European Journal of Heart Failure

European Journal of Heart Failure 1999 1(2):151-160; doi:10.1016/S1388-9842(99)00007-0

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© 1999 European Society of Cardiology

Quality of life in older patients with systolic and diastolic heart failure

T. Jaarsma^a,*, R. Halfens^a, H. Huijer Abu-Saad^a, K. Dracup^c, J. Stappers^b and J. van Ree^a

^a University of Maastricht PO Box 616, 6200 MD Maastricht, The Netherlands
^b Department of Cardiology University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
^c University of California 10833 Le Conte Avenue, Los Angeles, CA 90024–1702, USA

^* Corresponding author. Tel.: +31 43 3881703; fax: +31 43 3671004

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
Aims: To get insight into the quality of life of a clinical practice sample of patients with heart failure that are admitted to the hospital. Secondly to determine differences between patients with systolic and diastolic dysfunction and finally to describe factors relating to quality of life.

Methods: Three dimensions of quality of life (functional capabilities, symptoms and psychosocial adjustment to illness) were assessed during interviews of 186 patients with chronic heart failure. In addition, data on demographic, clinical and self-care characteristics were collected and patients completed a 6-min walk.

Results: On average patients walked 172 m in 6 min and reported functioning in daily life at a mean level of 4.5 MET. Patients experienced four different symptoms of heart failure. Most of them described dyspnea, fatigue, sleep disturbance and ankle oedema. Problems with psychosocial adaptation occurred mostly in social and vocational domains. Overall well-being of patients was rated as 6.4 on a 10-point scale. In regard to quality of life, the only differences between patients with systolic and diastolic heart failure was the occurrence of ankle oedema and health-care orientation. The variance in components of quality of life were partly explained by demographics and clinical characteristics. All three dimensions of quality of life were related to ability for self-care.

Conclusion: Patients with heart failure seen in clinical practice are often not comparable to patients described in major clinical trials or patients that are admitted for transplant evaluation. Their functional capabilities are more compromised, but they may have fewer problems with psychosocial adjustment. Patients with normal systolic dysfunction also report a low quality of life. It could be important to enhance self-care abilities of patients to improve psychosocial adaptation to illness.

Key Words: Heart failure • Quality of life • Systolic dysfunction • Diastolic dysfunction

Received December 21, 1998; Accepted December 24, 1998

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
Heart failure is one of the most prevalent cardiovascular disorders and the incidence of heart failure (HF) is expected to continue to increase in future [1, 2]. The incidence and prevalence of HF rise strongly with age [2]. It is generally recognised that treatment of patients with chronic HF has only two main goals: to improve quality of life and to prolong life [3, 4]. Quality of life is increasingly being incorporated in large clinical trials as a complementary endpoint to the traditional outcomes of mortality and morbidity. These clinical trials primarily include patients in New York Heart Association Class II and III and often only include patients with a Left Ventricular Ejection Fraction (LVEF) <40%. However, in today's clinical practice, the cardiologist and other health care providers are increasingly confronted with patients in NYHA Class IV. At the same time more patients are admitted with symptoms of HF and normal systolic function. Although the therapeutic and prognostic implications of systolic dysfunction and primary diastolic dysfunction are different [5–7], the symptoms and signs that patients exhibit seem often similar [5]. Information on the quality of life of patients with severe HF and patients with normal systolic function is scarce. Therefore the following research questions were formulated:

1. What is the quality of life in an older population with HF?
   
2. Are there differences in quality of life between patients with systolic and diastolic dysfunction?
   
3. Which clinical, demographic and self-care variables are related to quality of life of these patients?
   

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
2.1. Patients
During the time period May 1994–March 1997, 828 patients were admitted to the cardiology ward of the University Hospital in Maastricht with symptoms of HF. To evaluate the accuracy of the HF diagnosis, the Boston scoring system was used [8]. In this scoring system the various signs and symptoms documented in the history, physical examination and chest radiography are given a score. The score could range from 0 to 12, with a score of 8 or higher being designated as HF. After verifying the diagnosis, patients were included in the study if they met the following criteria: NYHA Class III and IV, diagnosed with HF longer than 3 months, older than 50 years of age and literate in Dutch. Patients were excluded if they had a co-existing severe chronic debilitating disease, had a psychiatric diagnosis, had a previous CABG/PTCA or valve replacement in the last 6 months or were expected to have such a treatment within 3 months. Two hundred and twenty-five patients were eligible for inclusion in the study, 186 agreed to participate based on informed consent. Data were collected on left ventricular ejection fraction (LVEF) obtained from two-dimensional echocardiography. Based on LVEF, patients were divided into 2 groups: Group I representing patients with primarily systolic HF and Group II, representing patients with predominantly diastolic HF. Patients with a LVEF 40% (n=144) were considered as having primary systolic HF [9–11]. Patients with a LVEF >50% (n=23) were considered having predominantly diastolic HF [6]. Patients with a LVEF ranging from 41 to 50 (n=19) were re-evaluated by a cardiologist who determined the patient group based on clinical data and data from echocardiography. Six of these patients were designated as Group I and 13 as Group II. After this procedure, Group I consisted of 150 patients and Group II of 36 patients.

