Investigation of the quality of life of patients with coronary heart disease during COVID-19 and analysis of influencing factors

ABSTRACT

At present, coronavirus disease 2019 (COVID-19) has become a global public health emergency, bringing a great threat to human health. This study aims to evaluate and analyze the factors that influence the quality of life (QOL) of patients with coronary heart disease (CHD) during COVID-19 to provide a realistic basis for improving their QOL. A total of 70 patients with CHD were selected through convenience sampling from three heart rehabilitation centers. The cross-sectional survey of the study cases were carried out using an online survey platform. All of the participants completed a general situation questionnaire, and QOL was assessed through the 36-item Short Form Health Survey. Results showed that the overall QOL of patients with CHD during COVID-19 was poor, having an average score of 65.99 ± 10.97. Moreover, multivariate linear regression analysis showed that worry about COVID-19 (P < 0.05) and different exercise intervention types (P < 0.05) were the main factors affecting the QOL of patients. On the one hand, positive measures should be taken to provide psychological counseling to ease their sense of concern. On the other hand, engaging in exercise is more important for these patients to improve physical function, particularly Tai Chi exercises.

Introduction

Coronavirus disease 2019 (COVID-19) broke out in Wuhan, China, in early December 2019 (J. Li et al., 2020; Paules et al., 2020), which spread rapidly throughout the country. Presently, this disease has spread globally (Lu et al., 2020; Misra et al., 2020). In view of the current spread of COVID-19 in many countries around the world, on February 28, General Tan Desai, the World Health Organization Director, announced in Geneva that the global risk level of COVID-19 ranged from ‘high risk’ to the highest level of ‘very high’ (World Health Organization, 2020a). On 24 September 2020, the total number of confirmed COVID-19 cases globally reached 31,798,308, with cumulative deaths of 973, 653. In addition, COVID-19 has affected more than 235 countries and regions worldwide (World Health Organization, 2020b).

To curb the spread of the pandemic, the Chinese government has adopted a series of prevention and control measures. Such measures include isolation treatment for confirmed patients, medical observation of suspected patients or close contacts, and isolation of ordinary people at home. Strict controls have succeeded in containing the spread of the pandemic. However, long-term home isolation has disrupted people’s normal lives, particularly for people with various chronic diseases. Coronary heart disease (CHD) is included in a high-risk group of chronic diseases, and individuals with CHD are extremely vulnerable to environmental, lifestyle, and emotional factors (Song et al., 2014). With the development of the biopsychosocial model in medicine, CHD treatment aims to not only maintain their life but also improve their QOL (Avila et al., 2020; Y. Li et al., 2019; Taylor-Piliae et al., 2012). To fully understand the living conditions and QOL of patients with CHD in this particular period and to explore the predictors of the latter, we carried out this investigation to provide a realistic plan for further effective intervention measures to improve the QOL of patients with CHD during COVID-19.

Methods/Design

Study design

The study employed a cross-sectional survey study design. The survey was conducted using the Wen Juanxing online survey platform (https://www.wjx.cn/jq/68746123.aspx). Wen Juanxing is a platform that administers professional online questionnaire surveys, evaluations, and voting, providing users with a wide range of functions including online questionnaire design, data collection, and survey result analysis. All participants provided their general information about COVID-19 and completed the 36-item Short Form Health Survey (SF-36), which is used to assess QOL. The study protocol was submitted to the Ethics Committee of the Chinese People’s Liberation Army General Hospital (S2019-060-02). This study is registered on ClinicalTrial.gov (NCT03936504).

Participants

Inclusion criteria

The inclusion criteria are as follows: (1) males or non-pregnant females aging from 30 to 80 years old, (2) patients with ‘stable’ angina symptoms and new onset of heart failure or left ventricular dysfunction, (3) patients with New York Heart Association (NYHA) class Ι or II classification, and (4) participants who understood the purpose of the clinical trial and voluntarily participated and signed the informed consent form.

Exclusion criteria

The exclusion criteria are the following: patients who had (1) acute myocardial infarction within the last two weeks, (2) severe aortic stenosis, (3) hypertrophic cardiomyopathy, (4) severe valvular heart disease, (5) malignant tachyarrhythmia, or (6) abnormal motor function caused by nervous system deterioration, motor system disease, or rheumatic disease.

