Health-related quality of life in Brazilian

outpatients with Chagas and non-Chagas

cardiomyopathy
Viviane Martinelli Pelegrino, MNS, RN,a Rosana Aparecida Spadoti Dantas, RN, PhD,b
Marcia Aparecida Ciol, PhD,c Alexander Michael Clark, RN, PhD,d Lidia Aparecida Rossi, RN, PhD,b
and Marcus Vincius Simoes, MD, PhDe

PURPOSE: To examine differences in demographic, clinical, and health-related characteristics of quality

of life in heart failure patients with Chagas and non-Chagas cardiomyopathy in Brazil.
METHODS: This observational study was carried out with 43 Brazilian out-patients with Chagas and 59
non-Chagas cardiomyopathy.
RESULTS: No differences were evident between the 2 groups regarding age, sex, mean left-ventricular
ejection fraction, and duration of follow-up. Compared with the non-Chagas group, patients with Chagas
cardiomyopathy had a higher percentage of participants using articial pacemakers (P < .001), more
symptoms of heart failure as measured by New York Heart Association classes III and IV (P = .02), higher
intakes of aspirin and warfarin, a higher use of articial pacemakers because of bradycardia, and lower
health-related quality of life in the Physical Functioning (P = .01) and Role Physical (P = .002) domains
of the Medical Outcomes Study Short Form 36-Item Health Status Survey.
CONCLUSION: Our study population was limited to one region endemic for Chagas disease in Brazil, and
therefore ndings need to be conrmed and should not be generalized to other populations without further
research. (Heart Lung 2011;40:e25e31.)

eart failure (HF) is an increasingly severe

public-health problem in developed countries,1 where it is most commonly caused by
chronic hypertension and myocardial infarction. The
rise in HF is usually associated with an aging
population, the prevalence of cardiovascular risk
factors and disease, conditions such as obesity and
diabetes, and improved survival rates for myocardial
infarctions.1
From the aClinical Hospital of Ribeirao Preto, University of Sao
Paulo, Ribeirao Preto, Brazil; bDepartment of General and Specialized Nursing, Ribeirao Preto College of Nursing, University of Sao
Paulo, Ribeirao Preto, Brazil; cDepartment of Rehabilitation
Medicine, School of Medicine, University of Washington, Seattle,
Washington; dFaculty of Nursing, University of Alberta, Edmonton,
Alberta, Canada; and eSchool of Medicine of Ribeirao Preto,
University of Sao Paulo, Ribeirao Preto, Brazil.
Corresponding author: Rosana Aparecida Spadoti Dantas, RN,
PhD, Escola de Enfermagem de Ribeirao Preto, Universidade de
Sao Paulo, Av. Bandeirantes 3900, CEP 14040-902 Ribeirao Preto,
Sao Paulo, Brazil. E-mail: rsdantas@eerp.usp.br
0147-9563/$ - see front matter
2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.hrtlng.2010.05.052

HEART & LUNG VOL. 40, NO. 3

HF is also a growing concern in developing countries. In Brazil, HF affects over 2 million people, with
240,000 new diagnoses per year,2 and it is present in
one third of patients treated in the public-health
system in Brazil,2 which serves mostly the oldest and
the poorest in the country. HF is the main cause of
heart-related hospitalizations in the public-health
system (293,759 admissions in 2007), with an annual
mortality rate of about 8%, or approximately 23,000
deaths per year.2
The main causes of HF in developing and underdeveloped countries may be different from those in developed countries. In Brazil, HF (particularly chronic
systolic HF) is often secondary to the Chagas cardiomyopathy that results from Chagas disease.3 This
tropical disease is caused by a parasite (Trypanosoma
cruzi) that is spread by insects to humans and other
mammals. Chagas disease affects around 20 million
individuals in Latin America, and tends to be most
common in economically poorer rural areas.4
HF is well-known to worsen health-related quality
of life (HRQL) significantly, by reducing an individuals

