Parametry jakości życia u pacjentów z współwystępującą stabilną chorobą niedokrwienną serca oraz przewlekłą obturacyjną chorobą płuc

Lesia V. Rasputina, Daria V. Didenko, Maria V. Ovcharuk

National Pirogov Memorial Medical University, Vinnytsia, Ukraine

ABSTRACT

Introduction: The part of patients with comorbide pathology, which includes ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD), increases among patients aged 40 and older. Combination of diseases has a great influence on patients’ quality of life (QOL).

The aim of the work was investigation of features of QOL parameters in patients with combination of stable IHD and COPD

Materials and methods: 272 patients have been studied; they have been divided into three groups: group I included 98 patients with combination of stable IHD and COPD, the average age 65.8±0.83 years, group II – 96 patients with stable IHD, the average age 58.9±0.9; group III consisted of 78 patients with COPD without IHD, the average age 57.9±0.85 years. Typical clinical examination, 6-minute walking test (6 MWT) and evaluation of QOL parameters with health survey questionnaire MOS SF 36 have been conducted.

Results: Patients with combination of stable IHD and COPD have decreased all life quality indices in comparison with patients of groups II and III: physical health in group I was 33.5 points, mental health – 27.5, general health – 50.3 points. QOL parameters in group I corelate with the doctor’s visit rate and the number of, hospitalizations and emergency calls. Significantly lower exercise tolerance (distance 336.8±40.8 m per 6 minutes) has been established in group I, as well as marked dyspnea (р=0,003), tachycardia (р=0,017) and a tendency towards blood pressure decrease during exercises (р=0,013).

Conclusions: Combination of IHD and COPD is accompanied by worsening of QOL parameters, which should be estimated in clinical practice. Combination of IHD and COPD is associated with requirement of hospital treatment (5.2 times in 5 years) and emergency aid (once a year), that distinguish such patients from patients with isolated IHD or COPD. Patients with combined diseases often need outpatient care, 70.4% – more than 3 times per year.

Wiad Lek 2018, 71, 8, -1565

Introduction

Among patients aged 40 and older the part of patients with comorbide pathology, including patients with ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) increases. Combination of these pathologies significantly modifies both diseases, complicates timely diagnostics, increases the risk of complications and influences the patients’ QOL. With combined development of COPD and IHD the number of exacerbations and the rate of hospitalizations grow due to different reasons [1,2].

Patients’ QOL is an important criterium of assessing the patient’s condition and treatment efficiency [3,4,5]

For assessing patients’ QOL various specific questionnaires are used: questionnaire MacNew for patients with heart diseases; questionaries for patients with chronic heart failure (CHF) (Chronic Heart Failure Questionnaire (CHFQ), Minnesota Living with Heart Failure Questionnaire (MLHFQ, Left Ventricular Dysfunction Questionnaire, Quality of Life Questionnaire in Severe Heart Failure (SHF)[6], questionnaire HeartQoL for IHD patients has been recently developed[5].

Questionnaire MOS SF 36 (Medical Outcomes Study Short Form-36) developed at the USA Health Institute and adapted to Ukraine [3] is universal one. It is used for assessment of PQL with different diseases and makes it possible to conduct complex assessment of QOL. This questionnaire is also frequently used by researches for assessment of IHD patients [5,6].

For majority of IHD patients reduced parameters of QOL are found; the level slightly differs depending on disease development, undergone PCI and coronary artery bypass surgery, presence of HF.For example, physical and psychological components of QOL assessed with MOS SF36 questionnaire in patients with stable angina pectoris constitute about 39 and 49 points respectively, in patients with Ischemic HF – 35 and 49 points respectively [6].

For assessment of QOL in patients with COPD the respiratory questionnaire of St.George’s hospital SGRQ (St. George’s Respiratory Questionnaire) and MOS SF 36 Q are widely used [3,7]. A number of researches have established, that the LQ of patients with COPD are mostly influenced by intensity of dyspnea, the number of exacerbations over the year, depression, concomitant IHD and low body mass index (BMI) [7,8]. The research, which included over 700 patients from 5 European countries has proved that the highest number of points of dyspnea (over 2 according to scale of mMRC) is connected to significant function disorders of the patient according to all indexes of health profile MOS SF 36 [9]. The results of the research of QOL of COPD patients in France have shown that patients with stable COPD development and adequate basic therapy have a low LQ level irrespective of severity of disease assessed by physicians [4].

