Patients report more severe daily limitations than recognized by their physicians

Abstract

Background: Patient limitations guide selection of heart failure therapies, for which indications often specify New York Heart Association Class.

Objectives: To determine the extent of patient-reported limitations during daily activities and compare to New York Heart Association class assigned by providers during the same visit, and to left ventricular ejection fraction (LVEF) group.

Methods and results: While waiting for their appointment, 948 patients on return visits to an ambulatory HF clinic completed a written questionnaire assessing specific activity limitations, which were compared to physician-assigned NYHA class during the same visit. Patient-reported limitation to perform daily activity ranged from 25% for bathing to 61% for yardwork or housework and 71% for jogging or hurrying. Most patients who did not report limitations to perform daily life activities were correctly classified as NYHA I by the physicians (76%), but 12% of the 376 patients classified as NYHA I reported limitations to showering or bathing and 73% reported limitations while doing yardwork or house work. Limitation to walking was reported by 172 patients (50%) classified as class II. Limitations to walking one block were most common in patients with LVEF ≥40% compared to patients with LVEF <40%, and least commonly, in HF with better EF (improved from 31 ± 13 to 52 ± 7).

Conclusions: Activity limitations are commonly reported by ambulatory HF patients, but underestimated by physicians. It is not clear how this should guide therapy validated for NYHA class but focused activity questions may merit wider use to track limitations and improvement in ambulatory HF.

Keywords: cardiomyopathy; cardiovascular disease; heart failure.

Figure 1

Patient's flow diagram. HF, heart failure; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association functional classification

Figure 2

Degree of limitations to perform daily activities reported by ambulatory heart failure patients. Panel A includes all patients (NYHA I to IV; n = 948) and panels B, C, and D include patients designated as NYHA class I (n = 376), II (n = 343), and III (n = 216), respectively. Colors indicate the perceived degree of limitation for each activity

Figure 3

Percentage of patients reporting limitations to perform daily life activities accordingly to left ventricular ejection fraction subtype. *P < .01 vs HFpEF & HFrEF. P values from multivariate logistic regression adjusted by age, body mass index, and comorbidities. HFrEF, heart failure with reduced ejection fraction (n = 400); HFbetterEF, heart failure with better ejection fraction (n = 382); HFpEF, heart failure with preserved ejection fraction (n = 166)