Skip to main content

Quality of life questionnaire predicts poor exercise capacity only in HFpEF and not in HFrEF

Abstract

Background

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is the most widely used measure of quality of life (QoL) in HF patients. This prospective study aimed to assess the relationship between QoL and exercise capacity in HF patients.

Methods

The study subjects were 118 consecutive patients with chronic HF (62 ± 10 years, 57 females, in NYHA I-III). Patients answered a MLHFQ questionnaire in the same day of complete clinical, biochemical and echocardiographic assessment. They also underwent a 5 min walk test (6-MWT), in the same day, which grouped them into; Group I: ≤ 300 m and Group II: >300 m. In addition, left ventricular (LV) ejection fraction (EF), divided them into: Group A, with preserved EF (HFpEF) and Group B with reduced EF (HFrEF).

Results

The mean MLHFQ total scale score was 48 (±17). The total scale, and the physical and emotional functional MLHFQ scores did not differ between HFpEF and HFpEF. Group I patients were older (p = 0.003), had higher NYHA functional class (p = 0.002), faster baseline heart rate (p = 0.006), higher prevalence of smoking (p = 0.015), higher global, physical and emotional MLHFQ scores (p < 0.001, for all), larger left atrial (LA) diameter (p = 0.001), shorter LV filling time (p = 0.027), higher E/e’ ratio (0.02), shorter isovolumic relaxation time (p = 0.028), lower septal a’ (p = 0.019) and s’ (p = 0.023), compared to Group II.

Independent predictors of 6-MWT distance for the group as a whole were increased MLHFQ total score (p = 0.005), older age (p = 0.035), and diabetes (p = 0.045), in HFpEF were total MLHFQ (p = 0.007) and diabetes (p = 0.045) but in HFrEF were only LA enlargement (p = 0.005) and age (p = 0.013. A total MLHFQ score of 48.5 had a sensitivity of 67% and specificity of 63% (AUC on ROC analysis of 72%) for limited exercise performance in HF patients.

Conclusions

Quality of life, assessment by MLHFQ, is the best correlate of exercise capacity measured by 6-MWT, particularly in HFpEF patients. Despite worse ejection fraction in HFrEF, signs of raised LA pressure independently determine exercise capacity in these patients.

Peer Review reports

Background

Heart failure (HF) represents end stage heart disease irrespective of the underlying etiology, and is acknowledged as a major cause of mortality and morbidity [1, 2]. Exercise intolerance and impaired quality of life (QoL) reflect poor prognosis in HF patients, and are considered the hallmark of disease severity, irrespective of left ventricular (LV) ejection fraction (EF) [3,4,5,6,7]. Treatment of HF aims at improving the clinical status, the functional capacity and QoL, as well as reducing mortality and hospitalizations [8]. Recently, QoL improvement has been shown as one of the most important treatment goals in HF, particularly with the documented increase in life expectancy [9, 10]. Moreover, bearing in mind the expected short life expectancy in these patients, QoL seems to be an important objective that needs to always be addressed [11,12,13].

The QoL in HF is commonly assessed by the Minnesota Living with Heart Failure questionnaire (MLHFQ) [14] and the Quality of Life with Heart Failure questionnaire (QLHF) [15, 16]. We have translated these two questionnaires into Albanian language and used them in Kosovo Heart Failure Patients [17]. The relationship between QoL and other demographic parameters proved controversial with some studies showing that older age is associated with lower QoL and others failing to show similar relationships [18,19,20,21]. Also, the relationship between QoL and other parameters, such as gender and race, remain controversial [22, 23]. Few studies investigated the relationship of QoL with exercise capacity and breathlessness, which showed that QoL correlated with limited exercise and higher NYHA class [24, 25]. But, in those studies the relationship of QoL and LV EF remains not certain [25,26,27]. Therefore, the aim of this prospective study was to assess the relationship between MLHFQ and exercise capacity in HF patients.

Methods

Study population

We studied 118 consecutive patients with a clinical diagnosis of congestive HF (age 62 ± 10 years, 57 female) with ischemic or non-ischemic aetiology, who were in New York Heart Association (NYHA) functional class I-III, and were referred to the Clinic of Cardiology, University Clinical Centre of Kosovo, between December 2014 and September 2016. At the time of the study all patients were on full cardiac medications, optimized at least 2 weeks prior to enrollment. Patients with NYHA class IV, those with limited physical activity due to factors other than cardiac symptoms (e.g. arthritis), with more than mild renal or hepatic failure, with chronic obstructive pulmonary disease, with recent acute coronary syndrome, stroke, psychological or psychiatric disorders, or those with severe anemia, were excluded from the study. All patients signed a written informed consent to participate in the study, which was approved by the Ethics Committee of the Medical Faculty, University of Prishtina. This study was supported and monitored by Kosovo Society of Cardiology [27], which is trying to implement European Society of Cardiology guidelines and other current diagnostic and therapeutic recommendations.

