versão impressa ISSN 1677-5449
J. vasc. bras. vol.8 no.2 Porto Alegre jun. 2009
Raymundo Fagner Farias Novais dos SantosI; Gustavo José Martiniano PorfírioII; Guilherme Benjamin Brandão PittaIII
de Medicina, Faculdades Integradas Aparício Carvalho (FIMCA), Porto Velho,
IIFisioterapeuta, Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil
IIIDoutor, Professor adjunto, Departamento de Cirurgia, UNCISAL, Maceió, AL, Brazil
Chronic venous disease afflicts individuals in their most productive years,
resulting in pain and loss of mobility and independence in performing routine
daily activities, which may directly interfere with the patient's quality of
life. Clinical symptoms result from venous hypertension caused by reflux and/or
Objective: To determine differences in the quality of life of patients with mild and severe chronic venous disease.
Methods: A cross-sectional comparative study was conducted in a health care facility during an 8-month period. The sample was composed of 88 patients divided into two groups: group A (clinical CEAP class 1, 2 and 3) and group B (clinical CEAP class 4, 5 and 6). The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire was used. Statistical analysis was conducted using the Student t test, with a 95% confidence interval and a level of significance set at p < 0.05.
Results: We analyzed 88 subjects, 47 in group A and 41 in group B. Of the total, 87.5% (77) were women and 34% (30) were aged 30 to 40 years. Subcutaneous changes (CEAP class 4) were the most common symptoms, observed in 28.4% of the individuals. Except for the general health perceptions domain, group B showed lower scores than group A in all other domains.
Conclusions: The quality of life of patients with mild and severe chronic venous disease proved to be different according to disease severity.
Keywords: Quality of life, varicose veins, venous insufficiency.
Chronic venous disease of the lower limbs is characterized by a hypertensive condition of the venous system. This hypertension, caused by insufficiency and/or obstruction of the deep venous system, is the actual responsible for the onset of clinical symptoms in this disease.
A significant increase in the incidence of chronic venous disease is observed from the third decade of life, afflicting individuals in their most productive years and directly affecting their work capacity.1 In Europe, 5 to 15% of adults aged 30 to 70 years have this disease and, of these, 1% have an ulcer.2,3 Approximately 7 million people have chronic venous disease in the United States, which is responsible for around 70 to 90% of stasis ulcerations in the lower limbs.2,3
In Brazil, an epidemiological study carried out in the city of Botucatu, state of São Paulo, southeastern Brazil, revealed a prevalence of 35.5% for varicose veins and severe forms of chronic venous disease, and, of these, 1.5% had active or healed ulcer.4 This high incidence results in substantial treatment costs. Chronic venous disease generally translates into pain and loss of mobility and functional independence, which directly affects - and decreases - the patient's quality of life.5-7
CEAP involves a more complete diagnosis and classifies clinical severity and incapacity to work in patients with chronic venous disease,8 analyzing etiological, pathological, clinical and anatomical criteria. Clinical classification is divided into: C0 (no signs of venous disease), C1 (telangiectases and reticular veins), C2 (varicose veins), C3 (edema), C4 (subcutaneous changes; divided into C4a, representing changes in pigmentation and eczema, and C4b, lipodermatosclerosis and atrophie blanche), C5 (healed venous ulcer), and C6 (active venous ulcer).
The valuation of quality of life reflects an increased concern with the patient, who is now seen as a whole. Treatment shifts the focus from disease cure to reintegration of patients under conditions to have a normal life, i.e., health-related quality of life. Since this is an extremely relevant disease, chronic venous disease afflicts people at different age groups, directly affecting socioeconomic levels because it can prevent an individual from performing routine daily activities, such as working, which can cause early retirement during an individual's most productive years.
The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) generic questionnaire has already been described in the literature.9,10 It is a 36-item survey that measures the following domains: physical functioning, role limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health.11
There are two types of questionnaire reported in the literature: generic and specific. The generic questionnaire evaluates more broadly the most important aspects concerning the definition of quality of life. The specific type includes only the aspects most affected by certain pathologies; aspects which have been previously described in various studies conducted with a generic questionnaire.
Assessing an individual's quality of life proved to be the best way to observe the true action of chronic venous disease on the individual and on the individual's socioeconomic capacity and psychological aspects.
The objective of this study was to determine differences in the quality of life of patients with mild and severe chronic venous disease.
The present study was approved by the Research Ethics Committee of UNCISAL (no. 667/2007), with permission from CAIC Virgem dos Pobres Basic Care Health Center, based on resolution no. 196/96 of the Brazilian National Health Council.
A cross-sectional, comparative, analytical study was conducted to measure the quality of life in patients at different stages of chronic venous disease between October 2007 and July 2008.
