Gender Differences in Anxiety, Depression, Insomnia, and Quality of Life in Heart Failure With Preserved Ejection Fraction: A Multicenter, Cross-sectional Study : Journal of Cardiovascular Nursing

Secondary Logo

Journal Logo

Articles

Gender Differences in Anxiety, Depression, Insomnia, and Quality of Life in Heart Failure With Preserved Ejection Fraction: A Multicenter, Cross-sectional Study

Yang, Xiaoyun MS; Wen, Yi MS; Peng, Huiji BS; Zhu, Hongjin MS; Wang, Wei Eric MD, PhD; Zhou, Jianrong MD, PhD

Author Information
The Journal of Cardiovascular Nursing: October 31, 2022 - Volume - Issue - 10.1097/JCN.0000000000000951
doi: 10.1097/JCN.0000000000000951
  • Free
  • PAP

Abstract

Heart failure (HF) is the advanced stage of many manifestations of cardiovascular disease. Heart failure is classified according to left ventricular ejection fraction into 3 categories: HF with preserved ejection fraction (HFpEF), HF with midrange ejection fraction, and with HF with reduced ejection fraction (HFrEF).1 The incidence of HFrEF has declined over the last decade, whereas the prevalence of HFpEF is on the rise.2 The 5-year survival rate of patients with HFpEF after a first hospitalization can be as low as 35% to 40%.3 Not only is HFpEF associated with increased risk of hospitalization and mortality, but also it is associated with poor quality of life (QoL).4

Adequate treatment of HFpEF is still considered to be the greatest unmet need in cardiovascular today. New potentially modifiable risk factors for HFpEF need to be identified. Psychosocial risk factors have been frequently studied in relation to HF, but literature about psychological distress mainly refers to HFrEF. Depression is a predictor of repeated hospitalization in patients with HF and is an independent risk factor for cardiovascular and all-cause mortality in prevalent HF cases.5 Depression and anxiety are associated with incident HF.6 Patients with HF have insomnia symptoms that are associated with disabling symptoms such as fatigue and depression, incident HF, cardiovascular events, and mortality.7 Depression and insomnia have been shown to be associated with poor QoL and adverse clinical outcomes.8,9 The prevalence of insomnia among patients with HFrEF is 23% to 73%10 and that of depression is 10% to 40%.11

Data on psychological distress in patients with HFpEF are limited. Moreover, women compose more than 50% of patients with HFpEF and female gender is a distinguishing feature of HFpEF versus HFrEF.12 Interestingly, in adults without HF, depression is nearly twice as prevalent in women as in men,13 and women are nearly 3 times more likely than men to report anxiety.14 Women are twice as likely as men to have an insomnia diagnosis.15 Quality of life is strongly impacted by depression and insomnia.16

There are few studies about gender differences in depression and QoL in patients with HF, and these studies are focused on HFrEF. Previous investigations showed that QoL was similar in men and women with HFrEF.17 The prevalence of suspected major depression was not different between the genders in 1 study,18 but another observational study demonstrated that more female than male patients had moderate or severe depressive symptoms.19

Gender differences in psychological distress in patients with HFpEF have not yet been determined. The aim of this study was to compare anxiety, depression, insomnia, and QoL between women and men with HFpEF. We conducted a multicenter study to provide generalizable evidence to benefit clinical management.

Methods

Participants

The present study was a multicenter, cross-sectional analysis of 263 consecutively enrolled HFpEF participants. We recruited patients with a diagnosis of HFpEF hospitalized at 3 hospitals (ie, First Affiliated Hospital of Chongqing Medical University, Second Affiliated Hospital of Chongqing Medical University, and Chengdu Second People's Hospital) from November 2020 to January 2021. Examination results including echocardiography, electrocardiogram and blood test were abstracted from the medical records, whereas questionnaire assessment was conducted by resident doctors trained by professional psychiatrists within 24 hours of patient admission. Diagnosis of HFpEF was defined as recommended by the European Society of Cardiology HF guidelines.1 Diagnosis of HFpEF was defined by the presence of clinical HF symptoms, a left ventricular ejection fraction of 50% or greater, at least 1 sign of cardiac structural or functional alteration (left atrial enlargement, left ventricular hypertrophy, and left ventricular dysfunction), and levels of B-type natriuretic peptide greater than 35 pg/mL or N-terminal pro–brain natriuretic peptide greater than 125 pg/mL.1 Exclusion criteria included the following: (1) cognitive impairment, (2) communication deficit such as hearing impairment, (3) severe symptoms such as severe shortness of breath, and (4) coma.