	3. Instruments

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
In this study three data collection measures were used, namely quality of life, self-care and demographic and clinical measures. Data were collected from the medical chart and via interview during admission of the patient, as soon as the patient could be interviewed. The 6-min walk was assessed one or two days before discharge.

Quality of life: To evaluate quality of life a multi-dimensional approach was used. It is generally accepted that both objective and subjective dimensions must be included to adequately assess the impact of HF on the quality of life [12–16]. Previous investigators have recommended using the three dimensions of functional capabilities, symptoms, and psychosocial perceptions [14, 17]. In this study a mix of subjective and objective instruments measured these three dimensions (Table 1)

View this table: [in this window] [in a new window]   Table 1 Overview of instruments and their reliabilities used in the study

 
3.1. Functional capabilities
To assess functional capabilities, the HF Functional Status Inventory was used [17]. This is a self-report questionnaire used in previous studies in this population [17, 18]. Thirteen physical activities are listed and patients are asked if they can perform that activity. If patients cannot perform the activity, they are instructed to indicate by which symptom the physical activity is limited. Each activity was assigned a metabolic equivalent (MET) based on previous research [17, 19]. For example, if patients can bathe themselves, that activity is assigned 2 METs. In a previous study content validity and interrater reliability was established [17].

To measure functional status in a more objective way [20, 21]the 6-min walking test was used. Patients were asked to walk as far as possible in 6 min in a hospital corridor. The distance covered was measured, as described by previous investigators [17, 20–22]. The 6-min walk test provides a useful alternative to treadmill exercise testing in the assessment of the severity and prognosis of HF [2, 22]. Patients consider the test to be closely related to their daily physical activity [21]. Standardised directions were given to the patient and the same hospital corridor was used each time. No encouragement was given during the test [23]. Symptoms experienced by patients during the walk (e.g. angina, dyspnea) were recorded

3.2. Symptoms
Symptoms were assessed by a questionnaire on symptom occurrence, symptom severity and symptom distress. Symptoms that were assessed were: ankle oedema, sleep disturbance, loss of appetite, fatigue, dyspnea and cough. A total score of symptoms was calculated by adding the number of symptoms (min: 0, max: 6). Patients were also asked to rate symptom severity and distress on a 10-point scale. A severity and distress score was calculated as the average score on all symptoms experienced.

3.3. Psychosocial adjustment to illness
A translated version of the Psychosocial Adjustment to Illness Scale was used to measure the changes a person has experienced on seven psychological and social dimensions as a result of physical illness [24]. Reliability coefficients for the Dutch version of the PAIS ranged from 0.66 to 0.90 on the different subscales.

3.4. Overall well-being
To get a measure of overall well-being, Cantril's Ladder (‘ladder of life’) was used [25]. Patients were asked to rate their sense of well-being with 10 reflecting best possible life and 0 reflecting worst possible life. This instrument has been used in previous studies and is considered a valid measurement of ‘global well-being’ [26].

	4. Self-care

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
The Appraisal of Self-care Agency (ASA) Scale [27]was used to assess patient's ability to care for him/herself. The ASA is a 24-item self-appraisal instrument. Scores range from 24 to 124, in which 24 represents minimal and 120 maximal abilities for self-care. In addition, a specific behaviour instrument was developed, the Heart Failure Self-care Behaviour Scale. This is a 19-item questionnaire, with each item listing a specific activity related to HF e.g. ‘I weigh myself twice a week’ or ‘I restrict my sodium intake’. For each item the patient is asked to respond with yes or no. A total score is calculated by all positive answers. Cronbach's for this scale was 0.61.

	5. Demographic and clinical data

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
At the time of admission to the hospital, data were collected on NYHA classification, demo-graphics, etiology and medication.

	6. Analysis

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
Descriptive statistics were used to characterize the study population. To compare the clinical, demographic and self-care characteristics of the patients with systolic and diastolic dysfunction, t-tests (2-tailed) for continuous variables and the ² statistic for discrete variables were used. Correlations were obtained using Pearson product-moment correlation coefficients. Three separate backward multiple regression analyses were used to identify variables that best predict the three components of quality of life.

