Validation of the Portuguese version of the Minnesota Living with Heart Failure Questionnaire

Carvalho, Vitor Oliveira; Guimarães, Guilherme Veiga; Carrara, Dirceu; Bacal, Fernando; Bocchi, Edimar Alcides

doi:10.1590/S0066-782X2009000700008

Abstracts

BACKGROUND: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is an important measurement instrument for assessing the quality of life of heart failure patients. Despite being largely used within our context, the questionnaire had not yet been translated and validated into the Portuguese language. OBJECTIVE: Of this study was to translate and validate the Portuguese version of the MLHFQ for use in heart failure patients. METHODS: Forty patients with heart failure (30 men, LVEF 30±6%, 55% ischemic etiology, classified as NYHA I to III), clinically stable and on optimized drug therapy underwent maximal cardiopulmonary stress testing to assess their physical capacity. Right after the test, the MLHFQ duly translated into Portuguese was administered by the same investigator. The NYHA functional classification was provided by the medical team. RESULTS: The Portuguese version of the MLHFQ had the same structure and metrics of the original version. There was no difficulty in the administration of the questionnaire or in the patient's understanding of the questions. The Portuguese version of the MLHFQ was consistent with peak VO2, duration of the cardiopulmonary test, and NYHA functional classification. There was no difference in the score mean for the questionnaire between the group of patients with ischemic etiology and the group with non-ischemic etiology. CONCLUSION: The Portuguese version of the MLHFQ proposed in this study proved to be valid for heart failure patients, and constitutes a new and important instrument for assessing quality of life.

Heart failure; validation; questionnaires; quality of life

FUNDAMENTO: O Minnesota Living with Heart Failure Questionnaire (MLHFQ) é uma importante ferramenta de avaliação da qualidade de vida em pacientes com insuficiência cardíaca. Apesar de amplamente usado em nosso meio, não contávamos com a sua tradução e validação em língua portuguesa. OBJETIVO: Este estudo pretendeu traduzir e validar a versão em português do MLHFQ em pacientes com insuficiência cardíaca. MÉTODOS: Quarenta pacientes com insuficiência cardíaca (30 homens, FEVE 30±6%, 55% de etiologia isquêmica, NYHA I a III) com estabilidade clínica e terapia medicamentosa otimizada realizaram teste cardiopulmonar máximo para avaliação da capacidade física. Logo após, o MLHFQ, devidamente traduzido, foi aplicado por um mesmo pesquisador. A classe funcional NYHA foi encaminhada pela equipe medica. RESULTADOS: A versão em português do MLHFQ apresentou-se com a mesma estrutura e métrica da versão original. Não houve dificuldade na aplicação e compreensão do questionário por parte dos pacientes. A versão em português do MLHFQ mostrou-se concordante com o pico de VO2, o tempo de exercício do teste cardiopulmonar e com a classificação funcional da NYHA. Não houve diferença da média do escore do questionário entre os grupos de etiologia isquêmica e não-isquêmica. CONCLUSÃO: A versão em língua portuguesa da MLHFQ, proposta no presente estudo, demonstrou ser válida em pacientes com insuficiência cardíaca, constituindo uma nova e importante ferramenta para avaliar a qualidade de