Ethical Approval and Informed Consent

The investigation conforms to the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study, and the informed consent process included education for the subject about the research, benefits and risks, and voluntary nature of their participation. The study was approved by the First Affiliated Hospital of Chongqing Medical University Ethic Committee for ethics in medical research (decision date: January 3, 2021; decision number 2021-163).

Study Variables

Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). The HADS is a 14-item self-report questionnaire comprising two 7-item subscales assessing anxiety (HADS-Anxiety) and depression (HADS-Depression) during the past week. Each item is rated from 0 to 3, yielding a sum score for each subscale of 0 to 21, with a higher score indicating worse symptoms. Scores of 0 to 7 indicate lack of symptoms of anxiety or depression, 8 to 10 indicate borderline symptoms, and 11 to 21 indicate high levels of anxiety or depression symptoms.20 A cutoff score of 8 on the HADS-Anxiety or HADS-Depression subscale (range, 0–21) provides the best compromise between sensitivity and specificity.21 In previous studies, the HADS-Anxiety and HADS-Depression subscales had excellent internal consistencies.22 In our sample, Cronbach's α values for the subscales were 0.80 (anxiety) and 0.85 (depression).

The Insomnia Severity Index (ISI) is a commonly used 7-item measure of insomnia that assesses difficulty with initiating or maintaining sleep, satisfaction with sleep, impairment, distress, and the extent to which others have noticed symptoms during the previous 2 weeks. Scores of 0 to 7 indicate no clinically significant insomnia, 8 to 14 indicate subthreshold insomnia symptoms, 15 to 21 indicate moderate insomnia, and 22 to 28 indicate severe insomnia.23 The Cronbach's α value in this study for the ISI was 0.83.

Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), a 19-item instrument composed of 7 components, which generate an overall score and 7 component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction during the previous month. The 7 component scores are combined into 1 global score, with a range of 0 to 21 points (0, no difficulty; 21, severe difficulty). Higher scores indicate worse global sleep quality, and scores higher than 5 indicate poor sleep.24 The Cronbach's α value for the PSQI in this study was 0.87.

The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to measure QoL. The KCCQ is a valid, reliable, and responsive health status measure for patients with HF and may serve as a clinically meaningful outcome in cardiovascular research, patient management, and quality assessment. The KCCQ is a 23-item self-administered disease-specific questionnaire, developed to provide a better description of QoL in patients with HF. It quantifies the following clinically relevant domains: physical limitation, symptoms, QoL, social limitation, and self-efficacy. To facilitate interpretability, 2 summary scores were developed: functional status score (combining the physical limitation and symptom domains) and clinical summary score (combining the functional status with the QoL and social limitation domains). It is scored by assigning each response an ordinal value, beginning with 1 for the response that implies the lowest level of functioning and summing items within each domain. Scale scores are transformed to a 0 to 100 range by subtracting the lowest possible scale score, dividing by the range of the scale and multiplying by 100. The KCCQ is scored from 0 to 100, with higher scores representing better QoL.25 The Cronbach's α value for the KCCQ was 0.89. Those questionnaires used in our study were previously validated for the Chinese population and local institutions.26

Statistical Analysis

All data and statistics are reported as mean ± SD for continuous data normally distributed or as median and interquartile range (25%–75%) for variables that were not normally distributed. Categorical variables were analyzed as frequencies (percentages), group differences were compared using the χ2 test, and bidirectional ordered categorical variables were compared by Γ test. Continuous variables were compared by t test if normality assumptions appeared to be reasonable. Highly skewed continuous variables were analyzed using the Mann-Whitney test. Bivariate regression analyses were conducted to identify the correlation between potential confounders with anxiety, depression, insomnia severity, sleep quality, and QoL. Multiple linear regression analyses were conducted to control for age, New York Heart Association (NYHA) class, income, and edema of the lower extremities.

