The concurrent impact of mild cognitive impairment and frailty syndrome in heart failure.

Pathological processes associated with ageing increase the risk of cognitive deficits and dementia. Frailty syndrome, also known as weakness or reserve depletion syndrome, may significantly accelerate these pathological processes in the elderly population. Frailty syndrome is characterized by decreased physiological function and neuropsychiatric symptoms, including cognitive decline and depressive states. In people with cardiovascular disease, the risk of frailty is 3 times higher. Frailty syndrome is particularly prevalent in severe heart failure, which increases the risk of mortality, increases hospital readmission, and reduces patients' quality of life. In addition, co-occurrence of cognitive impairment and frailty syndrome significantly increases the risk of dementia and other adverse outcomes, including mortality, in the heart failure population.

The effectiveness of self-care interventions in chronic illness: A meta-analysis of randomized controlled trials.

OBJECTIVE: To characterize and explain variation in the comparative effectiveness of self-care interventions on relevant outcomes of chronic illness compared with controls. DESIGN: Meta-analysis and meta-regression. METHODS: Data extraction was framed within the context of a previously-published scoping review of randomized trials designed to enhance self-care in type 2 diabetes mellitus, heart failure, hypertension, asthma, coronary artery disease, and chronic obstructive pulmonary disease (published between 2008 and 2019). Data were pooled using random-effects meta-analyses. Meta-regression was used to test the effect of potential moderators on trial effectiveness. RESULTS: 145 trials involving 36,853 participants were included. Overall, the effect size of self-care interventions on improving outcomes was small (Hedges' g = 0.29 (95% CI = 0.25-0.33), p < 0.001) with statistically significant heterogeneity across trials (Q = 514.85, p < 0.001, I2 = 72.0%). A majority of trials (n = 83, 57.2%) were rated as having a high risk of bias. There was no statistically significant difference in trial effectiveness based on the use of theory, specific components of self-care addressed, the number of modes of delivery, the number of behavioral change techniques, specific modes of delivery, specific behavioral change techniques, intervention duration, total number of hours of intervention, or either participant age or gender. CONCLUSIONS: Self-care interventions are modestly effective in improving outcomes. Poor trial quality limits the strength of conclusions in this area of science. There is much to be done to enhance the design, conduct and reporting of self-care trials in order to gain more insight into the effectiveness of self-care interventions. TWEETABLE ABSTRACT: New review highlights poor trial design as major impediment to understanding the contribution of self -care to outcomes in chronic illness.

Heart Failure Care: Testing Dyadic Dynamics Using the Actor-Partner Interdependence Model (APIM)-A Scoping Review.

Self-care behaviors are essential for the effective treatment of heart failure (HF), and poor self-care may lead to adverse clinical events in patients with HF. A growing body of literature addresses the need to analyze the characteristics of both patient and caregiver since they are in mutual, long-term interaction, and their reactions to events are dependent on each other. One of the most common approaches for analyzing data on HF self-care dyads is the Actor-Partner Interdependence Model (APIM). The purpose of this study was to conduct a scoping review to answer the following question: what did we learn from HF dyadic studies based on the APIM approach? Medline, Academic Search Ultimate, and CINAHL Complete databases were searched, using the terms "dyad," "dyadic," and "heart failure," for studies published between 2009 and April 2021. Fifteen studies were reviewed from a pool of 106 papers. Studies using the APIM approach revealed interrelated patient and caregiver characteristics that influence self-care and explain many complex dyadic behaviors. Our analysis provided evidence that (1) APIM is a useful analytical approach; (2) a family-oriented approach can improve the functioning of a patient with HF; and (3) social support from caregivers significantly enhances patients' adaptation to illness.

Patterns and predictors of dyspnoea following left ventricular assist device implantation.

AIMS: Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation. METHODS AND RESULTS: This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement. CONCLUSION: Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.

Physical, Psychological and Social Frailty Are Predictive of Heart Failure: A Cross-Sectional Study.

