Journals | Policy | Permission

Cardiology Research

Original Article

Volume 3, Number 6, December 2012, pages 264-270

Chronic Ischemic Heart Disease Affects Health Related Quality of Life

Chronic diseases endanger not only physical health but also psychological and social health of patient seriously and many of them live without hope to improve. Generally, cardiac disease is among such chronic diseases. Chronic ischemic heart disease (IHD) is common with rising age [1].

Congestive report of disease management published in Iran in 2001, the number of patients with heart disease in 18 provinces of Iran counted around 3,337 cases per 100,000. The 1998 survey showed that 25% of patients’ admissions in cardiac wards were related with chronic heart disease [2].

Goals of treatment in ischemic heart disease are to modulate symptoms and improve the prognosis. Chronic heart disease is associated with severe limitations of quality of life (QOL) [3, 4]. QOL constitutes the individual’s perceptional symptoms, well-being, and physical and mental functional capacity. Over the past decade, quality of life improvement has been increasingly used as an indicator of health outcome [5, 6]. So, another major goal of health care is to maximize function in everyday life and to elevate level of quality of life. Quality of life is supposed to have a relatively new scientific role to evaluate effectiveness of treatment strategies and the course of a disease [7-9].

In this context, we assess the influence of socio-demographic variables, objective measures of age, sex, heart disease severity and duration, anxiety and depressive co-morbidity on the quality of life in a cross-sectional analysis in patients with CHF. Thus, we had a particular interest to evaluate the quality of life in chronic heart diseases and affecting factors. Additionally, it is unknown whether there is relationship between depression and anxiety with QOL similar across different chronic conditions; we tried to clarify these aspects.

A descriptive-cross sectional study was designed to evaluate quality of life and mental health condition of chronic heart disease patients selected from congestive heart disease care unites and wards of Zanjan hospitals; Vali-e-asr and Mousavi. This study was approved and supported in the Zanjan University of medical sciences in 2011.

A total of 50 chronic heart disease volunteers were selected randomly from the patients who referred to congestive heart disease wards of vali-e-asr and Mousavi as referral academic hospitals, in Zanjan. The inclusion criteria of eligible patients enrolled in this study was aged of 30 - 80 years, with chronic ischemic heart disease dysfunction at least for 6 months. Subjects were excluded from the study if they were under 30 or over 80 years old, or if they suffered from new onset of congestive heart disease, or other co-morbidity such other simultaneous chronic somatic of psychological disease. Subjects gave their informed consent to participate in the present study. All subjects were asked to complete their demographic and medical information including age, sex, education, disease duration and its severity, substance abuse history, psychological disorder history in a questionnaire. Then, patients completed 26 question containing WHOQOL-BREF questionnaire which assessed 24 factors in quality of life in 4 parameters; physical, psychological, social and environmental. Also, the patients were asked to answer some self-rating questionnaires: the Zung Depression [10, 11]. All processes were conducted under supervision of general physician and the details of the study were explained to the entire participant. Questionnaire of illiterate participants were completed by her.

The ischemic heart disease was defined a clinical syndrome because of an inherited or acquired abnormality of congestive heart disease structure and/or function, develop a constellation of clinical symptoms (dyspnea and fatigue) and signs (edema and rales) that lead to frequent hospitalizations, a poor quality of life, and a shortened life expectance [12].Consecutive patients with stable ischemic heart disease were selected according to the NYHA functional class by assessment of electrocardiography, exercise test, echocardiography or angiography documents.

The World Health Organization Quality of Life-BREF (WHOQOL-BREF) is a 26 containing items designed by World Health Organization (WHO) to measure 24 factors affecting quality of life in 4 components representing physical, psychological, social and environmental functioning. Also, 2 question assessed total quality of life and general health condition. Scale scores are then transformed to a 0 to 20 range. The lower score the more poor quality life condition. Validity and reliability of WHOQOL-BREF questionnaire was determined first time by Dr Nejat and colleagues, 1,167 subject from Tehran completed this questionnaire and then its reliability was confirmed by Cronbach score (Cronbach alpha = 0.83). Intra class correlation and Cronbach alpha score in all domains were 7/0, respectively, but in the social domain alpha was calculated 55/0, which can be due to low number of questions or inquiries in this area. Questionnaire validity of this tool with the ability to distinguish healthy and patient groups were evaluated using linear regression and correlation matrix to assess the structural factors of the questionnaire were used. In 83% of cases, the correlation of each question with its main areas was higher than other areas. Results obtained in this study showed acceptable validity and reliability, and structural factors of this tool in healthy and patient groups, in Iran [13].

All descriptive statistics are presented as means and standard deviations for continuous variables, and as absolute and relative frequencies for categorical variables. Health related quality of life scores are presented as means and standard deviations.

Comparisons were performed with 2-sample t tests (for continuous variables) and chi-square tests (for categorical variables). Data were evaluated by soft ware SPSS version 16. Significant P-value was considered as P < 0.05.

