Microsoft Word - 28-Enf_37239 1089 Original Article Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 IMPACT OF PHYSICAL LIMITATION IN LIFE QUALITY HEALTH RELATED OF HEART FAILURE PATIENTS IMPACTO DA LIMITAÇÃO FÍSICA NA QUALIDADE DE VIDA RELACIONADA À SAÚDE DE PACIENTES COM INSUFICIÊNCIA CARDÍACA Paula Cristina SILVA 1 ; Bruno Fagundes dos SANTOS 2 ; Omar Pereira de ALMEIDA NETO 3 ; Cristiane Martins CUNHA 4 ; Elmiro Santos RESENDE 5 ; Leila Aparecida Kauchakje PEDROSA 6 1. Mestranda em Ciências da Saúde, Universidade Federal de Uberlândia – UFU, Uberlândia, MG, Brasil; 2. Enfermeiro, UFU, Uberlândia, MG, Brasil; 3. Doutorando em Atenção à Saúde – UFTM, Professor na Unidade de Ciências da Saúde - Universidade Federal de Goiás; 4. Doutora em Ciências – EERP/USP, Professora na Faculdade de Medicina - UFU, Uberlândia, MG, Brasil; 5. Doutor em Cardiologia, Professor na Faculdade de Medicina UFU, Uberlândia, MG, Brasil; 6. Doutora em Enfermagem, Professora na Universidade Federal do Triângulo Mineiro. ABSTRACT: The heart failure (HF) it’s a self-limiting and severe condition, of varied etiology, with negative repercussions to the political-economic framework, and to health related life quality (HRLQ) of patients with HF, due to its standard symptoms and effects. Its’s believed that due to the reduced cardiorespiratory competence coming for the HF, certain physical limitation levels would be expressed, impairing directly the HRLQ. To evaluate the physical limitation impact in the HRLQ of Heart Failure patients. Cross-sectional study, quantitative, descriptive and analytical character, conducted with patients treated at a Cardiology outpatient clinic from a university hospital. To evaluate the patients was used: characterization questionnaire Clinic and Socioeconomic, Minnesota Living With Heart Failure Questionnaire (MLHFQ) and the Veterans Specific Activity Questionnaire (VSAQ). The data was managed in Microsoft Office Excel® 2010 program, double independent entry. Subsequently imported into Statistical Package for Social Science program (SPSS), version 21.0, which were conducted exploratory analyzes of data from the calculation of simple absolute and percentage frequencies for categorical variables and measures of centrality and dispersion for quantitative variables, as well as parametric testing Pearson correlation, since the normal distribution of variables. In the research were included 108 patients, with a predominance of female participants (50.90%), mean age of 66.55±11.41 years. Regarding the NYHA functional classification at level II (50%) and NYHA III (39.80%) were the most prevalent. The etiologies of HF was the most prevalent Chagas' Heart (50.90%). The MLHFQ showed negative impact of the IC under the HRLQ, which presented a total score of MLHFQ of 51.87±15.74 points. At the physical limitation the VSAQ resulted in an average of 3, 37±1, 41 with bigger impairment to the METS3 (45, 4%). The MLHFQ and VSAQ correlation presented itself negative, moderate to strong and significant (p<0, 01) it results for each domain being: physical (-0,523); emotional (-0.436); nonspecific (- 0,411), and MLHFQ’s total score (-0,562). It has been confirmed that the greater the degree of heart damage due to HF presents, the lower will be the patient’s MET results confirming a physical limitation as a HRLQ’s impairing predictor. KEYWORDS: Heart Failure. Life Quality. Physical Capacity INTRODUCTION Heart diseases (HD) are one of the world’s most common causes of death (WHO, 2011). It stands as the third most common hospitalization cause in Brazil’ health system, Sistema Único de Saúde (SUS) from which Heart Failure (HF) is the most frequent of those (BOCCHI et al., 2012; BRASIL, 2012a; BRASIL, 2012b). HF is a severe, self-limiting and multi etiological condition when the heart muscle lacks the strength to sustain the body tissue’s nutrition and oxygen support (SPINAR et al., 2011; LATUF, 2013; DIAS et al., 2015). It’s known that the HF’s main consequences regarding its symptoms are the dyspnea, the edema and the fatigue related to the physical limitation, which due to its pathophysiology there is a cardiac output reduction and an increase from both, lung and systemic venous pressure, leading to functional capability’s deficits, the last being an important HD’s mortality predictor and prognostic marker (DI NASO et al., 2011; DIAS et al., 2015). Inside this context some instruments have been developed aiming to evaluate HF patient’s physical limitation. Among those methods there’s the HF’s functional