Analyses were performed using SPSS for windows version 23.0 (SPSS Inc, Chicago, Illinois). Outcomes were considered statistically significant when P < .05.

Results

Participant Characteristics

A total of 263 consecutive patients with HFpEF from November 2020 to January 2021 were enrolled in this study. As shown in Table 1, women accounted for 59% (n = 154/263) and men accounted for 41% (n = 109/263) of the total sample of patients with HFpEF. More women were widowed or divorced compared with men (χ2 = 17.250, P < .001). Women with HFpEF smoked less often than men (χ2 = 38.044, P < .001), engaged in alcohol abuse less often than men (χ2 = 9.188, P = .004), and had a lower income than men (γ = 0.456, P = <0.001).

TABLE 1 - Baseline Characteristics of Female and Male Patients Heart Failure Patients With Preserved Ejection Fraction
Women (n = 154, 59%) Men (n = 109, 41%) Statistics P
Age, y 70.9 ± 14.1 72.7 ± 12.6 t = −1.064 .288
Left ventricular ejection fraction, median (IQR), % 62 (59–66) 62 (59–67) Z = −0.347 .729
Body mass index, kg/m2 23.2 ± 3.9 23.7 ± 3.9 t = −1.094 .275
Widowed or divorced 55 (36) 14 (13) χ 2 = 17.250 <.001
Live alone 21 (14) 9 (8) χ 2 = 1.828 .176
Edema of the lower extremities 81 (53) 52 (48) χ 2 = 0.611 .434
Current smoking 3 (2) 30 (28) χ 2 = 38.044 <.001
Alcohol abuse 4 (3) 13 (12) χ 2 = 9.188 .004
Current exercising 56 (36) 51 (47) χ 2 = 2.875 .090
High-sensitivity C-reactive protein (n = 223), median (IQR), mg/L 2.2 (0.8–5.5)
(n = 133)
2.8 (1.1–8.1)
(n = 90)
Z = −1.144 .253
N-terminal brain natriuretic peptide (n = 224), median (IQR), pg/mL 1756 (808–3329)
(n = 132)
1691 (848–3656)
(n = 92)
Z = −0.111 .912
New York Heart Association class
 II 40 (26) 28 (26) .710
 III 96 (62) 64 (59) G = 0.043
 IV 18 (12) 16 (15)
Occupation
 Unemployed 17 (11) 4 (4) .060
 Retired 99 (64) 78 (72) χ 2 = 5.632
 Farmer 32 (21) 17 (16)
Income
 Low (<1000RMB) 32 (21) 13 (12) <.001
 Middle (1000–5000RMB) 112 (73) 69 (63) G = 0.456
 Higher (>5000RMB) 10 (6) 27 (25)
Values are presented as mean ± SD or n (%), unless otherwise indicated.
Abbreviation: IQR, interquartile range.

As shown in Table 2, women with HFpEF had significantly higher incidence of hydropericardium (χ2 = 4.011, P = .045), atrial fibrillation (χ2 = 6.950, P = .008), and rheumatic heart disease (χ2 = 6.517, P = .011) than men. Compared with men, women with HFpEF had significantly lower incidence of left ventricular diastolic dysfunction (χ2 = 6.741, P = .009) and chronic obstructive pulmonary disease (χ2 = 8.778, P = .003).

