Comparison of three quality of life instruments in stable angina pectoris: Seattle Angina Questionnaire, Short Form Health Survey (SF-36), and Quality of Life Index-Cardiac Version III

Comparative responsiveness of generic and specific quality-of-life instruments

We assessed the relative responsiveness of generic and specific quality of life instruments in 43 randomized controlled trials that compared head-to-head 31 generic and 84 specific instruments. Using weighted effect size as the metric of responsiveness, we assessed the impact of instrument type, disease category, and magnitude of underlying therapeutic effect on responsiveness, and assessed the responsiveness of specific instruments relative to the corresponding domains of generic measures. In studies with a nonzero therapeutic effect, specific instruments (mean = 0.57) were significantly more responsive than generic instruments (mean = 0.39, P =.01), and than the corresponding domains of generic instruments (mean = 0.40, P =.03). Studies with low, medium, and high therapeutic effects showed a corresponding gradation in responsiveness differences between specific and generic instruments. We conclude that, overall, specific instruments are more responsive than generic tools, and that investigators may come to misleading conclusions about relative instrument responsiveness if they include studies in which the magnitude of the underlying therapeutic effect is zero.

Neurocognitive sequelae following coronary artery bypass graft. A research agenda for behavioral scientists

Several studies have demonstrated that a sizeable proportion of patients undergoing coronary artery bypass graft (CABG) demonstrate persistent declines in cognitive functioning. However, several important questions remain regarding cognitive changes following CABG. First, can patients vulnerable to cognitive decline after CABG be identified, providing valuable information that can be factored into clinical decisions? Second, the specificity of CABG as a cause of cognitive decline, when compared to other coronary procedures such as percutaneous coronary interventions, has not been established. Third, what mechanisms account for the neurocognitive decline after CABG? Several mechanisms have been proposed to lead to post-CABG neurocognitive deficits, including pre-CABG neurocognitive deficits, physiological injury, psychosocial factors, and/or the patient's perceptual processes. Finally, no study has demonstrated that cognitive changes, as measured by neuropsychological tests, have ecological validity. Specifically, behavioral sciences research is needed to demonstrate that measured cognitive changes significantly impact health status independent of other risk factors.

Measuring disability-specific patient benefit in cochlear implant programs: developing a short form of the Glasgow Health Status Inventory, the Hearing Participation Scale

As healthcare resources are limited, evidence of program effectiveness is necessary. To demonstrate this, measurement should be conducted at the specific illness level, the generic health status level, and the utility level. Instruments need to be parsimonious to avoid cognitive overload, response burden, or participation refusal. Critical analysis of the Glasgow Hearing Status Inventory (GHSI) suggested that several items were redundant and the instrument could be shortened. We administered the GHSI and Assessment of Quality of Life (AQoL) instruments to 148 deafened adults with cochlear implants (CIs) and to 54 without CIs, as part of a cross-sectional study. We used standard psychometric procedures to examine the GHSI's structure, resulting in the removal of half of the items. The short version of the GHSI we labeled the Hearing Participation Scale (HPS), to avoid confusion with the GHSI. The HPS is an 11-item instrument measuring self-esteem, social handicap, and hearing handicap. Factor analysis suggested that each subscale was unidimensional. All items loaded on the principal component. Correlation with the GHSI was 0.95, suggesting that the two instruments could be used interchangeably. Both the HPS and the GHSI pro-vided evidence of monotonicity when used to predict AQoL scores. They were equally sensitive at differentiating between implantees and non-implantees. Although these findings need to be confirmed, the HPS is ready to be used in studies of interventions for deafness. At a time when evaluators are being asked for evidence of program effect, the parsimonious HPS achieves similar results to the GHS but requires half the items.

The value of patient-reported health status in predicting short-term outcomes after coronary artery bypass graft surgery

BACKGROUND

Risk stratification for comparison of outcomes after coronary artery bypass grafting (CABG) typically includes only clinical measures of risk. Patient-reported health status may be an important independent predictor of short-term health outcomes.

OBJECTIVE

To determine whether patient-reported health status, as measured by the Physical and Mental Component Summary scores of the SF-36, predicts in-hospital mortality and prolonged length of stay after CABG, after controlling for other clinical predictors of those outcomes.

RESEARCH DESIGN

Prospective cohort study conducted from September 1993 to November 1995.

SUBJECTS

One thousand seven hundred seventy-eight adults who underwent isolated CABG for myocardial ischemia.

MEASURES

In-hospital mortality and prolonged length of stay (> 14 days).

