International Journal of Nursing Practice 2016; 22: 4 –14

RESEARCH PAPER

Narrative review of health-related quality of life and its predictors among patients with coronary heart disease Imran Muhammad BSN (Honours) RN Staff Nurse, Ward B65 (General Medicine/Cardiology), Khoo Teck Phuat Hospital, Singapore

Hong-Gu He PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Yanika Kowitlawakul PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Wenru Wang PhD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Accepted for publication April 2014 Muhammad I, He H-G, Kowitlawakul Y, Wang W. International Journal of Nursing Practice 2016; 22: 4 –14 Narrative review of health-related quality of life and its predictors among patients with coronary heart disease This paper summarizes the empirical evidence concerning health-related quality of life (HRQoL) of patients with coronary heart disease (CHD) and attempts to identify its significant predictors. A systematic search of the literature from 2002 to 2012 was conducted using seven electronic databases (CINAHL, ScienceDirect, Medline, Scopus, PsycINFO, PubMed and Web of Science) using the search terms ‘HRQoL’. ‘CHD’, ‘social support’, ‘depression’, ‘anxiety’, ‘psychosocial factors’, ‘sociodemographic factors’, ‘clinical factors’ and ‘predictors’. A total of 1052 studies were retrieved, of which 24 articles were included in this review. Previous studies have consistently demonstrated the negative impact of CHD on HRQoL, citing three major types of predictive factors: sociodemographic, clinical and psychosocial factors. Studies have also highlighted the advantageous use of HRQoL as a gauge for treatment satisfaction and efficacy. There are, however, few studies that collectively investigate the relationship among concepts such as HRQoL, anxiety and depression, social support, and sociodemographic and clinical factors in relation to CHD. This review highlights the need to conduct further study on HRQoL of patients with CHD in the Asian context. Such research will promote patient-centric care and improved patient satisfaction through incorporation of the concept of HRQoL into clinical practice. Key words: coronary heart disease, health-related quality of life, narrative review, predictors.

Correspondence: Wenru Wang, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11,10 Medical Drive, Singapore 117597. Email: [email protected] doi:10.1111/ijn.12356

INTRODUCTION Coronary heart disease (CHD) continues to be one of the leading causes of morbidity and mortality among adults worldwide despite reductions in morbidity and mortality © 2014 Wiley Publishing Asia Pty Ltd

Quality of life in coronary disease

rates due to improvements in treatment and preventive measures.1–3 Given the prolonged life expectancy resulting from these improvements, patients have to contend with CHD symptoms such as chest pain and breathlessness, as well as complex treatment regimens, over a longer period of time, producing negative effects on both physical and mental well-being.4 Given the far-reaching effects of CHD on physical, social and psychological aspects of the patient’s life, health-related quality of life (HRQoL) is seen as a suitable outcome measure to guide clinical practice.4 HRQoL is a subjective evaluation by the individual regarding the effects of the illness and its accompanying treatment on the individual’s life.4 It is a multifaceted concept including physical, psychological and social well-being.5 This concept serves well as a gauge for treatment efficacy and considers factors that are possibly of more importance to patients, such as psychological and social well-being.5,6 With the rise in the incidence of cardiac risk factors like chronic diseases (e.g. hypertension, diabetes), obesity and an ageing population, many countries will face an increased number of patients with CHD in the near future.7 The aim of this review is therefore to summarize the evidence of the impact of CHD on HRQoL and its significant predictors. Through this review, research gaps will be identified to conduct future studies. This will assist health-care professionals in their efforts to better manage CHD and reduce dependency on the health-care system.8,9 Failure to do so will lead to a society burdened with increased costs of care for these patients.7

METHODS Search strategy A literature search was conducted using seven electronic databases: CINAHL, ScienceDirect, Medline, Scopus, PsycINFO, PubMed and Web of Science. The keywords ‘HRQoL’, ‘CHD’, ‘social support’, ‘depression’, ‘anxiety’, ‘sociodemographic factors’, ‘clinical factors’, ‘psychosocial factors’ and ‘predictors’ were used in various combinations while conducting the search. The reference and citation lists of selected articles were also screened for potentially relevant articles. Articles were included if they were (i) in English; (ii) peer-reviewed; (iii) primary research reports or systematic reviews; and (iv) published between 2002 and 2012. Articles were excluded (i) if they solely discussed HRQoL of patients with congestive heart failure, chronic kidney disease, stroke or other chronic diseases, or (ii) if they were editorial articles.

