Factors Associated with Quality of Life in Patients with Coronary Artery Disease in King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Samaa O Sangoof^*

^*Correspondence: Samaa O Sangoof, Preventive Medicine Program Saudi Board, KSA, Email:

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Introduction

Cardiovascular disease is a leading cause of disability and early mortality across the world, and it contributes significantly to rising health-care expenses [1]. It is the greatest cause of mortality worldwide, claiming the lives of an estimated 17.9 million people each year [2]. In 2016, it was responsible for 45.7 percent of noncommunicable disease mortality in Saudi Arabia [3]. The most frequent kind of heart disease in the Saudi Arabia is stable angina among coronary artery disease [4].

The term "acute coronary syndrome" refers to a group of cardiac ischemia conditions that include unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI), and ST-elevated myocardial infarction (STEMI) [5]. A comprehensive evaluation of clinical characteristics, including electrocardiogram (ECG) abnormalities and biochemical indicators of myocardial necrosis, is used to diagnose and classify ACS. The occurrence of ischemia symptoms without biomarker increases or transitory, if any, ECG alterations characterize UA. When there is evidence of myocardial necrosis in the setting of acute myocardial ischemia, the term myocardial infarction (MI) is employed. The presence of sustained ECG findings of ST segment elevation distinguishes STEMI from NSTEMI [6].

Health-related quality of life has been proven to influence health on an individual level, including physical and mental health perceptions, as well as its correlates such as health risks and conditions, functional status, social support, and socioeconomic status [7]. Unfortunately, most patients with coronary heart disease have a decline in quality of life, which might impair their prognosis [8]. As many facets of a patient's quality of life may be impacted by coronary artery disease, including angina symptoms, decreased exercise ability, physical limitations, and psychological stress related with chronic stress. Healthrelated quality of life is increasingly being utilized as a predictor of health outcomes. Nowadays, medicines are aimed not just at extending life expectancy but also at increasing quality of life. As a result, an increase in health-related quality of life is seen as a main outcome and a factor in determining treatment benefit [9].

The goal of this study is to assess the health-related quality of life and the factors that influence it in patients with coronary artery disease. Because coronary artery disease, or CVD, is a major public health concern and the leading cause of morbidity and mortality in the Saudi Arabia [1], and because it has a negative impact on many aspects of life, including patient quality of life, the findings of this study will aid in understanding the impact of coronary artery disease on health quality of life and the factors that influence it. Along with the physical effects, cardiovascular disease can have a significant emotional and social influence on a patient's quality of life.

To better understand health-related quality of life and the variables that influence it among patients with coronary heart disease (CHD) in Jeddah, Saudi Arabia.

Literature Review

The quality of life of patients with CHD has an average value of 63.29, according to research published in 2021 titled "Factors Related to the Quality of Life of Patients with Coronary Heart Disease at Saiful Anwar General Hospital, Malang." A total of 88.9% of CHD patients were classified as having a high quality of life. Furthermore, there was no link between the independent factors and overall quality of life [8]. Moreover, in 2021, a study titled "Health-related quality of life and related factors in coronary heart disease patients: results from the Henan Rural Cohort study" found that coronary heart disease patients with low income, diabetes, stroke, anxiety, and poor sleep quality had significantly lower healthrelated quality of life index [10]. Other factors that had a poorer quality of life score were male patients between the ages of 48 and 57, married patients with coronary artery disease, the retired or jobless, patients with hypertension, never using alcohol, never smoking, and never exercising [11].

