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Increased Mortality in Patients With HF Sedentary Lifestyles
Study Questions:
Is sedentary behavior associated with all-cause mortality in patients with heart failure (HF) who live in rural areas?
Methods:
REMOTE-HF (Rural Education to Improve Outcomes in Heart Failure) clinical trial outcomes data were examined for 602 participants living in Agency for Healthcare Research and Quality-defined rural areas from 12 sites in 3 states. All-cause mortality was determined at 3, 12, and 24 months. Medical record reviews were conducted with blinded adjudication procedures for in-hospital deaths, and physician and family members were interviewed to confirm out-of-hospital deaths. Self-reports on sedentary lifestyle, depressive symptoms, literacy, and HF knowledge were examined to assess whether the effect of sedentary lifestyle changed.
Results:
Of the 602 rural participants, the mean age was 66 ± 12.4 years, 244 (41%) were women, and 535 (90%) were white. Over one-third of the sample had low literacy levels; nearly 20% did not complete high school. Over half of the patients had HF with reduced ejection fraction. During the 24-month follow-up period, 125 (21%) patients died: 75 (60%) cardiac-related deaths and 50 (40%) non-cardiac deaths. No significant differences between patients who lived (vs. those who died) were found for gender, education, marital status, income, and ejection fraction. Patients were more likely to die with higher B-type natriuretic peptide, creatinine, and Charlson comorbidity score. However, patients with body mass index (BMI) >25 were less likely to die than those with BMI ≤25. Patients who died had a more sedentary lifestyle, higher depressive symptoms score, and lower literacy score than those who did not die. Sedentary lifestyle was associated with an 87% increase in all-cause mortality (hazard ratio [HR] 1.87; p = .001; 95% confidence interval [CI], 1.31-2.68). Adjusting for moderate to severe depressive symptoms, the association between sedentary lifestyle and mortality persisted (HR 1.75; p = .003; 95% CI, 1.21-2.54). After controlling for age, significant associations were found between sedentary lifestyle, BMI >25, moderate to severe depressive symptoms, low literacy, and all-cause mortality. An 89% increase in all-cause mortality among patients with sedentary lifestyle was found, holding all other variables constant (HR 1.89; p = .001; 95% CI, 1.28-2.78). Significant baseline characteristics were included in the model for all-cause mortality. Age, white ethnicity, BMI <25, creatinine, Charlson comorbidity score, sedentary lifestyle, depressive symptoms, and literacy were associated with all-cause mortality, except employment status and B-type natriuretic peptide. Adjusting for all other variables in the model, sedentary lifestyle was associated with a 95% increase in all-cause mortality (HR 1.95; p = .01; 95% CI, 1.28-2.98).
Conclusions:
This study was an initial attempt to identify lifestyle behavior predictors of mortality in rural patients with HF. Findings indicate patients with HF might benefit from cardiac rehabilitation and long-term exercise, which is supported by the current HF guidelines.
Perspective:
The importance of addressing modifiable risk factors of poor HF outcomes such as depression, BMI, literacy, and lifestyle activity behavior cannot be underestimated. With as few as 1.4% of patients with HF participating in cardiac rehabilitation programs due to lack of clinician referral and patient interest or access, there is much work yet to be done to address this problem. Additional studies that compare lifestyle behavior among patients living in rural areas with those living in urban areas are needed using objective measures as opposed to self-reports. Nonetheless, this study is an important first step in determining lifestyle predictors of death in patient with HF.
Keywords: Rural Population, Sedentary Behavior, Heart Failure, Stroke Volume, Natriuretic Peptide, Brain, Creatinine, Depression, Depressive Disorder, Body Mass Index, Self Report, Health Literacy, Comorbidity, Health Services Research
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