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A total of 1052 studies were retrieved from seven databases, and 24 studies, including 23 quantitative research reports and one systematic review, that met the inclusion criteria were reviewed. HRQoL was considered as the outcome variable for all these articles. Study participants were diagnosed with CHD, including acute myocardial infarction (AMI) or angina. The articles discussed the effects of CHD on patients’ HRQoL and the significant predictors of these effects. The studies were conducted with measurements being taken at various time points, providing a perspective on changes in HRQoL over time. The samples in the reviewed articles had a mean age range of 45–68 years old, ranged in size from 63 to 37 386 and consisted predominantly of male Caucasians. The characteristics of the reviewed articles are summarized in Table 1.

RESULTS HRQoL among patients with CHD Previous studies have highlighted poorer HRQoL among patients with CHD when compared with the healthy population, highlighting failure to return to premorbid status and the necessity to carefully manage these patients.11,15,20,21,33 Lee and colleagues34 explained that the negative impact of CHD on HRQoL resulted from persistent chest pain and fear of another attack. Thompson and Roebuck33 further stated that overwhelming management plans and poor coping after the onset of CHD were among other factors that resulted in poor HRQoL. Boersma and colleagues35 discussed how the impact of CHD on HRQoL results from emotional distress caused by the disruption of daily activities. Such emotional distress often manifests as anxiety and depression, which further impairs the individual’s physical and mental wellbeing.35 Patients with poor HRQoL often report poorer health status, accelerated disease progression and increased used of health-care services and assistance compared with healthier people with better HRQoL.5,27 Although the authors acknowledged the improvement that comes with learning to cope and increased acceptance of the disease, they emphasized the presence of low HRQoL scores, highlighting the necessity to carefully manage these patients.27 Boersma and colleagues35 warned that patients with poor HRQoL are at increased risk for cardiac-related mortality and chronic disabling conditions such as stroke. Christian and colleagues30 went on to show the influence of CHD on the individual’s physical, psychological and social experience, finding that variables such as © 2014 Wiley Publishing Asia Pty Ltd

© 2014 Wiley Publishing Asia Pty Ltd

To examine differences in HRQoL between CHD and healthy population To examine the effect of the interaction between CHD and diabetes on HRQoL

To examine the QoL of patients following hospital admission with CAD in Hong Kong and use of CR

To examine the baseline HRQoL of postmenopausal women with heart disease enrolled in the Estrogen Replacement and Atherosclerosis trial

To describe and compare the HRQoL of Comparative patients and their significant others correlational study To identify factors associated with HRQoL one month after CABG To examine the association between CHD Descriptive, patients’ illness beliefs and their quality of correlational, life three years after hospital discharge longitudinal study To examine whether persistent sex differences Comparative in the health status of patients with CAD can correlational study be attributed to social factors

To examine the effect of anxiety on mortality and nonfatal MI in patients with CAD

USA

Hong Kong

USA

Finland

USA

Ford et al., 200811

Chan et al., 200512

Sherman et al., 200313

Rantanen et al., 200814

Barry et al., 200619

Shibeshi et al., 200717 Škodová et al., 201118

USA

Slovakia

Lau-Walker UK et al., 200915 Norris et al., Canada 201016

Descriptive correlational study

Examine impact of symptoms on QoL

USA

Kimble et al., 201110

Descriptive, correlational, longitudinal study To explore the potential of psychological Single-cohort well-being and socioeconomic position as prospective predictors of HRQoL in patients with CAD longitudinal study Baseline, 1 year, 2 year To determine whether perceived SS predicted Descriptive, change in HRQoL, operationalized as change correlational, in mental health and physical functioning, 6 longitudinal study months after CABG (baseline, 6-month follow-up)

Descriptive correlational study

Pretest–posttest study

Comparative correlational study

Research design

Country Aims

Authors and year of

HRQoL Psychosocial and physical functioning Emotional well-being Sleep quality HRQoL

