Adverse events after left ventricular assist device implantation linked to psychosocial risk in women and men.

BACKGROUND: Reasons for women's increased probability to experience adverse events (AEs) after left ventricular assist device (LVAD) implantation compared with men's remain uncertain. We explored the role of psychosocial risk in the experience of AEs in women and men. METHODS: INTERMACS patients receiving a primary continuous-flow LVAD between July 2006 and December 2017, median follow-up 13.6 months, were included (n = 20,123, 21.3% women). Time-to-event was calculated with cumulative incidence functions for 10 types of AEs separately (e.g., infection, device malfunction), each time accounting for the competing outcomes death, heart transplant, and device explant due to recovery. Event-specific Cox proportional hazard models were run with a binary psychosocial risk variable (including substance abuse, psychiatric diagnosis, limited social support, limited cognition, repeated noncompliance), controlled for covariates. RESULTS: Psychosocial risk was more prevalent in men than in women (21.4% vs 17.5%, p < 0.001). Seven out of 10 AEs were more likely in women than in men (e.g., infection 44.5% vs 39.2%, p < 0.001). The association of psychosocial risk with each AE was either stronger in women than in men (e.g., device malfunction HRadj 1.29, 95% confidence interval (CI) (1.06-1.56) vs HRadj 1.10, 95% CI (0.97-1.25); rehospitalization HRadj 1.15, 95% CI (1.02-1.29) vs HRadj 1.03, 95% CI (0.97-1.10) or similar between sexes. CONCLUSIONS: Independent of clinical parameters, the presence of psychosocial risk is associated with increases in AEs. This suggests that early modification of psychosocial risk factors may have the potential to lower the risk for AEs in this patient population.

Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy.

Background The relevance of sex and preimplant factors for clinical outcomes among patients with left ventricular assist devices intended for destination therapy is unclear. Methods and Results INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) data (2006-2017) from 6771 men and 1690 women with left ventricular assist devices as destination therapy were analyzed to evaluate the contribution of preimplant clinical, demographic, and clinically judged psychosocial characteristics to time until death, heart transplant, device explant due to recovery, or complication-related device replacement. Associations of sex with time until each competing outcome were evaluated using cumulative incidence functions and event-specific Cox proportional hazards models. Women were younger, more likely to have nonischemic diagnoses, and reported less substance abuse but were more likely to be unmarried, not working for an income, overweight, and depressed than men. After 2 years, women had higher probabilities for recovery (3.7% versus 1.6%, P<0.001) and device replacement (12.1% versus 10%, P=0.019) than men but not for death and transplant (P>0.12). The sex differences remained after controlling for covariates (adjusted hazard ratio [HRadj] recovery, 1.85; 95% CI, 1.30-2.70; P<0.001; HRadj device replacement, 1.22; 95% CI, 1.04-1.33; P=0.015). Female-specific diagnoses (eg, postpartum heart failure) contributed to women's enhanced rate of recovery. Demographic and psychosocial factors were unrelated to women's increased event rates. Conclusions In destination therapy, women have higher rates of device replacement and recovery than men. The latter was partly explained by female-specific diagnoses. Standardized assessments of psychosocial characteristics are needed to elucidate their association with sex differences in outcomes.

Psychosocial Risk and Health Behaviors as Predictors of Clinical Events in Patients Wait-Listed for a New Heart: Results from 7 Years of Follow-Up.

We examined the long-term relationship of psychosocial risk and health behaviors on clinical events in patients awaiting heart transplantation (HTx). Psychosocial characteristics (e.g., depression), health behaviors (e.g., dietary habits, smoking), medical factors (e.g., creatinine), and demographics (e.g., age, sex) were collected at the time of listing in 318 patients (82% male, mean age = 53 years) enrolled in the Waiting for a New Heart Study. Clinical events were death/delisting due to deterioration, high-urgency status transplantation (HU-HTx), elective transplantation, and delisting due to clinical improvement. Within 7 years of follow-up, 92 patients died or were delisted due to deterioration, 121 received HU-HTx, 43 received elective transplantation, and 39 were delisted due to improvement. Adjusting for demographic and medical characteristics, the results indicated that frequent consumption of healthy foods (i.e., foods high in unsaturated fats) and being physically active increased the likelihood of delisting due improvement, while smoking and depressive symptoms were related to death/delisting due to clinical deterioration while awaiting HTx. In conclusion, psychosocial and behavioral characteristics are clearly associated with clinical outcomes in this population. Interventions that target psychosocial risk, smoking, dietary habits, and physical activity may be beneficial for patients with advanced heart failure waiting for a cardiac transplant.