Setting and recruitment

This multicenter study was conducted at the Beijing Normal University in China. All patients signed the consent before the investigation and then completed the questionnaires. During the session, the patients completed independently the questionnaires using a unified guide that explains the requirements for completion. The investigation process conformed to the principle of confidentiality. From March 28 to 2 April 2020, a total of 70 patients with CHD were selected through convenience sampling in three heart rehabilitation centers. Specifically, among the respondents, 57.14% were from the Chinese People’s Liberation Army General Hospital, 21.43% from Beijing Shuili Hospital, and 21.43% from Anzhen Community Health Service Center. Of the 80 questionnaires distributed, 70 were completed, thereby having a response rate of 87.5%.

Research tools

General situation questionnaire

The general situation questionnaire was a self-made form that mainly included three aspects: (1) general socio-demographic information, (2) disease situation, and (3) knowledge about COVID-19. The general socio-demographic data mainly included sex, age, nature of work, level of education, and smoking and drinking history. The disease situation data mainly included the type of CHD, the method of blood transport reconstruction, combined diseases, combined medication, family medical history, and exercise intervention type. Information about COVID-19 included attention to COVID-19, anxiety, depression, fear, and worry during the pandemic.

QOL scale

The SF-36 was used to assess QOL. The SF-36 scale was developed by the Boston Health Institute, USA, based on the Medical Outcomes Study scale developed by Stewartse. The SF-36 scale consists of eight dimensions: (1) physiological functioning, (2) role-physical, (3) bodily pains, (4) general health, (5) vitality, (6) social functioning, (7) role-emotional, and (8) mental health. Each dimension contains 2–10 items, for a total of 36 items (Ware et al., 1994). The calculated score is converted into a standard score of 0–100. The overall QOL score is the average of the eight dimension scores. A higher total score indicated better QOL. (Note: Using a positive score, the bodily pain score is negatively correlated with QOL).

Data management and monitoring

Beijing Normal University was responsible for managing data and performing statistical analyses. The research assistants were responsible for checking the integrity of the completed data and ensuring the timely entry of the collected data into the EpiData Manager. All investigators in the data management and analysis were unaware of the treatment allocation. This study used the Wen Juanxing online survey platform. The IP address could only be used once to ensure the reliability of data. To ensure the integrity of the data, only complete questionnaires could be submitted successfully.

Statistical analysis

EpiData 3.0 was used to establish a database, and all data were analyzed using the SPSS 22.0 (IBM, Chicago, IL, USA) software package. Categorical variables are described as the frequencies and percentages, and continuous variables are described as the means ± standard deviations (SD). For statistical analysis, the independent sample t-test, one-way ANOVA, and multivariate linear regression analysis were used. Statistical significance was defined as a two-sided P value < 0.05.

Results

Basic characteristics of the patients

A total of 70 questionnaires were collected in this study. Figures 1, Figures 2, and Figures 3 show the distribution of the general socio-demographic information, disease situation, and information about COVID-19, respectively.

Figure 1. Distribution of general socio-demographic data of patients.

Figure 2. Distribution of patients’ disease situation.

Figure 3. Distribution of patients’ knowledge of COVID-19.

QOL score of patients with CHD during COVID-19

The results of this survey showed that the overall QOL of patients with CHD during COVID-19 pandemic was poor, having an average score of 65.99 ± 10.97. The scores of the role-physical (66.71 ± 26.16), general health (65.39 ± 19.18), and role-emotional (56.01 ± 19.93) dimensions were also low, as shown in Table 1.

Table 1. QOL score of patients with CHD during COVID-19 (N = 70)

Dimension	Score
Physiological functioning	83.93 ± 9.92
Role-physical	66.71 ± 26.16
Bodily pains	32.20 ± 8.86
General health	65.39 ± 19.18
Vitality	73.14 ± 15.56
Social functioning	79.86 ± 19.76
Role-emotional	56.01 ± 19.93
Mental health	70.69 ± 15.55
Average score	65.99 ± 10.97

Abbreviations: QOL, quality of life; CHD, coronary heart disease; COVID-19, coronavirus disease 2019.

Single-factor analysis of the QOL of patients with CHD during COVID-19

A single-factor analysis of patients’ general socio-demographic data, disease situations, and COVID-19 information was conducted. The results showed that exercise intervention type, anxiety, depression, fear, and worry had an impact on the QOL of patients with CHD (P < 0.05). Sex, age, nature of work, level of education, smoking, drinking, and family medical history, type of CHD and revascularization, combined disease, combined medication, attention to COVID-19, and impact on life had no significant effect on the QOL of CHD patients (P > 0.05), as shown in Table 2.