TABLE 2 - Cardiac Structure/Function and Comorbidities of Female and Male Heart Failure Patients With Preserved Ejection Fraction
Women (n = 154) Men (n = 109) χ 2 P
Cardiac structure/function
 Left atrial dilatation 126 (82) 84 (77) 0.896 .344
 Left ventricular hypertrophy 28 (18) 23 (21) 0.348 .555
 Left ventricular diastolic dysfunction 64 (42) 63 (58) 6.741 .009
 Hydropericardium 20 (13) 6 (6) 4.011 .045
 Generalized cardiac enlargement 7 (5) 4 (4) 0.122 .727
Comorbidities
 Hypertension 97 (63) 66 (61) 0.161 .688
 Diabetes mellitus 41 (27) 38 (35) 2.062 .151
 Pulmonary hypertension 49 (32) 33 (30) 0.071 .790
 Coronary artery disease (previous MI or PCI) 73 (47) 58 (53) 0.861 .353
 Stroke 23 (15) 14 (13) 0.231 .631
 Rheumatic heart disease 22 (14) 5 (5) 6.517 .011
 Hyperlipidemia 16 (10) 7 (6) 1.259 .262
 Anemia 17 (11) 12 (11) 0.000 .994
 Atrial fibrillation 73 (47) 34 (31) 6.950 .008
 Chronic obstructive pulmonary disease 11 (7) 21 (19) 8.778 .003
 Chronic kidney disease 24 (16) 21 (19) 0.610 .435
 Cancer 7 (5) 7 (6) 0.446 .504
Values are presented as n (%).
Abbreviations: MI, myocardial infarction; PCI, percutaneous coronary intervention.

Anxiety and Depression

Sample HADS scores ranged from 0 to 21, where a higher score reflected increased symptom load.20 As shown in Table 3, 5% of patients with HFpEF had anxiety symptoms, as shown by HADS-Anxiety scores of 8 or higher, whereas 20% of patients with HFpEF had depression symptoms, as reflected by HADS-Depression scores of 8 or higher. Women had significantly higher scores for anxiety and depression than men (HADS-Anxiety: 2.4 ± 2.9 vs 1.6 ± 2.3, P = .014; HADS-Depression: 4.9 ± 3.7 vs 4.1 ± 3.6, P = .023).

TABLE 3 - Differences in Anxiety, Depression, Insomnia Severity, Sleep Quality, and Quality of Life Between Female and Male Heart Failure Patients With Preserved Ejection Fraction
Women (n = 154) Men (n = 109) t/Z/χ 2 P
HADS-A score 2.4 ± 2.9 1.6 ± 2.3 2.463 .014
HADS-A score ≥8 12 (8) 2 (2) 4.494 .034
HADS-D score 4.9 ± 3.7 4.1 ± 3.6 2.277 .023
HADS-D score ≥8 33 (21) 19 (17) 0.643 .423
ISI score 9.3 ± 6.4 8.0 ± 6.5 1.800 .072
ISI score ≥7 84 (55) 53 (49) 0.897 .344
PSQI score 9.9 ± 4.6 8.7 ± 4.5 1.901 .057
PSQI >5 118 (76) 75 (69) 1.996 .158
KCCQ 46.6 ± 12.6 47.6 ± 12.7 0.638 .523
KCCQ ≤50 73 (47) 56 (51) 0.403 .525
 Physical limitation 36.9 ± 17.2 38.2 ± 17.6 0.620 .535
 Symptoms 54.0 ± 14.8 55.1 ± 14.8 0.505 .614
 Self-efficacy 44.0 ± 17.1 44.0 ± 17.6 0.144 .886
 Quality of life 36.5 ± 11.3 37.3 ± 13.0 0.739 .460
 Social limitation 45.3 ± 24.9 46.7 ± 26.0 0.762 .446
 KCCQ functional status 46.4 ± 15.0 47.5 ± 14.6 0.493 .622
 KCCQ clinical summary 42.8 ± 12.6 43.7 ± 13.0 0.593 .553
Values are shown as n (%) or mean ± SD. Continuous variables with normal distribution were compared with independent Student t test, and the skewed variables were compared with Mann-Whitney U test. For HADS-A and HADS-D scales, a higher score indicates worse psychological status. For the ISI scale, a higher score indicates worse insomnia severity. For the PSQI scale, a higher score indicates worse sleep quality. For the KCCQ scale, a higher score indicates better quality of life.
Abbreviations: HADS-A, Hospital Anxiety and Depression Scale for anxiety; HADS-D, Hospital Anxiety and Depression Scale for depression; ISI, Insomnia Severity Index; PSQI, Pittsburgh Sleep Quality Index; KCCQ, Kansas City Cardiomyopathy Questionnaire.

