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The HeartQoL: Part I. Development of a new core health-related quality of life

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 Royal College of Surgeons in Ireland
e-publications@RCSI
Psychology Articles Department of Psychology

7-20-2012

The HeartQoL: Part I. Development of a new core

health-related quality of life questionnaire for
patients with ischemic heart disease.
Neil Oldridge
University of Wisconsin - Milwaukee

Stefan Höfer
Innsbruck Medical University

Hannah McGee
Royal College of Surgeons in Ireland

Ronan Conroy
Royal College of Surgeons in Ireland

Frank Doyle
Royal College of Surgeons in Ireland, [email protected]

See next page for additional authors

Citation
Oldridge N, Höfer S, McGee H, Conroy R, Doyle F, Saner H. The HeartQoL: Part I. Development of a new core health-related quality
of life questionnaire for patients with ischemic heart disease. European Journal of Preventive Cardiology. 2012 Jul 20. [Epub ahead of
print]

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of Psychology at e-publications@RCSI. It has been accepted for inclusion
in Psychology Articles by an authorized administrator of e-
publications@RCSI. For more information, please contact [email protected].
Authors
Neil Oldridge, Stefan Höfer, Hannah McGee, Ronan Conroy, Frank Doyle, and Hugo Saner

This article is available at e-publications@RCSI: http://epubs.rcsi.ie/psycholart/44

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The HeartQoL: I. Development of a new core health-related quality of life questionnaire for

patients with ischemic heart disease

a
Neil Oldridge
b
Stefan Höfer
c
Hannah McGee
d
Ronan Conroy
c
Frank Doyle
e
Hugo Saner
for the HeartQoL Project investigators

a. University of Wisconsin School of Medicine & Public Health and Aurora Cardiovascular
Services, Aurora Sinai/Aurora St. Luke’s Medical Center, Milwaukee, Wisconsin, USA
b. Department of Medical Psychology, Innsbruck Medical University, Innsbruck, Austria
c. Division of Population Health Sciences (Psychology), Royal College of Surgeons in Ireland,
Dublin, Ireland
d. Division of Population Health Sciences (Epidemiology & Public Health Medicine), Royal
College of Surgeons in Ireland, Dublin, Ireland
e. Cardiovascular Prevention and Rehabilitation, Swiss Cardiovascular Center Bern, Bern
University Hospital, University of Bern, Bern, Switzerland

Short title: HeartQoL questionnaire development

Word count: 3,719 [+ 4 tables]

7 February, 2012

1
Address for correspondence:

Neil Oldridge, PhD

Clinical Professor of Medicine

University of Wisconsin School of Medicine & Public Health and
Aurora Cardiovascular Services
th
960 North 12 Street, Suite 400
Milwaukee, WI 53217

Email: [email protected]

2
ABSTRACT

Background

Evaluation of health-related quality of life (HRQL) is important in improving the quality of patient

care.

Methods

The HeartQoL Project, with cross-sectional and longitudinal phases, was designed to develop a

core ischemic heart disease (IHD) specific HRQL questionnaire, to be called the HeartQoL, for

patients with angina, myocardial infarction (MI), or ischemic heart failure. Patients completed a

battery of questionnaires and Mokken scaling analysis was used to identify items in the HeartQoL

questionnaire.

Results

We enrolled 6,384 patients (angina, n=2,111, 33.1%; MI, n=2,351, 36.8%; HF, n=1,922, 30.1%)

across 22 countries and 15 languages. The HeartQoL questionnaire comprises 14-items with 10-

item physical and 4-item emotional subscales which are scored from 0 (poor HRQL) to 3 (better

HRQL) with a global score if needed. The mean baseline HeartQoL global score was 2.2 (±0.5) in

the total group and was different (p<0.001) by diagnosis (MI, 2.4 ±0.5; angina, 2.2 ±0.6; and heart

failure, 2.1 ±0.6).

Conclusion

The HeartQoL questionnaire, with global and subscale scores, has the potential to allow clinicians

and researchers to a) assess baseline HRQL, b) make between-diagnosis comparisons of HRQL,

and c) evaluate change in HRQL in patients with angina, MI, or heart failure with a single IHD-

specific HRQL instrument.

