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RATIONALE: Patient-reported outcomes such as health-related quality of life (HRQL) describe or characterize what patients have experienced as a result of their health care. However, treatment outcome comparisons among different pure or mixed populations of patients with myocardial infarction, angina or heart failure cannot be made using existing coronary heart disease (CHD)-specific HRQL instruments. AIMS AND OBJECTIVES: The aim of this study was to evaluate the psychometric properties of the Chinese version of the MacNew in a cohort of Hong Kong patients diagnosed with CHD. METHODS: Chinese translations of a CHD-specific HRQL instrument, the MacNew Heart Disease HRQL questionnaire (MacNew), the Short-form 36 Health Survey and the Hospital Anxiety and Depression Scale were administered to 365 Chinese-speaking patients with CHD at baseline and again 3 months later (n = 363). The Medical Outcomes Trust Scientific Advisory Committee criteria were used to examine the psychometric properties of the Chinese MacNew Heart Disease HRQL questionnaire. RESULTS: The results warrant recommending the use of the MacNew as an outcome measure to enhance treatment evaluation in Chinese patients with CHD and a diagnosis of myocardial infarction, angina or heart failure, substantiating previous psychometric data on the MacNew in a number of different studies in patients speaking seven different languages. CONCLUSION: The MacNew questionnaire may have value as a core CHD questionnaire for treatment outcome comparisons among pure or mixed populations of patients with myocardial infarction, angina or heart failure. [ABSTRACT FROM AUTHOR]

BACKGROUND AND RESEARCH OBJECTIVES: Patients with heart failure (HF) may be predisposed to malnutrition. Little is known about the nutritional status of patients with HF, particularly patients who have coexisting major medical conditions such as chronic kidney disease. The purposes of this study were to (1) describe the nutritional status of 211 patients with chronic HF, (2) examine relationships between nutrition variables and health-related quality of life, and (3) evaluate the nutritional status of the subset of HF patients with coexisting chronic kidney disease. SUBJECTS AND METHODS: The sample included 211 patients with chronic HF recruited for a larger study about health-related quality of life. Clinical data were retrieved retrospectively from the computerized medical records system at the study site. RESULTS AND CONCLUSIONS: Mean body mass index of the 122 patients for which height was available was 31.4, and no differences in body mass index were noted among patients with varying New York Heart Association class functional status. Evaluation of the mean laboratory values indicated that patients had abnormal elevations of serum glucose, hemoglobin A1C, creatinine, and low-density lipoprotein cholesterol. Higher hemoglobin A1C levels were significantly correlated with poorer health-related quality-of-life scores, although the magnitude of the correlations was modest. Estimated glomerular filtration rate indicated that 54 (27%) of the HF patients likely had coexisting chronic kidney disease, and these patients had significantly lower serum albumin and worsening anemia. The results indicate the need for future prospective studies that incorporate evaluation of nutritional status and the ways in which coexisting chronic kidney disease influences outcomes. [ABSTRACT FROM AUTHOR]

Objectives: This study evaluated the psychometric properties of the Mandarin version of the HeartQoL questionnaire, a core ischemic heart disease (IHD) health-related quality of life (HRQL) instrument, in patients with angina, myocardial infarction (MI), and ischemic heart failure (IHF)., Methods: The English version of HeartQoL was translated into Mandarin. A cross-sectional study was then conducted in mainland China using the Mandarin HeartQoL, Short Form-12 Health Survey, and Hospital Anxiety and Depression Scale. Factor analysis was used to establish the HeartQoL structure and internal consistency reliability and construct validity were assessed., Results: Patients with IHD (n = 412; angina = 112, MI = 151, and IHF = 149) were enrolled. Significantly higher HeartQoL HRQL scores were reported by patients with either angina or MI than by patients with IHF. The 2-factor structure was confirmed by Mokken scale analysis in the total group with strong H coefficients on the global scale (0.64) and both the physical (0.70) and emotional (0.80) subscales. Internal consistency reliability was strong with Cronbach's α ranging from 0.90 to 0.95. Convergent validity was confirmed with strong correlations between similar physical and mental HeartQoL and Short Form-12 Health Survey subscales ranging from 0.77 to 0.82 with divergent validity confirmed with significantly lower correlations between dissimilar constructs. Discriminative validity was confirmed for 72% of the a priori sociodemographic and clinical hypotheses., Conclusions: The Mandarin version of the HeartQoL HRQL questionnaire demonstrates acceptable internal consistency reliability and convergent, divergent, and discriminative validity in patients with IHD and in each diagnostic subgroup. The data support the use of the HeartQoL to assess and compare HRQL in Mandarin-speaking patients with IHD., (Copyright © 2022 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Purpose: Patient-reported health-related quality of life is a complementary healthcare outcome and important when assessing treatment efficacy. Using COSMIN methodological recommendations, this study evaluates the validity and reliability of a core heart disease-specific health-related quality of life questionnaire, the HeartQoL questionnaire (Danish version) in a sample of patients following heart valve surgery., Design: This project involved a cross-sectional validity study and a test-retest reliability study., Methods: Eligible patients completed the HeartQoL, the SF-36 health survey questionnaire, and the Hospital Anxiety and Depression Scale following heart valve surgery. Construct validity was tested using a priori hypotheses. Internal consistency reliability was assessed with Cronbach's alpha. An independent sample of patients participated in the test-retest study and reproducibility was determined with relative [intra-class correlation coefficient (ICC)] and absolute reliability [standard error of measurement (SEM) and smallest detectable change (SDC)]., Results: Internal consistency was high with Cronbach's alpha ≥ 0.87. ICC was 0.86-0.92. SEM ranged from 0.17 to 0.26 points and SDC ranged from 0.5 to 0.7 points. Construct validity was confirmed with 87% of all a priori hypotheses for predicted variables., Conclusions: The HeartQoL questionnaire demonstrates acceptable construct validity, internal consistency, and test-retest reproducibility in patients following heart valve surgery. Future studies should focus on assessing the responsiveness of the HeartQoL questionnaire over time and following heart valve surgery.