Gender differences in psychosocial and clinical characteristics in the European Registry for Patients with Mechanical Circulatory Support.

BACKGROUND: Not much is known about psychosocial characteristics of men and women receiving continuous flow left ventricular assist devices (CF LVAD). OBJECTIVE: To investigate gender differences in clinical and psychosocial (demographic, behavioral, psychological) characteristics in CF LVAD recipients. METHODS: We analyzed European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data (N=2395, 16.8% women; 2011 to 2017) and compared pre-implant characteristics in men and women intended for bridge-to-transplant (BTT) or destination therapy (DT). RESULTS: Women were underrepresented [DT (n=61): 13.4%; BTT (n=341): 17.6%]. They were more likely to be divorced/separated, widowed, in unstable clinical condition, and non-working (DT only), but less likely to be smokers, to have ischemic cardiomyopathy or diabetes, and younger (BTT only) than men. Missing data were abundant, especially those that reflect psychological characteristics (>87%). CONCLUSION: Gender differences were noted, some specific to device strategy. Improved collection of psychosocial characteristics is warranted to elucidate their relationship to future prognosis.

Prevalence and frequency of self-management strategies among female cancer survivors: the neglected roles of social relations and conscious living.

OBJECTIVE: To assess prevalence and frequency of use of self-management strategies among female cancer survivors and to empirically identify categories of self-management. METHODS: Female cancer survivors (N=673, mean age 51 years; >90% with breast cancer; M=5 years since diagnosis) completed an Internet survey indicating the frequency (never to very often) with which they had employed each strategy since diagnosis. The survey included commonly assessed self-management strategies, such as complementary and alternative medicine (CAM), religious practices, and exercise. Additionally we assessed the use of further strategies identified from recommendations of cancer survivors shared in Internet forums. RESULTS: A principal component analysis yielded five categories: More Conscious Living, Turning to Family/Friends, CAM, Religious/Spiritual Practices, and Exercise. Prevalence rates of commonly measured strategies like CAM, Religious Practices, and Exercise were similar to previous studies. Considering frequency of use, however, revealed that only few participants reported frequent use of these strategies (<10%). In contrast, about half of the women (>50%) reported Turning to Family/Friends and engaging in More Conscious Living strategies (very) often. CONCLUSIONS: Relying on prevalence assessments of commonly investigated behaviors such as CAM or exercise may overestimate their use among cancer survivors. Cancer survivors engage in a wide range of self-management strategies. Encouraging living more consciously and cultivating social relations might be of greater relevance compared with CAM use or exercise.

Role of Depression and Social Isolation at Time of Waitlisting for Survival 8 Years After Heart Transplantation.