Clinical signs of combined COPD and IHD have certain clinical and functional particularities, so QOL parameters in this group of patients can also be quite different.

The aim

The aim of researchto determine particularities of patients of QOL with IHD and COPD and to assess connection between QOL parameters and disease development.

Materials and methods

272 patients were studied, they were divided into 3 groups : group 1 included 98 patients with combination of stable IHD and COPD, group II – 96 patients with stable IHD, the average age 58.9±0.9 years: group III consisted of 78 patients with COPD without IHD, the average age 57.9±0.85 years ( Table I). The diagnosis of IHD was established according to European Society of Cardiologists (ESC) 2013 [10], IHD was confirmed by the results of coronarography or the results of undergone Q-myocardial infarction or revascularization. COPD was determined according to GOLD 2017 [8]. In all the study groups men prevailed , patients of group I were older in comparison with groups II,III.

The majority of patients in all groups had overweight or obesity, significant difference by BMI was not determined. A difference by the number of smokers was found – the biggest number of smokers was in group 1 – 70 (71.4 %). Patients of group 1 had the longest term of IHD (7,4 years), COPD of group 3 had the term of disease 8.7 years. The examined groups were representative by nosolological IHD forms, clinical COPD groups and presence of concomitant pathology.

All the patients underwent general clinical investigation, questionairing according to modified scale of dyspnea severity (mMRC) and the test of assessment COPD (CAT), computer spirometry (Master Scope CT), echocardiography (EchoCG) (Logiq-500’’,GE, USA) daily monitoring of ECG (DiaCard 03500, Solveig, AOZT Kyiv), assessment of QOL using adapted for Ukraine version MOS SF 36 [3], test with 6-minute walk of the American College of Sports Medicine (6 MWT American College of Sports Medicine, ACSM, 2006) to evaluate tolerance to physical exertion.

Questionnaire MOS SF 36 contains 36 questions, combined into scales : physical activity (PhA), role of physical problems in limitation of life activity (PhR), pain (P), general health (GH), stamina (S), social activity (SA), the role of emotional problems in limiting of life activity (RE), psychic health (PH), comparison of state of health with that of the previous year (CS).

PhA, PhR and P- correspond to the physical compound of health, SA, RE and PH – characterize psychological compound, S and GH- are correlated with both components , PH – makes it possible to see the dynamics of heath over the year. The maximal number of points for all the scales is 100, with characterizes the best health.

Statistical data analysis was done with the help of statistical program set STATISTICA 10.0 and Microsoft Excel. The results are given as «average number + standard overage number error (M±m), median and interquartile range between 25 і 75 percentile.

Significant difference of number frequency was estimated by χ²criterium, data of frequency characteristics were estimated using non parametric method by Kruscala Wallis and U-test Mann Whitney in case of abnormal distribution of numbers and by Student t-criterium in case of normal number distribution. Estimation of connections between characteristics was done using Candal correlation analyses. Statistically significant were considered the results of comparisons by error probability (Р)<0,05.

Results and discussion

Comparative analyses of the received data have shown significant differences in IHD and COPD patients from patients with isolated development of these diseases. For instancew, patients with combined pathology (group 1) required hospitalization in general practice department over the last 5 years significantly more often -5.2 times in overage, that is about 1 time per year, while IHD patients without CJPD and COPD patients were hospitalized about 4 and 3 times respectively 1-2=0,14, р1-3<0,001, р2-3=0,018) (Fig. 1)

The number of ambulance calls over the year also differs. The majority of calls were made by IHD and COPD patients (1 call a year average) , a little less IHD patients (0,69 times), and the least COPD patients (0,52 times )(р1-2=0,16, р1-3<0,001, р2-3=0,038).