Background Patient-reported health-related quality of life is increasingly used as an outcome measure in clinical trials and as a performance measure to evaluate quality of care. The objective of this study was to assess the psychometric properties of the Danish HeartQoL questionnaire, a core heart disease-specific health-related quality of life questionnaire, in implantable cardioverter defibrillator recipients. Design This study involved cross-sectional and test-retest study designs. Method Implantable cardioverter defibrillator recipients in the cross-sectional study completed the HeartQoL, the Short-Form 36 Health Survey, and the Hospital Anxiety and Depression Scale. The HeartQoL structure, construct-related validity (convergent and discriminative) and reliability (internal consistency) were assessed. HeartQoL reproducibility (test-retest) was assessed in an independent sample of implantable cardioverter defibrillator recipients. Results Mokken scale analysis supported the bi-dimensional structure of HeartQoL among 358 implantable cardioverter defibrillator recipients. Convergent ( r > 0.72) and discriminative validity were confirmed. The HeartQoL scales demonstrated satisfactory internal consistency (Cronbach's alpha > 0.90). Test-retest reliability (two weeks interval) was assessed in 89 implantable cardioverter defibrillator recipients and found to be acceptable for each scale (intra-class correlation > 0.90). Conclusion The Danish HeartQoL questionnaire demonstrated satisfactory key psychometric attributes of validity and reliability in this implantable cardioverter defibrillator population. This study adds support for the HeartQoL as a core heart-specific health-related quality of life questionnaire in a broad group of patients with heart disease including implantable cardioverter defibrillator recipients.

Importance: Cardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients' health status (eg, quality of life, symptoms, and functional status) is poorly defined., Objective: To examine the association of participation in CR with health status outcomes after AMI., Design, Setting, and Participants: A retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015., Exposures: Participation in at least 1 CR session within 6 months of hospital discharge., Main Outcomes and Measures: Patient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality., Results: After successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was -0.76 (95% CI, -2.05 to 0.52) for the SAQ quality of life score, -1.53 (95% CI, -2.57 to -0.49) for the SAQ angina frequency score, 0.38 (95% CI, -0.51 to 1.27) for the SAQ treatment satisfaction score, -0.42 (95% CI, -1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, -0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, -0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was -0.89 (95% CI, -2.20 to 0.43) for the SAQ quality of life score, -1.05 (95% CI, -2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, -0.54 to 1.29) for the SAQ treatment satisfaction score, -0.14 (95% CI, -1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, -0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, -0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75)., Conclusions and Relevance: In a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.

Background: Cardiorespiratory fitness measured by treadmill testing has prognostic significance in determining mortality with cardiovascular and other chronic disease states. The accuracy of a recently developed method for estimating maximal oxygen uptake (VO2peak), the heart rate index (HRI), is dependent only on heart rate (HR) and was tested against oxygen uptake (VO2), either measured or predicted from conventional treadmill parameters (speed, incline, protocol time)., Methods: The HRI equation, METs = 6 x HRI- 5, where HRI = maximal HR/resting HR, provides a surrogate measure of VO2peak. Forty large scale treadmill studies were identified through a systematic search using MEDLINE, Google Scholar and Web of Science in which VO2peak was either measured (TM-VO2meas; n = 20) or predicted (TM-VO2pred; n = 20) based on treadmill parameters. All studies were required to have reported group mean data of both resting and maximal HRs for determination of HR index-derived oxygen uptake (HRI-VO2)., Results: The 20 studies with measured VO2 (TM-VO2meas), involved 11,477 participants (median 337) with a total of 105,044 participants (median 3,736) in the 20 studies with predicted VO2 (TM-VO2pred). A difference of only 0.4% was seen between mean (±SD) VO2peak for TM- VO2meas and HRI-VO2 (6.51±2.25 METs and 6.54±2.28, respectively; p = 0.84). In contrast, there was a highly significant 21.1% difference between mean (±SD) TM-VO2pred and HRI-VO2 (8.12±1.85 METs and 6.71±1.92, respectively; p<0.001)., Conclusion: Although mean TM-VO2meas and HRI-VO2 were almost identical, mean TM-VO2pred was more than 20% greater than mean HRI-VO2., Competing Interests: The authors have declared that no competing interests exist.

Background: Achievement of secondary prevention guideline recommendations (i.e., goals) with cardiac rehabilitation (CR) is not well-documented, especially for women. This study examined achievement of the American Heart Association/American College of Cardiology (AHA/ACC) goals before and after CR by gender., Methods: Of 12,976 patients enrolled in the Wisconsin CR Outcomes Registry, 8,929 (68.8%) completed CR and were included in the sample. Attainment of 15 AHA/ACC goals before and after CR was examined by extracting corresponding data points in the registry as entered by CR program staff. Gender differences in achievement of these goals after CR were examined via generalized estimating equations technique., Results: Attainment of AHA/ACC goals before CR ranged from 15.3% of patients (physical activity) to 98.1% (aspirin), and by 17.6% (physical activity) to 98.4% (diastolic blood pressure) by CR completion. Significant improvements were achieved for 8 goals (53.3%), ranging from 0.7% for body mass index (BMI) to 50.8% for physical activity. Women were significantly less likely than men to achieve the following goals by CR completion: triglycerides (adjusted odds ratio [AOR], 0.54; 95% confidence interval [CI], 0.45-0.66), physical activity (AOR, 0.66; 95% CI, 0.59-0.74), and hemoglobin A1C (AOR, 0.50; 95% CI, 0.32-0.78). Women were significantly more likely than men to achieve the high-density lipoprotein goal (AOR, 1.39; 95% CI, 1.05-1.86). There were no gender differences in goal achievement for blood pressure, total cholesterol, low-density lipoprotein, BMI, smoking cessation, or medication use. More than 94% of patients were taking three of four recommended secondary prevention medications both before and after the program., Conclusions: Men and women generally improved similarly in terms of AHA/ACC goal achievement. Quality improvement strategies need to focus on physical activity and blood glucose control in women., (Copyright © 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Background: A Sinhalese version of a validated, disease-specific patient-reported heart disease health related quality of life instrument is lacking. The purpose of this study was to validate the interviewer-administered Sinhalese version of the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) in patients with clinically diagnosed stable angina., Methods: The Sinhalese translation of the MacNew was carried using standard forward- backward translation technique. In this validation study, the MacNew was administered to 200 patients with stable angina. Reliability was assessed by internal consistency and test-retest reliability. Construct validity was explored by exploratory factor analysis using principal component analysis and confirmed by confirmatory factor analysis using the robust maximum likelihood method and known group comparison. The correlation between compatible domain scores of MacNew and the World Health Organization's quality of life -brief questionnaire was used to assess concurrent validity., Results: The original 3-factor model (Physical, Emotional and Social) of the MacNew with cross-loadings was confirmed: principal component analysis with 53.42 % of the explained variance and confirmatory factor analysis with adequate fit for each of the three model fit criteria considered [root mean square error of approximation = 0.044 (90 % CI = 0.031 to 0.056); comparative fit index = 0.99; χ(2)/df = 1.39]. Internal consistency of the MacNew was acceptable with Cronbach's α of 0.92 on the Global scale and on the domain scales ranging from 0.85-0.91. Test-retest reliability was also found to be satisfactory with intraclass correlation coefficients of >0.9 for total and domain scores. A satisfactory level of concurrent validity was demonstrated with statistically significant correlations between compatible domain scores of MacNew and the World Health Organization's quality of life questionnaire (Pearson correlation ranging from 0.36-0.79)., Conclusions: The interviewer-administered Sinhalese MacNew is a valid and reliable patient-reported outcome measure to assess disease specific health-related quality of life among Sinhalese patients with stable angina.

