What is quality of life?
		People with angina are living longer—but not necessarily better
		How quality of life is measured
		Talk to your doctor about quality of life

1. A very high percentage—82% of patients with angina—downsize their lifestyles to avoid angina attacks.



2. Quality of life refers to how satisfied you are with your life; the way that you feel and your ability to function as you would like.



3. Living longer is important, but living better may be equally important.



4. The more information you give your doctor, the better she or he will be at prescribing treatment to help improve your quality of life.

If you've been diagnosed with chronic angina, your life is no longer the same. When fear of chest pain or discomfort stops you from carrying out your daily activities, you may need to rely on family members to do the simple chores you once performed, such as bringing in grocery bags, vacuuming, taking out the trash, or changing bed sheets. Maybe you've had to give up leisure activities, such as tennis or gardening. Perhaps you've missed time from work, and when you're on the job, you may find it hard to fulfill all of your duties.

When chronic angina limits your life in ways big and small, you may understandably feel anxious and depressed. It also doesn't help if worries about the next chronic angina attack cloud your peace of mind, or if your medications cause unpleasant side effects. Together, these physical and emotional burdens can work together to lower your quality of life.

What is quality of life?

Medically speaking, quality of life refers to how satisfied you are with your life; the way that you feel and your ability to function as you would like. Your quality of life is likely to be affected by a combination of factors such as your health, your symptoms, and the level of your physical and social functioning.

If a patient with chronic angina is able to do what he or she wants—to function without pain and self-imposed limitation—then quality of life may be good. But many patients are frustrated that their functioning falls short of their expectations. "The greater the discrepancy between the way that patients are actually functioning and how they'd like to be functioning, the worse their quality of life," says John Spertus, M.D., MPH, Associate Professor of Medicine at the University of Missouri—Kansas City, and Director of Cardiovascular Education and Outcomes Research at the Mid America Heart Institute of Kansas City, and a consultant to CV Therapeutics, Inc., which brings you LifeHeart.com.

Unfortunately, for most patients with chronic angina, poor quality of life seems to be the rule rather than the exception. One British study of 57 patients with angina showed that six months after being discharged from hospital for chest pain, 58% of patients still had angina attacks; 72% reported breathlessness; 79% reported lethargy; 76% felt anxious; and 78% felt depressed.¹

In another British study, seven patients with chronic angina who spoke about their experiences revealed feelings of resentment, annoyance, and indignation over having to "slow down." Patients carried out fewer activities, took longer to complete tasks, or were unable to do certain things. Some even retired from their jobs.² One patient said, "Now I've got to plan everything I do...and I find this frustrating." This emotional toll extended to family members. One man described adjusting to chronic angina as "quite stressful." He said, "I think my wife has probably suffered more than anyone else because at first I was short-tempered. I don't think I was very nice to live with."

But these patients realized that they had a serious condition. Ultimately, they came to accept the burden of angina and became cautious, especially with physical exertion, to avoid "something worse" from happening. One patient said, "It's fear ... the main thing that stops you doing even those things that you possibly could do. You feel as if you don't want to do it in case you did something more serious."

Undoubtedly, angina can disrupt daily routines. Results from one study showed that a very high percentage—82% of patients with angina—downsized their lifestyles by avoiding tasks that required exertion and slept and rested more to avoid angina attacks.³

While most patients with chronic angina must make adjustments to their daily lives to cope with chest pain and breathlessness, retreating too much may do more harm than good. Patients who try to prevent attacks by avoiding exercise may end up worsening their obesity, diabetes, or coronary artery disease (CAD). What's more, limiting one's activities and social interaction, combined with the emotional stress of having angina, can eventually lead to major depression, long recognized as a risk factor for many health problems. Ultimately, patients with chronic angina may become trapped in a cycle of pain, physical limitations, anxiety, and depression that impairs health and lowers quality of life. See Depression and Heart Disease for more information.

People with angina are living longer—but not necessarily better

Quality of life is a big consideration because more Americans have heart disease. In the United States, death rates from CAD have fallen dramatically in the past half-century—down by 61% since 1950.⁴

For survivors, living longer is one thing, but living better may be equally important. To a patient with chronic angina, improving quality of life is as crucial a goal of treatment as medications, surgery, and other therapies.

How can quality of life be enhanced for millions of patients with chronic angina? Greater awareness of the issue of improved lifestyle would help. Doctors can measure certain physical factors. They can check blood pressure and compare it with earlier results, or have patients perform an exercise tolerance test (ETT) to see if their ability to exercise has improved or worsened.

