Quality of Life and Psychological Distress in an Egyptian Sample of Patients with Dilated Cardiomyopathy

Background: Cardiovascular diseases are the leading cause of death globally. They also cause severe problems in psychological and social aspects. Those with Dilated Cardiomyopathy (DCM) have substantial limitations in daily activities; moreover, the poor prognosis may result in emotional distress among patients and their families. Results: Patients with DCM had a worse quality of life with lower mean SF-36 score (47.9±10.59) compared to the control group (69.9±8.1). They also had worse HADS (35.2±18.73) compared to the control group (17.3 ± 15.3). SF-36 score had strong positive correlation with left ventricular systolic function measured by ejection fraction (LVEF) with (r: 0.777, R2: 60.3%, p<0.001). While HAD scale had a strong negative one with (r: -0.734, R2: 53.9%, p<0.001). Conclusions: Patients with DCM have a worse quality of life as well as psychological distress (anxiety and depression symptoms) compared to healthy control with standardized references of 69.9±8.1 and 17.3±15. 3 for SF-36 and HAD scale respectively. Patients with lower LVEF are at higher risk. This is a cohort study that included one hundred patients suffering from dilated cardiomyopathy and another one hundred apparently healthy volunteers with normal echocardiogram especially left ventricular ejection fraction (LVEF) as a control group. Patients with history of psychiatric illness (mental, emotional, or behavioral disorders) were excluded.


Background
Cardiovascular diseases are one of the most prevalent chronic diseases with high rates of deaths and disability [1]. Beside mortality, disability and high disease burden, cardiovascular diseases cause severe problems in psychological and social aspects of people's lives [2].
Measuring and implementing effective steps to improve patients' quality of life is one of the most important items of cardiovascular diseases approaches [3]. Quality of life is considered as one of the most important components of quality of medical and health care [4].
Patients with dilated cardiomyopathy experience pronounced restrictions in quality of life and psychological wellbeing. These limitations are only partly accounted for by symptoms and the severity of underlying disease [5].
Those with Dilated Cardiomyopathy (DCM) have substantial limitations in daily activities; moreover the poor prognosis may result in emotional distress among patients and their families [5].
We aimed in this study to measure quality of life and psychological state in patients with dilated cardiomyopathy using standardized measures.

Methods
This is a cohort study that included one hundred patients suffering from dilated cardiomyopathy and another one hundred apparently healthy volunteers with normal echocardiogram especially left ventricular ejection fraction (LVEF) as a control group. Patients with history of psychiatric illness (mental, emotional, or behavioral disorders) were excluded.
• All candidates received a set of questionnaires and history and physical examination with emphasis on volume overload (weight gain, pulmonary rales, jugular venous distension, pedal edema, ascites, hepatomegaly), peripheral hypoperfusion (hypotension, pallor, mottled skin, cold extremities, and poor capillary refill) • Investigations: (ECG, echocardiography, and laboratory investigations)

Quality of life (QOL) assessment
Quality of life was assessed using the short form 36 health survey (SF-36), Eight dimensions of functioning are assessed with the SF-36: physical functioning or activities of daily living; role limitations owing to physical problems; role limitations resulting from emotional problems; social functioning; mental health; general perceptions of health; vitality or energy; and bodily pain (  The SF-36 is one of the most widely used measures of health-related QOL consisting of 36 items and covering eight dimensions: Physical Functioning (PF), Role limitations caused by physical health problems (RF), Bodily Pain (BP), General Health perception (GH), Vitality (VT), Social Functioning (SF), Role limitations caused by Emotional health problems (RE), and mental health (MH) [5]. Scores on all the subscales are transformed linearly to a possible range of 0-100; higher scores indicate more favorable physical functioning/psychological well-being [6].

Psychological wellbeing
Anxiety and depression were assessed with the Hospital Anxiety and Depression (HAD) scale, 14 items questionnaire designed to assess emotional distress with items uncontaminated by somatic symptoms [7]. We used the total HAD score as a global measure of psychological distress (Figure 1).

