Major Finding: Patients with chronic heart failure who participated in a self-management intervention later showed no difference from a control group in the rate of death and HF hospitalization.
Data Source: A partially blinded, randomized, controlled trial involving 902 Chicago residents with mild to moderate HF who were followed for 2-3 years.
Disclosures: The HART study was funded by the National Institutes of Health. An associate of Dr. Powell reported receiving research funding from Novartis after the HART study was concluded.
An intervention to teach patients self-management of their chronic heart failure failed to reduce mortality or hospitalizations for the disorder, compared with patient education alone.
Nonadherence to heart failure medications is 30%-60%, and nonadherence to lifestyle recommendationsris 50%-80% in the general population. Previous assessments of self-management techniques to improve adherencehaere limited bytheall samples siz inadequate follow-up times, said Lynda H. Powell, Ph.D., of the department of preventive medicine at Rush University Medical Center, Chicago, and her associates.
The investigators designed HART (Heart Failure Adherence and Retention Trial) to have the size, duration, methodologic rigor, and representation of typical HF patients. They assessed mortality and HF hospitalizations after 1 year of self-management and another 1-2 years of follow-up in 902 patients with mild to moderate HF.
In all, 451 patients (average age, 64 years) were randomized to receive thesintervention, and the other 451 served asa controls.
Slightly fewer than half of the study subjects were women, and 40% were members of racial/ethnic minority groups. Overall, 23% had preserved systolic function, and the remainder had impaired systolic function, making the sample “representative of typical clinical populations.”
At baseline, patients were taking an average of seven medications. Nearly 40% did not adhere to the prescribed dosage of either an ACE inhibitor or a beta-blocker. Median sodium intake was almost twice as high as is recommended for HF patients.
The intervention included 18 2-hour group meetings over the course of a year. Patients were educated about medication adherence, sudden weight gain, sodium restriction, moderate physical activity, and stress management, and were given American Heart Association tip sheets concerning HF. They also were counseled to help them develop mastery in problem-solving skills and in five self-management skills: self-monitoring, environmental restructuring, elicitation of support from family and friends, cognitive restructuring, and the relaxation response.
The control group received the AHA tip sheets by mail, and discussed the material by phone with study counselors.
The intervention did not improve the primary end point, which was hospitalization for HF events or death. There were 163 events in the intervention group (40%) and 171 in the control group (41%); the annual event rates were 18% and 19%, respectively. Both differences were nonsignificant.
Both study groups had a mean of 0.7 HF hospitalizations. At the study's conclusion, there were no differences between groups in 6-minute walk time, change in New York Heart Association class, heart rate, respiratory rate, blood pressure, or body mass index.
Nonadherence to prescribed ACE inhibitor or beta-blocker therapy had risen by 7% in both groups, the researchers said (JAMA 2010;304:1331-8).
View on the News
Telemonitoring Is the Wave of the Future
Unlike the self-management strategy used in this study, “new technologies to empower patients who have long-term medical conditions such as heart failure may motivate them to take a more active role in their own health care and may promote adherence to treatment,” said Dr. John G.F. Cleland and Inger Ekman, Ph.D.
The self-management intervention in the current study, which included 18 2-hour meetings over a year's time, incurred considerable cost and inconvenience to patients. “Ultimately, electronic media, rather than in-person meetings with nurses and physicians, may become the predominant method of delivering health information, ensuring implementation of advice and treatment, and sending motivational messages efficiently and effectively,” they said. Home telemonitoring also would allow patients to inform clinicians about symptoms, weight, heart rate, heart rhythm, and blood pressure on a daily or weekly basis.
The medical and nursing professions should be a catalyst to the “inevitable” changeover to telemonitoring, they said.
JOHN G.F. CLELAND, M.D., is a cardiologist at the University of Hull (England). INGER EKMAN, PH.D., R.N., is at Göteborg (Sweden) University. Dr. Cleland reported receiving research funding from Phillips, a manufacturer of telemonitoring equipment. These comments are taken from their editorial accompanying Dr. Powell's report (JAMA 2010;304:1383-4).
Vitals