RESULTS

There were 27 deaths and 223 patients with prolonged length of stay in the study sample. A 10-point decrease in the Physical Component Summary (PCS) score increased the odds of in-hospital mortality by 61% (OR, 1.61; 95% CI, 1.04-2.49), independent of established clinical risk factors. Similarly, a 10-point decrease in the PCS score increased the odds of prolonged length of stay by 33% (OR, 1.33; 95% CI, 1.13-1.57). A 10-point decrease in the Mental Component Summary score (MCS) decreased the odds of mortality by 36% (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSIONS

The PCS score is independently and significantly associated with in-hospital mortality and prolonged length of stay, after controlling for clinical risk factors. The MCS score is independently and significantly associated only with mortality, though the direction of the effect is unexpected. The result likely reflects a property of the scoring of the MCS and not a finding of clinical substance. Although caution must be taken when interpreting the summary scores, the SF-36 yields information not otherwise captured by clinical data and may be useful in risk stratification for in-hospital mortality and prolonged length of stay after CABG.

Factors influencing health-related quality of life in cardiac rehabilitation patients

Associations of age, gender, cardiac procedure (coronary artery bypass grafting or percutaneous transluminal coronary angioplasty), risk stratification, and number of comorbidities with health-related quality of life (HRQL) were examined among 217 men and 84 women (mean age, 63+/-11 years) consecutively enrolled in a phase II cardiac rehabilitation program. Female gender and high-risk stratification were independently associated with impaired treatment gains in most areas of HRQL. Older age and having a greater number of comorbidities were also associated with impaired gains in specific areas. HRQL was generally lower at baseline but not post-treatment in coronary artery bypass grafting vs. percutaneous transluminal coronary angioplasty patients. Cardiac rehabilitation patients also had lower HRQL scores than an age-matched, normative sample at baseline (most areas) and post-treatment (mainly on role physical). Findings reinforce the need for cardiac rehabilitation programs to tailor assessments and risk factor modification strategies to patient characteristics associated with low levels of HRQL, especially in women and those with higher risk stratification.

Clinically important change in quality of life in epilepsy

BACKGROUND

Health related quality of life (HRQOL) is increasingly recognised as an important outcome in epilepsy. However, interpretation of HRQOL data is difficult because there is no agreement on what constitutes a clinically important change in the scores of the various instruments.

OBJECTIVES

To determine the minimum clinically important change, and small, medium, and large changes, in broadly used epilepsy specific and generic HRQOL instruments.

METHODS

Patients with difficult to control focal epilepsy (n = 136) completed the QOLIE-89, QOLIE-31, SF-36, and HUI-III questionnaires twice, six months apart. Patient centred estimates of minimum important change, and of small, medium, and large change, were assessed on self administered 15 point global rating scales. Using regression analysis, the change in each HRQOL instrument that corresponded to the various categories of change determined by patients was obtained. The results were validated in a subgroup of patients tested at baseline and at nine months.

RESULTS

The minimum important change was 10.1 for QOLIE-89, 11.8 for QOLIE-31, 4.6 for SF-36 MCS, 3.0 for SF-36 physical composite score, and 0.15 for HUI-III. All instruments differentiated between no change and minimum important change with precision, and QOLIE-89 and QOLIE-31 also distinguished accurately between minimum important change and medium or large change. Baseline HRQOL scores and the type of treatment (surgical or medical) had no impact on any of the estimates, and the results were replicated in the validation sample.

CONCLUSIONS

These estimates of minimum important change, and small, medium, and large changes, in four HRQOL instruments in patients with epilepsy are robust and can distinguish accurately among different levels of change. The estimates allow for categorisation of patients into various levels of change in HRQOL, and will be of use in assessing the effect of interventions in individual patients.

Factors associated with Short Form-36 outcomes in nonoperative treatment for ipsilateral fractures of the clavicle and scapula

Twenty consecutive patients with ipsilateral fractures of the clavicle and scapula were treated nonoperatively with immobilization and physical therapy. Results were evaluated using the Herscovici, Rowe, and Constant scoring systems and the Short Form-36 (SF-36) questionnaire. The average comprehensive SF-36 score was lower than the scores obtained using the other scoring systems. In the SF-36 questionnaire, physical scores were strongly associated with nonphysical scores (P<.001). No association was found between SF-36 physical scores and age (P=.37), fracture pattern (clavicle, P=.81; scapula, P=.18), fracture displacement (P=.18), or injury severity score (P=.52). Outcomes were found to relate more to nonphysical factors than to the physical injury.

The impact of peripheral and coronary artery disease on health-related quality of life

Vascular diseases, like peripheral arterial diseases (PAD) and coronary artery disease (CAD), are common diseases with a high morbidity. We investigated and compared the impact of these diseases on daily life using health-related quality of life (HRQOL) analysis. In 89 patients with PAD and 89 patients with multivessel CAD, the SF-36 was assessed before diagnostic staging and compared with an age-matched reference population. Both groups of patients had a significantly impaired HRQOL as compared to a reference population. Patients with PAD scored significantly (p < 0.001) lower than those with CAD on the domains general health perception, change in health, physical functioning, social functioning, and pain. Patients with PAD have a reduced HRQOL in comparison with patients with CAD. Each disease has an impact on a specific domain of the HRQOL. Vascular disease mainly influences physical health.