Insuficiência cardíaca; validação; questionários; qualidade de vida

FUNDAMENTO: El Minnesota Living with Heart Failure Questionnaire (MLHFQ) es un importante instrumento de evaluación de la calidad de vida en pacientes con insuficiencia cardiaca. A pesar de su amplio empleo en nuestro medio, no contábamos con su traducción y validación en lengua portuguesa. OBJETIVO: Este estudio tuvo por objeto traducir y validar la versión en portugués del MLHFQ en pacientes con insuficiencia cardiaca. MÉTODOS: Se realizó la prueba de ejercicio cardiopulmonar máximo en 40 pacientes con insuficiencia cardiaca (30 varones, FEVE 30±6%, el 55% de etiología isquémica, NYHA I a III) con estabilidad clínica y terapia medicamentosa optimizada, para evaluarse la capacidad física. Acto seguido, un investigador aplicó el MLHFQ debidamente traducido. La clase funcional NYHA fue referida por el equipo médico. RESULTADOS: La versión en portugués del MLHFQ se presentó con la misma estructura y estándares de medición de la versión original. No hubo dificultad en la aplicación y compensación del cuestionario por parte de los pacientes. La versión en portugués del MLHFQ resultó concordante con el pico de VO2, el tiempo de ejercicio de la prueba de ejercicio cardiopulmonar y con la clasificación funcional de la NYHA. No hubo diferencia del promedio del score del cuestionario entre los grupos de etiología isquémica y no isquémica. CONCLUSIÓN: La versión en lengua portuguesa de la MLHFQ, propuesta en el presente estudio, resultó válida en pacientes con insuficiencia cardiaca, constituyendo un nuevo e importante instrumento para evaluar la calidad de vida.

Insuficiencia cardiaca; validación; cuestionarios; calidad de vida

ORIGINAL ARTICLE

Laboratório de Insuficiência Cardíaca e Transplante do Instituto do Coração do Hospital das Clinicas da Universidade de São Paulo (InCor HCFMUSP), São Paulo, SP - Brazil

Mailing address

SUMMARY

BACKGROUND: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is an important measurement instrument for assessing the quality of life of heart failure patients. Despite being largely used within our context, the questionnaire had not yet been translated and validated into the Portuguese language.

OBJECTIVE: Of this study was to translate and validate the Portuguese version of the MLHFQ for use in heart failure patients.

METHODS: Forty patients with heart failure (30 men, LVEF 30±6%, 55% ischemic etiology, classified as NYHA I to III), clinically stable and on optimized drug therapy underwent maximal cardiopulmonary stress testing to assess their physical capacity. Right after the test, the MLHFQ duly translated into Portuguese was administered by the same investigator. The NYHA functional classification was provided by the medical team.

RESULTS: The Portuguese version of the MLHFQ had the same structure and metrics of the original version. There was no difficulty in the administration of the questionnaire or in the patient's understanding of the questions. The Portuguese version of the MLHFQ was consistent with peak VO₂, duration of the cardiopulmonary test, and NYHA functional classification. There was no difference in the score mean for the questionnaire between the group of patients with ischemic etiology and the group with non-ischemic etiology.

CONCLUSION: The Portuguese version of the MLHFQ proposed in this study proved to be valid for heart failure patients, and constitutes a new and important instrument for assessing quality of life.

Key words: Failure; validation; questionnaires; quality of life.

Introduction

Heart failure, the final common pathway of every heart disease, is characterized by exacerbated neurohormonal activity, low tolerance to exercise, short survival time, and poor quality of life^1-3.

Quality of life is a discrepancy between the satisfaction or discontent of an individual regarding certain areas of his/her own life according to his/her own perception, and is considered the best indicator of quality of life^4. In conventional terms, satisfaction with life refers to the fulfillment of needs, expectations, longings, and desires⁵.

In dealing with quality of life, we evaluate the aspects of a patient's intimacy, interactions, and social and physical dimensions, i.e., how that person behaves before himself/herself and the world around him/her, taking into consideration interpersonal relationships and how the world interferes in his/her intimate, physical, and social status⁶.

The scientific community has attempted to quantify the impact of heart failure on patients' lives. Despite the existence of the New York Heart Association (NYHA) functional classification and the Six-minute Walk Test^7,8, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), was created and is today largely used within our context and worldwide. Nevertheless, the questionnaire had not yet been translated and validated in Brazil.

This study sought to translate and validate the Portuguese version of the MLHFQ for use in patients with heart failure.

Methods

Population

Forty patients with heart failure (30 men, left ventricular ejection fraction 30±6%) were recruited from an outpatient clinic specialized in heart failure of a high-complexity cardiology hospital, between March 2007 and March 2008 (Table 1).