Insomnia

As shown in Table 3, 52% of patients with HFpEF reported insomnia, identified by ISI scores of 7 or higher. A total of 73% of patients with HFpEF had poor sleep quality, identified by PSQI scores higher than 5. No significant differences in the scores of ISI and PSQI were found between female and male patients with HFpEF (ISI: 9.3 ± 6.4 vs 8.0 ± 6.5, P = .072; PSQI: 9.9 ± 4.6 vs 8.7 ± 4.5, P = .057).

Quality of Life

As shown in Table 3, there was no significant difference in the total scores of KCCQ between female and male patients with HFpEF (KCCQ: 46.6 ± 12.6 vs 47.6 ± 12.7, P = .523). Among the 7 domains of KCCQ, patients with HFpEF had lower scores on physical limitation and QoL domain. Moreover, no significant differences were found between women and men with HFpEF (P < .05 for all comparisons).

Anxiety, Depression, Insomnia, and Quality of Life After Adjustment

Bivariate regression of potential confounders (including age, NYHA functional class, income, and edema of the lower extremities) with anxiety, depression, insomnia severity, sleep quality, and QoL was performed. Some significant negative correlations (age and HADS-Anxiety: R = −0.251, P = .003; income and HADS-Depression: R = −0.224, P = .003; NYHA functional class and KCCQ: R = −0.160, P = .023; and edema of the lower extremities and KCCQ: R = −0.320, P < .001) and positive correlations (NYHA functional class and ISI: R = 0.132, P = .027; and edema of the lower extremities and PSQI: R = 0.123, P = .046) were observed (Table 4). We used multiple linear regression analyses adjusted for age, NYHA functional class, income, and edema of the lower extremities as confounders.

TABLE 4 - Correlation Between Confounders With Anxiety, Depression, Insomnia Severity, Sleep Quality, and Quality of Life of Female and Male Heart Failure Patients With Preserved Ejection Fraction
Age NYHA Class Income Edema HADS-A HADS-D ISI KCCQ PSQI
Age
NYHA class 0.049
Income 0.219a −0.045
Edema 0.042 0.004 0.069
HADS-A −0.251a 0.002 −0.121 0.061
HADS-D 0.027 0.081 −0.224a 0.039 0.469a
ISI 0.035 0.132b −0.116 0.013 0.246a 0.402a
KCCQ −0.006 −0.160b 0.096 −0.320a −0.256a −0.368a −0.279a
PSQI 0.069 0.088 −0.091 0.123b 0.249a 0.442a 0.873a −0.415a
Pearson or Spearman method was used to analyze the correlation between 2 variables.
Abbreviations: NYHA, New York Heart Association; HADS-A, Hospital Anxiety and Depression Scale for anxiety; HADS-D, Hospital Anxiety and Depression Scale for depression; ISI, Insomnia Severity Index; KCCQ, Kansas City Cardiomyopathy Questionnaire; PSQI, Pittsburgh Sleep Quality Index.
aP < .01.
bP < .05.

After adjusting for confounders, women remained having significantly higher anxiety scores than men (HADS-Anxiety: P = .025), whereas the depression scores were not significantly different between the 2 groups (HADS-Depression: P = .222) after adjustment (Table 5). Interestingly, the between-group difference of PSQI scores showed that women suffered worse sleep quality than men (PSQI: P = .046; Table 5) (Figure).

TABLE 5 - Multiple Linear Regression Analyses for Men Versus Women on Anxiety, Depression, Insomnia Severity, Sleep Quality, and Quality of Life
Unstandardized Coefficients Standardized Coefficients t P
B SE β
HADS-A score 0.749 0.332 0.136 2.251 .025
HADS-D score 0.567 0.463 0.077 1.225 .222
ISI score 1.262 0.809 0.096 1.560 .120
PSQI score 1.150 0.574 0.123 2.004 .046
KCCQ score −0.499 1.490 −0.019 −0.335 .738
 Physical limitation −1.174 2.114 −0.033 −0.556 .579
 Symptoms −0.054 1.507 −0.002 −0.036 .971
 Self-efficacy 0.417 2.175 0.012 0.192 .848
 Quality of life −0.597 1.499 −0.024 −0.398 .691
 Social limitation −0.756 3.110 −0.015 −0.243 .808
 KCCQ functional status −0.422 1.641 −0.014 −0.257 .797
 KCCQ clinical summary −0.514 1.484 −0.020 −0.347 .729
Men Reference group
Twelve different regression analyses were performed with 1 regression for each of the 12 outcome variables.
Abbreviations: HADS-A, Hospital Anxiety and Depression Scale for anxiety; HADS-D, Hospital Anxiety and Depression Scale for depression; ISI, Insomnia Severity Index; PSQI, Pittsburgh Sleep Quality Index; KCCQ, Kansas City Cardiomyopathy Questionnaire.

