Quality of life of patients with myocardial infarction.
EZEQUIEL H. FORTE, CARLOS E PEDROZA, FEDERICO I. GRAZIANO,
CONSTANZA LAGOS, RICARDO IGLESIAS
Centro diagnóstico cardiovascular (CENDIC). Instituto Medico Garat (IMQG).
(3200) Concordia, Entre Ríos E-mail
Recibido 21-JUN-18 – ACEPTADO despues de Revisión el 14-JULIO-2018.
There are no conflicts of interest to disclose.
The information about how different factors impact on quality of life of patients with AMI remains unclear. The aim of this study was to analyze how different factors impact over the quality of life of patients who had suffered an AMI. Methods: We conducted a survey of quality of life (EQ5D questionnaire and the EQ VAS scale) and follow-up of a cohort of patients who had suffered an AMI and compared them with a control group. Results: There were no differences in relation to motility disorders, personal care, daily activities or pain; although 69% of patients in the AMI group had some problems in quality of life compared to 39% in the control group (p <0.001). Overall the EQ VAS scale represented an average of 80.3 in the AMI group and 88.7 in the control group (p = 0.001). The EQ5D index was lower in the AMI group (0.8861) than in the control group (0.9317) (p=0.03). These differences were found in relation to the question about anxiety and depression: 48% of patients in the AMI group reported developing anxiety / depression against only 11% in the control group (p <0.0001). Similarly, patients who reported being anxious / depressed had a higher percentage of cardiovascular events in the follow-up (38% vs 26% p <0.005). Conclusions: In patients who had an AMI, factors such as anxiety / depression were more frequent and had a negative impact on quality of life.
In spite of the advancements in management in recent years, cardiovascular disease represents in our country around 30% of overall mortality  and is still a leading cause of death in developed countries .
Acute myocardial infarction is its most dramatic manifestation, due to the number of deaths caused and the disability it produces on quality of life. Its incidence in Argentina is 9 patients per 10,000 inhabitants .
A series of unsolved aspects influence on the recovery and evolution of patients: psychosocial, cultural, economic and affective factors may play a significant role in the evolution of cardiovascular disease .
The definition of health covers physical, psychological and social aspects, closely linked to the concept of quality of life. This concept depends on factors related to the satisfaction of human needs and the development of a full social life.
Emotional lability, expressed through feelings of anxiety and depression are frequent after coronary symptoms. Although these entities are considered as different conditions, most of times there is overlapping . In the registry made by the Consejo Argentino de Residentes de Cardiología (CONAREC XVII), 28% of patients presented a psychosocial stress factor as a possible trigger of the coronary event .
The World Bank and World Health Organization state that cardiovascular disease and depression disorders will be, by year 2020, between the leading causes of disability .
The publications in Argentina that study the quality of life of patients that presented myocardial infarction are scant. Precisely this was the reason that led us to conduct this pilot experience. Thus, the aim of this study was to analyze how different factors may impact on the quality of life of patients who had suffered acute myocardial infarction.
MATERIAL AND METHODS
A survey was made, where clinical data, risk factors, medication and a questionnaire on quality of life (EuroQuol – EQ5D) were included. The EuroQuol is a tool originally used in European populations, although it was also validated in non-European populations [8-9] and specifically in regard to CAD .
The EQ5D questionnaire, in its adjustment to Argentina, is composed by 5 topics: mobility, personal care, daily activities, pain/discomfort, anxiety/depression. Every category has three possible replies (Likert-type scale): 1- no problems, 2- moderate problems, and 3- severe problems, and also a visual analog scale was added (EQ VAS) of general perception tabulated from 0 to 100 (worst health state to best health state). Likewise, a value from 1 to 3 is assigned (1-no problems, 2- moderate problems, and 3- severe problems) to each reply with which a profile is prepared for each patient and a quantitative scale is prepared (EQ5D Index) for comparison in different scenarios. This scale was validated in Argentina standardizing it by the American scale .
A “control arm” was included, that was constituted by patients discharged from the Institution with noncoronary precordial pain, and matched by age and presence of co-morbidities.
From both arms of patients, patients were excluded when they presented a history of cerebrovascular disease, chronic renal failure, diabetes with organic lesion, dementia, COPD, peripheral vascular disease, connective tissue pathology or liver disease.