Background: By 2030, more than 80% of cardiovascular disease-related deaths and disability-adjusted life years will occur in the 139 low- and middle-income (LMIC) countries. Cardiac rehabilitation (CR) has been demonstrated to be effective and cost-effective mainly based on data from high-income countries. The purpose of this paper was to review the literature for cost and cost-effectiveness data on CR in LMICs., Methods: MEDLINE (Ovid) and EMBASE (Ovid) electronic databases were searched for CR 'cost' and 'cost-effectiveness' data in LMICs., Results: Five CR publications with cost and cost-effectiveness data from middle-income countries were identified with none from low-income countries. Studies from Brazil demonstrated mean monthly savings of US$190 for CR, with a US$48 increase in a control group with mean costs of US$503 for a 3-month CR program. Mean costs to the public health care system of US$360 and US$540 when paid out-of-pocket were reported for a 3-month CR program in seven Latin American middle-income countries. Cardiac rehabilitation is reported to be cost-effective in both Brazil and Colombia., Conclusions: Cardiac rehabilitation for patients with heart failure in Brazil and Colombia was estimated to be cost-effective. However, given the limited health care budgets in many LMICs, affordable CR models will need to be developed for LMICs, particularly for low-income countries., (© The Author 2015. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The MacNew health-related quality of life questionnaire was designed to assess feelings about how heart disease affects their daily physical, emotional and social functioning in patients with 1 of the 3 major coronary artery diagnoses, stable coronary artery disease (CAD) with angina, ST-elevation myocardial infarction (STEMI), and ischemic heart failure (HF). The aim of this study was to determine the reliability and validity of the Polish version of the MacNew in patients with CAD., Methods: Patients with CAD completed a self-report sociodemographic and clinical ques-tionnaire: the MacNew, the Short-Form 36 Health Survey, and HADS at baseline; 10% of the patients completed each questionnaire 2 weeks later., Results: We studied patients with stable CAD with angina (n = 115), with STEMI (n = 112), and with ischemic HF (n = 105). Internal consistency reliability was demonstrated with Cronbach's a from 0.86 to 0.95 for the MacNew global scale and subscales. The original 3-factor structure was confirmed for the Polish version of the MacNew explaining 53.5% of the variance. Convergent validity of similar MacNew and SF-36 subscales was confirmed in the total group and in each diagnosis. Discriminant validity with the SF-36 health transition was fully confirmed in the total group and in patients with HF and partially confirmed in patients with stable CAD with angina or myocardial infarction., Conclusions: The Polish MacNew health-related quality of life questionnaire can be recommended in patients with stable CAD with angina, myocardial infarction and HF.

Purpose: Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment., Methods: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities., Results: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll., Conclusions: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment.

Background: Despite documented benefits of cardiac rehabilitation, adherence to programs is suboptimal with an average dropout rate of between 24% and 50%. The goal of this study was to identify organizational and patient factors associated with cardiac rehabilitation adherence., Methods and Results: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry Project (N = 38) were surveyed and records of 4412 enrolled patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. The results show that organizational factors associated with significantly increased adherence were relaxation training and diet classes (group and individual formats) and group-based psychological counseling, medication counseling, and lifestyle modification, the medical director's presence in the cardiac rehabilitation activity area for ≥ 15 min/week, assessment of patient satisfaction, adequate space, and adequate equipment. Patient factors associated with significantly increased adherence were aged ≥ 65 years, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) high-risk category, having received coronary artery bypass grafting, and diabetes disease. Non-white race was negatively associated with adherence. There was no significant gender difference in adherence. None of the baseline patient clinical profiles were associated with adherence including body mass index, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and blood pressure., Conclusions: Factors associated with adherence to cardiac rehabilitation included both organizational and patient factors. Modifiable organizational factors may help directors of cardiac rehabilitation programs improve patient adherence to this beneficial program.

Purpose: Energy expenditure measured in METs is widely used in cardiovascular medicine, exercise physiology, and nutrition assessment. However, measurement of METs requires complex equipment to determine oxygen uptake. A simple method to predict oxygen uptake on the basis of HR measurements without requirement for gas analysis, movement-recording devices, or exercise equipment (treadmills, cycle ergometers) would enable a simple prediction of energy expenditure. The purpose of this study was to determine whether HR can be used to accurately predict oxygen uptake., Methods: Published studies that reported a measured resting HR (HR(rest)), a measured activity HR (HR(absolute)), and a measured oxygen uptake (mL O(2)·kg(-1)·min(-1)) associated with the HR(absolute) were identified. A total of 220 data sets were extracted from 60 published exercise studies (total subject cohort = 11,257) involving a diverse range of age, pathophysiology, and the presence/absence of β-blocker therapy. Net HR (HR(net) = HR(absolute) - HR(rest)) and HR index (HR(index) = HR(absolute)/HR(rest)) were calculated from the HR data. A regression analysis of oxygen uptake (expressed as METs) was performed against HR(absolute), HR(net), and HR(index)., Results: Statistical models for the relationship between METs and the different HR parameters (HR(absolute), HR(net), and HR(index)) were developed. A comparison between regression analyses for the models and the actual data extracted from the published studies demonstrated that the best fit model was the regression equation describing the relationship between HR(index) and METs. Subgroup analyses of clinical state (normal, pathology), testing device (cycle ergometer, treadmill), test protocol (maximal, submaximal), gender, and the effect of β-blockade were all consistent with combined data analysis, demonstrating the robustness of the equation., Conclusions: HR(index) can be used to predict energy expenditure with the equation METs = 6HR(index) - 5.