Is subjective well-being a useful parameter for allocating resources among public interventions?

Scarce public resources require trade-offs between competing programs in different sectors, and the careful allocation of fixed resources within a single sector. This paper argues that a general quality of life instrument encompassing health-related and non-health-related components is suitable for determining the best trade-offs between sectors. Further, this paper suggests that subjective well-being shows the properties crucial to a general quality of life measure and has additional advantages that makes it particularly useful for the allocation of public and health care resources. The paper argues that Western societies are in an unusually prosperous situation today which allows to concentrate efforts not only on reducing harm but also on improving positive states of health. Further, subjective well-being can be evaluated from the patient's perspective and incorporates a valuation of life expectancy. Criteria required for an appropriate questionnaire that measures subjective well-being are presented.

Magnetic resonance imaging demonstrates improved regional systolic wall motion and thickening and myocardial perfusion of myocardial territories treated by laser myocardial revascularization

OBJECTIVES

This study was designed to investigate the use of magnetic resonance (MR) functional and perfusion imaging to evaluate laser myocardial revascularization (LMR).

BACKGROUND

Most clinical studies of LMR have shown improvements in angina class and exercise capacity, with minimal or absent improvements in myocardial perfusion and function.

METHODS

Fifteen patients who underwent percutaneous Biosense-guided holmium:yttrium aluminum garnet LMR to areas of viable but ischemic myocardium were followed clinically and underwent functional and perfusion MRI at baseline, 30 days and 6 months.

RESULTS

The mean age was 64 +/- 11 years; four patients were women. The ejection fraction was 47.4 +/- 14.0%. Angina class at baseline was 3.4 +/- 0.6 and improved to 2.5 +/- 1.4 at six months (p = 0.054). Exercise time at baseline was 298 +/- 97 s and increased to 350 +/- 95 s at 30 days and 365 +/- 79 s at six months, p = 0.04. There were no significant changes in nuclear perfusion scans. Although MR determined that resting radial motion and thickening of the target wall were significantly less than normal at baseline (p < 0.001), they improved significantly during follow-up (wall thickening: baseline, 30.6 +/- 11.7%; day 30, 41.2 +/- 13.3% and day 180, 44.2 +/- 11.9%, p = 0.01). The size of the underperfused myocardial area was 14.5 +/- 5.4% at baseline and was reduced to 6.3 +/- 2.8% at 30 days and 7.7 +/- 3.7% at 6 months (p < 0.001).

CONCLUSIONS

This small phase I, open-label, uncontrolled study of MR functional and perfusion imaging in patients undergoing Biosense-guided LMR suggests a beneficial effect of this treatment strategy on myocardial function and perfusion. The efficacy of Biosense-guided LMR is being evaluated in a large phase II, randomized, blinded placebo-controlled trial with an MRI substudy (DIRECT).

Randomized trial of a medical food for the dietary management of chronic, stable angina

OBJECTIVES

We determined the electrocardiographic, vascular and clinical effects of a medical food bar enriched with L-arginine and a combination of other nutrients known to enhance endothelium-derived nitric oxide (NO) in patients with stable angina.

BACKGROUND

Enhancement of vascular NO by supplementation with L-arginine and other nutrients has been shown to have clinical benefits in patients with angina secondary to atherosclerotic coronary artery disease (CAD). However, the amounts and combinations of these nutrients required to achieve a clinical effect make traditional delivery by capsules and pills less suitable than alternative delivery methods such as a specially formulated nutrition bar.

METHODS

Thirty-six stable outpatients with CAD and class II or III angina participated in a randomized, double-blind, placebo-controlled, crossover trial with two treatment periods each of two weeks' duration (two active bars or two placebo bars per day). Flow-mediated brachial artery dilation was measured by ultrasound. Electrocardiographic measures of ischemia, exercise capacity and angina onset time were measured by treadmill exercise testing and by Holter monitor during routine daily activities. Quality of life was assessed by SF-36 and Seattle Angina Questionnaires and by diary.

RESULTS

The medical food improved flow-mediated vasodilation (from 5.5 +/- 4.5 to 8.0 +/- 4.9, p = 0.004), treadmill exercise time (by 20% over placebo, p = 0.05) and quality-of-life scores (SF-36 summary score; 68 +/- 13 vs. 63 +/- 21 after placebo, p = 0.04, Seattle Angina Questionnaire summary score; 67 +/- 10 vs. 62 +/- 18, p = 0.04) without affecting electrocardiographic manifestations of ischemia or angina onset time.

