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Evaluation of Quality of Life in Patients with and without Heart Failure in Primary Care

Abstract

Background:

Heart failure (HF) is a major public health issue with implications on health-related quality of life (HRQL).

Objective:

To compare HRQL, estimated by the Short-Form Health Survey (SF-36), in patients with and without HF in the community.

Methods:

Cross-sectional study including 633 consecutive individuals aged 45 years or older, registered in primary care. The subjects were selected from a random sample representative of the population studied. They were divided into two groups: group I, HF patients (n = 59); and group II, patients without HF (n = 574). The HF group was divided into HF with preserved ejection fraction (HFpEF - n = 35) and HF with reduced ejection fraction (HFrEF - n = 24).

Results:

Patients without HF had a mean SF-36 score significantly greater than those with HF (499.8 ± 139.1 vs 445.4 ± 123.8; p = 0.008). Functional capacity - ability and difficulty to perform common activities of everyday life - was significantly worse (p < 0.0001) in patients with HF independently of sex and age. There was no difference between HFpEF and HFrEF.

Conclusion:

Patients with HF had low quality of life regardless of the syndrome presentation (HFpEF or HFrEF phenotype). Quality of life evaluation in primary care could help identify patients who would benefit from a proactive care program with more emphasis on multidisciplinary and social support. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Keywords:
Heart Failure; Quality of Life; Primary Health Care

Resumo

Fundamento:

A insuficiência cardíaca (IC) é um importante problema de saúde pública, com implicações na qualidade de vida relacionada à saúde (QVRS).

Objetivo:

Comparar a QVRS, estimada através do Questionário SF-36 (Short-Form Health Survey), em pacientes com e sem IC na comunidade.

Métodos:

Estudo transversal incluindo 633 indivíduos consecutivos com idade igual ou superior a 45 anos, registrados na atenção primária e selecionados de uma amostra aleatória representativa da população estudada. Foram divididos em dois grupos: grupo I, pacientes com IC (n = 59); e grupo II, pacientes sem IC (n = 574). O grupo I foi dividido em pacientes com IC com fração de ejeção preservada (ICFEP - n = 35) e pacientes com IC com fração de ejeção reduzida (ICFER - n = 24).

Resultados:

Pacientes sem IC tiveram um escore médio do SF-36 significativamente maior do que aqueles com IC (499,8 ± 139,1 vs 445,4 ± 123,8; p = 0,008). A capacidade funcional - habilidade e dificuldade para realizar atividades comuns da vida diária - foi significativamente pior (p < 0,0001) nos pacientes com IC independentemente de sexo e idade. Não houve diferença entre ICFEP e ICFER.

Conclusão:

Pacientes com IC mostraram baixa qualidade de vida a despeito da apresentação da síndrome (fenótipo ICFEP ou ICFER). A avaliação da qualidade de vida na atenção primária poderia auxiliar a identificar pacientes que se beneficiariam de um programa de atenção à saúde pró-ativo com maior ênfase em suporte multidisciplinar e social. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Palavras-chave:
Insuficiência Cardíaca; Qualidade de Vida; Atenção Primária à Saúde

Introduction

Heart failure (HF) is a major public health issue with implications in health-related quality of life (HRQL).11 Morgan K, McGee H, Shelley E. Quality of life assessment in heart failure interventions: a 10-year (1996-2005) review. Eur J Cardiovasc Prev Rehabil. 2007;14:589-660. doi: 10.1097/HJR.0b013e32828622c3.
https://doi.org/10.1097/HJR.0b013e328286...
Patients with HF present limitations on their usual activities, suffering impairment on social interaction, with a progressive loss of physical autonomy. Signs and symptoms of HF have a strong impact on HRQL regardless of the phenotype, affecting patients with either preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF). Although HFrEF and HFpEF differ regarding mortality and hospitalization rates,22 Redfield MM, Jacobsen SJ, Burnett Jr JC, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. J Am Med Assoc. 2003;289(2):194-202. PMID: 12517230.

3 Vasan RS, Benjamin EJ, Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol. 1995;26(7):1565-74. doi: 10.1016/0735-1097(95)00381-9.
https://doi.org/10.1016/0735-1097(95)003...
-44 Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, Evans JM, Bailey KR, et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation. 1998;98(21):2282-9. PMID: 9826315. manifested signs and symptoms appear to have a similar impact on the well-being of those patients.55 Malki Q, Sharma ND, Afzal A, Ananthsubramaniam K, Abbas A, Jacobson G, et al. Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function. Clin Cardiol. 2002;25(4):149-52. PMID: 12000071.