BACKGROUND: Little is known about frailty among patients hospitalized with heart failure (HF). To date, the limited information on frailty in HF is based on a unidimensional view of frailty, in which only physical aspects are considered when determining frailty. The aims of this study were to study different dimensions of frailty (physical, psychological and social) in patients with HF and the effect of different dimensions of frailty on the incidence of heart failure. METHODS: The study used a cross-sectional design and included 965 patients hospitalized for heart failure and 164 healthy controls. HF was defined according to the ESC guidelines. The Tilburg Frailty Indicator (TFI) was used to assess frailty. Probit regression analyses and chi-square statistics were used to examine associations between the occurrence of heart failure and TFI domains of frailty. RESULTS: Patients diagnosed with frailty were 15.3% more likely to develop HF compared to those not diagnosed with frailty (p < 0.001). An increase in physical, psychological and social frailty corresponded to an increased risk of HF of 2.9% (p < 0.001), 4.4% (p < 0.001) and 6.6% (p < 0.001), respectively. CONCLUSIONS: We found evidence of the association between different dimensions of frailty and incidence of HF.

A Multibiomarker Latent Class Analysis in Moderate to Advanced Heart Failure: Differentiating Factors.

BACKGROUND: Biomarker science in heart failure (HF) is advancing quickly in our ability to diagnosis and treat patients with this complex syndrome. Researchers are urged to not use single-marker strategies, but instead evaluate biomarkers in patterns to better understand their relationship to one another, as well as disease progression. Latent class mixture modeling allows researchers to determine novel associations between biomarkers. OBJECTIVE: The objectives of this study were to identify and compare latent classes of cardiovascular biomarkers among patients with moderate to advanced HF. METHODS: This was a cross-sectional study of 96 participants with moderate to advanced HF. Latent class mixture modeling was used to identify unique classes of biomarkers and their associations to sociodemographic and clinical variables. RESULTS: The average age of the sample was 54 years, with most of the sample being men (77%) and having an average ejection fraction of 23%. Two unique classes of biomarkers were identified. Latent class 1 had higher levels of all biomarkers, whereas latent class 2 had lower levels. The higher biomarker class had, on average, more neurohormonal activation and fluid retention; however, the higher levels of biomarker class were not more likely to be diagnosed with advanced HF or have more comorbidities. CONCLUSION: By identifying classes of biomarkers, providers may be better able to identify patients who are at risk of progressing into advanced HF quicker or those who are more likely to have more severe complications, such as fluid overload or renal disease.

Factors Associated With Cognitive Impairment in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Cognitive impairment is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind cognitive impairment in heart failure with preserved ejection fraction (HFpEF) has not been established. OBJECTIVE: The aim of this study was to evaluate associations between abnormal cardiac hemodynamics and cognitive impairment in individuals with HFpEF. METHODS: A secondary analysis of Atherosclerosis Risk in Communities (Atherosclerosis Risk in Communities) study data was performed. Participants free of stroke or dementia who completed in-person assessments at visit 5 were included. Neurocognitive test scores among participants with HFpEF, heart failure with reduced ejection fraction (HFrEF), and no heart failure were compared. Sociodemographics, comorbid illnesses, medications, and echocardiographic measures of cardiac function that demonstrated significant (P < .10) bivariate associations with neurocognitive test scores were included in multivariate models to identify predictors of neurocognitive test scores among those with HFpEF. Multiple imputation by chained equations was used to account for missing values. RESULTS: Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. Neurocognitive test scores were not significantly different among participants with HFpEF and HFrEF. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on 1 test of attention. CONCLUSIONS: Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the importance of cognitive screening in patients with heart failure. An association between abnormal cardiac hemodynamics and cognitive impairment was observed, but other factors are likely involved.

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

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.

Cognition and Frailty in Patients With Heart Failure: A Systematic Review of the Association Between Frailty and Cognitive Impairment.

