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vol. 8
Original paper

Assessing the quality of life and depression among patients with heart failure and heart attack

Anna-Maria Giournta
1, 2
Victoria Alikari
Charalampos Platis
Georgia Oikonomopoulou
5, 6
Dimitrios Alefragkis
Paraskevi Theofilou
2, 8

Department of Psychology, University of Central Lancashire, Preston, UK
College for Humanistic Sciences – ICPS, Athens, Greece
Department of Nursing, University of West Attica, Athens, Greece
National Centre of Public Administration & Local Government, Athens, Greece
European Association of Hospital Managers (ΕΑΗΜ), Bertrange, Luxemburg
Hellenic Health Services Management Association (HHSMA), Athens, Greece
Errikos Ntynan Hospital Center, Athens, Greece
General Direction of Health Services, Ministry of Health, Athens, Greece
Health Psychology Report, 8(3), 211–218
Online publish date: 2020/06/01
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People who suffer from heart failure have diverse physical and emotional symptoms such as shortness of breath, fatigue, edema, sleeping difficulties, depression, and chest pain (Alpert, Smith, Hummel, & Hummel, 2017; DeVon et al., 2017). These symptoms decrease patients’ daily physical and social activities as a result of poor quality of life (QoL) (Dunlay et al., 2015). Poor QoL is associated with high rates of hospitalization and mortality (Bundgaard et al., 2020). There are heart failure symptoms and limitations to patients’ daily life but they have a positive attitude towards physical, psychological, and social status as well as their behavior. Juenger et al. (2002) established that in congestive heart failure, QoL decreases as New York Heart Associa-tion (NYHA) functional class worsens. Though the NYHA functional class is the most dominant predictor among the somatic variables studied, the major determinants of reduced QoL remain unknown (Juenger et al., 2002).
As far as heart attack is concerned, patients who are at working age have the worst QoL. Impaired quality of life is reported by patients unfit for work, those with angina and dyspnoea, patients with coexistent lung disease, and those with anxiety and sleep disturbances (Brown, 2000). Furthermore, according to Höfer, Lim, Guyatt, and Oldridge (2004) the most repeated and significant problem is in the domains of symptoms, restriction, confidence, self-esteem, and emotions. General self-efficacy is positively related to physical and mental QoL two years after the heart attack. For patients with cardiac illness, there is a correlation between self-efficacy and quality of life (Banik, Schwarzer, Knoll, Czekierda, & Luszczynska, 2018; Barham, Ibraheem, & Zyoud, 2019). Of course, there are correlations with other aspects such as fatigue, disturbed sleep, self-efficacy, and QoL. Hoekstra et al. (2013) inform us that poor QoL predicts higher mortality in patients with heart failure. This study was the first in this specific domain with a large sample (N = 661), where the effect of QoL on mortality was adjusted for levels of brain natriuretic peptide, a widely accepted marker for disease severity and a prognostic tool to predict mortality.
Depression is higher in hospitalized heart failure patients than in stabilized outpatients. Indeed, the assessment of depression in heart failure outpatients is more reliable because symptoms of heart failure are more stable in this phase. Therefore, evaluation and treatment of depression should be started at the diagno-sis of heart failure and continued throughout the course of the disease because the level of depression is fre-quently altered, due to the involvement of other factors. Studies have suggested a worse outcome in heart fail-ure patients with depression across a broad range of events including mortality, healthcare use, and associat-ed clinical conditions. Depression was found to be an independent risk factor for mortality in heart failure, and this persists independently of NYHA class. Three predictors for depression in congestive heart failure hospitalized patients have been identified: functional impairment, the severity of illness, and comorbid psy-chiatric disorder (Lefteriotis, 2013; Mbakwem, Aina, & Amadi, 2016; Kourkouta et al., 2015; Hiriscau & Bodolea, 2019). Joekes, Van Elderen, and Schreurs (2007) found that general self-efficacy was positively related to physical and mental QoL two years after a heart attack.
Treatment of chronic diseases such as heart failure and coronary artery disease aims not only at the improvement of prognosis and relief of symptoms but also at the improvement of QoL, which is decreased in these patients (Unsar, Sut, & Durna, 2007). The restriction of their usual activities due to the development and worsening of symptoms (dyspnea, angina, fatigue) as well as the increased incidence of rehospitalization, impacts negatively their QoL. In these patients, their daily activity is restricted as well as their social interac-tion since symptomatic patients with heart failure and/or coronary artery disease (especially in advanced stage) confine their activity to home because of their symptoms or because of the fear to reveal symptoms. Thus, the QoL is considered nowadays at least as important as symptoms and has been recognized as an im-portant target of therapy. Also, health care interventions which aim to control heart failure and coronary heart disease are assessed (Huffman, Adams, & Celano, 2018).
Many studies on the quality of life in patients with heart failure and a heart attack have been per-formed. The outcomes are so interesting and some of them were mentioned. Based on the above, the aim of the present study was to investigate 1) the QoL among patients with heart failure and a heart attack, 2) de-pression among patients with heart failure and a heart attack as well as 3) correlation between these two vari-ables (quality of life and depression) among these groups of patients. Moreover, there is a gap in the bibliog-raphy in these specific aspects, as there are no articles related to these patients, so there was a challenge to investigate these domains together. Specifically, our main hypotheses are the following: 1) patients with heart failure will present higher levels of depression compared to those with a heart attack, 2) patients with heart failure will present lower QoL than patients with a heart attack and 3) depression is correlated with overall QoL in the total sample.