Background: The purpose of this study was to evaluate the reliability, validity, and responsiveness to change of the Health Utilities Index Mark-3 (HUI-3) in heart failure (HF) for use in cost-effectiveness studies., Methods and Results: Two hundred eleven patients with HF recruited from outpatient clinics were enrolled; 165 completed the 26-week study. Patients completed 4 health-related quality of life questionnaires (baseline and 4, 8, and 26 weeks), including the HUI-3, the Medical Outcomes Study Short-form 12 (SF-12), the Minnesota Living with Heart Failure Questionnaire (LHFQ), and the Chronic Heart Failure Questionnaire (CHQ). The HUI-3 indicated moderate or fair health-related quality of life overall; the attributes most impaired were pain, ambulation, cognition, and emotion. Internal consistency reliability (Cronbach's alpha = 0.51) was low and test-retest reliability (intraclass correlation coefficient = 0.68) was adequate. The HUI-3 total score was significantly associated with the SF-12, LHFQ, and CHQ total scores. It discriminated among patients with varying New York Heart Association class (P < .001) and varying perceived health (P < .001). The HUI-3 was less responsive to perceived change in health condition than the LHFQ or the CHQ., Conclusions: The HUI-3 demonstrated satisfactory reliability and validity in this sample supporting its use in cost-effectiveness studies., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The rate of war-related amputations in current U.S. military personnel is now twice that experienced by military personnel in previous wars. We reviewed the literature for health outcomes following war-related amputations and 17 studies were retrieved with evidence that (a) amputees are at a significant risk for developing cardiovascular disease; (b) insulin may play an important role in regulating blood pressure in maturity-onset obesity; (c) lower-extremity amputees are at risk for joint pain and osteoarthritis; (d) transfemoral amputees report a higher incidence of low back pain than transtibial amputees; and (e) 50 to 80% report phantom limb pain, with many amputees stating they were either told that their pain was imagined or their mental state was questioned. The consistency of the observations on health outcomes in these studies warrants careful examination for their implication in the contemporary treatment of war-related amputation.

1. The Chinese version of the 27-item MacNew health-related quality of life (HRQL) questionnaire is a valid, reliable and responsive core coronary heart disease (CHD)-specific HRQL measure. It can be used to compare the health outcomes, burdens of illness, and treatment effectiveness in pure or mixed populations of patients with myocardial infarction, angina, or heart failure in clinical trials and in routine clinical practice. 2. The Chinese version of the 35-item Myocardial Infarction Dimensional Assessment Scale (MIDAS) did not perform as well. Although four of the seven subscales, which cover the physical and psychosocial aspects of HRQL, are psychometrically sound when used to evaluate HRQL among CHD patients with different cardiac diagnostic categories, the remaining three subscales covering treatment-related aspects are not. The latter had only weak validity and responsiveness, which may be due to cultural differences. 3. To improve the overall performance of the Chinese version of the MIDAS, further effort is required to clarify the treatment-related impact of CHD on well-being from the patient's perspective.

Objective: To perform a psychometric evaluation of the Myocardial Infarction Dimensional Assessment Scale (MIDAS) in Chinese patients with coronary heart disease., Design and Setting: Patients with angina (n=162), MI (n=124) or heart failure (n=95) were recruited from a regional university-affiliated hospital. The Chinese version of the MIDAS (C-MIDAS), the Hospital Anxiety and Depression Scale (HADS) and the Short-Form 36 Health Survey (SF-36) were administered to all patients at baseline and the C-MIDAS was also administered seven day (n=92) and three months (n=363) later., Results: The C-MIDAS conforms to the 7-factor structure as proposed in the original version. It is reliable with Cronbach's alphas from 0.73 to 0.94 and test-retest reliabilities from 0.76 to 0.92. Four of its subscales (physical activity, insecurity, emotional reaction and dependency) correlated significantly with the SF-36 and the HADS in each diagnostic group and had good discriminative properties in terms of gender, emotional disturbance and perceived health deterioration, with responsiveness supported by medium-high effect sizes (0.43-0.83) and standardize response means (0.46-0.82). The other three subscales measuring treatment-related impacts added little to the validity and responsiveness of the C-MIDAS., Conclusion: To render the C-MIDAS a core health-related quality of life measure for Chinese-speaking patients with coronary heart disease, further studies need to clarify the content adequacy and cultural relevancy of those subscales measuring treatment-related impact.

Increasingly important objectives for developed and especially for developing countries include increasing the numbers of individuals who do not smoke, who eat healthy diets and who are physically active at levels that are health enhancing. In developing countries, deaths from chronic disease are projected to increase from 56% of all deaths in 2005 to 65% by 2030 (driven largely driven by deaths due to cardiovascular and coronary heart disease); in developed countries, however, the increase is only from 87.5 to 88.5%. The data on physical inactivity presented in this review were derived primarily from World Health Organization (WHO) publications and data warehouses. The prevalence of physical inactivity at less than the levels recommended for enhancing health is high; from 17 to 91% in developing countries and from 4 to 84% in developed countries. In developed countries, physical inactivity is associated with considerable economic burden, with 1.5-3.0% of total direct healthcare costs being accounted for by physical inactivity. Other than on some exciting work in Brazil, there is little information on the effectiveness and cost-effectiveness of physical activity-enhancement strategies in developing countries. The WHO has signaled a shift from the treatment of illness to promotion of health, with an emphasis on changing modifiable health-risk factors, including smoking, unhealthy diets and physical inactivity: the real question, especially for developing countries, is 'what is the future healthcare cost of not encouraging healthier lifestyles today?'

