Lo scompenso cardiaco cronico rappresenta attualmente una patologia ad alta prevalenza e incidenza a livello mondiale, come evidenziato dall'aumento del numero di ospedalizzazioni e soprattutto di riospedalizzazioni, dal numero crescente di decessi e, di conseguenza, dai costi elevati associati all'assistenza dei pazienti.
Nell'ottica di una migliore gestione del paziente, sia in termini di sopravvivenza che di qualità di vita, ma anche per costruire percorsi di gestione territoriale, è necessario specificare quali siano i maggiori fattori predittivi di riacutizzazione di scompenso cardiaco cronico.
In questo studio, condotto su una popolazione di 50 pazienti affetti da scompenso cardiaco cronico, è stata effettuata una valutazione clinica, strumentale e della qualità di vita del paziente, ipotizzando come quest'ultima avesse un ruolo sostanziale nel predire il rischio di riacutizzazione.
I risultati hanno mostrato come gli indicatori della qualità di vita, ad eccezione della scala delle attività strumentali della vita quotidiana (IADL), non siano correlati ad un maggiore rischio di riacutizzazione di SCC. I fattori predittivi che hanno superato l'analisi univariata sono la classe funzionale NYHA, il numero di reperti obiettivi, la presenza di rumori umidi alle basi polmonari, il grado di rigurgito transmitralico, la dose settimanale di diuretico dell'ansa e il numero di farmaci assunti quotidianamente. Alcuni di questi si sono affermati in modo indipendente all'analisi multivariata: è stato quindi possibile sviluppare un modello predittivo multivariato validato attraverso la curva di ROC (AUC= 0,945) e comprendente la classe
funzionale NYHA, la scala IADL, la sodiemia e il numero di reperti obiettivi.
Dall'analisi invece dei fattori predittivi di ricovero per altre cause è emersa l'importanza del declino funzionale, valutato come dipendenza nelle attività strumentali della vita quotidiana (IADL), e delle comorbidità.
I risultati ottenuti permettono di concludere come la valutazione clinica dello stato di congestione sistemica e polmonare del paziente abbia un ruolo importante nel predire il rischio di riacutizzazione di scompenso cardiaco cronico. A questo deve associarsi un colloquio con il paziente che conduca ad una corretta attribuzione della classe funzionale NYHA, e che indaghi in maniera precisa sulla capacità funzionale residua del paziente.
Una futura validazione del modello multivariato potrebbe condurre allo sviluppo di uno score, in modo da stratificare i pazienti in base al rischio di sviluppare una riacutizzazione di scompenso cardiaco, e migliorare dunque l'outcome della malattia sia in termini di sopravvivenza che di qualità di vita.
BIBLIOGRAFIA
1. Givertz MM, Colucci WS, Braunwald E. Aspetti clinici dell'insufficienza cardiaca: insufficienza ad alta gittata; edema polmonare. In: Braunwald E, Zipes DP, Libby P, editors. Malattie del cuore di Braunwald: Trattato di medicina cardiovascolare. 6.a ed. Milano: Elsevier; 2004. p. 557-87.
2. Mann DL. Trattamento dello scompenso cardiaco nei pazienti con frazione di eiezione ridotta. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Malattie del cuore di Braunwald: Trattato di medicina cardiovascolare. 9.a ed. Milano: Elsevier Health Sciences Italy; 2012. p. 562-97.
3. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart (British Cardiac Society). 2007; 93(9): 1137-46.
4. Braunwald E. Heart failure. JACC Heart Fail. 2013; 1(1): 1-20.
5. Lloyd-Jones DM. The risk of congestive heart failure: sobering lessons from the Framingham Heart Study. Current cardiology reports. 2001; 3(3): 184-90.
6. Braunwald E. Insufficienza cardiaca e cuore polmonare. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison: Principi di medicina interna: McGrow-Hill
2005. p. 1543-55.
7. Greenberg B, Kahn AM. Valutazione clinica dell'insufficienza cardiaca. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Malattie del cuore di Braunwald: Trattato di medicina cardiovascolare. 9.a ed. Milano: Elsevier Health Sciences Italy; 2012. p. 525-36.
8. Kim J, Jacobs DR, Jr., Luepker RV, Shahar E, Margolis KL, Becker MP. Prognostic value of a novel classification scheme for heart failure: the Minnesota Heart Failure Criteria. American journal of epidemiology. 2006; 164(2): 184-93.