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Chagas and non-Chagas cardiomyopathy in Brazil

functional capacity and ability to perform activities of

daily living.5-8 Health-related quality of life is usually
defined as a construct that encompasses various aspects of self-perceived well-being that are related to,
or affected by, the presence of a disease and its treatment, and it includes three main domains: physical,
psychological, and social. The physical domain includes functional and working-capacity aspects. The
psychological domain is related to satisfaction, wellbeing, self-esteem, anxiety, and depression. The social domain relates to work, leisure, and social and
family interactions.9 HF was found to affect each of
these domains,10-12 and exerts more adverse effects
than any other chronic conditions, eg, hypertension, diabetes, and chronic lung disease.13
Many studies examined the factors associated with
HRQL in HF patients,3,5,11,14-23 including patients of
nonischemic11,18,19,21,24 and ischemic etiology.16,25,26
However, HRQL in persons with HF was studied
mostly in patients from the United States,8,25,27-30
Canada,31-34 Europe,5,7,18,24,35-38 and Asia.17 These
HF populations differ from the Brazilian population
in various respects, including the countrys level of
development, healthcare system, and disease etiologies. Few studies have been conducted in South
America,3,39,40 and of those, only one examined
patients with Chagas cardiomyopathy.3
The purpose of this study was to examine the
differences in distribution of age, sex, New York
Heart Association Functional Class (NYHA FC),
left-ventricular ejection fraction (LVEF), the use of
an artificial pacemaker or resynchronization therapy,
duration of follow-up for HF, and HRQL between two
groups of HF etiologies: Chagas cardiomyopathy and
non-Chagas cardiomyopathy.

MATERIALS AND METHODS

Design, setting, and participant
enrollment
This study analyzed secondary data collected for
a broader study of HRQL in patients with cardiomyopathy whose primary results are being prepared
for publication in a separate article. The original
study used a cross-sectional design, and was based
at the Hospital das Clnicas de Ribeirao Preto (Ribeirao Preto, Sao Paulo, Brazil), a university hospital
that serves a mixed rural and urban population in
southeastern Brazil. The study was approved by the
Institutional Review Board of the School of Medicine
at the University of Ribeirao Preto. Participants were
recruited from the Division of Cardiology at the university hospital. Inclusion criteria comprised an age
of 18 years or older, a diagnosis of HF based on clin-

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Pelegrino et al

ical signs and radiologic and echocardiography findings, and a scheduled medical visit at the
Cardiomyopathy Specialty Clinic of the university
hospital during the study period. Exclusion criteria
involved the presence of neurologic disorders,
major psychiatric conditions (such as dementia or
schizophrenia), or cognitive impairment. The enrollment period covered February 2005 to August 2006,
and was constrained by the time and human resources available to conduct the study. No power calculations were performed a priori, because the main
study was observational in nature, and its primary
objective was exploratory rather than confirmatory.
All patients visiting the clinic during the study period were invited to participate, and of 138 eligible patients with HF, 2 patients declined enrolment, and 6
patients could not participate because of physical,
psychological, or cognitive conditions. In addition,
28 patients were excluded from this part of the study,
either because the results of their echocardiography
were not available within 2 months before the interview (27 patients), or for 1 patient, because the medical records did not include a defined HF etiology.
Data were collected immediately after an individuals
medical visit. Because of the high rate of low literacy
among patients attending public hospitals in Brazil,
participants were given the choice of completing the
questionnaires by themselves, or having the questionnaires read to them by one of the researchers
(V.M.P.). All patients chose to have the questionnaire
read to them. Other clinical data were obtained
through reviews of patients medical records. To test
comprehension and the relevance of the datacollection instruments, a pilot test was performed
on 10 subjects. Because no changes proved necessary
in the data-collection instruments, these patients
were included in the final sample.

Measures
Perceived health status and HRQL. The Medical
Outcomes Study Short Form 36-Item Health Status
Survey (SF-36) was used to measure HRQL.41
Although SF-36 is now viewed as an HRQL measure,
it was originally developed to assess a persons
overall health status. The tool consists of 36
multiple-choice questions in 8 domains: Physical
Functioning, Role Physical, Bodily Pain, General
Health Status, Vitality, Social Functioning, Role
Emotional, and Mental Health. Scores for each
domain range from 0 to 100, where 0 is the worst
and 100 the best possible health status.41 We used
a Portuguese version of SF-36, which was culturally
adapted to Brazil and shown to be reliable and valid

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Pelegrino et al

in samples of Brazilian patients with HF.42 In the main

study (including all 130 participants), the internal
consistency for items of the SF-36 domains had
Cronbach a values that varied from .44 to .88,
corresponding to good internal consistency, except
for the Role Social (a = .44) and General Health
Status (a = .57) domains.
Other variables. Demographic data collected
during interviews included age, sex, educational
level (years of education), marital status (married
or living with a significant other vs not married
or living with a significant other), and work status
(having a paid job versus not having a paid job).
Clinical data collected from a participants medical
records included HF etiology (Chagas cardiomyopathy and non-Chagas cardiomyopathy), duration
of follow-up of HF disease (in years), LVEF,
NYHA FC (I, II, III, or IV), types of medications
prescribed, and presence of artificial pacemaker
or resynchronization therapy.