BACKGROUND: We evaluated depression and social isolation assessed at time of waitlisting as predictors of survival in heart transplant (HTx) recipients. METHODS AND RESULTS: Between 2005 and 2006, 318 adult HTx candidates were enrolled in the Waiting for a New Heart Study, and 164 received transplantation. Patients were followed until February 2013. Psychosocial characteristics were assessed by questionnaires. Eurotransplant provided medical data at waitlisting, transplantation dates, and donor characteristics; hospitals reported medical data at HTx and date of death after HTx. During a median follow-up of 70 months (<1-93 months post-HTx), 56 (38%) of 148 transplanted patients with complete data died. Depression scores were unrelated to social isolation, and neither correlated with disease severity. Higher depression scores increased the risk of dying (hazard ratio=1.07, 95% confidence interval, 1.01, 1.15, P=0.032), which was moderated by social isolation scores (significant interaction term; hazard ratio = 0.985, 95% confidence interval, 0.973, 0.998; P=0.022). These findings were maintained in multivariate models controlling for covariates (P values 0.020-0.039). Actuarial 1-year/5-year survival was best for patients with low depression who were not socially isolated at waitlisting (86% after 1 year, 79% after 5 years). Survival of those who were either depressed, or socially isolated or both, was lower, especially 5 years posttransplant (56%, 60%, and 62%, respectively). CONCLUSIONS: Low depression in conjunction with social integration at time of waitlisting is related to enhanced chances for survival after HTx. Both factors should be considered for inclusion in standardized assessments and interventions for HTx candidates.

Causes and Consequences of Missing Health-Related Quality of Life Assessments in Patients Who Undergo Mechanical Circulatory Support Implantation: Insights From INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).

BACKGROUND: Missing health-related quality of life (HRQOL) data in longitudinal studies can reduce precision and power and bias results. Using INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), we sought to identify factors associated with missing HRQOL data, examine the impact of these factors on estimated HRQOL assuming missing at random missingness, and perform sensitivity analyses to examine missing not at random (MNAR) missingness because of illness severity. METHODS AND RESULTS: INTERMACS patients (n=3248) with a preimplantation profile of 1 (critical cardiogenic shock) or 2 (progressive decline) were assessed with the EQ-5D-3L visual analog scale and Kansas City Cardiomyopathy Questionnaire-12 summary scores pre-implantation and 3 months postoperatively. Mean and median observed and missing at random-imputed HRQOL scores were calculated, followed by sensitivity analyses. Independent factors associated with HRQOL scores and missing HRQOL assessments were determined using multivariable regression. Independent factors associated with preimplantation and 3-month HRQOL scores, and with the likelihood of missing HRQOL assessments, revealed few correlates of HRQOL and missing assessments (R2 range, 4.7%-11.9%). For patients with INTERMACS profiles 1 and 2 and INTERMACS profile 1 alone, missing at random-imputed mean and median HRQOL scores were similar to observed scores, before and 3 months after implantation, whereas MNAR-imputed mean scores were lower (≥5 points) at baseline but not at 3 months. CONCLUSIONS: We recommend use of sensitivity analyses using an MNAR imputation strategy for longitudinal studies when missingness is attributable to illness severity. Conduct of MNAR sensitivity analyses may be less critical after mechanical circulatory support implant, when there are likely fewer MNAR data.

Smoking Status at Time of Listing for a Heart Transplant Predicts Mortality on the Waiting List: A Multicenter Prospective Observational Study.

OBJECTIVE: We examined the association of smoking status at time of listing with waitlist mortality among heart transplant (HTx) candidates. PARTICIPANTS AND DESIGN: Data were analyzed from 316 participants (aged 53 ± 11; 18% female) of the Waiting for a New Heart Study, a prospective observational study of patients newly listed for HTx at 17 hospitals. RESULTS: During the study period (April 2005 to March 2010), 14% of those who never smoked died, 18% among former smokers died, and almost half (42%) died among those who reported smoking at time of wait listing. Multivariate Cox regression models controlling for age, sex, and disease severity revealed smoking at time of listing was associated with significantly higher risk of mortality compared to never smoking (hazard ratio [HR] = 3.43; P = .03). The relationship between smoking and mortality risk appeared to follow a dose-dependent pattern: adjusted HRs were 1.80 for those who quit ≤1 year ago, 1.25 for those who quit >1 to 10 years ago, and 0.90 for those quit >10 years ago, compared to never smokers. Smoking at time of listing may increase risk of mortality during the waiting period, indicating the need for improved strategies to achieve smoking cessation as early as possible in the course of HTx.

A self-regulation-based intervention to increase physical activity in cancer patients.