3
Keywords: Ischemic heart disease; angina; myocardial infarction; heart failure; health-related

quality of life

4
INTRODUCTION

As one means to improve the quality of health care, the Institute of Medicine has
1 2
emphasized the need for more patient-centered care . Both the European Medicines Agency
3
and the US Food and Drug Administration have defined evaluations or reports of a patient’s

health condition that come directly from the patient, such as health-related quality of life (HRQL), as

patient-reported outcomes. Patient-reported outcomes are valuable in national and international

clinical and research studies for assessing achievement of health goals, assessing health

disparities between population segments, evaluating health care intervention effectiveness, and

making between-diagnosis treatment comparisons. Specific HRQL questionnaires are designed

4
for patients with either a specific disease or a specific diagnosis within a given disease . However,

this precludes between-diagnosis HRQL outcome comparisons. Core disease-specific HRQL

questionnaires provide a solution to this limitation; for example, between-diagnosis HRQL

5, 6
comparisons have been possible for two decades in patients with different cancer diagnoses .
7
Ischaemic heart disease (IHD) accounts for approximately 15.4% of all deaths in Europe
8
and 15.8% in the USA . Patients with IHD, specifically angina, myocardial infarction (MI), and

ischemic heart failure, present on a continuum of disease. With a wide range of health status

deficits, IHD treatment and therapeutic goals include reduced mortality and an enhanced quality of

the longer life. The National Heart, Lung and Blood Institute has stressed the importance of
9
patient-reported outcomes in clinical care and relevant clinical trials for patients with IHD . While

valid and reliable IHD diagnosis-specific health status and HRQL tools are available for patients

with angina, MI, and heart failure, no valid core IHD-specific HRQL instrument was available at the

time the present project was initiated.

The HeartQoL Project was designed to develop and validate a core IHD-specific HRQL

instrument for making between-diagnosis comparisons following interventions such as

revascularization or cardiac rehabilitation that are routinely used in more than one IHD diagnosis.

5
The purpose of this paper is to describe the development of a core IHD-specific HRQL

questionnaire, called the HeartQoL questionnaire, with psychometric properties described in a

following paper.

6
METHODS
The HeartQoL Project was conducted between 2002 and 2011 in five regions (Eastern,

Northern, Southern, and Western European regions and an English-speaking region) with a total of

22 countries where 15 languages are spoken: Danish, Dutch, English (Australia, Canada, Ireland,

United Kingdom, and the United States of America), French, Flemish, German (Austria, Germany,

and Switzerland), Hungarian, Italian, Norwegian, Polish, Portuguese, Russian, Spanish (Cuba and
10
Spain), Swedish, and Ukrainian . Each of the sites (n=54) received local Ethics Committee or

Institutional Review Board approval.

The study was conducted in two phases: 1) a cross-sectional survey phase with three

validated IHD-specific HRQL questionnaires to identify items for inclusion in the HeartQoL

questionnaire and described in this manuscript; 2) a second phase to test the questionnaire’s
11
psychometric properties (described in a separate manuscript ).

Patients

The target in the cross-sectional study was to enroll at least 315 patients (105 with angina, 105

with MI and 105 with heart failure) speaking each of 15 languages, i.e., a sample size of at least 4,725
10
patients . Physicians referred patients if they met the following eligibility criteria:

a. Experienced a documented MI between 1-6 months previously; or

b. Currently treated for angina (Canadian Cardiovascular Society class II, III or IV) with an objective

measure of IHD (previous MI, exercise testing, echocardiogram, nuclear imaging or angiography); or

c. Currently treated for ischaemic heart failure (New York Heart Association Class II, III, or IV) with

evidence of left ventricular dysfunction (ejection fraction <40% by invasive or non-invasive testing) and

an objective measure of IHD (previous MI, exercise testing, echocardiogram, nuclear imaging or

angiography), and

d. Were ≥18 years old and considered by the referring physician to 1) be able to complete the self-

administered battery of HRQL instruments in the particular language, 2) not have serious

7
psychiatric disorder, and 3) not be a current substance abuser.

Patient-reported outcome assessment

The referring clinician identified their patient’s clinical characteristics. All patients completed a

battery of patient-reported questionnaires. This included a sociodemographic questionnaire, the Short-

12, 13 14, 15
Form 36 (SF-36) , the Hospital Anxiety and Depression Scale (HADS) , and three validated

IHD-specific questionnaires selected as the foundation of to-be-developed HeartQoL questionnaire,

16, 17
the Seattle Angina Questionnaire (SAQ) , the MacNew Heart Disease Health-related Quality of Life
18, 19 20,
Questionnaire (MacNew) , and the Minnesota Living With Heart Failure (MLHF) Questionnaire
21
. The SAQ and MLHF diagnosis-specific cues (“due to chest pain, chest tightness, or angina …” and

“how your heart failure …”, respectively) were both modified, with author permission, to “how your

heart problem …”. The MacNew timeframe was modified, also with permission, from “2 weeks” to “4

weeks” to complement the timeframe used in the SAQ and MLHF. Each questionnaire was either a)

available in one of the 15 different languages or b) when language-specific translations were not

available, accepted linguistic translation techniques such as forward-backward translation were used to
22
translate the questionnaires . Two independent translators, one a health care professional and the

other a non-health care person and fluent in each language and English, were used to develop

necessary questionnaires.

