Risk factors and prognostic implications of unwanted loneliness in heart failure

This study found that among HF patients, female gender and widowhood were factors associated with undesirable loneliness, while a history of AMI was associated with a lower risk. It has also been confirmed that self-perceived loneliness is associated with an increased risk of adverse clinical events during follow-up. From Mr. Sullivan¹⁴ As defined to date, loneliness has gained relevance as a risk factor that negatively impacts mental health, physical health, health behaviors, and risk of mortality.^11,15,16,17. At the same time, concepts related to loneliness are being narrowed down (including loneliness and social isolation) and multiple scales are being developed and studied.¹⁸. Although not widely adopted, the WHO defines “loneliness'' as a painful subjective feeling resulting from a discrepancy between desired and actual social connections, or “social distress.'' , defines “social isolation” as the national goal of having a small network of families and relatives. Little or infrequent interaction with others due to non-family relationships¹¹. The ESTE II Social Loneliness Scale was developed and validated in 2009 at the University of Granada, Spain, and targeted the population aged 65 years and older. This score delves into social loneliness, understood as the subject's perceptions and experiences, and membership in social networks.⁵.

Loneliness in heart failure: existing evidence

The association between loneliness, social isolation and poor health is bidirectional^19,20. Most studies linking unwanted loneliness and heart failure have focused on investigating the role of loneliness and social isolation as risk factors for developing heart failure. There is a consistent link between loneliness and social isolation and coronary heart disease^{twenty one,twenty two,twenty three}. However, evidence of an association between unwanted loneliness and the development of heart failure is limited and inconclusive, likely due to definitional heterogeneity. A prospective study of a cohort of men aged 60 to 79 drawn from general practice clinics in 24 UK cities found that low social contact was associated with an increased risk of heart failure.^{twenty four}. In another study, Cené et al. In a cohort of postmenopausal women without a Women's Health Initiative diagnosis of heart failure, we showed that social isolation increases the risk of heart failure independent of traditional cardiovascular risk factors.¹⁰. Similarly, in a population cohort drawn from the UK Biobank database, Liang et al. concluded that loneliness and social isolation were independently associated with the development of heart failure, independent of genetic risk.^{twenty five}.

There is also a lack of scientific literature regarding factors associated with unwanted loneliness and in patients already diagnosed with heart failure. In the current study, the loneliness rate in heart failure patients was 36.9%. Previous studies have shown very different numbers for unwanted loneliness, ranging from 20% to 78%.^26,27,28. The presence of moderate to high loneliness was more uniform across validated scales (20-25%)^26,27 Increased loneliness (78%) than when measured with unvalidated scales²⁸. In Spain, the prevalence of unwanted loneliness in people over 65 is around 20%, and slightly higher in women.²⁹. There are many possible reasons for the high prevalence of loneliness in this study. (a) Type of scale used. (b) Old age. (c) chronic nature of HF; (d) Sample size. (e) the type of population evaluated here, most of which have features of advanced heart failure;^30,31,32. Our results show that loneliness in HF patients is associated with female gender (this result is consistent with remaining studies in HF patients)^26,27,28 And as a widow. Widowhood is typically not valued in this particular context. However, previous research suggests that people with heart failure are married.²⁷ or live with someone²⁶ It has been shown to be inversely correlated with the development of social isolation and loneliness. In the same sense, living alone was a risk factor for developing loneliness in multimorbid patients aged 50 years and older in Southeastern Europe.³³.

What stands out in our study is the result linking history of AMI as a factor that is inversely correlated with the presence of unwanted loneliness. Previous studies have not shown an association between a history of ischemic heart disease and loneliness in this patient profile.^26,27. As mentioned above, loneliness is a risk factor for the development of ischemic heart disease and has been considered comparable to other traditional cardiovascular risk factors such as obesity and smoking.¹⁶. Therefore, it is surprising that a history of AMI was inversely associated with loneliness in our study. The reasons explaining this association remain unclear. However, we suspect that the AMI story resonates as a culturally serious situation. Perhaps this is why those closest to patients who have had AMI in the past develop stronger bonds with patients and reduce feelings of loneliness. Furthermore, ischemic heart disease patients appear to be the main beneficiaries of cardiac rehabilitation programs that increase social contact, at least initially.³⁴.

Prognostic implications: the importance of measuring unwanted loneliness in heart failure

Increased mortality and health care resource utilization associated with loneliness have been reported in a variety of clinical scenarios and several times since the original study by Gellers et al.^16,26,27,29. Recent meta-analyses regarding increased mortality³⁵ They concluded that in the general population, loneliness and social isolation were significantly associated with an increased risk of all-cause mortality in the overall sample and in individuals with cardiovascular disease. Our results thus confirm the association between unwanted loneliness and worse clinical outcomes, which has already been observed in a variety of other clinical settings.

This study confirms the prevalence of unwanted loneliness in heart failure, but also adds new and relevant information about its clinical impact. Specifically, this is the first study to show that unwanted loneliness in Spain may be associated with an increased risk of adverse clinical events in patients with established heart failure.

The causes explaining the association between unwanted loneliness and poor clinical outcomes in heart failure appear to be multifactorial and not completely understood. We speculate that the following may play a role: (a) loneliness causes greater anxiety and stress than symptoms/signs of illness;⁷(b) unhealthy lifestyle habits;⁸(c) lack of treatment adherence;⁹and (d) biological factors.³⁶.

Given its high prevalence and deleterious effects, it seems reasonable to suggest that assessment of unwanted loneliness should be more routine in heart failure care settings. In this way, a closer clinical approach can be taken to identify the most vulnerable patients and then implement dedicated social/psychological intervention strategies aimed at reducing feelings of loneliness. How these strategies can contribute to better care and clinical outcomes deserves to be the subject of dedicated prospective studies.

Restrictions

Several limitations of this study must be acknowledged. First, this is an observational study, and numerous confounding factors may be at play. Second, this study was conducted in a single institution, so there may be selection bias that makes it difficult to extrapolate the results to other settings. Third, this study was not designed to understand the social/cultural/psychological/biological mechanisms behind the current findings. Fourth, the power of this study does not allow us to evaluate clinical adverse events such as isolated mortality or specific readmissions due to heart failure.