HRQoL SD factors CR uptake

HRQoL SD factors Clinical factors

HRQoL Symptom cluster: fatigue, chest pain, dyspnea SD factors Clinical Factors

Outcome measures

1072 Mean age: 67.2

106 Mean age: 57

Psychosocial factors HRQoL Psychological well-being Vital exhaustion QoL Mental health Physical functioning SS

HRQoL Perception of symptoms Sense of control 2403 Gender roles 1950 male; mean SD factors age: 64 Clinical factors 453 female; Depression mean age: 66 HRQoL 516 Anxiety Mean age: 68 HRQoL

270 CABG patients 240 significant others 253

301 Mean age 65.5

182 Mean age: 62

50 573 Mean age: 45.8

134 Mean age: 64

Sample (n)

Patients with CHD: • Increased number of physically and mentally unhealthy days and activity-limited days Predictors of poorer QoL: • CHD and diabetes • Women 25% of 182 attended CR Significant improvement in HRQoL after 6 months No significant group differences in HRQoL between CR attendees and absentees Social support was positively associated with better functioning for all measured outcomes Social strain was negatively associated with HRQL functioning

Predictors of poorer HRQoL: • Greater angina, fatigue and dyspnea frequency • Lower social status • Greater comorbidity • Younger adults (poorer mental health)

Key findings

Maastricht interview (vital exhaustion) GHQ-28 SF-36 ENRICHD Social Support Inventory SF-36

KSQ

SAQ HADS

SF-36 IPQ

Psychosocial factors (psychological well-being, vital exhaustion) are more important predictors of change in HRQoL compared with some objective medical indicators (ejection fraction) among patients with CHD Frequent instrumental support predicted positive change in mental health Change scores were higher when participants had low pre-CABG mental health Neither SS variable predicted change in physical functioning

CHD patients’ perception of their symptoms and sense of control at time of discharge were significantly associated with their quality of life three years after discharge Factors affecting HRQoL: • Gender role • Angina frequency • Physical limitations Women reported higher anxiety levels Increased anxiety score, increased risk of MI or death among CAD

15-dimensional CABG patients had poorer QoL compared with general generic instrument population Significant others had QoL similar to general population

SF-36 MOS-SSS CESD

SF-36 (Chinese)

SF-36 HFFISS SAQ CCI RQ-S SORT-R CDD-R CDC HRQOL-4

Instruments

Table 1 Characteristics of reviewed studies evaluating health-related quality of life and its associated factors among patients with coronary heart disease

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Australia Investigate the impact of potentially modifiable illness beliefs about CAD on depressive symptomatology Examined the association between these beliefs and HRQoL and SD variations in illness beliefs USA To quantify the national impact of CHD on patient-reported health status in the noninstitutionalized population in the USA

Stafford et al., 200921

To determine the clinical and SD factors related Simple descriptive to the physical and mental components of study the HRQoL in coronary patients

Spain

Soto et al., 200524

Sweden

Australia To establish via multiple regression analyses the Simple descriptive, determinants of physical and mental HRQoL longitudinal study 5 years post-CABG

Brink et al., 200525

Lee, 200926

To determine the clinical and SD factors related Comparative to the physical and mental components of descriptive study HRQoL in coronary patients

To generate nationally representative HRQoL Simple descriptive estimates for CVD and cardiac comorbidities study Assess differential impacts by socioeconomic position using data from the Health Survey for England

109

33 women 65 men

132 Mean age: 60.7

37 386 With CHD: 2091 Without CHD: 35 196 Random sample Random sample 26 104

Descriptive, comparative study

UK

193 Mean Age: 61

432 Mean age: 65.9

Sample (n)

Longitudinal study

Stafford et al., 201223

Xie et al., 200822

Austria

Höfer et al., 200520

Research design

To test a conceptual model of HRQoL in CAD Descriptive, using structural equation modelling correlational, longitudinal study (baseline, 1- and 3-month follow up)

Country Aims

Authors and year of

Table 1 Continued

HRQoL SD factors Mental health Clinical factors Psychosocial factors HRQoL Gender Depression Fatigue HRQoL Dietary, physical activity and psychological well-being

