 adults 5 years post-HT. Outcome Measures: Cardiac Depression Scale and the Positive and Negative Affect Schedule (PANAS). Research Method: Stepwise multiple regression analyses were used to test 32 potential demographic, medical, functional, and psychosocial factors in adjustment. Results: Predictor variables accounted for 53% of the variance of depression scores and 45% of the variance of PANAS negative affect scores. The best predictors (p .001) for depression were neurological symptoms, younger age, lower recreational functioning, and lower satisfaction with emotional support, and the best predictors for negative affect were neurological symptoms, lower mobility functioning, and perceived uncertainty about health. Depression scores were lower than norms for nontransplanted heart failure patients, and negative affect levels were comparable to those of the general population. Conclusions: The findings indicate normal long-term adjustment among HT recipients. Several factors associated with negative emotions, including younger age, have not been identified in previous research.

Background: Researchers have not examined relationships between perception of physical functional disability and demographic, clinical, and psychological variables at 5 to 10 years after heart transplantation. Therefore, the purposes of this study were to describe physical functional disability over time and identify predictors of physical functional disability from 5 to 10 years after heart transplantation.Methods: The study enrolled 555 patients who were between 5 and 10 years post-heart transplant (age, 54 +/- 9 years; 78% male, 88% white, 79% married). Patients completed 6 instruments that measure physical functional disability and factors that may impact physical functional disability. Statistical analyses included calculation of frequencies, means +/- standard deviation (plotted over time), Pearson correlation coefficients, and multiple regression coupled with repeated measures.Results: Between 5 and 10 years after heart transplantation, physical functional disability was low, and 34% to 45% of patients reported having no functional disability. More physical functional disability was associated with having more symptoms, having depression/mood/negative affect and lower use of negative coping strategies, having more comorbidities and more specific comorbidities (e.g., more orthopedic problems and diabetes); higher New York Heart Association functional class; having more acute rejection, infection, or cardiac allograft vasculopathy; being female, older, less educated, and unemployed; higher body mass index; and more hospital readmissions (explaining 46% of variance [F = 84.75, P < 0.00011).Conclusions: Demographic, clinical, and psychological factors were significantly related to physical functional disability. Knowledge of these factors provides the basis for development of therapeutic plans of care. J Heart Lung Transplant 2007;26:1182-91. Copyright (c) 2007 by the International Society for Heart and Lung Transplantation.

This study investigated how changes in the explanatory style of university students can lead to conditions that can enhance creative thinking. Seligman's theory of explanatory style optimism has been associated with increased feelings of well-being, academic success, popularity, and creative problem-solving. In contrast his theory of pessimism has been associated with depression, low achievements, poor social skills, and lack of creativity. Other theorists have linked blocks for creativity to attitudes of failure avoidance, past experiences of failure, repeated stress, extrinsic motivation, lack of enjoyment, and reactive attitudes. Qualitative analyses using Nvivo 7 was made of the comments of 50 students who completed the nine week programme "Get optimistic about study". The programme was presented using innovative and creative methodology. Data taken at pre-programme and post-programme intervals showed themes that suggest enhanced creativity in post-programme comments. Further quantitative analysis of the data is recommended to investigate how changes in creativity may have influenced the academic results of participants.

Beta-blockers (BB) improve survival in heart failure patients (HF pts). COMET suggested that carvedilol extended survival more than short-acting metoprolol tartrate. The objective of this retrospective study of pts followed in a HF specialty clinic is to compare outcomes of pts taking carvedilol vs long-acting metoprolol succinate. We statistically analyzed data on 140 pts from the Rush HF database (1/94–6/04): 66 pts on carvedilol twice daily and 74 pts on metoprolol succinate once daily. Follow-up (f/u) was defined from start of therapy, with the intention to treat principle, until death or end of f/u. Mean duration of f/u was 1435 days (d). Outcomes were defined as all-cause mortality and hospitalizations. More patients on metoprolol succinate were in NYHA classes 3 and 4 (50 vs 27%, p = 0.038), while other baseline characteristics were not different between the two groups (carvedilol vs metoprolol succinate): mean age 53 vs 56 years; female 22 vs 32%; African-American 24 vs 39%; Caucasian 70 vs 54%; ischemic cardiomyopathy 25 vs 32% and NYHA class 1(29 vs 21%); 2(44 vs 29%). Mean duration of carvedilol treatment was 1300d with a median daily maximum dose of 50 mg (range 6.25-100 mg). Mean duration of metoprolol succinate treatment was 885d with a median daily maximum dose of 100 mg (range 12.5-300 mg). During f/u 4 pts discontinued carvedilol; 9 pts discontinued metoprolol succinate; 13 pts switched from carvedilol to metoprolol succinate; and 3 pts switched from metoprolol succinate to carvedilol due to side effects, cost, or physician preference. Most pts in both groups had BB discontinued prior to death. At the time of death, only 1 pt was on BB (carvedilol). There was no difference in all-cause mortality between groups 9% (6/66 pts) for carvedilol vs 7% (5/74 pts) for metoprolol succinate (p = 0.608), regardless of HF etiology. There was no difference in the number of pts hospitalized during BB therapy (carvedilol vs metoprolol succinate): 21% (14/66 pts) vs 18% (13/74 pts), and all-cause hospitalizations 22 vs 22 (p = 0.656). The choice of BB did not significantly affect outcomes in HF pts in clinical practice. More patients on long-acting metoprolol succinate were in NYHA classes 3 and 4, which may imply that metoprolol succinate is better tolerated by ill patients. There may be no difference in efficacy between BBs when an adequate dose of the medication is achieved.