Background: An objective of exercise-based cardiac rehabilitation is improvement in patient-reported outcomes such as health-related quality of life as well as anxiety and depressive symptoms. There are no direct comparisons of the effectiveness of inpatient and outpatient exercise-based cardiac rehabilitation programmes on patient-reported outcomes., Methods: In this non-randomized study we collected patient-reported outcomes data with the MacNew Heart Disease health-related quality of life questionnaire and the Hospital Anxiety and Depression Scale at baseline, 1 month and again 3 months after admission to exercise-based cardiac rehabilitation in a cohort of 216 consecutive patients enrolled either in a 4-week inpatient exercise-based cardiac rehabilitation (n=62) or a 3-month outpatient exercise-based cardiac rehabilitation (n=87) and in a usual care group (n=67) to document the natural course in patient-reported outcome variables without exercise-based cardiac rehabilitation., Results: Although MacNew health-related quality of life scores improved more with inpatient than outpatient exercise-based cardiac rehabilitation by month 1, the improvement was still significant in both groups at month 3 and also in the usual care group when compared to baseline. The health-related quality of life scores in the inpatient group, however, decreased between month 1 and 3 whereas they continued to improve in the outpatient group. The significant reduction in both anxiety and depressive symptoms in both exercise-based cardiac rehabilitation groups by month 1 was maintained at month 3 only with outpatient exercise-based cardiac rehabilitation. No significant changes over the 3 months were observed in the usual care group., Conclusion: Significant improvements of 1-month patient-reported outcomes are achieved in patients attending inpatient as well as outpatient exercise-based cardiac rehabilitation when compared with no exercise-based cardiac rehabilitation. In contrast to inpatient exercise-based cardiac rehabilitation, however, outpatient exercise-based cardiac rehabilitation leads to a further improvement of patient-reported outcomes. These results suggest that, if patients have to be admitted for inpatient exercise-based cardiac rehabilitation, this programme should be followed by an outpatient exercise-based cardiac rehabilitation to further improve and stabilize these patient-reported outcome variables.

Background: Little is known about physical activity levels in patients with coronary artery disease (CAD) who are not engaged in cardiac rehabilitation. We explored the trajectory of physical activity after hospitalization for CAD, and examined the effects of demographic, medical, and activity-related factors on the trajectory., Design: A prospective cohort study., Methods: A total of 782 patients were recruited during CAD-related hospitalization. Leisure-time activity energy expenditure (AEE) was measured 2, 6 and 12 months later. Sex, age, education, reason for hospitalization, congestive heart failure (CHF), diabetes, and physical activity before hospitalization were assessed at recruitment. Participation in cardiac rehabilitation was measured at follow-up., Results: AEE was 1948+/-1450, 1676+/-1290, and 1637+/-1486 kcal/week at 2, 6 and 12 months, respectively. There was a negative effect of time from 2 months post-hospitalization on physical activity (P<0.001). Interactions were found between age and time (P=0.012) and education and time (P=0.001). Main effects were noted for sex (men more active than women; P<0.001), CHF (those without CHF more active; P<0.01), diabetes (those without diabetes more active; P<0.05), and previous level of physical activity (those active before hospitalization more active after; P<0.001). Coronary artery bypass graft patients were more active than percutaneous coronary intervention (PCI) patients (P=0.033)., Conclusions: Physical activity levels declined from 2 months after hospitalization. Specific subgroups (e.g. less educated, younger) were at greater risk of decline and other subgroups (e.g. women, and PCI, CHF, and diabetic patients) demonstrated lower physical activity. These groups need tailored interventions.

Background: Economic evaluation is an important tool in the evaluation of competing healthcare interventions. Little is known about the economic benefits of different cardiac rehabilitation program delivery models., Design: The goal of this study was to review and evaluate the methodological quality of published economic evaluations of cardiac rehabilitation services., Methods: Electronic databases were searched for English language evaluations (trials, modeling studies) of the economic impact of cardiac rehabilitation. A review of study characteristics and methodological quality was completed using standardized tools. All costs are adjusted to 2004 US dollars., Results: Fifteen economic evaluations were identified which met eligibility criteria but which displayed wide variation in the use of comparators, evaluation type, perspective and design. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation in myocardial infarction and heart failure patients was identified. The range of cost per life year gained was estimated as from 2193 dollars to 28,193 dollars and from - 668 dollars to 16,118 dollars per quality adjusted life year gained. The level of evidence supporting the economic value of home-based cardiac rehabilitation interventions is limited to partial economic analyses., Conclusions: Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. Further trials are required to support the cost-effectiveness of cardiac rehabilitation in cardiac patients who have under gone revascularization. The literature evaluating home-based and alternative delivery models of cardiac rehabilitation was insufficient to draw conclusions about their relative cost-effectiveness. The overall quality of published economic evaluations of cardiac rehabilitation is poor and further well-designed trials are required.

Background: Secondary prevention through cardiac rehabilitation (CR) has been recommended for most patients with coronary artery disease (CAD). Although generally reimbursed for 3 months, to date, optimal CR program duration and frequency of patient contact has yet to be identified. This study compared standard (33 sessions for 3 months) versus distributed (33 sessions for 12 months) CR for effects on exercise variables, risk factors, health-related quality of life (HRQL), depressive symptoms, and direct costs to the cardiac health care system., Methods: We randomly assigned 392 patients to either standard CR (n = 196) or distributed CR (n = 196). Outcomes were cardiorespiratory fitness, daily physical activity, coronary risk factors, generic and heart disease HRQL, and depressive symptoms, measured 12 and 24 months after program intake. Secondary outcomes included these variables measured after 3 months. Costs to the cardiac health care system were determined 2 years after program initiation., Results: Both groups showed improvements over time in cardiorespiratory fitness, daily physical activity, low-density lipoprotein cholesterol, generic and heart disease HRQL, and depressive symptoms. Over time, blood pressure and body mass index values worsened. Smoking status, high-density lipoprotein cholesterol, and triglyceride levels remained unchanged. There were no clinically meaningful or statistically significant between group differences for outcomes at 12 or 24 months. The costs of the programs to the cardiac health care system were not different., Conclusions: From a clinical standpoint, this study indicates that both standard and distributed program formats serve patients with CAD equally well over the longer term. Programs could use either program delivery model (standard or distributed) depending on patient or program needs. Costs to the cardiac health care system are similar.