The sample12 was calculated in 88 patients, taking into account standard deviation of 19.39 related to SF-36 domains,11, difference of 10 score points to be detected, level of significance of 5%, and study power of 80%. The sample was composed of patients with chronic venous disease of any origin classified as one of CEAP classes (C1 to C6), aged between 30 and 70 years (the pathology has a great occurrence at this age group), both men and women. Exclusion criteria were: pregnant women, patients with cognitive deficit, and indigenous patients. Before inclusion in the study, written informed consent was obtained from all patients.
Patients were divided into two groups allocated by non-probabilistic convenience sampling. Group A was composed of patients classified as clinical CEAP class 1, 2 and 3 (milder form of the disease); and group B, clinical CEAP class 4, 5 and 6 (more severe form of the disease). All patients were examined by an angiologist and diagnosed according to clinical CEAP classes. After diagnosis, SF-36 questionnaire was applied by the researcher. In addition to SF-36, data collection form included questions to characterize the sample regarding sex, age group, income, schooling, and clinical CEAP. SF-36 scores were used to determine whether there was a significant difference between groups. Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) software version 15.0 and the Student t test, with a 95% confidence interval (95%CI) and level of significance set at p < 0.05.
We collected data from 88 individuals. Among them, only 11 (12.5%) were men and 77 (87.5%) were women. Regarding age group, 30 (34%) were aged between 30 and 40 years, 25 (28.4%) between 41 and 50 years, 21 (23.9%) between 51 and 60 years, and the remaining, 11 (12.5%), between 61 and 70 years. Regarding schooling, 49 individuals (55.7%) had incomplete elementary school education, 19 (21.6%) had complete elementary school education, 12 (13.6%) had incomplete high school education, and the remaining, 6 (6.8%), had complete high school education. Regarding an individual's monthly income, most patients, 45 (51.1%), earned a maximum wage of R$ 400.00, 14 (15.9%) earned less than R$ 200.00 per month, 26 (29.5%) had a monthly wage of up to R$ 800.00, and only the remaining, 2 (2.3%), earned more than R$ 800.00 per month, reflecting the reality of patients in our health care facilities.
For the main variable, each group's SF-36 scores were compared using the Student t test and, if p-value < 0.05, statistical difference between groups was considered significant. Analysis between groups revealed that group B showed a worse quality of life when compared to group A in almost all domains, except for the general health perceptions domain Table 1). The following domains, physical functioning, role limitations due to physical aspects, vitality, social functioning, and bodily pain, had a p-value < 0.0001, i.e., extremely significant. The domains role limitations due to emotional problems (p = 0.0230) and mental health (p = 0.0014) also showed values less than 0.05, being considered statistically relevant. The general health perceptions domain, however, with a p-value = 0.0593, although close to borderline, could not be considered relevant (Table 1). In general, group B had scores lower than those of group A, except for the general health perceptions item.
Table 1 - Comparison between groups using SF-36 domains
SD = standard
deviation; SF-36 = Medical Outcomes Study 36-Item Short-Form Health Survey.
In relation to frequency of CEAP classification, confidence interval was used and the lower the interval, the more significant the sample. By observing clinical CEAP, in 28.4% (25 individuals, 95%CI 20.0-38.6) subcutaneous changes (C4) were the most common symptoms among individuals attending the basic care health facility (Table 2), followed by varicose veins (C2), with 22.7% (20 individuals, 95%CI 15.1-32.6), telangiectases (C1) with 17% (15 individuals, 95%CI 10.5-26.3), healed venous ulcer (C5) with 15.9% (14), edema (C3) showing 13.6% (12), and active venous ulcer (C6) with only 2.3% (2) (other values expressed in Table 2).
Table 2 - Frequency of CEAP clinical classification
95%CI = 95% confidence interval.
A study carried out in Brazil1 demonstrated that the incidence of chronic venous disease is higher among women, being 45% in the general population. In the present study, 88% of all participants were women, also with a higher incidence when compared to men.
Even in developed countries, incidence of chronic venous disease is significant (5 to 15% in adults).2 When compared to that of developing countries, such as Brazil,4 around 35.5% show some stage of the disease.
Analyzing low rates of quality of life, a randomized prospective study13 observed that, even after surgical intervention, the level of quality of life did not improve significantly during a 2-year period, which confirms the impact of the disease also observed in the present study. In addition to reporting quality of life scores similar to those herein obtained, a study carried out in Turkey14 indicated that the anatomical landmark of venous insufficiency and/or obstruction may also show a relationship.
The scores concerning pain, physical functioning and mobility have already been mentioned as the most commonly affected by chronic venous disease,15 similar to the results found in this study.
A multicenter study16 conducted in developed countries revealed that the most common incidence of chronic venous disease is the presence of varicose veins associated with skin changes, varicose veins with the presence of edema and telangiectases, respectively.