HRQoL SD factors Clinical factors

Health status HRQoL SD factors

HRQoL Psychosocial factors SD factors Illness perception Neuroticism

HRQoL SS Anxiety and depression Clinical status SD data

Outcome measures

SF-36 HADS Somatic Health Complaints SF-36 Allied Dunbar National Fitness Survey diet sheet Physical activity/ exercise sheet. BDI STAI

SF-36 GHQ-28

EuroQoL/EQ-5D

SF-12 EuroQoL/EQ-5D

SF-36 MacNew HD-HRQoL Questionnaire HADS STAI CCOQ IPQ HADS SF-36 MSPSS NEO PI-R

Instruments

Improvement in HRQoL at 1 year for all participants Women reported better mental health; men demonstrated better physical health Predictors of lower HRQoL: anxiety and depression Anxiety and depressive symptoms are strongly implicated in determining PCS and MCS 5 years post-CABG using the SF-36

Doctor-diagnosed stroke, heart attack and angina were associated with the greatest decreases in EQ-5D Reduction in EQ-5D associated with the condition/risk factor was greater for those occupying lower socioeconomic positions Statistically significantly so for obesity, hypertension and diabetes History of CHD and greater age increased the PCS of the HRQoL No CHD history and lower age diminished the PCS score Younger adults had lowest MCS score

Poorer HRQoL among CHD participants Predictors: • Female • Aged 18–49 • Black or Hispanic

Negative illness beliefs predictive of higher levels of depressive symptomatology Positive illness perceptions predictive of better HRQoL Older and less socially advantaged had more negative illness beliefs

Depression and anxiety symptoms exerted the most significant influence on HRQoL

Key findings

Quality of life in coronary disease 7

© 2014 Wiley Publishing Asia Pty Ltd

USA

© 2014 Wiley Publishing Asia Pty Ltd

To determine the construct and criterion validity of the SF-12 in CAD patients with either AMI or angina in Spain

China

Spain

Wang et al., 201431

Failde et al., 201032

Simple descriptive study

Simple descriptive study

Pretest–posttest study

Simple descriptive study

Pretest–posttest study

Comparative correlational study

Systematic review

IHD Depression Treatment HRQoL Psychosocial factors

186 Mean age: 68.1

192 Mean age: 65

160 Mean age: 63

Clinical factors SD factors HRQoL Mental health

CHD Clinical factors SD factors HRQoL

CHD Women HRQoL Clinical status Psychosocial status Educational intervention

CABG HRQoL SD factors Clinical factors 1872 men CABG 522 women HRQoL SD factors Clinical factors 84 dyads (patient CHD and caregiver) HRQoL SS

405 men 269 women

—

SF-12 SF-36 GHQ-28

MIDAS SF-36 HADS

CCI PRIME-MD STAI SF-36

SF-12 STAI CESD CLLS SAQ EuroQoL/EQ-5D CESD MOS-SSS SF-12 MOS-SSS

Literature search

Significant improvements in HRQoL from admission to 6 months post hospitalization. Predictors: • Employed • Married • Physically active • Enrolled in CR • Not depressed Intervention group had significantly less bodily pain at 6 months compared with usual care in a model Predictors of overall HRQoL: • Increased age • Anxiety and depression • Heart failure • Smoking • Hypertension Female patients and those with low educational level, worse mental health, unstable angina, cardiovascular risk factors and comorbidity obtained a lower score in the SF-12 High correlations between SF-12 and SF-36 summary scores

Patients with low informational/emotional support had poorer mental health

Clinical characteristics of depression, such as severity of depression, number of episodes and duration of depression, might moderate the relationship between depression and CVD Marital status, education and income are moderators of this relationship Both male and female patients improved in physical, social and emotional functioning after CABG Women’s HRQoL scale scores remained less favorable than men’s through 1 year after surgery Women with CAD reported poorer HRQoL 1 year after coronary angiography compared with men