Instrument development and item reduction

Only the SAQ, MacNew, and MLHF items designated as physical, emotional, or social

domain items were considered for the candidate pool of items as they are central to the
4
assessment of HRQL . The item reduction process consisted of two stages, first ranking the
23
candidate pool items using the clinical impact method and then using Mokken scaling to derive
24, 25
scales .

8
1. Clinical impact method
23
The clinical impact method asks patients to identify symptoms, activity limitations, and

feelings that bother them in their everyday lives with the clinical impact score the product of the

proportion bothered by an item and the “bothersomeness” score for that item on a scale from 1 to 5

(‘little’ to ‘very’ bothered). If a patient had responded affirmatively to an item but had given no

“bothersomeness” score, it was imputed conservatively as follows. Item scores ranging from “little

to very bothered” on the original questionnaire were given a “bothersomeness” score = 1. If the

“bothersomeness” score was missing and the patient’s response on the original questionnaire was

“not bothered”, those items were given a score = 0. Items with scores ≥ 1.00 were included in the

candidate pool of items for Mokken scaling.

2. Mokken scaling

Mokken scale analysis, a hierarchical scaling method similar to Guttman scaling, 1)

examines items in the candidate item pool for an underlying latent attribute represented by a set of

items, 2) orders these items by degree of difficulty, and 3) uses an iterative selection procedure to
24, 25
form scales . Loevinger's H-coefficients measure the relationship between the numbers of

Guttman observed errors and errors expected by chance. By convention, strong Mokken scales
24,
are indicated by H-coefficients ≥0.5, 0.49 to 0.40 for moderate, and 0.39 to 0.30 for weak scales
25
. Item and subscale thresholds of H ≥0.5 were set; both subscale and global scale H-values were

determined.

3. Formatting the HeartQoL questionnaire

The HeartQoL items are introduced with the following preamble: “We would like to know how your

heart problem has bothered you and how you have been feeling during the last 4 weeks”. The
26
HeartQoL response options were determined with item characteristic curve modeling with scores

ranging from 0 to 3, higher scores indicating better HRQL.

9
RESULTS
International cohort (Table 1)

A cohort of 6,384 patients, living in 5 different geographical regions (22 countries with 54

sites in total) and speaking one of 15 languages, was enrolled in the HeartQoL Project; Eastern

Europe (n=1,307 patients), Northern Europe (n=1,022 patients), Southern Europe (n=1,132

patients), Northern Europe (n=1,449 patients), and an English-speaking region (n=1,474 patients).

Patients were referred with a diagnosis of angina (n=2,110; 33%), MI (n=2,350; 37%), or heart

failure (n=1,920; 30%) meeting the project target of enrolling approximately equal proportions in

each diagnosis.

Self-report sociodemographic and risk factors (Table 2)

Women made up 25% (n=1,694) of the cohort and the mean age in the total group was

62.5 years (SD= 11.3). The oldest patients were those with heart failure. Patients with angina

were significantly less likely to be men or to smoke but more likely to report hypertension or high

cholesterol and have a higher BMI than either patients with MI or patients with HF. Patients with MI

were significantly more likely to be younger, to report being diabetic, and less likely to be inactive

than patients with either angina or HF.

Health status, anxiety and depression (Table 2)

a. SF-36:

The mean physical and mental component summary (PCS and MCS, respectively) scores

were below the population norm of 50 with lower PCS than MCS scores in all cases. Patients with

MI had significantly higher PCS scores than patients with angina who had higher scores than

patients with heart failure. There were no significant between-diagnosis MCS score differences.

b. HADS:
Patients with MI had significantly lower anxiety and depression scores than patients with

either angina or heart failure and were also least likely to have depression scores >7 (19%)

10
although most likely to report anxiety scores >7 (39%). Patients with heart failure had lower

anxiety scores than patients with angina while the opposite was true for depression.