Chagas and non-Chagas cardiomyopathy in Brazil

Data were analyzed using the Statistical Package

for Social Sciences, version 15.0 (SPSS, Inc., Chicago,
IL). A descriptive analysis was performed for all variables. Differences in the distribution of categorical
variables according to HF etiology were tested using
Pearsons c2. Differences in the mean of numeric variables according to HF etiology were tested using a
t test for independent samples. We set the significance level of statistical tests at .05. Because this
study was exploratory and we were looking for potential associations, we did not make any corrections for
multiple comparisons.

Table I also shows the durations of follow-up of HF

since the diagnosis of the condition, which was similar
for both groups of patients (P = .15). In both groups,
most patients were asymptomatic (NYHA FCs I and
II). However, the group with Chagas cardiomyopathy
contained more symptomatic patients (39%; NYHA
FCs III and IV) than did the non-Chagas group (15%),
resulting in a statistically significant difference between them (P = .02). Among the 42 patients with
Chagas cardiomyopathy, the mean LVEF was 28%
(SD, 7.7%), which was slightly lower than the mean
LVEF in the group with non-Chagas cardiomyopathy
(mean, 30.3%; SD, 6.3%). This difference was not
statistically significant (P = .10). In both groups of HF
etiology, the most common medications used by
patients, as reported in the medical records, were
diuretics, angiotensin-converting enzyme inhibitors,
b-blockers, and digitalis (digoxin). However, the only
statistically significant differences involved a greater
consumption of aspirin (P = .03) and warfarin (P =
.05) among patients with Chagas cardiomyopathy.
The presence of an artificial pacemaker because
of bradycardia was more frequent among patients
with Chagas cardiomyopathy (37.2%) than in the
non-Chagas group (5.1%) (P < .001). No patients
had undergone cardiac resynchronization therapy in
either group.
For HRQL, Table II shows the mean values for the 8
SF-36 components in the Chagas and non-Chagas
cardiomyopathy groups. The group with Chagas cardiomyopathy always produced lower scores (indicative of worse condition) than did the non-Chagas
cardiomyopathy group. However, only Role Physical
and Physical Functioning measures were statistically significant (P = .002 and P = .01, respectively).

RESULTS

DISCUSSION

Of 102 eligible patients with HF, 43 (42%) had Chagas cardiomyopathy, and 59 (58%) had non-Chagas
cardiomyopathy. In the group with Chagas cardiomyopathy, the mean age was 58.7 years (SD, 14.9 years),
and most participants were male (63%), were married
or living with a significant other (63%), had a low level
of education (mean, 4.0 years of formal study; SD, 3.7
years), and did not have paid work (93%). In the group
with non-Chagas cardiomyopathy, the mean age was
54.9 years (SD, 13.8 years), and most were male (58%),
were married or living with a significant other (59%),
had a low level of education (mean, 4.8 years of education; SD, 3.8 years), and did not have paid work
(78%) (Table I). The demographic variables were not
statistically different between the 2 groups (P values
varied from .05 to .69).

No differences were evident between the 2 groups

regarding age, sex, mean LVEF, and duration of HF
follow-up. However, the group with Chagas cardiomyopathy contained a higher percentage of participants taking aspirin and warfarin, using an artificial
pacemaker because of bradycardia, and falling within
NYHA FCs III and IV.
Higher intakes of aspirin and warfarin among patients with Chagas cardiomyopathy reflects a general
clinical concern about the thromboembolic risk associated with mural thrombi frequently detected in
chagasic patients, especially in patients with apical
aneurysms.43 Recent reports support the notion
that Chagas cardiomyopathy is a risk factor for
stroke.44,45 This preliminary evidence was used to
justify the use of aspirin and warfarin in the

Data analysis

HEART & LUNG VOL. 40, NO. 3

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Chagas and non-Chagas cardiomyopathy in Brazil

Pelegrino et al

Table I
Characteristics of participants according to etiology of HF (n = 102)
Chagas
cardiomyopathy
(n = 43)
Characteristics