	7. Results

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
7.1. Demographic, clinical and self-care characteristics
Demographic, clinical and self-care characteristics of patients in the two groups are listed in Table 2. In the total group the majority of the patients were male, married and retired or on a disability pension. The age ranged from 50 to 94 years (mean age of 73±9 years). Most patients (62%) were NYHA classification IV. The mean LVEF of the total sample was 34.5% (±13.4). The underlying reasons for HF, as mentioned in the medical chart were ischaemic heart disease (98 patients, 53%), valvular disease (86 patients, 46%), cardiomyopathy (42 patients, 23%) and hypertension (23%). Patients could be classified with more than one underlying reason for HF.

View this table: [in this window] [in a new window]   Table 2 Demographics, clinical characteristics and self-care in relation to type of heart failure (n=186)

 
Fifty-eight percent of the patients had a history of MI and 26% had had a CABG in the past. On average, patients had been diagnosed with heart disease for 9 years and the majority of them had been hospitalised at least once with a cardiac event. Almost one-third of the patients had atrial fibrillation at time of admission. At admission, most of the patients were using diuretics (84%), vasodilators (72%) and nitrates (70%) (Table 3). Serum sodium was 139 (±4) mEq l^–1 and creatinine was 147 (±79) µmol l^–1.

View this table: [in this window] [in a new window]   Table 3 Medication on admission and discharge of the total group (n=186)

 
Of the specific self-care behaviours related to HF, patients reported on average compliance with nine of the 19 self-care behaviours. On the general self-care agency scale, patients scored an average of 89.5 (±12).

7.2. Quality of life
Quality of life as described by the three dimensions of functional capabilities, symptoms and psychosocial perceptions, are described in Table 4. Of the total sample, 113 patients (61%) completed the 6-min walk. Twenty-three patients did not complete this test because they refused to do so or because they were discharged without the possibility of completing the test. Fifty patients were not able to complete the test due to physical disabilities. Of the 113 patients, 25 (22%) were unable to walk 25 m; the maximum distance covered in 6 min was 543 m. On average patients were able to walk 172 (±113) m. Patients in NYHA-Class III walked longer distances than patients in Class III–IV and IV (216 m, 160 m, 158 m, respectively); however, these differences did not reach statistical significance (17=1.9, P=0.16). Forty-three patients did not report any symptoms during the test; seven complained of dyspnea, 23 had fatigue, six reported both dyspnea and fatigue, four reported dizziness and five suffered from leg pain.

View this table: [in this window] [in a new window]   Table 4 Dimensions ol Quality of life in relation to type ot heart tailure (n=186)

 
Patients reported functioning in their daily lives at a mean level of 4.5 METs. Only 12 patients stated they were able to perform heavy work, such as scrubbing floors or lifting heavy furniture. On average, patients reported having four different symptoms (±1.5) of advanced HF. Most of them experienced dyspnea (90%), fatigue (73%), sleep disturbance (70%) and ankle oedema (70%). Symptom severity and symptom distress was rated an average of 7.2 on a 10-point scale.

On the Psychosocial Adjustment to Illness Scale patients reported most problems in social and vocational environment and least on extended family relationships. On the ladder of life, patients placed themselves on average at 6.4 (±2.2) out of 10.

7.3. Differences between patients with systolic and diastolic HF
Group I patients (systolic HF) were more likely to be male, younger and had a higher prevalence of prior myocardial infarction. Systemic hypertension was diagnosed more often in Group II (diastolic HF) (Table 2).

On the quality of life dimensions (Table 4), only the occurrence of ankle oedema was different. More patients with diastolic HF reported having experienced ankle oedema than patients with systolic HF (X=8.3, P<0.005).

Group I patients (systolic dysfunction) had an overall worse psychosocial adjustment to illness (higher scores on the PAIS). They had higher scores on all the subscales of the PAIS, except the domain ‘health care orientation’. Patients with systolic dysfunction reported a statistically significant higher adaptation than patients with diastolic dysfunction.

7.4. Relation between quality of life dimensions
In Table 5 the relations between the quality of life dimensions are presented. All dimensions were moderately inter-related, with exception of the 6-min walk. The 6-min walk was not correlated with symptoms and psychosocial adjustment to illness.

