|Year : 2014 | Volume
| Issue : 2 | Page : 92-97
Effect of angioplasty on quality of life in a tertiary care hospital of South India
Anil Tumkur1, Pradeep M Muragundi1, Ranjan K Shetty2, G Vivek2, Anantha Naik Nagappa1
1 Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal, Karnataka, India
2 Department of Cardiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||3-Oct-2014|
Ranjan K Shetty
Department of Cardiology, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Patients' perception about the status of their current health and its direct measurement has become vital among researchers measuring outcomes. Health-related quality of life (HRQOL) scoring systems have been used as the objective measurement of performance status in various cardiovascular diseases.
Objective: Our aim of the study was to determine the HRQoL of the patients undergoing angioplasty procedure.
Materials and Methods: In this prospective interventional study period, all consecutive patients treated with Percutaneous Coronary Intervention (PCI), due to myocardial infarction. EQ5D questionnaire was introduced to them and the responses were collected by self response/interview method. Same procedure was repeated at 1 month follow-up. At the baseline, mean utility and visual analog score was relatively low.
Results: In the conditions of anterior wall, inferior wall myocardial infarction conditions, mean utility value and VAS was improved after the intervention.
Conclusions: The present study shows the prominent changes occurring in mobility and pain domains and moderate changes in usual activity, self care and anxiety domains.
Keywords: Angioplasty, EQ-5D-5L, myocardial infarction, quality of life
|How to cite this article:|
Tumkur A, Muragundi PM, Shetty RK, Vivek G, Nagappa AN. Effect of angioplasty on quality of life in a tertiary care hospital of South India. Nig J Cardiol 2014;11:92-7
|How to cite this URL:|
Tumkur A, Muragundi PM, Shetty RK, Vivek G, Nagappa AN. Effect of angioplasty on quality of life in a tertiary care hospital of South India. Nig J Cardiol [serial online] 2014 [cited 2019 Dec 9];11:92-7. Available from: http://www.nigjcardiol.org/text.asp?2014/11/2/92/142090
| Introduction|| |
Cardiovascular disease (CVD) imparts greater socioeconomic burden across the world causing 16.7 million deaths, which is about 29 percent of total deaths occurring due to different forms of cardiovascular diseases.  About 80 percent of these deaths were from low-income countries.  By 2020 there will be threefold increase in these diseases as compared in developed countries.  South Asians have very high prevalence of cardiovascular risk factors which make them vulnerable even at younger age.  Even though non communicable diseases are usually expected to occur in the old age, their peak occurrence in India is a decade earlier than western countries.  Hence, the issue is not only the burden, but also its prematurity and the resulting socioeconomic consequences. 
Compared to ST elevation myocardial infarction (STEMI), unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) show lower early mortality, but the long-term prognosis of these conditions is known to be worse. As the patients with UA/NSTEMI tend to be older and have more extensive coronary disease and more comorbidity compared with those with STEMI, their health status would be so worse to be related to adverse long-term clinical outcome. 
Traditionally, health care was viewed successful if clinical goals were met, and seldom point of view of the patients' choices was given any importance. Patients' perception about the status of their current health and its direct measurement has become vital among researchers measuring outcomes. Measuring patients' perception and the extent to which they can actually function in their daily activities are very important when the main objective of treatment is to improve how the patient feels.  Health-related quality of life (HRQOL) scoring systems have been used as the objective measurement of performance status in various cardiovascular diseases.  Even though the effectiveness of percutaneous coronary intervention (PCI) in chronic stable angina is proven beyond doubt in alleviating ischemic symptoms and improving quality of life,  importance given to quality-of-life measurement is comparatively very minimal during the management of acute coronary syndrome (ACS) as, prime focus would be on mortality reduction.
