American University of Beirut

Congestive Heart Failure


1. Outcomes of adherence to guidelines in the management of Heart failure: The role of HF specialist

Heart failure is a chronic disease that affects millions of people every year and associated with high levels of mortality and morbidity worldwide. The adherence to guidelines in treating HF patients is an important predictor of their clinical worsening.

Objectives: to evaluate the level of adherence to ESC guidelines in the management of HF patients, as well as assessing the impact of poor adherence on mortality and readmission after a 1-year follow-up period. This study also aims to evaluate the role of a HF-specialist in implementing these guidelines.​

2.Validation of the Arabic version of the Minnesota Living with Heart Failure Questionnaire (MLHFQ)

Quality of life in patients with heart failure should be assessed appropriately since it is an important outcome that can be used to assess the effectiveness of heart failure treatments. The MLHFQ is the most commonly used disease specific instrument to measure quality of life in heart failure patients.

Objectives: This study aim is to examine the psychometric properties and cultural validity of an Arabic translated version of the MLHFQ as a disease-specific measure of Quality of life in heart failure patients.

3. Potentially inappropriate medications in elderly patients with heart failure

Elderly heart failure patients are considered among the highest consumers of drugs. Their complex drug regimens and various comorbidities predispose them to inappropriate prescribing of medications. “Beers criteria" is among the most widely used criteria for the evaluation of potentially inappropriate medications (PIMs) use in elderly patients.

Objectives: The aim of this study is to evaluate the proportion of PIMs in elderly HF patients as well as the factors associated with the number of PIMs. Also, to test for the correlation between PIMs and the impairment in quality of life and depression in this vulnerable population.​

Heart Failure Self-Care​

Patients with heart failure are encouraged to be more involved in their healthcare through participation in disease management programs; central to these programs is the concept of self-care. Self-care is recognized as a universal approach for improving outcomes of heart failure, yet failed self-care is common.
Consistent with an anthropological lens that perceptions about health and illness are culturally constructed, culture becomes a fundamental context in which to explore self-care behaviors. Studies to date have not addressed what predicts successful self-care in Lebanese heart failure patients.
Until we understand self-care behaviors from a cultural perspective, failed self-care will remain common, with tremendous socioeconomic costs and burdens to the individual, family, and society. Knowledge from this study will facilitate clinician understanding of what factors affect the performance or lack thereof of self-care in Lebanon and aid in designing tailored behavioral modification interventions targeting improved heart failure self-care.


Study 4. Determinants of Self-Care in Patients with Heart Failure

Aim:  to describe self-care behaviors and their determinants in a sample of Lebanese patients with heart failure and subsequently make recommendations for interventions to promote self-care among this vulnerable patient population.

Findings of this study confirmed that the patient-caregiver relationships and their influence on heart failure self-care is complex and multifaceted. Yet, research that recognizes the interdependence between patients and their caregivers and examines patients and caregivers within the context of the dyad is rare. Dyad based studies are complex and are challenged by their methods, recruitment of dyads, analysis of data, and increased costs.

Ongoing Research Projects

Study 5. Dyad Engagement in Heart Failure Self-Care

Aim: to identify patient and dyadic determinants of self-care in heart failure care dyads while controlling for dyadic interdependence.

Secondary Aims: (1) to typify distinct patterns of heart failure patient-caregiver dyads engagement in self-care and link these patterns to heart failure disease outcomes (2) to establish a neurocognitive profile of the heart failure patient and determine whether an association exists between the severity of heart failure and cognitive abilities as well as cognitive abilities and self-care, and (3) to validate the knowledge, attitudes and behaviors related to sodium intake of Lebanese adults tool against a 24 hour urine sodium collection.

Knowledge gained from this study will help clinicians better support heart failure self-care, facilitate better conceptualizing of the concept, and aid in developing effective interventions that support both the patient and their caregiver. Additionally, recognizing cognitive deficits in this population is imperative to inform the content and nature of heart failure treatment plans, and to maximize adherence, symptom recognition, decision-making, and self-care. ​


Under Review

  1. Massouh, A., Huijer, H., Meek, P., Skouri, H. Determinants of Self-Care in Patients with Heart Failure: Observations from a Developing Country in the Middle East. Under Review in the Journal of Transcultural Nursing.
  2. Massouh, A., Cook, P., Meek, P., Huijer, H., Khoury, M., & Skouri, H. Self-Care Confidence Predicts Self-Care Management and Maintenance in Patients with Heart Failure. Submitted to the International Journal of Behavioral Medicine.


  1. Noureddine, S., & Massouh, A. (2019). Self-Care in Cardiovascular Nursing. European Journal of Cardiovascular Nursing Retrieved from:​

List of People Involved in the Project

  • Principal Investigator: Angela Massouh
  • Co-PIs:
    • Self-Care Dyad: Hadi Skouri, Huda Huijer, Souha Fares, and Paula Meek
    • Cognitive Profiling: Hala Darwish and Paula Meek
    • ​Salt Tool Validation: Lara Nasreddine, Hussain Ismail, and Hadi Skouri

  • ​Mariam Zahwe, PhD student
  • Samar Noureddine, PhD, RN, FAHA, FAAN
  • Hani Tamim, PhD
  • Maurice Khoury, MD
  • Hussain Isma’eel, MD, FSCCT, FESC
  • Angala Massouh, PhD, MScN, CNS
  • Hadi Skouri, MD
  • Fouad Zouein, PhD​

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