F1
FIGURE:
Gender differences in anxiety, depression, insomnia severity, and sleep quality in heart failure patients with preserved ejection fraction. HADS-A, Hospital Anxiety and Depression Scale for anxiety; HADS-D, Hospital Anxiety and Depression Scale for depression.

Discussion

The present study compared anxiety, depression, insomnia, and QoL between women and men in a multicenter study of patients with HFpEF. Both female and male patients with HFpEF had the comorbidities of anxiety and depression symptoms, impaired sleep quality, and reduced QoL. Our data indicated that women had more severe anxiety and worse sleep quality compared with men, whereas there were no gender differences in depression, insomnia, and QoL when adjusting for age, NYHA functional class, income, and edema of the lower extremities.

We showed that among the patients with HFpEF, 21% had depression or borderline depression (≥8 points in the HADS-Depression questionnaire). Previous investigators have shown that the prevalence of depression in a female non-HF population was almost twice that of men,13 whereas our data indicated that depressive symptoms were comparable between female and male patients with HFpEF. The prevalence of insomnia among patients with HFrEF ranges from 23% to 73%,11 but data on insomnia among patients with HFpEF have been rare. Among the enrolled 263 patients with HFpEF, 52% met clinical insomnia criteria in the ISI questionnaire and 73% had poor sleep quality in the PSQI questionnaire. In populations without HF, women are twice more likely than men to have an insomnia diagnosis.15 Interestingly, our data showed that there was no significant gender difference in insomnia in patients with HFpEF.

Depression, anxiety, and insomnia have been found to be associated with poor QoL.6,27 In previous HFpEF studies, women showed worse general but similar disease-specific QoL compared with men.28 Quality of life has been found to be more strongly associated with HF severity in men, and in women, it appears less determined by HF itself and potentially more by other factors.29 However, our data indicated that women suffered similar QoL impairment compared with men. This discrepancy might be associated with the fact that women had worse NYHA functional class in the previous studies, whereas NYHA class was comparable between genders in our data. In addition, in the 7 domains of KCCQ assessment, gender-related differences were not observed after adjusting for confounders.

Our data indicated that women had more severe anxiety than men. Interestingly, baseline characteristics showed that more women were divorced or widowed compared with men, which might contribute to more severe anxiety. Negative affect is a fundamental dimension of human emotion. When extreme, it contributes to a variety of adverse outcomes like mental illness.30 Recent divorce has been found to be positively associated with anxiety. Marital disruption in midlife or at an older age can be detrimental to health, particularly psychological health in the short term.30

Heavy and frequent smoking and alcohol use are associated with both insomnia symptoms and sleep dissatisfaction.31 Our data indicated that women had worse sleep quality compared with men, but women had smoked less and used alcohol less than men. The cause of poor sleep quality is multifactorial. For example, the prevalence of sleep disturbances significantly increased during and after menopause in women compared with men at similar ages.32 In our study, most women were in postmenopause (women's age: 70.9 ± 14.1 years). This might explain why women reported worse sleep quality, despite lower levels of smoking and alcohol abuse.

This study had some limitations. First, we used a cross-sectional design, which could not provide data regarding long-term changes in psychological distress. Enrolled patients were mostly from southwest China of the Han race, and therefore, generalizability of the study results to all patients with HFpEF is limited. A longitudinal follow-up study of patients' psychological distress is recommended for future studies to better understand changes in psychological distress.