Purpose: The purpose of this study was to describe the impact of self-report heart disease, other chronic comorbidities, and perceived health status on activity limitation among community dwelling persons older than 50 years of age., Methods: Odds ratios for activity limitation in activities of daily living, mobility, and other activities were estimated for respondents with self-report heart disease, eight other chronic comorbid conditions, and perceived health status using data generated in two nationally representative cross-sectional surveys, the Health and Retirement Survey (HRS; respondents aged 51 to 60 years) and the Assets and Health Dynamics of the Oldest Old study (AHEAD; respondents aged 70 years and older)., Results: The prevalence of activity limitation increased significantly across the spectrum from activities of daily living to mobility to other activities in both surveys in respondents with and without heart disease. There was a significantly increased likelihood of mobility and other activity limitation among those with heart disease. Among the HRS respondents with heart disease, five or more of the eight comorbid conditions plus poor or fair perceived health were associated with a significantly increased limitation in each activity category. Among the AHEAD respondents with heart disease, three comorbid conditions plus perceived health were associated with a significantly increased limitation in activities of daily living whereas six comorbid conditions plus perceived health were associated with a significantly increased limitation in mobility and in other activities., Conclusions: As a prime objective of cardiac rehabilitation is to reduce activity limitation, the strong associations between comorbidity and activity limitation observed in this study among persons older than 50 years with heart disease suggest that the burden of comorbidity-associated is considerable but should not be an automatic exclusion criterion for referral to cardiac rehabilitation. The lack of rigorous scientific information on how these associations may influence clinicians who refer patients to rehabilitation and those who manage these programs strongly reinforces the need for more research to explore the real-world spectrum of comorbidity among persons with heart disease and the impact on activity limitation.

Background: Although health-related quality of life is diminished among patients with chronic heart failure, few investigators have examined interactions of age and sex with health-related quality of life longitudinally., Objectives: To examine differences in health-related quality of life among 4 groups of patients with heart failure on the basis of age (< 65 years and > or = 65 years) and sex and to evaluate relationships of age and sex to changes in health-related quality of life during 6 months., Methods: Patients from 2 outpatient clinics in an urban county hospital were interviewed at baseline and 26 weeks later Health-related quality of life was measured by using the Minnesota Living With Heart Failure Questionnaire and the Chronic Heart Failure Questionnaire., Results: A total of 165 patients (52% women; mean age, 57.6 years) completed interviews at baseline and 26 weeks later. At baseline, patients younger than 65 years had poorer health-related quality of life scores on total scales and some subscales than did older patients. Women had poorer scores than did men on some scales, particularly the emotional subscales. At 26 weeks, patients younger than 65 had poorer total health-related quality of life on 1 scale than did patients 65 and older, and women had poorer scores than did men on 1 total scale. With demographic and clinical factors controlled for, women younger than 65 had improvements in health-related quality of life on some scales., Conclusions: Women younger than 65 years had relatively poorer initial health-related quality of life that improved after 26 weeks.

Background: Medications can improve the functioning and health-related quality of life of patients with chronic heart failure (CHF) and reduce morbidity, mortality, and costs of treatment. However, patients may not adhere to therapy. Patients with complex medication regimens and low health literacy are at risk for nonadherence., Objective: The primary goal of this project is to develop and assess a multilevel pharmacy-based program to improve patient medication adherence and health outcomes for elderly CHF patients with low health literacy., Methods: In this 4-year, controlled trial, patients aged 50 years with a diagnosis of CHF who are being treated at Wishard Health Services (Indianapolis, Indiana) are randomly assigned to pharmacist intervention or usual care. Intervention patients receive 9 months of pharmacist support and 3 months of postintervention follow-up. The intervention involves a pharmacist providing verbal and written education, icon-based labeling of medication containers, and therapeutic monitoring. The pharmacist identifies patients' barriers to appropriate drug use, coaches them on overcoming these barriers, and coordinates medication use issues with their primary care providers. Daily updates of relevant monitoring data are delivered via an electronic medical record system and stored in a personal computer system designed to support pharmacist monitoring and facilitate documentation of interventions. To measure medication adherence objectively, electronic monitoring lids are used on all CHF medications for patients in both study groups. Other assessments include self-reported medication adherence, results of echocardiography (eg, ejection fraction), brain natriuretic peptide concentrations, and health-related quality of life. Health services utilization, refill adherence, and cost data derive from electronic medical records. After completion of this study, the data can be used to assess the effectiveness and cost-effectiveness of our intervention., Results: One hundred twenty-two patients have been assigned to receive the intervention and 192 to receive usual care., Conclusions: Our study aims to improve patients' knowledge and self-management of their medication and to improve medication monitoring in a multilevel pharmacy-based intervention. By doing so, we intend that the intervention will improve the health outcomes of elderly patients with CHF.

Background and Aim: The assessment of health-related quality of life (HRQL) increasingly is an important outcome in the management and care of patients with angina. The aim of this study was to describe the baseline HRQL in patients with coronary artery disease (CAD) and angina and to report the impact of the three established therapeutic strategies, continued medical treatment (CMT), percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on HRQLover a 12-month follow-up period., Patients and Methods: The change in specific HRQL scores and angina severity was evaluated in a routine clinical practice setting in 158 patients with CAD and angina treated either with CMT, PCI, or CABG. The measure used in this study to assess HRQL was the MacNew Heart Disease HROL Questionnaire (MacNew). It was administered before coronary angiography and 12 months after treatment stratification. Angina pectoris was assessed with the modified Canadian Cardiovascular Society's classification., Results: The MacNew discriminated between treatment groups with lowest (poorest HROL) baseline global, physical,and social HRQL scores seen in patients with subsequent CABG. There were significantly greater improvements in global and emotional HRQL scores after both PCI and CABG than after CMT. In all three treatment groups, improved HRQLscores were associated with improved angina grade., Conclusion: The present study has shown clearly that evaluating HRQL as an outcome before and after different treatments for angina is feasible and useful in routine clinical practice. Measurement of HRQL discriminated between treatment groups at baseline and was responsive demonstrating improvement with each treatment alternative but most notably with CABG. The improved HROL was consistent with changes in angina severity. The MacNew may be useful when comparing outcomes across different treatments among patients with CAD and angina.

Background: Health-related quality of life (HRQL) assessment is an important measure of the impact of a wide range of disease process on an individual. To date, no HRQL tool has been evaluated in an Iranian population with cardiovascular disorders, specifically myocardial infarction, a major cause of mortality and morbidity. The MacNew Heart Disease Health-related Quality of Life instrument is a disease-specific HRQL questionnaire with satisfactory validity and reliability when applied cross-culturally., Method: A Persian version of MacNew was prepared by both forward and backward translation by bilinguals after which a feasibility test was performed. Consecutive patients (n = 51) admitted to a coronary care unit with acute myocardial infarction were recruited for measurement of their HRQL with retest one month after discharge in the follow-up clinic. Principal components analysis, intra-class correlation reliability, internal consistency, and test-retest reliability were assessed., Results: Trivial rates of missing data confirmed the acceptability of the tool. Principal component analysis revealed that the three domains, emotional, social and physical, performed as well as in the original studies. Internal consistency was high and comparable to other studies, ranging from 0.92 for the emotional and physical domains, to 0.94 for the social domain, and to 0.95 for the Global score. Domain means of 5, 5.3 and 4.9 for emotional, physical and social respectively indicate that our Iranian population has similar emotional and physical but worse social HRQL scores. Test-retest analysis showed significant correlation in emotional and physical domains (P < 0.05)., Conclusion: The Persian version of the MacNew questionnaire is comparable to the English version. It has high internal consistency and reasonable reproducibility, making it an appropriate specific quality of life tool for population-based studies and clinical practice in Iran in patients who have survived an acute myocardial infraction. Further studies are needed to confirm its validity in larger populations with cardiovascular disease.