An Access database was used after converting it to Excel, and analyzed with EPIINFO 3.5.1 in its free version. The quantitative variables were expressed with means with their standard deviation. To the dichotomous variables, Chi squared was applied, except in those that had less than 5 expositions, which were analyzed by Fisher’s exact test. Means were compared by the ANOVA test for samples with normal distribution and by the Kruskal-Wallis test for samples with nonhomogeneous distribution.
To estimate the EQ5D profile and estimate its index (EQ5D Index), we used a free Excel calculator downloaded from its official site (http://www.euroqol.org/).
Additionally and retrospectively (not included in the aim of the study), a COX regression curve was made on the AMI arm, and major cardiovascular events (new AMI, angioplasties, stroke and myocardial revascularization surgery) were grouped, and confronted with two variables: not being anxious/depressed vs being anxious/depressed to observe whether this variable had an impact on the appearance of cardiovascular events.
The database of the Coronary Unit of the Sanatorio Garat was used (Concordia, Enter Ríos province) to identify patients with NSTEMI admitted to the Coronary Unit, with more than one year elapsed since the coronary event. There were 71 patients contacted and included in the study, who completed the quality of life survey (Table 1). 69% were men (49 pts), 61% (43 pts) smokers, 69% (49 pts) presented dyslipidemia, 71% (50 pts) hypertension, and 21% (16 pts) diabetes. The mean age was 58.5% ±11.2 years, 13% were >65 years. The mean time since the coronary event (NSTEMI) until the survey was taken was 35 months (mean 2.9 years, range 12-63 months).
The control group was selected between patients discharged from the Coronary Unit with diagnosis of noncoronary precordial pain. It was constituted by 46 pts, who were chosen by age, gender, and presence/absence of DM as risk factor to homogenize it with the AMI arm. Only the presence of smoking was more frequent in the infarction arm. No significant differences were detected in the other coronary risk factors (Table 1).
Table 1. General characteristics of the population
Time since AMI/admission due to precordial pain (years)
In the quality of life questionnaire, there were no differences between both groups in the first four questions (in relation to mobility disorders, personal care, daily activities or presence of pain) (Table 2). The fifth question (related to anxiety/depression) presented a significant difference: 48% of the AMI group patients mentioned presenting anxiety/depression vs 1% of the control group (p<0.0001). In Table 2, we may also observe the most frequent profiles in the EQ5D questionnaire. 3% of patients in the AMI group and 63.8% of patients in the control group presented a 11111 profile (5 negative replies, “no problems”). The second profile with more replies was 11112 for the AMI arm (28.2%) and 11121 (8.5%) for the control arm. The EQ5D index was 0.8861 for the AMI group and 0.9317 for the control group (p=0.03). 69% of the patients in the AMI group replied affirmatively some of the questions, in comparison to just 39% in the control arm (p<0.001) (Figure 1). Likewise, the overall perception of quality of life in the EQ VAS scale presented a mean of 80.3 in the AMI arm and 88.7 in the control arm (p = 0.001) (Table 2).
Figure 1. Affirmative reply to some of the EQ5D questionnaire items.
Table 2. Result of the questionnaire. EQ5D, EQvas, profile and EQ5D index
2- Personal care
3- Daily activities
I’m not anxious or depressed
I’m moderately anxious or depressed
Very anxious or depressed
Global quality of life score
Additionally, we conducted a retrospective analysis on both groups in terms of the evolution since the index event (NSTEMI or admission because of noncoronary precordial pain) in relation to major cardiovascular events (new AMI, stroke and revascularization), and we observed that the patients that mentioned being anxious/depressed had a greater percentage of cardiovascular events than those that did not mention having anxiety/depression (38% vs 26%) (Figure 2). This difference was statistically significant in the COX regression curve where we detected a divergence at 20 months with a significant separation at 50 months (p<0.005) (Figure 3).
Figure 2. Reply to the anxiety/depression question and major cardiovascular events.
DISCUSSION Quality of life is increasingly more used to measure outcomes in clinical trials and observational studies.
In this pilot experience, we observed that there are emotional factors that have a negative impact on the quality of life of the patients who have presented an acute coronary event. In the case of the study made, as this is not a cohort-like study, it is not possible to know if the patients were already presenting emotional lability (anxiety/depression) before the coronary event or if it was a consequence of it (there is a correlation, but this does not indicate time or reciprocity).