classification from New York Heart Association (NYHA), which is based according with the symptoms presented by the patient when performing daily activities, varying from I to IV and the Veterans Specific Activity Questionnaire (VSAQ), which is an instrument able to measure the HF’s physical limitation though metabolic equivalents (METs) (MYERS et al., 1994; DOMINGUES, 2010; DI NASO et al., 2011). Each MET represents an increase of 10% in the Received: 11/12/16 Accepted: 05/05/17 1090 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 survival rate, meaning that the higher the MET result, the better the patient’s aerobical capability is, as well as its functional performance (COELHO- RAVAGNANI et al., 2013). It’s believed that the HF’s physical repercussions have direct influence in the individual’s social relationships and emotional aspects, directly and indirectly affecting its live quality (LQ) and resulting in a HRLQ’s impairment. In this context, the measurement of the HF patient’s HRLQ becomes important due to the possibility to evaluation and/or comparison of the clinical interventions effects (MONTEIRO et al., 2010; SANTOS et al., 2012). Recently the research of the physical limitation’s impact over the HRLQ has been increased in the international dimension. However, despite it’s an important marker and HRLQ influencer, there are very few researches developed and the physical aptitude instruments and the HF patient’s HRLQ evaluation are not normally used in the national literature (DOMINGUES, 2010; SPINAR et al., 2011; DIAS et al., 2015). It’s already known that researches regarding this type of subjects (LQ and physical limitation evaluation) may present valuable information when establishing parameters, making possible the construction of an situational diagnosis for each patient aiming to identify its needs and risks, help in the health professional approach, improve the health team’s communication, and verify the health results in pre-developed goals and objectives (DI NASO et al., 2011). In this context the objective of this research was to evaluate the physical limitation impact in HF patient’s HRLQ. MATERIAL AND METHODS Research type, Population and Ethic aspects Cross-sectional study, quantitative, descriptive and analytical character, conducted with patients treated at a Cardiology outpatient clinic from a university hospital from Minas Gerais (MG), approved by the Ethics and Research Committee with Human under protocol nº1.240.465, conducted with HF patients, older than 18 years old who haven’t been admitted to the hospital in the last 30 days. Applicants Recruiting and Data Collect Instruments It has been developed a pilot study to ten patients how fit in the requirements to participate in the study, and obtained a total sample of 108 patients, the collecting period stretched out from December 2015 until February 2016. Through the consent form’s singing, the participants answered the instruments questions, beginning with the instrument named, Clinical and Socio-demographic Characterization Questionnaire (DE ALMEIDA NETO; PEDROSA, 2015). Next, It’s been utilized the Minnesota Living With Heart Failure’s (MLHFQ) Brazilian validated version, for HRLQ’s measurement (RECTOR; COHN, 1992; CARVALHO et al., 2009). And finally it was applied the VSAQ’s Brazilian validated version in order to quantify de HD patient’s physical limitation corresponding MET (MYERS et al., 1994; DOMINGUES, 2010). Data Managing and Statistical Analysis The data were managed in the Program Microsoft Office Excel® 2010, followed by its data bank validation. Afterwards, the data were imported to the Statistical Package for the Social Science (SPSS®) software, 20.0 version, for statistical analysis. Exploratory analysis of the data were made after the definition of the absolute simple and percentage frequencies to de categorical variables and centrality and dispersion measures to the quantitative variables. The Cronbach α internal consistency measures were used to verification of MLHFQ’s results. In order to verify the relation between the quantitative variables (MLHFQ/VSAQ), Pearson’s correlation test was applied. A significance level equals 5% (p≤ 0, 05) was adopted to the bivariate analyzes. The correlations were classified as: weak (0< r < 0, 3), moderate (0, 3< r < 0, 5) or strong (r ≥ 0, 5). RESULTS AND DISCUTION Socioeconomic characteristics Were found in this study a prevalence of participants in white color, married, retired and from the female gender (Table 1). The women prevalence diverge from other studies (NOGUEIRA; RASSI; CORRÊA, 2010; ALITI et al., 2011; LINDVALL; HULTMAN; JACKSON, 2014; ALMEIDA; GUTIERREZ; MARQUES, 2012). 