Improvement in health-related quality of life after hospitalization predicts event-free survival in patients with advanced heart failure

Abstract

Background: Health-related quality of life (HRQOL) is a major clinical outcome for heart failure (HF) patients. We aimed to determine the frequency, durability, and prognostic significance of improved HRQOL after hospitalization for decompensated HF.

Methods and results: We analyzed HRQOL, measured serially using the Minnesota Living with Heart Failure Questionnaire (MLHFQ), for 425 patients who survived to discharge in a multicenter randomized clinical trial of pulmonary artery catheter versus clinical assessment to guide therapy for patients with advanced HF. All patients enrolled had 1 or more prior HF hospitalizations or chronic high diuretic doses and 1 or more symptom and 1 sign of fluid overload at admission. Improvement, defined as a decrease of more than 5 points in MLHFQ total score, occurred in 68% of patients by 1 month and stabilized. The degree of 1-month improvement differed (P < .0001 group x time interaction) between 6-month survivors and non-survivors. In a Cox regression model, after adjustment for traditional risk factors for HF morbidity and mortality, improvement in HRQOL by 1 month compared to worsening at 1 month or no change predicted time to subsequent event-free survival (P=.013).

Conclusions: In patients hospitalized with severe HF decompensation, HRQOL is seriously impaired but improves substantially within 1 month for most patients and remains improved for 6 months. Patients for whom HRQOL does not improve by 1 month after hospital admission merit specific attention both to improve HRQOL and to address high risk for poor event-free survival.

Figure 1

Health-related quality of life (measured using the Minnesota Living with Heart Failure Questionnaire) at each of the time points in patients who survived to 6-month follow-up. P < 0.001 for improvement in score at 1 month; FUp, follow-up; MLHFQ, Minnesota Living with Heart Failure Questionnaire. Plots indicate the lowest and highest scores, the 25^th and 75^th percentiles, and the median. The mean is indicated by the dot. Sample sizes for baseline, 1 month, 3 months and 6 months are 425, 313, 287, and 227 respectively.

Figure 2

Health-related quality of life (measured using the Minnesota Living with Heart Failure Questionnaire and presented as means ± SD) compared between those who died or were rehospitalized (event) during 6-month follow-up and those with no event during follow-up. P<0.001 for group × time interaction; MLHFQ, Minnesota Living with Heart Failure Questionnaire.

Figure 3

Survival curves (p = 0.009) derived from the multivariate Cox proportional hazards model based on degree of improvement in health-related quality of life (HRQOL) reflected by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores at baseline and 1 month, and adjusted for left ventricular ejection fraction, serum sodium, blood urea nitrogen, 6-minute walk distance, whether the patient was too ill to perform the 6-minute walk, age, systolic blood pressure, and patient group assignment. The adjusted curves were developed using the population-based adjustment method proposed by Makuck.