AMI, acute myocardial infarction; BDI, Beck Depression Inventory; CABG, coronary artery bypass graft; CAD, coronary artery disease; CCI, Charlson Comorbidity Index; CCOQ, Competence and Control Orientations Questionnaire; CDC, Centers for Disease Control; CDD-R, Chest Discomfort Diary—Revised; CESD, Centre for Epidemiologic Studies (Depression); CHD, Coronary Heart Disease; CLLS, Cantril Ladder of Life Satisfaction; CR, cardiac rehabilitation; CVD, cardiovascular disease; ENRICHD, Enhancing Recovery in Coronary Heart Disease; GHQ-28, General Health Questionnaire-28; HADS, Hospital Anxiety and Depression Scale; HFFISS, Hollingshead Four-Factor Index of Social Status; HRQoL, health-related quality of life; IPQ, Illness Perception Questionnaire; KSQ, Kellner Symptom Questionnaire; MCS, Mental Component Summary; MI, myocardial infarction; MIDAS, Myocardial Infarction Dimension Assessment Scale; MOS-SSS, Medical Outcome Studies—Social Support Survey; MSPSS, Multidimensional Scale of Perceived Social Support; NEO PI-R, NEO Personality Inventory—Revised; PCS, Physical Component Summary; PRIME-MD, Primary Care Evaluation of Mental Disorders; QoL, quality of life; RQ-S, Rose Questionnaire; SAQ, Seattle Angina Questionnaire; SD, sociodemographic; SF-12, Short Form-12 Health Survey; SF-36, Short Form-36 Health Survey; SORT-R, Slosson Oral Reading Test—Revised; SS, social support; STAI, State-Trait Anxiety Inventory.

To assess HRQoL and identify associated factors in hospitalized Chinese MI patients

USA

Christian et al., 200730

To assess differences in SS and QoL in patients and partners awaiting CABG To examine whether patients’ and partners’ perceived SS predicted their own, as well as their partner’s, QoL before CABG To evaluate predictors of HRQoL and determine the impact of a brief educational intervention on HRQoL 6 months post-hospitalization

UK

To compare HRQoL including patient-perceived neurocognitive function at preoperative baseline and 3 months after CABG surgery. To compare the HRQoL outcomes of men and women

Systematic review of the moderating influence of clinical and SD variables on the observed interrelationship between depressive disorders and CVD

Thomson et al., 20124

Norris et al., Canada 200829

Lindquist et al. 200328

Baune et al., Various 201227

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Quality of life in coronary disease

sociodemographic, clinical and psychosocial factors mediated the effect of CHD on HRQoL and, as such, served as significant predictors of HRQoL among patients with CHD.

Measuring HRQoL There are two types of instruments used to measure HRQoL: generic and disease-specific questionnaires. Generic instruments such as the Short Form Health Survey questionnaires (SF-36 and SF-12) cover a broad spectrum of quality-of-life components, which allows for comparison of health status across different diseases, severities, interventions and even cultures.24,32 Diseasespecific questionnaires such as the Myocardial Infarction Dimension Assessment Scale (MIDAS) and Seattle Angina Questionnaire (SAQ) are more sensitive in measuring the impact of CHD on the participant’s HRQoL.36 One study used SF-36 to measure HRQoL and found low HRQoL scores, highlighting the failure to return to premorbid status.13 It reported lower Mental and Physical Component Summary scores among CHD patients compared with the healthy population.13 The reliability of these findings was further supported when Wang and colleagues31 used both a disease-specific instrument (MIDAS) and a generic questionnaire (SF-36), obtaining poor HRQoL scores from both instruments. Garster and colleagues37 concluded that generic instruments were able to capture differences in HRQoL between populations with or without CHD. They went on to highlight that generic instruments allow for comparison between different disease populations and can assist with public policy decisions.37

Predictors of HRQoL among patients with CHD Sociodemographic factors

Several studies have found age to be inversely related to HRQoL, with younger and middle-aged patients with CHD reporting poorer results in the mental health component of HRQoL as compared with the elderly (aged 65 years old and above).11,18,25,35 This could be due to how the onset of disease affects the level of productivity of young working individuals.11 Moreover, the experience that comes with age probably assists elderly patients to better deal with the challenges resulting from CHD.10,22 However, better physical functioning was reported among younger participants compared with the elderly, so CHD is viewed to be less debilitating in the younger

