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Objective The purpose of this study is to compare the effectiveness of a combined 12-week home-based exercise (EX)/cognitive behavioral therapy (CBT) program (n=18) with CBT alone (n=19), EX alone (n=20), and with usual care (UC, n=17) in stable New York Heart Association Class II to III heart failure (HF) patients diagnosed with depression. Methods Depressive symptom severity [Hamilton Rating Scale for Depression (HAM-D)], physical function [6-min walk test (6MWT)], and health-related quality of life (HRQOL) (Minnesota Living with Heart Failure Questionnaire) were evaluated at baseline (T1), after the 12-week intervention/control (T2), and following a 3-month telephone follow-up (T3). A repeated measures analysis of variance was used to determine group differences. Depression severity was dichotomized as minor (HAM-D, 11–14) and moderate-to-major depression (HAM-D, ≥15), and group intervention and control responses were also evaluated on that basis. Results The greatest reduction in HAM-D scores over time occurred in the EX/CBT group (−10.4) followed by CBT (−9.6), EX (−7.3), and UC (−6.2), but none were statistically significant. The combined group showed a significant increase in 6-min walk distance at 24 weeks (F=13.5, P<.001). Among all groups with moderate-to-major depression, only those in CBT/EX had sustained lower HAM-D scores at 12 and 24 weeks, 6MWT distances were significantly greater at 12 (P=.018) and 24 (P=.013) weeks, and the greatest improvement in HRQOL also occurred. Conclusions Interventions designed to improve both physical and psychological symptoms may provide the best method for optimizing functioning and enhancing HRQOL in patients with HF.

Many patient education guidelines for teaching heart failure patients recommend inclusion of the family; however, family-focused interventions to promote self-care in heart failure are few. This article reviews the state of the science regarding family influences on heart failure self-care and outcomes. The literature and current studies suggest that family functioning, family support, problem solving, communication, self-efficacy, and caregiver burden are important areas to target for future research. In addition, heart failure patients without family and those who live alone and are socially isolated are highly vulnerable for poor self-care and should receive focused attention. Specific research questions based on existing science and gaps that need to be filled to support clinical practice are posed.Keywords caregiver outcomes; family functioning; family support; heart failure; patient education; self-care; self-management Efforts to bolster self-care in heart failure (HF) patients are paramount to improving behaviors related to diet and medication adherence, reducing hospitalization, and enhancing overall outcomes. Self-care in HF is quite variable, and new approaches are needed to promote preventable hospitalizations, reduce symptoms, and improve quality of life. Published clinical practice guidelines suggest that both patients with HF and their family members or care-givers should receive individualized education and counseling that emphasizes self-care 1 ; however, the data to guide family education and care in HF are sparse. This review will examine the literature related to HF self-care and family concepts including descriptive research on family variables and behaviors, the relationship of family variables to outcomes, and family intervention studies. Finally, recommendations for HF practice and future research will be presented. Copyright NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptThe concept of family is highly relevant to self-care, and a recent framework published by Grey and colleagues 2 outlines the relationships among family factors, individual, and family selfmanagement of chronic illness. Using a structure, process, and out-comes framework, the model identifies family structural variables as risk and protective factors that influence individual and family self-care and self-management behaviors as part of health promotion or chronic disease care. These behaviors, such as healthy eating or medication-taking activities, then lead to clinical outcomes. Family functioning (which has dimensions of adaptability, problem solving, and communication and roles) in this model also is viewed as an outcome of self-management; however, in other chronic illness populations, family functioning is often understood as a precursor to effective self-care. Regardless of where it is placed in models, when family functioning is not optimal, managing a complex self-care regimen, such as that prescribed for HF patients, will not be as effective as it could be. Better family fun...

Background Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (NA) intake and medication adherence (MA). Methods HF patients and family member (FM) dyads (N = 117) were randomized to: usual care (UC), Patient-FM education (PFE), or a family partnership intervention (FPI). Dietary NA (3-day food record), Urine NA (24-hour urine) and MA (MEMS®) were measured at baseline (BL) prior to randomization, and at 4 and 8 months (M). Results FPI and PFE reduced Urine NA at 4 M, and FPI differed from UC at 8 M (p=.016). Dietary NA decreased from BL to 4M with both PFE (p=.04) and FPI (p=.018) lower than UC. The proportion of subjects adherent to NA intake (≤ 2500 mg/day) was higher at 8 M in PFE and FPI vs UC (χ2(2)=7.076, p=.029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention. Conclusions Dietary NA intake, but not MA, was improved by the PFE and FPI interventions compared with UC. UC was less likely to be adherent with dietary NA. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.