Table 2. Single-factor analysis of the QOL of patients with CHD during COVID-19 (N = 70)

Variable	Item	n (freq, %)	Score	F/t	P value
Sex	Male	47 (67.1)	65.80 ± 10.99	t = −0.208	0.836
	Female	23 (32.9)	66.39 ± 11.42
Age(years)	≤45	9 (12.9)	63.35 ± 15.78	F = 0.521	0.596
	46–59	30 (42.9)	67.36 ± 8.94
	≥60	31 (44.2)	65.43 ± 11.53
Nature of work	Mental work	59 (84.3)	66.14 ± 11.28	t = 0.252	0.802
	Manual work	11 (15.7)	65.22 ± 10.18
Education	Secondary and below	8 (11.4)	61.19 ± 9.32	F = 3.027	0.055
	High school	16 (22.9)	61.84 ± 12.11
	University and above	46 (65.7)	66.27 ± 10.46
Smoking history	No smoking	37 (52.9)	67.01 ± 11.38	F = 0.470	0.627
	Previous but not current smoking	26 (37.1)	64.31 ± 11.18
	Current smoking	7 (10.0)	66.84 ± 9.39
Drinking history	No drinking	38 (54.3)	66.72 ± 10.61	F = 1.698	0.191
	Previous but not current drinking	24 (34.3)	67.07 ± 12.04
	Current drinking	8 (11.4)	59.30 ± 8.67
Family medical history	Yes	29 (41.4)	64.92 ± 11.59	t = −0.678	0.500
	None	41 (58.6)	66.75 ± 10.74
Type of CHD	Angina pectoris	22 (31.4)	63.50 ± 12.63	F = 1.337	0.270
	MI	29 (41.4)	68.44 ± 10.15
	Other	19 (27.1)	65.14 ± 10.21
Type of revascularization	PCI	46 (65.7)	65.73 ± 12.20	F = 0.510	0.603
	CABG	5 (7.1)	70.80 ± 8.21
	None	19 (27.1)	65.35 ± 8.60
Combined disease	Yes	58 (82.9)	65.42 ± 10.54	t = −0.196	0.845
	None	12 (17.1)	66.11 ± 11.24
Combined medication	Yes	65 (92.9)	65.99 ± 10.97	t = −0.009	0.993
	None	5 (7.1)	65.95 ± 13.53
Exercise intervention type	TCCRP	23 (32.9)	70.59 ± 9.37	F = 4.440	0.015
	CERP	23 (32.9)	66.16 ± 12.42^a
	None	24 (34.3)	61.43 ± 9.60^ab
Attention to COVID-19	Yes	57 (81.4)	66.36 ± 11.15	t = 0.585	0.561
	None	13 (18.6)	60.37 ± 10.89
Anxiety	Not at all	10 (14.3)	70.80 ± 13.68	F = 7.822	0.001
	A little bit	58 (82.9)	66.06 ± 9.42
	Quite large	2 (2.9)	39.88 ± 9.55^ab
Depression	Not at all	36 (51.4)	68.83 ± 10.55	F = 8.672	0.000
	A little bit	32 (45.7)	64.43 ± 9.35
	Quite large	2 (2.9)	39.88 ± 9.55^ab
Fear	Not at all	17 (24.4)	69.75 ± 10.39	F = 9.045	0.000
	A little bit	50 (73.3)	66.08 ± 9.85
	Quite large	3 (2.2)	43.25 ± 8.93^ab
Worry	Not at all	13 (22.2)	71.33 ± 10.31	F = 9.892	0.000
	A little bit	54 (75.6)	65.97 ± 9.78
	Quite large	3 (2.2)	43.25 ± 8.93^ab
Impact on life	Not at all	5 (6.7)	68.65 ± 12.18	F = 2.158	0.123
	A little bit	39 (55.6)	67.99 ± 8.98
	Quite large	26 (37.8)	62.49 ± 13.05

Note: a, compared with layer 1, P < 0.05; b, compared with layer 2, P < 0.05.

Abbreviations: n, number; freq, frequency; MI, myocardial infarction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft; TCCRP, Tai Chi cardiac rehabilitation program; CERP, conventional exercise rehabilitation program.

Multivariate analysis of the QOL of patients with CHD during COVID-19

The QOL score was categorized into dependent variables. Moreover, 18 factors, such as sex, age, education level, type of CHD, basic medication situation, exercise intervention type, and anxiety, depression, and worry about COVID-19, were used as independent variables. The two-classification variables and the rank variables in the independent variables were transformed quantitatively, and the multiclass variables were transformed into dummy variables. Multiple linear regression analysis was conducted using the entry method (α_input = 0.05, α_output = 0.10). The results revealed that worry about COVID-19 and different exercise intervention types were the main factors affecting the QOL of patients with CHD (P < 0.05), as shown in Table 3.

