Prognostic Value of Estimating Functional Capacity With the Use of the Duke Activity Status Index in Stable Patients With Chronic Heart Failure

doi:10.1016/j.cardfail.2014.08.013

Journal of Cardiac Failure

Volume 21, Issue 1, January 2015, Pages 44-50

https://doi.org/10.1016/j.cardfail.2014.08.013 Get rights and content

Highlights

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The Duke Activity Status Index is a simple self-assessment tool estimating functional capacity.
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1,700 subjects with chronic heart failure completed the questionnaire.
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All subjects were undergoing elective coronary angiography upon entry to this prospective cohort.
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Lower scores were associated with higher mortality on long-term follow-up.
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These results highlight the importance of functional status assessment in chronic heart failure.

Abstract

Background

Over the years, several methods have been developed to reliably quantify functional capacity in patients with heart failure. Few studies have investigated the prognostic value of these assessment tools beyond cardiorenal prognostic biomarkers in stable patients with chronic heart failure.

Methods and Results

We administered the Duke Activity Status Index (DASI) questionnaire, a self-assessment tool comprising 12 questions for estimating functional capacity, to 1,700 stable nonacute coronary syndrome patients with history of heart failure who underwent elective diagnostic coronary angiography with 5-year follow-up of all-cause mortality. In a subset of patients (n = 800), B-type natriuretic peptide (BNP) was measured. In our study cohort, the median DASI score was 26.2 (interquartile range [IQR] 15.5–42.7). Low DASI score provided independent prediction of a 3.3-fold increase in 5-year mortality risk (quartile 1 vs quartile 4: hazard ratio [HR] 3.33, 95% confidence interval [CI] 2.57–4.36; P < .0001). After adjusting for traditional risk factors, BNP, and estimated glomerular filtration rate, low DASI score still conferred a 2.6-fold increase in mortality risk (HR 2.57, 95% CI 1.64–4.15; P < .0001).

Conclusions

A simple self-assessment tool of functional capacity provides independent and incremental prognostic value for mortality prediction in stable patients with chronic heart failure beyond cardiorenal biomarkers.

Section snippets

Study Population

The Cleveland Clinic Genebank study prospectively enrolled a total of 8,987 subjects who underwent coronary angiography in the absence of an acute coronary syndrome, without a history of revascularization within 30 days before enrollment, and ≥5 years of long-term adjudicated follow-up data. Detailed medical histories were obtained on all subjects (predominantly outpatients) at enrollment. Blood samples were collected at the time of cardiac catheterization after arterial sheath placement, but

Results

Baseline characteristics are described in Table 2 and are representative of a patient population with chronic HF. The reasons for cardiac catheterization within the study cohort were as follows (subjects can have >1 reason): history of positive or abnormal stress test (30%), evaluation for possible ischemic causes of symptoms (63.5%), preoperative evaluation (24%), and history of cardiomyopathy (14%). DASI surveys were successfully completed by 1,700 study participants, and scores across this

Discussion

There are several key findings in our study. First, we surveyed a large cohort of patients with chronic stable HF undergoing elective coronary evaluation and observed an association between lower functional status (as measured with the use of the DASI questionnaire) and greater risk of 5-year mortality. Second, this association remained robust after multivariate adjustment for traditional cardiac risk factors and, in a subset of patients, after additional adjustment for cardiorenal biomarkers.

Conclusion

In patients with stable HF, functional status assessment, as measured by the DASI questionnaire, predicts mortality at 5 years. This assessment provides independent and additional prognostic information beyond the measurement of BNP and eGFR. Lower DASI scores predict mortality across a variety of subgroups of differing prognosis in patients with HF. These results highlight the importance of assessing functional status in patients with HF. Future studies using functional status assessment as a

