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A specific activity questionnaire to measure the functional capacity of

cardiac patients

Article  in  The American Journal of Cardiology · June 1996

DOI: 10.1016/S0002-9149(97)89157-6 · Source: PubMed

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 A Specific Activity Questionnaire to
Measure the Functional Capacity of
Cardiac Patients
Sarah L. Rankin, BSC, Tom G. Briffa, MSC, Alan R. Morton, EDD, MSC,
and Joseph Hung, FRACP

Exercise testing is often performed in persons with car-
diac disease to measure their functional capacity. Phys-
ical activity questionnaires assessing functional capacity
have been used as a low-cost and convenient alternative
to exercise testing, but have not been well validated
against measured oxygen consumption in a cardiac
population. This study assesses the ability of a simple,
134tem, self-administered activity questionnaire, known
as the Specific Activity Questionnaire (SAQ), to measure
functional capacity prospectively in a large sample of
cardiac patients. Ninety-seven consecutive cardiac out-
patients (85 men and 12 women aged 59 ? 10 years
[mean ? SD]) completed the SAQ before an elective
symptom-limited treadmill test. Subjects returned within
10 days to repeat the treadmill test, following the same
protocol, with the additional measurement of peak ox-
ygen consumption, VOz (ml . kg-’ smin-‘), using open
circuit spirometry. The SAQ score was significantly re-
lated to measured peakV02 (r = 0.57, p <O.OOl). Step-
wise multiple linear regression analysis found that the
addition of patient age, height, and body weight to SAQ
score improved the measurement of peak vO2, account-
ing for 51% of-the sample variance (R = 0.71, p
<O.OOl). Peak VOn was obtained from the following
regression formula:
VOz = (2.36)SAQ + (0.35)HEIGHT - (0.19)AGE
- (0.16)BODY WEIGHT - 33.89; SEE 5.43.
Thus SAQ, a simple 13-item self-administered activity
questionnaire, is able to provide a moderately good
measure of functional capacity in cardiac patients and
may be a useful tool in studies of the cardiac population
when formal exercise testing is impractical or uneco-
nomical.
(Am J Cardiol 1996;77: 1220- 1223)

number of interview-based and self-adminis- tionnaire known as the Duke Activity Status Index
A tered activity questionnaires have been devel-
oped to provide a low-cost and convenient measure
(DASI) was developed using a continuous measure
of functional capacity.6 The DASI was found to have
of functional capacity in patients with cardiovascular a higher correlation with measured peak VO, than
disease. The best known of these activity question- earlier questionnaires (Table I). The most recent ac-
naires are the functional classifications of the New tivity questionnaire, the Veterans Specific Activity
York Heart Association (NYHA) ’ and the Canadian Questionnaire (VSAQ) , lo also provides a continu-
Cardiovascular Society (CCS ) .’ These question- ous measure of functional capacity and reported a
naires group patients into 1 of 4 functional classes strong correlation with treadmill time, but was not
based on a physician’s subjective assessment of the validated against measured VO,. This study pro-
patient’s degree of symptoms when performing eve- spectively assesses the correlation of the Specific
ryday activities. Both the NYHA and CCS classifi- Activity Questionnaire (SAQ) to measure peak \iO,
cations have a poor inter-observer reproducibility in a large ambulatory cardiac outpatient population
and low correlation with treadmill time and mea- and compares the SAQ with 3 previously published
sured peak oxygen consumption (\iO,) 3-8(Table I). activity questionnaires.
Goldman et al attempted to improve the measure-
ment of functional capacity by developing the inter-
view-based Specific Activity Scale (SAS), which METHODS
classifies the functional capacity of patients based on Subjects: Ninety-seven consecutive cardiac out-
their ability to perform well-defined specific activi- patients, 85 male and 12 female, aged 59 + 10 years
ties, each with a known metabolic equivalent (mean + SD), referred for symptom-limited exer-
(MET). Like the NYHA and CCS, however, it is cise testing at Sir Charles Gairdner Hospital between
limited by the continued use of only 4 functional November 1993 and May 1994, gave written in-
classes. In 1989, a self-administered activity ques- formed consent for this study. Their clinical char-
acteristics are summarized in Table II. Seventy-four
From the Department of Human Movement, The University of Western
percent of the patients had documented coronary
Australia, and the Department of Cardiovascular Medicine, Sir artery disease, defined as a previous myocardial in-
Charles Gairdner Hospital, Nedlands, Western Australia, Australia. farction or a coronary revascularization procedure.
Manuscript received September 22, 1995; revised manuscript re- The remaining 26% of the patients were under in-
ceived and accepted Januury 1 1, 1996.
Address for reprints: Joseph Hung, FRACP, The University De-
vestigation for coronary artery disease. None of the
partment of Medicine, Sir Charles Gairdner Hospital, Verdun Street, subjects had congestive heart failure. Twenty-nine
Nedlands, Western Australia, Australia 6009. percent of the patients were taking p blockers at the