View this table: [in this window] [in a new window]   Table 5 Correlations between quality of life dimensions

 
Overall well-being score of patients was significantly correlated with two of the dimensions of quality of life, psychosocial adjustment (r=–0.41) and functional capabilities (6-min walk: r=0.36, MET level: r=19). That is, the higher the global feeling of well-being, the better the functional capacity and the better psychosocial adjustment to illness was reported. The number of symptoms was not related to overall well-being.

7.5. Relation between quality of life and clinical, demographic, and self-care variables
Three separate backward multiple regression analyses were used to identify variables that best predict the three components of quality of life (Table 6). Based on findings from literature the variables from Table 1 were entered into the model. Instead of LVEF, type of HF (systolic/diastolic) was entered into the model.

View this table: [in this window] [in a new window]   Table 6 Results of backward multiple linear regression analysis with the quality of life dimensions as the dependent variables

 
Demographic, clinical characteristics and self-care behaviour explained 26% of the variance in psychosocial adjustment to illness (as measured by the PAIS). NYHA Class III–IV, low previous admission rate, having a history of bypass surgery, and a higher self-care agency were associated with a higher level of psychosocial adjustment to illness.

Demographic, clinical characteristics and self-care behaviour explained 38% of the variance of functional capacity as measured by MET level. Being male, having diabetes, not having lung disease and better self-care were associated with higher MET levels (i.e. patients were able to perform more strenuous activities of daily life).

Demographic, clinical characteristics and self-care behaviour explained 21% of the variance in number of symptoms. Being older, being male, having lost fewer kilos during admission, fewer previous admissions and a higher self-care agency were associated with fewer symptoms.

To determine how much these three components of quality of life predicted the overall sense of well-being of patients, a separate backward multiple regression analysis was used with overall well being as the dependent variable and MET level, 6-min walk, PAIS-score and number of symptoms as predictors. Psychosocial adjustment, MET-level and 6-min walk explained 25% of the variance of global well-being.

	8. Discussion

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
8.1. Quality of life and related factors
This study described objective and subjective dimensions of quality of life in a sample of older patients with systolic or diastolic HF in NYHA III and IV. Functional capabilities of this sample are relatively low, compared to findings from previous research. On average patients walked 172 m in 6 min. There was a large difference within the group. Some patients only walked 20 m and others walked up to 543 m in 6 min. For comparison, in a study of patients in NYHA Class III and IV by Dracup et al. [17], the average distance walked was 255 m and in a study by Stevenson et al. [28]patients walked 445 m. In another study, normal subjects walked 683 m in 6 min [21]. Part of the differences can be explained by the higher age of this sample, since walking distance correlates significantly with age [22]. Another explanation is that these patients completed the test during admission to the hospital instead of during a visit to an outpatient clinic or during evaluation for transplantation.

Some authors question whether the 6-min walk does capture important elements of quality of life for some patients, for example patients who must live or prefer to live a sedentary life-style [16]. In this study, however, performance on the 6-min walk correlated significantly with overall well-being. Patients that could walk longer distances reported higher scores on overall quality of life. Patients in this study also reported lower average functioning in their daily lives compared to other studies. Patients reported functioning at a mean level of 4.5 METs. For comparison, in other studies of patients with advanced HF, MET levels of 5, 5.9 and 5.3 [17, 28, 29]were reported. Post-transplantation patient populations reported levels of 7.9 and 7.3 METs [28, 29]. As one might anticipate, comorbidity was related to levels of functioning. Patients with multiple conditions have been described as showing greater decline in functioning and well-being than those with one condition [30]. The additive effects of comorbid conditions on functional status and well-being underscore the importance of considering both the primary diagnosis and comorbidity [30].

In this study, patients reported higher psychosocial adaptation compared with other studies with similar patient populations [17]and with patients recovering from a cardiac event [31]. Dracup et al. [17]converted their PAIS scores to standardised area t-scores with a score of 50 as the reference norm using a reference group of patients with ischaemic heart disease. After converting our PAIS scores to the same standardised area t-scores, patients reported a better psychosocial adjustment to illness than their HF sample (48 vs. 55). A possible explanation is that patients in this study were older and their expectations of life might have been less high than young patients. Previous studies have demonstrated that chronically ill patients have a remarkable capacity to adapt to their illness and generally will report better quality of life than individuals in the general population who are asked to imagine themselves having a chronic illness and to rate their quality of life [32].

In contrast to other studies [17]clinical factors were related to psychosocial adjustment. Patients with a history of bypass surgery, NYHA Class III–IV and more hospital admissions in the past reported more problems in adaptation. Since the proportion of patients that return to the hospital increases with every new readmission [33], it could be important to evaluate patients' problems with adaptation to prevent possible readmission.