A total of 50 patients fulfilled inclusion criteria and participated in the study. Their characteristics are summarized in Table 1.They were in a mean age of 58.6 years old, 60% female. More than 85% suffered from moderate and server ischemic heart failure (according to York Heart Association (NYHA) functional class) but less than 120 months, 60% were illiterate and 80% had economic income less than 300$ monthly. Psychological problem including anxiety or depression was found in only 16% of subjects which was not statistically meaningful.

Click to view

Table 1. Baseline Characteristic of Congestive Heart Failure Patients

Scores in each parameter in physical, psychological, social and environmental domains evaluated in WHOQOL-BREF questionnaire was respectively 12.19, 11.98, 12.08, and 12.4. It was revealed all parameters of quality of life had a significant correlation with sex and educational level and income (P < 0.05). It means that educated women with high income experienced better mental health and quality life. Age, duration of disease, substance abuse history, and Psychological problem history were not correlated with quality of life components.

Severity of anxiety and depression among patients was shown in Table 1. Approximately one fifth of patients expressed severe symptoms of anxiety and one forth suffered from severe depressed mood. Evaluation of quality of life parameters relationship with anxiety and depression showed a statistically meaningful correlation in those ischemic heart disease patients. In congestive heart disease, quality of life decreases as anxiety and depression severity worsens (P < 0.05) Table 2.

Click to view

Table 2. Relationship Between Quality of Life Score and the Degree of Anxiety in Congestive Heart Patients

Click to view

Table 3. Relationship Between Quality of Life Score and the Degree of Depression in Congestive Heart Patients

Chronic heart disease (CHF) is associated with impaired quality of life (QOL) due to repeated hospital admissions, and a bad prognosis. Many patients suffer from depressive and anxiety symptoms with additional negative impact on prognosis [1, 3, 4, 14-17].

In this cross sectional study, we evaluated the impact of socio demographic variables, objective measures of heart disease duration, anxiety, and depressive co-morbidity on the QOL in patients with CHF treated in hospital cardiac wards.

We found that socio demographic factors such as age, duration of disease, substance abuse history, and psychological problem history weakly correlated with some QOL scales. But aspect of quality of life may improve in female sex, high education level and income.

Inconsistent previous findings showed worse QOL in women than men, others found that association only in the physical domains of QOL10 or not at all [18, 19]. Several reasons for this inconsistency have been discussed, such as different symptom perception or depression rates in women in comparison in men [3, 19]. Our patient sample was predominantly female, therefore our sample had only 40% male, which was potentially the reason why sex had only a marginal impact on QOL [20].

Similar to our study with a population of 184 showed that approximately 50% of the patients’ quality of life is undesirable, type of job, income overall life education, home care, disease severity, disease duration, frequency of doctor and hospital admission, duration of hypertension, edema, hyperlipidemia, fatigue and various medications were associated with significantly with quality of life scores [2].

Chronic heart disease duration played no or only a minor role in predicting QOL. But significant correlation between heart disease duration and QOL has been described in some studies which evaluated acute unstable cardiac angina admitted in cardiac care units [21, 22].

The relationship between depression and quality of life (QOL) has been studied in many chronic condition including populations with ischemic heart disease (IHD). The prevalence of depression in this group seems to be higher than in the general population, ranging from 15 to 50% [22-25].

Similar to previous findings, our results show that patients with chronic HD experiences different signs of depression, anxiety, and emotional stress [26, 27]. Data from Brazil study revealed that depression and anxiety prevalence was considerable and depression is an independent factor associated with worse QOL in congestive heart disease. Among the priorities aiming at improving QOL must be evaluation and management of depressive symptoms [28].

In the recent study, anxiety and depression had a statistically meaningful correlation with quality of life in those congestive heart disease patients and quality of life decreases as anxiety and depression severity worsens. These findings are consistent with data reported by other authors considering depression and anxiety as the variable most predictive of worse quality of life [24, 29, 30].

Our study reinforces the more severe depression and anxiety experience, the worse quality of life is supposed in chronic illness. Our findings also highlight the importance of assessment and management of depression and anxiety in the IHD. It can be deduced to pay special attention to psychological aspects.