CONCLUSIONS

These findings reveal that this arginine-rich medical food, when used as an adjunct to traditional therapy, improves vascular function, exercise capacity and aspects of quality of life in patients with stable angina.

Effects of enhanced external counterpulsation on Health-Related Quality of Life continue 12 months after treatment: a substudy of the Multicenter Study of Enhanced External Counterpulsation

BACKGROUND

The Multicenter Study of Enhanced External Counterpulsation (MUST-EECP) was the first prospective, randomized, blinded, sham-controlled study of enhanced external counterpulsation (EECP) in the treatment of chronic stable angina. We previously reported that EECP therapy lengthens the time to exercise-induced myocardial ischemia and reduces angina. We now describe the effects of EECP therapy versus a sham-treated control group in terms of patients' functioning, their senses of well-being and other Health-Related Quality Of Life (HQOL) parameters from baseline to end of treatment and from baseline to 12 months after treatment.

OBJECTIVE

To determine whether a 35-hour course of EECP affects the HQOL of patients with symptomatic coronary artery disease, 12 months following treatment.

METHODS

Seventy-one of the 139 patients enrolled in MUST-EECP provided evaluable patient-completed questionnaires at baseline, at the end of treatment, and 12 months post-treatment. The Medical Outcomes Study 36-Item Short-Form Health Survey and the Quality of Life Index-Cardiac Version III were used to assess effects on HQOL.

RESULTS

Both groups had similar HQOL scores at baseline. At end of treatment and at 12-month follow up, patients who had active-CP reported greater improvement than those who had inactive-CP in all nine quality of life scales, including ability to perform activities of daily living, ability to work, bodily pain, confidence in health, energy, ability to engage in social activities with family and friends, anxiety and depression, and quality of life issues from the effects of angina on health and functioning. Despite small sample sizes, active-CP patients demonstrated significantly greater improvement at 12 months following treatment in bodily pain, social functioning, and quality of life specific to cardiac patients compared with inactive-CP patients.

CONCLUSION

Significant health-related quality of life improvements were measurable up to 12 months after the completion of treatment with EECP. Improvements in this controlled study are consistent with HQOL changes reported in case series and patient registries. Larger studies are warranted.

Reliability and validity of comprehensive health status measures in children: The Child Health Questionnaire in relation to the Health Utilities Index

This study assesses the feasibility, reliability and validity of the Child Health Questionnaire-Parent Form (CHQ-PF50), consisting of 11 multi-item scales covering the physical, emotional and social well-being of children. The Health Utilities Index mark 2 (HUI2) was selected for comparison. Parents of 467 Dutch schoolchildren (age 5-13) were sent CHQ and HUI questionnaires. A subgroup of 79 parents of children aged 10-11 were sent a retest after 2 weeks. Feasibility: 78% response with few missing/non-unique CHQ-answers (<1%). Internal consistency: Cronbach's alphas of.39-.96 (mean.72). Item-own scale correlations were higher than item-other scale correlations. Test-retest ICCs were statistically significant for all but two CHQ scales (ICCs.31-.84). Test-retest CHQ-scale means did not show statistically significant differences except for one scale ("Behavior").

VALIDITY

the CHQ-scales, with one exception, correlated better with predefined parallel HUI domains (ICCs.26-.53), than with non-parallel domains. Six CHQ scales discriminated clearly between children with and without chronic conditions and three scales discriminated between high and low medical consumption. This was at least equivalent to the discriminative ability of the HUI2 in this study. Additional studies of test-retest reliability and responsiveness to change of the CHQ in varied populations are needed. From the present study and literature data on other (clinical) populations we conclude that psychometric properties of CHQ-based health status measurement justify application in pediatric outcome studies, in addition to clinical measures.

Quality of life after balloon angioplasty or stenting for acute myocardial infarction. One-year results from the Stent-PAMI trial

OBJECTIVES

The goal of this study was to compare the impact of primary stenting or percutaneous transluminal coronary angioplasty (PTCA) on health-related quality of life (HRQOL) in patients undergoing direct angioplasty for acute myocardial infarction (AMI).

BACKGROUND

Previous studies have demonstrated that coronary stenting reduces clinical and angiographic restenosis compared with PTCA. However, the impact of stenting on HRQOL from the patient's perspective remains unknown.

METHODS

We administered the Seattle Angina Questionnaire and the Medical Outcomes Study Short-form Survey at 1, 6 and 12 months after initial treatment to all North American patients in the Stent-Primary Angioplasty for Myocardial Infarction trial (Stent-PAMI) (n = 509)-a randomized trial comparing primary stenting to conventional PTCA for patients with AMI.