The study examined whether a behavior-change intervention focusing on self-regulatory strategies and emphasizing role model support increases physical activity (PA) among insufficiently active (not meeting PA guidelines of 150 min/week) cancer patients. Ambulatory cancer patients [N = 72; 54% female; M = 56 years, SD = 12.34; most with breast or colon cancer (34, 15%)] were enrolled in the MOTIVACTION-study, a 4-week intervention (1-hr counseling, followed by weekly phone calls), with pretest (T1), posttest (T2) and a 10-week follow-up (T3). Participants were randomized to either an exercise or to a stress management intervention (active control). The exercise intervention emphasized self-regulatory strategies (e.g. action- and coping planning and self-monitoring); patients were also encouraged to contact a physically active same-sex role model as a potential exercise partner. The active control condition consisted of coping and relaxation techniques. Sixty-seven patients remained in the study and completed the SQUASH assessment of PA and a measure of perceived stress. PA was validated by Actigraph accelerometry. At T2, 46% of the patients in the exercise group and 19% of stress management patients increased their activity levels to meet PA guidelines (>150 min/week; χ(2)(1) = 5.51, p = .019). At T3, participants in the exercise intervention maintained their exercise level (46%), but also 31% of the stress management patients met the guidelines. All patients reported reductions in perceived stress. Additional analyses comparing patients in the exercise group by role model contact (63% realized contact) revealed that those who had contact with their role model were significantly more likely to adhere to the recommended guidelines (T2:50%; T3:64%) compared to those who did not have contact with a role model (T2:39%; T3:15%), suggesting the potential of mobilizing role model support to facilitate PA. In sum, cancer patients may not only benefit from an exercise intervention emphasizing self-regulation, but also from stress management, regarding both reducing stress and increasing PA.

Change in health-related quality of life from before to after destination therapy mechanical circulatory support is similar for older and younger patients: analyses from INTERMACS.

BACKGROUND: Destination therapy left ventricular assist devices (DT LVADs) are being implanted in older adults on an increasing basis. Older patients have a higher risk for mortality and morbidity post-LVAD, which may impact their health-related quality of life (HRQOL). We aimed to determine the change in HRQOL by age from before implant to 1 year after DT LVAD implant and identify factors associated with the change. METHODS: Data were collected from 1,470 continuous-flow DT LVAD patients at 108 institutions participating in INTERMACS from January 21, 2010 to March 31, 2012. Patients were divided into three cohorts: <60 years of age (n = 457); 60 to 69 years of age (n = 520); and ≥70 years of age (n = 493). HRQOL was measured using the generic EuroQol instrument (EQ-5D-3L). Data were collected pre-implant and 3, 6 and 12 months post-implant. Statistical analyses included descriptive statistics, Kaplan-Meier survival analyses and multivariable regression analyses. RESULTS: HRQOL improved in all patients. Generally, older patients reported better HRQOL than younger patients pre-implant (≥70 years: mean 40; 60 to 69 years: mean 33; and <60 years: mean 31; p < 0.0001) and 1 year post-implant (≥70 years: mean 77; 60 to 69 years: mean 72; <60 years: mean 70; p = 0.01) using the EQ-5D visual analog scale (VAS), with 0 = worst imaginable health state and 100 = best imaginable health state. The magnitude of improvement in EQ-5D scores from pre-implant to 1-year post-LVAD implant was similar in all age groups (≥70 years: mean change 33; 60 to 69 years: mean change 35; <60 years: mean change 35; p = 0.77). Factors associated with improvement in HRQOL from before to 1 year after implant were a lower VAS score pre-implant and fewer rehospitalizations post-implant (R(2) = 61.3%, p < 0.0001). CONCLUSIONS: Older patients reported better HRQOL than younger patients before and after LVAD implantation. The magnitude of improvement was similar for all age groups, with >70% of all patients showing clinically significant increases (>10 points on the VAS). Rehospitalization appears to reduce the magnitude of improvement.

Physical activity and depression predict event-free survival in heart transplant candidates.

