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European Journal of Heart Failure 2005 7(4):583-589; doi:10.1016/j.ejheart.2004.07.016
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© 2005 European Society of Cardiology

Depression and health-related quality of life in elderly patients suffering from heart failure and their spouses: a comparative study

Emma Pihla,b,*, Anna Jacobssona,b, Bengt Fridlundb,c, Anna Strömbergd,e and Jan Måtenssonb,f

a Department of Medicine, Cardiac Care Unit, Halmstad Central Hospital Halmstad, Sweden
b School of Social and Health Sciences, Halmstad University Halmstad, Sweden
c Department of Nursing, Lund University Lund, Sweden
d Department of Cardiology, Linköping University Hospital Linköping, Sweden
e Department of Medicine and Care, Faculty of Health Sciences, Linköping University Sweden
f Development Unit for Primary Health Care Qulturum, Jönköping, Sweden

* Corresponding author. Björkallén 8, 313 32 Oskarström, Sweden. Tel.: +46 35 68 334; Fax: +46 35 10 16 10. E-mail address: emma{at}kullendyk.nu


   Abstract
Top
 Abstract
1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 6. Implications
 References
 
Background: Little is known about the factors that influence the health outcome of elderly patients suffering from heart failure or the health of their spouses. The aim of this comparative study was to determine if older patients suffering from heart failure and their spouses experience similar levels of health-related quality of life (HRQOL) and depression. The aim was also to identify those factors that contribute to HRQOL and depression in patient–spouse pairs.

Methods: Data were collected from 47 couples, using the Short Form 36 (SF-36) and Zung Self-rating Depression Scale (SDS) questionnaires.

Results: Patients suffering from heart failure and their spouses differed significantly in their experience of the physical, but not the mental, health-related quality of life, with patients experiencing significantly worse physical functioning. Physical symptoms of heart failure seemed to dominate the experience of the patient and was positively related to mental health and inversely related to the New York Heart Association classification (NYHA class) and patients' depression. Depressive symptoms as reflected in SDS showed no significant difference between patients and spouses. Patients' depression was positively related to high NYHA class, while spouse depression was positively related with higher age of the patient.

Conclusion: Physical symptoms seem to dominate the experience of heart failure.

Key Words: Depression • Heart failure • Health-related quality of life • Patient–spouse pairs

Received December 11, 2003; Revised July 14, 2004; Accepted July 29, 2004


   1. Background
Top
 Abstract
 1. Background
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 6. Implications
 References
 
Little is known about the factors that affect the health outcome of elderly patients suffering from heart failure and their spouses. It is known that chronic illness in a family member influences all aspects of family life and that the family has a key role in the development of the course and outcome of chronic illness as well as in the way the illness is perceived and experienced by the patient [1]. Mårtensson et al. [2] found that American male patients in their sixties suffering from heart failure were significantly more depressed and had poorer physical functioning compared to their spouses. The present study addresses patients older than 60 years suffering from heart failure and their spouses. Living with heart failure can be stressful because the condition leads to complex demands on patients and their families [3]. Patients suffering from heart failure and their spouses face several difficult issues [2]. Mild to moderate heart failure can have a minor influence, whereas severe heart failure requires major changes in the lives of the couple [4]. Debilitating physical symptoms, frequent hospitalisations, forced retirement, role changes, financial pressure and disruption of the usual sources of social support characterise the course of the disease. All of these changes can lead to significant depression and reduction in quality of life in both patients [5] and spouses [6], which in turn can increase morbidity and mortality [7]. Symptoms experienced by the spouses can be high levels of anxiety, depression, tension, fatigue, sleep and eating disturbances as well as other psychosomatic symptoms [8]. The spouses' central concern seems to be the patient's well being [9]. In one of the few studies addressing spouses of patients suffering from heart failure, Karmilovich [6] found that providing caring for the sick husband was burdensome and stressful. The most burdensome activities, from the Physical Care Scale, were watching the spouse's condition deteriorate without being able to intervene and not knowing if they would be able to cope with caring for the patient in the future. The most burdensome behaviours, from the Role Alterations Scale, were being unable to participate in social/recreational activities; being unable to share problems and concerns with the partner, and changes in the personality of the partner. Young and Kahana [10] stated that caring for patients suffering from heart disease was similar to caring for terminally ill patients, as both groups tend to suffer from depression, anxiety and other serious mental health problems. Most spouses of cardiac patients ignore their own needs when their loved ones are ill [11]. The spouse's primary concern is the patient and they may therefore feel guilty about seeking help for themselves, which creates a barrier to receiving emotional support from others [9]. Psychosocial issues have been studied in patients suffering from heart failure as well as their spouses, but only one study has focused on patient–spouse pairs to determine if they experience similar feelings of depression and health-related quality of life (HRQOL) [2]. Heart failure is a growing problem with major clinical importance in the general population with the highest prevalence among the elderly [12]. Therefore, it is of great importance to study this group of patients and their spouses. The aim of this comparative study was to determine if elderly patients suffering from heart failure and their spouses experience similar levels of HRQOL and depression. The aim was also to identify factors that contribute to HRQOL and depression in patient–spouse pairs.