RESULTS

At one month, most HRQOL measures were similar for the two groups, but stent patients reported less bodily pain than PTCA patients (p = 0.03). At six-month follow-up, stenting resulted in significant improvements in several dimensions of HRQOL including reduced anginal frequency and bodily pain as well as improved disease perception (all p < or = 0.03) and a trend towards better anginal stability (p = 0.056). By 12-month follow-up, however, none of these differences remained statistically significant. These differences in HRQOL were largely explained by the greater need for ischemia-driven target-vessel repeat revascularization procedures in PTCA patients during the first six months (16.0% vs. 6.2%, p < 0.001).

CONCLUSIONS

In patients undergoing revascularization for AMI, initial stent placement is associated with improvements in several dimensions of health status during the first six months of follow-up. In the absence of differences in mortality, these findings add to the overall argument in favor of initial stenting in patients treated with mechanical reperfusion for myocardial infarction.

The UK version of the Seattle Angina Questionnaire (SAQ-UK): reliability, validity and responsiveness

The study assesses the reliability, validity and responsiveness of the UK version of the Seattle Angina Questionnaire (SAQ-UK). The instrument was anglicised and administered by self-completed postal questionnaire to 959 patients recruited from general practices in the North East of England. A total of 655 (68.3%) patients returned a completed questionnaire. Principal component analysis produced three important dimensions: physical limitations, anginal frequency and perception and treatment satisfaction. Four items that performed poorly were removed from the instrument. The removal of items greatly increased the number of computable scale scores. Estimates of internal reliability for the three dimensions ranged from 0.83-0.92. Estimates of test-retest reliability were above accepted standards. The correlation between the SAQ-UK scores and the SF-12, EuroQol and health transition was evidence for the validity of the instrument. The SAQ-UK produced responsiveness statistics that were comparable to the parent instrument and was more responsive to improvements in health than the generic instruments. The SAQ-UK is recommended as a measure of health outcome for the evaluation of angina management.

Development and validation of the ITG Health-Related Quality-of-Life Short-Form measure for use in patients with coronary artery disease. Integrated Therapeutics Group

BACKGROUND

Available coronary artery disease (CAD)-specific health-related quality-of-life (HRQL) measures are not ideally suited for routine clinical practice. We report development of a valid and reliable CAD-specific short-form measure.

HYPOTHESIS

The Integrated Therapeutics Group (ITG) CAD-specific short-form HRQL measure is reliable and valid for assessing the health status of patients with CAD.

METHODS

In all, 409 patients (mean age 62.4 years) completed the 24-item CAD-specific HRQL questionnaire. Factor analysis was used to identify the scaling of the 24 CAD-specific items. Analysis of variance was used to reduce the number of items within each scale, and reliability (Cronbach's alpha), discriminant validity, and ceiling and floor effects of short-form scales were evaluated. Short-form scales were compared with the longer scales using relative validity coefficients. The CAD severity was assessed using New York Heart Association criteria, physician assessment, electrocardiogram results, the number of myocardial infarctions, and the number of CAD-specific medications. Clinical validity of short-form scales was then assessed based on their ability to discriminate across severity levels of these clinical criteria.

RESULTS

Four scales were identified: Extent of Chest Pain, Functioning and Well-Being, Activities Level-Physical, and Activities Level-Social. The 24-item questionnaire was reduced to a 13-item short form, with reliability exceeding 0.70 for all four scales. Relative validity estimates comparing short-form to original scales ranged from 0.68 to 2.58. Mean scores varied significantly (p < 0.05) by clinical severity, supporting the discriminant validity of the ITG CAD short-form scales.

CONCLUSIONS

The ITG CAD short form (used alone or with a general HRQL measure) is valid and practical for assessing patients with CAD.

Assessing sexual functioning in patients with chronic disorders by using a generic health-related quality of life questionnaire

This study was an assessment of sexual functioning by making cross-sectional surveys of patients aged 45 84 years with chronic disorders; 397 had diabetes, 248 had glaucoma and 1914 had chronic, stable, angina pectoris; 1669 came from a standard population sample (SPS). Sexual functioning was assessed on one scale from the Swedish health-related quality of life survey (SWED-QUAL), adapted from the medical outcomes study (MOS). Both sexual functioning in general and specific sexual items were studied. Values were adjusted for non-respondents and standardised to the Swedish population. Response rates in the samples were 54-64% among men and 22-41% among women, decreasing with age for women. General sexual functioning decreased with age and was most apparent in patients with diabetes and angina pectoris, while glaucoma patients reported better results than the SPS. Loss of male erectile function was as common in diabetes (30%) as in angina pectoris (29%) and significantly higher than in the SPS (20%) (p < 0.001). Besides age, significant factors for erectile dysfunction were, in diabetes, the presence of microvascular complications, treatment with long-acting nitroglycerine and psychiatric disease, and in angina, the presence of diabetes and peripheral artery disease.

