Health-related quality of life among congestive heart failure patients with preserved and reduced ejection fraction

A cross-sectional study design was conducted in this research. The sample collection technique used stratified random sampling. First, we divided the sample using two stratifications: respondents with EF <40% and EF >40%. Next, we randomly selected respondents according to the criteria using a lottery. Inclusion criteria included HF patients in the cardiac outpatients’ clinic of a hospital in the Sukoharjo region of Central Java, Indonesia, age >18 years, NYHA functional class I–IV. The study excluded patients with communication impairment, cognitive disorders, and experience dyspnea.

The sample size for the present study was determined using the Lemeshow formula field, (Z²PQ/d2).⁹ The alpha parameters 5% (Zalpha² = 1.96), proportion 0.5, and precision 10% were used to calculate the sample size. In total, 97 people were required for the sample. In order to prevent missing during the collection of data, we recruited 10% more participants. Therefore, a minimum of 107 participants was needed.

A set of self-administered demographic characteristics and medical condition questionnaires, the Family Support Questionnaire by Friedman et al.¹⁰ and Minnesota Living with Heart Failure Questionnaire (MLHFQ), were used to gather data in this study. Age, gender, employment status, education level, NYHA functional class, and length of disease were all sociodemographic characteristics and medical conditions mentioned in the questionnaire. The Indonesian version of the Friedman’s Family Support Questionnaire has good internal consistency across studies and an overall Cronbach’s alpha of 0.949 in the current study.

The QoL variable was assessed utilizing the Indonesian version of the MLHFQ. The MLHFQ has 21 questions and two domains: the physical domain (8 items, 0–40 points) and the emotional domain (5 items, 0–25 points). The overall score, calculated using a 6-point Likert scale with a range of 0–5, could range between 0 and 105. Higher scores indicate impairment of HRQOL. However, the MLHFQ has satisfactory construct validity and good internal consistency.¹¹

Researchers coordinate to carry out the same under-standing of research methods and data collecting. After receiving approval from the Sukoharjo General Hospital, the study officially started. A list of patients with HF together with their ejection fraction results, was provided to the researchers. Following that, they conducted a simple randomization for each group using a lottery (HFrEF and HFpEF).

Researchers approached participants who had registered as cardiac outpatients. The study’s aims, procedures, and participation options were briefly explained to all eligible patients. An informed consent form was given to study participants after they consented to participate. Participants were required to complete questionnaires including their demographic characteristics, family support, and QoL. The researcher verified that the respondents had filled out all the questionnaires once they had finished them.

Statistical analysis was done on the data. In the descriptive analysis, the following measures include frequency, percentage, mean, and standard deviation (SD). Bivariate correlation analyses were carried out to investigate the association between sociodemographic variables, medical variables, family support, and QoL. Chi-square for categorical measures and Spearman’s correlation analysis for ordinal measures, with a significant correlation P-value < 0.05 were used. An independent t-test was conducted to investigate the mean difference in HRQOL among HF patients with preserved and reduced ejection fraction.

All respondents received informed consent forms to sign before enrolling in the study, which the hospital ethics committee approved. Additionally, the respondents were assured that their privacy would be protected throughout the study.

The purpose of this study was to compare the QoL scores of cardiac patients with varying ejection fraction values. In this study, the QoL scores of HF patients was lower than the overall mean score (105). According to the MLHFQ, the lower the score, the higher the patient’s QoL. The mean QoL scores substantially different between patients with HFrEF and HFpEF were 41.07 and 54.97, respectively. These data demonstrated that patients with HFpEF have a better QoL than those with HFrEF. It was consistent with the findings of prior research, which indicated that patients with a preserved ejection fraction might have worse health outcomes than those with a decreased ejection fraction.¹² Pelegrino et al.¹³ also found a correlation between Left Ventricular Ejection Fraction (LVEF) and HRQOL in a study.

This phenomenon is explained by the notion that HF with preserved ejection fraction is caused by ventricular dysfunction, which causes altered hemodynamics, particularly during activity. Besides, various physiological conditions such as body composition, endothelium, blood vessels, and skeletal muscles develop simultaneously. All of these variables will compromise functional capacity^14,15 that contributes to poor QoL conditions in people with HFpEF, comparable to or even worse than those described by patients with HF with reduced ejection fraction.