OBJECTIVE: This study prospectively evaluated the relationship of physical activity (PA), depression, and anxiety to event-free survival during waiting time for heart transplantation in ambulatory patients enrolled in the Waiting for a New Heart Study. METHOD: Data from 227 ambulatory patients newly listed for heart transplantation were analyzed. Everyday PA (number of activities, caloric expenditure), depression, and anxiety at time of listing were assessed via questionnaires. Events were defined as death, high-urgency transplantation, delisting due to clinical deterioration, and mechanical circulatory support device implantation. Associations of PA scores, depression, and anxiety with event-free survival were analyzed using Cox proportional hazards models. Covariates included age, sex, body mass index, and objective indicators of disease severity. RESULTS: After a median follow-up of 478 days (6-1,849 days), 132 events occurred (46 deaths, 20 mechanical circulatory support device implantations, 54 high-urgency transplantations, 12 delistings). A higher number of activities was significantly associated with a reduced hazard ratio (HR) to experience an event (HR = 0.88, 95% CI [0.81, 0.96]), and depression increased this risk (HR = 1.64, 95% CI [1.16, 2.32]). Both effects remained significant in multivariate analyses (HR = 0.91, 95% CI [0.83, 0.99]; HR = 1.60, 95% CI [1.12, 2.29], ps < .02). No significant interactions between PA scores and emotions were observed and anxiety was unrelated to survival. CONCLUSION: Both everyday PA and the absence of depression prolonged event-free survival in ambulatory heart transplant candidates. These findings were independent of objective measures of disease severity. Patients waiting for cardiac transplantation may benefit from interventions focused on increasing their everyday PA and reducing depressive symptoms.

Everyday physical activity in ambulatory heart transplant candidates: the role of expected health benefits, social support, and potential barriers.

BACKGROUND: Physical activity (PA) is recommended for stable patients with advanced heart failure (HF). PURPOSE: We evaluated expected health benefits of PA and social support as facilitators of PA, and physical symptom distress and psychological distress (depression, anxiety) as barriers to PA. Additionally, we investigated if facilitators of PA are of particular importance for patients who report barriers. METHOD: We analyzed data assessed at time of waitlisting in 231 ambulatory patients (53.4 ± 10.3 years, 18 % women) who were enrolled in the multisite Waiting for a New Heart Study in 1 Austrian and 16 German hospitals. Self-reported everyday PA scores (number of activities, duration of activities) was regressed on demographic characteristics and indicators of disease severity (ejection fraction, peak oxygen consumption), facilitators (expected health benefits of PA, perceived emotional support, perceived support for PA), and barriers to PA (physical symptom distress, psychological distress). Interaction terms of facilitators with barriers were also examined. RESULTS: PA was positively associated with higher peak oxygen consumption, validating self-reported PA. Regarding facilitators, expected health benefits of PA were independently associated with higher PA (p values < 0.001). There were no main effects for social support on PA. Regarding barriers, depression tended to be associated with fewer activities (p = 0.068). However, in the presence of barriers (depression, physical symptoms), feeling supported for being physically active was positively associated with PA (p values < 0.05). CONCLUSION: Interventions to improve PA may benefit from strengthening positive expectations of health outcomes associated with everyday PA and fostering PA-specific social support for those distressed by HF symptoms or depression.

Overall quality of life improves to similar levels after mechanical circulatory support regardless of severity of heart failure before implantation.