   2. Methods
Top
 Abstract
 1. Background
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 6. Implications
 References
 
2.1. Design and setting
This study utilised a cross-sectional comparative design and was conducted at primary health care centres situated in two cities in south-eastern Sweden. The Ethical Committee for Human Research at Linköping University, Linköping, Sweden, approved the study.

2.2. Sample and criteria
The inclusion criteria were; diagnosed heart failure based on echocardiography, radiographic evidence of pulmonary congestion or typical symptoms, signs of heart failure and New York Heart Association (NYHA) classes II–IV, aged over 60 years, and resident in the catchment area. Spouses were included if they were living in the same household as the patient. Patients and spouses were excluded if they had dementia or other psychiatric illness expected to affect the study outcome or had difficulties in understanding or reading the Swedish language.

2.3. Instruments
Data on actual health status was obtained through simple questions about mobility, pain/discomfort and self-care. The reliability and the validity of the SF-36 have been established in patients suffering from heart failure [13]. The SF-36 has been translated into Swedish, adjusted to and tested in a Swedish population [14]. The SF-36 comprises 36 multiple-choice questions divided into two dimensions and eight subscales that describe overall health status. The subject is asked to rate each of the 36 items as it applies to him/her. The physical health (PCS) is obtained by combining scores on the following four subscales of the SF-36: The physical functioning subscale (PF), the role physical subscale (RP), the bodily pain subscale (BP) and the general health subscale (GH). The mental health scale (MCS) is also based on four subscales of the SF-36: vitality (VT), social functioning (SF), role emotional (RE) and mental health (MH) [14]. The instrument does not yield a total score.

The Zung Self-rating Depression Scale (SDS) has been designed to provide a quantitative assessment of the subjective experience of depression, and it emphasises somatic and behavioural components (50% of the total score) to a greater extent than most other self-rating depression scales. A translated and back-translated Swedish version was used in the study. The SDS contains 20 items covering affective, psychological and somatic features of depression. Of the 20 items, 10 were worded positively and 10 negatively. The subject is asked to rate each of the 20 items on a Likert scale with values ranging from 1 to 4 to indicate how it applied to him/her. The total raw SDS scores range from 20 to 80. An index for the SDS was used by dividing the sum of the values (raw scores) of the twenty items by the maximum possible score, which equaled 80. The converted SDS scores range from 0.25 to 1.0. Non-depressed individuals typically score less than 0.50, mildly depressed 0.50–0.60, moderately depressed 0.61–0.70, while the score of those with severe depression is generally higher than 0.70 [15]. The scale correlates well with clinician ratings, DSM-III-R diagnosis of depression, and with Beck Depression Inventory scores [16].

2.4. Procedure
The primary health care centres were screened for patients suffering from heart failure through the Diagnosis Related Groups (DRGs) registry in order to identify those who fulfilled the inclusion criteria. A primary health care nurse visited the patients in their homes and provided both verbal and written information about the study. The patients were asked to complete the questionnaire at home and to give another copy of the questionnaire to their spouse. The completed questionnaires were returned in a stamped addressed envelope. Patients and spouses were informed that participation was voluntary and that they could withdraw from the study at any time. Confidentiality was guaranteed, and it was also emphasised that none of the informants could be identified. They were instructed to complete the questionnaires without discussing their answers with each other.