In conclusion, both female and male patients with HFpEF reported a high prevalence of anxiety and depression symptoms, impaired sleep quality, and reduced QoL. There were no gender differences in depression, insomnia, and QoL in patients with HFpEF, but women reported more severe anxiety and worse sleep quality than men. Thus, it is recommended that clinicians assess psychological distress in patients with HFpEF, and that gender differences should be taken into consideration. Because of the larger proportion of women with HFpEF and their more severe psychological distress, adequate treatment measures for women should be carefully considered.

What’s New and Important

  • Both female and male patients with HF and preserved ejection fraction had a high prevalence of anxiety and depression symptoms, impaired sleep quality, and reduced QoL. Nursing care should include assessment of psychological distress in patients with HF and preserved ejection fraction and referral to appropriate resources as indicated.
  • There were no gender differences in depression, insomnia, or QoL in patients with HFpEF. Because of the larger proportion of women among patients with HFpEF, future research should focus on testing strategies to help reduce depression and insomnia and improve QoL in this clinical population.
  • Female patients with HFpEF had worse anxiety and worse sleep quality than men. Therefore, individualized interventions are needed that consider gender differences in anxiety and sleep quality to patients with HF and preserved ejection fraction.

Acknowledgments

Thanks to the assistance by Dr Shuxin Luo, Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University; Prof Yazhou Wu of the Department of Health Statistics, the Third Military Medical University; and Dr Qiang She, Jianlin Du, and Jing Huang, Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University.

