ABC | Volume 114, Nº1, January 2019

Original Article Synergistic Effect of Disease Severity, Anxiety Symptoms and Elderly Age on the Quality of Life of Outpatients with Heart Failure José Henrique Cunha Figueiredo, 1 Gláucia Maria Moraes de Oliveira, 1 Basílio Bragança Pereira, 1 Ana Elisa Bastos Figueiredo, 2 Emília Matos Nascimento, 3 Marcelo Iorio Garcia, 1 Sergio Salles Xavier 1 Universidade Federal do Rio de Janeiro – Cardiologia, 1 Rio de Janeiro, RJ – Brazil Fundação Oswaldo Cruz, 2 Rio de Janeiro, RJ – Brazil Centro Universitário Estadual da Zona Oeste, 3 Rio de Janeiro, RJ – Brazil Mailing Address: Gláucia Maria Moraes de Oliveira • Universidade Federal do Rio de Janeiro – R. Prof. Rodolpho P. Rocco, 255 – 8°. Andar – Sala 6, UFRJ. Postal Code 21941-913, Cidade Universitária, RJ – Brazil E-mail: glauciam@cardiol.br , glauciamoraesoliveira@gmail.com Manuscript received August 06, 2018, revised manuscript January 21, 2019, accepted January 07, 2019 DOI: 10.5935/abc.20190174 Abstract Background: Heart failure (HF) is a multifactorial syndrome with repercussions on quality of life (QoL). Objectives: To investigate the main interacting factors responsible to worsen quality of life of outpatients with HF. Methods: Cross-sectional observational study with 99 patients of both genders, attending a HF outpatient clinic at a university hospital, all with a reduced ejection fraction (<40%) by echocardiography. They were evaluated using sociodemographic and clinical questionnaires, the Minnesota Living with Heart Failure (MLwHF), and the Hospital Anxiety and Depression scale (HADS). QoL was the outcome variable. Two multivariate models were used: the parametric beta regression analysis, and the non-parametric regression tree, considering p < 0.05 and 0.05 < p < 0.10 for statistical and clinical significance, respectively. Results: Beta regression showed that depression and anxiety symptoms worsened the QoL of HF patients, as well as male sex, age younger than 60 years old, lower education level, lower monthly family income, recurrent hospitalizations and comorbidities such as ischemic heart diseases and arterial hypertension. The regression tree confirmed that NYHA functional class III and IV worsen all dimensions of MLwHF by interacting with anxiety symptoms, which influenced directly or indirectly the presence of poorer total score and emotional dimension of MLwHF. Previous hospitalization in the emotional dimension and age younger than 60 years in general dimension were associated with anxiety and NYHA functional class, also worsening the QoL of HF patients. Conclusion: HF with reduced ejection fraction was associated with poorer MLwHF. Anxiety symptoms, previous hospitalization and younger age were also associated with worsened MLwHF. Knowledge of these risk factors can therefore guide assessment and treatment of HF patients. (Arq Bras Cardiol. 2020; 114(1):25-32) Keywords: Heart Failure; Anxiety/diagnosis; Hospitalization; Quality of Life; Age; Systolic Volume. Introduction Heart failure (HF) is the leading cause of heart disease morbidity and mortality and is more common among people aged 60 or older. 1 HF deeply affects the health of an individual, and has physical, psychological and social consequences. HF is a syndrome that severely impairs quality of life (QoL), predisposing patients to recurrent hospitalizations, 2 and high morbidity and mortality rates, as observed in the Framingham’s study. 3 In a study 4 of 204 HF outpatients, the authors found that 46% of the outpatients had depressive and anxiety symptoms at baseline. After a five-year follow-up, even after controlling for disease severity and other risk factors, depressive symptoms were still associated with outcomes such as hospitalization and death. 5 When analyzing patients who had difficulty in taking medication, the authors pointed out that these patients had more severe HF symptoms and worse quality of life, which can be partially explained by the coexistence of depression and psychological distress such as dysphoria and anxiety. 6 The association between depression, physical symptoms and QoL in HF patients was observed by Bekelman et al. 7 in a cross-sectional study with 60 outpatients. It was more common to see patients with depression and anxiety after they suffered dyspnea (OR 5.28, p < 0.05), and those who exhibited more symptoms of depression presented more HF symptoms (p < 0.0001) and poorer quality of life. Another study with patients who had been diagnosed with HF concluded that depression was associated with a worse health status at the baseline, and was a strong predictor of hospitalization, and worse HF symptoms, functional status and QoL. 8 Physical symptoms are affected by depression and anxiety, as reported in a study 9 that showed that psychological variables could affect QoL as much as physical symptoms of HF. In a multiple regression analysis, physical symptoms, age, employment status and anxiety at baseline were the best QoL predictors after a three-month follow-up. Depression, perceived control of HF, employment status 25