But when it comes to quality of life, doctors have a harder time assessing the effect of chronic angina on their patients' day-to-day physical and emotional states. Doctors may think that their patients' chronic angina is controlled, but patients may believe otherwise. A large study published in the American Journal of Cardiology revealed that, of 5125 patients with angina, half reported two or more angina attacks per week, and 62% described their health as only "fair" or "poor."⁵

How quality of life is measured

Physicians now have access to a tool that evaluates chronic angina patients' quality of life. Dr. Spertus and colleagues have developed the Seattle Angina Questionnaire (SAQ), a 19-item questionnaire specifically designed to objectively measure how much chronic angina and CAD affect a patient's life.⁶

The SAQ includes questions for patients about their daily life, activity levels, response to medications, frequency of attacks, satisfaction with treatment, and how their chronic angina affects their quality of life.

Patients can take the multiple-choice survey in their doctor's waiting room in about five minutes. Questions include:

• Over the past four weeks, how much has your chest pain, chest tightness, or angina limited your enjoyment of life?



• Indicate how much limitation you have had because of chest pain, chest tightness, or angina over the past four weeks while dressing yourself, showering, walking more than a block at a brisk pace, running or jogging, lifting or moving heavy objects, or participating in strenuous sports.



• Overall, how satisfied are you with the current treatment of your chest pain, chest tightness, or angina?

The SAQ is a reliable, rigorously tested instrument that has been used mainly in clinical trials, but doctors can also ask their patients to fill it out. A few physicians have done so, and Dr. Spertus hopes that many more will follow suit. He has made the SAQ available to doctors, free of charge. If you're interested in taking the SAQ, ask your doctor if he or she is familiar with it.

According to Dr. Spertus, doctors can use the SAQ not only to measure quality of life at a single point in time, but also to monitor changes over time. For example, the questionnaire can track how well medical and surgical treatments eliminate chronic angina pain. If patients have received chronic angina medications or have undergone surgery for a coronary artery bypass graft, "before" and "after" SAQ scores might help their doctor measure the success of the treatment and decide whether additional therapies might be needed. Taking the SAQ over the long term can also help you and your doctor keep track of your progress.

Talk to your doctor about quality of life

Perhaps you've never brought up quality-of-life issues with your doctor. Maybe you're reluctant to convey your frustration that treatment isn't effective, or perhaps you've resigned yourself to believing that angina is a normal part of aging. Or maybe you believe that nothing more can be done to improve your angina.

Don't give up. Tell your doctor about your concerns. Says Dr. Spertus, "I think most doctors would be receptive to a frank discussion. Their primary goal is to make their patients feel better and if they don't know that there is an opportunity to improve their patients' quality of life, then they can't achieve their goals of best helping their patients and being a successful physician."

You can help your doctor by keeping a log of your angina attacks. Record:

• The time of day an attack occurred



• What you were doing at the time



• How long the attack lasted



• What the symptoms were



• How severe the symptoms were



• What you did to relieve the attack

The more information you provide your doctor, the better he or she will be at prescribing the most effective treatment to help improve your quality of life. See Talk to Your Doctor for a helpful list.

Ask about steps you may need to take, which may include the best use of available therapies—such as drugs and surgery—and lifestyle changes, such as diet, exercise, and stress management. See Angina Medications, Surgery and Related Therapies, Nutrition Matters, Exercise for Heart Health, and Managing Stress for specific information.

You can also learn more about additional resources available from the U.S. Food and Drug Administration (FDA).

	Progressive relaxation, breathing techniques, and guided imagery are methods for: Click here.

Sources

1. Smith, K, Ross, D., et al. "Investigating Six-Month Health Outcomes of Patients with Angina Discharged from a Chest Pain Service," European Journal of Cardiovascular Nursing, 2002 Dec; 1(4):253-264. PubMed.
   
   
2. MacDermott, A.F., "Living with angina pectoris—a phenomenological study," European Journal of Cardiovascular Nursing, 2002 Dec; 1(4); 265-272. PubMed.
   
   
3. Chestnut, L.G., et al. "Measuring Heart Patients' Willingness to Pay for Changes in Angina Symptoms: Some Methodological Implications." Journal of Medical Decision Making, 1996, Vol. 16. 65-77. PubMed.
   
   
4. National Heart, Lung, and Blood Institute. "Change in Age-Adjusted Death Rates Since 1950, U.S., 1950-2002."National Heart, Lung, and Blood Institute Morbidity and Mortality Chartbook. 2004. 23. http://www.nhlbi.nih.gov/resources/docs/04_chtbk.pdf. Accessed June 18, 2004.
   
   
5. Pepine, C.J., et al., "Characteristics of a Contemporary Population with Angina Pectoris." American Journal of Cardiology, 1994, Vol. 74. 226-231. PubMed.
   
   
6. Spertus J., et al., "Development and Evaluation of the Seattle Angina Questionnaire: A New Functional Status Measure for Coronary Artery Disease." Journal of the American College of Cardiology, 1995, Vol. 25. 333-341. PubMed.