Association between Spirituality and Adherence to Management in Outpatients with Heart Failure

Alvarez, Juglans Souto; Goldraich, Livia Adams; Nunes, Alice Hoefel; Zandavalli, Mônica Cristina Brugalli; Zandavalli, Rafaela Brugalli; Belli, Karlyse Claudino; Rocha, Neusa Sica da; Fleck, Marcelo Pio de Almeida; Clausell, Nadine

doi:10.5935/abc.20160076

person Juglans Souto Alvarez

schoolHeart Failure Program, Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre - Brazil

person Livia Adams Goldraich

schoolHeart Failure Program, Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre - Brazil

person Alice Hoefel Nunes

schoolFederal University of Rio Grande do Sul, Porto Alegre - Brazil

person Mônica Cristina Brugalli Zandavalli

schoolFederal University of Rio Grande do Sul, Porto Alegre - Brazil

person Rafaela Brugalli Zandavalli

schoolFederal University of Rio Grande do Sul, Porto Alegre - Brazil

person Karlyse Claudino Belli

schoolHospital de Clinicas de Porto Alegre, Porto Alegre - Brazil

person Neusa Sica da Rocha

schoolDivision of Psychiatry, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre - Brazil

person Marcelo Pio de Almeida Fleck

schoolDivision of Psychiatry, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre - Brazil

person Nadine Clausell

schoolHeart Failure Program, Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre - Brazil

Mailing Address: Nadine Clausell, Rua Ramiro Barcelos, 2350, Division of Cardiology - room 2060. Postal Code 90035903, Rio Branco, Porto Alegre, RS - Brazil. E-mail:
nclausell@hcpa.edu.br

Author contributions

Conception and design of the research: : Alvarez JS, Goldraich LA, Nunes AH, Rocha NS, Fleck MPA, Clausell N. Acquisition of data: Alvarez JS, Zandavalli MCB, Zandavalli RB, Belli KC. Analysis and interpretation of the data: Alvarez JS, Goldraich LA, Nunes AH, Rocha NS, Fleck MPA. Statistical analysis: Alvarez JS, Goldraich LA, Nunes AH, Rocha NS. Obtaining financing: Alvarez JS. Writing of the manuscript: Alvarez JS, Goldraich LA, Nunes AH, Clausell N. Critical revision of the manuscript for intellectual content: Alvarez JS, Goldraich LA, Nunes AH, Rocha NS, Fleck MPA, Clausell N. Supervision / as the major investigador: Alvarez JS, Clausell N. Formatting and translation: Zandavalli RB.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

N		130
Demographics
Age, years		60 ± 13
Gender, male		88 (67.5%)
Ethnicity
	Caucasian	113 (87%)
	African-descendent	9 (7%)
	Other	8 (6%)
Education
	Functionally illiterate	5 (4%)
	Elementary, non-graduated	79 (61%)
	Elementary, graduated	26 (20%)
	High school, non-graduated	6 (5%)
	High school, graduated	14 (11%)
Marital status
	Single	31 (24%)
	Married	78 (60%)
	Divorced	15 (11.5%)
	Widowed	6 (4.5%)
Heart failure history
Etiology
	Ischemic	42 (32.5%)
	Idiopathic	28 (21.5%)
	Hypertensive	29 (22.5%)
	Valvular	14 (10%)
	Alcoholic	10 (7.5%)
	Other	7 (5%)
Ejection fraction, %		36 ± 13
Functional class, NYHA
	I-II	97 (74.5%)
	III-IV	33 (25.5%)
Cardiac devices (ICD or CRT-D)		23 (18%)
Hospital admissions in the previous year
	None	82 (63%)
	One	26 (20%)
	More than one	22 (17%)
Comorbidities
	Hypertension	75 (57.5%)
	Dyslipidemia	64 (49%)
	Previous myocardial infarction	39 (30%)
	Previous cardiac surgery	24 (18.5%)
	Diabetes	50 (38.5%)
	COPD	10 (7.5%)
	Chronic kidney impairment	52 (40%)
	Previous stroke	20 (15.5%)
	Collagen tissue disease	11 (9%)
	Smoking, past or present	66 (50.5%)
	Alcoholism, past or present	29 (22.5%)
	Neoplasia	18 (14%)