Data collection

A detailed history and clinical assessment were obtained in all patients. Routine biochemical tests, including hemoglobin, lipid profile, blood glucose level and kidney function, were also performed in all study patients. Estimated body mass index (BMI) was calculated from weight and height measurements. Waist and hip measurements were also made and waist/hip ratio was calculated.

Quality of life assessment

The MLHFQ contains 21 questions, whose aim is to determine how HF affects the physical, psychological and socioeconomic conditions of the patients (Additional file 1 Table S1). The questions refer to the signs and symptoms of HF, social relationships, physical and sexual activity, work and emotions [14] and assesses how HF affected the patient’s life during the previous month. The MLHFQ has a scoring range of 0 for no impairment to 105 for maximum impairment. The questions cover symptoms and signs relevant to HF, physical activity, social interaction, sexual activity, work, and emotions. Three scores were determined: an overall score (21 items, 0–105), the physical dimension (8 items, 0–40), and the emotional dimension (5 items, 0–25), with the highest scores reflecting the worse QoL. The scale of answers to each question ranges from 0 (none) to 5 (very much), where 0 represented no limitation and 105 represented maximal limitation.

Echocardiographic examination

A single operator performed all echocardiographic examinations using a Philips Intelligent E-33 system with a multi-frequency transducer, and harmonic imaging as appropriate. Using conventional landmarks and recommendations of the American Society of Echocardiography and European Association of Echocardiography [28, 29] we obtained all measurements including, interventricular septal (IVS) thickness, posterior wall (PW) thickness, and LV dimensions, LV volumes and EF using the modified Simpson’s method and left ventricular mass (LVM) using Devereux formula [30].

Ventricular long axis motion was also studied using conventional methods previously described [31], from which the following measurements were obtained; total amplitude as the mitral annular plane systolic excursion (MAPSE) and the tricuspid plane systolic excursion (TAPSE), and long axis myocardial velocities in systole (s’), early (e’) and late (a’) diastole. Mean value of the lateral and septal e’ velocities was also calculated. LV diastolic function was assessed from spectral Doppler recordings, from which LV early (E wave), late (A wave) diastolic velocities, E/A ratio and E/e’ (mean lateral and septal) ratio were all calculated. Finally, LV isovolumic relaxation time (IVRT) was measured. LV filling pattern was considered ‘restrictive’ when E/A ratio was >2.0, E wave deceleration time < 140 ms and the LA trasverse diameter was >40 mm [33]. LA diameter and volumes were measured, according to the guidelines of the American Society of Echocardiography and European Association of Echocardiography [29], maximal volume (LAV max) at the end systole and LA minimal volume (LAV min) at end diastole. LA total emptying fraction was calculated using the formula [32]:

$$ \mathrm{LA}\ \mathrm{total}\ \mathrm{emptying}\ \mathrm{fraction}=\mathrm{LAV}\ \max \hbox{--} \mathrm{LA}\mathrm{V}\ \min /\mathrm{LAV}\ \max\ \mathrm{x}\ 100 $$

Measurements of LV dyssynchrony

Indirect assessment of LV dyssynchrony was obtained by measuring total isovolumic time (t-IVT), Tei Index and LV-RV pre-ejection time delay, a spreviously described [33] using total LV filling time and ejection times. Total isovolumic time (t-IVT) was calculated as 60 - (total ejection time + total filling time) and was expressed in s/min [34]. Tei index was calculated as the ratio between t-IVT and ejection time [35].

Mitral and tricuspid regurgitation severity were assessed by colour and continuous wave Doppler and was graded as mild, moderate, or severe according to the relative jet area to that of the left atrium (LA) in line with the recommendations of the American Society of Echocardiography [36]. Retrograde trans-tricuspid pressure drop >35 mmHg was taken as an evidence for pulmonary hypertension [28]. All M-mode and Doppler recordings were made at a fast speed of 100 mm/s with a superimposed ECG (lead II). From the pulmonary artery flow recordings pulmonary artery acceleration time (PAAT) [37]. The LV outflow tract (LVOT) diameter and area were measured [38] in order to calculate the average velocity time integral (VTI) and the stroke volume (SV) [39].