Clinical Impact Method (Table 3)

A candidate pool of 26 items (physical, n= 14; emotional, n= 8; social, n= 4; SAQ, n= 5;

MacNew, n= 13; MLHF, n= 8) with clinical impact scores ≥ 1.0 was identified for the Mokken

scaling analysis.

a. SAQ

Two of the 9 eligible SAQ items, items #9 (strenuous sports) and #7 (running or jogging),

were considered inappropriate for most patients with IHD. Four items had clinical impact scores ≥

1.0 and, to capture a full range of physical activities, we included item #2 (‘walk indoors on level’;

clinical impact score = 0.26) in the candidate pool for Mokken analysis.

b. MacNew

Sixteen of the 27 eligible MacNew items had clinical impact scores ≥ 1.0. Items #4 (‘down

in the dumps’), #6 (‘worn out’), and #9 (‘short of breath’) had lower scores than similar MLHF items

(#21, #13, and #12) and were excluded from the candidate pool for Mokken analysis.

c. MLHF

Nine of the 13 eligible MHLF items had a score ≥ 1.0. Item #3 (‘walking or climbing stairs’)

was excluded from the item candidate pool for Mokken analysis with a lower score than the

corresponding SAQ item (#4).

Scale building (Tables 3)

Mokken analysis, with a threshold H-value ≥0.50 (“strong” scale), was used to build the

HeartQoL from the candidate pool of the 26 items. Mokken analysis identified a bi-dimensional

instrument with a 10-item physical subscale (H= 0.56) and a 4-item emotional subscale (H =0.54)

(Table 3). Without setting an H threshold, the overall HeartQoL questionnaire with all 14 items (H-

value ≥0.50), i.e., the global score, had a uni-dimensional H-value = 0.47 (Table 3

HeartQoL scores (Table 4)

11
 On a HeartQoL scale response of 0 to 3, higher scores indicate better HRQL. Mean

baseline HeartQoL global score in the group as a whole was 2.2 ±0.5; mean global scores were

highest in patients in patients with MI (2.4 ±0.5), significantly higher (p<0.001) than in patients with

angina (2.2 ±0.6) that, in turn, were significantly higher (p<0.001) than in patients with heart failure

(2.1 ±0.6). A similar pattern by diagnosis was seen in the physical HeartQoL subscale; emotional

subscale scores were highest in patients with MI but were not different in patients with angina or

heart failure.

12
DISCUSSION
The HeartQoL questionnaire is a new 14-item IHD-specific core HRQL questionnaire

based on the items in the SAQ, the MacNew, and the MLHF, with data provided by a cohort of

6,384 patients living in one of 22 countries with approximately equal numbers of patients with

angina, MI, or ischemic heart failure. The HeartQoL appears to have potential as a core IHD-

specific HRQL questionnaire demonstrating that patients with MI have a significantly better HRQL

than patients with angina who in turn have a significantly better HRQL than patients with heart

failure. The evidence for the validity of the HeartQoL questionnaire will be presented in a separate

manuscript.

The 14 items in the HeartQoL scale cluster as a bi-dimensional questionnaire with a 10-

item HeartQoL physical and a 4-item HeartQoL emotional subscale providing a global assessment

and evaluation of how much a patient with angina, MI, or heart failure perceives he or she is

bothered by their heart disease. Conventionally, HRQL consists of at least three domains, a
4
physical, an emotional, and a social domain . However, although four MacNew social domain

items met the clinical impact score inclusion criteria for the 26-item candidate item pool these were

not included among the 14 items underlying the bi-dimensional latent HRQL HeartQoL construct as

determined by Mokken analysis. It appears that that whatever social problems these patients with

IHD may have, they are not sufficiently unique or strong enough to form an independent latent

construct. Alternatively, the MacNew social items may be culture- or diagnosis-specific, and thus

do not generalize across the three IHD diagnostic groups assessed in this study.

There has been global explosion of interest in HRQL instruments as outcomes both in

clinical practice but also in national and international research endeavors. We therefore designed

the HeartQoL Project as an international effort and communicated our interest in conducting the

project to members of the European Association of Cardiovascular Prevention and Rehabilitation.

Volunteer investigators from 22 different countries agreed to enroll patients who met the project

eligibility criteria that, among other factors, required 15 different language versions of the battery of

13
patient-reported questionnaires. Although the lack of language translations may be considered a

limitation of the project, accepted linguistic translation techniques such as forward-backward

22
translations were used where language versions were unavailable . Although another limitation

of the project may be the length of time it took to enroll all 6,384 patients, all site investigators were

volunteers using their own and their staff time and effort to recruit patients.