"Health-Related Quality of Life in Premature Acute Coronary Syndrome: Does Patient Sex or Gender Really Matter?" was the title of a research published in 2014. Female patients with pre-acute coronary syndrome had a lower health-related quality of life than male patients, both in terms of physical and mental functioning [12]. "Gender disparities and predictors of health-related quality of life in coronary patients: a follow-up study," research published in 2011, found. Following a heart attack, men and women have different outcomes in terms of health-related quality of life. In both men and women, mental health is the most common predictor of healthrelated quality of life [13]. Furthermore, according to a research published in Turkey in 2009 titled "Factors impacting quality of life in patients with coronary heart disease," married patients and those with higher salaries had higher quality of life ratings. Patients with heart issues who struggled at work had a worse quality of life. Patients who had previously had coronary intervention or surgery exhibited identical quality of life scores to those who had not. Patients who received emotional and social support scored better on the social/economic scale, while those who received actual social assistance scored higher on the overall quality of life scale. Marital and financial position, past myocardial infarction, and difficulties in everyday labour were all independent factors that influenced overall quality of life [11]. Another study, "Determinants of health-related quality of life in patients with coronary artery disease," published in 2006, found that mood disturbance may have a stronger influence on health-related quality of life changes after medical and interventional treatment in patients with coronary artery disease than treatment methods [14]. Moreover, the patients' quality of life mean score for all domains was poor, according to a 2017 research titled "Quality of Life among Patients with Acute Coronary Syndrome." The physical domain was the one that suffered the most damage. The emotional realm comes next, followed by the social domain. Gender, degree of education, work position, physical activity, history of dyslipidemia, and medical diagnosis all had statistically significant variations in quality of life scores [15].

Methodology

A cross-sectional analytic study design. Study population was adult patients with coronary artery disease in Jeddah's King Abdulaziz University Hospital. Study enrolled in the Saudi Arabian city of Jeddah, the King Abdulaziz University Hospital is located. The sample was 367 patients with coronary artery disease in king Abdelaziz university hospital were taken.

Patients were recruited using simple random sampling technique.

The data was collected on a data collection sheet that is divided into four sections:

Socio-demographic and clinical characteristics: information on the patient's age, gender, marital status, educational level, work status, and average income were collected.

Current medical condition: including medical diagnosis, smoking status, exercise, weight and height, hypertension status, dyslipidemia status, diabetes status, and presence of other chronic medical conditions.

The Arabic version of MacNew heart disease health associated quality of life among patients with acute coronary syndrome (MacNew): This tool assesses the quality of life of heart disease patients across three primary dimensions (physical, emotional and social). Each item is rated on a Likert scale from one to seven by the participants. The instrument's overall score goes from 7 to 189. The mean of the global score was then computed, with a minimum of one indicating poor quality of life and a maximum of seven indicating excellent quality of life. The mean score of the 13 domain-specific elements was used to compute the score for the physical domain. The mean score of the 14 domain-specific items was used to construct the emotional domain. The social domain was determined by taking the average of the 13 things that made up the domain. It is important to remember that certain products are listed in many domains [15].

This instrument's Arabic version has excellent psychometric properties. The Arabic version of the MacNew had an internal consistency (Cronbach's alpha) of 0.91 for each domain and the overall score. Furthermore, test-retest reliability scores for a group of 58 patients varied from 0.81 to 0.87. The investigation concluded that the Arabic version of the MacNew is accurate and dependable [16,17].

The MacNew questionnaire is a 27-item selfadministered questionnaire with a global scale and a physical, emotional and social subscale. The MacNew has a 2-week timeframe and is designed to assess patient’s feelings about how CAD affects daily functioning with each item scored from 1 (low HRQL) to 7 (high HRQL) [6,11]. A score is generated for each of the physical, emotional and social MacNew subscales as the mean of the number of subscale items with a response; the MacNew global score is the sum of the score on all scored items divided by the number of scored items. The MacNew was translated into Polish using the linguistic validation forward-backward translation technique Multidimensional scale of perceived social support (MSPSS), it is a 12- items scale designed to measure perceived social support from three sources: family, friends, and significant other. Cronbach’s alpha value was 0.976 [18-20].

Data was collected from patients with coronary artery disease at King Abdulaziz University Hospital clinics in Jeddah, Saudi Arabia, using a combination of techniques, including phone calls and direct contact during clinic visits.

The Statistical Package for the Social Sciences was used to analyze the data (SPSS 26). The sample characteristics are described using descriptive statistics (frequency, means, percentages, and standard deviations). To find any significant differences in QoL based on patients' socio-demographic and clinical features, an independent sample t-test and a one-way ANOVA are employed. P value of less than 0.05 was considered significant

A pilot study was undertaken to ensure that the questionnaire is well understood and that the time required to complete it is reasonable, and any necessary changes were made. A total of 30 patients were included in the pilot trial.