In this cross-sectional study, 60 participants (30 with heart failure and 30 with a heart attack) were recruited from Tzaneion General Hospital of Piraeus (Attica, Greece). Selection criteria included i) age > 18 years old, ii) clinical diagnosis: heart failure stage I-II, and heart attack. Exclusion criteria were: heart failure stage III and IV, difficulty in communication, and psychiatric problems. Patients were stratified so that the two groups had the same demographic and clinical characteristics.


In the current study, two instruments were used:
The Missoula-VITAS Quality of Life Index (MVQ-oLI-15; Byock & Merriman, 1998) compiles infor-mation about QoL during an advanced illness. The specific questionnaire can be used in a variety of health care settings such as hospitals, hospices, home health, long-term care, outpatient palliative care, and pre-hospice programs (Byock, 1996). The MVQoLI-15 examines 5 dimensions or domains of QoL: Symptoms, Function, Interpersonal, Well-Being, and Transcendence. Within each dimension, three kinds of information are gathered from respondents in order to illuminate their overall experience: Assessment (A) – the subjective measurement of actual status or circumstance; Satisfaction (S) – the degree of acceptance or mastery of actual circumstance; Importance (I) – the degree to which a dimension has an impact on overall QoL. The items are scored as follows: Assessment (–2 to +2), Satisfaction (–4 to +4) Importance (1 to 5) where: (Assessment + Satisfaction) × Importance = QoL in each dimension. Negative dimensions diminish QoL, positive dimensions increase QoL. In this study, the Greek version of MVQoLI-15 was translated by Theofilou, Kapsalis, and Panagiotaki (2012) with very good psychometric properties (Cronbach’s α index: .74) (Theofilou, Aroni, Ralli, Gouzou, & Zyga, 2013). It has been used in many studies in Greece (Zyga et al., 2015; Alikari et al., 2019). The reliability of the scale was investigated in this study (Cronbach’s α: .78).
The Center for Epidemiological Studies Depression Scale (CES-D) was used for the assessment of de-pression. This questionnaire was designed for research for the general population; for this reason, it is shortly extended. This 20-item scale asks subjects to estimate the frequency of their experienced symptoms related to depression during the last week including restless sleep, poor appetite, and feeling lonely. Responses range from 0 to 3 for each item (0 – rarely or never, 1 – some or little of the time, 2 – moderately or much of the time, 3 – most or almost all the time) and scores range from 0 to 60 (Radloff, 1977). There are cutoff scores (16 or higher), that help to identify people at risk of clinical depression. In this study, the Greek version of the CES-D was used (Fountoulakis et al., 2001). It has been used for a variety of other studies (Fountoulakis et al., 2003; Mougias et al., 2015). The reliability was tested in this study (Cronbach’s α: .88)
Finally, the sociodemographic elements were recorded. The study took place between February 2018 and April 2018.