There has been a proliferation of HRQL instruments in the past two or three decades with

widely varying methods of development, content, breadth of use, and quality principles and
27
psychometric property criteria to carry out instrument assessments have been published .

Guidelines for key psychometric attributes of HRQL instruments such as the HeartQoL include the

conceptual and measurement model, reliability, validity, responsiveness, and respondent and
27 11
administrative burden and these are the focus of a separate manuscript .

CONCLUSIONS

The HeartQoL questionnaire is a new 14-item, international core IHD-specific assessment

and evaluation system of the impact of cardiac interventions on patient-reported HRQL that has the

potential to have an impact on the quality of patient care in the future. The psychometric properties

of the HeartQoL questionnaire, with a global score and two subscales, will need to be

demonstrated before it can be used by clinicians and researchers to a) assess baseline HRQL, b)

make between-diagnosis comparisons of HRQL, and c) evaluate change in HRQL in patients with

angina, MI, and heart failure.

14
Acknowledgments:

The international HeartQoL Project was initiated in 2002 and supported by the European Society of

Cardiology (start-up funding); the European Association for Cardiovascular Prevention and

Rehabilitation (project conduct funding); with academic support from the European Health

Psychology Society.

We would like to acknowledge all HeartQoL investigators and their clinic personnel without whose

time and effort, which was provided voluntarily, the HeartQoL Project could not have been

conducted. Special thanks also go to the patients who agreed to the task of completing the

questionnaires.

The Authors declare that there is no conflict of interest

15
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18
Table 1. Numbers of patients by region, country within region and by diagnosis
[angina, myocardial infarction, and heart failure]

Region [sites] Country Diagnosis

IHD Angina Myocardial Heart
(n) (n) infarction failure
(n) (n)
Total cohort (54) 6,384 2,111 2,351 1,922
Eastern Europe (4) 1,307 442 443 422
Hungary 330 106 117 107
Poland 332 115 112 105
Russia 322 110 107 105
Ukraine 323 111 107 105

Northern Europe (6) 1,022 349 362 311

Denmark 364 142 117 105
Norway 335 105 125 105
Sweden 323 102 120 101

Southern Europe (13) 1,132 366 451 315

Italy 327 105 117 105
Portugal 354 113 136 105
Spain + Cuba 451 148 198 105

Western Europe (16) 1,449 433 590 426

Austria, Germany,
Switzerland 365 116 143 106
Belgium 348 105 137 106
France 374 106 159 109
Netherlands 362 106 151 105

English-speaking (15) 1,474 521 505 448

Australia 296 77 111 108
Canada 352 105 142 105
UK + Ireland 357 117 131 109
USA 469 222 121 126

19
Table 2. Self-report sociodemographic, risk factors, and Short-form-36 –Version 1
(SF-36) and Hospital Anxiety and Depression Scale (HADS) mean scores (standard
deviation) or proportion in the total group and in patients with angina (AP), myocardial
infarction (MI), or heart failure (HF)

Demographic & risk Total Group AP MI HF

factors (n= 6,380) (n= 2,110) (n= 2,350) (n= 1,920) p-value *
a,b,c
Age (years) 62.5 (11.3) 63.1 (10.2) 59.7 (11.4) 65.1 (11.5) <0.001
a,c
Male 75.2% 72.4% 75.9% 77.2% <0.001
¶ a,c
Hypertension 55.5% 63.9% 50.0% 52.7% <0.001
¶ a,b
Diabetes 20.9% 22.7% 15.4% 25.7% <0.001
¶ a,c
Hypercholesterol 59.5% 67.2% 57.7% 53.1% <0.001
a,c
Smoking 15.1% 13.3% 16.7% 15.1% <0.01
a,c
BMI 27.4 (5.0) 28.0 (5.0) 26.9 (4.7) 27.3 (5.3) <0.001
¶¶ b,c
Physical inactivity 69.9% 69.8% 65.4% 75.8% <0.001
Questionnaires
SF-36
a,b,c
PCS 39.1 (10.3) 37.9 (9.8) 43.1 (9.7) 35.5 (10.0) <0.001
MCS 47.1 (11.0) 46.8 (11.0) 47.4 (10.9) 47.1 (11.2) = 0.17
HADS
a,b,c
Anxiety 6.3 (4.1) 6.8 (4.0) 5.8 (4.1) 6.3 (4.2) <0.001
§ a,b,c
% anxious 34.6% 30.4% 38.6% 35.2% <0.001
a,b,c
Depression 5.1 (3.8) 5.3 (3.7) 4.4 (3.7) 5.8 (3.9) <0.001
§ a,b,c
% depressed 25.1% 25.7% 19.2% 31.8% <0.001