1091 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 Table 1. Socioeconomic characteristics of the following categorical variables: sex, color, marital status, religion, work condition, from HD patients attended at the heart clinic of an university Hospital from MG since December 2015, until February 2016. VARIABLE N % Sex Female 55 50,90 Male 53 49,10 Color White 56 51,90 Brown 35 32,40 Black 14 13,00 Yellow 3 2,80 Marital state Married 58 53,70 Widower 22 20,40 Devorced 16 14,80 Single 12 11,10 Religion Catolic 65 60,20 Evangelic 30 27,80 Spiritist 6 5,60 Other 5 4,60 No religion 2 1,90 Work Condition Retired 95 88,00 Active 7 6,50 Inactive 6 5,60 TOTAL 108 100 Source: O Author, 2016 The 2010 census from the Brazilian Institute of Geography and Statistics (IBGE) may justify the divergence above mentioned due to the bigger number of women living in the country (IBGE, 2010). Another explanation lays on the fact that the male population tends to delay the heath assistance exposing themselves to risky situations, more frequent hospitalization and other comorbidities (BARBOSA; JURKEVICZ, 2010). Clinical characteristics As observed in Table 3, the number of patients with NYHA I classification was very low, but this may be explained by the asymptomatic characteristic of this level classification. While those who got NYHA IV normally tend to skipping directly and frequently to hospital internment, which is not this research focus. Table 3. Clinical characteristics from HF patients attended at the heart clinic of an university Hospital from MG since December 2015, until February 2016. VARIABLE N % NYHA Functional Class I 7 6,50 II 54 50,00 III 43 39,80 IV 4 3,70 Etiology Chagasic Heart disease 55 50,90 1092 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 Isquemic Heart disease 29 26,90 Hipertensive Heart disease 12 11,10 Valvular Heart disease 6 5,60 Idiopatic 6 5,60 Medications Betablocker 63 58,30 Diuretic 70 64,80 ACEI / ARB 62 57,40 Antithrombotic 46 42,60 Estatin 26 24,10 Nitrate 24 22,20 Digitalic 19 17,60 Antidepressant / Axiolytic 18 16,70 Comorbidities Chagas 64 59,30 Systemic artherial hipertension 57 52,80 Arrhithmia 31 28,70 Atrioventricular block 27 25,00 Dyslipidemia 17 15,70 Coronarian Artherial Desiese 16 14,80 Anxiety / Depression 16 14,80 Diabetes mellitus 13 12,00 Hipotireoidism 9 8,30 Angina 9 8,30 Atrial fibrilation 8 7,40 Stroke 6 5,60 Chronic renal failure 6 5,60 Obesity 5 4,60 Surgical Heart Procedure Pacemaker 82 75,90 Angioplasty 21 19,40 Revascularization 6 5,60 Valvuloplasty 2 1,90 Life Habits Physical Activite 3 2,80 Smoker 13 12,00 Ex-smoker 28 25,90 Alcoholic 10 9,30 Ex-Alcoholic 20 18,50 Heart Rehabilitation 0 0 Source: The Author, 2016. The main HF cause identified in this study was the chagasic heart desiese (55;50,90%) followed by the isquemic heart desiese (29; 26,90%), such data corroborate with the ones found by Nogueira, Rassi and Corrêa, (2010) and Porto, Rassi and Costa Neto, (2012). This data is justified by the prevalence of Chagas disease (64; 59, 30%) as main comorbidity found among the selected patients. According to WHO, about sixteen to eighteen million people have Chagas disease in Latin America, in Brazil the number of infected it’s close to five million people, with the highest infection rates being of the southeast region (XAVIER et. al, 2015). Following this reasoning, it’s justifiable the surgical procedures most common at the study (Pacemaker 75,90% and angioplasty 19,40%), because the pace maker implant is a standard procedure in patients with Chagas disease, due to the damage caused on the cardiac muscle, generating clinical conditions of bradyarrhithmia, VAB and deficient sinus node conduction (GONZALEZ et. al, 2014.). 1093 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 Health Related life quality in Heart Failure Patients The LQ evaluation is as important at the health area as in the generic scientific field, since its concept interposes to the health concept: satisfaction and wellbeing in all physical, socioeconomic and cultural scope (MONTEIRO et al., 2010; PEREIRA; TEIXEIRA; SANTOS, 2012). At the HRLQ measurement, the MLHFQ presented the scores shown at Table 4. Table 4. MLHFQ’s characteristics classified by domains and total score, from HF patients attended at the heart clinic of an university Hospital from MG since December 2015, until February 2016. VARIABLE AVAREGE±SD MINIMUN MAXIMUN CRONBACH’S