Participants signed the consent form and were informed about the anonymity of the data, that the data would be used for research purposes only and that they had the right to refuse or discontinue participation, accord-ing to the ethical standards of the Helsinki Declaration of 1983. Ethical permission for the research was ob-tained from the Scientific Committee of the Tzaneion Hospital.


Analyses such as standard deviations, means including maximum and minimum values and statistical signif-icance were performed. As far as descriptive statistics is concerned, frequencies were determined for each variable. The normality of variables was examined in order to determine any statistical significance in these variables. Consequently, statistically significant differences occur only for the variable CES-D Total that ex-presses the depression level of the participants. The variables CES-D Total, Symptoms, Function, Interperson-al, Well-being, and Transcendence do not follow the normal distribution. On the other hand, the variable MVQoLI-15 Total is normally distributed (p > .05). This means that for the variables CES-D Total, Symptoms, Function, Interpersonal, Wellbeing, and Transcendence non-parametric tests were used, while for the variable MVQoLI-15 Total parametric tests were used. The reliability of both scales was investigated through the Cronbach’s α index. In order to test the differences between the two study groups, the Mann-Whitney test was carried out. Finally, for the correlation of CES-D Total and MVQoLI-15 Total, the Pearson test was performed. Data were analyzed through IBM Statistics SPSS 20.0. The statistical level was set at 0.05%.



The basic demographic characteristics of the sample are presented. Most patients were male, married and the mean value of the participants’ age was 67.24 years (Table 1).
Table 2 summarizes the main descriptive results for (i) the sample suffering from heart failure and (ii) the sample suffering from a heart attack. The mean value of CES-D Total is higher for the patients suffering from heart failure. Moreover, the QoL for the patients suffering from heart failure is higher regarding Function, lower regarding Interpersonal Relationships, Well-Being, Transcendence, and about the same regarding Symp-toms, compared to the levels of the patients suffering from a heart attack. Regarding the CES-D, the minimum value is 1, which means no depression at all, and the maximum is 38, which indicates a very depressed per-son, leading to a range of 37.
In order to verify the differences between the two groups, the Mann-Whitney test was carried out (Ta-ble 3).
As shown in Table 4, statistically significant differences occur only for the variable CES-D Total, which expresses the depression level of the participants (p < .05). More specifically, the depression levels are higher for the patients suffering from heart failure, compared to those suffering from a heart attack. For all the other variables, the differences are not statistically significant (p > .05 for all cases).
As far as the MVQoLI-15 Total is concerned, the variable followed the normal distribution. The t-test (t = –1.53) showed that although we have a mean difference equal to –9.64 (mean for MVQoLI-15 = 28.42, mean for CES-D = 38.06) between the two groups of participants, that difference is not statistically significant (p > .05).
Finally, for the correlation of CES-D Total with the MVQoLI-15 Total variables, both Pearson r and Spearman rho tests were carried out. As shown in Table 5, according to the Pearson r test, there is a statistically significant negative correlation between the two variables (p = .001).