2.5. Statistical analysis
Descriptive statistics were used to characterise the study population. For statistical evaluation, non-parametric tests were used. The Wilcoxon matched pairs test was used to evaluate the differences in depression and HRQOL, between patients suffering from heart failure and their spouses. Correlations between age, physical and mental health, and depression were evaluated for both patients and spouses, while NYHA class was only assessed in patients. Pearson product-moment correlation coefficients were used for variables that were normally distributed and on an interval scale. Variables that were not normally distributed due to outliers were analysed using Spearman's rank correlation coefficient. Univariate linear regression was performed with age, PCS, MCS and SDS in patients and spouses and NYHA class in patients as dependent variables, in order to identify which variables could significantly predict depression and HRQOL. The variables that significantly predicted depression and HRQOL were then included in a multivariate stepwise regression analysis to identify which combination of variables provided the most predictive power. A p value <0.05 was considered statistically significant.


   3. Results
Top
 Abstract
 1. Background
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 6. Implications
 References
 
As shown in Table 1, 47 couples participated in the study. Thirty-four of the patients were male and 24 were in NYHA class II and 19 in NYHA class III. The actual health status according to three questions was similar between patients and spouses regarding pain/discomfort and self-care, whereas the patients had more problems in walking about. Patients had a mean age of 78 years while the spouses had a mean age of 75 years.


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  		Table 1 Characteristics of the pairs (n=47) consisting of patients suffering from heart failure and their spouses (n=94)

 
3.1. Comparison of depression and health related quality of life (HRQOL)
There was no significant difference between patients and spouses regarding depressive symptoms, as reflected in SDS scores (p=0.115). Patients had a mean of 0.52 (±0.12), while spouses had a mean of 0.50 (±0.11). Using the SDS, 28 patients were identified as having mild to severe depression (20 mild, 4 moderate and 4 severe) and 22 spouses as having mild to severe depression (16 mild, 4 moderate and 2 severe). When patients and spouses were compared using the two dimensions and the eight scales of the SF-36 (Fig. 1), a significant difference was documented in the physical component (PCS) (p=0.008). Three aspects of the physical functioning component individually; physical functioning (p=0.002), role physical (p=0.044), and general health (p=0.021). In each case patients experienced significantly lower HRQOL than their spouses. There was no difference between the groups in the mental component (MCS) (p=0.891) except for the dimension social functioning (p=0.031) with patients experiencing significantly lower HRQOL than their spouses.


Figure 1
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  		Fig. 1 Radar plot comparing mean SF-36 scores between patients and spouses. * indicates statistically significant differences at p<0.05. Each spoke represents a subcategory of the SF-36: PCS, physical component summary; PF, physical functioning; RP, role physical; BP, bodily pain; GH general health; MCS, mental component summary; VT, vitality; SF, social functioning; RE, role emotional; MH, mental health. Plots are read from the centre outward along each spoke. Scores are shown on the concentric circles beginning with 0 (at the centre) and increasing to 100 (outer line).

 
3.2. Correlates of depression and health related quality of life
In the interpretation of the correlations presented in Table 2, it is important to keep in mind that high scores on the SDS indicate high levels of depressive symptoms, while high SF-36 levels indicate better HRQOL.


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  		Table 2 Correlations between socio-demographic data, depression and health-related quality-of-life components for patients suffering from heart failure (n=47) and their spouses (n=47)

 
3.2.1. Results from Zung Self-rating Depression Scale
Patients' depression was positively related to high NYHA class and spouses' depression and inversely related to patients' mental and physical health (i.e. the patients' depressive symptoms increased with a higher NYHA class, more impaired mental and physical functioning and more depressive symptoms of the spouse). Patients' mental and physical functioning accounted for 50% of the adjusted variance in patients' depression.

Spouses' depression was positively related to the age of the patient, patients' depression, and inversely related to patients' mental health and spouse's mental and physical health (i.e. the spouse's depressive symptoms increased with higher age of the patient, more impaired mental health and depression in the patient as well as with more impaired mental and physical health of the spouse). The mental and physical health of the spouse accounted for 50% of the adjusted variance in spouses' depression.