N		130
Adherence (REMADHE)		16.2 ± 4.1
Quality of life
Generic (WHOQoL-Bref)
	Total	13.0 ± 3.7
	Domains
	Physical	12.2 ± 3.1
	Psychological	14.1 ± 2.7
	Social	13.7 ± 2.1
	Environmental	14.8 ± 1.9
Disease-specific (MLHFQ)		50.5 ± 16.9
Depression (PHQ-9)		4.8 ± 5.3
Religiosity (DUREL)
Total		23.5 ± 4.6
	Intrinsic	15.5 ± 2.8
	Organizational	3.3 ± 1.6
	Non-organizational	4.7 ± 1.3
Spirituality (WHOQoL-SRPB)
Total		3.8 ± 0.61
Domains
	Connect	3.7 ± 0.7
	Meaning	3.9 ± 0.6
	Awe	3.8 ± 0.8
	Whole	3.7 ± 0.6
	Strength	3.8 ± 0.8
	Peace	3.8 ± 0.7
	Hope	3.8 ± 0.8
	Faith	3.8 ± 0.7

		r	p
Clinical characteristics
	Age, years	0.10	0.24
	Ejection fraction, %	-0.09	0.30
	NYHA functional class	0.03	0.70
Quality of Life
Generic (WHOQoL-Bref)
Total		0.21	0.02
Domains
	Physical	0.13	0.16
	Psychological	0.28	0.001
	Social	0.08	0.36
	Environmental	0.21	0.01
Disease-specific (MLHFQ)		-0.09	0.29
Depression (PHQ-9)		-0.12	0.16
Religiosity (DUREL)
Total		0.13	0.14
	Intrinsic	0.20	0.02
	Organizational	0.02	0.79
	Non-organizational	-0.006	0.95
Spirituality (WHOQoL-SRPB)
Total		0.26	0.003
Domains
	Connect	0.31	< 0.0001
	Meaning	0.23	0.008
	Awe	0.27	0.002
	Whole	0.19	0.02
	Strength	0.21	0.02
	Peace	0.23	0.01
	Hope	0.19	0.03
	Faith	0.27	0.002

		DUREL		DUREL-ORA		DUREL-NORA		DUREL-IR
		r	p	r	p	r	p	r	p
WHOQoL-SRPB		0.55	0.0001	0.36	0.0001	0.29	0.001	0.57	0.0001
	Connect	0.54	0.0001	0.29	0.0001	0.34	0.0001	0.59	0.0001
	Meaning	0.38	0.0001	0.19	0.03	0.18	0.04	0.44	0.0001
	Awe	0.36	0.0001	0.27	0.02	0.10	0.25	0.38	0.0001
	Whole	0.47	0.0001	0.30	0.0001	0.27	0.002	0.48	0.0001
	Strength	0.49	0.0001	0.33	0.0001	0.28	0.001	0.51	0.0001
	Peace	0.39	0.0001	0.27	0.002	0.20	0.02	0.41	0.0001
	Hope	0.37	0.0001	0.29	0.001	0.22	0.01	0.31	0.0001
	Faith	0.54	0.0001	0.33	0.0001	0.34	0.0001	0.56	0.0001

