Background
Methods
Patients
Patient-reported questionnaires
Sociodemographic and clinical variables
HeartQoL
Hospital Anxiety and Depression Scale (HADS)
SF-36 Health Survey (SF-36)
Statistical analyses
Results
Patient characteristics and questionnaire means
Total cohort (N = 305) | AP (N = 101; 33.1%) | MI (N = 123; 40.3%) | HF (N = 81; 26.6%) | p-value | |
---|---|---|---|---|---|
Demographics | |||||
Age | 63.46 ± 11.1 | 66.06 ± 9.91 | 62.19 ± 11.89 | 62.20 ± 10.85 | < .05a,c |
Female | 65 (21.3%) | 24 (23.8%) | 31 (25.2%) | 10 (12.3%) | < .05b |
Male | 237 (77.7%) | 76 (75.2%) | 92 (74.8%) | 69 (85.2%) | n.s. |
Marital status | |||||
Single | 51 (16.7%) | 13 (12.9%) | 23 (18.7%) | 15 (18.5%) | n.s. |
Married/partnership | 217 (71.1%) | 81 (80.2%) | 83 (67.5%) | 53 (65.4%) | < .05a,c |
Other | 32 (10.5%) | 5 (5.0%) | 16 (13.0%) | 11 (13.6%) | < .05a,c |
Education | |||||
< High school | 191 (62.6%) | 64 (63.4%) | 76 (61.8%) | 51 (63.0%) | n.s. |
= High school | 40 (13.1%) | 11 (10.9%) | 15 (12.2%) | 14 (17.3%) | n.s. |
> High school | 44 (14.4%) | 13 (12.9%) | 23 (18.7%) | 8 (9.9%) | < .05a |
Employment | |||||
Blue collar | 73 (23.9%) | 25 (24.8%) | 26 (21.1%) | 22 (27.2%) | n.s. |
White collar | 159 (52.1%) | 46 (45.5%) | 69 (56.1%) | 44 (54.3%) | n.s. |
Risk factors | |||||
BMI | 26.98 ± 4.71 | 26.61 ± 4.59 | 27.02 ± 4.72 | 27.38 ± 4.88 | n.s. |
Comorbidities† | 41 (13.4%) | 21 (20.8%) | 4 (3.3%) | 16 (19.8%) | < .001a,b |
Diabetes§ | 44 (14.4%) | 11 (10.9%) | 15 (12.2%) | 18 (22.2%) | < .05c |
Hypercholesterolemia§ | 169 (55.4%) | 65 (64.4%) | 62 (50.4%) | 42 (51.9%) | < .05a |
Hypertension§ | 155 (50.8%) | 55 (56.4%) | 64 (52.0%) | 36 (44.4%) | n.s. |
Physical inactivity# | 185 (60.7%) | 57 (56.4%) | 84 (68.3%) | 44 (54.3%) | < .05b |
Smoking | 43 (14.1%) | 11 (10.9%) | 19 (15.4%) | 13 (16.0%) | n.s. |
Interventions | |||||
PCI | 113 (37.0%) | 60 (59.4%) | 35 (28.5%) | 18 (22.2%) | < .001a,c |
CR | 166 (54.4%) | 41 (40.6%) | 88 (71.5%) | 37 (45.7%) | < .001a,b |
Disease severity | |||||
CCS ≤ II | 57 (56.4%) | 57 (56.4%) | – | – | – |
CCS III and IV | 42 (41.6%) | 42 (41.6%) | – | – | – |
NYHA ≤ II | 38 (46.9%) | – | – | 38 (46.9%) | – |
NYHA III & IV | 40 (49.4%) | – | – | 40 (49.4%) | – |
Questionnaire scores | |||||
Heart QoL | |||||
Physical subscale | 1.81 ± .72 | 1.65 ± .73 | 1.97 ± .70 | 1.79 ± .70 | < .05a |
Emotional subscale | 2.20 ± .74 | 2.21 ± .72 | 2.29 ± .74 | 2.18 ± .74 | n.s. |
Global scale | 1.92 ± .64 | 1.80 ± .65 | 2.07 ± .63 | 1.90 ± .63 | < .05a |
HADS | |||||
Anxiety scores | 5.68 ± 3.75 | 5.90 ± 3.51 | 5.47 ± 3.82 | 5.49 ± 3.78 | n.s. |