Changes in the quality of life: a major goal of cardiac rehabilitation

BACKGROUND

Quality of life (QOL) is a major goal in the context of preventive and therapeutic cardiology. In this article, quality of life concepts are reviewed, factors limiting QOL in cardiac disease are identified, methods of measurement are explored, and clinically significant changes are defined. The changes effected by cardiac rehabilitation are considered, together with their physiological and psychological correlates. A final section suggests avenues for future research.

METHODS

Relevant articles were identified by computer literature searches and review of extensive personal files.

FINDINGS

In the past, there has been an excessive focus on extending the length rather than the quality of the cardiac patient's life. The overall QOL is a broad concept, influenced by personal perceptions, coping mechanisms, and environmental constraints. The ideal test instrument would be reliable, valid, and responsive to clinical change. Potential options include a Gestalt-type instrument, a disease-specific instrument, a function-specific instrument, or a detailed generic questionnaire. There have been relatively few comparisons between these potential approaches. Currently, the Standard Gamble (Gestalt-type), and Living With Heart Failure Questionnaire (disease-specific type), and the Medical Outcomes Study Short-Form 36 (SF-36) Health Survey (generic-type) are among the most popular approaches. Problems arise in distinguishing a clinically important from a statistically significant change; commonly a score change of 1 standard error of the mean is regarded as clinically important. Correlations of scores with clinical, physiological, and psychological change are sometimes weak, in part because of floor and ceiling effects. Nevertheless, potential gains in QOL provide a stronger argument for preventive and therapeutic programs than do increases in longevity.

CONCLUSIONS

The current literature supports the value of QOL measurements in the management of patients with cardiac disease. However, further research is needed to determine the optimum test instrument, and the best method of interpreting resultant scores.

Intracoronary basic fibroblast growth factor (FGF-2) in patients with severe ischemic heart disease: results of a phase I open-label dose escalation study

OBJECTIVES

Evaluate the safety, tolerability and preliminary efficacy of intracoronary (IC) basic fibroblast growth factor (bFGF, FGF-2).

BACKGROUND

FGF-2 is a heparin-binding growth factor capable of inducing functionally significant angiogenesis in animal models of myocardial ischemia.

METHODS

Phase I, open-label dose-escalation study of FGF-2 administered as a single 20-min infusion in patients with ischemic heart disease not amenable to treatment with CABG or PTCA.

RESULTS

Fifty-two patients enrolled in this study received IC FGF-2 (0.33 to 48 microg/kg). Hypotension was dose-dependent and dose-limiting, with 36 microg/kg being the maximally tolerated dose. Four patients died and four patients had non-Q-wave myocardial infarctions. Laboratory parameters and retinal examinations showed mild and mainly transient changes during the 6-month follow-up. There was an improvement in quality of life as assessed by Seattle Angina Questionnaire and improvement in exercise tolerance as assessed by treadmill exercise testing (510+/-24 s at baseline, 561+/-26 s at day 29 [p = 0.023], 609+/-26 s at day 57 (p < 0.001), and 633+/-24 s at day 180 (p < 0.001), overall p < 0.001). Magnetic resonance (MR) imaging showed increased regional wall thickening (baseline: 34+/-1.7%, day 29: 38.7+/-1.9% [p = 0.006], day 57: 41.4+/-1.9% [p < 0.001], and day 180: 42.0+/-2.3% [p < 0.001], overall p = 0.001) and a reduction in the extent of the ischemic area at all time points compared with baseline.

CONCLUSIONS

Intracoronary administration of rFGF-2 appears safe and is well tolerated over a 100-fold dose range (0.33 to 0.36 microk/kg). Preliminary evidence of efficacy is tempered by the open-label uncontrolled design of the study.

A comparison of four quality of life instruments in cardiac patients: SF-36, QLI, QLMI, and SEIQoL

BACKGROUND

With the increasing use of quality of life measures in evaluations of cardiac interventions, criteria are needed for selecting appropriate quality of life measures. An important criterion is the sensitivity of a measure for detecting clinically important changes.

OBJECTIVES

To compare the sensitivity of four measures when used in a group of cardiac patients undergoing the same intervention.

METHODS

The short form 36 (SF-36), the quality of life index-cardiac version (QLI), the quality of life after myocardial infarction questionnaire (QLMI), and the schedule for the evaluation of individual quality of life (SEIQoL) were used to evaluate quality of life in a group of 22 patients after myocardial infarction or coronary artery bypass graft (CABG), at the beginning of rehabilitation and six weeks later. Analysable data were obtained from 16 patients.