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population.27,31,35 This phenomenon would be useful to investigate in an ageing society. CHD has been found to be more prevalent among the male population.15,37,38 However, female patients with CHD tend to be older and medically worse off compared with male patients.40 Current evidence shows female patients with CHD report poorer HRQoL compared with male patients even after controlling for clinical and psychosocial factors.12,14,16,22,28,34,35 These studies attributed their findings to differences in clinical course between genders, with female patients reporting atypical symptoms, being poorer candidates for coronary artery bypass graft (CABG) treatments and having different coping mechanisms. Another plausible reason for such a difference would be the increased risk of depression experienced by female patients with CHD, which could further impact HRQoL compared with their male counterparts.11,37 Burell and Granlund40 added that low selfesteem, exhaustion and stressors related to family demands have also been found to lower the HRQoL and delay recovery process among female patients with CHD. Xie and colleagues,22 investigating HRQoL among different sociodemographic groups, highlighted lower HRQoL among minority black and Hispanic CHD patients compared with Caucasians. Cepeda-Valery and colleagues41 added that African American CHD patients reported higher incidence of angina, poorer physical functioning and poorer HRQoL compared with Caucasian Americans. The researchers attributed this difference to the inequality that exists in access to health care in America. It appears that the negative impact of CHD on HRQoL extends beyond the Western population, with three Chinese-based studies reporting poor HRQoL among Chinese patients with CHD.9,31,34 In Singapore, variations in CHD have been observed between the major ethnic groups, with Indian patients having the highest rates of cardiac-related mortality compared with Malays and Chinese.42,43 There appears to be sufficient evidence that socioeconomic status (SES), as measured by education, income and occupation, is a major predictive factor of HRQoL.13,22,23,44,45 Farin and Meder45 found that individuals with higher SES generally reported higher HRQoL and better health outcomes when compared with individuals with lower SES. Such a phenomenon is probably due to the increased accessibility and affordability of healthcare services for higher-SES individuals, which ultimately improves their health outcomes.22,23 Barbareschi and © 2014 Wiley Publishing Asia Pty Ltd

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colleagues44 added that low-SES individuals possessed limited resources to promote well-being and had poor treatment adherence, poorer physiological functioning, and higher psychosocial stress, resulting in accelerated disease progression and lower HRQoL. It is crucial that socially disadvantaged individuals be provided with the necessary assistance to cope with CHD and improve HRQoL. The aforementioned point was emphasized by Škodová and colleagues,18 who attributed the lack of significant difference in HRQoL among different SES levels in Slovakia to compulsory individual health-care coverage, which reduces social inequalities in access to health-care services. Other studies account for the individual effects of education, occupation and income on HRQoL. In Spain, Failde and colleagues32 reported a correlation between lower education and lower MCS score using the SF-36. Apart from the possible social inequality in Spain, the authors explained that lack of knowledge translated to poor understanding of disease and treatment plans, which led to stress, reducing HRQoL among these patients.32 On the other hand, employment predicted better HRQoL as it gave participants a sense of purpose and importance, indirectly improving HRQoL.12,13,31

Clinical factors

Cardiac-related comorbidities such as hypertension and diabetes were strong predictors of poor HRQoL among patients with CHD.13,23,25 Sherman and colleagues13 explained that the chronic nature of diabetes and its associated complications, such as peripheral vascular disease and diabetic retinopathy, can contribute to reducing the HRQoL of patients with CHD. Other cardiac risk factors such as smoking have also been found to be predictors of poor HRQoL of patients with CHD.31,46 The type of diagnosis has also been found to be a predictor of HRQoL, with patients diagnosed with unstable angina reporting poorer HRQoL compared with AMI patients.10,16,24,32 Kimble and colleagues10 attributed these findings to the symptoms of pain, fatigue and dyspnoea that are strongly associated with unstable angina. These symptoms were found to negatively impact individuals’ physical and emotional functioning, which in turn reduced their HRQoL through self-imposed limitations on daily routines to avoid episodes of chest pains.10 Patients receiving revascularization therapies such as CABG and percutaneous coronary intervention (PCI) reported better HRQoL compared with patients receiving © 2014 Wiley Publishing Asia Pty Ltd