It has been established that IHD and COPD patients due to different reasons attended outpatient department much more often than patients of the compared groups. Only 9 (9,2%) patients with both pathologies called the doctor 1 or less times over the year (р1-2=0,13, р1-3=0,36, р2-3=0,63), 20 patients – 2 times (20,4%) (р1-2=0,004, р1-3=0,18, р2-3=0,12), 23 patients – 3 times (23,5%), in this group the number of patients, who called the doctor 4 times grows to 22 (22,4%) (р1-2=0,14, р1-3=0,43, р2-3=0,46) and 24 patients -5 times (24,5%)(р1-2=0,004, р1-3=0,18, р2-3=0,12). At the same time among IHD patients without COPD and COPD patients without IHD statistically significant difference in the rate of patients’ calls has not been found (Fig. 2).

With the aim of evaluating tolerance to physical exertion we have conducted 6 MWTs in different studied groups. The results of the tests indicate a probable decrease of the distance covered by patients with both pathologies in comparison with IHD patients. (the average distance of the 1 group 336 m, p1-2=0,007) a more pronounced dyspnea by Borg scale – 5 points (р1-2=0,003), a bigger growth of the heart rate (HR) – 20 beats per minute (р1-2=0,017) and a much slower growth of blood pressure (BP) – 4 mmHg. (р1-2=0,013, р1-3=0,011), and in some cases a lowering of BP which testifies to a pathological type of reaction of cardio-vascular system to physical exertion. (Table II).

By comparing the results of patients of other groups it has been found that COPD patients are more prone to intensive dyspnea and tachycardia than patients of IHD group, though the covered distance was practically the same.

The analysis of QOL parameters has shown lower results of patients of all groups, but a statistically significant worse result had patients with both IHD and COPD groups in comparison with IHD or COPD patients. A statistically significant difference was not found only when we took into account emotional problems in limited life activity (Table III). The results indicate a significant influence of both pathologies on the changes of physical and psychological status, more specifically patients of group 1 have more limited physical activity (PhA 44,4 points), the role of physical problems in limitation of physical activity is more pronounced (PhR 0 points, the low index shows a very limited everyday activity) the pain limits the activity of patients (P 45 points, the low number testifies to a bigger influence of pain) , social functioning is damaged due to physical and emotional condition (SF 62 points).

The level of mental health is also lowered which testifies to predominance of depressive troubled conditions (GH 51 points), everyday activity is limited by emotional problems ( RE 50) , patients feel weakness tiredness more often (S 30 points, the low number indicates lowering of heath activity energy), these patients estimate their health condition and prospects of treatment worse (HC 30) and speak of worsening of their health incomparison with the previous year ( CS 25 points).

The numbers of the summary scales demonstrate a probable decreasing of the physical status (PhS) of I group patients – 33,5 points, the number in group II is 45, group III -59 points (р1-2,1-3<0,001). Psychical status (PS) of patients of the group I is changed even more than the physical status and constitutes 27.5 points, group II – 45 points, group III – 42.5 points (р1-2,1-3<0,001).The level of general status (GS) in group I is 50.3 points, group II – 76.8 points, group III -79.7 points (р1-2=0,001, р1-3=0,002). It is worth noticing that patients with isolated IHD had a bigger influence of pain syndrome as compared to patients with isolated COPD (P 57 and 80 points respectively, р<0,001), all the other numbers in these groups are comparable.

In the group with both pathologies PhS was most correlated with the intensity of dyspnea by mMRC (Kendall tau=-0,51, р<0,001) and the CAT number (Kendall tau=-0,41, р<0,001). A little weaker feedback of PhS was established with respiratory rate (Kendall tau=-0,24, р=0,0017), with functional class HF by NYHA ( Kendall tau=-0,23, р=0,002), concentrated hypertrophy of the left ventricle (LV) by EchoCG (Kendall tau=-0,21, р=0,034) and the rate of calls to the family doctor 4 times per year ( Kendall tau=-0,23, р=0,003) The Positive connection of PhS was established with normal geometry of LV (Kendall tau=0,26, р=0,007).