Table 3. Multivariate analysis of the QOL of patients with CHD during COVID-19 (N = 70)

Variable	Item	B	Sb	B^,	t	P value	R	R^2
Constant term	–	85.121	6.324	–	13.459	0.000	–	–
Worry about COVID-19	–	−9.165	2.576	−0.381	−3.545	0.001	0.532	0.239
Exercise intervention type	TCCRP	7.618	2.785	0.338	2.735	0.008	0.475	0.190
	CERP	3.800	2.965	0.156	1.282	0.205	0.329	0.081

Abbreviations: B, regression coefficient; Sb, standard error; B^,, standardized regression coefficient; R, correlation coefficient; R², coefficient of determination; TCCRP, Tai Chi cardiac rehabilitation program; CERP, conventional exercise rehabilitation program.

Discussion

Analysis of the QOL of patients with CHD during COVID-19

In recent years, clinical studies on the effect of various drugs and non-drug treatments on the QOL of patients with CHD have shown that QOL has gradually become an important index to determine the best treatment method or to re-evaluate the curative effect (Bi et al., 2018; Lins & Carvalho, 2016). The results of this survey showed that the overall QOL of patients with CHD during COVID-19 pandemic was poor, having an average score of 65.99 ± 10.97. Therefore, the QOL of patients with CHD during COVID-19 needs to be further improved. This study provides suggestions to improve their QOL. First, patients with CHD should pay additional attention to self-management. Notably, CHD treatment focuses not only on in-hospital rehabilitation but also on gradual expansion to full-process management. Second, patients with CHD should face the impacts of COVID-19 on the cardiovascular system. The following are suggestions on how patients with CHD can avoid the pandemic at home. (1) They should take drugs for CHD on time and according to the amount and not add or reduce drugs at will. If the medication needs adjustment, then they must consult a doctor in time. (2) It is important for patients with CHD to pay attention to their daily diet. They should intake various foods, more fruits and vegetables, whole grains, olive oil, nuts, as well as moderate amount of fish and poultry. While, they should eat less foods rich in sodium and sugar (Cristina, 2017). (3) Patients can choose a suitable exercise program and gradually carry out rehabilitation training while ensuring sleep and reasonable rest. (4) Family members should actively communicate with patients, adjust their mentality, and ease their negative emotions.

Analysis of factors that influence QOL in patients with CHD during COVID-19

Worry about COVID-19

The multivariate analysis revealed that worry about COVID-19 was an important factor affecting QOL among CHD patients. The results of this study showed that worry about COVID-19 was negatively correlated with the QOL. This result indicates that the QOL of patients with CHD gradually decreased as worry about COVID-19 increased. According to previous studies, with the development of the pandemic, psychosocial problems, such as worry and fear, gradually emerged, which may lead to several mental health problems (Huang & Zhao, 2020). A similar phenomenon occurred during the severe acute respiratory syndrome outbreak and other related public health emergencies in 2002 (Lei & Klopack, 2020). Numerous problems, such as strong infectivity, fast transmission, unclear transmission mode, the uncertainty of public access to information, and lack of authoritative antiviral agents, have led patients with CHD to experience a certain psychological burden. Furthermore, severely ill patients experience negative emotions, such as worry, fear, anxiety, and depression. Studies showed that worry and fear in the face of public health emergencies is a normal self-defense response to stress. However, extreme psychological and emotional fluctuations can lead to psychological problems and mental illness (Xiang et al., 2020). Therefore, the mental health of patients with CHD during COVID-19 should receive great attention, and psychological intervention strategies should be provided according to the different psychological state characteristics.

On the one hand, for the patients with CHD to self-assess their mental state and rapidly detect mental problems, a special mental health consulting service platform can be established through information network technology. On the other hand, a mental health assistance hotline service could be opened to provide patients with relevant scientific knowledge about pandemic prevention and control. Finally, when formulating emergency management policies for public health emergencies, government departments should completely consider the influencing factors of the public’s social psychology.

In addition, 18.6% of patients with CHD did not pay attention to the latest changes in COVID-19 pandemic situation. This result shows that patients should be aware of COVID-19 pandemic situation in real time. However, considering the diversity of social media, several pseudo-science and popular rumors have flooded the entire cyberspace. Therefore, the public should understand the pandemic situation in real time through the information provided by government departments. Moreover, they should continue to be rational and improve the ability to identify false information.