The research ethics committee approved this protocol. Permission from a higher authority, as well as municipal, institutional, and departmental approval. The goal of the study was explained to each patient, and signed agreement to participate in the study was acquired, with confidentiality guaranteed. There is no commitment to participate in the study in any way, and the participant is free to leave at any moment. There is no potential for a conflict of interest.

Results

Participant’s characteristics

The current study included 367 participants. Among them, there were 241 males (65.7%) and 126 females (34.3%). The most frequent age group was 55 years and more (n=209, 56.9%). Most of study participants are married (n=288, 78.5%) while 28 participants were divorced. Most of study participants had an educational degree, however, there were 119 participants who were illiterate or attended until preparatory school (32.4%). The current job status for study participants was retired among 140 participants (38.1%). Most of study participants had good monthly income (n=140, 38.1%).

The activity level varied among study participants. However, most of study participants had weak activity level per week (1-3 times) (n=166, 45.2%). On the other hand, there are 96 participants who don’t perform any physical activity per week (n=22.2%). By contrast, high activity level (6-7 times per week) was found among 12 participants (3.3%). And the rest of participants (n=93, 25.3%) do 3-5 times physical activity per week.

The mean weight among study participants is 76.13 + 20.85 kg with median weight of 76 kg and the mean height among study participants is 1.59 + 0.36 meters with median height of 1.65 meters. The mean body mass index among study participants is 26.98 + 7.36 kg/m2 with median BMI of 27.16 kg/m2. Regarding the distribution of BMI by gender; it is noticed that women had higher BMI when compared to men, however, this was not statistically significant.

There were several comorbidity and risk factors among participants included in this study such as diabetes, hypertension smoking and others as presented in Table 1.

Table 1: Comorbidities associated with coronary artery disease patients in the study.

The current coronary artery disease (CAD) diagnosis varied among study participants with most frequent diagnosis of myocardial infarction (n=152, 41.4%) followed by atherosclerosis (n=88, 24%). Other diagnoses were angina pectoris (n=43, 11.7%) and others (n=84, 22.9%). Participants were diagnosed since less than 6 months (n=90, 24.5%), 6 to 12 months (n=91, 24.8%), 1 to 3 years (n=92, 25.1%) and more than 3 years (n=94, 25.6%). There were 125 participants suffering from recurrent episodes regarding CAD (34.1%). There were 238 patients underwent diagnostic percutaneous intervention (PCI) (64.9%) and among them 180 patients underwent stent placement PCI (49%). On the other hand, 45 patients had open-heart surgery (12.3%). Most of study participants are on chronic use of medications (n=317, 86.4%).

Quality of life assessment

Quality of life among study participants was assessed using MacNew questionnaire which is designed for cardiac disease patients as shown in the following Table 2.

Table 2: Participants’ responses to the quality-of-life questionnaire.

The global score of the QoL was (5.2 ± 1.0). The physical domain was the domain with the lowest score (5.1 ± 1.1), followed by emotional (5.3 ± 1.1) and finally, the social domain (5.4 ± 1.15).

Social support assessment

Social support among study participants was assessed using 12-questionas 7-points Likert scale questionnaire as shown in the following Table 3.

Table 3: Participants’ responses to social support scale.

Regression analysis

Statistically significant relationships between study participants characteristics and scales used are illustrated in Table 4. The patient's global quality of life score varied considerably according to age, gender, work status, occupation, and educational status. Female patients reported a worse QoL global score than male patients (2.46 1.03 vs. 3.74 1.11; t (-4.893), P=0.034). Furthermore, jobless patients had a substantially worse QoL MacNew global score (3.76 1.06 vs. 4.26 1.11, t (- 4.361), P=0.001). Furthermore, individuals with dyslipidemia in their medical history had a substantially lower QoL MacNew global score than those without dyslipidemia (3.85 1.08 vs. 4.29 1.11, t (-3.856), P=0.0295). Post-hoc comparison tests revealed that patients with a secondary education or less were responsible for the major impact. This group's QoL MacNew global score was much lower than those of postgraduate groups (P<0.001).