NT-pro BNP measurement

Blood was taken from an antecubital vein in the morning, sober and after staying extended for 20 min. Blood samples were collected into tubes containing potassium ethylenediaminetetraacetic acid (EDTA) (1 g/L plasma) and N-terminal proBNP were calculated with the Cobas Elecsys E411 analyzer (range 5–35,000 pg/mL) using chemiluminescent immunoassay kit (Roche Diagnostics, Grenach -Wyhlen, Germany).

Six minute walk test

Within 24 h of the echocardiographic examination a 6-MWT was performed on a level hallway surface and was administered by a specialized nurse blinded to the results of the echocardiogram. According to the method of Gyatt et al. [40] patients were informed of the purpose and protocol of the 6-MWT, which was conducted in a standardized fashion without interrupting patient’s regular medications [41]. A 15 m flat, obstacle-free corridor was used and patients were instructed to walk as far as they can, turning 180° after they had reached the end of the corridor, during the allocated time of 6 min. Patients walked unaccompanied so as not to influence walking speed. At the end of the 6 min the supervising nurse measured the total distance walked by the patient.

Statistical analysis

Data are presented as mean ± SD or proportions (% of patients). Continuous data was compared with two-tailed unpaired Student’s t test and discrete data with Chi-square test. Correlations were tested with Pearson coefficients. Predictors of 6-MWT distance were identified with univariate analysis and multivariate logistic regression was performed using the step-wise method, a significant difference was defined as P < 0.05 (2-tailed). Patients were divided according to their ability to walk >300 m into good and limited exercise performance groups [42], and were compared using unpaired Student t-test.

Results

The baseline characteristics of the study population are presented in Table 1. All 118 patients completed the MLHFQ. Patients mean age was 62 ± 9.8 years, and 48% were women. The most common comorbidities were hypertension (67%) and diabetes mellitus (27%) and 30% were smokers. Mean 6-MWT distance was 315 ± 115 m, and 47% were in NYHA class II. Table 2 presents baseline echocardiographic variables.

Table 1 Baseline characteristics of the study patients
Table 2 Comparison of quality of life between patients HFpEF and HFrEF

The score of total MLHFQ scale was 48 ± 17, whereas the physical and emotional MLHFQ subscales scores were 24 ± 9 and 9 ± 5, respectively (Table 1). The total physical and emotional MLHFQ subscale scores were not different in patients with HF and preserved EF (HFpEF) compared to those with HF and reduced EF (HFrEF) (Table 2).

Five of 59 (10%) patients with HFpEF had AF, compared to 13 of 59 (22%) patients with HFrEF (p = 0.07). LA diameter was significantly larger in AF patients compared to non-AF patients in HFrEF patients (p = 0.001), but not in HFpEF (p = 0.123). However, the 6-MWT distance was not significant in both subgroups.

Patients with limited exercise vs. preserved exercise capacity (Tables 3 and 4)

Patients with limited exercise, who walked <300 m during 6-MWT, were older (p = 0.003), had higher NYHA functional class (p = 0.002), faster baseline heart rate (p = 0.006), higher prevalence of smoking (p = 0.015), and higher global, physical and emotional MLHFQ scores (p < 0.001, for all), compared to those with good exercise capacity. Patients with limited exercise also had larger LA diameter (p = 0.001), shorter LV FT (p = 0.027), smaller septal MAPSE (p = 0.037), higher E/e’ ratio (0.020), shorter IVRT (p = 0.028), PAAT (p = 0.005), lower septal a’ (p = 0.019) and s’ (p = 0.023), compared to those with preserved exercise capacity. All other clinical and echocardiographic parameters were not significantly different between two groups.

Table 3 Comparison of clinical and biochemical data between patients with limited exercise vs. preserved exercise capacity (6-min walk distance)
Table 4 Comparison of echocardiographic data between patients with limited exercise vs. preserved exercise capacity (6-min walk distance)

Relationship of total MLHFQ with clinical, biochemical and echocardiographic variables (Table 5)

In the patients’ group as a whole, total MLHFQ score had strong correlation with 6-MWT distance, lateral s’ (p < 0.001 for both), good correlation with LVMI (p = 0.001) and with lateral MAPSE (p = 0.009), and weak correlation with hemoglobin level (p = 0.024). In HFpEF, total MLHFQ score had strong correlation with 6-MWT distance (p < 0.001, Fig. 1), and weak correlation with lateral s’ (p = 0.014), LVMI (p = 0.027) and with hemoglobin level (p = 0.016), whereas in HFrEF patients it has only a weak correlation with lateral s’ (p = 0.03), LVMI (p = 0.027), lateral MAPSE (p = 0.027) and with E/A ratio (p = 0.047).

