ABC | Volume 114, Nº1, January 2019

Original Article Figueiredo et al. Poor quality of life in heart failure outpatients Arq Bras Cardiol. 2020; 114(1):25-32 Figure 1 – Regression tree (A- Total Score, B- Physical Dimension, C- Emotional Dimension, D-General Dimension) illustrating that advanced NYHA (New York Heart Association) functional class worsened all dimensions of MLwHF (Minnesota Living with Heart Failure). Anxiety symptoms influenced directly or indirectly the presence of poorer total score and emotional well-being dimension of MLwHF. The same was observed for previous hospitalization in the emotional well-being dimension, demonstrating an interaction with functional class NYHA I and II. In the general well-being dimension, the NYHA functional classes I and II were associated with poorer MLwHF in patients younger than 60 years old. NYHA p < 0.001 AnxSymp p = 0.002 AnxSymp p < 0.001 NYHA p = 0.024 NYHA p = 0.003 PrevHosp p = 0.02 A B C D Age p = 0.016 NYHA p < 0.001 NYHA p < 0.001 NYHA p = 0.048 Node 4 (n = 14) Node 4 (n = 27) Node 5 (n = 13) Node 6 (n = 24) Node 7 (n = 35) Node 3 (n = 27) Node 4 (n = 32) Node 5 (n = 40) Node 5 (n = 26) Node 6 (n = 19) Node 7 (n = 40) Node 3 (n = 19) Node 4 (n = 40) Node 5 (n = 40) I, II I, II III, IV III, IV III, IV I, II I, II No No Yes Yes III, IV Yes 1 1 1 1 No II 2 2 2 2 II I 3 3 I < 59 > 59 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 0 1 0.8 0.6 0.4 0.2 0 support had positive perception of HF control, and anxiety and depression symptoms directly and negatively affected HF-related physical symptoms, which, in turn, interfered with QoL of these patients. A meta-analysis concluded that somatic/affective depression symptoms were more strongly and consistently associated with mortality and cardiovascular events in patients with heart disease compared with cognitive/affective symptoms. 25 Another study 26 with 55 congestiveHF patients also showed that somatic/affective depressive symptoms, but not cognitive depression symptoms and anxiety symptoms, were associatedwith poor health‑related QoL and behavioral functional capacity, independent of age, clinical functional status and comorbidities. 26 Our study disagreed with these results because NYHA functional class III and IV worsened all dimensions of MLwHF, and anxiety symptoms, combined with age under 60 years, influenced directly or indirectly the presence of poorer score. A willing attitude toward following a low sodium diet, and an increased social support were significantly associated with higher levels of perceived control and better QoL. 27 A recent study 28 pointed out that depressive symptoms exerted a negative effect on medication adherence related to the complexity of medication regimen commonly prescribed to HF patients. In the present study, we also observed that the current use of medications as betablockers, ACE and furosemide were associated with poor MLwHF in different dimensions, suggesting that it could be a barrier to reach medication adherence by HF patients. 30