RESULTS

A significant improvement over time was only observed for the SF-36 subscale, vitality (p < 0.05). Five of the eight SF-36 subscales and one of the four QLMI subscales showed modest sensitivity (index: > 0.2 and < 0.5), while all other subscales showed poor sensitivity (index: < 0.2). Using SEIQoL, family was most often nominated as an area of importance to quality of life (n = 13), followed by health (n = 10), leisure/hobbies (n = 8), marriage (n = 8), and work (n = 6).

CONCLUSIONS

All four QOL measures used in this study were found to lack sensitivity to change. Further research is needed using other cardiac populations and interventions in order to verify these findings, with a view to developing more sensitive quality of life scales.

Health-related quality of life and post-traumatic stress disorder in patients after cardiac surgery and intensive care treatment

OBJECTIVES

Health-related quality of life and patient satisfaction have become important end points in cardiac surgery. Post-traumatic stress disorder has been described in patients with life-threatening heart disease. In this study, we investigated the occurrence of post-traumatic stress disorder in a sample of patients after cardiac surgery and compared health-related quality of life and patient satisfaction between patients with and without evidence of post-traumatic stress disorder.

METHODS

We studied 80 patients serially admitted to the intensive care unit after cardiac surgery (bypass grafting, n = 51; aortic valve replacement, n = 29). Health-related quality of life was assessed with the use of the SF-36 Health Status Questionnaire. Post-traumatic stress disorder was measured with a previously validated instrument (the Post-Traumatic Stress Syndrome 10-Questions Inventory), and 20 different aspects of life satisfaction were quantified on a scale ranging from 0 to 10. For measurements of health-related quality of life and post-traumatic stress disorder, age- and gender-comparable healthy individuals, as well as patients with cardiovascular diseases, served as control groups.

RESULTS

Patients who had cardiac surgery described high life satisfaction summary scores (156 of a maximum of 200 points) and only small impairments in physical and mental SF-36 summary scores when compared with healthy control groups (median reduction 7.15, P <.05). Patients with evidence of post-traumatic stress disorder (n = 15) reported the lowest SF-36 mental health summary scores when compared with patients without stress disorder (38.3 vs 48.4, P =.004) and rated their life satisfaction lower (121.5 vs 162.0, P =.002).

CONCLUSIONS

Patients who have had cardiac surgery demonstrate a high life satisfaction with an acceptable degree of physical and mental health-related quality of life. Impairments in psychosocial function and life satisfaction were found in a subgroup of patients with evidence of post-traumatic stress disorder.

Measuring the health related quality of life of people with ischaemic heart disease

OBJECTIVES

To inform researchers and clinicians about the most appropriate generic and disease specific measures of health related quality of life for use among people with ischaemic heart disease.

METHODS

MEDLINE and BIDS were searched for research papers which contained a report of at least one of the three most common generic instruments or at least one of the five disease specific instruments used with ischaemic heart disease patients. Evidence for the validity, reliability, and sensitivity of these instruments was critically appraised.

RESULTS

Of the three generic measures-the Nottingham health profile, sickness impact profile, and short form 36 (SF-36)-the SF-36 appears to offer the most reliable, valid, and sensitive assessment of quality of life. However, a few of the SF-36 subscales lack a sufficient degree of sensitivity to detect change in a patient's clinical condition. According to the best available evidence, the quality of life after myocardial infarction questionnaire should be preferred to the Seattle angina questionnaire, the quality of life index cardiac version, the angina pectoris quality of life questionnaire, and the summary index. Overall, research on disease specific measures is sparse compared to the number of studies which have investigated generic measures.

CONCLUSIONS

An assessment of the quality of life of people with ischaemic heart disease should comprise a disease specific measure in addition to a generic measure. The SF-36 and the quality of life after myocardial infarction questionnaire (version 2) are the most appropriate currently available generic and disease specific measures of health related quality of life, respectively. Further research into the measurement of health related quality of life of people with ischaemic heart disease is required in order to address the problems (such as lack of sensitivity to detect change) identified by the review.

Comparison between the GHQ-28 and SF-36 (MH 1-5) for the assessment of the mental health in patients with ischaemic heart disease

OBJECTIVE

To assess the mental health of patients admitted to hospital with suspected ischaemic heart disease, by means of two instruments, the General Health Questionnaire (GHQ-28) and the MH (1-5) dimension of the SF-36 Health Survey Questionnaire, and to compare the psychometric properties of both questionnaires in this population.

METHODS

A study was conducted of 185 patients consecutively admitted to hospital with suspected ischaemic heart disease, classified into four groups: Acute Myocardial Infarctus (AMI), unstable angina, non-ischaemic cardiologies, and non-cardiological conditions. Their mental health was assessed by means of the GHQ-28 and the MH 1-5 sub-scales of the SF-36; the validity of the results were analysed by the association of each instrument with socio-demographic (age, sex, social class, and educational level) and clinical (co-morbidity, risk factors, diagnostic groups and background to the illness) variables. The correlation of each instrument with other sub-scales of the SF-36 was studied. The internal consistency was measured by Cronbach's alpha, together with the item-internal consistency and item-discriminant validity.