3.2.2. Results from SF-36
Patients' physical functioning was positively related to the mental health of the patient and inversely related to NYHA class and patients' depression (i.e. physical functioning improved with better mental health, lower NYHA class and less depressive symptoms). NYHA class and depression accounted for 57% of the adjusted variance of the patients' physical functioning.

Patients' mental health was positively related to patients' physical functioning and spouses' mental health and inversely related to NYHA class, and depression in the patient and spouse (i.e. better mental health in the patient with better mental health in the spouse, lower NYHA class, less depression in patient and spouse and better physical functioning in the patient). Patient's depression and mental health of the spouse accounted for 47% of the adjusted variance in patients' mental health.

Spouses' mental health was positively related to the mental health of the patient and inversely related to spouses' depression. Patients' mental health and spouses' depression accounted for 36% of the adjusted variance in spouses' mental health.


   4. Discussion
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 6. Implications
 References
 
This study demonstrates that elderly patients suffering from heart failure and their spouses have different perceptions of their physical health, with patients experiencing significantly lower physical health than their spouses. High NYHA class, depression and age were predictors of low physical health in the patients. It should be noted that the levels of physical health of patients, but not of spouses, were significantly lower than the Swedish norm for persons older than 75 years, (with means of physical functioning 59.0, role physical 49.3, bodily pain 63.2, and general health 59.8) (Fig. 1) [14]. Unfortunately, limited data on spouses' health status and no data on spouses' medical history were obtained, and therefore we do not know the possible influence these factors might have on the outcome. In a study of spouses caring for individuals suffering from heart failure, Karmilovich [6] found that almost 1/3 of the spouses reported having cardiovascular problems despite their mean age not being higher than 57 years. Other reported health problems were diabetes mellitus (17%), arthritis (12%) and stress related symptoms (10%). Ebbesen et al. [17] found that spouses of cardiac patients suffered from headache, increased blood pressure and non specific chest pain and that their symptoms were so severe that they had consulted a physician. Since spouses in this study were older, it is not surprising that they had health problems of their own. In the present study, there was no significant difference between patients and spouses regarding depressive symptoms. Patients' depression correlated with high NYHA class, but there was no correlation between spouses' depression and high NYHA class. These results are in concordance with Rohrbaugh et al. [18], but contrast to Mårtensson et al. [2] where the majority of the patients were in NYHA class III and had a mean age of 61 years. Mårtensson et al. found that patients were more depressed than their spouses and that there was a correlation between spouses' depression and high NYHA class. In the present and in Rohrbaugh et al.'s [18] study, the majority of the patients were in NYHA class II. This might explain why they did not feel more depressed than their spouses as well as the fact that no correlation was found between low functional class and spouses' depression. Mårtensson et al. [2] also found that spouses' depression correlated with lower patient age. In contrast, spouses' depression in the present study correlated with higher patient age. It seems that the younger wives have difficulties adjusting to the functional impairment in younger partners while, among elderly couples, the oldest experience most difficulties. As one would expect, there was a significant positive relationship between spouses' and patients' mental health and depression. This relationship was not seen among younger patient–spouse pairs [2]. Surprisingly, no positive relationship was found between spouses' mental health and depression and patients' physical functioning. Older spouses might be better prepared to accept a deterioration in the physical functioning of their husband or wife than personality changes and depression [4,19]. Interestingly, patients and spouses did not report any significant difference in the overall mental component of their HRQOL, a scale that reflects vitality, social functioning, role limitations and mental health. This suggests that the disease has a bearing on the psychological well being of older married couples equally. Contrary to this result, Rohrbaugh et al. [18] found that younger patients with heart failure (mean=53 years) were generally more distressed than their spouses. Spouses have low priority in health care and there is a risk, especially for older spouses, that they are forgotten in an environment essentially devoted to patient care [4,20]. This is devastating since the spouse appears to suffer as much emotional disturbance as their partner. Although couples are faced with the same issues related to lifestyle changes, physical challenges, and future uncertainties that require a common approach, they also have unique responses that need to be acknowledged and supported by nurses and physicians. Spouses may feel resentment due to the new demands that the illness places on them. British researchers found that female spouses who continued to enjoy their work and leisure activities and who had satisfying marriages were less distressed one year after their partner became ill [18]. In the present study the spouses had a mean age of 75 years, which means that they were past retirement age and thus no longer working outside the home. This could lead to a higher degree of isolation especially since heart failure has been shown to restrict the life situation for both patient and spouse [4]. Patients suffering from heart failure often feel like a burden due to their dependence on others for carrying out daily activities and because they are a source of worry to others [21,22]. Isolation is a major impediment to recovery for both patient and spouse. Limitations of the result are the small sample size and cross-sectional design, which means that no causality could be discerned among the variables. Although the informants were instructed to complete the questionnaires without discussing their answers with each other, there is no guarantee that they adhered to these instructions. The unequal sex distribution in the study could have confounded the analysis since it is well known that physical restrictions are experienced as most bothersome for men with heart failure, whereas women seem to experience a lower overall quality of life than men [23]. Data on education was not obtained and this is also a factor which could have confounded the analysis.