For Patients with both IHD and COPD the closest correlation of PhS was established with mMRC number (Kendall tau=-0,33, р<0,001) and CAT number (Kendall tau=-0,44, р<0,001) that is the harder dyspnea and COPD manifestations, the more suffered the psychic link of QOL. Less intensive feedback was established with the width of inter ventricular septum (WIVS)(Kendall tau=-0,25, р=0,04), the index of the mass of LF myocardium (iMMLV)(Kendall tau=-0,26, р=0,03), the presence of eccentric LV hypertrophy by EchoCG (Kendall tau=-0,23, р=0,03), the number of pairs of ventricle premature beats per day (Kendall tau=-0,21, р=0,03). An average strong feedback with the number of ambulance calls has been found (Kendall tau=-0,26, р<0,001) and weak feedback – with more frequent outpatient calls (4,5 and more times per year), hospitalization rate. A weak positive correlation PhS has been found with outpatient calls only 1 or less times per year (Kendall tau=0,2, р=0,009) and normal geometry of LV (Kendall tau=0,21, р=0,026).

An average feedback of average strength of GS with both pathologies with mMRS number has been found (Kendall tau=-0,31, р<0,001) and CAT (Kendall tau=-0,39, р<0,001), ratio of E/A (Kendall tau=-0,29, р=0,035), the connection was weak with mature age, duration of COPD, frequent outpatient calls and hospitalizations.

Conclusions

1. For patients with both IHD and COPD statistically significant decreasing of QOL parameters by MOS SF 36 has been found, particularly PhS, PS and GS(33,5; 27,5; 50,3 respectively). The conducted analyses included patients of compared groups and has included and found signs of higher QOL, which testifies to the influence on patients QOL.

2. The QOL indexis for IHD and COPD patients have feedback correlation intensity of dyspnea by mMRC, CAT points, the rate of outpatients call to the doctor, the number of hospitalizations and ambulance calls, signs of remodelling of LV by EchoCG data.

3. Combination IHD and COPD is associated with bigger need of patients for hospitalization (the average number 5,2 times per 5 years), outpatient and emergency medical help (1 ambulance call per year), than patients with isolated IHD and COPD development.

The prospects of further scientific
researcher.

The prospects of this research are establishment of mutual relationship of functional parameters of the cardiovascular system and Quality of Life of patients with both IHD and COPD, evaluation of tolerance to physical exertion depending on clinical and functional parameters of the cardiovascular system and the respiratory function , as well as evaluation of the mutual influence of the tolerance to exertion and QOL parameters.

REFERENCES

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2. Andell, P., Koul, S., Martinsson, A., Sundström, J., Jernberg, T., Smith, J., James, S., Lindahl, B. and Erlinge, D. (2014). Impact of chronic obstructive pulmonary disease on morbidity and mortality after myocardial infarction. Open Heart, 1(1), p.e000002.

3. Feshchenko, Y.I., Mostovoy, Y.M., Babiychuk Y.V. (2002). Procedure of adaptation of international MOS Short Form Health Survey(SF-36) in Ukraine. Experience of practice in patients with bronchial asthma. Ukrainskuy pulmonologichnuy zhurnal, 3, pp.9-11.

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5. Oldridge, N., Höfer, S., McGee, H., Conroy, R., Doyle, F. and Saner, H. (2012). The HeartQoL: Part II. Validation of a new core health-related quality of life questionnaire for patients with ischemic heart disease. European Journal of Preventive Cardiology, 21(1), pp.98-106.

6. Buck, H., Lee, C., Moser, D., Albert, N., Lennie, T., Bentley, B., Worrall-Carter, L. and Riegel, B. (2012). Relationship Between Self-care and Health-Related Quality of Life in Older Adults With Moderate to Advanced Heart Failure. The Journal of Cardiovascular Nursing, 27(1), pp.8-15.