The outcomes of this study have variations of opinion with earlier investigations. Contrary to earlier investigations, Chen et al.¹⁶ discovered that patients with HFpEF had a higher QoL than those with HFrEF. Several investigations have also demonstrated that individuals with HFpEF have lower mortality rates than those without.^17,18 Reduced LVEF is closely related to the deteriorating QoL and health outcomes. A low LVEF is an objective clinical measure of HF, leading to pulmonary edema, fatigue, and dyspnea. Multiple studies have demonstrated that LVEF is a substantial predictor of mortality and hospitalization in HF patients.¹⁶ Effective LVEF therapy can improve a patient’s overall signs and symptoms, diminish mortality, hospitalization, fatigue, and enhance the QoL.

According to several available explanations, the age of the respondents is a potential explanation for the outcomes of this study. In the HFpEF group, most respondents were elderly, but in the HFrEF group, the majority were pre-elderly. In line with the results of Seo et al.,¹⁹ older age is a significant predictor of diminished QOL. In addition, the majority of respondents in the HFpEF group were female, whereas the majority of respondents in the HFrEF group were male. In their study, Seo et al.¹⁹ also reported that the female sex was closely connected to a worse QoL in HF patients.

These contradicting results can be generated from variances in HFpEF phenotypes based on geographic differences. Most of the study respondents with HFpEF had a feminine phenotype with a normal Body Mass Index (BMI) and a high comorbidity burden. Thus, the factors of impaired QOL may differ considerably depending on the HFpEF phenotype.

Another objective of this study was to identify the factors that influence the QoL of HF patients. According to a recent study, some of the respondents’ demographic data and medical conditions, including age, duration of disease, NYHA functional class, and family support, had a substantial correlation with their QoL. In contrast, gender and education level did not strongly correspond with the QoL.

The current study indicated that age was one of the factors impacting the QoL of HF patients. The average pre-elderly respondent can demonstrate a higher QoL. Negarandeh et al.²⁰ found that the mean age of patients with HF was pre-elderly. Pelegrino et al.¹³ discovered a substantial negative correlation between age and QoL in their study. As demonstrated by the findings of our study, older patients have a lower QoL than younger ones.

A study by Moradi et al.²¹ discovered a similar finding that the QoL of elderly HF patients was worse than that of adult patients. Since age alone was a substantial risk factor for heart disease and other chronic diseases, several studies have indicated that older HF patients have a lower QoL. Patients who were elderly had been more vulnerable to experiencing underlying conditions that diminished their QoL. Afsharipur et al.²² observed contradictory results in their study and no correlation between the age of HF patients and their QoL.

The current study documented a link between the lower QoL and NYHA functional classes.²³ In accordance with the findings of Hwang et al.,²⁴ the QoL of patients with HF declined as their NYHA functional class deteriorated. It is based on the fact that HF patients commonly face a loss of functional independence in daily tasks such as eating, dressing, and washing, as well as other common symptoms that can severely impact the patient’s QoL.²⁵ Hudiyawati et al.²⁶ also mentioned in their study that the condition of HF patients with NYHA functional class I, a slight decrease in functional capacity, will have a more stable condition.

Our investigation revealed a significant correlation between the duration of HF and the QoL of HF patients. Tarekegn et al.²⁷ explained that the findings are consistent, the QoL has a significant association with the number of years suffering from HF, particularly in the psychological domain, which has a direct adverse effect. It may be related to the patient’s decreased independence in doing daily activities. The duration of HF can also reflect the severity of HF, which may affect physical and mental health.

Having strong family support can improve the QoL for HF patients. This study concluded that most respondents have family members who helped them overcome their conditions. We assume that culture plays a role in this regard. According to local tradition, Indonesians are responsible for caring for sick family members, including providing support in managing ill family members, covering medical expenses, and providing emotional and spiritual support. Tangible support describes this type of evidence.

According to prior studies, family support was highly associated with overall health. A review of the relevant research has determined that social support from family and friends correlates with lower hospitalization rates and a higher QoL. Arrested et al.²⁸ found a correlation between social support and QoL among patients with HF, particularly in the emotional aspect. In addition, social support is closely related to depressive conditions in HF patients.²⁹ Barutcu and Mert’s³⁰ Middle East investigation was substantially identical. A study revealed that their families give a variety of social supports (tangible). The level of family support that HF patients receive has a substantial effect on their QoL. It should recognize that HF patients with complex symptoms, limitations, and care require adequate support.³¹