Table 5 Correlation of MLHFQ total score in HF patients with clinical, biochemical and echocardiographic variables in study patients
Fig. 1
figure1

Correlation between total MLHFQ score and 6-MWT distance in patients with heart failure

Predictors of limited 6-MWT distance in HF patients (Table 6)

Predictors of limited 6 MWT distance in all HF patients

In univariate analysis, total MLHFQ (p < 0.001), physical MLHFQ (p = 0.002), emotional MLHFQ (p = 0.002), age (p = 0.005), diabetes (p = 0.017), atrial fibrillation (p = 0.006), LA diameter (p = 0.001), IVRT (p = 0.047), PAAT (p = 0.008), septal MAPSE (p = 0.04), E/e’ (p = 0.029), septal a’ (p = 0.033), and septal s’ (p = 0.041), predicted limited 6 MWT distance. In multivariate analysis, only total MLHFQ score (p = 0.005), age (p = 0.035) and the diabetes (p = 0.045) remained independent predictors of limited 6-MWT distance. A total MLHFQ score of 48.5 had a sensitivity of 67% and specificity of 63% (AUC on ROC analysis of 72%) for predicting limited exercise performance (Fig. 2).

Table 6 Predictors of limited exercise in HF patients
Fig. 2
figure2

ROC-curve of MLHFQ - total score in predicting poor exercise performance on 6-min walk test in patients with heart failure

Predictors of limited 6-MWT distance in HFpEF patients

Univariate analysis identified total MLHFQ (p = 0.001), physical MLHFQ (p = 0.026), emotional MLHFQ (p = 0.007), BSA (p = 0.009), diabetes (p = 0.036), and NYHA class >1 (p = 0.012), hemoglobin level (p = 0.039), increased LVMI (p = 0.023), low lateral s’ (p = 0.013) and a’ (p = 0.032) as predictors of limited 6-MWT distance. In multivariate analysis, total MLHFQ (p = 0.007) and diabetes (p = 0.045) independently predicted the limited 6-MWT distance.

Predictors of limited 6 MWT distance in HFrEF patients

In univariate analysis, physical MLHFQ (p = 0.044), age (p = 0.015), NYHA class >1 (p = 0.036), LV mass (p = 0.036) and LA diameter (p = 0.008), predicted the 6-MWT limited exercise distance. In multivariate analysis, only LA enlargement (p = 0.005) and age (p = 0.013) remained independent predictors of limited 6-MWT distance.

Discussion

Findings

The results of this study analysis can be summarized as follows: 1) the total scale, physical and emotional MLHFQ subscale scores were not different between HFpEF and HFrEF patients. 2) Patients with limited exercise capacity were older, had higher NYHA functional class, faster baseline heart rate, higher prevalence of smoking and higher global, physical and emotional MLHFQ scores, compared to those with good exercise capacity. 3) Patients with limited exercise capacity, also had larger LA, shorter LV FT, worse longitudinal systolic function and raised LV filling pressures, compared to those with preserved exercise capacity. 4) Total MLHFQ score had strong correlation with 6-MWT distance in the patients group as a whole and in HFpEF subgroup, but not in HFrEF. 5) Total MLHFQ score, age and diabetes were the only independent predictors of limited 6-MWT distance in the whole group of patients and in HFpEF subgroup. It was LA enlargement and age which independently predicted limited exercise capacity in HFrEF.

Results interpretation

MLHFQ irrespective of its components; physical or emotional seems to be a good measure of exercise capacity, since it correlated strongly with the 6-MWT distance in the HF group irrespective of EF. Thus, it could be used to reflect the overall cardiac status, when used to evaluate patients’ response to treatment. It however, does not reflect the underlying cardiac structural or functional disturbances, which contribute to the limited exercise capacity in individual patients, and which might need different treatments. Age seemed to be correlating with limited exercise capacity but nothing can be done about it. On the other hand baseline heart rate proved to be an equally important factor but can be managed by beta blockers [43] or other forms of heart rate controlling medications e.g. Ivabridine [44], or the combination of the two [45]. Furthermore, patients with limited exercise capacity proved to have dilated LA [46, 47], the underlying pathophysiology of which is known to be complicated. It proved to be related to the high filling pressures in some [48] and poor LA emptying, as shown be short LV filling time, in others [49]. In addition to the variety of mechanisms of disturbed physiology, the matter is further complicated by the way patients differ in their response to treatment. While the former group usually responds to LA pressure lowering medications i.e. ACE-inhibitors or A2 blockers [50], the latter respond better to cardiac resynchronization therapy [51]. Finally, it seems that predictors of the limited exercise capacity differed fundamentally according to the cardiac physiology. While specifically the causes of LA enlargement; pressure, mitral regurgitation, stiff LV, etc., that limited patients exercise in HFrEF, the respective reasons were multifactorial including age, diabetes, as well as emotional and physical scores that predicted exercise capacity in HFpEF. The latter finding adheres to what is known about HFpEF in terms of its etiology, comorbidities as well as limited benefit when using conventional guidelines-based treatment recommendations [52]. The lack of an acceptable relationship between LA volume and exercise capacity in HFpEF could be explained by either strict early treatment with vasodilators which reduced cavity pressure and hence volume or less myocardial stiffness compared with HFrEF. Also, despite higher AF prevalence in HFrEF patients compared to HFpEF, our analysis suggest that AF was not necessarily a determinant factor for the difference in relationship between left atrial enlargement and 6-MWT. It seems therefore that more than one factor could contribute to the lack of direct relationship between the LA volume and exercise capacity in HFpEF. It was however not feasible to run a number of permutations and combinations in order to identify the additive value of various individual variables in predicting exercise capacity.