Anxious* | 92 (30.2%) | 35 (34.7%) | 33 (26.8%) | 24 (29.6%) | n.s. |
Depression scores | 4.85 ± 3.57 | 4.89 ± 3.16 | 4.45 ± 3.70 | 5.01 ± 3.86 | n.s. |
Depressed* | 63 (20.7%) | 26 (25.7%) | 22 (17.9%) | 15 (18.5%) | n.s. |
General distress scores | 10.53 ± 6.62 | 11.15 ± 6.00 | 10.02 ± 6.88 | 10.54 ± 6.96 | n.s. |
Generally stressed* | 116 (38.0%) | 47 (46.5%) | 42 (34.1%) | 27 (33.3%) | n.s. |
SF-36 | |||||
PCS | 41.10 ± 9.94 | 39.53 ± 9.56 | 42.12 ± 10.54 | 41.56 ± 9.86 | n.s. |
MCS | 47.02 ± 11.19 | 47.42 ± 10.67 | 46.85 ± 11.88 | 47.98 ± 10.76 | n.s. |
Total cohort (N = 302) | AP (N = 100) | MI (N = 123) | HF (N = 79) | |
---|---|---|---|---|
Physical subscale | 1.81 ± .72 | 1.66 ± .73 | 1.93 ± .71 | 1.80 ± .69 |
Floor effect | .7% | 2.0% | 0% | 0% |
Ceiling effect | 3.0% | 1.0% | 4.9% | 2.5% |
Cronbach’s alpha | .91 | .91 | .92 | .90 |
Emotional subscale | 2.20 ± .74 | 2.16 ± .73 | 2.24 ± .75 | 2.19 ± .73 |
Floor effect | 1.7% | 1.0% | 3.3% | 0% |
Ceiling effect | 23.3% | 20.4% | 25.2% | 24.1% |
Cronbach’s alpha | .89 | .89 | .90 | .89 |
Global scale | 1.92 ± .64 | 1.80 ± .64 | 2.02 ± .65 | 1.91 ± .62 |
Floor effect | .7% | 2.0% | 0% | 0% |
Ceiling effect | 1.7% | 0% | 3.3% | 1.3% |
Cronbach’s alpha | .92 | .91 | .93 | .91 |
Psychometric properties of the HeartQoL
Factor structure
Loevinger’s H coefficients | |||
---|---|---|---|
Physical Hi (N = 260) | Emotional Hi (N = 287) | Global Hi (N = 255) | |
1. Walk indoors on level ground? | .52 | .44 | |
2. Garden, vacuum, or carry groceries? | .63 | .53 | |
3. Climb a hill or a flight of stairs without stopping? | .65 | .56 | |
4. Walk more than 100 yards at a brisk pace? | .59 | .51 | |
5. Lift or move heavy objects? | .60 | .51 | |
6. Feeling short of breath? | .54 | .49 | |
7. Being physically restricted? | .61 | .56 | |
8. Feeling tired, fatigued, low on energy? | .48 | .53 | |
9. Not feeling relaxed and free of tension? | .74 | .46 | |
10. Feeling depressed? | .76 | .43 | |
11. Being frustrated? | .78 | .46 | |
12. Being worried? | .81 | .47 | |
13. Being limited in doing sports or exercise? | .59 | .53 | |
14. Working around the house or yard? | .68 | .61 | |
HeartQoL H | .59 | .77 | .51 |
Reliability
Validity
HeartQol | Physical subscale | Emotional subscale | p-value# |
---|---|---|---|
Total cohort (N = 265) | |||
SF-36 PCS | .68** | .14* | < .001 |
SF-36 MCS | .38** | .74** | < .001 |
p-value# | < .001 | < .001 | |
AP (N = 80) | |||
SF-36 PCS | .78** | .23* | < .001 |
SF-36 MCS | .30** | .71** | < .001 |
p-value# | < .001 | < .001 | |
MI (N = 111) | |||
SF-36 PCS | .62** | .14 | < .001 |