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All patients were clinically stable, with no changes in their drug regimen, and had not been hospitalized in the previous three months. Patients with additional functional limitations other than heart failure, such as important osteoarthrosis, cerebrovascular accident, and chronic obstructive pulmonary disease, were excluded from the study.

All patients were previously informed about the aims of the study and were asked to give their informed consent by signing the appropriate form, approved by the institution's Research in Ethics Committee.

Dynamics of the study

In this cross-sectional study, all patients came to our laboratory to undergo a maximal cardiopulmonary stress test in order to evaluate their physical capacity. Right after the test, the Portuguese version of the MLHFQ, duly translated, was applied twice with a one-week interval by the same investigator so as to preserve homogeneity of standards and interpretation of the responses, thus allowing higher accuracy of the data obtained. NYHA functional classifications were provided by the medical team of the outpatient clinic responsible for the patient's care⁹.

Cardiopulmonary stress testing

Patients were instructed not to perform any tiring physical activity and not to have coffee or alcohol during the 24 hours preceding the test. The last meal had to be made at least two hours before the test. All patients underwent maximal cardiopulmonary stress testing (Naughton protocol) on a treadmill (Series 2000, Marquette Electronics, Milwaukee, WI, USA) in a room with controlled temperature (21ºC to 23ºC) between 10:00 a.m. and 3:00 p.m., with a 12-lead electrocardiographic recording (Max 1, Marquette Electronics, Milwaukee, WI, USA) and arterial blood pressure measured by the auscultatory method. Ventilation (LV, BTPS), oxygen consumption (VO₂, STPD), carbon dioxide (VCO₂, STPD), and the other cardiopulmonary variables were obtained by breath-by-breath analysis using a computerized system (Vmax 229 model, SensorMedics, Yorba Linda, CA, USA). Peak VO₂ was considered as the mean of the last 30-second values before exhaustion. A test was considered satisfactory when a respiratory quotient (R/Q) >1.05 was associated with symptoms of maximal effort.

Translation into Portuguese of the Minnesota Living with Heart Failure Questionnaire

Translation was performed according to a few stages proposed by coordinators of the IQOLA - International Quality of Life Assessment Project,²⁰ and also based on literature addressing the methodology used for the translation of quality of life evaluation questionnaires into other languages. ²⁰

The first translation

The items in the original version of the MLHFQ were initially translated into Portuguese by two independent Brazilian English teachers who were familiar with the goals of the study. At that time, the main focus was on the concepts underlying the document and not on the strictly literary translation. The two translations were then compared by the translators and the investigator; in case of any disagreement, changes were made in order to reach a consensus as to the initial translation (Portuguese Version Number 1).

Evaluation of the first translation

The Portuguese Version Number 1 was back-translated into English by two English teachers, one from England and the other one from the United States, who had not participated in the previous phase. Later on, these two versions were compared to the original questionnaire in English, and the existing discrepancies were documented and analyzed by a group consisting of two cardiologists, a nurse, a psychologist, and one of the English teachers. When necessary, the sentences in Portuguese were rewritten until a consensus was reached, thus generating Version Number 2 in Portuguese.

Statistical analysis

Data were analyzed using the 11.5 version of the SPSS statistical software (SPSS Inc., Chicago, IL, USA). The Intraclass Correlation Coefficient (r_i) with 95% confidence interval was used to test the concordance between the MQLQ utilization and re-utilization. Additionally, a visual analysis was carried out through the Bland & Altman plot with a 95% limit of concordance. The internal consistency of the scale was evaluated through Cronbach's alpha coefficient. The validity of the MQLQ in comparison to peak VO₂, time of exercise at the cardiopulmonary test and the NYHA functional classification was assessed by Spearman's coefficient of correlation. The non-paired Student's t test was used to compare the means of the MQLQ score between the groups with ischemic and non-ischemic etiology.