Multiple observational studies relate the presence of psychological and/or behavioral variables with CAD. An example of this, is the well-known INTERHEART study where psychosocial history was a risk factor with greater weight than hypertension, smoking or diabetes .
Age, and the mentioned psychosocial factors are strong predictors of quality of life of patients who have suffered AMI .
The questionnaire used in this study (EQ5D) is widely validated to evaluate the quality of life in patients with CAD and has a proven correlation in its “anxiety/depression” item with the BAI and BDI scores (Beck Anxiety Inventory and Beck Depression Inventory) .
It is estimated that the prevalence of depression in post-infarction patients is between 15 to 23% greater than in the general population, which is around 4% .
In the MONICA/KORA registry, 36% of patients who had suffered AMI, presented some degree of deterioration in their quality of life measured by the EQ5D questionnaire .
A coronary event may have a very significant negative impact on the emotions of patients, and for this reason it was decided not to include patients within the first year of AMI because maybe their emotional symptoms could be influenced by the acute event and did not represent the true personality characteristics.
In our study, we found a high prevalence of anxiety/depression in patients, greater than the previously mentioned studies, although we have no statistics for a comparison, so this could be influenced by other factors inherent to the studied population, some unperceived bias, or be an isolated phenomenon that could vanish if the number of patients was larger.
Fan et al, evaluated anxiety and depression in CAD in more than 129,000 patients, and observed that those with cardiovascular disease were more prone to experience anxiety disorders (16.6% vs 10%, 95% CI – 1.46 [1.37-1.54]) and depression disorders (22.3% vs 5.1%, 95% CI – 1.56 [1.45-1.67]) than individuals without this disease .
There are multiple causes why the patients with CAD present negative emotions. Acute myocardial infarction generates physical and emotional impairment in a stage of life when most patients remain socially and workwise active. The fear of death, disability, the feeling of weakness, the perception of loss of the role of administrators/providers of the family, a decrease in libido, erectile dysfunction, a decrease in financial resources, the loss of work and uncertainty are usual manifestations that interfere with recovery . The high rate of events in follow-up and taking medications could also be associated to a more frequent appearance of negative emotions. In turn, this type of emotions influence on the development of heart disease and are associated to a high morbidity and mortality in follow-up.
It is estimated that only 25% of cardiac patients with major depression have a diagnosis, and that approximately only half of them receive an antidepressant treatment .
Strik et al, evaluated anxiety and depression in patients after a first cardiac event and found after 3.4 years of follow-up, that anxiety is an independent predictor of fatal and nonfatal cardiac events (HR 3.01, 95% CI – 1.1 to 7.03; p=0.005) .
This study showed that quality of life deterioration in this group of post-AMI patients was the result of the significant presence of anxiety/depression symptoms, in a greater percentage than the control group. In this sense, the group of patients that had underwent AMI mentioned feeling anxiety or depression four times more than the control group, similarly to other epidemiological studies .
There were no differences in the other areas evaluated (mobility, daily activities, personal care and pain).
In the HUNT2 study, that analyzed a cohort of more than 59,000 patients with a follow-up of more than 11 years, the presence of anxiety/depression was in relation to a 20-30% increase in the risk of presenting a first infarction ; likewise, in our study, when we analyzed the evolution of our patients (not planned in the original study), we found that the presence of anxiety/depression was an independent factor of new event in follow-up. This difference was significant for major cardiovascular events when we performed a COX regression curve, although these results could present biases since the populations were not homogenous, and a specific study would be necessary to corroborate it. On the other hand, the presence of a positive correlation does not ensure the bidirectionality of results (we ignore whether being more anxious/depressed generated more coronary events or if the presence of coronary events generated more anxiety/depression).
The patients with anxiety/depression often present a more difficult evolution for multiple reasons, with probably the most powerful one being less adherence to the recommended treatments . In this regard, depression symptoms relate to multiple and complex factors such as autonomic variations and neuro-hormonal mediators release .
The treatment of myocardial infarction should focus not only on the organic aspects of the disease, since other variables have an impact on the overall wellbeing of patients.
For this reason, prevention guidelines and post-AMI depression treatment recommend the early detection and follow-up of depression symptoms and the treatment with psychotherapy and/or drugs .