The German versions of two patient-perceived heart disease specific health-related quality of life (HRQL) questionnaires, the Seattle Angina Questionnaire (SAQ) and the MacNew Heart Disease questionnaire, were examined for their psychometric properties in patients with angiographically documented coronary artery disease and angina who were treated either medically or invasively and followed up for 1 year. Both HRQL questionnaires and the modified Canadian Cardiovascular Society (CCS) angina-associated disability scale were completed by 158 patients at baseline and 12 months later when they also completed a generic health status questionnaire, the SF-36. Both specific HRQL questionnaires were acceptable to patients. Three of the four MacNew scales, but none of the SAQ scales, discriminated between patients by baseline CCS disability levels I and IV. Internal consistency ranged from 0.75 to 0.94 for the SAQ and from 0.86 to 0.97 for the MacNew scales. Test-retest reliability over a 4-week period of time ranged from 0.45 to 0.81 for the SAQ scales and 0.61 to 0.68 for the MacNew scales. Over 12 months, HRQL improved (p < 0.001) on three of the five SAQ and on all four of the MacNew scales with the responsiveness statistic ranging from 0.59 to 1.55 for the SAQ and 0.86 to 1.12 for the MacNew. The 12 month scores on all SAQ and MacNew scales were significantly higher in patients who improved than those who deteriorated on the SF-36 reported health transition question. We conclude that the SAQ and the MacNew are both valid, reliable, and responsive in German, that the MacNew discriminates better between angina grades at baseline, that HRQL improves over 12 months with both measures, that the SAQ angina frequency and disease perception scales have the largest effect sizes, and that the 12-month change in HRQL with both instruments was associated with change in SF-36 reported health transition status.

Since its introduction in the 1970s percutaneous treatment of lumbar disc herniation has been an attractive concept that has been the object of technical development and clinical application throughout the world. Little scientific evaluation of the efficacy and effectiveness of the procedure has been done. To estimate the success rates of automated percutaneous and conventional discectomy in comparable patients and to document the resource consumption of patients treated in these ways, a multicenter randomized clinical trial designed to compare both treatment efficacy and cost-effectiveness of automated percutaneous discectomy and conventional discectomy in adult patients with no prior lumbar spinal surgery, no coexistent lumbar spinal disease, unilateral single level lumbar radiculopathy with images confirming disc herniation at the appropriate level. In the course of the trial important technical advances allowing epidural extraction of free-fragment disc herniation was incorporated into the trial. It was not possible to enroll the required number of patients to complete the trial. Of 5735 screened patients, 95 were eligible and 36 were enrolled. Two elected watchful waiting and did not have any surgical procedure. Eight patients were lost to follow-up. Among the 27 evaluable patients, 41% of the percutaneous discectomy patients and 40% of the conventional discectomy patients were assessed as achieving "success" on the primary outcome measure. No clinical trial of any percutaneous discectomy technique provides definitive evidence supporting the efficacy or effectiveness of the procedure. Such evidence should be required by patients to whom such procedures are proposed and those who are asked to pay for them., (Copyright 2002 Elsevier Science Ltd.)

Although previous studies have found automated percutaneous discectomy and epidural percutaneous discectomy to be less efficacious than conventional discectomy, these percutaneous procedures may be effective and cost-effective as a first surgical treatment for herniated lumbar disc. Percutaneous procedures for herniated lumbar disc continue to be performed throughout the world without definitive evidence of efficacy or effectiveness. The objective of this article is to report the design considerations and final design of a study with the following objectives: (1) to estimate the efficacy of automated percutaneous and conventional discectomy in treating single level herniated lumbar discs in comparable patient populations, and (2) to test the hypothesis that the use of percutaneous discectomy as the first surgical procedure in such patients would result in less cost and fewer complications than utilizing conventional discectomy as the first procedure. A multicenter randomized clinical trial was designed that followed published eligibility criteria closely, allowed flexibility in timing of surgery (while collecting natural history information on patients identified before electing surgery), incorporated adjustments for newly developed technology and accommodated the unusual demands of assessing a procedure acknowledged to have inferior medical outcomes when compared to conventional therapy but which offered potential advantages in cost and safety. The study was successfully designed and funded. In its implementation we experienced several obstacles that may affect the success of other clinical trials. Despite using established eligibility criteria, our patient enrollment was lower than expected. Academic health centers and traditional research settings are seeing fewer patients who would be eligible for discectomy; private clinical centers are treating eligible patients but lack the incentives to participate in clinical research. Automated percutaneous discectomy and epidural percutaneous discectomy are widely performed procedures and, despite the aforementioned obstacles, their efficacy and cost-effectiveness need to be scientifically evaluated if we are committed to delivering appropriate patient care., (Copyright 2002 Elsevier Science Ltd.)

Health-related quality of life (HRQL) instruments have been used to measure HRQL in heart failure patients, but how different instruments compare in the same groups of patients is not known. The purpose of this study was to compare the reliability and validity of three HRQL measures in 211 heart failure patients recruited from clinics affiliated with an urban hospital. Two disease-specific instruments, the chronic heart failure questionnaire (CHQ) and the living with heart failure questionnaire (LHFQ), and one generic instrument, the short-form 12 (SF-12), were administered. Patients reported moderate to low HRQL scores. Floor or ceiling effects were noted in the disease-specific instruments. Internal consistency reliabilities of the CHQ and LHFQ were satisfactory. Construct, convergent, and discriminant validity were supported for each instrument. Each scale and subscale, except for the SF-12 mental component scale, differentiated between patients with New York Heart Association (NYHA) class I, II, and III plus IV; the LHFQ physical subscale was the only measure to differentiate between patients with NYHA class III and IV. All three instruments were satisfactory for measuring HRQL, but the disease-specific instruments were preferable to the generic instrument. The decision of which instrument to use depends on the purpose of the study.