conservative management or medical therapy.13,28,47–49 Even among patients receiving PCI, differences have been noted in HRQoL outcomes, with patients receiving drugeluting stents reporting better HRQoL compared with those receiving bare metal stents, with reduced restenosis rate, improved health outcome and reduced uncertainty of a recurrent attack.39 Another predictive factor would be the severity of the CHD, with triple-vessel disease patients reporting increased symptom burden, poorer health outcomes and poorer HRQoL when compared with patients with singlevessel disease.47 Apart from the severity of disease, chronicity of CHD has been seen as an influencing factor in HRQoL. Newly diagnosed AMI patients experienced comparatively lower HRQoL than patients with history of CHD.34

Psychosocial factors

Anxiety and depression among patients with CHD. Several studies found anxiety and depression to be strong independent predictive factors of poor HRQoL among patients with CHD.13,20,27,37,50 Previous studies indicated that about 17–27% of patients with CHD experienced major depression, whereas 20–45% demonstrated depressive symptoms, with female AMI patients facing a higher risk of depression.30,50,51 On the other hand, twothirds of patients with CHD were reported to experience anxiety post-diagnosis.52 Antoniou and Dokoutsidou53 explained that the loss of self-esteem, stress, inability to fulfill one’s roles (social, familial, professional), uncertainty and distorted self-image are known to contribute to the onset of anxiety and depression after AMI and angioplasty. Their onset is also accelerated by the absence of coping mechanisms, lack of social support, increased stress and sociodemographic factors like gender.5,50 Anxiety and depression differ in terms of their influence on HRQoL. Höfer and colleagues20 explained that HRQoL, in terms of general health perception and physical functioning, is directly affected by anxiety and indirectly by depression. Two studies reported that participants experiencing depression faced a higher risk of suffering from a recurring heart attack,5,39 whereas another revealed an association between high anxiety scores and increased risk of death or non-fatal myocardial infarction.17 Myers and colleagues6 associated the above findings with reduced engagement in secondary preventive behaviours crucial in delaying disease progression. They went

Quality of life in coronary disease

on to explain that reduced engagement in health behaviours can be caused by medical mistrust, lack of support and motivation, or a fatalistic attitude.6 Lee added that depressive symptoms increase distress levels and impair work and personal and social functioning, which affects personal and psychological well-being and HRQoL.26 Although the majority of patients with CHD adapt over time, nearly one-fifth of patients fail to adjust to the emotional strain.30 Social support. Social support has been found to be a predictor of HRQoL in several studies.25,54 Previous studies reported that presence of emotional support exerted a positive influence on HRQoL in patients with CHD, with widowed participants experiencing lower HRQoL compared with married individuals.4,19,35 In Hong Kong, an Asian culture with a strong concept of filial piety and family values, the presence of children as a form of social support contributed to better health outcomes among patients with CHD.12 However, Barry and colleagues19 argued that emotional support was an insignificant predictor of HRQoL 6 months post-CABG, as compared with instrumental support, which positively predicted improved mental health. This could be due to the greater importance placed by CABG patients on receiving assistance with activities of daily living during the course of recovery.19 Other negative predictors of HRQoL included social strain, high levels of uncertainty, poor patient–physician relationship, anger and cynicism.36,45,48 Lau-Walker and colleagues15 highlighted poor sense of control post-CABG surgery as a predictor of poorer HRQoL, and Stafford and colleagues50 reported poor HRQoL outcomes among patients with CHD with negative illness perception. All these factors eventually lead to stress and anxiety among patients with CHD, resulting in poor HRQoL.15,45,48

DISCUSSION According to current evidence, patients with CHD tend to report lower HRQoL compared with the healthy population.37 There is no universal definition of HRQoL4; however, authors agree that it involves the subjective evaluation of the impact of the disease and treatment on the patient’s lifestyle, often encompassing the physical, social, psychological and environmental aspects.49 CHD influences HRQoL by affecting aspects of patients’ lifestyle and alters their health perception in the process.15 The effect can be caused by pain from a single episode of