Age (years)
Sex (% male)
Marital status
(% married)y
Educational
background (years)
Work status (% with no
paid job)
Duration of HF followup (years)
NYHA (% in each class)
I
II
III-IV
LVEF
Medication (% using
each type)
Diuretics
ACE
b-blocker
Digoxin
Aspirin use
Warfarin
Articial pacemaker
(% using)

Mean (SD)

% (n)

58.7 (14.9)

Non-Chagas
cardiomyopathy
(n = 59)
Mean (SD)

% (n)

P Value*

57.6 (34)
59.3 (35)

.19
.59
.69

54.9 (13.8)
62.8 (27)
62.8 (27)

4.0 (3.7)

4.8 (3.8)
93.0 (40)

1.2 (1.4)

.25
78.0 (46)

1.7 (1.5)

.05
.15
.02

32.6 (14)
27.9 (12)
39.5 (17)
28.0 (7.7)

45.8 (27)
39.0 (23)
15.3 (9)
30.3 (6.3)

95.3 (41)
79.1 (34)
72.1 (31)
69.8 (30)
44.2 (19)
39.5 (17)
37.2 (16)

.10
84.7 (50)
78.0 (46)
74.6 (44)
61.0 (36)
22.0 (13)
20.3 (12)
5.1 (3)

.46
.70
.45
.56
.03
.05
<.001

ACE, angiotensin-converting enzyme.

*P values are derived from t test for numeric continuous variables, and from c2 test for categorical variables.
yPercentage refers to married or living with a signicant other.

prevention of thromboembolic events in chagasic

patients with HF.
The higher proportion of pacemakers among people with Chagas cardiomyopathy was expected.
Pacemakers are frequently indicated for people
with Chagas cardiomyopathy because of the high incidence of bradycardia and atrioventricular conduction disturbances in this population.46,47
In our study, HRQL, as measured by SF-36 subscales, varied between 23.2 (Role Physical) and
64.8 (Social Functioning) in the group with Chagas
cardiomyopathy, and between 47.4 (Role Physical)
and 66.5 (Social Functioning) in the non-Chagas
group. Although the mean values for the 8 SF-36

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subscales were always lower (ie, worse) in the

non-Chagas group, these differences were only statistically significant for the 2 subscales related to
Physical Functioning, demonstrating that the HF related to Chagas disease is more physically debilitating than HF without it. The lower scores obtained
in the physical domains of the SF-36 can be explained by the larger proportion of patients in
classes III and IV in the group with Chagas cardiomyopathy. Previous studies showed that quality of life
decreases with worsening HF symptoms,6,35,48-50
and improvements in NYHA functional classification are associated with improved quality of life.48
In our study, patients in the group with Chagas

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Pelegrino et al

Chagas and non-Chagas cardiomyopathy in Brazil

Table II
Comparison of SF-36 domains according to HF etiology
Chagas
cardiomyopathy
(n = 43)

SF-36 domains
Role Physical
Physical
Functioning
Role Emotional
General Health
Status
Vitality
Social Functioning
Mental Health
Bodily Pain

Non-Chagas
cardiomyopathy
(n = 59)

mean (SD) and

median (Min, Max)

mean (SD) and

median (Min, Max)

23.2 (36.7)
0.0 (0, 100)
50.1 (25.7)
45.0 (0, 90)
37.2 (43.1)
33.3 (0, 100)
55.2 (19.8)
55.0 (15, 100)
57.7 (24.0)
55.0 (15, 100)
64.8 (25.0)
62.5 (12.5, 100)
64.7 (23.2)
64.0 (8, 100)
58.6 (30.2)
52.0 (0, 100)

47.4 (41.1)
50.0 (0, 100)
62.7 (23.7)
65.0 (15, 100)
52.5 (42.5)
33.3 (0, 100)
59.2 (18.9)
57.0 (20, 97)
61.0 (20.2)
60.0 (20, 100)
66.5 (25.4)
62.5 (25, 100)
65.4 (23.5)
68.0 (0, 100)
58.7 (25.2)
62.0 (12, 100)

P value*

.002
.01
.08
.30
.46
.73
.88
.99

Min, minimum; Max, maximum.