Patients' baseline clinical characteristics
Regarding demographic data and patients' characteristics there was no difference between the two groups. Most of the candidates in both groups were males (70.6% in patients' groups vs. 61% in control group; p value >0.05). The mean age among patients was 52.06±9.3 years, about one fourth were hypertensive, 18% were diabetics and 65% were active smokers with mean BMI of 31±10.4 ( Table 2).  Patients with DCM compared to the control group showed a trend of higher serum creatinine and lower hemoglobin levels but with no statistical significance. Echocardiographic Results

Degree of mitral regurgitation
There were 16 patients with normal mitral valve, 7 patients with trivial mitral regurgitation, 52 patients with mild mitral regurgitation, 50 patients with moderate regurgitation, 17 patients with severe mitral regurgitation, 8 patients with mitral prosthesis. (Figure 3). Correlations with SF-36 and HAD and other parameters are shown in Table 3.

Relationship between quality of life, psychological wellbeing, and different degrees of LV dysfunction
Among patients with DCM SF-36 scores were the lowest (37.5±10.67) among patients with severe LV dysfunction. Also, the mean HAD scale was highest (57.24±16.1) among those with severe LV dysfunction, denoting worst quality of life and highest psychological distress among patients with severe LV dysfunction (Table 5, Figure 8).

Discussion
The quality of life is becoming a cornerstone in management of patients with different cardiac diseases, especially cardiomyopathy, due to its chronic nature and impairments of physical functioning. There are different available tools for assessment of quality of life in patients with DCM including the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Short Form-36 (SF-36). In this study, we used the SF-36 which is a generic QoL tools which is widely used in research projects and daily practice, to assess, follow and supervise health status [8].
SF-36 assesses eight different aspects of health. It is generic by nature that it, as opposed to disease-specific measures, is used to compare outcomes across different diseases and treatments. An Arabic version of SF-36 was translated and validated by El-Kalla, et al. in 2016 [8]. This provides a more practical method for QoL assessment in Arabic speaking countries like Egypt. We aimed in this study to assess the QOL in patients with DCM using the SF-36 Form that was not done before in Egyptian population. We compared the results of each aspect to a healthy control as a standard group.
Those with DCM showed significantly lower SF-36 score, i.e., worse QOL. Similar results with a relatively higher average scores were shown earlier by Steptoe A, et al. [5] where they compared the SF-36 form results among patients with different cardiomyopathy.
Different factors affect the QOL in patients with DCM, in our study the lower the LV systolic function the worse the QOL. This highlights the group at higher risk and so who necessitates intense and earlier interventions to improve QOL.
The existing data assessing QOL among Egyptian population in specific diseases like DCM is sparse; using SF-36 Form in our study creates a standardized score that can be compared with results from other areas and from other diseases as well.
For the psychological wellbeing we used the widely spread and easy tool, the HAD scale for assessment of anxiety and depression. We preferred the use of the total score as a global measure for the ease of use and to show the negative psychological impact of such debilitating chronic disease. In our study, those with DCM showed nearly double the total HAD score when compared to healthy control group. This shows the marked psychological distress in such group of patients.
Again, the lower LV systolic function was an important predictor of psychological distress in patients with DCM. In a study done by Shu Guan et.al., [9] investigating the prevalence of anxiety and depression among patients with DCM in China, of 115 patients with DCM, 23.4% were diagnosed with anxiety and 21.7% with depression and this increases with poor cardiac functions, mental work, and arrhythmia.
There above results spot the light upon the need for routine assessment of QOL and psychological wellbeing among patients with DCM, especially those with severe LV dysfunction. To decrease the psychological impact and improve QOL in such patients using non-pharmacological and pharmacological therapies.

Conclusions
Patients with DCM have a worse quality of life as well as psychological distress (anxiety and depression symptoms) and those with lower LVEF are at higher risk.

Ethics Approval and Consent to Participate
No data were collected before detailed information was given to the patient and a written consent was obtained. The study was approved by the local Institutional ethical committee Faculty of Medicine, Ain Shams University