ALFA Physical Domain 25,27±8,86 8 40 0,680 Emotional Domain 10,07±5,69 0 25 0,789 Unspecific Domain 13,78±3,54 6 21 0,816 Minnesota Total 51,87±15,74 16 92 0,811 Source: The Author, 2016. The physical domain average score presented higher than other studies results which used the same instrument, varying between 7, 9 – 17 points (SACCOMANN; CINTRA; GALLANI, 2011; LIMA; MORAIS, 2014). According to MLHFQ’s interpretation, the symptoms and physical limitations which disturbs the HF patient’s work, recreation, autonomy and independence are identified by them as LQ reducers. Regarding the emotional domain, the study shown a deterioration of the psychic aspects when compared with other cross-sectional studies performed at the states of São Paulo and Goiás which found 6,8 and 7,8 scores in the emotional evaluation respectively (SACCOMANN; CINTRA; GALLANI, 2011; LIMA; MORAIS, 2014). However another research found a higher value equal to 15, 1 indicating a HRLQ loss in the emotional aspects (SANTOS; PLEWKA; BROFMAN, 2009). The total average of MLHFQ remained high when compared with other studies where the maximum values got a variation from 34,95 to 38, meaning that the patients included in this study presented higher HRLQ deficit (NOGUEIRA; RASSI; CORRÊA, 2010; SACCOMANN; CINTRA; GALLANI, 2011; LIMA; MORAIS, 2014). A recent research regarding the general and specific HRLQ of HF patients and their socioeconomic profile in some University Hospital from the Triangulo Mineiro, presented very close results with the ones found at the present study (DE ALMEIDA NETO; PEDROSA, 2015). A possible result justification could be the fact that both studies were performed at the same region, therefore the population and data behavior were very likely to be similar. Another hypothesis would be the non- adhesion to the suggested therapeutic treatment as well as a multiprofessional treatment, which leads to a HRLQ loss aggravation. Physical limitation on Heart Failure patients There are very fill studies using the VSAQ (Table 5), initially being directed to patients with Lung Capacity Test (PCT) indication, this last considered the gold standard in functional capacity evaluation. Despite the direct measure being more precise and considered the main clinical measurement method, a big cut of the population doesn’t get access to it, due to its high price, extended procedure time and great risk of cardiovascular events in HD patients (COOK et al., 2001; PIERSON et al., 2003; MCAULEY et al., 2006; ROCHA et al, 2006; DOMINGUES, 2010; CARVALHO et al., 2011). Table 5. VSAQ instrument characteristics sorted by centrality measures, dispersion and simple frequency from HF patients attended at the heart clinic of an university Hospital from MG since December 2015, until February 2016. VARIABLE AVERAGE±SD MINIMUN MAXIMUN N % VSAQ 3,37±1,41 1 8 - - 1 MET - - 5 4,6 2 METS - - 20 18,5 3 METS - - 49 45,4 4 METS - - 13 12,0 5 METS - - 14 13,0 6 METS - - 2 1,9 1094 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 7 METS - - 2 1,9 8 METS - - 3 2,8 Source: The Author, 2016; MET: Metabolic Equivalent; METS: Metabolic Equivalents The result presented by VSAQ’s application in this study has presented itself lower than other studies (Table 5) meaning that the sample patients have higher functional loss and greater mortality risk (COOK et al., 2001; PIERSON et al., 2003; MCAULEY et al., 2006). The patients shown physical capability to perform simple daily activities (eating, getting dressed, taking shower, walking slowly through small distances), an explanation for the VSAQ’s low score could be the physical activity and heart rehabilitation low adhesion, found at this study (Table 3). It’s know that physical inactivity generally leads to poor conditioning and reduced aerobial capability, especially in older subjects (MUELLA; BASSAN; SERRA, 2011; ALMEIDA et al., 2013; SILVEIRA; RIBEIRO; RAMIS, 2012). Specific HRLQ and VSAQ correlation There weren’t any reference, either national or international making a MLHFQ and VSAQ correlation, until the reference revision of this study, making it the first of its kind. The results obtained through Pearson’s correlation, between VSAQ and MLHFQ domains, is justified by the HF’s symptomatology and therapeutic characteristics themselves as above mentioned. Table 6. Pearson’s correlation between MLHFQ domains and VSAQ’s score from HF patients attended at the heart clinic of an university Hospital from MG since December 2015, until February 2016 VARIABLE VSAQ Minnesota Physical Domain -0,523** Minnesota