Exercise intervention type

The multivariate analysis revealed that the exercise intervention type was an important factor that affected QOL. This study found that the exercise intervention type was positively correlated with QOL and that the QOL of patients participating in an exercise rehabilitation program was significantly higher than that of patients not participating in an exercise intervention program (P < 0.05). Studies have shown that aerobic exercise can promote adaptive changes in muscle tissue and peripheral arteries, enhance cardiovascular function, and promote rehabilitation treatment in patients with CHD, thereby improving their QOL (Nery et al., 2015). Previous studies have confirmed that cardiac rehabilitation programs containing exercise prescriptions can significantly improve exercise endurance, reduce cardiovascular risk, and improve the QOL of patients (Sato et al., 2010; Yokota et al., 2019, November). Therefore, patients with CHD should increase physical exercise to improve their QOL during COVID-19.

In addition, based on the type of exercise intervention, participants were divided into the Tai Chi Cardiac Rehabilitation Program (TCCRP) group and the Conventional Exercise Rehabilitation Program (CERP) group. The TCCRP is a set of exercise prescriptions specially designed for patients with CHD. This program combines the Eastern methods of Tai Chi with Western elastic band resistance training methods. Each training course in the TCCRP group includes the following: (1) traditional Tai Chi warm-up exercises, such as breathing methods, weight shifting, and arm-swinging, (2) Bafa Wubu of Tai Chi, (3) Tai Chi elastic belt exercise including Tai Chi Spinning, and Tai Chi Twining movements, (4) Tai Chi cool-down exercises including various relaxation methods. By contrast, the training course in the CERP group comprises a set of conventional exercise prescriptions based on Western aerobic exercise, including aerobic exercises, such as cycling, jogging, resistance, and flexible stretching. The results showed that the QOL score (70.59 ± 9.37) of the TCCRP group was significantly higher than that of the CERP group (66.16 ± 12.42) (P < 0.05). Chinese traditional sports, such as Tai Chi and Baduanjin, play an active role in the rehabilitation of COVID-19 patients (The Office of the National Health Commission the People’s Republic of China and the Office of the National Administration of Traditional Chinese Medicine, 2020). Moreover, the ‘Consensus of Chinese Experts on Rehabilitation and Secondary Prevention of Coronary Heart Disease’ noted that Tai Chi exercises are beneficial to the recovery of body function in patients with CHD (Liu, 2012).

Recent research has shown that Tai Chi has positive effects on patients with chronic obstructive pulmonary disease and similar symptoms and is more effective than conventional therapies (Ratarasarn & Kundu, 2020). COVID-19 is a new type of respiratory disease characterized by fever, fatigue, cough, and shortness of breath, with pulmonary symptoms similar to those of chronic obstructive pulmonary disease. During COVID-19 pandemic, the Wuhan Fangcang Hospital in China had several cases of the mild novel coronavirus. Apart from the conventional treatment, these patients also received necessary respiratory training in the early stages. According to studies, respiratory training improves respiratory function and relieves disease-induced anxiety and tension (Meng, 2007). Tai Chi requires abdominal breathing and focuses on the coordination of movement, breathing, and consciousness. Studies showed that through deep and uniform breathing methods, Tai Chi can improve lung interstitial elasticity, myocardial contractility, and pulmonary ventilation and function (Guo et al., 2016; Jia. et al., 2018). Tai Chi is a multimodal mind and body exercise that combines gracefulness, mindfulness, and gentleness. Walther et al. (2018) found that long-term practice of Tai Chi can relieve anxiety and depression in patients with CHD. Moreover, they found Tai Chi has a positive effect on cardiovascular diseases and a negative one on psychological stress. Therefore, patients with CHD are recommended to practice Tai Chi during COVID-19 pandemic to enhance their respiratory function, improve mental state, and strengthen immune resistance.

Conclusion

During COVID-19 pandemic, patients with CHD had a relatively low QOL. The results of this study showed that worry about COVID-19 and exercise intervention types were the main factors that affect their QOL. On the one hand, government departments must take active measures to conduct high-quality psychological counseling to alleviate patients’ worries. At the same time, the government must remind the public to continue to be rational and improve their ability to screen false information. On the other hand, patients are encouraged to actively participate in physical exercises, particularly Tai Chi exercises, to promote mental and physical health.

Presently, COVID-19 pandemic has not been completely controlled, and considering the various safety concerns, patients with CHD may not be able to receive in-hospital rehabilitation. Therefore, home-based rehabilitation may receive great attention for future studies. The study hopes to provide a reference for the future home rehabilitation treatment of patients with CHD. This study also aims to provide guidance for the intervention of the psychological crisis in various public health emergencies that may occur in the future.

Acknowledgments

The authors are most grateful to the physicians and nurses of the Chinese People’s Liberation Army General Hospital, Beijing Shuili Hospital, and Anzhen Community Health Service Center, Chaoyang District, Beijing. We also thank all the participants in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work is financially supported by the National Key R&D Program of China (2018YFC2000600).