RESULTS

Of the population studied, 71.9% were males and the mean age was 60.2 years (SD: 10.4). The diagnosis for 33.5% was AMI and for 37.8% unstable angina. For all the variables studied, the scores in the two instruments were ordered in the same way, and were significantly worse for females and for the most disadvantaged social class. None of the scales discriminated in respect of the diagnostic group or the presence of comorbidity. However, a linear relationship was observed with risk factors. Cronbach's alpha was 0.95 for the GHQ-28 and 0.80 for the MH 1-5. Correlations with the other dimensions showed ranges of -0.35 to -0.61 for the GHQ-28 and of 0.26 to 0.61 for the MH 1-5. These were highest for the Vitality and Social Functioning sub-scales in both instruments.

CONCLUSIONS

The subjective perception of mental health is measured in a similar way by both the MH 1-5 scale of the SF-36 and the GHQ-28. However, since the MH 1-5 questionnaire is shorter, it should be administratively easier to introduce into routine cardiological practice.

Quality of life after coronary angioplasty or continued medical treatment for angina: three-year follow-up in the RITA-2 trial. Randomized Intervention Treatment of Angina

OBJECTIVES

We sought to evaluate the impact of percutaneous transluminal coronary angioplasty (PTCA) and medical treatment on self-perceived quality of life among patients with angina.

BACKGROUND

The second Randomized Intervention Treatment of Angina trial (RITA-2) implemented initial policies of PTCA or continued medical treatment in patients with angina, allowing assessment of long-term health consequences.

METHODS

A total of 1,018 patients were randomly assigned (504 to PTCA and 514 to medical treatment). The short form 36 (SF-36) self-administered quality-of-life questionnaire was completed at randomization and three months, one year and three years later. To date, 98% of patients reached one year and 67% reached three years.

RESULTS

The PTCA group had significantly greater improvements in physical functioning, vitality and general health at both three months and one year, but not at three years. These quality-of-life scores were strongly related to breathlessness, angina grade and treadmill exercise time both at baseline and at one year. The treatment differences in quality of life are explained by the PTCA group's improvements in breathlessness, angina and exercise time. The attenuation of treatment difference at three years is partly attributed to 27% of medically treated patients receiving nonrandomized interventions in the interim. For both groups, there were also improvements in ratings of physical role functioning, emotional role functioning, social functioning, pain and mental health, but for these the superiority of PTCA over medical treatment was less pronounced. After one year, 33% and 22% of the PTCA and medical groups, respectively, rated their health much better.

CONCLUSIONS

Coronary angioplasty substantially improves patient-perceived quality of life, especially physical functioning and vitality, as compared with continued medical treatment. These differences are attributed to alleviation of cardiac symptoms (specifically, breathlessness and angina), but must be balanced against the small procedure-related risks of PTCA.

Selecting a measure of health related quality of life

Quality of life is becoming recognized increasingly as an important outcome measure which needs to be considered by social workers. However, there does not appear to be a clear consensus about the definition of quality of life. In addition, social workers are likely to experience difficulties choosing and applying an appropriate instrument with which to measure quality of life because of the many available instruments purporting to assess quality of life. This paper discusses the definition of health-related quality of life and explains the main measurement properties of an instrument that must be appraised when considering whether or not an instrument is appropriate. The paper will assist social workers to make an informed choice about measures of health-related quality of life.

Quality of life comparisons after coronary angioplasty and coronary artery bypass graft surgery

OBJECTIVE

To examine the differences in realization of expected benefits, complications, and quality of life (QOL) 3 months after percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery.

DESIGN

Nonexperimental, prospective, and comparative. Before discharge, participants listed benefits expected from the procedure, as well as comorbid health problems (Charlson Comorbidity Index) and complications. At 3 months, they quantified their realization of expected benefits, reported postdischarge complications, and completed Ferrans and Powers' Quality of Life Index-Cardiac Version III.

SAMPLE

36 patients who had PTCA; 38 patients who had CABG.

RESULTS

There were no differences between groups in realization of expected benefits or QOL. Patients who had CABG reported a greater number of complications after discharge, and a greater proportion of patients who had PTCA reported angina. Patients who had PTCA and then recurrent angina had significantly lower health QOL and psychologic and spiritual QOL.

CONCLUSIONS

Patients who undergo CABG need guidance regarding what complications to expect, and patients who undergo PTCA need to know that recurrent angina is possible and how to manage it.