Disclosure

Dr Tang has previously received investigator-initiated research grant support from Abbott Laboratories with no personal financial payments. Dr Hazen is named as coinventor on pending patents held by the Cleveland Clinic relating to cardiovascular diagnostics; has been paid as a consultant for Abbott Diagnostics, Cleveland Heart Lab, Esperion, Lilly, Liposcience, Merck and Co, P&G, and Pfizer; has received research funds from Abbott, Cleveland Heart Lab, Liposcience, P&G, and Pfizer; and has the

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Citation Excerpt :
Their recommendation is to use the Fried Frailty Phenotype, which is thought to be the best measure of frailty, with modifications that are more applicable to patients with heart failure.8 These modifications include the use of the Duke Activity Status Index questionnaire, which has been validated and predicts long-term survival in heart failure patients9-11; removal of the weight loss question due to weight fluctuation secondary to edema; and the incorporation of the Montreal Cognitive Assessment, as it improves the predictive accuracy of frailty for adverse outcomes.12 Seese et al. conducted a retrospective analysis of 36,790 HT recipients from the United Network Organ Sharing (UNOS) registry to create and validate a simple, bedside 12-point HT frailty screening tool13 (Table 1).
This special article focuses on the highlights in the cardiac transplantation literature in the year 2020. These include the selection and optimization of both the recipient and donor organs, including the use of prehabilitation, the use of new bridging techniques, the use and outcomes of using mechanical circulatory support, including left ventricular assist devices and the total artificial heart, the effects of the COVID-19 pandemic in previously transplanted patients and transplant candidates, and updates the perioperative management of this patient population.
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To investigate the association of Duke Activity Status Index (DASI) with 6‐minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT.
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The total score can range from 0 to 58.2, with higher scores indicating better functional status. The questionnaire has good reliability and validity (Fan et al., 2015)and has been validated in people with HF (Grodin, Hammadah, Fan, Hazen, & Tang, 2015; Snipelisky et al., 2017). The 36-Item Short-Form Health Survey (SF-36), the Chinese version (Li, Wang, & Shen, 2002), was utilised to measure the HRQOL in patients with HF.
In order to develop effective interventions targeting improvement in poor HRQOL, it is necessary to understand the factors that influence HRQOL and the relationships in patients with heart failure.
The purpose of this study was to examine factors associated with HRQOL and the relationships in patients with heart failure.
A cross-sectional survey design was utilised to survey 301 heart failure patients in a hospital. Participants completed measures of social support, symptom status, functional status, HRQOL, demographic and disease characteristics. Structural equation modeling was used to test the hypothesised model.
Structural equation modeling revealed that symptom status, functional status, NYHA, age, residence, marital status, monthly income, number of hospitalizations, LVEF, disease duration, and social support are factors that influence HRQOL. The hypothesised model showed reasonably adequate fit (χ² = 11.941 (df = 14, P = 0.611), RMSEA=0.000, CFI=1.000, AGFI=0.963; GFI=0.993, NFI=0.988). Functional status played a mediating role in the association between symptom status and HRQOL and Physical Component Summary (PCS).
To enhance HRQOL, doctors and caregivers should take these influential factors, especially symptom status and functional status, into account. Interventions focused on reinforcement of symptom management and assessment of functional status may promote HRQOL in patients with HF directly and indirectly.

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: Funding: National Institutes of Health (R01HL103931, P20HL113452, P01HL076491, P01HL098055), National Institutes of Health Office of Dietary Supplements (R01HL103866), and a Cleveland Clinic Clinical Research Unit of the Case Western Reserve University Clinical and Translational Science Award (UL1TR 000439). Dr Hazen is also partially supported by a gift from the Leonard Krieger endowment and by the Foundation LeDucq.

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Clinical InvestigationPrognostic Value of Estimating Functional Capacity With the Use of the Duke Activity Status Index in Stable Patients With Chronic Heart Failure

Highlights

Abstract

Background

Methods and Results

Conclusions

Section snippets

Study Population

Results

Discussion

Conclusion

Disclosure

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Card Fail

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Clinical Investigation
Prognostic Value of Estimating Functional Capacity With the Use of the Duke Activity Status Index in Stable Patients With Chronic Heart Failure