Daily symptoms and well-being trends reported by patients with heart failure

This invited commentary refers to ‘Shortness of breath, fatigue and well-being in patients with heart failure: a daily trend analysis over 12 weeks,’ by P. Deka et al., https://doi.org/10.1093/eurjcn/zvaf038. Heart failure (HF) remains a significant global health challenge, characterized by a complex interplay of signs and symptoms that substantially impact patients’ lives and healthcare resources.1 Early recognition and response to worsening signs and symptoms of HF are critical aspects of self-care to facilitate timely interventions and prevent adverse outcomes.2 Daily HF sign and symptom diaries have been studied as a tool to promote routine monitoring in adults with HF.3 Deka et al.4 expanded this work by conducting a secondary analysis of daily trends in shortness of breath, fatigue, and well-being in adults with HF over a 12-week period captured during a randomized controlled trial of an exergaming intervention (HF-Wii).5,6 The HF-Wii study was a multicenter randomized controlled trial designed to evaluate the efficacy of a highly innovative, structured exergaming intervention (using Nintendo Wii) compared to a motivational support control group in improving exercise capacity (primary outcome) in patients with HF.5 HF-Wii participants used paper diaries to record daily intensity of shortness of breath and fatigue at rest, and overall well-being using a 0–10 visual analogue scale for 12 weeks. This comprehensive daily data collection enabled the analysis of trends and correlations between these symptoms and well-being over time by Deka et al.4 We are delighted to provide this commentary to summarize key findings and offer additional ‘food for thought’ on these findings in the context of physical activity in HF. Deka, et al. included 141 HF-Wii participants with complete daily diary data for 12 weeks. Participants were mostly classified as New York Heart Association Class II, indicating mild symptoms at baseline. On average, participants reported shortness of breath and fatigue intensity >5 out of 10 and well-being <6 out of 10 on the visual analogue scales. Mean shortness of breath and fatigue scores demonstrated a strong, positive, and statistically significant correlation. Significant negative correlations were reported between well-being and fatigue and well-being and shortness of breath. Higher symptom scores were related to lower well-being. Deka et al. also sub-divided participants into two groups by reported symptom intensity. The high-intensity group included participants reporting symptom intensity of ≥5 out of 10 at least 21 days of the 84 reporting days. Participants in the high-intensity group were slightly more likely to have comorbid chronic obstructive pulmonary disease, peripheral vascular disease, and/or cancer than the low-intensity group which may have influenced symptom intensity and well-being. Interestingly, in the discussion, Deka et al. note incidental findings that although some participants reported a high symptom intensity (≥5/10) on more than 60 days of tracking, none were hospitalized during the reporting period. While daily diaries have been successfully used to monitor weight, HF symptoms, and treatment responses over a range of time periods, including 30 days post-discharge to 24 months.3,7 Deka et al. is the first team to date to report trends in daily symptom intensity and examine how symptom intensity relates to well-being over time. Their findings reinforce the importance of daily monitoring of symptoms and well-being. In particular, the negative relationship between symptom intensity and well-being has important implications for HF clinicians and caregivers as we aim to improve both quantity and quality of life in patients with HF. In this secondary analysis of the HF-Wii study, exercise capacity and physical activity data were not reported nor were daily symptom and well-being trends assessed within the context of the intervention. In prior reports, we noted that although the HF-Wii study did not demonstrate significant improvements in submaximal exercise capacity6 or physical activity8 between the exergame and motivational support control groups, clinically relevant increases in non-sedentary time in a portion of participants were noted.8 This suggests that the HF-Wii study may have helped some participants to incorporate more movement into their daily lives. Regular physical activity and structured exercise training are widely endorsed to improve functional status, reduce symptoms, and enhance the well-being of patients with HF.9 Given the well-established benefits of physical activity in HF, it is possible that the HF-Wii intervention could have influenced daily fluctuations of symptoms and well-being reported by the participants—despite no difference in exercise capacity. While physical exertion during exergaming might acutely increase shortness of breath and fatigue symptom intensity, particularly at the initiation of the programme, consistent engagement in physical activity over the 12-week study period would likely lead to improvements in these very symptoms and enhanced well-being. Physical activity alone or in combination with the act of recording a daily diary may have served a protective role3—helping to avoid hospitalization, even in those participants with high symptom intensity. Without analysing the relationships between participation in physical activity, the intervention, and the likelihood of hospitalization, particularly among those reporting high symptom intensity, this study overlooks a potentially crucial finding regarding the HF-Wii intervention's protective effects. In conclusion, Deka et al.’s focus on daily trends in shortness of breath, fatigue, and well-being in patients with HF contributes to the growing body of literature on sign and symptom tracking.4 Future analyses of this valuable dataset could incorporate analyses of concurrent physical activity in the context of daily symptom and well-being tracking and is an exciting potential opportunity. Continued prospective work could incorporate physical activity and other healthy lifestyle behaviours, like sleep and nutrition, to provide a more comprehensive understanding of the daily symptom, well-being, and healthy lifestyle trends in patients with HF. Gaining a longitudinal understanding of these complex relationships will aid in the continued development of innovative, well-informed, patient-centred interventions to improve the lives of patients with HF. Windy W Alonso (Conceptualization: [lead]; Writing—original draft: [lead]; Writing—review & editing: [lead]), and Troy Scheer (Conceptualization: [supporting]; Writing—original draft: [supporting]; Writing—review & editing: [supporting]) The author(s) received no financial support for the authorship, and/or publication of this article. No new data were generated or analysed in support of this research.