Finally, we believe that it is essential to work jointly and in an interdisciplinary manner with psychiatrists and psychologists that know this pathology and that are part of the work team with CAD patients.
Instituto Nacional de Estadística y Censos (INDEC). www.indec.mecon.ar
Caccavo A, Álvarez A, Bello F, et al. Incidencia poblacional del infarto con elevación del ST o bloqueo de rama izquierda a lo largo de 11 años en una comunidad de la provincia de Buenos Aires. Rev Argent Cardiol 2007; 75: 185-88.
Oldridge N, Guyatt G, Jones N, et al. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. Am J Cardiol 1991; 67 (13): 1084-89.
Blumenthal JA, Smith PJ. Risk factors: anxiety and risk of cardiac events. Nat Rev Cardiol 2010; 7: 606-08.
Perez GE, Costabel JP, Gonzalez N, et al. Infarto Agudo del Miocardio en la Republica Argentina Registro CONAREC XII. Rev Argent Cardiol 2013; 81: 390-99.
Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global burden of disease study. Lancet 1997, 349 (9064): 1498-504.
Calidad de vida relacionada ala salud (HR-QoL) en la población general. Chile 2005. Departamento de Estudios y Desarrollo. Superintendencia de salud. Mayo 2006.
Ellis J, Eagle K, Kline-Rogers EM, Erickson SR. Validation of the EQ-5D in Patients With a History of Acute Coronary Syndrome. Curr Med Res Opin 2005; 21 (8): 1209-16.
Nowels D, McGloin J, Wesfall JAM, Holcomb S. Validation of the EQ-5D quality of life instrument in patients after myocardial infarction. Qual Life Res 2005; 14 (1): 95-105.
Augustovski FA, Irazola VE, Velazquez AP, et al. Argentine valuation of the EQ-5D Health States. Value Health 2009; 12 (4): 10.1111 / j.1524-4733.2008.00468.x.
Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries. Lancet 2004; 364: 937-52.
Beck CA, Joseph L, Bélisle P, et al. Predictors of quality of life 6 months and 1 year after acute myocardial infarction. Am Heart J. 2001; 142 (2): 271-79.
Lane D, Carroll D, Lip H. Anxiety, depression and prognosis after myocardial infarction. Is there a causal association?. Am J Cardiol 2003; 42: 1801-3.
Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007; 370: 1089-1100.
Schweikert B, Hunger M, Meisinger C, Ko ̈nig H, Gapp1 O, Holle R. Quality of life several years after myocardialinfarction: comparing the MONICA/KORAregistry to the general population. Eur Heart J 2009; 30 (4): 436-43.
Fan AZ, Strine TW, Jiles R, Mokdad AH. Depression and anxiety associated with cardiovascular disease among persons aged45 years and older in 38 states of the united states. Preventive Medicine 2006; 46(5): 445-450
Simmonds RL, Tylee A, Walters P, Ross D. Patient´s perceptions of depression and coronary heart disease. A Qualitative UPBEAT-UK Study. BMC Fam Pract 2013; 14 (38) doi: 10.1186/1471-2296-14-38.
Lane D, Carroll D, Lip GY. Anxiety, depression, and prognosis after myocardial infarction: is there a causal association?. J Am Coll Cardiol 2003; 19 (42): 1808-10.
Strik JJ, Denollet J, Lousberg R, et al. Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol 2003; 42 (10): 1801-07.
König HH, Born A, Günther O, et al. Validity and responsiveness of the EQ-5D inassessing and valuing health status in patients withanxiety disorders. Health Qual Life Outcomes 2010; 8: 47 - doi: 10.1186/1477-7525-8-47.
Gustaud LT, Laugsand LE, Janszky I, et al. Symptoms of anxiety and depression and risk of acute myocardial infarction: the HUNT 2 study. Eur Heart J 2014; 135 (21): 1-1394-403.
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353: 487-89.
Drago S, Bergerone S, Anselmino M, et al. Depression in patients with acute myocardial infarction: Influence on autonomic nervous system and prognostic role. Results of a five-year follow-up study. Int J Cardiol 2006; 115 (1): 46-51.
Green LA, Dickinson WP, Nease DE, et al. Myocardial Infarction Depression Clinical Practice Guideline Panel. Ann Fam Med 2009; 7 (1): 71-79.