   5. Conclusion
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
6. Implications
 References
 
A quantitative, comparative study design, based on the SF-36 and SDS questionnaires, was used to determine if elderly patients suffering from heart failure and their spouses experienced similar levels of HRQOL and depression. Forty-seven couples completed the questionnaires. In the SF-36 it was found that the patients' physical dimension of HRQOL was clearly impaired by heart failure but that the mental QOL showed no significant difference. High NYHA class, depression and age accounted for more than half of the patient's experience of poor physical health. The fact that couples did not exhibit significantly different mental health suggests that the disease affects the psychological well being of both partners equally. Depressive symptoms as reflected in SDS scores showed no significant difference between patients and spouses. Patients' depression was positively related to high NYHA class, while spouses' depression was positively related to higher age of the patient.


   6. Implications
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 6. Implications
References
 
The care of patients suffering from heart failure remains a challenge. It is important to inform patients and spouses that they may develop feelings of burden, which can vary in severity. Specialised cardiac nurses can have a great influence upon the level of demands and stress experienced by spouses of patients suffering from heart failure. Patients and spouses have to confront many difficult issues, and a chronic illness in a partner influences all aspects of the relationship. It is important to be honest with the patient and their spouse about the future and deteriorating physical health, the frequent personality changes and reduced life expectancy. Because spouses' responses to illness influence patients, it is important to design interventions to support spouses. Clinicians need to develop strategies that focus on the individual as well as the couple, aimed at enhancing communication between patients and their spouses. Nurses can encourage spouses to take care of themselves, to talk to others with similar experiences and to join a support group. Since the physical functioning of patients is clearly impaired by heart failure, clinical interventions should be targeted at improving their functional status by encouraging them to engage in physical activity and regular exercise whenever possible. The spouses' involvement might help the patient to better manage such activities, thus reducing the risk of a further deterioration in their condition. It is important that the spouse be taught ways to support patient choices that lead to increased physical activity, such as simple but concrete guidelines on how to exercise by performing everyday activities. The bulk of the research on spouses of cardiac patients has utilised quantitative approaches with few studies concentrating on the perceptions of spouses following their partners' illness. Increasingly, overburdened healthcare systems, although sensitive to the patients' needs, often overlook the spouses' needs. Further research with a more equal sample of male and female patients is needed to determine gender differences in patient and spouse roles in relation to the influence of the illness and satisfaction with family function. It will however, prove difficult to achieve gender balance in future research, due to the fact that there are fewer female cardiac patients and, in general, females suffering from coronary disease tend to be older as well as widowed at the time of the cardiac event. No instrument can adequately describe the experience of caring for a spouse with an illness such as heart failure, and in-depth interviews may be the most effective way to examine this problem.