Clinical implications

Our findings suggest that the MLHFQ correlates with 6MWT distance in heart failure patients as a whole and is able, fairly accurately, to predict those with limited exercise capacity. These findings apply better to patients with HFpEF much more than those with HFrEF in whom clearly signs of raised LA pressures are those which independently determine their limited exercise capacity. These differences support the need for continuing the use of detailed Doppler echocardiographic follow up of heart failure patients in order to better understand the pattern of disturbances that explain symptoms as well as the most accurate treatment option.

Limitations

Obvious limitations can easily be seen in this study. The small number of patients included in this study limits general application of the findings before results are revalidated in a larger cohort. We consider that further prospective cohort studies with a larger sample size, are undoubtedly needed to strengthen or refute our findings. Speckle tracking ultrasonography to measure the global longitudinal strain, which might be associated with reduced functional capacity in HF patients was not used. However, assessing longitudinal LV function with conventional tools, provided an estimate of other overall longitudinal LV function. We cannot ignore the emotional element in conducting the 6-MWT and patient encouragement to walk faster, although unassisted. We did not assess the reproducibility of the results of the MLHFQ neither the 6-MWT distance, which could have shown significant differences.

Conclusion

Although the conventionally used MLHFQ, irrespective of its components, correlates closely with the 6-MWT distance in HF patients particularly HFpEF. Raised filling pressures seem to be the strongest independent predictor of limited exercise capacity in HFrEF. These differences might impact treatment options in the two conditions.

Abbreviations

6-MWT:

Minute walk test

A:

Atrial diastolic velovity

a’:

Atrial myocardial velocity

BMI:

Body mass index

BSA:

Body surface area

DT:

Deceleration time

E:

Early diastolic velocity

e’:

Early diastolic myocardial velocity

EF:

Ejection fraction

FT:

Filling time

HF:

Heart failure

HFpEF:

Heart failure with preserved ejection fraction

HFrEF:

Heart failure with reduced ejection fraction

LA EF:

Left atrial emptying fraction

LA:

Left atrium

LAV max:

Left atrial maximal volume

LAV min:

Left atrial minimal volume

LV:

Left ventricle

LVM:

Left ventricular mass

LVMI:

Left ventricular mass index

LVPWd:

Left ventricular posterior wall in diastole

MAPSE:

Mitral annular plane systolic excursion

MLHFQ:

The Minnesota Living with Heart Failure Questionnaire

NYHA:

New York Heart Association

PA:

Pulmonary artery

QoL:

Quality of life

RV:

Right ventricle

s’:

Systolic myocardial velocity

TAPSE:

Tricuspidal annular plane systolic excursion

References

  1. 1.

    Jessup M, Marwick TH, Ponikowski P, Voors AA, Yancy CW. 2016 ESC and ACC/AHA/HFSA heart failure guideline update - what is new and why is it important? Nat Rev Cardiol. 2016;13(10):623–8.

    Article  PubMed  Google Scholar 

  2. 2.

    Working Group on Cardiac Rehabilitation & Excercise Physiology and Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise testing in chronic heart failure patients. Eur Heart J. 2001;22(1):37–45.

    Article  Google Scholar 

  3. 3.

    Wilson JR, Hanamanthu S, Chomsky DB, Davis SF. Relationship between exertional symptoms and functional capacity in patients with heart failure. J Am Coll Cardiol. 1999;33(7):1943–7.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Bittner V, Weiner DH, Yusuf S, Rogers WJ, McIntyre KM, Bangdiwala SI, et al. Prediction of mortality and morbidity with a 6-min walk test in patients with left ventricular dysfunction. SOLVD investigators. JAMA. 1993;270(14):1702–7.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Alahdab MT, Mansour IN, Napan S, Stamos TD. Six minute walk test predicts long-term all-cause mortality and heart failure Rehospitalization in African-American patients hospitalized with acute Decompensated heart failure. J Card Fail. 2009;15(2):130–5.