7. Monteagudo, M., Rodríguez-Blanco, T., Llagostera, M., Valero, C., Bayona, X., Ferrer, M. and Miravitlles, M. (2013). Factors associated with changes in quality of life of COPD patients: A prospective study in primary care. Respiratory Medicine, 107(10), pp.1589-1597.

8. Global Initiative for Chronic Obstructive Lung Disease (Updated 2017). [Electronic Resourses]: www.goldcopd.com.

9. Gruenberger, J., Vietri, J., Keininger, D. and Mahler, D. (2017). Greater dyspnea is associated with lower health-related quality of life among European patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, Volume 12, pp.937-944.

10. Montalescot G. Sechtem U., Achenbach S., Andreotti F., Arden C., Budaj A., … Vrints C. (2013) Guidelines on the management of stable coronary artery disease ESC. European Heart Journal, Volume 34, pp. 2949–3003.

Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Maria V. Ovcharuk

National Pirogov Memorial Medical University

Pirogova str. 56, 21018, Vinnytsia, Ukraine

tel: +380974801234

e-mail: movcharuk@ukr.net

Received: 18.07.2018

Accepted: 19.11.2018

Table I. Characteristics of examined patients

Number

of patients

Patients with ІHD and COPD (group І)

n=98

Patients with ІHD

(group ІІ)

n=96

Patients with COPD

(group ІІІ)

n=78

Р

Average, years

65,8±0,83

(58;73)

58,9±0,9

(52,5;66,5)

57,9±0,85

(53;64)

р1-2<0,001

р1-3<0,001

р2-3=0,51

Men, аbs., %

78 (79,6%)

70 (72,9%)

46 (59%)

р1-2=0,33

р1-3=0,002

р2-3=0,031

Women, аbs., %

20 (20,4%)

26 (27,1%)

32 (41%)

р1-2=0,332

р1-3=0,002

р2-3=0,031

BMI, кg/м²

30,5±0,56 (26,7;33)

29,3±0,48 (26;32,6)

29,2±0,77 (24;33,9)

р1-2=0,196

р1-3=0,129

р2-3=0,556

Smoking, аbs., %

70 (71,4%)*

51 (53,1%)

44 (56,4%)

р1-2=0,012

р1-3=0,039

р2-3=0,734

Average duration of IHD, years

7,4±0,6 (2;10)

5,7±0,53 (1;10)

0,23

Average duration of COPD, years

4,9±0,56 (0,5;9)

8,7±0,75 (2;15)

0,014

Notes: 1. Data of quantitative characteristics are shown as М±m -overage number ± mathematical error of average and (per25; per75) – interquartile range (25 і 75 percentile)

2. Comparison of percentage among groups was made by criteriumχ2

3. Comparison of medians of quantitative characteristics was made by criterium

U Manna-Whitney.

4. Statistically significant was considered the difference with р<0,05.

Fig.1. Number of hospitalizations and ambulance calls of IHD and COPD patients and their combination

Note : 1.The results are given as (М ± m); 2. Statistically significant was difference by р<0,05; 3. *- significant difference between group 1 and group II, **-significant difference between group І and ІІІ, *** – significant difference between group II та ІІІ.

Таble II. Results of 6 MWTs for different groups of patients

Measure

Group І

n=98

Group ІІ

n=96

Group ІІІ

n=78

р

Distance, м

336,8±40,8

335 (220;480)

488±15,5

495 (460;525)

370,9±70,8

465 (120;550)

р1-2= 0,007

р1-3=0,54

р2-3=0,59

Intensity of dyspnea by Borg scale, point

5,4±0,63

5 (4;7)

2,7±0,47

2 (2;3)

5±0,64

5 (3;7)

р1-2=0,003

р1-3=0,67

р2-3=0,007

HR before attempt, beats/min

73,3±3,5

72 (65;78)

63,5±1,42

65 (60;65)

80±3,3

79 (74;84)

р1-2= 0,026

р1-3=0,12

р2-3=0,002

HR after attempt, beat/min

92±6,1

84 (78;110)

71±2,1

70 (65,78)

102±14,9

100 (110;135)

р1-2= 0,007

Р1-3=0,49

р2-3=0,002

Growth of HR, per 1 min.