Background: Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation. Methods: All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures. Results: At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained >= 1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance). Conclusions: At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes. J Heart Lung Transplant 2007; 26:535-43. Copyright (C) 2007 by the International Society for Heart and Lung Transplantation.

BACKGROUND:Ventricular assist devices (VADs) are commonly used to bridge patients to heart transplantation. Recipients of VADs may develop anti-human histocompatibility leukocyte antigen antibodies, as reflected by elevated panel-reactive antibodies (PRA). The purpose of this study was to evaluate the relationship between bridging with VAD before heart transplantation and development of cellular rejection, humoral rejection, and allograft vasculopathy after transplantation. METHODS:Data on all patients who underwent cardiac transplantation between July 1994 and February 2001 at Rush Presbyterian St Luke's Medical Center were retrospectively reviewed. Data collected included sex, age, etiology of cardiomyopathy, percentage panel reactive antibodies (by cytotoxic method), type and duration of mechanical circulatory support, transfusion history, rejection history (both cellular and humoral) after cardiac transplantation, and development of allograft vasculopathy. Cellular rejection was treated when International Society of Heart and Lung and Transplantation Grade 2 or greater in the first 12 months after transplant and Grade 3 or greater after 12 months and treated with intensification of immunosuppression. Humoral rejection was defined clinically as allograft dysfunction by echocardiography without evidence of cellular rejection on endomyocardial biopsy or allograft vasculopathy. Allograft vasculopathy was defined by presence of any degree of luminal narrowing or pruning of distal vessels by coronary arteriography. Statistical analyses were performed by chi-square test, Fisher's exact test, and Wilcoxon rank sum test, as appropriate. RESULTS:Ninety-eight patients underwent cardiac transplantation during the study period (87 men, mean age 49 years, 46 ischemic etiology). Of these, 48 were bridged with HeartMate VAD (20 patients received vented electric device, 28 received pneumatic device). Nineteen percent of VAD patients had a peak pretransplant PRA > or =10% vs 2% of patients without VAD (p = 0.014). PRA > or =10%, use of VAD, or duration of VAD support did not predict development of humoral rejection. Use of VAD did not predict development of cellular rejection or allograft vasculopathy. VAD use was not associated with sudden death after heart transplantation. In the entire group of 98 patients, neither humoral nor cellular rejection predicted development of allograft vasculopathy. Longer ischemic time correlated with increased cellular rejection and humoral rejection after transplantation (p = 0.01). CONCLUSIONS:Some patients bridged to cardiac transplantation with VADs have increased PRA before heart transplantation, but this does not appear to translate into increased risk of either humoral or cellular rejection after transplantation or development of allograft vasculopathy as detected by coronary angiography.

Background: Only a few researchers have examined quality of fife (QOL) outcomes more than 5 years after heart transplantation. Therefore, the purpose of this study was to describe QOL (overall, satisfaction with, and perceived importance); identify differences in QOL by age, sex, and race; and identify predictors of QOL at 5 to 6 years after heart transplantation.Methods: A nonrandom sample of 231 patients (60 years of age, 76916 men, 90% white, 79% married, and fairly well educated) who were 5 to 6 years after heart transplantation were investigated. Patients completed 12 QOL instruments via self-report. Data analyses included descriptive statistics, chi(2), independent. t-tests, correlations, and stepwise multiple regression. Level of significance was set at 0.05.Results: Patient satisfaction with all areas of life was high at 5 to 6 years after heart transplantation. Similarly, patients believed that these same areas of life were very important. Yet areas of QOL with lower levels of satisfaction were identified. Patients who were >= 60 years were more satisfied with their QOL than patients <60 years. At 5 to 6 years after heart transplantation, almost 80% of variance in QOL was explained by psychological, physical, social, clinical, and demographic variables.Conclusions: At 5 to 6 years after heart transplantation, patients were very satisfied with their QOL, although differences in level of satisfaction were identified by demographic variables, and areas of QOL with lower levels of satisfaction were identified. Understanding those variables that contribute to QOL in the long term after heart transplantation provides direction for assisting patients to improve their QOL.