Reflecting about current health policies, which are concerned with the individual's integrality, quality of life is an important aspect and is intended to explain rates that are closely related to an individual's actual health status. In a systematic review,17 the most advanced stage of chronic venous disease proved to have an impact on the quality of life, significantly reducing its rates, due to severity and impact on an individual's most productive years.
In Brazil,18 the decrease in the quality of life of patients with venous ulcer is clear, underscoring the importance of a multidisciplinary team involved in its treatment, since this impact can be observed both on the physical and psychological aspects. Studies defining the situation of chronic venous disease nationwide are scarce; however, based on international studies of great impact16 and some national studies, we can observe that the quality of life is directly affected by the disease and, therefore, there is a growing need for the promotion of quality of life among these individuals.
The quality of life is different among patients with mild and severe chronic venous disease. Individuals showing more severe forms of the disease had lower SF-36 scores. Items such as pain, physical aspects, social and emotional aspects, vitality, mental health, and functional capacity were more significantly affected in individuals with a more advanced stage of the disease.
1. Maffei FHA. Insuficiência venosa crônica: diagnóstico e tratamento clínico. In: Maffei FHA, Lastória S, Yoshida WB, Rollo HA, Giannini M, Moura R. Doenças vasculares periféricas. Rio de Janeiro: Guanabara Koogan; 2008. [ Links ]
2. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham study. Am J Prev Med. 1988;4:96-101. [ Links ]
3. Heit JA, Rooke TW, Silverstein MD, et al. Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study. J Vasc Surg. 2001;33:1022-7. [ Links ]
4. Maffei FHA, Magaldi C, Pinho SZ. Varicose veins and chronic venous insufficiency in Brazil: prevalence among 1755 inhabitants of a country town. Int J Epidemiol. 1986;15:210-7. [ Links ]
5. Miller WL. Chronic venous insufficiency. Curr Opin Cardiol. 1995;10:543-8. [ Links ]
6. Ibrahim S, Macpherson DR, Goldhaber SZ. Chronic venous insufficiency: mechanisms and management. Am Heart J. 1996;132:856-60. [ Links ]
7. Kan YM, Delis KT. Hemodynamic effects of supervised calf muscle exercise in patients with venous leg ulceration. Arch Surg. 2001;136:1364-9. [ Links ]
8. Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-52. [ Links ]
9. McHorney CA, Ware JE, Raczek AE. The MOS 36-item short-form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-63. [ Links ]
10. Ware JE Jr, Sherbourne D. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473-83. [ Links ]
11. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol. 1999;39:143-50. [ Links ]
12. Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva: World Health Organization; 1991. [ Links ]
13. Blomgren L, Johansson G, Bergqvist D. Quality of life after surgery for varicose veins and the impact of preoperative duplex: results based on a randomized trial. Ann Vasc Surg. 2006;20:30-4. [ Links ]
14. Sadikoglu G, Ozcakir A, Ercan I, Yildiz C, Sadikoglu Y. Does the anatomical localization of lower extremity venous disease affect the quality of life? Saudi Med J. 2006;27:1683-7. [ Links ]
15. Bergan JJ, Schmid-schönbein GW, Smith PDC, Nicolaides AN, Boisseau MR, Eklöf B. Chronic venous disease. Minerva Cardioangiol. 2007;55:459-76. [ Links ]
16. Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg. 2001;34:641-8. [ Links ]
17. Herber OR, Schnepp W, Rieger MA. A systematic review on the impact of leg ulceration on patients' quality of life. Health Qual Life Outcomes. 2007;5:44. [ Links ]
18. Longo Jr O, Buzatto SHG, Fontes AO, Miyazaki COM, Godoy JMP. Qualidade de vida em pacientes com lesões ulceradas crônicas na insuficiência venosa de membros inferiores. Cir Vasc Angiol. 2001;17:21-6. [ Links ]
Correspondence: Article submitted
Nov 03 2008, accepted for publication Feb 18 2009. No conflicts of
interest declared concerning the publication of this article.
Raymundo Fagner Farias Novais dos Santos
Rua Dep. Rubens Canuto, 215/101 - Ponta Verde
CEP 57035200 Maceió, AL, Brazil
Tel.: +55 (82) 8803.4087
Study conducted at Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil.
The project of the present study was presented as poster at the 37th Brazilian Congress of Angiology and Vascular Surgery (Congresso Brasileiro de Angiologia e Cirurgia Vascular, CBACV) in 2007.
Financial source: PROBIC Research Grant Program, offered by Fundação de Amparo a Pesquisa de Alagoas (FAPEAL), AL, Brazil.
Article submitted Nov 03 2008, accepted for publication Feb 18 2009.
No conflicts of
interest declared concerning the publication of this article.