9. K.A. C. AHA medical/scientific statement. 1994 revisions to classification of functional capacity and objective assessment of patients with diseases of the heart. Circulation. 1994; 90(1): 644-5.
10. Raphael C, Briscoe C, Davies J, Ian Whinnett Z, Manisty C, Sutton R, et al. Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure. Heart (British Cardiac Society). 2007; 93(4): 476-82.
11. Tjam EY, Heckman GA, Smith S, Arai B, Hirdes J, Poss J, et al. Predicting heart failure mortality in frail seniors: comparing the NYHA functional classification with the Resident Assessment Instrument (RAI) 2.0. International journal of cardiology. 2012; 155(1): 75-80.
12. Velavan P, Khan NK, Goode K, Rigby AS, Loh PH, Komajda M, et al. Predictors of short term mortality in heart failure - insights from the Euro Heart Failure survey. International journal of cardiology. 2010; 138(1): 63-9.
13. Abraham WT, Fonarow GC, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Journal of the American College of Cardiology. 2008; 52(5): 347-56.
14. Ketchum ES, Levy WC. Establishing prognosis in heart failure: a multimarker approach. Progress in cardiovascular diseases. 2011; 54(2): 86-96. 15. Frazier CG, Alexander KP, Newby LK, Anderson S, Iverson E, Packer M, et al. Associations of gender and etiology with outcomes in heart failure with systolic dysfunction: a pooled analysis of 5 randomized control trials. Journal of the American College of Cardiology. 2007; 49(13): 1450-8.
16. Ingelsson E, Lind L, Arnlov J, Sundstrom J. Socioeconomic factors as predictors of incident heart failure. Journal of cardiac failure. 2006; 12(7): 540-5. 17. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, et al. Underlying causes and long-term survival in patients with initially
unexplained cardiomyopathy. The New England journal of medicine. 2000; 342(15): 1077-84.
18. Lee DS, Massaro JM, Wang TJ, Kannel WB, Benjamin EJ, Kenchaiah S, et al. Antecedent blood pressure, body mass index, and the risk of incident heart failure in later life. Hypertension. 2007; 50(5): 869-76.
19. Kalantar-Zadeh K, Block G, Horwich T, Fonarow GC. Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure. Journal of the American College of Cardiology. 2004; 43(8): 1439-44.
20. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. The New England journal of medicine. 2005; 352(3): 225-37.
21. Lindenfeld J, Feldman AM, Saxon L, Boehmer J, Carson P, Ghali JK, et al. Effects of cardiac resynchronization therapy with or without a defibrillator on survival and hospitalizations in patients with New York Heart Association class IV heart failure. Circulation. 2007; 115(2): 204-12.
22. Kirkpatrick JN, Vannan MA, Narula J, Lang RM. Echocardiography in heart failure: applications, utility, and new horizons. Journal of the American College of Cardiology. 2007; 50(5): 381-96.
23. Wong M, Staszewsky L, Latini R, Barlera S, Glazer R, Aknay N, et al. Severity of left ventricular remodeling defines outcomes and response to therapy in heart failure: Valsartan heart failure trial (Val-HeFT) echocardiographic data. Journal of the American College of Cardiology. 2004; 43(11): 2022-7.
24. Solomon SD, Anavekar N, Skali H, McMurray JJ, Swedberg K, Yusuf S, et al. Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation. 2005; 112(24): 3738-44.
25. Agha SA, Kalogeropoulos AP, Shih J, Georgiopoulou VV, Giamouzis G, Anarado P, et al. Echocardiography and risk prediction in advanced heart failure: incremental value over clinical markers. Journal of cardiac failure. 2009; 15(7): 586- 92.
26. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. The New England journal of medicine. 2005; 352(9): 875-83.
27. de Groote P, Millaire A, Foucher-Hossein C, Nugue O, Marchandise X, Ducloux G, et al. Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure. Journal of the American College of Cardiology. 1998; 32(4): 948-54.
28. Hansen A, Haass M, Zugck C, Krueger C, Unnebrink K, Zimmermann R, et al. Prognostic value of Doppler echocardiographic mitral inflow patterns: implications for risk stratification in patients with chronic congestive heart failure. Journal of the American College of Cardiology. 2001; 37(4): 1049-55.