1. McMurray JJ, Stewart S. Epidemiology, aetiology, and prognosis of heart failure. Heart. 2000;83(5):596-602.
   doi
2. Rahnavard Z, Zolfaghari M, Kazemnejad A, et al. An investigation of quality of life and factors affecting it in the patients with congestive heart failure. Hayat. 2006;12(1):77-86.
3. Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, Haass M. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart. 2002;87(3):235-241.
   doi pubmed
4. Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM, Spertus JA. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail. 2004;10(5):368-373.
   doi pubmed
5. Thompson DR, Meadows KA, Lewin RJ. Measuring quality of life in patients with coronary heart disease. Eur Heart J. 1998;19(5):693-695.
   pubmed
6. Hillers TK, Guyatt GH, Oldridge N, Crowe J, Willan A, Griffith L, Feeny D. Quality of life after myocardial infarction. J Clin Epidemiol. 1994;47(11):1287-1296.
   doi
7. Bullinger M. [Health related quality of life and subjective health. Overview of the status of research for new evaluation criteria in medicine]. Psychother Psychosom Med Psychol. 1997;47(3-4):76-91.
   pubmed
8. Wenger NK. Quality of life: can it and should it be assessed in patients with heart failure?. Cardiology. 1989;76(5):391-398.
   doi pubmed
9. Wenger NK, Mattson ME, Furberg CD, Elinson J. Assessment of quality of life in clinical trials of cardiovascular therapies. Am J Cardiol. 1984;54(7):908-913.
   doi
10. Zung WW. A Self-Rating Depression Scale. Arch Gen Psychiatry. 1965;12:63-70.
    doi pubmed
11. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12(6):371-379.
    pubmed
12. American Heart Association. International Cardiovascular Disease Statistics, Cardiovascular Disease. Availablefrom:http://www.sld.cu/galerias/pdf/servicios/hta/internationalcardiovascular_disease_statistics.pdf. (Accessed 10Jul. 2010).
13. Nejat S, Montazeri A, Holakouie Naieni K, et al. The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. Journal of School of Public Health. 2006;4(4):1-12.
14. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More 'malignant' than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail. 2001;3(3):315-322.
    doi
15. Bouvy ML, Heerdink ER, Leufkens HG, Hoes AW. Predicting mortality in patients with heart failure: a pragmatic approach. Heart. 2003;89(6):605-609.
    doi pubmed
16. Konstam V, Moser DK, De Jong MJ. Depression and anxiety in heart failure. J Card Fail. 2005;11(6):455-463.
    doi pubmed
17. O'Connor CM, Joynt KE. Depression: are we ignoring an important comorbidity in heart failure?. J Am Coll Cardiol. 2004;43(9):1550-1552.
    doi pubmed
18. Calvert MJ, Freemantle N, Cleland JG. The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study. Eur J Heart Fail. 2005;7(2):243-251.
    doi pubmed
19. Riedinger MS, Dracup KA, Brecht ML, Padilla G, Sarna L, Ganz PA. Quality of life in patients with heart failure: do gender differences exist?. Heart Lung. 2001;30(2):105-116.
    doi pubmed
20. Muller-Tasch T, Peters-Klimm F, Schellberg D, Holzapfel N, Barth A, Junger J, Szecsenyi J, et al. Depression is a major determinant of quality of life in patients with chronic systolic heart failure in general practice. J Card Fail. 2007;13(10):818-824.
    doi pubmed
21. Hasanpour A, Hasanpour M, Foruzandeh N. A survey on quality of life in patients with myocardial infarction, referred to Shahrekord Hagar hospital in 2005. J Shahrekord Univ Med. 2006;9(3):78-84.
22. Gaynes BN, Burns BJ, Tweed DL, Erickson P. Depression and health-related quality of life. J Nerv Ment Dis. 2002;190(12):799-806.
    doi pubmed
23. Rudisch B, Nemeroff CB. Epidemiology of comorbid coronary artery disease and depression. Biol Psychiatry. 2003;54(3):227-240.
    doi
24. Rumsfeld JS, Magid DJ, Plomondon ME, Sales AE, Grunwald GK, Every NR, Spertus JA. History of depression, angina, and quality of life after acute coronary syndromes. Am Heart J. 2003;145(3):493-499.
    doi pubmed
25. Valkamo M, Hintikka J, Niskanen L, Koivumaa-Honkanen H, Honkalampi K, Viinamaki H. Depression and associated factors in coronary heart disease. Scand Cardiovasc J. 2001;35(4):259-263.
    doi pubmed
26. Paul S, Sneed N. Patient perceptions of quality of life and treatment in an outpatient congestive heart failure clinic. Congest Heart Fail. 2002;8(2):74-79.
    doi pubmed
27. Ekman I, Fagerberg B, Skoog I. The clinical implications of cognitive impairment in elderly patients with chronic heart failure. J Cardiovasc Nurs. 2001;16(1):47-55.
    pubmed
28. Nascimento Cruz L, Almeida Fleck MP, Polanczyk CA. Depression as a determinant of quality of life in patients with chronic disease: data from Brazil. Soc Psychiat Epidemiol. 2010;45:953-961.
    doi pubmed
29. Steele TE, Baltimore D, Finkelstein SH, Juergensen P, Kliger AS, Finkelstein FO. Quality of life in peritoneal dialysis patients. J Nerv Ment Dis. 1996;184(6):368-374.
    doi pubmed
30. Swenson JR, O'Connor CM, Barton D, Van Zyl LT, Swedberg K, Forman LM, Gaffney M, et al. Influence of depression and effect of treatment with sertraline on quality of life after hospitalization for acute coronary syndrome. Am J Cardiol. 2003;92(11):1271-1276.
    doi pubmed

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cardiology Research is published by Elmer Press Inc.