Background: Reasons for non-adherence (NA) to medical regimens in heart failure (HF) patients are poorly defined. We examined adherence (AD) to warfarin therapy and factors influencing it.

Background: Cardiac resynchronization therapy (CRT) produces clinical benefit in heart failure (HF) patients (pts) with intraventricular conduction delay. Previous studies excluded pts who already had a pacing device. In this study, pts with denovo (DN) CRT were compared to those undergoing upgrade (UP) to CRT from standard pacing.

Background: The landmark MADIT-II trial showed that ischemic heart disease (IHD) patients (pts) with left ventricular ejection fraction (LVEF) ≤ 30% had improved survival after placement of implantable cardioverter defibrillators (ICDs) without antecedent electrophysiology studies or symptoms suggestive of ventricular arrhythmias (VA). However, pts enrolled in MADIT-II received their care in a variety of settings. We hypothesized that IHD pts cared for in a heart failure (HF) specialty clinic would have low rates of lethal VA as detected by their ICDs.

BACKGROUND:Differences in mortality are thought to exist between African Americans and Caucasians with heart failure. These differences may be due to a variety of factors, including differences in disease process, socioeconomic status, and access to health care. Additionally, little data exist on racial differences between these two groups after cardiac transplantation. This study examines a single center, urban experience in treating African Americans and Caucasians with heart failure and after cardiac transplantation. We hypothesize that treatment in a specialized, comprehensive heart failure/cardiac transplantation program results in similar survival between African Americans and Caucasians.METHODS:We retrospectively reviewed the Rush Heart Failure and Cardiac Transplant Database from July 1994 to August 2000. Variables analyzed in the cardiomyopathy patients included survival (until death, placement of left ventricular assist device or cardiac transplantation), number of hospitalizations per year, length of stay per year, and utilization of outpatient resources. Follow-up period was from initial visit to death, transplantation, or implantation of left ventricular assist device. In those who underwent cardiac transplantation, we examined rejection rates (cellular and humoral), rejection burden, hospitalization data, and 5-year survival. A subgroup bridged to cardiac transplantation with a left ventricular device was also analyzed.RESULTS:Seven hundred thirty-four cardiomyopathy patients were identified: 203 were African Americans and 531 were Caucasians. The etiology of cardiomyopathy was more commonly ischemic in Caucasians as compared to non-ischemic in African Americans (P <.01). African Americans had more admissions to the hospital per year compared with Caucasians, 1.2 +/- 2.1 versus.5 +/- 1.1 (P <.01) with longer length of stay per year, 1.4 +/- 25.2 days versus 4.4 +/- 14.3 days (P <.01). Utilization of outpatient resources was significantly higher in African Americans compared with Caucasians with more use of continuous inotropes (13% versus 6%, P <.01), intermittent inotropes (11% versus 5%, P <.01), and home nursing after hospital discharge (52% versus 32% of hospital discharges, P <.01). Survival by Kaplan-Meier analysis was comparable between the two groups (mean survival 1,470 +/- 72 days in African Americans versus 1521 +/- 46 days in Caucasians, log rank test [P =.6]). During this time, 30 African Americans and 73 Caucasians underwent cardiac transplantation. Fifty-three were bridged to transplantation with a left ventricular assist device (20 African Americans, 33 Caucasians). There were no differences in 5-year survival by Kaplan-Meier analysis despite higher peak preoperative panel reactive antibody levels in African Americans versus Caucasians (12% +/- 30% compared with 5% +/- 15%, P =.04), more overall treated rejection episodes per year in the African Americans (P <.01), as well as more posttransplant hospitalizations (2.2 +/- 1.2 times per year as compared with 1.7 +/- 2.1 times per year, P =.04).CONCLUSION:Delivery of care to heart failure patients in a comprehensive, specialized program results in similar survival regardless of race despite higher utilization of inpatient and outpatient resources. The finding that, after cardiac transplantation, African Americans do not have higher mortality rates, despite having higher rates of rejection overall and more hospitalizations, further supports the hypothesis that optimal care can improve outcomes despite unfavorable baseline clinical characteristics.

Background: Racial differences in mortality are thought to exist between African American (AA) and Caucasian (C) patients with heart failure. No data exists on potential differences in outcomes between these groups after orthotopic heart transplantation (OHT).