Cardiovascular disease impacts significantly on HRQoL of patients who survive coronary disease such as heart attacks (myocardial infarction) or stroke. HRQoL measurement in CVD can be assessed using disease-specific instruments such as the Seattle Angina Questionnaire (SAQ);  MacNew Heart Disease Health-related Quality of Life Questionnaire;  and the Minnesota Living with Heart Failure score (MLHF).  These questionnaires are particularly sensitive to changes in aspects of HRQoL directly related to cardiovascular disease. Alternatively, commonly used generic measures of HRQoL including the SF-36,  Health Utilities Index (HUI)  and the EQ-5D  have also been used in cardiovascular disease studies.
The main advantages of such generic multi-attribute health state classifiers are that they allow the calculation of Quality-adjusted life years (QALYs) within cost-utility analyses as well as allowing comparison of HRQoL across different conditions and against age-sex matched population norms.
In a study involving ACS patients, indicated that EQ-5D was highly accepted.  The EQ-5D index has a relatively strong relationship across different levels of coronary heart diseases severity. 
| Materials and methods|| |
Design and study population
Our aim of the study was to determine the HRQoL of the patients undergoing angioplasty procedure. In this prospective interventional study period, all consecutive patients treated with PCI, due to Anterior wall, Inferior Wall, or Lateral Wall Myocardial Infarction (AWMI/IWMI/LWMI) in the cardiology wards of Kasturba Hospital, Manipal University, Manipal, were asked to participate in the study and their written consent was obtained. Kasturba Hospital Ethics committee had approved the study procedure. Both the demographic and clinical factors, such as age, gender, residence place, income, education were collected by direct interview with participants and verified with their medical records. Verification of diagnosis and treatment was obtained by medical records. EQ-5D-5L questionnaire was introduced to them and the responses were collected by self response/interview method. This questionnaire is simple, standardized, validated, and available in regional language (Kannada). Visual analoge scale (VAS) was explained and asked them to mark on the scale and write the same value in the response sheet. Same procedure was repeated at one month follow up. There was no loss of follow up as it was short term, and duration for the whole interview process took less than 10 minutes.
Sample size was calculated, considering 5% level of significance, 80% power along with clinically significance difference is 8; the sample number is 33.
Quality of Life questionnaire: The EQ-5D-5L, a generic measure of perceived health status developed by the EuroQol Group, was used to assess general health status in the current study. The EQ-5D consists of five questions assessing the following domains: Mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A VAS, rating their health status on a scale from 0 (worst imaginable health status) to 100 (best imaginable health status) was determined. Each question can be scored as: Having no problems (level 1), slight problems (level 2), moderate problems (level 3), severe problems (level 4), or extreme problems (level 5). A total of 3125 possible health states are defined in this way. Each state is referred to in terms of a 5 digit code. For example, state 11111 indicates no problems on any of the 5 dimensions, while state 12345 indicates no problems with mobility, slight problems with washing or dressing, moderate problems with doing usual activities, severe pain or discomfort and extreme anxiety or depression.  In addition, it is possible to calculate a utility score, a single summary index derived on the basis of the EQ-5D domains. EQ-5D levels were dichotomized into 'no problems' (i.e. level 1) versus 'problems' (i.e. levels 2 to 5). The EQ VAS records the participant's self-rated health on a 20 cm vertical, visual analogue scale with endpoints labeled 'the best health you can imagine' and 'the worst health you can imagine'. This information can be used as a quantitative measure of health as judged by the individual respondents.
All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc, Chicago, IL). Descriptive statistics were used for reporting demographic, clinical variables. To determine the change in the mean utility value before and after one month of angioplasty, Wilcoxon Sign Rank test with 95% confidence interval was used. Mean change in VAS was calculated by paired 't' test with 95% confidence interval was used. Demographic characteristics like, age, gender, residence and disease status like SVD, DVD and TVD were correlated with mean utility value and mean VAS score by using paired 't' test with 95% confidence interval.
| Results|| |
Demographics were enlisted in [Table 1]. Total number of participants was 75. Majority of the patients were male (59, 78.7%), mean age of 58.70 with standard deviation of 10.89 years and having median age of 60 years (range, 29-79), having up to 10 th standard education as major education (40, 53.3%), and skilled labor as major occupation (18, 24.3%).