BACKGROUND: The severity of pre-implantation heart failure may affect post-implantation health-related quality of life (HRQOL). The purpose of our study was to examine differences in HRQOL from before mechanical circulatory support (MCS) through 1 year after surgery by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) patient profiles. METHODS: Data from 1,559 adults with advanced heart failure who received primary continuous-flow pumps between June 23, 2006, and March 31, 2010, and were enrolled in INTERMACS were analyzed. HRQOL data were collected using the EQ-5D-3L survey before implantation and at 3, 6, and 12 months after implantation. Statistical analyses included chi-square and t-tests, using all available data for each time period. Paired t-tests and sensitivity analyses were also conducted. RESULTS: HRQOL was poor before MCS implantation among patients with INTERMACS profiles 1 to 7 and significantly improved after MCS implantation for all profiles. Stratified by INTERMACS profile, problems within each of the 5 dimensions of HRQOL (i.e., mobility, self-care, usual activities, pain, and anxiety/depression) generally decreased from before to after implantation. By 6 months after implantation, patients with all INTERMACS profiles reported similar frequencies of problems for all HRQOL dimensions. Paired t-tests and sensitivity analyses supported almost all of our findings. CONCLUSIONS: HRQOL is poor among advanced heart failure patients with INTERMACS profiles 1 to 7 before MCS implantation and improves to similar levels for patients who remained on MCS 1 year after surgery. Patients have problems in HRQOL dimensions before and after MCS; however, the frequency of reporting problems decreases for all dimensions within most profiles across time.

Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study.

BACKGROUND: Telomere shortness in human beings is a prognostic marker of ageing, disease, and premature morbidity. We previously found an association between 3 months of comprehensive lifestyle changes and increased telomerase activity in human immune-system cells. We followed up participants to investigate long-term effects. METHODS: This follow-up study compared ten men and 25 external controls who had biopsy-proven low-risk prostate cancer and had chosen to undergo active surveillance. Eligible participants were enrolled between 2003 and 2007 from previous studies and selected according to the same criteria. Men in the intervention group followed a programme of comprehensive lifestyle changes (diet, activity, stress management, and social support), and the men in the control group underwent active surveillance alone. We took blood samples at 5 years and compared relative telomere length and telomerase enzymatic activity per viable cell with those at baseline, and assessed their relation to the degree of lifestyle changes. FINDINGS: Relative telomere length increased from baseline by a median of 0·06 telomere to single-copy gene ratio (T/S)units (IQR-0·05 to 0·11) in the lifestyle intervention group, but decreased in the control group (-0·03 T/S units, -0·05 to 0·03, difference p=0·03). When data from the two groups were combined, adherence to lifestyle changes was significantly associated with relative telomere length after adjustment for age and the length of follow-up (for each percentage point increase in lifestyle adherence score, T/S units increased by 0·07, 95% CI 0·02-0·12, p=0·005). At 5 years, telomerase activity had decreased from baseline by 0·25 (-2·25 to 2·23) units in the lifestyle intervention group, and by 1·08 (-3·25 to 1·86) units in the control group (p=0·64), and was not associated with adherence to lifestyle changes (relative risk 0·93, 95% CI 0·72-1·20, p=0·57). INTERPRETATION: Our comprehensive lifestyle intervention was associated with increases in relative telomere length after 5 years of follow-up, compared with controls, in this small pilot study. Larger randomised controlled trials are warranted to confirm this finding. FUNDING: US Department of Defense, NIH/NCI, Furlotti Family Foundation, Bahna Foundation, DeJoria Foundation, Walton Family Foundation, Resnick Foundation, Greenbaum Foundation, Natwin Foundation, Safeway Foundation, Prostate Cancer Foundation.

Dietary habits are related to outcomes in patients with advanced heart failure awaiting heart transplantation.

BACKGROUND: Empirical evidence supporting the benefits of dietary recommendations for patients with advanced heart failure is scarce. We prospectively evaluated the relation of dietary habits to pre-transplant clinical outcomes in the multisite observational Waiting for a New Heart Study. METHODS AND RESULTS: A total of 318 heart transplant candidates (82% male, age 53 ± 11 years) completed a Food Frequency Questionnaire (foods high in salt, saturated fats, poly-/monounsaturated fats [PUFA+MUFA], fruit/vegetables/legumes, and fluid intake) at time of waitlisting. Cox proportional hazard models controlling for heart failure severity (eg, Heart Failure Survival Score, creatinine) estimated cause-specific hazard ratios (HRs) associated with each dietary habit individually, and with all dietary habits entered simultaneously. During follow-up (median 338 days, range 13-1,394), 54 patients died, 151 received transplants (110 in high-urgency status, 41 electively), and 45 became delisted (15 deteriorated, 30 improved). Two robust findings emerged: Frequent intake of salty foods, which correlated positively with saturated fat and fluid intake, was associated with transplantation in high-urgency status (HR 2.90, 95% confidence interval [CI] 1.55-5.42); and frequent intake of foods rich in PUFA+MUFA reduced the risk for death/deterioration (HR 0.49, 95% CI 0.26-0.92). CONCLUSIONS: These results support the importance of dietary habits for the prognosis of patients listed for heart transplantation, independently from heart failure severity.