To improve the HRQL of patients with HF is one of the major aims of the treatment. Additionally, many patients with HF usually attribute more importance to HRQL than to improvement in their survival.66 Lewis EF, Johnson PA, Johnson W, Collins C, Griffin L, Stevenson LW. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant. 2001;20(9):1016-24. PMID: 11557198.

In the community setting, patients with HF are about a decade older, have multiple comorbidities and polypharmacy prescriptions, and are taking more medications than patients usually recruited for clinical trials.77 King D. Diagnosis and management of heart failure in the elderly. Postgrad Med J. 1996;72(852):577-80. PMID: 8977936.

8 McDonald K. Current guidelines in the management of chronic heart failure: practical issues in their application to the community population. Eur J Heart Fail. 2005;7(3):317-21. doi: 10.1016/j.ejheart.2005.01.013.
https://doi.org/10.1016/j.ejheart.2005.0...
-99 Jorge AL, Rosa ML, Martins WA, Correia DM, Fernandes LC, Costa JA, et al. The prevalence of stages of heart failure in primary care: a population-based study. J Card Fail. 2016;22(2):153-7. doi: 10.1016/j.cardfail.2015.10.017.
https://doi.org/10.1016/j.cardfail.2015....
These patients may benefit from measures that may improve their HRQL.

The objective of the present study was to compare the HRQL, estimated by the Short-Form Health Survey (SF-36), in patients with and without HF, and between the two phenotypes, HFrEF and HFpEF, in the community.

Methods

The Digitalis Study was a cross-sectional study including 633 volunteers, whose methodology is published elsewhere.1010 Jorge AJ, Rosa ML, Fernandes LC, Freire MD, Freire MD, Rodrigues RC, et al. Estudo da prevalência de insuficiência cardíaca em indivíduos cadastrados no Programa Médico de Família - Niterói. Estudo DIGITALIS: desenho e método. Rev Bras Cardiol. 2011;24(5):320-5. Briefly, individuals aged 45 to 99 years, registered in the Family Doctor Program (PMF) of the city of Niterói, Rio de Janeiro State, Brazil, were randomly selected to attend community visits for examination. Data were collected from July 2011 to December 2012. Initially, the healthcare units of the PMF were randomly selected, proportionally to the number of individuals enrolled. Then, in each unit, individuals aged 45 to 99 years were also randomly selected.

For the present study, individuals were divided into two groups: group I, formed by HF1111 McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al; ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Eur Heart J. 2012;33(14):1787-847. Erratum in: Eur Heart J. 2013;34(2):158. doi: 10.1093/eurheartj/ehs104.
https://doi.org/10.1093/eurheartj/ehs104...
patients (HF group - n = 59); and group II, formed by individuals without HF (n = 574). The HF group was divided into HFpEF (n = 35) and HFrEF (n = 24).

The Portuguese version of the SF-36 Questionnaire was used to classify HRQL.1212 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(3):143-50.

Statistical analysis

Statistical analysis was performed with the SPSS software, version 21.0 (Chicago, Illinois, USA). Categorical variables were expressed as absolute numbers and/or percentages. Quality of life and its domains presented non-Gaussian distribution, thus, the differences between categories were presented as median and interquartile range, and the differences were tested with the non-parametric Mann-Whitney test. All comparisons were assessed with bilateral tests. A 5% statistical significance level was considered.

Ethical considerations

This study was conducted in accordance with the principles of the Declaration of Helsinki, revised in 2000. The study protocol was approved by the Ethics Committee of the Institution under number 0077.0.258.000-10.

Results

We evaluated 633 subjects (59.6 ± 10.4 years; 62% female; 63% black or brown skin-color). The HF patients were older, had lower educational levels, consumed less alcohol, and showed a higher prevalence of former smokers. The average overall score, bodily pain and general health perception differed between patients without HF as compared to patients with HF. Two dimensions, physical and emotional aspects, showed no variation (Table 1).

Table 1
Demographic characteristics and mean scores of the SF36 dimensions of individuals with and without heart failure

Physical functioning was lower in patients with HF regardless of sex or age. Women, regardless of the presence of HF, scored lower for most of the dimensions than men did. The functional capacity - ability and difficulty to perform common everyday life activities -, general health perception and overall score were significantly worse in patients with HF independently of sex and age (Table 2).

Table 2
Mean SF-36 scores by sex and age in patients with and without heart failure

Women had lower HRQL (vitality and general health perception) even in the absence of HF. Individuals younger than 60 years had a worse HRQL in the presence of HF, which was not observed in patients aged 60 years and older (Table 2).