Inferior wall myocardial infarction (39, 52%) is the major cause for the patients, having single vessel disease (40, 53.3%). LAD and RCA were major arteries (26, 34.7% and 25, 33.3%) to which angioplasty was performed. Diabetes and hypertension were the major comorbid conditions of the selected patient population.
[Figure 1] shows the mean utility scores with 95% confidence intervals at base line and at 1-month period after angioplasty.
|Figure 1: The EQ 5D index mean values with 95% confidence intervals before and after 1 month of angioplasty|
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[Table 2] shows the utility values along with mean, SEM, and range. The mean differences in utility scores were 0.23359 which is very significant (P < 0.001).
|Table 2: Utility values of EQ 5D before and after 1 month of angioplasty: Wilcoxon sign rank test; Exact P<0.001|
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[Figure 2] shows the mean VAS with 95% confidence intervals at base line and at 1-month period after angioplasty.
|Figure 2: Mean VAS score with 95% confidence interval before and after 1 month of the angioplasty|
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[Figure 3] shows the domains of EQ -5D-5L domains which were dichotomized into problem and no problem category.
|Figure 3: The changes in the domains of EQ5D were dichotomized into problem and no problem|
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[Table 3] shows the changes occurring in utility and VAS in the participants having AWMI, IWMI and LWMI. The changes were prominent in the condition of AWMI and IWMI with P < 0.001. LWMI had no prominent changes in the mean values.
|Table 3: The mean utility values and mean VAS score before and after the angioplasty|
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[Table 4] shows the values of utility and VAS, in the sub group of SVD, DVD and TVD. Changes in the mean values were prominent with P < 0.001.
It was observed that, similar results were obtained with DES and BMS, rural and urban, male and female gender with P < 0.001.
|Table 4: The mean utility values and mean VAS score before and after the angioplasty|
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| Discussion|| |
Percutaneous coronary intervention was indicated only as the treatment for chronic stable angina, is now becoming widely used in the management of unstable angina and acute myocardial infarction by either primary PCI or rescue PCI. The effectiveness and safety of the procedure had benefited patients in terms of morbidity and mortality.
The focus of the attention immediate period to angioplasty is, generally, physical functioning, but following the discharge from the hospital, and in long term is general health, vitality, social, and emotional functions will also become equally important.
Health-related quality of life (HRQoL) is increasingly being assessed as an outcome parameter, especially in chronic diseases such as coronary artery disease (CAD), in which the goal of treatment is not only to prolong life but also to relieve symptoms and improve function. HRQoL is increasingly being assessed as an outcome parameter when evaluating the effectiveness of medical, interventional, and surgical treatment strategies.
At baseline, before revascularization, the patients' mean scores on all domains were substantially lower, implying poorer quality of life. Mean VAS, before the angioplasty was 60.50 (SD 15.69) were increased to 77.94 (SD 11.06) having median of 65 and 80, respectively (P < 0.001). HRQoL data on angioplasty patients was evaluated by us, as per our knowledge, is first of its kind in the Indian context, specifically South Indian population.
Study done by Kahler  et al., shows the improvement in the quality of life in both octogenarians and age group of 60-70, significantly in the physical abilities and decrease pain.
In a study, examining the dimension-specific burden of disease among cardiovascular studies, the trend in the distribution of scores was fairly similar across all five dimensions. In general, problems with usual activities tended to be most common, followed by problems with mobility and pain/discomfort. In terms of the dimension-specific burden of cardiovascular disease, problems with pain or discomfort were the most common, followed by problems with usual activities and mobility. 