19±3,5

20 (8;25)

7±1

8 (5;8)

21±3,2

20 (15;32)

р1-2= 0,017

Р1-3=0,17

р2-3=0,001

SPB before attempt, mmHg

124±4,5

120 (112;137)

123±3,1

125 (120;130)

122±5,7

120 (110;135)

Р1-2= 0,78

р1-3=0,68

р2-3=0,81

SPB after attempt, mmHg

122±6,7

120 (110;138)

136±4

135 (130;145)

138±5,2

142 (125;147)

р1-2= 0,17

р1-3=0,09

р2-3=0,56

Growth of BP, mmHg

4,3±2

4 (0;5)

13±2,9

14 (7;17)

10±1,6

10 (7;15)

р1-2= 0,013

р1-3=0,011

р2-3=0,9

Notes: 1. The quantitative results are given as М±m – average datae ± mathematic error average and asn Med (per25; per75) – median and interquartile range between (25 і 75 percentile);

2. Comparison of medians of quantitative data perfomed by U Manna Witney criterium.

3. Statistically significant was difference by р<0,05.

Fig. 2. The Rate of patients’ outpatient calls during the year

Notes: Statistically significant was difference by p<0,05.

*- significant difference between group 1 and group II,

**-significant difference between group І and ІІІ,

*** – significant difference between group II and ІІІ.

Таble III. QOL parameters for patients with stable IHD, COPD and both pathologies

Measure

Group І

n=98

Group ІІ

n=96

Group ІІІ

n=78

р1-2

р1-3

р2-3

Physical activity, point

43,7±2,6

44,4(27,7;66,6)

67,4±2,7

72 (61;83)

64,7±2,8

72,2(50;77,9)

<0,001

<0,001

0,61

Role of physical problems, point

9,93±2,9

0 (0)

26,9±5,1

0 (0;50)

39,6±5,4

25(0;75)

0,001

<0,001

0,11

General pain, point

51,9±2,2

45(45;67,5)

62±2,7

57 (45;80)

76,7±2,8

80(67,5;90)

0,003

<0,001

<0,001

Social functioning, point

63,2±2,5

62(50;75)

77,7±2,6

75 (62,5;100)

76,1±3

75(62,5;100)

<0,001

<0,001

0,89

General mental health, point

51,8±2,3

51(36;72)

66,9±2,5

72 (52;80)

61,4±2,3

68(52;72)

<0,001

0,006

0,056

Role of emotional problems, point

53,1±5

50(0;100)

64±6,2

100 (0;100)

67,2±5,6

100(33,3;100)

0,19

0,079

0,74

Stamina (energy,

fatigue), point

30,2±1,9

30(20;35)

48,5±2,3

50 (35;55)

45,3±2,5

45(35;55)

<0,001

<0,001

0,23

General perception of health, point

30,9±1,8

30(20;45)

39,6±1,7

40 (35;50)

38,8±1,9

40(30;50)

0,001

0,003

0,83

Comparison of state of health with that of the previous year, point

26,8±2.2

25(15;50)

39±3,4

25 (25;50)

39,6±2,9

37(25;50)

0,006

0,0014

0,84

Physical status, point

35,1±1,9

33,5(21;42)

52,1±2,8

48 (37,7;65,6)

60,9±3

59(40;85,9)

<0,001

<0,001

0,067

Psychical status, point

30,4±1,7

27,5(20,37,5)

44,1±1,7

45 (37,5;52,5)

42,1±2,1

42,5(32,5;55)

<0,001

<0,001

0,39

General status, point

56,3±2,7

50,3(35;80)

69,6±3,1

76,8(49;89)

68,2±3,2

79,7(48,2;89,3)

0,001

0,002

0,96

Notes: 1.The quantitative results are given as М±m – average data ± mathematic error average and as Med (per25; per75) – median and interquartile range between (25 і 75 percentile);

2. Comparison of medians of quantitative data performed by Kruscala Wallis and U Manna Whitney criterium.

3. Statistically significant was difference by р<0,05