SF-36 MCS | .44** | .76** | < .001 |
p-value# | .032 | < .001 | |
HF (N = 74) | |||
SF-36 PCS | .69** | .04 | < .001 |
SF-36 MCS | .41** | .76** | < .001 |
p-value# | .007 | < .001 |
HeartQoL | |||
---|---|---|---|
Physical subscale | Emotional subscale | Global scale | |
Total cohort | |||
Age | |||
Young (< 60 years; N = 107) | 1.94 [1.80–2.07] | 2.07 [1.92–2.22] | 1.98 [1.85–2.09] |
Middle age (60–70 years; N = 99) | 1.81 [1.66–1.95] | 2.30 [2.15–2.46] | 1.94 [1.80–2.06] |
Elderly (> 70 years; N = 96) | 1.68 [1.56–1.84] | 2.35 [2.16–2.45]c | 1.86 [1.75–2.00] |
p-value | p < .05 | ||
Sex | |||
Female (N = 65) | 1.79 [1.61–1.96] | 2.06 [1.84–2.22] | 1.86 [1.70–2.02] |
Male (N = 237) | 1.82 [1.73–1.91] | 2.27 [2.16–2.34] | 1.95 [1.86–2.02] |
p-value | p < .05 | ||
SF-36 general health status | |||
Excellent/very good (N = 34) | 2.23 [2.00–2.51] | 2.62 [2.44–2.75] | 2.34 [2.16–2.55] |
Good (N = 187) | 1.97 [1.87–2.05]b | 2.39 [2.26–2.45]b | 2.08 [1.99–2.15]b |
Fair/poor (N = 82) | 1.31 [1.16–1.45]c | 1.71 [1.52–1.87]c | 1.43 [1.29–1.54]c |
p-value | p < .001 | p < .001 | p < .001 |
SF-36 health transition | |||
Improve (N = 69) | 1.90 [1.75–2.10] | 2.41 [2.22–2.60] | 2.03 [1.91–2.19] |
No change (N = 80) | 2.17 [2.03–2.29]b | 2.34 [2.19–2.45] | 2.22 [2.09–2.32]b |
Deteriorate (N = 152) | 1.59 [1.48–1.70]c | 2.10 [1.94–2.21]c | 1.74 [1.62–1.83]c |
p-value | b: p < .001; c: p < .05 | p < .05 | b: p < .001; c: p < .05 |
HADS* | |||
Anxious (N = 92) | 1.53 [1.41–1.69] | 1.65 [1.50–1.78] | 1.56 [1.45–1.70] |
Not anxious (N = 208) | 1.94 [1.83–2.02] | 2.45 [2.37–2.54] | 2.09 [2.00–2.16] |
p-value | p < .001 | p < .001 | p < .001 |
Depressive (N = 63) | 1.36 [1.19–1.55] | 1.49 [1.32–1.65] | 1.40 [1.25–1.56] |
Not depressive (N = 237) | 1.93 [1.85–2.03] | 2.41 [2.32–2.47] | 2.07 [2.00–2.14] |
p-value | p < .001 | p < .001 | p < .001 |
Generally stressed (N = 116) | 1.53 [1.88–2.09] | 1.70 [1.59–1.82] | 1.58 [1.47–1.70] |
Not generally stressed (N = 184) | 1.99 [1.40–1.67] | 2.55 [2.46–2.64] | 2.14 [2.06–2.23] |
p-value | p < .001 | p < .001 | p < .001 |
Angina | |||
Age | |||
Young (< 60 years; N = 23) | 1.86 [1.58–2.14] | 2.12 [1.83–2.41] | 1.93 [1.68–2.19] |
Middle age (60–70 years; N = 42) | 1.77 [1.52–2.01] | 2.13 [1.91–2.35] | 1.87 [1.66–2.08] |
Elderly (> 70 years; N = 34) | 1.46 [1.25–1.68]c | 2.27 [1.98–2.55] | 1.70 [1.50–1.89] |
p-value | p < .05 | ||
Sex | |||
Female (N = 24) | 1.60 [1.30–1.96] | 2.14 [1.71–2.45] | 1.72 [1.42–2.01] |
Male (N = 76) | 1.68 [1.50–1.83] | 2.23 [2.09–2.42] | 1.83 [1.70–1.99] |
SF-36 general health status | |||