Symptoms of HF were consistent with findings from other studies [17]. Younger patients and women reported more symptoms than older and male patients, which is consistent with other researchers [34]who reported higher frequencies of psychological and psychosomatic complaints in female cardiac patients. Patients with more admissions in the past reported more symptoms during this admission. As expected, patients who lost more weight during admission reported more symptoms at admission. All three dimensions of quality of life were related to self-care. Patients who reported higher abilities to care for themselves reported higher levels of functioning, better psychosocial adjustment and fewer symptoms. However, one has to be careful with assigning cause and effect between self-care and quality of life variables. One might argue that patients with high self-care abilities would have fewer problems adapting to their illness. Enhancing patients' self-care abilities by education and support could help patients adapt to their HF. However, patients could have fewer symptoms because they have higher self-care abilities or their self-care abilities could be restricted because of their symptoms. More research is needed to gain insight into these relationships.

Patients' rating of their overall well-being in this study (6.4) was comparable to a sample of patients before their bypass surgery who rated their overall well-being as 6 pre-operatively [26]. On first instance, one might argue that patients' overall quality of life is not as bad as one might expect. However, patients in cardiac rehabilitation and patients after cardiac surgery rated their overall quality of life much higher (8 and 7.5) [26, 35].

Overall well-being of patients was related to psychosocial adjustment and functional capabilities. However, only 25% of the variance was explained by these variables. Health-related quality of life constitutes one dimension of quality of life; economic and social aspects play a major role [16, 36].

8.2. Diastolic/systolic dysfunction
The sample with diastolic dysfunction was significantly older, consisted of more female patients and more often had a history of MI and hypertension. This is comparable to other studies [5, 6, 11]. Although prognosis in patients with normal systolic function is better than patients with systolic dysfunction [37], their quality of life is as bad. No considerable differences in quality of life between patients with diastolic and systolic dysfunction were found. Patients reported the same amount of symptoms, with the exception of ankle oedema, which was reported significantly more often by patients with diastolic dysfunction. Patients also did not differ significantly in most aspects of psychosocial adjustment, except that patients with systolic HF reported less problems with the medical system and treatment than patients with diastolic HF. Functional capabilities did not differ either. In clinical practice, patients with HF and a normal systolic function comprise a large number of all cases of HF. In a recent study it was found that 70% of subjects with clinical HF had normal left ventricular systolic function [33]. Although the most appropriate approach for diagnosis and treatment of diastolic dysfunction has not been defined completely [38]it seems important to consider quality of life issues in this population, because their quality of life is as compromised as in a systolic HF population.

8.3. Study limitations
In this study quality of life was assessed based on the three dimensions identified by Wenger et al. [14]. By using three dimensions of quality of life it is not possible to give a ‘single one’ score for quality of life. However, by considering dimensions instead of a total score, it is possible to look at different aspects of quality of life. Knowledge of the different aspects can help shape the development of appropriate intervention strategies impacting on QOL.

To assess functional capabilities patients' self-report was used and the 6-min walking test. Patients only performed the 6-min walk once according to our protocol. It is possible that absolute distances walked might have increased with subsequent walks due to the ‘training effect’ previously documented [22, 39]. However, even though distance may increase during multiple testing, first and second walks have been shown to be highly correlated [22]. It is thus unlikely that additional walks would have materially altered our results. Fifty patients could not take the 6-min walking test because of their physical condition and 23 would not take the test or refused primarily because they thought it might exhaust them too much. These high numbers of patients that could not perform the test also confirm the statement that patient comorbidity (e.g. arthritis) and frailty [16]limit the use of the 6-min walk. The HFFSI can be used in a frail population, however, it is based on self-report.

	9. Conclusion and clinical implications

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 
Patients with HF seen in clinical practice are often not comparable to patients described in major clinical trials or patients that are admitted for transplant evaluation. Their functional capabilities are more compromised, but they may have fewer problems with psychosocial adjustment. It is known that quality of life in heart failure is diminished in patients with systolic dysfunction. It is also important to notice that patients with normal systolic function also report low quality of life, compared to other samples. Interventions to enhance quality of life in heart failure patients have to be developed. It could be important to enhance self-care abilities of patients to improve psychosocial adaptation to illness.

	Acknowledgements

 
This study was financially supported by the Netherlands Heart Foundation (grant number 43.033).

	References

Top Abstract 1. Introduction 2. Methods 3. Instruments 4. Self-care 5. Demographic and clinical... 6. Analysis 7. Results 8. Discussion 9. Conclusion and clinical... References

 

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