Health behaviors contribute to quality of life in patients with advanced heart failure independent of psychological and medical patient characteristics.

BACKGROUND: Little is known about the contribution of health behaviors to quality of life (QoL) in heart transplant candidates. We examined physical activity, dietary habits, psychological, and medical patient characteristics as correlates of QoL among patients enrolled in the multisite Waiting for a New Heart Study. METHOD: QoL (Minnesota Living with Heart Failure Questionnaire), demographic variables, psychological variables (e.g., depression, coping styles), and health behaviors (physical activity, dietary habits) were assessed in 318 patients (82% male, 53 ± 11 years) at the time of wait-listing and analyzed in 312 patients (excluding six underweight patients). Eurotransplant provided BMI and medical variables to compute the Heart Failure Survival Score (HFSS). Hierarchical multiple regression models were used to assess the independent contribution of health behaviors to QoL. RESULTS: The HFSS was unrelated to QoL. As expected, psychological characteristics (depression, anxiety, vigilant coping style) contributed to impaired QoL, accounting for 22.9, 35.9, and 12.9% of the variance in total, emotional, and physical QoL, respectively. Physical inactivity further impaired QoL (total: 4.1%, p < 0.001; physical: 7.4%, p < 0.001). Dietary habits typically considered as unhealthy (i.e., infrequent consumption of fruits/vegetables/legumes; frequent intake of foods high in saturated fats) were related to enhanced physical QoL, but only among the overweight and obese patients. CONCLUSION: Lifestyle interventions to modify negative emotions and to increase physical activity could help to improve QoL in heart transplant candidates, regardless of their disease severity. The role of eating habits in QoL among obese and overweight patients needs further exploration.

Medical and psychosocial predictors of mechanical circulatory support device implantation and competing outcomes in the Waiting for a New Heart Study.

BACKGROUND: Medical and psychosocial factors are related to 1-year outcomes in the Waiting for a New Heart Study. With increased use of mechanical circulatory support devices (MCSD) over the course of the study, we can now evaluate these variables as predictors of MCSD in an extended follow-up. METHODS: Analyses focused on 313 MCSD-free patients (82% men; aged 53 ± 11 years) newly listed for heart transplantation (HTx). Variables assessed at time of listing included psychosocial risk (depression, social isolation), quality of life, waiting list stress, and medical risk (Heart Failure Survival Score, pulmonary capillary wedge pressure). Cumulative incidence functions and cause-specific Cox models examined the association of medical and psychosocial risk (low: non-depressed and socially integrated; medium: depressed or socially isolated; high: depressed and socially isolated) with time until MCSD, considering covariates and competing outcomes (death, high-urgency transplantation [HU-HTx], elective HTx, and delisting due to clinical improvement or deterioration). RESULTS: Psychosocial risk groups were comparable regarding demographics, medical parameters, and quality of life, but differed in waiting list-related stressors. During follow-up (median, 326; range, 5-1,849 days), 26 patients received MCSD, 53 died, 144 underwent HTx (103 in HU status), and 53 were delisted (15 deteriorated, 31 improved). Non-depressed and socially integrated patients did not require MCSD. Controlling for medical risk, psychosocial risk significantly contributed to MCSD, HU-HTx, and improvement; medical risk and female gender predicted death (p < 0.05). CONCLUSIONS: Psychosocial risk at time of listing affects the prognosis of HTx candidates beyond medical risk. Psychosocial interventions may help to stabilize patients' health.