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AMI or the persistent and often disruptive pain of unstable angina.32 Moreover, the stress induced by the experience of being diagnosed with CHD, the increased risk for a recurrent attack and the overwhelming lifestyle changes post-diagnosis often alter patients’ perceptions of HRQoL for the worse.11,36 Severity of disease and even the number of cardiac comorbidities also negatively affect HRQoL.36 Current evidence shows that the impact of CHD on HRQoL can be amplified or reduced depending on several factors, which can serve as predictors of HRQoL.22 Gender has been reported to be a predictor, with female patients reporting poorer HRQoL; these findings are often attributed to poor coping mechanisms and altered role perception.16,29 Lower income level, resulting in reduced access to health care and inability to cope with rising health-care costs, can delay the recovery process and can be viewed as another predictor of worse impact of CHD on HRQoL.23 However, this might not be entirely applicable in settings where there is sufficient health-care assistance provided.45 Psychological morbidities such as anxiety and depression that occur before or after diagnosis of CHD have been found to increase the risk of recurrent AMI, delay recovery process and reduce medication compliance.5,6 Lack of social support also worsens the impact of CHD on HRQoL in view of the absence of a spouse or a reliable source of support to help patients meet their various lifestyle needs and to cope with the stress related to CHD management.12,19 This review has several implications for nursing practice. Nurses conducting cardiac rehabilitation could consider tailoring programmes towards elderly patients in an attempt to improve physical functioning in view of their poorer physical health.18 The inclusion of cognitive restructuring can improve self-esteem and reduce psychosocial stressors among younger outpatients with CHD.40 In addition, nurses must get support from spouses and caregivers in the cardiac rehabilitation process. In addition, this review supports the suggestion that nurses caring for patients with CHD should use screening tools in routine clinical management.35,36 These screening tools could assist nurses in identifying patients with poor HRQoL who might require alternative medical interventions to improve treatment adherence, clinical outcomes and HRQoL.38,39 Although much is known on HRQoL among patients with CHD and its significant predictors, research findings were limited in terms of generalizability, as studies © 2014 Wiley Publishing Asia Pty Ltd

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predominantly investigated Western populations. There is limited knowledge of Asian CHD outpatient populations with regard to their perceptions of what supports or undermines their HRQoL, the extent of anxiety and depression post-CHD and the influence of social support on HRQoL. There might be variation in the impact of CHD on HRQoL among different ethnic groups, which warrants attention given the presence of ethnic differences in CHD prevalence in Asian countries such as Singapore, where Indian residents face a higher risk of AMI compared with the Chinese and Malay populations.42,55 In addition to that, there are few studies that clearly investigate the relationships among concepts such as HRQoL, anxiety and depression, social support, and sociodemographic and clinical factors related to CHD. Another underresearched area is whether multiple medications or polypharmacy can influence HRQoL of outpatients with CHD, given the numerous prescriptions that the majority of patients are required to adhere to in order to manage CHD and its associated comorbidities. There have also been reports of improvements in HRQoL among patients undergoing revascularization therapy.19,28,47 However, there are few comparisons of HRQoL between patients who opt for only pharmacological treatments and patients who undergo PCI or CABG. This gap deserves more attention in order to enhance efforts to promote medication adherence and other treatment options. Another underresearched area is the efficacy of incorporating HRQoL measurement tools such as the SF-36 and SF-12 into clinical practice for evaluating care needs of patients.

LIMITATIONS AND CONCLUSION Although a careful literature search was conducted, the search strategy might not have found all the relevant published literature. The varying time-points used in the studies included in this review were not considered in the analysis. This might account for certain effects that were not identified in this current review. Nevertheless, this review meets its aim to summarize the empirical evidence concerning HRQoL of outpatients with CHD and to identify its significant predictors. Current evidence highlights the need to conduct a study to address research gaps and achieve better understanding of the HRQoL of CHD outpatients in Asian societies. Such efforts promote patient-centric care and improve patient satisfaction through incorporating the concept of HRQoL into clinical © 2014 Wiley Publishing Asia Pty Ltd

practice. This literature review is therefore the first step in moving towards providing holistic care to CHD outpatients in Asia.

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