Table 4: Statistical significant relationships between participants’ characteristics and study scales.

Discussion

The current study aimed to spot light on the factors associated with quality of life in patients with coronary artery disease in King Abdulaziz University hospital. The current study included 367 participants. Among them, there were 170 males (67.7%) and 81 males (32.3%). The most frequent age group was 55 years and more (n=139, 55.4%). Most of study participants are married (n=197, 78.5%) The activity level varied among study participants. However, most of study participants had weak activity level per week (1-3 times) (n=112, 44.6%). The mean body mass index among study participants is 26.98 + 7.36 kg/m2 with median BMI of 27.16 kg/m2. Regression analysis showed statistically significant relationship between age and quality of life (P=0.001), gender (P=0.0025), marital status (P<0.001), educational level (P<0.001) and occupation (P=0.0295).

Predictable with the legitimate truth that CHD greatest affects patients' actual capability, the outcomes show that aggravation/uneasiness was the most often detailed issue in EQ-5D-5L (66.9 percent), while distress and side effects was the most impeded aspect in 15D with a score of 0.69. SAQ appraisals uncovered that patients' sickness explicit wellbeing status was decaying, especially with regards to angina strength [21,22]. The discoveries underline the way that angina, combined with chest uneasiness, chest snugness, exhaustion, or a terrible state of mind, is a predominant side effect in people with CHD. Past exploration has shown that chest torment brought about by CHD could impact QoL [19]. Ongoing examination proposes that coronary microvascular endothelial brokenness is connected to cardiovascular occasions and might be a contributing variable to these people's persistent chest distress [20]. Besides, past exploration has connected angina treatment to upgrades in the physical, mental, and social parts of QoL [21]. To upgrade the QoL of CHD patients, it is basic to instantly recognize chest torment and other angina side effects, as well as treat microvascular endothelial brokenness. Comorbidities have been linked to a worse quality of life (QOL) in patients with heart failure (HF), which increases the probability of death. Comorbid diabetes and depression were linked to worse HF survival rates and higher rehospitalizatio. According to studies, having a greater comorbidity load was associated with more depressed symptoms as well as lower physical functioning, physical limits, and overall health. Literature demonstrated a significant age and ethnicity relationship, with deteriorating QOL ratings associated with greater depression [22-50]. PCS QOL was greater in Afro-Trinidadians than in Indo-Trinidadians younger than 35, 35-44, and 55-64 years old, while the difference was not significant in patients 75 and older. In terms of MCS QOL, however, the contrary was typically true among Indo-Trinidadians, with patients younger than 35 years of age and patients aged 35-44 years having greater MCS than Afro-Trinidadian patients, while the inverse was true among patients 75 years of age or above. Lower physical composite scores among young Indo-Trinidadians might be attributed to sedentary lifestyles and probable overprotection from relatives. Age has no influence on QOL, according to Jankowska et al. [50]. However, AbuRuz et al. discovered that age was an independent predictor of poor QOL, citing that anxiety and depression scores, as well as disease severity, increased with age, which would have resulted in a reduction in physical and mental abilities, resulting in the lower QOL [40] found in HF patients.

Age, depression, and the number of comorbidities were shown to be predictors of QoL, whereas age, depression, and sex were found to be predictors of QoL. Men's higher QOL may be attributed to our male-dominated culture or to men's greater exposure to support services in terms of social and physical activities. Male sex was also found to be an independent physical component predictor of better QOL by Najafi et al. [41]. In contrast, Nesbitt et al. suggested that male sex was related with lower QOL [42], and that the gender difference was attributed to variations in family duty, gender roles, and responsibility for one's own health. Depression was found to be a predictor of physical health-related QOL in individuals with coronary heart disease (CHD) by Dickens et al. [43]. Another study found that patients with CHD who had anxiety and depression had significantly worse healthrelated QOL in all areas, particularly physical functioning and role functioning [44]. According to AbuRuz, the severity of the disease, work status, and social support were all predictors of high depression levels in patients with cardiac problems, all of which resulted in worse QOL [40]. Depression, according to Wang et al., is a predictor of mental health-related QOL in patients with acute myocardial infarction [45]. Cruz et al. colleagues discovered that depressive individuals with IHD had poorer QOL ratings in the mental health, emotional, and social functioning categories than their non-depressed counterparts [46]. MCS QOL was predicted by age and gender. Hawkes et al. identified younger age as a predictor [48], while McBurney et al. discovered that age under 65 years was related with poor MCS-12 scores [48]. El-baz et al. [49] discovered that female sex is a major predictor of and associated with poor mental health, respectively.