*P value according to Student t test.

cardiomyopathy had more symptoms of HF than the

non-Chagas group, and the observed values are
consistent with those in other studies.5,18,35
Brazilian patients in this study were primarily of
a low socioeconomic status. This population was
poorer than those enrolled in studies of other countries,5,18,27,31 but similar to populations enrolled in
other studies in Brazil.3,39,40 Participants were also
relatively young and tended to be male, in keeping
with other Brazilian studies of patients with
Chagas cardiomyopathy.3
Various implications follow from our results. First,
because the population of patients with HF in Brazil
contains a large proportion with Chagas cardiomyopathy, results of studies conducted in countries
where this etiology rarely occurs may not directly apply to our population. Our findings show that the
scores for physical domains of HRQL are usually
lower for a person whose HF is related to Chagas disease than for a non-Chagas patient. Consequently,
we need to develop protocols to manage Chagas cardiomyopathy that allow these patients to participate
more in their lives, especially from a physical point

HEART & LUNG VOL. 40, NO. 3

of view. Our study is of an exploratory nature,

but its results highlight that a subpopulation of
HF patients may need more attention and would
benefit from further studies. The public-health system in Brazil receives most of the countrys patients with Chagas cardiomyopathy, and as such,
a confirmation of our results could have important
policy implications. Future studies should confirm
the results of HRQL, and assess whether these
patients consume more resources than other
groups with HF. Longitudinal studies could elucidate these questions.

Study limitations
This study was limited insofar as it was an analysis of secondary data from a cross-sectional study,
and the final sample used in the data analysis could
have been biased. Individuals with Chagas disease
tend to have more symptoms of HF and may be
more likely to seek medical care, and thus are
more likely to be sampled. However, because the accrual time for the study spanned more than 1 year,

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Chagas and non-Chagas cardiomyopathy in Brazil

the sample would be unlikely to comprise only the

most severe cases of HF.
This study was cross-sectional and does not provide information on the course of the disease in
terms of HRQL and its consequences over time.
The subscales of the SF-36 did not present very
high internal consistency, especially for the domains
of Role Social and General Health Status. Future
studies should use more reliable instruments to
assess HRQL among patients with HF.
Finally, our study population included only patients followed in one Brazilian region endemic for
Chagas disease. Although this study is important
because it represents a relatively under-researched
population, these findings need to be confirmed,
and should not be generalized to other populations.

CONCLUSION
Chagas cardiomyopathy was associated with higher
intakes of aspirin and warfarin, a higher use of artificial
pacemakers because of bradycardia, and lower HRQL
in the Physical Functioning and Role Physical domains, compared with non-Chagas cardiomyopathy.
Although this study was exploratory, it suggests that
Chagas cardiomyopathy may cause a greater health
burden to the patient. In countries where a large proportion of HF patients have Chagas cardiomyopathy,
more research is needed for a better understanding
of the health burden inflicted by this condition on patients, and to develop ways of improving their HRQL.
REFERENCES
1. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke
statistics2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-146.
2. DatasusDepartamento de Informatica do Sistema Unico de
Saude. Available at: http://tabnet.datasus.gov.br/cgi/idb2008/
matriz.htm. Accessed December 1, 2009.
3. Dourado KC, Bestetti RB, Cordeiro JA, Theodoropoulos TA.
Assessment of quality of life in patients with chronic heart
failure secondary to Chagas cardiomyopathy. Int J Cardiol
2006;108:412-3.
4. Brener Z, Gazzinelli RT. Immunological control of Trypanosoma
cruzi infection and pathogenesis of Chagas disease. Int Arch
Allergy Immunol 1997;114:103-10.
5. Ekman I, Fagerberg B, Lundman B. Health-related quality of
life and sense of coherence among elderly patients with
severe chronic heart failure in comparison with healthy
controls. Heart Lung 2002;31:94-101.
6. Westlake C, Dracup K, Creaser J, et al. Correlates of healthrelated quality of life in patients with heart failure. Heart
Lung 2002;31:85-93.
7. Lainscak M, Keber I. Patients view of heart failure: from the
understanding to the quality of life. Eur J Cardiovasc Nurs
2003;2:275-81.
8. Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs 2005;4:198-206.