    Article  PubMed  Google Scholar 

  6. 6.

    Morcillo C, Aguado O, Delás J, Rosell F. Utilidad del Minnesota Living With Heart Failure Questionnaire en la evaluación de la calidad de vida en enfermos con insuficiencia cardiaca. Rev Esp Cardiol. 2007;60(10):1093–6.

    Article  PubMed  Google Scholar 

  7. 7.

    Bussoni MF, Guirado GN, Roscani MG, Polegato BF, Matsubara LS, Bazan SGZ, et al. Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction. Braz J Med Biol Res Rev Bras Pesqui Médicas E Biológicas Soc Bras Biofísica Al. 2013;46(9):803–8.

    CAS  Google Scholar 

  8. 8.

    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200.

    Article  PubMed  Google Scholar 

  9. 9.

    Wasywich CA, Gamble GD, Whalley GA, Doughty RN. Understanding changing patterns of survival and hospitalization for heart failure over two decades in New Zealand: utility of “days alive and out of hospital” from epidemiological data. Eur J Heart Fail. 2010;12(5):462–8.

    Article  PubMed  Google Scholar 

  10. 10.

    Joffe SW, Webster K, McManus DD, Kiernan MS, Lessard D, Yarzebski J, et al. Improved survival after heart failure: a community-based perspective. J Am Heart Assoc. 2013;2(3):e000053.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Stevenson LW. Design of therapy for advanced heart failure. Eur J Heart Fail. 2005;7(3):323–31.

    Article  PubMed  Google Scholar 

  12. 12.

    Jaarsma T, Beattie JM, Ryder M, Rutten FH, McDonagh T, Mohacsi P, et al. Palliative care in heart failure: a position statement from the palliative care workshop of the heart failure Association of the European Society of cardiology. Eur J Heart Fail. 2009;11(5):433–43.

    Article  PubMed  Google Scholar 

  13. 13.

    Hoekstra T, Lesman-Leegte I, van Veldhuisen DJ, Sanderman R, Jaarsma T. Quality of life is impaired similarly in heart failure patients with preserved and reduced ejection fraction. Eur J Heart Fail. 2011;13(9):1013–8.

    Article  PubMed  Google Scholar 

  14. 14.

    Rector TS, Cohn JN. Assessment of patient outcome with the Minnesota living with heart failure questionnaire: reliability and validity during a randomized, double-blind, placebo-controlled trial of pimobendan. Pimobendan multicenter research group. Am Heart J. 1992;124(4):1017–25.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Dobre D, de Jongste MJL, Haaijer-Ruskamp FM, Sanderman R, van Veldhuisen DJ, Ranchor AV. The enigma of quality of life in patients with heart failure. Int J Cardiol. 2008;125(3):407–9.

    Article  PubMed  Google Scholar 

  16. 16.

    Guyatt GH. Measurement of health-related quality of life in heart failure. J Am Coll Cardiol. 1993;22(4):A185–91.

    Article  Google Scholar 

  17. 17.

    Ahmeti A, Bajraktari G. Use of the “Minnesota living with heart failure questionnaire” quality of life questionnaire in Kosovo’s heart failure patients. Int Cardiovasc Forum J. 2016;9(1):36–40.

    Google Scholar 

  18. 18.

    Clark DO, Tu W, Weiner M, Murray MD. Correlates of health-related quality of life among lower-income, urban adults with congestive heart failure. Heart Lung J Acute Crit Care. 2003;32(6):391–401.

    Article  Google Scholar 

  19. 19.

    Gott M. Predictors of the quality of life of older people with heart failure recruited from primary care. Age Ageing. 2006;35(2):172–7.

    Article  PubMed  Google Scholar 

  20. 20.

    Pascale JM, Sosa CE, Orn A. Evaluation of interleukin-2 soluble receptor in patients with trypanosomiasis americana in Panama. Rev Med Panama. 1991;16(3):184–8.

    CAS  PubMed  Google Scholar 

  21. 21.

    Adebayo S, Olunuga T, Durodola A, Ogah O. Quality of life in heart failure: a review. Niger. J Cardiol. 2017;14(1):1.

    Google Scholar 

  22. 22.

    Hoekstra T, Jaarsma T, van Veldhuisen DJ, Hillege HL, Sanderman R, Lesman-Leegte I. Quality of life and survival in patients with heart failure. Eur J Heart Fail. 2013;15(1):94–102.