REFERENCES

1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37:2129–2200. doi:10.1093/eurheartj/ehw128.
2. Dunlay SM, Roger VL, Redfield MM. Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2017;14:591–602. doi:10.1038/nrcardio.2017.65.
3. Withaar C, Lam CSP, Schiattarella GG, de Boer RA, Meems LMG. Heart failure with preserved ejection fraction in humans and mice: embracing clinical complexity in mouse models. Eur Heart J. 2021;42:4420–4430. doi:10.1093/eurheartj/ehab389.
4. Udelson JE, Lewis GD, Shah SJ, et al. Effect of praliciguat on peak rate of oxygen consumption in patients with heart failure with preserved ejection fraction: the CAPACITY HFpEF randomized clinical trial. JAMA. 2020;324:1522–1531. doi:10.1001/jama.2020.16641.
5. Ogilvie RP, Everson-Rose SA, Longstreth WT Jr., Rodriguez CJ, Diez-Roux AV, Lutsey PL. Psychosocial factors and risk of incident heart failure: the multi-ethnic study of atherosclerosis. Circ Heart Fail. 2016;9:e002243. doi:10.1161/CIRCHEARTFAILURE.115.002243.
6. Garfield LD, Scherrer JF, Hauptman PJ, et al. Association of anxiety disorders and depression with incident heart failure. Psychosom Med. 2014;76:128–136. doi:10.1097/PSY.0000000000000027.
7. Jeon S, Redeker NS. Sleep disturbance, daytime symptoms, and functional performance in patients with stable heart failure: a mediation analysis. Nurs Res. 2016;65:259–267. doi:10.1097/NNR.0000000000000169.
8. Laugsand LE, Strand LB, Platou C, Vatten LJ, Janszky I. Insomnia and the risk of incident heart failure: a population study. Eur Heart J. 2014;35:1382–1393. doi:10.1093/eurheartj/eht019.
9. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA. 2003;290:215–221. doi:10.1001/jama.290.2.215.
10. Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–1537. doi:10.1016/j.jacc.2006.06.055.
11. Redeker NS, Jeon S, Muench U, Campbell D, Walsleben J, Rapoport DM. Insomnia symptoms and daytime function in stable heart failure. Sleep. 2010;33:1210–1216. doi:10.1093/sleep/33.9.1210.
12. Beale AL, Meyer P, Marwick TH, Lam CSP, Kaye DM. Sex differences in cardiovascular pathophysiology: why women are overrepresented in heart failure with preserved ejection fraction. Circulation. 2018;138:198–205. doi:10.1161/CIRCULATIONAHA.118.034271.
13. Malhi GS, Mann JJ. Depression. Lancet. 2018;392:2299–2312. doi:10.1016/S0140-6736(18)31948-2.
14. Vasiliadis HM, Desjardins F, Roberge P, Grenier S. Sex differences in anxiety disorders in older adults. Curr Psychiatry Rep. 2020;22:75. doi:10.1007/s11920-020-01203-x.
15. Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6:97–111. doi:10.1053/smrv.2002.0186.
16. Morssinkhof MWL, van Wylick DW, Priester-Vink S, et al. Associations between sex hormones, sleep problems and depression: a systematic review. Neurosci Biobehav Rev. 2020;118:669–680. doi:10.1016/j.neubiorev.2020.08.006.
17. Riegel B, Moser DK, Carlson B, et al. Gender differences in quality of life are minimal in patients with heart failure. J Card Fail. 2003;9:42–48. doi:10.1054/jcaf.2003.1.
18. Faller H, Stork S, Schowalter M, et al. Depression and survival in chronic heart failure: does gender play a role?Eur J Heart Fail. 2007;9:1018–1023. doi:10.1016/j.ejheart.2007.06.011.
19. Kao CW, Chen TY, Cheng SM, Lin WS, Friedmann E, Thomas SA. Gender differences in the predictors of depression among patients with heart failure. Eur J Cardiovasc Nurs. 2014;13:320–328. doi:10.1177/1474515113496493.
20. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52:69–77. doi:10.1016/s0022-3999(01)00296-3.
21. Poole NA, Morgan JF. Validity and reliability of the Hospital Anxiety and Depression Scale in a hypertrophic cardiomyopathy clinic: the HADS in a cardiomyopathy population. Gen Hosp Psychiatry. 2006;28:55–58. doi:10.1016/j.genhosppsych.2005.08.004.
22. Waqas A, Aedma KK, Tariq M, Meraj H, Naveed S. Validity and reliability of the Urdu version of the Hospital Anxiety & Depression Scale for assessing antenatal anxiety and depression in Pakistan. Asian J Psychiatr. 2019;45:20–25. doi:10.1016/j.ajp.2019.08.008.
23. Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307. doi:10.1016/s1389-9457(00)00065-4.
24. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. doi:10.1016/0165-1781(89)90047-4.
25. Green CP, Porter CB, Bresnahan DR, Spertus JA. Development and evaluation of the Kansas City Cardiomyopathy Questionnaire: a new health status measure for heart failure. J Am Coll Cardiol. 2000;35:1245–1255. doi:10.1016/s0735-1097(00)00531-3.
26. Goh VJ, Tromp J, Teng TK, et al. Prevalence, clinical correlates, and outcomes of anaemia in multi-ethnic Asian patients with heart failure with reduced ejection fraction. ESC Heart Fail. 2018;5:570–578. doi:10.1002/ehf2.12279.
27. Javaheri S, Redline S. Insomnia and risk of cardiovascular disease. Chest. 2017;152:435–444. doi:10.1016/j.chest.2017.01.026.
28. Faxen UL, Hage C, Donal E, Daubert JC, Linde C, Lund LH. Patient reported outcome in HFpEF: sex-specific differences in quality of life and association with outcome. Int J Cardiol. 2018;267:128–132. doi:10.1016/j.ijcard.2018.04.102.
29. Dewan P, Rorth R, Raparelli V, et al. Sex-related differences in heart failure with preserved ejection fraction. Circ Heart Fail. 2019;12:e006539. doi:10.1161/CIRCHEARTFAILURE.119.006539.
30. Ding D, Gale J, Bauman A, Phongsavan P, Nguyen B. Effects of divorce and widowhood on subsequent health behaviours and outcomes in a sample of middle-aged and older Australian adults. Sci Rep. 2021;11:15237. doi:10.1038/s41598-021-93210-y.
31. Hussain J, Ling L, Alonzo RT, et al. Associations between sleep patterns, smoking, and alcohol use among older adults in Canada: insights from the Canadian Longitudinal Study on Aging (CLSA). Addict Behav. 2022;132:107345. doi:10.1016/j.addbeh.2022.107345.
32. Luo M, Li J, Tang R, et al. Insomnia symptoms in relation to menopause among middle-aged Chinese women: findings from a longitudinal cohort study. Maturitas. 2020;141:1–8. doi:10.1016/j.maturitas.2020.06.010.
Keywords:

anxiety; depression; heart failure; insomnia; sex characteristic

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.