Results

Patients included in this study displayed a deteriorated physical capacity (peak VO₂ less than 20 mL/Kg/min), significant functional impairment as measured by the NYHA, and a high score for the Portuguese version of the MLHFQ (i.e., Questionário de Qualidade de Vida Minnesota - QQVM) (Table 1). No difference was found for the QQVM score between the ischemic group and the non-ischemic group (53±15 and 42±19, respectively; p=0.57; CI = -4.5212 to 27.1640).

The Portuguese version of the MLHFQ had the same structure and metrics of the original version (Appendix 1). The MQLQ demonstrated concordance between its utilization and re-utilization (r_i=0.97; p<0.0001) (Figure 1). Cronbach's alpha coefficient was 0.97. Significant correlations were observed between the total MQLQ score and peak VO_2, time of exercise at the cardiopulmonary test and the NYHA functional classification (Table 2).

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Discussion

This study did the translation of the MLHFQ into the Portuguese language. Moreover, this version was consistent with the NYHA functional classification, peak VO₂ and duration of physical exercise during the cardiopulmonary stress test in heart failure patients. The investigator had no difficulty in applying the Portuguese version, and the patients had no difficulty understanding it.

Patients should answer the questions considering the preceding month. The scale of answers to each question ranges from 0 (None) to 5 (Very much), where 0 represents no limitation and 5 represents maximal limitation. These questions involve a physical dimension (from 1 to 7, 12, and 13) which is highly interrelated with dyspnea and fatigue, an emotional dimension (from 17 to 21), and other questions (8, 9, 10, 11, 14, 15, and 16) which added to the previous dimensions, make up the total score. Because this subset of questions does not have a pattern of answers, it was not grouped as a separate dimension in the questionnaire¹⁰.

MLHFQ was developed specifically for heart failure, which makes it an instrument much more suited to the reality of this type of patient. For this reason, this questionnaire may differ in some questions when compared to other generic questionnaires such as the 36-item Short-Form Health Survey (SF-36) which was developed for chronic diseases^11,12. In spite of this, in a prior study good consistency was found between the QQVM and the SF-36, although no one datum for physical capacity was investigated¹².

It is known that the NYHA functional classification is characterized by the severity of the heart failure symptoms and, for this reason, MLHFQ was expected to be useful for patients with different degrees of severity. Nevertheless, this hypothesis was not confirmed¹². In our study, the NYHA classification provided by the medical team, as well as the value of peak VO₂ and the duration of the cardiopulmonary stress test, were consistent with the QQVM score. In a Spanish study, a strong correlation was reported between the NYHA functional classification and the score for the Spanish version of MLHFQ, a fact which led the authors to conclude that MLHFQ may reflect the severity of heart failure¹³. In our study, the result was the same. This finding leads us to think that the Portuguese version of the MLHFQ may also reflect the severity of heart failure. Despite the prognostic nature of the etiology in heart failure¹⁴, we found no difference in the QQVM between the ischemic and non-ischemic groups.

MLHFQ can be used in a unique way to assess the quality of life of heart failure patients or to evaluate the outcome of an intervention. Due to its great importance, several studies conducted in Brazil used MLHFQ even before it had been translated, validated, and published. Bocchi et al¹⁵ studied the quality of life of heart failure patients under treatment with Levosimendan using the Minnesota score. Issa et al¹⁶ studied the effect of Bisoprolol on the quality of life, and Vilas-Boas et al¹⁷ analyzed the transplantation of spinal cord cells to the myocardium of patients with chagasic heart failure.

Limitations of the study

This study was limited by the non application of a quality of life questionnaire validated in Brazil, such as the SF-36. Nevertheless, this comparison had been made before¹².

Conclusion

The Portuguese version of the MLHFQ proposed in this study proved to be a new valid and important instrument for assessing quality of life and limitations in the capacity of heart failure patients to perform daily activities.

Potential Conflict of Interest

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

Sources of Funding

This study was partially funded by CAPES.

Study Association

This study is not associated with any post-graduation program.

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