1220 01996 by Excerpta Media, Inc. 0002-9 149/96/S 15.00

All rights reserved. PII SOOO2-9149(96)00163-A
 TABLE I Previous Validation Studies of Activity Questionnaires Predicting Functional Capacity

NYHA ccs SAS DASI VSAQ

Reproducibility 56%* 73%* 73%*

Correlation with treadmill time -0.54* -0.64* -0.66* 0.82’
Correlation with peak i/O, -0.28% 0.49” 0.30” 0.58”
Year developed 1964 1972 1981 1989 1994

*Goldman et al, 198 1’; n = 75.

‘Myersetol, 1994”; n = 212.
*Smith et al, 1 9937; n = 804.
§Hlatky et al, 1989’; n = 50.
CCS = Canadian Cardiovascular Society’; DASI = Duke Activity Status Inde#; NYHA = New York Heart Association’; SAS = Specific Activity Scale class9; VSAQ
= Veterans Specific Activity Questionnaire”
-

time of the exercise test. All subjects were instructed calibration gas immediately before each testing ses-
to remain on their usual medications for the study. sion.
Questionnaire: Before the elective exercise test, Statistics:All data are expressed as mean -+ stan-
subjects completed the SAQ, which is a 13-item, dard deviation (SD). A Student’s paired t test was
self-administered activity questionnaire including a used to compare exercise duration between the tread-
range of common physical activities associated with mill tests. The relationship of the SAQ score and
personal care, ambulation, household tasks, and rec- peak VO, was examined using a Pearson product-
reation (Table III). All activities have a known met- moment correlation. Stepwise multiple linear regres-
abolic equivalent (MET) obtained from the current sion analysis was used to determine whether age,
Compendium of Physical Activities.” Each question height, body weight, body mass index, sex, history
required a “yes” or “no” response. A SAQ score of documented disease, and cardiac medications
was obtained by recording the corresponding MET added to the correlation of SAQ score and peak VO, .
value of the most demanding activity that the subject Statistical procedures were performed using Fastat
perceived he or she could complete without symp- (SYSTAT Inc., Evanston, Illinois) and the Statistics
toms. Responses to the SAQ were used to calculate Package for Social Sciences (SPSS Inc., Chicago,
scores for the SAS,” DAS16 and VSAQ.” All.scores Illinois).
were then correlated against measured peak VOZ.
Exercise testing: Within 10 days of the elective ex- RESULTS
ercise test, subjects performed a second exercise test Peak exercise responses: Exercise duration was
following the identical protocol, with the additional similar for the first and second exercise tests (9.4 +
measurement of V02, using open circuit spirometry. 3.1 minutes vs 9.7 + 3.2 minutes; p = NS). The
All exercise tests were symptom-limited and used measured peak V02 was 19.9 +- 7.3 ml . kg-’ .
the Standardised Exponential Exercise Protocol, ‘* min-’ (5.6 +- 2.0 METS). At test termination, the
designed for the treadmill, beginning at a work load maximal rating of perceived exertion was 16.6 ? 3.2,
of 2 METS and increasing by 15% each minute by maximal heart rate was 143 2 28 beats/min or 88%
increases in either speed or gradient. The treadmill, of predicted maximal heart rate (220 - age), and
a Tetley Treadmaster, was automatically controlled maximal rate-pressure product was 22,790 i: 7,090.
by a Nihon Kohden Stress Test system, which also Exercise test termination was due to leg fatigue