    Article  PubMed  Google Scholar 

  23. 23.

    Mbakwem AC, Aina FO, Amadi CE, Akinbode AA, Mokwunyei J. Comparative analysis of the quality of life of heart failure patients in south western Nigeria. World J Cardiovasc Dis. 2013;3(1):146–53.

    Article  Google Scholar 

  24. 24.

    Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, et al. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart Br Card Soc. 2002;87(3):235–41.

    CAS  Article  Google Scholar 

  25. 25.

    dos SJJA, JEA P, PRS B. Quality of life and clinical indicators in heart failure: a multivariate analysis. Arq Bras Cardiol. 2009;93(2):159–66.

    Article  Google Scholar 

  26. 26.

    Bajraktari G, Batalli A, Poniku A, Ahmeti A, Olloni R, Hyseni V, et al. Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction. Cardiovasc Ultrasound. 2012;10(1):36.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Bajraktari G. The Kosovo Society of Cardiology. Int Cardiovasc Forum J [Internet]. 2015 12 [cited 2016 Sep 18];2(1). Available from: http://icfjournal.org/icfj/index.php/icfj/article/view/93.

  28. 28.

    Gardin JM, Adams DB, Douglas PS, Feigenbaum H, Forst DH, Fraser AG, et al. Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography’s nomenclature and standards committee and task force for a standardized echocardiography report. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr. 2002;15(3):275–90.

    Article  Google Scholar 

  29. 29.

    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification. Eur J Echocardiogr J Work Group Echocardiogr Eur Soc Cardiol. 2006;7(2):79–108.

    Article  Google Scholar 

  30. 30.

    Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986;57(6):450–8.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Höglund C, Alam M, Thorstrand C. Atrioventricular valve plane displacement in healthy persons. An echocardiographic study. Acta Med Scand. 1988;224(6):557–62.

    Article  PubMed  Google Scholar 

  32. 32.

    Wakatsuki Y, Funabashi N, Mikami Y, Shiina Y, Kawakubo M, Takahashi M, et al. Left atrial compensatory function in subjects with early stage primary hypertension assessed by using left atrial volumetric emptying fraction acquired by transthoracic echocardiography. Int J Cardiol. 2009;136(3):363–7.

    Article  PubMed  Google Scholar 

  33. 33.

    Henein MY, Das SK, O’Sullivan C, Kakkar VV, Gillbe CE, Gibson DG. Effect of acute alterations in afterload on left ventricular function in patients with combined coronary artery and peripheral vascular disease. Heart Br Card Soc. 1996;75(2):151–8.

    CAS  Article  Google Scholar 

  34. 34.

    Duncan AM, Francis DP, Henein MY, Gibson DG. Importance of left ventricular activation in determining myocardial performance (Tei) index: comparison with total isovolumic time. Int J Cardiol. 2004;95(2–3):211–7.

    Article  PubMed  Google Scholar 

  35. 35.

    Tei C, Ling LH, Hodge DO, Bailey KR, JK O, Rodeheffer RJ, et al. New index of combined systolic and diastolic myocardial performance: a simple and reproducible measure of cardiac function--a study in normals and dilated cardiomyopathy. J Cardiol. 1995;26(6):357–66.

    CAS  PubMed  Google Scholar 

  36. 36.

    Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr. 2003;16(7):777–802.

    Article  Google Scholar 

  37. 37.

    Olariu A, Wellnhofer E, Gräfe M, Fleck E. Non-invasive estimation of left ventricular end-diastolic pressure by pulmonary venous flow deceleration time. Eur J Echocardiogr J Work Group Echocardiogr Eur Soc Cardiol. 2003;4(3):162–8.

    CAS  Article  Google Scholar 

  38. 38.

    Mowat DH, Haites NE, Rawles JM. Aortic blood velocity measurement in healthy adults using a simple ultrasound technique. Cardiovasc Res. 1983;17(2):75–80.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Finegold JA, Manisty CH, Cecaro F, Sutaria N, Mayet J, Francis DP. Choosing between velocity-time-integral ratio and peak velocity ratio for calculation of the dimensionless index (or aortic valve area) in serial follow-up of aortic stenosis. Int J Cardiol. 2013;167(4):1524–31.

    Article  PubMed  Google Scholar 

  40. 40.

    Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, et al. The 6-min walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J. 1985;132(8):919–23.

    CAS  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Guyatt GH, Thompson PJ, Berman LB, Sullivan MJ, Townsend M, Jones NL, et al. How should we measure function in patients with chronic heart and lung disease? J Chronic Dis. 1985;38(6):517–24.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Ingle L, Rigby AS, Nabb S, Jones PK, Clark AL, Cleland JGF. Clinical determinants of poor 6-min walk test performance in patients with left ventricular systolic dysfunction and no major structural heart disease. Eur J Heart Fail. 2006;8(3):321–5.

