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Meta-Analysis
. 2023 Oct;10(2):e002452.
doi: 10.1136/openhrt-2023-002452.

Associations of health-related quality of life with major adverse cardiovascular and cerebrovascular events for individuals with ischaemic heart disease: systematic review, meta-analysis and evidence mapping

Anzhela Soloveva  1 , Chris P Gale  2 , Naung Tun Han  3 , Ben Hurdus  2 , Suleman Aktaa  4 , Victoria Palin  4 , Teumzghi F Mebrahtu  5 , Harriette Van Spall  6   7 , Gorav Batra  8 , Tatendashe Bernadette Dondo  2 , Maria Bäck  9 , Theresa Munyombwe  10
Affiliations
Meta-Analysis

Associations of health-related quality of life with major adverse cardiovascular and cerebrovascular events for individuals with ischaemic heart disease: systematic review, meta-analysis and evidence mapping

Anzhela Soloveva et al. Open Heart. 2023 Oct.

Erratum in

Abstract

Objective: To investigate the association between health-related quality of life (HRQoL) and major adverse cardiovascular and cerebrovascular events (MACCE) in individuals with ischaemic heart disease (IHD).

Methods: Medline(R), Embase, APA PsycINFO and CINAHL (EBSCO) from inception to 3 April 2023 were searched. Studies reporting association of HRQoL, using a generic or cardiac-specific tool, with MACCE or components of MACCE for individuals with IHD were eligible for inclusion. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the studies. Descriptive synthesis, evidence mapping and random-effects meta-analysis were performed stratified by HRQoL measures and effect estimates. Between-study heterogeneity was assessed using the Higgins I2 statistic.

Results: Fifty-one articles were included with a total of 134 740 participants from 53 countries. Meta-analysis of 23 studies found that the risk of MACCE increased with lower baseline HeartQoL score (HR 1.49, 95% CI 1.16 to 1.93) and Short Form Survey (SF-12) physical component score (PCS) (HR 1.39, 95% CI 1.28 to 1.51). Risk of all-cause mortality increased with a lower HeartQoL (HR 1.64, 95% CI 1.34 to 2.01), EuroQol 5-dimension (HR 1.17, 95% CI 1.12 to 1.22), SF-36 PCS (HR 1.29, 95% CI 1.19 to 1.41), SF-36 mental component score (HR 1.18, 95% CI 1.08 to 1.30).

Conclusions: This study found an inverse association between baseline values or change in HRQoL and MACCE or components of MACCE in individuals with IHD, albeit with between-study heterogeneity. Standardisation and routine assessment of HRQoL in clinical practice may help risk stratify individuals with IHD for tailored interventions.

Prospero registration number: CRD42021234638.

Keywords: cardiovascular outcomes; health-related quality of life; meta-analysis; mortality; systematic review.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare the following: AS has received grant from the European Society of Cardiology, support from AstraZeneca, Bayer, Novartis, Gedeon Richter, Amgen and Servier—outside the submitted work; CPG has received grants or contracts from Alan Turing Institute, British Heart Foundation, National Institute for Health Research, Horizon 2020, Abbott Diabetes, Bristol Myers Squibb, European Society of Cardiology; consulting fees from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol Myers Squibb, Boehrinher-Ingleheim, CardioMatics, Chiesi, Daiichi Sankyo, GPRI Research, Menarini, Novartis, iRhyth, Organon, The Phoenix Group, Payment or honoraria from AstraZeneca, Boston Scientific, Menarini, Novartis, Raisio Group, Wondr Medical, Zydus, support form AstraZeneca, participation on a Data Safety Monitoring Board or Advisory Board in DANBLCOK trial and TARGET CTCA trial, leadership or fiduciary role in EHJ Quality of Care and Clinical Outcomes as Deputy Editor, NICE Indicator Advisory Committee, Chair ESC Quality Indicator Committee, Stock or stock options CardioMatics Receipt of Kosmos device. SA has received support for attending meetings and/or travel from the European Society of Cardiology and participates on a Data Safety Monitoring Board or Advisory Board of EuroHeart; HVS has received grants from CIHR and Heart and Stroke Foundation; GB has received fees to the institution from Bayer and Pfizer, honoraria for lectures from AstraZeneca, Bristol Myers Squibb, Boehringer Ingelheim, Novo Nordisk, Pfizer and Sanofi—outside of present work. Other authors have nothing to declare.