Background/Aim: Pathological processes associated with aging increase the risk of cognitive deficits. Frailty syndrome may significantly accelerate these pathological processes in elderly patients with heart failure. The objective of this review was to better understand the association between frailty syndrome and co-occurring cognitive decline in patients with heart failure. Methods: We conducted a systematic review based on PubMed/MEDLINE, Scopus, EMBASE, and CINAHL as databases. The search followed the method described by Webb and Roe. For inclusions, the studies were selected employing cross-sectional and longitudinal designs. The included studies had to evaluate frailty syndrome and cognitive impairments among participants with heart failure. As we were interested in older adults, the search was limited to individuals >65 years of age. The search was limited to primary research articles written in English published since the year 2000. Results: Of the 1,245 studies retrieved by the systematic review, 8 relevant studies were enclosed for the full-text review. Our review revealed that most studies of patients with HF demonstrated evidence of an association between greater frailty and cognitive impairment. In particular, six studies reported evidence for the significant association between higher levels of frailty and cognitive impairment in patients with heart failure. The remaining two studies failed to find an association between frailty and cognitive impairment. Conclusions: The development of frailty and cognitive impairment in heart failure is particularly important because this cardiovascular disease is a common cause of both morbidity and mortality in the world. The results of this review fill the existing gap in the literature related to the identification of clinical factors linked with frailty syndrome that contribute to cognitive impairment in patients with a diagnosis of heart failure. The prevalence of overlapping frailty and cognitive impairment in patients with heart failure, therefore, necessitates a routine assessment of these components in the care of patients with cardiovascular disease.

Exploring gender differences in trajectories of clinical markers and symptoms after left ventricular assist device implantation.

AIMS: Despite well-known gender differences in heart failure, it is unknown if clinical markers and symptoms differ between women and men after left ventricular assist device (LVAD) implantation. Our aim was to examine gender differences in trajectories of clinical markers (echocardiographic markers and plasma biomarkers) and symptoms from pre- to post-LVAD implantation. METHODS AND RESULTS: This was a secondary analysis of data collected from a study of patients from pre- to 1, 3, and 6 months post-LVAD implantation. Data were collected on left ventricular internal end-diastolic diameter (LVIDd) and ejection fraction (LVEF), plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), and soluble suppressor of tumorigenicity (sST2). Physical and depressive symptoms were measured using the Heart Failure Somatic Perception Scale and Patient Health Questionnaire-9, respectively. Latent growth curve modelling was used to compare trajectories between women and men. The average age of the sample (n = 98) was 53.3 ± 13.8 years, and most were male (80.6%) and had non-ischaemic aetiology (65.3%). Pre-implantation, women had significantly narrower LVIDd (P < 0.001) and worse physical symptoms (P = 0.041) compared with men. Between pre- and 6 months post-implantation, women had an increase in plasma sST2 followed by a decrease, whereas men had an overall decrease (slope: P = 0.014; quadratic: P = 0.011). Between 1 and 6 months post-implantation, women had a significantly greater increase in LVEF (P = 0.045) but lesser decline in plasmoa NT-proBNP compared with men (P = 0.025). CONCLUSION: Trajectories of clinical markers differed somewhat between women and men, but trajectories of symptoms were similar, indicating some physiologic but not symptomatic gender differences in response to LVAD.

Health-Related Quality of Life in Patients With a Left Ventricular Assist Device (QOLVAD) Questionnaire: Initial Psychometrics of a New Instrument.

BACKGROUND: Patients with a left ventricular assist device are a unique and growing population who deserve their own valid, reliable instrument for health-related quality of life. OBJECTIVE: We developed and tested the Health-Related Quality of Life with a Left Ventricular Assist Device (QOLVAD) questionnaire. METHODS: In a prospective, descriptive study, patients from 7 sites completed the QOLVAD and comparator questionnaires. Construct validity was tested using confirmatory factor analysis. Convergent validity was tested using correlations of QOLVAD scores to well-established measures of subjective health status, depression, anxiety, and meaning/faith. Reliability and test-retest reliability were quantified. RESULTS: Patients (n = 213) were 58.7 ± 13.9 years old; 81.0% were male, 73.7% were White, and 48.0% had bridge to transplant. Questionnaires were completed at a median time of 44 weeks post ventricular assist device. The 5 QOLVAD domains had acceptable construct validity (root mean square error of approximation = 0.064, comparative and Tucker-Lewis fit indices > 0.90, weighted root mean square residual = 0.95). The total score and domain-specific scores were significantly correlated with the instruments to which they were compared. Internal consistency reliability was acceptable for all subscales (α = .79-.83) except the cognitive domain (α = .66). Unidimensional reliability for the total score was acceptable (α = .93), as was factor determinacy for multidimensional reliability (0.95). Total test-retest reliability was 0.875 (P < .001). CONCLUSION: Our analysis provided initial support for validity and reliability of the QOLVAD for total score, physical, emotional, social, and meaning/spiritual domains. The QOLVAD has potential in research and clinical settings to guide decision making and referrals; further studies are needed.