Present study had demonstrated that, problems with mobility, pain and anxiety domains were large at baseline and after the PCI intervention, mobility had improved along with pain and anxieties were declined [Figure 3].
In a study involving 2002 patients with acute myocardial infarction (AMI) enrolled, across 24 sites in the TRIUMPH registry that completed assessments of independence and physical function at the time of AMI and 1 year later. This study found on 1-year post-AMI, 43.0% of patients experienced health status declines: 12.8% independence loss alone, 15.2% physical function decline alone and 15.0% both. 
Most of the researchers compared both CABG and PCI group of patients for HRQoL measurements. Hofer and colleagues reported that, the short and intermediate-term results revealed HRQoL differences between PCI and CABG in the month immediately after intervention despite the almost identical reduction in angina severity over the first month in both groups. PCI was associated with a relatively rapid increase in HRQoL in the first month, with little further change by 3 months.  Zhang et al., reported that, both CABG and stent-assisted PCI resulted in significant improvement in angina-related health status at 6 months and 1 year after intervention. 
Study conducted by Szygula-Jurkiewicz et al., had shown significant difference arises from better physical function for coronary artery bypass graft surgery patients compared with PCI patients. Despite impairment of the physical health status, the mental health status remained similar in both groups.  HRQoL in both patients' group was increased statistically significant by 6 months. No significant change in health-related quality of life took place in either group from 6 to 12 months. 
In a multicentre study, patients with UA/NSTEMI and STEMI underwent PCI, angina-specific, and general health-related quality-of-life (HRQOL) was investigated at baseline and at 30 days after PCI. After PCI, both angina-specific and general HRQOL scores were improved, but improvement was much more frequent in angina-related HRQOL of patients with UA/NSTEMI than those with STEMI (44.2% vs 36.8%, P < 0.001). At 30-days after PCI, angina-specific HRQOL of the patients with UA/NSTEMI was comparable to those with STEMI (56.1 ± 18.6 vs. 56.6 ± 18.7, P = 0.521), but general HRQOL was significantly lower (0.86 ± 0.21 vs. 0.89 ± 0.17, P = 0.001) after adjusting baseline characteristics (P < 0.001). The general health status of those with UA/NSTEMI was not good even after optimal PCI. 
The present study shows the prominent changes occurring in mobility and pain domains and moderate changes in usual activity, self care and anxiety domains.
Since this was a pilot study project, it had the limitation of having only one follow-up at 1-month period. Hence, study will need to be continued for a minimum period of 1 year and further to study the trend of changes over a period. In this study, only generic version of HRQoL was used. To get more accurate results, it is necessary to use both generic and a disease-specific questionnaire and correlate the same.
| Conclusions|| |
Percutaneous coronary intervention will increase the quality of life of the patients who had been diagnosed as myocardial infarction. Before the procedure, at the baseline, mean utility score was relatively low and had been improved after the intervention. Mean VAS was also improved after the intervention. Mean Utility and VAS values were improved in both AWMI and IWMI patients' subgroup. Subgroup analysis between SVD, DVD and TVD, BMS and DES were also shown prominent changes after the intervention. There were significant differences observed in all the five domains of EQ5D, prominent changes occurring in mobility and pain domains.