The actual area acquired the most reduced QoL score among the three QoL spaces. These discoveries are predictable with those of past examinations [18,19]. Other examination have shown that ACS signs and side effects disturb people's actual working and corrupt their actual capacities [20,21]. A finding of ACS is a dangerous event that might bring about actual limits inferable from the illness' signs and side effects (for example chest torment, trouble in breathing, and the failure to play out an actual work).

Intense coronary condition may likewise cause close to home and social disability attributable to feelings associated with mortality and family misfortune (i.e., powerlessness to support family obligations and associations) [22]. On account of the previously mentioned sickness related reasons and the way that around 80% of the patients had never participated in any actual exercises, it seems levelheaded for members to report poor QoL appraisals in the actual space. One more Jordanian review [24], which planned to gauge the learning requests of ACS patients, backs up this finding. As per Eshah et al. [24], members didn't see the worth of actual practice in working on actual working and positioned it as a low need among different requests.

The other two areas (social and close to home) had comparable QoL worldwide scores that were higher than the actual space score. These discoveries contrast the discoveries of different creators [16], who showed that the infection's effect on QoL was reliable across spaces. Other exploration, in any case, found that the social area scored higher than the physical and profound spaces [25,26]. Be that as it may, our review didn't support such discoveries, which may be credited to the fundamental Jordanian social space. Jordanians like to conceal their profound feelings from their family and people in general during sickness, and they oppose looking for social and close to home assistance [27]. Moreover, Jordanian patients much of the time areas of strength for get from their families, especially first-degree family members, for strict and socio-social reasons [27]. It ought to be accentuated that, while the social and close to home classes had higher evaluations than the physical, they were still lower than the general review results [12]. This may be because of an absence of enlightening projects and rehabilitative administrations in Jordan.

As per Eshah et al. [23], Jordanian patients with ACS have areas of strength for a for data in regards to their ACS conclusion prior to being let out of clinics. This absence of data might affect their capacity to conform to their new condition and find out about their infection and how to carry on with a sound way of life [27]. The review found that the QoL worldwide score of UA patients was impressively lower than that of MI patients. This end seems, by all accounts, to be steady with the discoveries of past examinations [28,29]. These discoveries may be made sense of by the clinical highlights of UA versus MI patients.

Patients with Unstable Angina have numerous angina occasions that deteriorate over the long run. They likewise have higher comorbidities and extreme coronary issues, which bring about a more drawn out term forecast connected with a lower ailment [30,31]. Myocardial localized necrosis is in every case more extreme than UA and is a possibly deadly occasion, expecting patients to look for crisis clinical consideration and remedial treatment. This clinical and remedial treatment might impact their QoL, as opposed to UA patients, whose issues bring about deferred or insufficient clinical consideration, decreasing their QoL [29].

Therefore, information uncovered that male patients had more prominent QoL than female patients. This finding is steady with the discoveries of different examinations [32,33]. Female patients frequently have a lesser level of sickness adapting than male patients, and they utilize particular survival strategies [35]. Different analysts uncovered that female patients have a bigger number of ACS entanglements than male patients [35]. Confusions of the condition might bring about more unfortunate outcomes and, thus, a diminished level of QoL [36]. Moreover, female patients are bound to be melancholy after an ACS occurrence than male ones.