'Real-world' effectiveness of omalizumab in adults with severe allergic asthma: a meta-analysis.

Background: Severe asthma affects 5-10% of the 350 million people with asthma worldwide. Findings from the authors' previous meta-analysis supported omalizumab use as an adjuvant treatment for severe allergic asthma. The publication of fourteen new articles necessitates an update of the meta-analysis.Objective: To evaluate the 'real-world' effectiveness of omalizumab in the treatment of acute allergic asthma in adults by calculating pooled effects estimates from data in published articles.Methods: Articles on omalizumab effectiveness in 'real-world' settings were identified. Effect sizes, including point estimates of the proportion of patients who met a given criteria, mean improvements relative to baseline, and change in the proportion of patients requiring oral corticosteroids compared to baseline were extracted. Meta-analysis of proportions was conducted to pool effect sizes based on proportions. Standardized mean differences (Hedges' g) were calculated from means and standard deviations. Relative risk was calculated from changes in proportions. Variability within and between studies was evaluated.Results: Omalizumab increases the percentage of individuals rated 'good' or 'excellent' on the Global Evaluation of Treatment Effectiveness Scale. Omalizumab also improves respiratory function, quality-of-life, and asthma control while reducing medication usage, exacerbations, hospitalizations, and adverse events.Conclusion: 'Real-world' evidence continues to support the use of omalizumab as adjuvant treatment for severe allergic asthma.

A longitudinal comparison of health-related quality of life in rural and urban recipients of left ventricular assist devices.

Left ventricular assist devices (LVAD) are a common treatment for advanced heart failure (HF) to improve ventricular function, symptoms, and health-related quality of life (HRQOL). Many LVAD recipients travel long distances from rural areas for LVAD implantation and follow-up care. Individuals with HF in rural settings who have not undergone LVAD implantation have reported poor HRQOL. However, to date, no studies have compared HF-specific or generic HRQOL in rural and urban LVAD recipients. The purpose of this study was to compare generic and HF-specific HRQOL longitudinally from preimplantation to 1-, 3-, and 6- months postimplant in a cohort of rural and urban LVAD recipients (n = 95; rural n = 32 and urban n = 63). We measured generic HRQOL using the European Quality of Life Visual Analog Scale and HF-specific HRQOL with the quality of life domain of the Kansas City Cardiomyopathy Questionnaire (KCCQ). Latent growth curve modeling identified two phases of change in generic and HF-specific HRQOL: the initial response to LVAD between preimplantation and 1-month postimplant and the subsequent change between 1- and 6-months postimplant. Comparable improvements in generic HRQOL were noted in rural and urban LVAD recipients during both phases of change. Urban LVAD recipients had greater initial improvements in HF-specific HRQOL (KCCQ) compared with rural recipients (13.0 ± 5.6, p = .02), but subsequent improvements were similar among rural and urban recipients. Ongoing assessment of generic and HF-specific HRQOL is necessary during LVAD therapy.

Patterns of Heart Failure Dyadic Illness Management: The Important Role of Gender.

BACKGROUND: The ways in which patients with heart failure (HF) and their care partners work together to manage HF are often overlooked. OBJECTIVE: The aim of this study was to identify and compare different patterns of HF dyadic illness management. METHODS: This was a secondary analysis of data on HF dyads. Heart failure management was measured using patient and care partner versions of the Self-Care of HF Index and European HF Self-care Behavior Scale. Latent class modeling was used to identify patterns of HF dyadic management. RESULTS: The mean age of the 62 patients and their care partners was 59.7 ± 11.8 and 58.1 ± 11.9 years, respectively. A majority of patients (71.0%) had class III/IV HF, and a majority of the couples (95.2%) were married. Two distinct dyadic patterns were observed, 1 collaborative management type (n = 42, 67.7%) and 1 autonomous management type (n = 20, 32.3%). Dyads in the autonomous pattern were mostly female patients with male care partners; patients in this pattern also were more anxious and depressed, and reported worse relationship quality compared with collaborative dyads. CONCLUSION: There is an engendered spectrum of collaboration in how HF patient-care partner dyads work together to manage HF that needs to be considered in clinical care and research.