| References|| |
|1.||World Health Organisation: The World Health Report 2003: Shaping the Future. Geneva; 2003. |
|2.||Reddy KS. Cardiovascular disease in non-Western countries. N Engl J Med 2004;350:2438-40. |
|3.||Yusuf S, Reddy S, Ounpuu S, Anand S, Global burden of cardiovascular diseases: Part II: Variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001;104:2855-64. |
|4.||Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007;297:286-94. |
|5.||The Country Cooperation Strategy briefs. World Health Organization 2006. Available from: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ind_en.pdf. [Last accessed on 2011 Dec 03]. |
|6.||García-García C, Subirana I, Sala J, Bruguera J, Sanz G, Valle V, et al. Long-term prognosis of first myocardial infarction according to the electrocardiographic pattern (ST elevation myocardial infarction, non-ST elevation myocardial infarction and nonclassified myocardial infarction) and revascularization procedures. Am J Cardiol 2011;108:1061-7. |
|7.||Muragundi PM, Tumkur A, Shetty R, Naik A. Health-related quality of life measurement. J Young Pharm 2012;4:54. |
|8.||Guyatt GH. Measurement of health-related quality of life in heart failure. J Am Coll Cardiol 1993;22:185-91A. |
|9.||Dyer MT, Goldsmith KA, Sharples LS, Buxton MJ. A review of health utilities using the EQ-5D in studies of cardiovascular disease. Health Qual Life Outcomes 2010;8:13. |
|10.||Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M, et al. Development and evaluation of the Seattle Angina Questionnaire: A new functional status measure for coronary artery disease. J Am Coll Cardiol 1995;25:333-41. |
|11.||Hofer S, Lim L, Guyatt G, Oldridge N. The MacNew Heart Disease health-related quality of life instrument: A summary. Health Qual Life Outcomes 2004;2:3. |
|12.||Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ 2002;21:271-92. |
|13.||Furlong WJ, Feeny DH, Torrance GW, Barr RD. The Health Utilities Index (HUI) system for assessing health-related quality of life in clinical studies. Ann Med 2001;33:375-84. |
|14.||Rabin R, de Charro F. EQ-5D: A measure of health status from the EuroQol Group. Ann Med 2001;33:337-43. |
|15.||Schweikert B, Hahmann R, Leidl R. Validation of the EuroQol questionnaire in cardiac rehabilitation. Heart 2006;92:62-7. |
|16.||Goldsmith KA, Dyer MT, Schofield PM, Buxton MJ, Sharples LD. Relationship between the EQ-5D index and measures of clinical outcomes in selected studies of cardiovascular interventions. Health Qual Life Outcomes 2009;7:96. |
|17.||Brooks R. EuroQol: The current state of play. Health Policy 1996;37:53-72. |
|18.||Kahler J, Lutke M, Weckmuller J, Koster R, Meinertz T, Hamm CW. Coronary angioplasty in octogenarians. Quality of life and costs. Eur Heart J 1999;20:1791-8. |
|19.||Dodson JA, Arnold SV, Reid KJ, Gill TM, Rich MW, Masoudi FA, et al. Physical function and independence 1 year after myocardial infarction: Observations from the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients′ Health status registry. Am Heart J 2012;163:790-6. |
|20.||Hofer S, Doering S, Rumpold G, Oldridge N, Benzer W. Determinants of health-related quality of life in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil 2006;13:398-406. |
|21.||Zhang Z, Mahoney EM, Stables RH, Booth J, Nugara F, Spertus JA, et al. Disease-specific health status after stent-assisted percutaneous coronary intervention and coronary artery bypass surgery: One-year results from the stent or surgery trial. Circulation 2003;108:1694-700. |
|22.||Szygula-Jurkiewicz B, Zembala M, Wilczek K, Wojnicz R, Polonski L. Health related quality of life after percutaneous coronary intervention versus coronary artery bypass graft surgery in patients with acute coronary syndromes without ST-segment elevation. 12-month follow up. Eur J Cardiothorac Surg 2005;27:882-6. |
|23.||Kattainen E, Merila¨inen P, Sintonen H. Sense of coherence and health-related quality of life among patients undergoing coronary artery bypass grafting or angioplasty. Eur J Cardiovasc Nurs 2006;5:21-30. |
|24.||Kim MJ, Jeon DS, Gwon HC, Kim SJ, Chang K, Kim HS, et al., Korean Mustang Investigators. Health-related quality-of-life after percutaneous coronary intervention in patients with UA/NSTEMI and STEMI: The Korean multicenter registry. J Korean Med Sci 2013;28:848-54. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]