e30

www.heartandlung.org

Pelegrino et al
9. Fayers PM, Machin D. Quality of life. Assessment, analysis and
interpretation. Chichester: John Wiley & Sons; 2007.
10. Dunderdale K, Thompson DR, Miles JN, Beer SF, Furze G. Qualityof-life measurement in chronic heart failure: do we take account
of the patient perspective? Eur J Heart Fail 2005;7:572-82.
11. Gottlieb SS, Khatta M, Friedmann E, et al. The influence of
age, gender, and race on the prevalence of depression in heart
failure patients. J Am Coll Cardiol 2004;43:1542-9.
12. Sin MK, Sanderson B, Weaver M, Giger J, Pemberton J,
Klapow J. Personal characteristics, health status, physical activity, and quality of life in cardiac rehabilitation participants.
Int J Nurs Stud 2004;41:173-81.
13. Bennet SJ, Oldridge NB, Eckert GJ, et al. Discriminant properties of commonly used quality of life measures in heart failure.
Qual Life Res 2002;11:349-59.
14. Middel B, Bouma J, de Jongste M, et al. Psychometric properties of the Minnesota Living with Heart Failure Questionnaire
(MLHF-Q). Clin Rehabil 2001;15:489-500.
15. Sneed NV, Paul S, Michel Y, Vanbakel A, Hendrix G. Evaluation
of 3 quality of life measurement tools in patients with chronic
heart failure. Heart Lung 2001;30:332-40.
16. Meyer K, Laederach-Hofmann K. Effects of a comprehensive rehabilitation program on quality of life in patients
with chronic heart failure. Prog Cardiovasc Nurs 2003;18:
169-76.
17. Jeng C, Yang MH, Chen PL, Ho CH. The influence of exercise
tolerance on quality of life among patients with heart failure.
Qual Life Res 2004;13:925-32.
18. Rodriguez-Artalejo F, Guallar-Castillon P, Pascual CR, et al.
Health-related quality of life as a predictor of hospital readmission and death among patients with heart failure. Arch
Intern Med 2005;165:1274-9.
19. Shively M, Kodiath M, Smith TL, et al. Effect of behavioral
management on quality of life in mild heart failure: a randomized controlled trial. Patient Educ Couns 2005;58:27-34.
20. Riegel B, Moser DK, Carlson B, et al. Gender differences in quality of life are minimal in patients with heart failure. J Card Fail
2003;9:42-8.
21. Parajon T, Lupon J, Gonzalez B, Urrutia A, Altimir S, Coll R,
et al. Use of the Minnesota Living With Heart Failure Quality
of Life Questionnaire in Spain. Rev Esp Cardiol 2004;57:
155-60.
22. Calvert MJ, Freemantle N, Cleland JG. The impact of chronic
heart failure on health-related quality of life data acquired
in the baseline phase of the CARE-HF Study. Eur J Heart Fail
2005;7:243-51.
23. Johansson P, Dahlstrom U, Brostrom A. Factors and interventions influencing health-related quality of life in patients with
heart failure: a review of the literature. Eur J Cardiovasc Nurs
2006;5:5-15.
24. Koukouvou G, Kouidi E, Iacovides A, Konstantinidou E,
Kaprinis G, Deligiannis A. Quality of life, psychological and
physiological changes following exercise training in patients
with chronic heart failure. J Rehabil Med 2004;36:36-41.
25. Artinian NT, Harden JK, Kronenberg MW, et al. Pilot study of
a Web-based compliance monitoring device for patients
with congestive heart failure. Heart Lung 2003;32:226-33.
26. Riegel B, Carlson B, Glaser D, Romero T. Changes over
6-months in health-related quality of life in a matched sample
of Hispanics and non-Hispanics with heart failure. Qual Life
Res 2003;12:689-98.
27. Cowley AJ, Wiens BL, Segal R, Rich MW, Santanello NC,
Dasbach EJ, et al. Randomised comparison of losartan vs. captopril on quality of life in elderly patients with symptomatic
heart failure: the Losartan Heart Failure ELITE Quality of
Life Substudy. Qual Life Res 2000;9:377-84.
28. Bennett SJ, Perkins SM, Lane KA, Deer M, Brater DC,
Murray MD. Social support and health-related quality of life
in chronic heart failure patients. Qual Life Res 2001;10:671-82.
29. Badano LP, Albanese MC, De Biaggio P, et al. Prevalence,
clinical characteristics, quality of life, and prognosis of

May/June 2011

HEART & LUNG

Pelegrino et al

30.
31.

32.
33.

34.
35.

36.

37.
38.