* p-value between-diagnosis with ANOVA (post-hoc Bonferroni correction; with non-homogeneous

variances, Welch’s F-statistic and post-hoc Games Howell correction) and Chi-square for
proportions
a, MI vs. AP; b, MI vs. HF; c, AP vs. HF
¶ As told by his/her physician;
¶¶ Active on <3 occasions per week
§ HADS score >7

20
Table 3. Candidate item pool (n=26) from the Seattle Angina, MacNew, Minnesota
Living with Heart Failure questionnaires and the items (n=14) included in the HeartQoL
questionnaire (physical and emotional subscales); % (proportion bothered); bother score
(mean); CIS ≥1.00 [clinical impact score; % * bother); H-values bi (bi-dimensional subscales)
and uni (uni-dimensional scale)

Candidate Pool Items % Bother CIS H-value H-value

score ≥1.00 bi uni
Physical subscale 0.56 --
Lift, move heavy objects, e.g., furniture,
children * 69.4 3.2 2.2 0.55 0.49
‡
Sports/exercise limited 69.9 2.9 2.0 0.52 0.47
¶
Tired, fatigued, low on energy 70.2 2.7 1.9 0.56 0.55
Walking > a block at a brisk pace * 57.7 2.9 1.7 0.60 0.52
‡
Physically restricted 62.3 2.6 1.6 0.53 0.49
Climb, flight stairs without stopping * 58.5 2.7 1.6 0.58 0.51
¶
Short of breath 54.0 2.9 1.6 0.53 0.48
Garden, carry groceries * 51.8 2.6 1.3 0.62 0.54
¶
House or yard work difficult 38.9 2.8 1.1 0.59 0.52
**
Walk indoors on level 11.7 2.2 0.26 0.52 0.46
Emotional subscale 0.54 --
¶
Worry 49.9 2.7 1.3 0.57 0.42
‡
Not relaxed 55.5 2.3 1.3 0.52 0.36
‡
Frustrated 48.8 2.6 1.3 0.51 0.38
¶
Feel depressed 40.0 2.6 1.0 0.58 0.42
H-value for uni-dimensional scale -- 0.47
Items >1.0 but not included
‡
Worn out 64.8 2.6 1.7
‡
Sex 44.7 3.2 1.4
¶
Sit or lie down 54.1 2.6 1.4
¶
Sleeping well at night difficult 47.0 3.0 1.4
‡
Restricted or limited 58.0 2.4 1.4
‡
Unsure about exercise 55.7 2.5 1.4
‡
Aching legs 52.8 2.6 1.4
‡
Chest pain 50.9 2.5 1.3
‡
Confident 49.3 2.5 1.3
¶
Difficult to concentrate, remember 41.6 2.7 1.1
‡
Happy with personal life 44.2 2.4 1.1
‡
Dizzy/lightheaded 45.5 2.3 1.0
* Seattle Angina item; ** Seattle Angina item included as an activity most patients were not
‡ ¶
bothered by; MacNew item; Minnesota Living with Heart Failure item

21
 Table 4. HeartQoL health-related quality of life questionnaire mean (± standard
deviation) scores in the total group and in patients with angina, myocardial infarction (MI),
or heart failure

Total Group Angina MI Heart p-value *

(n=6,384) (n=2,111) (n=2,351) failure
HeartQoL (n=1,922)
a,b,c
Physical score 2.2 (0.7) 2.2 (0.6) 2.4 (0.6) 2.0 (0.7) <0.001
a,b
Emotional score 2.4 (0.6) 2.3 (0.6) 2.4 (0.6) 2.3 (0.7) =0.003
a,b,c
Global score 2.2 (0.5) 2.2 (0.6) 2.4 (0.5) 2.1 (0.6) <0.001

p-value between diagnosis with ANOVA (post-hoc Bonferroni correction; in case of inhomogeneous
variances, Welch’s F-statistic and post-hoc Games Howell correction) and with Chi-square for
proportions

a, AP vs. MI; b, MI vs. HF; c, AP vs. HF

22

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