Model 1	β coefficient	OR (CI 95%)	p
WHOQoL-SRPB, 1-point increase	1.01	2.76 (1.31 – 5.81)	0.007
Age, 1-year increase	-0.01	0.98 (0.95 – 1.01)	0.32
Ejection fraction, 1% increase	-0.01	0.98 (0.95 – 1.02)	0.40
Marital status, married	0.56	1.75 (0.76 – 4.08)	0.19
Instruction, ≥ elementary school graduation	0.31	1.36 (0.59 – 3.11)	0.47
Model 2	β coefficient	OR (CI 95%)	p
WHOQoL-SRPB, 1-point increase	1.17	3.23 (1.49 – 7.01)	0.003
Heart failure of ischemic etiology	-0.31	0.73 (0.32 – 1.67)	0.45
Implantable cardiac defibrillator	-0.91	0.40 (0.15 – 1.05)	0.06
Chronic kidney disease	-0.72	0.48 (0.21 – 1.08)	0.08
Marital status, married	-0.36	0.69 (0.31 – 1.57)	0.38
Model 3	β coefficient	OR (CI 95%)	p
WHOQoL-SRPB	-0.12	4.89 (1.64 – 14.58)	0.004
WHOQoL-Bref	1.59	1.03 (0.98 – 1.06)	0.19
MLHFQ	0.03	1.02 (0.98 – 1.06)	0.26
PHQ-9	0.02	1.03 (0.92 – 1.16)	0.60
DUREL	0.03	0.89 (0.79 – 1.00)	0.05

		REMADHE, points	p (t test)
Demographics
Age
	< 60	15.9 ± 4.1	0.31
	≥ 60	16.6 ± 3.7	0.31
Gender
	Male	16.6 ± 3.8	0.16
	Female	15.6 ± 4.2	0.16
Ethnicity
	Caucasian	16.5 ± 3.9	0.23
	Other	15.2 ± 3.8	0.23
Education
	Elementary graduated or higher degree	16.0 ± 3.8	0.56
	Other	16.5 ± 4.0	0.56
Marital status
	Married	17.0 ± 4.1	0.01
	Other	15.2 ± 3.5	0.01
Heart failure history
Etiology
	Ischemic	17.4 ± 3.6	0.02
	Non-ischemic	15.8 ± 4.0	0.02
Ejection fraction
	≤ 35%	16.4 ± 3.9	0.83
	> 35%	16.2 ± 3.9	0.83
Functional class, NYHA
	I-II	16.1 ± 4.0	0.38
	III-IV	16.8 ± 3.7	0.38
Cardiac Defibrillator
	Yes	17.7± 3.2	0.05
	No	16.0 ± 4.1	0.05
Admissions in the previous year
	None	16.1 ± 4.0	0.52
	Any	16.6 ± 3.8	0.52
Comorbidities
Hypertension
	Yes	16.6 ± 3.7	0.34
	No	15.9 ± 4.2	0.34
Previous myocardial infarction
	Yes	17.2 ± 3.6	0.11
	No	15.9 ± 4.0	0.11
Previous cardiac surgery
	Yes	16.5 ± 4.4	0.8
	No	16.3 ± 3.9	0.8
Diabetes
	Yes	16.0 ± 3.7	0.50
	No	16.5 ± 4.0	0.50
Chronic kidney impairment
	Yes	17.2 ± 3.8	0.04
	No	15.8 ± 3.9	0.04
Previous stroke
	Yes	16.6 ± 2.7	0.69
	No	16.3 ± 4.1	0.69
Smoking, past or present
	Yes	14.3 ± 4.1	0.28
	No	15.8 ± 4.2	0.28
Alcoholism, past or present
	Yes	16.1 ± 4.0	0.34
	No	16.9 ± 3.7	0.34
Neoplasia
	Yes	15.6 ± 4.4	0.38
	No	16.4 ± 3.9	0.38

[TFN01] NYHA: New York Heart Association; ICD: implantable cardiac defibrillator; CRT-D: cardiac resynchronization therapy-defibrillator; COPD: chronic obstructive pulmonary disease. Data expressed as mean ± SD and number (percentage). Ejection fraction assessed by bi-dimensional echocardiography (Simpson method).