Excellent/very good (N = 16) | 2.15 [1.88–2.48] | 2.61 [2.13–2.86] | 2.28 [2.06–2.51] |
Good (N = 61) | 1.71 [1.55–1.91] | 2.35 [2.19–2.55]b | 1.89 [1.74–2.04]b |
Fair/poor (N = 23) | 1.22 [.93–1.44]c | 1.60 [1.27–1.90]c | 1.33 [1.10–1.50]c |
p-value | p < .05 | p < .05 | p < .05 |
SF-36 health transition | |||
Improve (N = 21) | 1.40 [1.17–1.78]a | 2.40 [2.05–2.73] | 1.65 [1.41–1.98] |
No change (N = 33) | 2.05 [1.79–2.23]b | 2.25 [2.00–2.41] | 2.11 [1.88–2.26]b |
Deteriorate (N = 46) | 1.49 [1.30–1.68] | 2.10 [1.85–2.33] | 1.66 [1.48–1.85] |
p-value | p < .05 | p < .05 | |
HADS* | |||
Anxious (N = 35) | 1.48 [1.27–1.73] | 1.69 [1.47–1.85] | 1.54 [1.35–1.74] |
Not anxious (N = 64) | 1.73 [1.57–1.94] | 2.46 [2.28–2.62] | 1.93 [1.80–2.11] |
p-value | p < .05 | p < .001 | p < .001 |
Depressive (N = 26) | 1.22 [.95–1.41] | 1.61 [1.39–1.93] | 1.33 [1.08–1.56] |
Not depressive (N = 73) | 1.79 [1.59–1.91] | 2.41 [2.24–2.54] | 1.96 [1.78–2.12] |
p-value | p < .05 | p < .001 | p < .001 |
Generally stressed (N = 47) | 1.47 [1.26–1.68] | 1.78 [1.60–1.96] | 1.55 [1.37–1.73] |
Not generally stressed (N = 52) | 1.80 [1.61–1.99] | 2.57 [2.40–2.73] | 2.01 [1.84–2.17] |
p-value | p < .05 | p < .001 | p < .001 |
Disease severity | |||
CCS grade II (N = 57) | 1.89 [1.72–2.10] | 2.41 [2.24–2.54] | 2.03 [1.89–2.20] |
CCS grade III/IV (N = 42) | 1.33 [1.18–1.55] | 1.92 [1.60–2.13] | 1.50 [1.34–1.67] |
p-value | p < .001 | p < .05 | p < .001 |
Myocardial infarction | |||
Age | |||
Young (< 60 years; N = 52) | 2.09 [1.86–2.26] | 2.11 [1.88–2.35]a | 2.10 [1.89–2.27] |
Middle age (60–70 years; N = 31) | 1.94 [1.72–2.27] | 2.53 [2.27–2.84] | 2.11 [1.80–2.26] |
Elderly (> 70 years; N = 39) | 1.84 [1.61–2.08] | 2.35 [2.10–2.61] | 1.99 [1.74–2.15] |
p-value | p < .05 | ||
Sex | |||
Female (N = 31) | 1.95 [1.68–2.23] | 2.16 [1.82–2.40] | 2.01 [1.75–2.25] |
Male (N = 92) | 1.98 [1.83–2.13] | 2.33 [2.18–2.50] | 2.08 [1.95–2.22] |
SF-36 general health status | |||
Excellent/very good (N = 12) | 2.10 [1.56–2.72] | 2.64 [2.40–2.88] | 2.24 [1.83–2.73] |
Good (N = 80) | 2.14 [1.96–2.22]b | 2.39 [2.24–2.53]b | 2.22 [2.06–2.29]b |
Fair/poor (N = 31) | 1.49 [1.20–1.74]c | 1.73 [1.41–2.04]c | 1.58 [1.29–1.79]c |
p-value | b: p < .001; c: p < .05 | p < .001 | b: p < .001; c: p < .05 |
SF-36 health transition | |||
Improve (N = 22) | 2.33 [2.00–2.64] | 2.51 [2.21–2.74] | 2.38 [2.06–2.51] |
No change (N = 29) | 2.39 [2.10–2.60]b | 2.44 [2.20–2.67] | 2.41 [2.21–2.56]b |
Deteriorate (N = 71) | 1.71 [1.57–1.90]c | 2.17 [1.99–2.37] | 1.85 [1.65–1.96]c |
p-value | b: p < .001; c: p < .05 | p < .05 | |
HADS* | |||
