DALLAS, June 18 - People with heart disease who responded to a survey saying that they were limited by their symptoms and had a poor quality of life were more likely to suffer a heart attack or die, according to a report in today's rapid access Circulation: Journal of the American Heart Association.
Physical functioning (the ability to perform routine tasks), severity of symptoms and quality of life, are measures that scientists have often considered "soft" data, says the study's lead author John A. Spertus, M.D., M.P.H., an associate professor at the University of Missouri, Kansas City, and director of outcomes research at the Mid America Heart Institute. "This study shows that these measurements are not as 'soft' as one might think and they are associated with 'hard' end points, including hospitalization and death."
Spertus developed an instrument called the Seattle Angina Questionnaire (SAQ) to measure heart disease patients' perceptions of their quality of life. The SAQ is a 19-question survey that asks heart disease patients to what degree angina (chest pain) limits their physical activity; how often they have angina, and how it affects their quality of life. Patients' responses are scored on a scale of 0 to 100. Higher scores indicate less physical limitation, less angina and better quality of life.
This is the first study to use a disease-specific questionnaire to predict death and heart attack rates in patients with coronary artery disease, says Spertus.
"We spend a lot of time in medicine doing tests to figure out who is at the highest risk so we can be more aggressive in treating those patients. Here's a simple questionnaire that could be used for a similar purpose. "It is much easier to administer than a nuclear stress test, which can cost $1500 to $1800, and is best interpreted by highly experienced cardiologists.
"I wouldn't recommend it in lieu of other tests, but it is not practical to give patients a nuclear stress test every month. However, filling out this questionnaire every month or every three months is a very cost-effective way to monitor patients' health."
In an accompanying editorial, John S. Rumsfeld, M.D., Ph.D., director of cardiology and health sciences research, Denver Veterans Affairs Medical Center, Denver, Colo., says that it is becoming increasingly important for physicians to deliver more patient-centered care and this study speaks to that need.
"This article starts to show us that health status surveys, used in addition to other testing, may be clinically useful, in this case by helping us determine which patients with coronary disease are at highest risk," Rumsfeld says.
However, Rumsfeld adds, this is only the first step toward the routine measurement and use of a health status in clinical practice. "While this is an important first step, this study does not prove that using a health status survey in clinical practice will actually translate into improved patient outcomes. Studies are needed to pick up where this study leaves off and test whether surveys like this will improve the care we provide."
Patients in the study were followed for two years after completing the SAQs. Spertus and co-researchers reviewed the completed SAQs and one-year follow up data of 5,558 patients who had visited outpatient clinics in the Veterans Administration system. Basing their research on the 83 percent of those patients who completed the SAQ, they evaluated the association between patients' reported functional limitations, frequency of chest pain and quality of life to their risk of hospitalization and death from heart disease.
The researchers found that lower SAQ scores were associated with increased risk of death and hospital admissions related to their heart disease, even after taking into account patients' other risk factors, such as age, heart failure, diabetes and high blood pressure.
The study shows that the most limited patients (scoring from 0 to 24 on a 100-point scale) had a four-fold greater risk of dying compared with the least limited patients, even after controlling for other clinical risk factors such as age, heart failure, high blood pressure or diabetes.
Patients with scores from 25 to 49 were twice as likely to die within a year from heart disease as those who scored their symptoms as "minimal" (75 to 100). Patients who scored from 50 to 74 were 50 percent more likely to die within the year.
Those who reported at the start of the study that they had severe angina, meaning it occurred at least every day, had a 60 percent higher risk of dying than did patients whose angina was rated as minimal, occuring less than once a month or not at all. People rating their angina as moderate, meaning several times a week to every day, were 20 percent more likely to die, versus those with minimal angina.
The likelihood of being admitted to the hospital for a heart attack or threatened heart attack was 40 percent more for patients with mild angina; while those with moderate and severe angina were 2.0 and 2.2 times more likely to be admitted.
Co-authors of the study include: Philip Jones, M.S.; Mary McDonell, M.S.; Vincent Fan, M.D.; and Stephan D. Fihn, M.D., MPH.
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