Identifying unique profiles of perceived dyspnea burden in heart failure.

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.

Identifying subgroups: Part 2: Trajectories of change over time.

Methods to identify multiple trajectories of change over time are of great interest in nursing and in related health research. Latent growth mixture modeling is a data-centered analytic strategy that allows us to study questions about distinct trajectories of change in key measures or outcomes of interest. In this article, a worked example of latent growth mixture modeling is presented to help expose researchers to the use and appeal of this analytic strategy.

Identifying subgroups: Part 1: Patterns among cross-sectional data.

Non-experimental designs are common in nursing and allied health research wherein study participants often represent more than a single population or interest. Hence, methods used to identify subgroups and explore heterogeneity have become popular. Latent class mixture modeling is a versatile and person-centered analytic strategy that allows us to study questions about subgroups within samples. In this article, a worked example of latent class mixture modeling is presented to help expose researchers to the nuances of this analytic strategy.

Scoping review: Hospital nursing factors associated with 30-day readmission rates of patients with heart failure.

AIMS AND OBJECTIVES: To review the current literature on hospital nursing factors associated with 30-day readmission rates of patients with heart failure. BACKGROUND: Heart failure is a common, yet debilitating chronic illness with high mortality and morbidity. One in five patients with heart failure will experience unplanned readmission to a hospital within 30 days. Given the significance of heart failure to individuals, families and healthcare system, the Center for Medicare and Medicaid Services has made reducing 30-day readmission rates a priority. DESIGN: Scoping review, which maps the key concepts of a research area, is used. METHODS: Published primary studies in English assessing factors related to nurses in hospitals and readmission of patients with heart failure were included. Other inclusion criteria were written in English and published in peer-reviewed journals. RESULTS: The search resulted in 2,782 articles. After removing duplicates and reviewing the inclusion and exclusion criteria, five articles were selected. Three nursing workforce factors emerged as follows: (i) nursing staffing, (ii) nursing care and work environment, and (iii) nurses' knowledge of heart failure. CONCLUSIONS: This is the first scoping review examining the association between hospital nursing factors and 30-day readmission rates of patients with heart failure. Further studies examining the extent of nursing structural and process factors influencing the outcomes of patients with heart failure are needed. RELEVANCE TO CLINICAL PRACTICE: Nurses are an integral part of the healthcare system. Identifying the factors related to nurses in hospitals is important to ensure comprehensive delivery of care to the chronically ill population. Hospital administrators, managers and policymakers can use the findings from this review to implement strategies to reduce 30-day readmission rates of patients with heart failure.

Psychometric Testing of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI).

Although coronary heart disease (CHD) requires a significant amount of self-care, there are no instruments available to measure self-care in this population. The purpose of this study was to test the psychometric properties of the Self-Care of Coronary Heart Disease Inventory (SC-CHDI). Using the Self-Care of Chronic Illness theory, we developed a 22-item measure of maintenance, management, and confidence appropriate for persons with stable CHD and tested it in a convenience sample of 392 adults (62% male, mean age 61.4 ± 9.6 years). Factorial validity was tested with confirmatory factor analysis. Convergent validity was tested with the Medical Outcomes Study MOS-SAS Specific Adherence Scale and the Decision Making Competency Inventory (DMCI). Cronbach alpha and factor determinacy scores (FDS) were calculated to assess reliability. Two multidimensional self-care scales were confirmed: self-care maintenance included "consultative behaviors" (e.g., taking medicines as prescribed) and "autonomous behaviors" (e.g., exercising 30 minute/day; FDS = .87). The multidimensional self-care management scale included "early recognition and response" (e.g., recognizing symptoms) and "delayed response" (e.g., taking an aspirin; FDS = .76). A unidimensional confidence factor captured confidence in each self-care process (α = .84). All the self-care dimensions were associated with treatment adherence as measured by the MOS-SAS. Only self-care maintenance and confidence were associated with decision-making (DCMI). These findings support the conceptual basis of self-care in patients with CHD as a process of maintenance that includes both consultative and autonomous behaviors, and management with symptom awareness and response. The SC-CHDI confidence scale is promising as a measure of self-efficacy, an important factor influencing self-care. © 2016 Wiley Periodicals, Inc.