Anxious (N = 33) | 1.69 [1.46–1.95] | 1.64 [1.43–1.91] | 1.68 [1.46–1.93] |
Not anxious (N = 89) | 2.08 [1.92–2.22] | 2.52 [2.37–2.65] | 2.21 [2.02–2.28] |
p-value | p < .05 | p < .001 | p < .001 |
Depressive (N = 22) | 1.61 [1.26–2.20] | 1.58 [1.26–1.89] | 1.61 [1.30–1.86] |
Not depressive (N = 100) | 2.05 [1.91–2.17] | 2.43 [2.29–2.52] | 2.16 [2.03–2.25] |
p-value | p < .05 | p < .001 | p < .001 |
Generally stressed (N = 42) | 1.66 [1.44–1.89] | 1.76 [1.54–1.97] | 1.69 [1.50–1.89] |
Not generally stressed (N = 80) | 2.15 [1.99–2.31] | 2.57 [2.42–2.72] | 2.27 [2.13–2.41] |
p-value | p < .001 | p < .001 | p < .001 |
Ischemic heart failure | |||
Age | |||
Young (< 60 years; N = 32) | 1.75 [1.52–2.01] | 1.92 [1.71–2.22] | 1.80 [1.61–2.04] |
Middle age (60–70 years; N = 26) | 1.77 [1.48–2.06] | 2.30 [2.00–2.61] | 1.92 [1.66–2.18] |
Elderly (> 70 years; N = 23) | 1.84 [1.56–2.21] | 2.35 [2.06–2.67] | 1.99 [1.73–2.31] |
Sex | |||
Female (N = 10) | 1.77 [1.40–2.13] | 1.63 [1.00–2.25] | 1.73 [1.37–2.09] |
Male (N = 69) | 1.79 [1.62–1.98] | 2.25 [2.11–2.44] | 1.92 [1.78–2.09] |
SF-36 general health status | |||
Excellent/very good (N = 6) | 2.67 [2.06–3.28]a | 2.67 [2.21–3.13] | 2.67 [2.23–3.10]a |
Good (N = 46) | 2.01 [1.89–2.17]b | 2.37 [2.20–2.57]b | 2.11 [2.01–2.26]b |
Fair/poor (N = 28) | 1.19 [.98–1.45]c | 1.69 [1.44–2.04]c | 1.33 [1.15–1.58]c |
p-value | a: p < .05; b,c: p < .001 | p < .05 | a: p < .05; b,c: p < .001 |
SF-36 health transition | |||
Improve (N = 26) | 1.97 [1.72–2.23] | 2.31 [2.11–2.56] | 2.07 [1.87–2.28] |
No change (N = 18) | 2.10 [1.81–2.40]b | 2.35 [2.04–2.65] | 2.17 [1.90–2.44]b |
Deteriorate (N = 35) | 1.48 [1.27–1.75]c | 1.96 [1.68–2.18] | 1.62 [1.43–1.87]c |
p-value | p < .05 | p < .05 | |
HADS* | |||
Anxious (N = 24) | 1.42 [1.14–1.70] | 1.58 [1.29–1.87] | 1.47 [1.22–1.71] |
Not anxious (N = 55) | 1.96 [1.78–2.14] | 2.44 [2.29–2.61] | 2.10 [1.95–2.24] |
p-value | p < .05 | p < .001 | p < .001 |
Depressive (N = 15) | 1.29 [.93–1.66] | 1.16 [.86–1.46] | 1.26 [.96–1.55] |
Not depressive (N = 64) | 1.90 [1.73–2.07] | 2.40 [2.26–2.55] | 2.04 [1.91–2.18] |
p-value | p < .05 | p < .001 | p < .001 |
Generally stressed (N = 27) | 1.47 [1.19–1.74] | 1.54 [1.31–1.78] | 1.49 [1.26–1.72] |
Not generally stressed (N = 52) | 1.95 [1.75–2.14] | 2.48 [2.32–2.65] | 2.10 [1.94–2.26] |
p-value | p < .05 | p < .001 | p < .001 |
Disease severity | |||
NYHA grade II (N = 38) | 1.84 [1.65–2.04] | 2.28 [2.04–2.53] | 1.97 [1.79–2.15] |
NYHA grade III/IV (N = 40) | 1.73 [1.49–1.00] | 2.06 [1.84–2.31] | 1.82 [1.62–2.06] |