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Kotecha D, Flather MD, Altman DG, Holmes J, Rosano G, Wikstrand J, et al. Heart rate and rhythm and the benefit of Beta-blockers in patients with heart failure. J Am Coll Cardiol. 2017;69(24):2885–96.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Roth S, Fernando C, Azeem S, Moe GWI. There a role for Ivabradine in the contemporary Management of Patients with chronic heart failure in academic and community heart failure clinics in Canada? Adv Ther. 2017;34(6):1340–8.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Hidalgo FJ, Anguita M, Castillo JC, Rodríguez S, Pardo L, Durán E, et al. Effect of early treatment with ivabradine combined with beta-blockers versus beta-blockers alone in patients hospitalised with heart failure and reduced left ventricular ejection fraction (ETHIC-AHF): a randomised study. Int J Cardiol. 2016 Aug 15;217:7–11.

    Article  PubMed  Google Scholar 

  46. 46.

    Acarturk E, Koc M, Bozkurt A, Unal I. Left atrial size may predict exercise capacity and cardiovascular events in patients with heart failure. Tex Heart Inst J. 2008;35:136–43.

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Batalli A, Ibrahimi P, Bytyi? I, Ahmeti A, Haliti E, Elezi S, et al. Different determinants of exercise capacity in HFpEF compared to HFrEF. Cardiovasc Ultrasound [Internet]. 2017 Dec [cited 2017 Jun 15];15(1). Available from: http://cardiovascularultrasound.biomedcentral.com/articles/10.1186/s12947-017-0103-x.

  48. 48.

    Bajraktari G, Dini FL, Fontanive P, Elezi S, Berisha V, Napoli AM, et al. Independent and incremental prognostic value of Doppler-derived left ventricular total isovolumic time in patients with systolic heart failure. Int J Cardiol. 2011;148(3):271–5.

    Article  PubMed  Google Scholar 

  49. 49.

    Bytyçi I, Bajraktari G, Ibrahimi P, Berisha G, Rexhepaj N, Henein MY. Left atrial emptying fraction predicts limited exercise performance in heart failure patients. IJC. Heart Vessel. 2014;4:203–7.

    Article  Google Scholar 

  50. 50.

    Henein MY, O’Sullivan CA, Coats AJ, Gibson DG. Angiotensin-converting enzyme (ACE) inhibitors revert abnormal right ventricular filling in patients with restrictive left ventricular disease. J Am Coll Cardiol. 1998;32(5):1187–93.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Salukhe TV, Francis DP, Morgan M, Clague JR, Sutton R, Poole-Wilson P, et al. Mechanism of cardiac output gain from cardiac resynchronization therapy in patients with coronary artery disease or idiopathic dilated Cardiomyopathy. Am J Cardiol. 2006;97(9):1358–64.

    Article  PubMed  Google Scholar 

  52. 52.

    Oktay A, Shah S. Diagnosis and Management of Heart Failure with preserved ejection fraction: 10 key lessons. Curr Cardiol Rev. 2014;11(1):42–52.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Author information

Affiliations

Authors

Contributions

GB, SE and MH designed the manuscript; Data acquisition was made by AB, AP and EH; AA, PI and GB analyzed and interpreted the data; AB, AA AP and EH drafted the manuscript; MH, PI, GB and SE revised critically. All authors read, approved the manuscript for publication and agreed to be authors of the manuscript.

Corresponding author

Correspondence to Gani Bajraktari.

Ethics declarations

Ethics approval and consent to participate

All patients signed a written informed consent to participate in the study, which was approved by the Ethics Committee of the Medical Faculty, University of Prishtina (Statement Nr.3729, date 22.10.2010). This study was supported and monitored by Kosovo Society of Cardiology [27], which is trying to implement European Society of Cardiology guidelines and other current diagnostic and therapeutic recommendations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional file

Additional file 1: Table S1.

The Minnesota Living with Heart Failure Questionnaire. (DOC 29 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ahmeti, A., Henein, M.Y., Ibrahimi, P. et al. Quality of life questionnaire predicts poor exercise capacity only in HFpEF and not in HFrEF. BMC Cardiovasc Disord 17, 268 (2017). https://doi.org/10.1186/s12872-017-0705-0

Download citation

Keywords

  • Heart failure
  • The Minnesota Living with Heart Failure Questionnaire
  • Exercise capacity
  • 6 min walk test
  • Echocardiography
  • Quality of life