Although the differences were not statistically significant (except for the vitality dimension), patients with HFpEF had lower mean values as compared to those with HFrEF (Table 3).

Table 3
SF-36 overall and dimension scores of individuals with heart failure with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively)

Discussion

Patients with HF had a lower mean overall SF-36 score than patients without HF (53.1 ± 29.6 vs. 76.2 ± 24.9; p < 0.001). The HRQL worsening observed in this study was similar to data obtained in the literature.1313 O'Mahony MS, Sim MF, Ho SF, Steward JA, Buchalter M, Burr M. Diastolic heart failure in older people. Age Ageing. 2003;32(5):519-24. PMID: 12958001.

14 Riegel B, Carlson B, Glaser D, Romero T. Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure. Qual Life Res. 2003;12(6):689-98. PMID: 14516178.
-1515 Jaarsma T, Halfens R, Abu-Saad HH, Dracup K, Stappers J, van Ree J. Quality of life in older patients with systolic and diastolic heart failure. Eur J Heart Fail. 1999;1(2):151-60. PMID: 10937925.

Age, vitality, pain and the overall SF-36 score were the four characteristics associated with worse HRQL in patients with HFrEF. On the other hand, only age was related to HRQL worsening in patients with HFpEF.

The CHARM study1616 Lewis EF, Lamas GA, O'Meara E, Granger CB, Dunlap ME, McKelvie RS, et al; CHARM Investigators. Characterization of health-related quality of life in heart failure patients with preserved versus low ejection fraction in CHARM. Eur J Heart Fail. 2007;9(1):83-91. doi: 10.1016/j.ejheart.2006.10.012.
https://doi.org/10.1016/j.ejheart.2006.1...
has evaluated the HRQL in HF patients and has concluded that those with HFpEF had a similar HRQL when compared to patients with low left ventricular ejection fraction (LVEF). That study showed that the extent of HRQL worsening was independent of LVEF. Our data did not show a difference between the overall SF-36 scores in patients with HFpEF and HFrEF (418.9 ± 122.5 vs. 476.6 ± 120.5; p = 0.101).

In general, older HF patients reported better quality of life than younger ones, regardless of the LVEF value. Studies have shown a better HRQL among older patients than among younger patients with HFrEF, although older patients had a worse functional status and performed worse in the six-minute walk test.1717 Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM, et al; Cardiovascular Outcomes Research Consortium. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail. 2004;10(5):368-73. doi: 15470645. Our data show that patients aged 45 to 59 years with HF have a more pronounced worsening of HRQL than those without HF (394.0 ± 106.4 vs. 501.3 ± 139.8; p = 0.012) when compared to patients aged ≥ 60 years (459.9 ± 125.7 vs. 497.7 ± 138.3; p = 0.113).

Patients with HF usually do not understand the cause and prognosis of their disease and rarely discuss the quality and end of life with the professionals involved in their care. Care for people with advanced progressive illnesses is currently prioritized by diagnosis rather than need. Patients with advanced HF should receive care that is proactive and designed to meet their specific needs.1818 Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. British Med J. 2002;325(7370):929. PMID: 12399341.

A chronic syndrome such as HF, which requires continuous treatment for an indeterminate period and is linked to aging and presence of comorbidities, is inexorably associated with worse quality of life.1313 O'Mahony MS, Sim MF, Ho SF, Steward JA, Buchalter M, Burr M. Diastolic heart failure in older people. Age Ageing. 2003;32(5):519-24. PMID: 12958001.

14 Riegel B, Carlson B, Glaser D, Romero T. Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure. Qual Life Res. 2003;12(6):689-98. PMID: 14516178.
-1515 Jaarsma T, Halfens R, Abu-Saad HH, Dracup K, Stappers J, van Ree J. Quality of life in older patients with systolic and diastolic heart failure. Eur J Heart Fail. 1999;1(2):151-60. PMID: 10937925.

The present study had some limitations. This is a cross-sectional study where all evaluations were performed in a single day without follow-up of the population, leading to difficulty in establishing causal relationships between HF and loss of quality of life. Another limitation is related to the reduced number of HF cases assessed, which diminishes the power of the study, leading to the lack of statistical significance of some associations.

Conclusions

Patients with HF have low quality of life independent of the syndrome phenotype. The quality of life evaluation in primary care could help identify patients who would benefit from a proactive healthcare program with more emphasis on multidisciplinary and social support. Therefore, strategies that can improve the quality of life of those patients and bring them greater benefits than the prolongation of life without associated quality are needed.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This article is part of the Postgraduate course submitted by Prof. Dr Antonio José Lagoeiro Jorge, from Universidade Federal Fluminense.