- Age: HRQL score differences were significant on the physical subscale in patients with angina with better HRQL in young patients and on the emotional subscale in the total cohort with higher HRQL in elderly patients and in patients with MI with better HRQL in middle-aged patients.
- Sex: HRQL score differences were only significant in the total cohort on the emotional subscale with higher HRQL in males.
- SF-36 health status: Global HRQL score differences were always significant with higher HRQL in the total cohort and each diagnosis when patients reported excellent/very good health or good health on the SF-36 health status item when compared to patients reporting fair/poor health. Other HRQL score differences on the physical and emotional subscales are detailed in Table 5.
- SF-36 health transition: The HRQL score differences were not as consistent with the SF-36 health transition item as with the health status item. However, patients in the total cohort and each diagnosis reporting either improved health or no change in health always had higher physical and global HRQL than patients reporting deteriorated health. Other HRQL score differences on the physical and emotional subscales are detailed in Table 5.
- Anxiety, depression, and general distress scores: HRQL score differences were significant on each scale in the total cohort as well as in each diagnosis with higher HRQL in patients who did not report anxiety or depression scores exceeding the cut-off ≥ 8 or general distress scores ≥ 12.
- Disease severity: HRQL score differences were significant on each scale in patients with angina with better HRQL in patients assigned to CCS grade II whereas no HRQL score differences were found in patients with ischemic heart failure.
Responsiveness
HeartQol | PCI (N = 97) | CR (N = 87) |
---|---|---|
Physical subscale | ||
Baseline | 1.75 ± .78 | 1.86 ± .71 |
Follow-up | 1.96 ± .72 | 2.27 ± .58 |
p-value for change | .002 | < .001 |
Effect size (SRM) | .31 | .68 |
Emotional subscale | ||
Baseline | 2.24 ± .73 | 2.25 ± .71 |
Follow-up | 2.35 ± .73 | 2.55 ± .60 |
p-value for change | n.s. | < .001 |
Effect size (SRM) | .48 | |
Global scale | ||
Baseline | 1.89 ± .70 | 1.96 ± .63 |
Follow-up | 2.07 ± .66 | 2.35 ± .52 |
p-value for change | .002 | < .001 |
Effect size (SRM) | .31 | .72 |
SF-36 PCS | ||
Baseline | 39.49 ± 10.38 | 41.88 ± 10.31 |
Follow-up | 43.85 ± 10.08 | 46.11 ± 8.73 |
p-value for change | < .001 | < .001 |
Effect size (SRM) | .61 | .51 |
SF-36 MCS | ||
Baseline | 49.19 ± 10.78 | 45.96 ± 11.45 |
Follow-up | 50.80 ± 10.77 | 51.03 ± 9.95 |
p-value for change | n.s. | < .001 |
Effect size (SRM) | .55 |