29. Bruch C, Rothenburger M, Gotzmann M, Sindermann J, Scheld HH, Breithardt G, et al. Risk stratification in chronic heart failure: independent and incremental prognostic value of echocardiography and brain natriuretic peptide and its N-terminal fragment. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2006; 19(5): 522- 8.
30. Guazzi M, Dickstein K, Vicenzi M, Arena R. Six-minute walk test and cardiopulmonary exercise testing in patients with chronic heart failure: a comparative analysis on clinical and prognostic insights. Circulation Heart failure. 2009; 2(6): 549-55.
31. Weber KT, Janicki JS. Cardiopulmonary exercise testing for evaluation of chronic cardiac failure. The American journal of cardiology. 1985; 55(2): 22A-31A. 32. O'Neill JO, Young JB, Pothier CE, Lauer MS. Peak oxygen consumption as a predictor of death in patients with heart failure receiving beta-blockers. Circulation. 2005; 111(18): 2313-8.
33. Triposkiadis F, Karayannis G, Giamouzis G, Skoularigis J, Louridas G, Butler J. The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications. Journal of the American College of Cardiology. 2009; 54(19): 1747-62.
34. Moore RK, Groves DG, Barlow PE, Fox KA, Shah A, Nolan J, et al. Heart rate turbulence and death due to cardiac decompensation in patients with chronic heart failure. European journal of heart failure. 2006; 8(6): 585-90.
35. Omland T, Aakvaag A, Bonarjee VV, Caidahl K, Lie RT, Nilsen DW, et al. Plasma brain natriuretic peptide as an indicator of left ventricular systolic function and long-term survival after acute myocardial infarction. Comparison with plasma atrial natriuretic peptide and N-terminal proatrial natriuretic peptide. Circulation. 1996; 93(11): 1963-9.
36. Doust JA, Pietrzak E, Dobson A, Glasziou P. How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ (Clinical research ed). 2005; 330(7492): 625.
37. Maisel A, Hollander JE, Guss D, McCullough P, Nowak R, Green G, et al. Primary results of the Rapid Emergency Department Heart Failure Outpatient Trial (REDHOT). A multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath. Journal of the American College of Cardiology. 2004; 44(6): 1328-33.
38. Verdiani V, Nozzoli C, Bacci F, Cecchin A, Rutili MS, Paladini S, et al. Pre- discharge B-type natriuretic peptide predicts early recurrence of decompensated heart failure in patients admitted to a general medical unit. European journal of heart failure. 2005; 7(4): 566-71.
39. Deswal A, Petersen NJ, Feldman AM, Young JB, White BG, Mann DL. Cytokines and cytokine receptors in advanced heart failure: an analysis of the cytokine database from the Vesnarinone trial (VEST). Circulation. 2001; 103(16): 2055-9.
40. Klein L, O'Connor CM, Leimberger JD, Gattis-Stough W, Pina IL, Felker GM, et al. Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study. Circulation. 2005; 111(19): 2454-60.
Renal function as a predictor of outcome in a broad spectrum of patients with heart failure. Circulation. 2006; 113(5): 671-8.
42. Aaronson KD, Schwartz JS, Chen TM, Wong KL, Goin JE, Mancini DM. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation. 1997;
95(12): 2660-7.
43. Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, et al. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation. 2006; 113(11): 1424-33.
44. May HT, Horne BD, Levy WC, Kfoury AG, Rasmusson KD, Linker DT, et al. Validation of the Seattle Heart Failure Model in a community-based heart failure population and enhancement by adding B-type natriuretic peptide. The American journal of cardiology. 2007; 100(4): 697-700.
45. Ketchum ES, Moorman AJ, Fishbein DP, Mokadam NA, Verrier ED, Aldea GS, et al. Predictive value of the Seattle Heart Failure Model in patients undergoing left ventricular assist device placement. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2010;
29(9): 1021-5.
46. Levy WC, Lee KL, Hellkamp AS, Poole JE, Mozaffarian D, Linker DT, et al. Maximizing survival benefit with primary prevention implantable cardioverter- defibrillator therapy in a heart failure population. Circulation. 2009; 120(10): 835-42. 47. Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. JAMA : the journal of the American Medical Association. 2003;
290(19): 2581-7.
48. Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC. Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. Journal of the American College of Cardiology. 2006; 47(1): 76-84.
49. O'Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M, et al. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. Journal of the American College of Cardiology. 2010; 55(9): 872-8.
50. Brophy JM, Dagenais GR, McSherry F, Williford W, Yusuf S. A multivariate model for predicting mortality in patients with heart failure and systolic dysfunction. The American journal of medicine. 2004; 116(5): 300-4.
51. Pocock SJ, Wang D, Pfeffer MA, Yusuf S, McMurray JJ, Swedberg KB, et al. Predictors of mortality and morbidity in patients with chronic heart failure. European heart journal. 2006; 27(1): 65-75.
52. Florea VG, Anand IS. Predicting survival in heart failure. Current cardiology reports. 2007; 9(3): 209-17.
53. O'Connor CM, Whellan DJ, Wojdyla D, Leifer E, Clare RM, Ellis SJ, et al. Factors related to morbidity and mortality in patients with chronic heart failure with systolic dysfunction: the HF-ACTION predictive risk score model. Circulation Heart failure. 2012; 5(1): 63-71.
54. de la Camara AG, Guerravales JM, Tapia PM, Esteban EA, del Pozo SV, Sandubete EC, et al. Role of biological and non biological factors in congestive heart failure mortality: PREDICE-SCORE: a clinical prediction rule. Cardiology journal. 2012; 19(6): 578-85.
55. Ross JS, Mulvey GK, Stauffer B, Patlolla V, Bernheim SM, Keenan PS, et al. Statistical models and patient predictors of readmission for heart failure: a systematic review. Archives of internal medicine. 2008; 168(13): 1371-86.
56. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA : the journal of the American Medical Association. 2004; 291(11): 1358-67.
patients with congestive heart failure. The American journal of cardiology. 1997;
79(12): 1640-4.
58. Philbin EF, DiSalvo TG. Prediction of hospital readmission for heart failure: development of a simple risk score based on administrative data. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology. 1999; 18(9): 855-6.
59. Krumholz HM, Chen YT, Wang Y, Vaccarino V, Radford MJ, Horwitz RI. Predictors of readmission among elderly survivors of admission with heart failure. American heart journal. 2000; 139(1 Pt 1): 72-7.
60. Felker GM, Leimberger JD, Califf RM, Cuffe MS, Massie BM, Adams KF, Jr., et al. Risk stratification after hospitalization for decompensated heart failure. Journal of cardiac failure. 2004; 10(6): 460-6.
61. Yamokoski LM, Hasselblad V, Moser DK, Binanay C, Conway GA, Glotzer JM, et al. Prediction of rehospitalization and death in severe heart failure by physicians and nurses of the ESCAPE trial. Journal of cardiac failure. 2007; 13(1): 8- 13.
62. van Jaarsveld CH, Sanderman R, Miedema I, Ranchor AV, Kempen GI. Changes in health-related quality of life in older patients with acute myocardial infarction or congestive heart failure: a prospective study. Journal of the American Geriatrics Society. 2001; 49(8): 1052-8.
63. Buck HG, Riegel B. The impact of frailty on health related quality of life in heart failure. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology. 2011;
10(3): 159-66.
64. Faller H, Stork S, Schuler M, Schowalter M, Steinbuchel T, Ertl G, et al. Depression and disease severity as predictors of health-related quality of life in patients with chronic heart failure--a structural equation modeling approach. Journal of cardiac failure. 2009; 15(4): 286-92 e2.
65. Jones AM, O'Connell JE, Gray CS. Living and dying with congestive heart failure: addressing the needs of older congestive heart failure patients. Age and ageing. 2003; 32(6): 566-8.
66. Rector TS, Cohn JN. Assessment of patient outcome with the Minnesota Living with Heart Failure questionnaire: reliability and validity during a randomized, double-blind, placebo-controlled trial of pimobendan. Pimobendan Multicenter Research Group. American heart journal. 1992; 124(4): 1017-25.
67. Santos JJ, Plewka JE, Brofman PR. Quality of life and clinical indicators in heart failure: a multivariate analysis. Arquivos brasileiros de cardiologia. 2009;
93(2): 159-66.