Emotional Domain -0,436** Minnesota Inespecific Domain -0,411** Minnesota Total Score -0,562** Source: O Author, 2016; **p<0,01 In this context the correlation presented strong and significant values between the MLHFQ domains and VSAQ’s METS scores (r= 0, 562) and negative due to the instruments inverse proportionality, while the lower the METS result, the higher the task execution difficulty, the same idea is expressed in the MLHFQ with higher results (PENA et al., 2011; SANTOS et al., 2011; SANTOS et al., 2015). The predominance of NYHA functional class II and III in the study (Table 3) could be a justification since the higher NYHA classification, the more severe is the individual performance loss. This predominance also implies in a larger number of early retirement, work field removal, greater dependency to perform simple activities, which leads to emotional degradation, low self-esteem, depression and anxiety signals (PEREIRA et al., 2012). CONCLUSIONS The negative impact of the HF in all domains of the specific HRLQ were higher than previous studies involving the subject. VSAQ’s results show in this study were lower than any other study found, and they also prove the relationship between HF and physical capability limitation. This study confirmed the hypothesis that the HF patients with higher classification (sorted by NYHA functional class and low LVEF) presents reduced METS, identifying the physical limitation as a low therapeutic adhesion predictor, disease maintenance loss and evolution, confirming its HRLQ negative impact. Therefore, longitudinal studies using VSAQ and MLHFQ must be encouraged, in order to keep up with this population’s possible changes in both METs and HRLQ, with the understanding that these instruments when associated with clinical and propaedeutic exams will converge in a better HF patient’s situational diagnosis allowing better and more efficient ways of intervention and treatment for this patient type. 1095 Physical limitation’s impact in heart… SILVA, P. C. et al. Biosci. J., Uberlândia, v. 33, n. 4, p. 1089-1098, July/Aug. 2017 RESUMO: A Insuficiência Cardíaca (IC) é uma condição grave e auto limitante, de etiologia variada, que reduz a qualidade de vida (QVRS), e esta entre as patologias que mais onera o sistema público de saúde, devido aos sinais e sintomas desencadeados e ao grande numero de internações devido as complicação da doença. Acredita-se que o desempenho cardiorrespiratório prejudicado pela IC expresse os níveis de limitação física e que impacte negativamente a QVRS. Avaliar o impacto da limitação física na QVRS de indivíduos com IC. Estudo transversal, de caráter quantitativo, descritivo e analítico, conduzido com pacientes atendidos no Ambulatório de Cardiologia de um Hospital Universitário. Para avaliação dos pacientes, utilizou-se: Questionário de caracterização Clínica e Socioeconômica, Minnesota Living With Heart Failure Questionnaire (MLHFQ) e o Veterans Specific Activity Questionnaire (VSAQ). Os dados foram gerenciados no Programa Microsoft Office Excel® 2010, em dupla digitação independente. Posteriormente, importados para Programa Statistical Package for the Social Science (SPSS), versão 21.0, onde foram realizadas análises exploratórias dos dados a partir da apuração de frequências simples absolutas e percentuais para as variáveis categóricas e medidas de centralidade e de dispersão para variáveis quantitativas, assim como teste paramétrico de correlação de Pearson, visto a distribuição normal das variáveis. Foram inclusos no estudo 108 pacientes, com predomínio de participantes do sexo feminino (50,90%), idade média dos pacientes de 66,55±11,41 anos. A classificação funcional NYHA no nível II (50%) e NYHA III (39,80%) foram as mais evidenciadas, com predomínio da etiologia chagásica (50,90%). O MLHFQ evidenciou impacto negativo da IC sob a QVRS, cujo o escore total foi de MLHFQ de 51,87±15,74 pontos. Na avaliação da limitação física o VSAQ obteve média de 3,37±1,41, com um maior comprometimento em atividades referente ao METS 3 (45,4%). A correlação entre os domínios do MLHFQ e VSAQ mostrou-se negativa, moderada à forte e significante (p<0,01) para os domínios: físico (- 0,523); emocional (- 0,436); inespecífico (-0,411), e o escore total do MLHFQ (-0,562). A hipótese de que pacientes com maiores graus de IC e FEVE baixa apresentam MET reduzido foi confirmada, identificando a limitação física como um preditor para a piora na QVRS. PALAVRAS-CHAVES: Doença Cardiaca. Qualidade de Vida. 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