   References
Top
 Abstract
 1. Background
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 6. Implications
 References
 

  1. Leake R., Friend R. Chronic illness. In: Encyclopedia of mental health—Friedman H.S., ed. (1998) San Diego: Academic press. 449–459.
  2. Mårtensson J., Dracup K., Canary C., Fridlund B. Living with heart failure: depression and quality of life in patients and spouses. J. Heart Lung Transplant. (2003) 22(4):460–467.[CrossRef][Web of Science][Medline]
  3. Hawthorne M.H., Hixon M.E. Functional status, mood disturbance, and quality of life in patients with heart failure. Prog. Cardiovasc. Nurs. (1994) 9:22–32.[Medline]
  4. Mårtensson J., Dracup K., Fridlund B. Decisive situations influencing spouses' support of patients with heart failure: a critical incident technique analysis. Heart Lung (2001) 30:341–350.[CrossRef][Web of Science][Medline]
  5. Jaarsma T., Halfens R., Huijer Abu-Saad H., Dracup K., Stappers J., Van Ree J. Quality of life in older patients with systolic and diastolic heart failure. Eur. Heart J. (1999) 1:155–160.
  6. Karmilovich S.E. Burden and stress associated with spousal caregiving for individuals with heart failure. Prog. Cardiovasc. Nurs. (1994) 9:33–38.[Medline]
  7. Vaccario V., Kasl S.V., Abramson J., Krumholz H.M. Depressive symptoms and risk of functional decline and death in patients with heart failure. J. Am. Coll. Cardiol. (2001) 38:199–205.[Abstract/Free Full Text]
  8. Kettunen S., Solovieva S., Laamanen R., Santavirta N. Myocardial infarction, spouses' reactions and their need of support. J. Adv. Nurs. (1999) 30:479–488.[CrossRef][Web of Science][Medline]
  9. Dickerson S. Cardiac spouses' help-seeking experiences. Clin. Nurs. Res. (1998) 7:6–28.[Abstract/Free Full Text]
  10. Young R.F., Kahana E. Conceptualizing stress, coping, and illness management in heart disease caregiving. Hosp. J. (1987) 3:53–73.[CrossRef][Medline]
  11. Levin R.F. Caring for the cardiac spouse. Am. J. Nurs. (1993) 93:50–53.[Medline]
  12. Hughes C.V., Lakatta E., Leier C., Santinga J. Congestive heart failure in the elderly: is it different. Patient Care (1990) 15:39–50.
  13. Ware J.E., Kosinski M., Keller S.D. SF-36 physical and mental health summary scales: a users' manual. (1994) 5th ed. Boston: New England Medical Centre.
  14. Sullivan M., Karlsson J. SF-36 health questionnaire. Swedish manual and interpretation guide. (1994) Gothenburg: Gothenburg University.
  15. Zung W.W.K., Richards C.B., Short M.J. Self-rating depression scale in an outpatient clinic. Arch. Gen. Psychiatry (1965) 13:508–515.[Abstract/Free Full Text]
  16. Schaefer A. Comparison of the validities of the Beck, Zung, and MMPI depression scales. J. Consult. Clin. Psychol. (1985) 53:415–418.[CrossRef][Web of Science][Medline]
  17. Ebbesen L.S., Guyatt G.H., McCartney N., Oldridge N.B. Measuring quality of life in cardiac spouses. J. Clin. Epidemiol. (1990) 43:481–487.[CrossRef][Web of Science][Medline]
  18. Rohrbaugh M.J., Shoham V., Cranford J.A., Nicklas J.M., Sonnega J.S., Coyne J.C. Couples coping with congestive heart failure: role and gender differences in psychological distress. J. Fam. Psychol. (2002) 16(1):3–13.[CrossRef][Web of Science][Medline]
  19. Koenig H.G. Depression in hospitalized older patients with congestive heart failure. Gen. Hosp. Psych. (1998) 20:29–43.[CrossRef]
  20. Thompson D. The coronary patient and his spouse. Nursing (1990) 4:6–8.
  21. Ekman I., Ehnfors M., Norberg A. The meaning of living with severe chronic heart failure as narrated by elderly patients. Scand. J. Caring Sci. (2000) 14:130–136.[CrossRef][Web of Science][Medline]
  22. Mårtensson J., Karlsson J.E., Fridlund B. Female patients with congestive heart failure: how they conceive their life situation. J. Adv. Nurs. (1998) 28:1216–1224.[CrossRef][Web of Science][Medline]
  23. Strömberg A., Mårtensson J. Gender differences in patients with heart failure. Eur. J. Cardiovasc. Nurs. (2003) 2:7–18.[CrossRef][Medline]

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