Objective: To report reference data for the heart-specific MacNew Heart Disease Health-Related Quality of Life instrument., Methods: One thousand five hundred and six patients with myocardial infarction (n = 346), heart failure (n = 201), and ischaemic heart disease (IHD, n = 959) were surveyed 4 months after hospital discharge. Quality of life scores were determined, stratified by diagnostic category, age and sex. Changes in scores from 4 to 8 months post-discharge were calculated for a subset of 830 patients, stratified by age and sex., Results: At 4 months there were no significant differences in scores between myocardial infarction and electively admitted IHD patients, however the scores of heart failure patients were significantly lower (indicating poorer quality of life) than those of patients with other diagnoses. There were few significant differences between age groups or sexes when comparing within diagnostic groups. Change from 4 to 8 months was not associated with diagnosis, age, or sex but was associated with events within the period (readmission or revascularisation). The change data suggest that a value of 0.5 may be a useful indicator of the minimal clinically important difference., Conclusions: These reference data will assist in sample size calculations and with comparison of results in other studies, and will be of use to researchers who are using or intending to use the MacNew instrument.

Unlabelled: To estimate age group differences in the prevalence and outcomes of three common and often comorbid metabolic conditions (i.e., obesity, hypertension, and diabetes) and heart disease., Design: Nationally representative prospective cohort study., Setting: PARTICIPANTS' homes., Participants: 9825 adults aged 51 to 61 years (middle-age) in 1992, and 7370 adults aged 70 years and over (older-age) in 1993., Measurements: Two-year dichotomous outcomes included: doctor visits, hospitalization, mobility difficulty, activity of daily living limitation, poor perceived health, and mortality. Odds ratios (OR) were adjusted for sociodemographic characteristics and history of cancer or lung disease., Results: Those with one condition represented 80% and 70% of the middle- and older-age groups, respectively, while just 1-2% of each age group reported all three metabolic conditions. Thirteen percent and 32%, respectively, reported heart disease with or without metabolic conditions. Diabetes comorbid with other metabolic conditions, and particularly with heart disease, substantially elevated the risk of adverse outcomes such as health-related quality of life deficits, health services use, and mortality in both middle- and older-age adults. In the middle-age group, the OR was 6.81 for mortality in patients with a combination of obesity and diabetes and 6.10 in those with a combination of heart disease and diabetes. There also were significant ORs for mortality in middle-aged patients with heart disease (OR = 2.40), diabetes (OR = 2.63) and for those with a combination of obesity, hypertension, and diabetes (OR = 3.26)., Conclusion: The impact of these often comorbid conditions underscores the importance of targeted and aggressive prevention, particularly among middle-age adults.

Background: The advantage of specific quality of life instruments is its ability to evaluate specific issues related to the illness of interest. The aim of the present study is to develope a Spanish version of the self-administered questionnaire MacNew QLMI, specific for patients after myocardial infarction (MI)., Material and Method: Forward and back-translation method by bilinguals was performed; once the test for feasibility and comprehension was carried out. 143 patients with a first MI completed the Spanish version of the MacNew QLMI and principal components factor analysis was performed. Reliability was assessed in 50 patients with stable MI that completed twice the questionnaire (with an interval of two weeks), measuring reproducibility and internal consistency with Student t test, intraclass correlation and Cronbach's alpha., Results: Factor analysis showed a similar three dimensional structure as the original version. Intraclass correlation coeficient were 0.83, 0.87 and 0.83, and Cronbach's alpha coeficients were 0.85, 0.88 and 0.83 for the emotional, physical and social dimensions respectively., Conclusions: The Spanish version of the MacNew QLMI questionnaire has a good equivalence with the original version, a good internal consistency and a good reproducibility; it can be used in the Spanish population to study its validity.

Objectives: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age-related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI., Design, Setting, and Participants: Data is from baseline assessment of 265 post-MI patients (age range 45-85 years) enrolled in the Cardiac Rehabilitation in Advanced Age randomized, controlled trial. Patients with major comorbidities or severe MI complications were excluded from the trial. Exercise tolerance was determined from symptom-limited exercise testing and expressed as total work capacity (TWC, kg.m) or peak oxygen consumption (VO2peak, mL/kg/min). The associations between both TWC and VO2peak and baseline demographic, social, clinical, and neuropsychological variables and an index of health-related quality of life were determined with univariate and multivariate analysis., Results: With univariate analysis, TWC decreased by 1285 kg.m per decade of increasing age between 45 and 85 years of age. With multivariate analysis, TWC decreased by 922 kg.m per decade. Increasing age (P < .001), female gender (P < .001), a small body surface area (P < .001), a low level of usual physical exercise before MI (P < .002), and the presence of post-MI depressive symptoms (P < .024) were independently associated with a lower TWC. The same factors, in addition to a small arm muscle area (P < .002), were also independently associated with a lower VO2peak., Conclusions: Age per se accounts for approximately 70% of the age-related decay in TWC or VO2peak. However, the inclusion of modifiable factors such as physical exercise and depression in the prediction model reinforces the importance of a multidimensional approach to the evaluation and treatment of older patients with a recent MI.

A major challenge for all health care systems is to identify the most efficient use of limited and finite resources available for health care. Economic evaluation provides a balance sheet of the benefits, harms and costs for making choices between alternative health care services and is one strategy to assist decision-makers to make rational choices about effective and efficient health care. Cost and outcomes data collected on two or more alternatives form the basis for economic evaluations and calculating a cost-effectiveness ratio. While comprehensive cardiac rehabilitation has been shown to be an effective intervention for patients with documented heart disease, the economic evaluation data from which to determine the efficiency of cardiac rehabilitation are limited. Available economic evaluations of comprehensive cardiac rehabilitation suggest that it is a cost-effective intervention following an acute coronary event that can be economically justified. Although the majority of data from studies with less rigorous designs suggest either savings or a decrease in health care utilization, there were increased costs per quality-adjusted life year gained in the only randomized controlled trial with a cost-effectiveness analysis of cardiac rehabilitation. As the traditional delivery of cardiac rehabilitation services is undergoing re-examination, there is a need for considerably more research on the cost-effectiveness of cardiac rehabilitation before any definitive statement about reimbursement is made.