68. Havranek EP, Lapuerta P, Simon TA, L'Italien G, Block AJ, Rouleau JL. A health perception score predicts cardiac events in patients with heart failure: results from the IMPRESS trial. Journal of cardiac failure. 2001; 7(2): 153-7.
69. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More 'malignant' than cancer? Five-year survival following a first admission for heart failure. European journal of heart failure. 2001; 3(3): 315-22.
70. Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ (Clinical research ed). 2002; 325(7370): 929. 71. Steinhauser KE, Arnold RM, Olsen MK, Lindquist J, Hays J, Wood LL, et al. Comparing three life-limiting diseases: does diagnosis matter or is sick, sick? Journal of pain and symptom management. 2011; 42(3): 331-41.
72. McCarthy M, Hall JA, Ley M. Communication and choice in dying from heart disease. J R Soc Med. 1997; 90(3): 128-31.
73. Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al. Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Annals of internal medicine. 1997; 126(2): 97-106.
74. Singh M, Stewart R, White H. Importance of frailty in patients with cardiovascular disease. European heart journal. 2014; 35(26): 1726-31.
75. Gastelurrutia P, Lupon J, Altimir S, de Antonio M, Gonzalez B, Cabanes R, et al. Effect of fragility on quality of life in patients with heart failure. The American journal of cardiology. 2013; 112(11): 1785-9.
76. McNallan SM, Chamberlain AM, Gerber Y, Singh M, Kane RL, Weston SA, et al. Measuring frailty in heart failure: a community perspective. American heart journal. 2013; 166(4): 768-74.
77. Cacciatore F, Abete P, Mazzella F, Viati L, Della Morte D, D'Ambrosio D, et al. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. European journal of clinical investigation. 2005; 35(12): 723-30.
78. Simonsick EM, Newman AB, Nevitt MC, Kritchevsky SB, Ferrucci L, Guralnik JM, et al. Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the Health ABC study. J Gerontol A Biol Sci Med Sci. 2001; 56(10): M644-9.
79. Khan H, Kalogeropoulos AP, Georgiopoulou VV, Newman AB, Harris TB, Rodondi N, et al. Frailty and risk for heart failure in older adults: the health, aging, and body composition study. American heart journal. 2013; 166(5): 887-94.
80. Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Archives of internal medicine. 2002; 162(20): 2333-41.
81. Wilhelm-Leen ER, Hall YN, Deboer IH, Chertow GM. Vitamin D deficiency and frailty in older Americans. J Intern Med. 2010; 268(2): 171-80.
82. Murad K, Kitzman DW. Frailty and multiple comorbidities in the elderly patient with heart failure: implications for management. Heart failure reviews. 2012;
17(4-5): 581-8.
83. Braunstein JB, Anderson GF, Gerstenblith G, Weller W, Niefeld M, Herbert R, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality
among medicare beneficiaries with chronic heart failure. Journal of the American College of Cardiology. 2003; 42(7): 1226-33.
84. Wong CH, Weiss D, Sourial N, Karunananthan S, Quail JM, Wolfson C, et al. Frailty and its association with disability and comorbidity in a community-dwelling sample of seniors in Montreal: a cross-sectional study. Aging Clin Exp Res. 2010;
22(1): 54-62.
85. Morley JE. Anorexia, sarcopenia, and aging. Nutrition. 2001; 17(7-8): 660-3. 86. Pfisterer M, Buser P, Rickli H, Gutmann M, Erne P, Rickenbacher P, et al. BNP-guided vs symptom-guided heart failure therapy: the Trial of Intensified vs Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME- CHF) randomized trial. JAMA : the journal of the American Medical Association. 2009; 301(4): 383-92.
87. Demir M, Unsar S. Assessment of quality of life and activities of daily living in Turkish patients with heart failure. International journal of nursing practice. 2011;
17(6): 607-14.
88. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969; 9(3): 179-86.
89. Norberg EB, Boman K, Lofgren B. Impact of fatigue on everyday life among older people with chronic heart failure. Australian occupational therapy journal. 2010; 57(1): 34-41.
90. Norberg EB, Boman K, Lofgren B. Activities of daily living for old persons in primary health care with chronic heart failure. Scandinavian journal of caring sciences. 2008; 22(2): 203-10.
91. Yamada S, Shimizu Y, Suzuki M, Izumi T. Functional limitations predict the risk of rehospitalization among patients with chronic heart failure. Circulation