39.

patients with congestive heart failure and isolated left ventricular diastolic dysfunction. J Am Soc Echocardiogr 2004;
17:253-61.
Pattenden JF, Roberts H, Lewin RJ. Living with heart failure:
patient and carer perspectives. Eur J Cardiovasc Nurs 2007;
6:273-9.
Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A,
Graham ID. Quality of life of individuals with heart failure:
a randomized trial of the effectiveness of two models of
hospital-to-home transition. Med Care 2002;40:271-82.
Ducharme A, Doyon O, White M, Rouleau JL, Brophy JM.
Impact of care at a multidisciplinary congestive heart failure
clinic: a randomized trial. Can Med Assoc J 2005;173:40-5.
Gwadry-Sridhar FH, Arnold JM, Zhang Y, Brown JE,
Marchiori G, Guyatt G. Pilot study to determine the impact
of a multidisciplinary educational intervention in patients
hospitalized with heart failure. Am Heart J 2005;150:982.
Heo S, Doering LV, Widener J, Moser DK. Predictors and effect
of physical symptom status on health-related quality of life in
patients with heart failure. Am J Crit Care 2008;17:124-32.
Juenger J, Schellberg D, Kraemer S, et al. Health related quality
of life in patients with congestive heart failure: comparison with
other chronic diseases and relation to functional variables.
Heart 2002;87:235-41.
Pihl E, Jacobsson A, Fridlund B, Stromberg A, Martensson J.
Depression and health-related quality of life in elderly
patients suffering from heart failure and their spouses: a comparative study. Eur J Heart Fail 2005;7:583-9.
Faller H, Stork S, Schowalter M, et al. Is health-related quality
of life an independent predictor of survival in patients with
chronic heart failure? J Psychosom Res 2007;63:533-8.
Hagglund L, Boman K, Olofsson M, Brulin C. Fatigue and
health-related quality of life in elderly patients with and without heart failure in primary healthcare. Eur J Cardiovasc Nurs
2007;6:208-15.
Saccomann IC, Cintra FA, Gallani MC. Psychometric properties of the Minnesota Living With Heart FailureBrazilian
versionin the elderly. Qual Life Res 2007;16:997-1005.

HEART & LUNG VOL. 40, NO. 3

Chagas and non-Chagas cardiomyopathy in Brazil

40. Scattolin FAA, Diogo MJD, Colombo RCR. Correlation between
instruments for measuring health-related quality of life and
functional independence in elderly with heart failure. Public
Health 2007;23:2705-15.
41. Ware JE Jr., Sherbourne CD. The MOS 36-Item Short-Form
Health Survey (SF-36). I. Conceptual framework and item
selection. Med Care 1992;30:473-83.
42. Ciconelli RM, Ferraz MB, Santos W, Meinao I, Quaresma MR.
Brazilian-Portuguese version of the SF-36. A reliable and valid
quality of life outcome measure. Rev Bras Reumatol 1999;39:
143-50.
43. Samuel J, Oliveira M, Correa De Araujo RR, Navarro MA,
Muccillo G. Cardiac thrombosis and thromboembolism in
chronic Chagas heart disease. Am J Cardiol 1983;52:147-51.
44. Oliveira-Filho J, Viana LC, Vieira-de-Melo RM, et al. Chagas
disease is an independent risk factor for stroke: baseline
characteristics of a Chagas disease cohort. Stroke 2005;36:
2015-7.
45. Carod-Artal FJ, Vargas AP, Horan TA, Nunes LG. Chagasic
cardiomyopathy is independently associated with ischemic
stroke in Chagas disease. Stroke 2005;36:965-70.
46. Dias E, Laranja FS, Miranda A, Nobrega G. Chagas disease:
a clinical, epidemiologic, and pathologic study. Circulation
1956;14:1035-60.
47. Scanavacca M, Sosa E. Electrophysiologic study in chronic
Chagas heart disease. Sao Paulo Med J 1995;113:841850.
48. Hobbs FD, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK.
Impact of heart failure and left ventricular systolic dysfunction
on quality of life: a cross-sectional study comparing common
chronic cardiac and medical disorders and a representative
adult population. Eur Heart J 2002;23:1867-76.
49. Rector TS, Anand IS, Cohn JN. Relationships between clinical
assessments and patients perceptions of the effects of heart
failure on their quality of life. J Card Fail 2006;12:87-92.
50. Woodend AK, Sherrard H, Fraser M, Stuewe L, Cheung T,
Struthers C. Telehome monitoring in patients with cardiac
disease who are at high risk of readmission. Heart Lung
2008;37:36-45.

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