The main focus of the present study was to examine QoL in patients with heart failure and heart attack and investigate the possible differences. The results provide evidence that although the sense of wellbeing is low accompanied by a low level of daily activities (function) in the overall population, parameters such as QoL, Interpersonal Relationships, Symptoms, and Transcendence (sense of life meaning) are above the average. Low sense of wellbeing and function are common in patients with heart failure and/or a heart attack. Several studies (Saran, Puri, & Agarwal, 2012; Juenger et al., 2002) assessed this issue and found that the symptoms that accompanied these diseases as well as the global limitation of their activity affected negatively those pa-rameters. In a prospective study (Herlitz et al., 1999) the authors found that in these patients, wellbeing and quality of life were impaired, and the presence of supervening diseases, such as diabetes mellitus and chronic obstructive pulmonary disease, aggravated further their quality of life and the sense of wellbeing. Similarly, in another prospective study among coronary heart disease patients (Lukkarinen & Hentinen, 1997), the authors found that the quality of life of those patients was significantly poorer in all the six dimensions of physical mobility, pain, sleep, energy, emotional reactions, and social isolation before treatment. Likewise, in patients with heart failure, well-being, and quality of life are compromised. In a prospective study, Juenger et al. (2002) concluded that the QoL and wellbeing were significantly related to functional status and precisely to NYHA class. Patients with higher NYHA class presented a worse sense of wellbeing and quality of life.
In addition, we found that the depression levels were higher in patients suffering from heart failure than in those suffering from a heart attack. The complexity of heart failure, as well as the plethora of symp-toms, and the increased incidence of rehospitalization due to heart failure decompensation, may explain these results. Although the groups of patients (with coronary heart disease and heart failure) require a close follow-up and monitoring, patients with heart failure present more often progressive or acute decompensation due to the nature of this syndrome. Current guidelines recommend, for those patients, very close monitoring with a ‘seamless’ system of care, embracing both the community and hospital, to ensure that the management of every patient is optimal (McMurray et al., 2012). In fact, these patients need to be monitored daily in order to assess symptoms, weight, fluid intake and output and to prevent consequently or diagnose early a decompensation (McMurray et al., 2012). In a prospective study that assessed the prevalence of depression in patients with or without heart failure who were hospitalized with a heart attack, major depression was ob-served in 43% in the heart failure group compared with 36% in the non-heart failure group (Powel et al., 2005). Likewise, in another prospective study among patients after a heart attack, patients with symptoms of angina reacted to the illness with anxiety more than depression, whereas patients with heart failure with dyspnea reacted to the illness with depressive symptoms more than anxiety (Moryś, Bellwon, Höfer, Ryn-kiewicz, & Gruchała, 2016).
Nowadays, it is established that from the societal and social points of view, the patients’ quality of life is even more important than the objective medical outcome. In a prospective study that enrolled 99 patients with advanced heart failure, heart failure patients expressed meaningful preferences about quality of life with respect to the length of life (Lewis et al., 2001).


Since the sample size of our study is small, it is not possible to generalize these results for all patients with heart failure and/or a heart attack. However, this single-center study is in line with other multicenter studies assessing this issue. In addition, the questionnaires were completed during the course of treatment. Thus, the presence of other patients and medical staff may influence the objectivity of the responses. However, this is a common limitation of such studies when the results are based on the subjective perception of patients.


According to the findings of this study, patients with heart failure present higher levels of depression and lower quality of life than patients with a heart attack. However, some dimensions of QoL are higher for heart failure patients. Also, depression is correlated with the quality of life in the overall sample. Thus, we suggest the creation of interdisciplinary teams that also involve nurses in order to amplify and expand health care management, assessing not only the medicinal side of care but also including broader aspects of physi-cal, mental, and social health. We also suggest the creation of specialized nurse personnel in heart failure and/or coronary artery disease in order to better perceive and understand not only symptoms but also the nature of the disease, improving health care management.
Health psychologists use a bio-psychosocial guide in recognizing health practices. This method cen-ters on understanding wellness to be the result not only of biological processes (hormonal and endocrine functioning) but also of mental processes such as approaches toward health and how people cope with stress in their lives.


We thank patients for their participation and the Scientific Council of Tzaneion Hospital.


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