Acknowledgements

We thank the support of the Municipality of Niterói in the accomplishment of this research.

References

  • 1
    Morgan K, McGee H, Shelley E. Quality of life assessment in heart failure interventions: a 10-year (1996-2005) review. Eur J Cardiovasc Prev Rehabil. 2007;14:589-660. doi: 10.1097/HJR.0b013e32828622c3.
    » https://doi.org/10.1097/HJR.0b013e32828622c3
  • 2
    Redfield MM, Jacobsen SJ, Burnett Jr JC, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. J Am Med Assoc. 2003;289(2):194-202. PMID: 12517230.
  • 3
    Vasan RS, Benjamin EJ, Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol. 1995;26(7):1565-74. doi: 10.1016/0735-1097(95)00381-9.
    » https://doi.org/10.1016/0735-1097(95)00381-9
  • 4
    Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, Evans JM, Bailey KR, et al. Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation. 1998;98(21):2282-9. PMID: 9826315.
  • 5
    Malki Q, Sharma ND, Afzal A, Ananthsubramaniam K, Abbas A, Jacobson G, et al. Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function. Clin Cardiol. 2002;25(4):149-52. PMID: 12000071.
  • 6
    Lewis EF, Johnson PA, Johnson W, Collins C, Griffin L, Stevenson LW. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant. 2001;20(9):1016-24. PMID: 11557198.
  • 7
    King D. Diagnosis and management of heart failure in the elderly. Postgrad Med J. 1996;72(852):577-80. PMID: 8977936.
  • 8
    McDonald K. Current guidelines in the management of chronic heart failure: practical issues in their application to the community population. Eur J Heart Fail. 2005;7(3):317-21. doi: 10.1016/j.ejheart.2005.01.013.
    » https://doi.org/10.1016/j.ejheart.2005.01.013
  • 9
    Jorge AL, Rosa ML, Martins WA, Correia DM, Fernandes LC, Costa JA, et al. The prevalence of stages of heart failure in primary care: a population-based study. J Card Fail. 2016;22(2):153-7. doi: 10.1016/j.cardfail.2015.10.017.
    » https://doi.org/10.1016/j.cardfail.2015.10.017
  • 10
    Jorge AJ, Rosa ML, Fernandes LC, Freire MD, Freire MD, Rodrigues RC, et al. Estudo da prevalência de insuficiência cardíaca em indivíduos cadastrados no Programa Médico de Família - Niterói. Estudo DIGITALIS: desenho e método. Rev Bras Cardiol. 2011;24(5):320-5.
  • 11
    McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, et al; ESC Committee for Practice Guidelines. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Eur Heart J. 2012;33(14):1787-847. Erratum in: Eur Heart J. 2013;34(2):158. doi: 10.1093/eurheartj/ehs104.
    » https://doi.org/10.1093/eurheartj/ehs104
  • 12
    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(3):143-50.
  • 13
    O'Mahony MS, Sim MF, Ho SF, Steward JA, Buchalter M, Burr M. Diastolic heart failure in older people. Age Ageing. 2003;32(5):519-24. PMID: 12958001.
  • 14
    Riegel B, Carlson B, Glaser D, Romero T. Changes over 6-months in health-related quality of life in a matched sample of Hispanics and non-Hispanics with heart failure. Qual Life Res. 2003;12(6):689-98. PMID: 14516178.
  • 15
    Jaarsma T, Halfens R, Abu-Saad HH, Dracup K, Stappers J, van Ree J. Quality of life in older patients with systolic and diastolic heart failure. Eur J Heart Fail. 1999;1(2):151-60. PMID: 10937925.
  • 16
    Lewis EF, Lamas GA, O'Meara E, Granger CB, Dunlap ME, McKelvie RS, et al; CHARM Investigators. Characterization of health-related quality of life in heart failure patients with preserved versus low ejection fraction in CHARM. Eur J Heart Fail. 2007;9(1):83-91. doi: 10.1016/j.ejheart.2006.10.012.
    » https://doi.org/10.1016/j.ejheart.2006.10.012
  • 17
    Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM, et al; Cardiovascular Outcomes Research Consortium. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail. 2004;10(5):368-73. doi: 15470645.
  • 18
    Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. British Med J. 2002;325(7370):929. PMID: 12399341.

Publication Dates

  • Publication in this collection
    17 Aug 2017
  • Date of issue
    Sept 2017

History

  • Received
    07 Dec 2016
  • Reviewed
    05 May 2017
  • Accepted
    15 May 2017
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