Hitched patients in the review detailed more noteworthy QoL, which is reliable with prior examinations that show marriage is a defensive element for QoL in CHD patients [22,23]. As indicated by current realities, the marriage association biggestly affects wellbeing [24]. There were different potential outcomes. To begin with, as individuals become more established, their intimate relationships become more essential to them, which affects their prosperity [25,26]. Second, poor conjugal status was a significant wellspring of stress for people, which can weaken resistant function [28] and decreases with age, adversely affecting wellbeing [29]. Third, conjugal pressure would set off and keep up with cardiovascular reactivity (eg, hypertension, raised pulse), and those people with CHD might be more powerless against this wellspring of stress [29].

The discoveries show that CHD patients with repeats and extended sickness span had lower QoL. Infection repeat was incredibly predominant, with 40% of ACI survivors readmitted to an emergency clinic in the span of 30 days of delivery [30] and 20% encountering a repetitive heart episode inside the main year [30]. Past examination has shown that people with long haul disease had a higher gamble of heart failure and aortic analyzation [31]. Besides, patients with cardiovascular breakdown or who endure an intense coronary occasion might live for a drawn out timeframe however are frequently crippled [32], and backslid patients might experience the ill effects of physical and social dysfunctions, for example, slurred discourse and diminished tangible responsiveness, which can deteriorate the patient's QoL. Subsequently, heart restoration (CR), which joins numerous treatments and attempts to improve different components of a patient's life, is required. Work out based CR is the most broadly acknowledged CR procedure [33], and a new deliberate survey reasoned that work out based CR could accomplish clinically significant enhancements in actual execution, general wellbeing, and actual working in contemporary intense coronary condition patients in the short and long haul [34]. Beginning around 2020, the Chinese government has created public suggestions to support the utilization of heart restoration in essential emergency clinics to upgrade patients' actual working, limit actual cut-off points, and re-establish previous abilities [34].

Comorbidity altogether affects QoL variety. As indicated by the discoveries of this review, CHD patients had a huge recurrence of corresponding hypertension (63.9 percent), and patients with hypertension detailed more unfortunate QoL than those without comorbidities, which is reliable with past examination [35,36]. Hypertension is the main modifiable gamble factor for cardiovascular infection, which is the essential driver of mortality [37]. As indicated by a countrywide report, 23.2 percent (244.5 million individuals) of the Chinese grown-up populace matured 18 had hypertension [38]. Past exploration has uncovered that for each 10 mmHg expansion in circulatory strain, the occurrence of CHD ascends by generally 30%. Hypertension can animate the improvement of coronary atherosclerosis and increment the oxygen interest of the heart, bringing about angina side effects [39]. On account of the absence of apparent signs and side effects, numerous CHD patients disregard hypertension. Thus, medical care suppliers should know about the additional effect of comorbidities on the QoL of CHD patients to lay out a proper therapy technique.

Better emotional prosperity (i.e. when WHO-513 was available) was demonstrated to be connected with patients' QoL. Mounting proof that emotional well-is being and wellbeing are inseparably connected, and that great mental qualities are connected to a diminished gamble of CHD passing [40]. Positive abstract prosperity has been displayed to further develop wellbeing by buffering the impacts of pressure and changing conduct through the course of commitment and withdrawal. 65 Other examinations have shown that upgraded abstract prosperity might impact coronary illness by implication through wellbeing ways of behaving like superior nourishment and more prominent actual activity [41] or straightforwardly through changes in the neuroendocrine, cardiovascular, and fiery frameworks [42-45]. These discoveries involved that estimating and observing the SWB of CHD patients is vital to work on their SWB and QoL.

Conclusion

The study simultaneously applies generic and diseasespecific QoL instruments to measure cardiac patients’ QoL in Saudi Arabia. It showed that QoL in cardiac patients was lower than that of the general population in Saudi Arabia and was significantly associated with patients’ marital status, disease state, comorbidity and subjective well-being. To improve the QoL of cardiac patients in Saudi Arabia, more attention needs to be paid to unmarried and relapsed patients, especially those with comorbidity of hypertension. Additionally, more social support and psychological counselling should be provided to patients.

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