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. HRQoL, health-related quality of life;IHD, ischaemic heart disease; MACCE, major adverse cardiac and cerebrovascular events.
Figure 2
Figure 2
Characteristics of included studies. ACS, acute coronary syndrome; CABG, coronary artery bypass graft; DASI, Duke Activity Status Index; EQ-5D, EuroQol 5-dimension; EQ-VAS, EuroQol visual analogue scale; HRQoL, health-related quality of life; IHD, ischaemic heart disease; KCCQ, The Kansas City Cardiomyopathy Questionnaire; MacNew, MacNew Questionnaire; MI, myocardial infarction; NHP, Nottingham Health Profile; PCI, percutaneous coronary intervention; QLMI, Quality of Life after Myocardial Infarction; SAQ, Seattle Angina Questionnaire; SF-12, 12-Item Short Form Survey; SF-36, 36-Item Short Form Survey; WHOQOL-BREF, WHO Quality of Life Questionnaire, brief version.
Figure 3
Figure 3
A summary of the number and proportion of publications that were high risk of bias for each HRQoL and outcomes. The assessment of bias was conducted on all the reports that were included in the study. The table displays the number of publications that were identified as having a high risk of bias (low quality). The colours used in the table signify the proportion of reports that were found to have a high risk of bias (red) and those with a low risk of bias (green). Grey-coloured cells represent situations where no publications were available that examined the relationship between the HRQoL measure and the outcome. Certainty assessment was performed using downgrading and upgrading indicators. Downgrading indicators: (a) limitations in study design and/or execution (serious for each outcome, very serious for cardiovascular and vascular mortality due to significant proportion of studies with high risk of bias due to participants’ selection and outcomes assessment); (e) imprecision (low number of studies with positive results only in half of them); (f) inconsistency of effect (a significant proportion of the studies did not show associations with cardiovascular mortality and a component of MACCE outcome; a high statistical heterogeneity (Higgins I2 >50%) in meta-analysis of studies of HRQoL and components of MACCE outcome; a relatively small number of trials and heterogeneity of components of MACCE outcome, limiting our ability to draw conclusions); *publication bias was addressed, but considered insufficient to downgrade the quality of evidence. Upgrading indicators: (b) effect size (considering reports showing HR (or OR >2), (c) dose-response gradient (linear associations between HRQoL have been reported or a gradual increase in the effect size presented for more than two categories of HRQoL), (d) adjustment for confounding factors (the estimate of effect is controlled for age, sex and other factors in the majority of reports). DASI, Duke Activity Status Index; EQ-5D, EuroQol 5-dimension; EQ-VAS, EuroQol visual analogue scale; HRQoL, health-related quality life; KCCQ, The Kansas City Cardiomyopathy Questionnaire; MacNew, MacNew Questionnaire; NHP, Nottingham Health Profile; QLMI, Quality of Life after Myocardial Infarction; SAQ, Seattle Angina Questionnaire; SF-12, 12-Item Short Form Survey; SF-36, 36-Item Short Form Survey; WHOQOL-BREF, WHO Quality of Life Questionnaire, brief version.
Figure 4
Figure 4
Evidence maps for associations of HRQoL with (A) all-cause mortality, (B) components of MACCE outcomes and (C) CV events for patients with IHD. Associations between HRQoL and outcomes are mapped by publication year of the study results and follow-up duration. Circle colour indicates IHD nosological form, size—sample size, contour—no (dashed) or presence of predictive value of a HRQoL instrument (or domain). If a study reported different results for different HRQoL instruments, associations with outcomes are presented for the instrument with a statistically significantly association. Δ indicates changes in HRQoL score by time. ACS, acute coronary syndrome; CABG, coronary artery bypass graft; CV, cardiovascular; DASI, Duke Activity Status Index; EQ-5D, EuroQol 5-dimension; EQ-VAS, EuroQol visual analogue scale; HHF, hospitalisation for heart failure; HRQoL, health-related quality of life; IHD, ischaemic heart disease; KCCQ, The Kansas City Cardiomyopathy Questionnaire; MacNew, MacNew Questionnaire; MCS, mental component summary score; MI, myocardial infarction; NHP, Nottingham Health Profile; PCI, percutaneous coronary intervention; PCS, physical component summary score; QLMI, Quality of Life after Myocardial Infarction; SAQ, Seattle Angina Questionnaire; SF-12, 12-Item Short Form Survey; SF-36, 36-Item Short Form Survey; WHOQOL-BREF, WHO Quality of Life Questionnaire, brief versio.
Figure 5
Figure 5
Meta-analysis of studies reporting associations of overall HRQoL scores at baseline with all-cause mortality (panels A and B) and component of MACCE of (panel C). The effect estimates are presented for a difference in baseline HRQoL scores estimated as a continuous variable. Components of MACCE outcome comprised death or cardiac readmissions (MI, HF, stroke, cardiac arrest, ventricular tachycardia or fibrillation, acute CABG)—for HeartQoL; death, stroke or TIA, ACS, acute cardiac readmission or revascularisation—for EQ-VAS; death, hospitalisation due to heart failure, MI, stroke, cardiac arrest, ventricular tachycardia or fibrillation, acute CABG—for SF-12 PCS and SF-12 MCS. ACS, acute coronary syndrome; CABG, coronary artery bypass graft; EQ-5D, EuroQol 5-dimension; EQ-VAS, EuroQol visual analogue scale; HF, heart failure; HRQoL, health-related quality of life; MACCE, major adverse cardiovascular and cerebrovascular events; MCS, mental component summary score; MI, myocardial infarction; PCS, physical component summary score; SF-12, 12-Item Short Form Survey; SF-36, 36-Item Short Form Survey; TIA, transient ischaemic attack.
Figure 6
Figure 6
Meta-analysis of studies reporting associations of EQ-5D domains with all-cause mortality (panel A) and components of MACCE outcome of death, myocardial infarction, stroke and unstable angina requiring urgent revascularisation (panel B), SF-36 domains with all-cause mortality (panel C) and SAQ domains with all-cause mortality (panel D). HRs for EQ-5D domains are reported for each domain as categorical variables (‘no problems’ vs ‘moderate or severe problems’), in the study by Lissaker et al, the HR for cardiovascular mortality was included. HRs for SF-36 domains are reported for the lowest tertile indicating poor health status versus the other two highest tertiles indicating good health status. HRs for SAQ domains are reported for each domain as categorical variables (indicated level of limitations vs no or minimal limitations (score 75–100)). EQ-5D, EuroQol 5-dimension; MACCE, major adverse cardiovascular and cerebrovascular events; SAQ, Seattle Angina Questionnaire; SF-36, 36-Item Short Form Survey.
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