displayed a continuous 12-lead electrocardiograph (43% ) , shortness of breath (2 1%) , chest discomfort
trace and elapsed exercise time. The O2 and CO, ( 13%)) leg claudication ( 11% ) , and dizziness
content of expired air was calculated by an AME- (2%). Thirty-five percent of the patients reached a
TEK Applied Electra Chemistry 53A O2 analyzer respiratory exchange ratio of 2 1.15.
and an Applied Electra Chemical CD3A CO2 ana- Correlation with measured peak i’O2: There was a
lyzer (Pittsburgh, Pennsylvania), respectively. A significant correlation (r = 0.57, p <O.OOl ) between
Morgan Ventilometer (Cheltham, England) deter- the SAQ score (MET) and measured peak VOZ
mined the inspired volume, which was then used to (ml.kg-‘.min-’ ) (Figure 1). This correlation im-
calculate the expired volume using the Haldane proved to R = 0.71 (p <O.OOl ) when age, height,
transformation. An IBM XT computer continuously and body weight were included in the regression
sampled the output of the 2 analyzers, calculating analysis. A measure of functional capacity from the
the V02, VCO*, and respiratory exchange ratio SAQ is derived from the following regression for-
every 30 seconds. Blood pressure and ratings of per- mula:
ceived exertion, from the Borg scale, I3 were re- VO, = (2.36)SAQ + (0.35)HEIGHT [cm]
corded every alternate minute during exercise, and
heart rate was recorded each minute. All subjects - (0.19)AGE [years] - (0.16) WEIGHT [kg]
were encouraged to do their best and to refrain from
holding onto the handrails. The gas analyzers were SEE = 5.43.
- 33.89;
calibrated with a known, gravitationally determined Table IV compares the correlations between mea-

METHODS/MEASURING FUNCTIONAL CAPACIIY BY ACTIVITY QUESTIONNAIRE 1221

 prove their measurement of functional capacity.
TABLE II Subject Characteristics
These modifications include the use of a continuous
Men/women 85/12 scoring system based on activities with known met-
Age iyd 592 10 abolic equivalents.6,9-11The scoring system of the
Height (cm] 173 t7
Weight (kg) 83.72 13.8
SAQ incorporates these modifications, with the score
Body mass index (kg/cm’) 27.9 k 4.53 obtained simply as the most demanding activity that
Previous myocardial infarction 34 (35%) the patient could complete without symptoms. In our
Previous coronary revascularization 38 (39%) prospective validation of the SAQ, we found, in ac-
0 Blockers 28 (29%)
Nitrates 10 (10%)
cordance with previous studies, 14~17~18 that the addi-
Angiotensinconverting enzyme inhibitors 17 (17%) tion of age, height, and body weight to the SAQ
Calcium channel blockers 9 (9%) score significantly increased the correlation of SAQ
Values are expressed OS mean A SD or number (%).
with measured peak VOz (R = 0.71, SEE = 5.43; p
<O.OOl ).
The low correlation found in our patient sample
between SAS and measured peak VOz (r = 0.35) is
TABLE Ill The Specific Activity Questionnaire
consistent with that reported by Hlatky et al6 and
Can You Complete the Following Activities further illustrates the limitations of the 4-tier func-
without Symptoms? MET Value tional classification system. Lee et all6 reported a
Dress without stopping because of symptoms? 2.00 higher correlation between SAS and measured peak
Do moderate work around the house like VO:!, but in only a small sample of cardiac patients.
vacuum, sweep floors, or carry groceries? 2.50 The DASI and the VSAQ questionnaires yielded cor-
Walk down a flight of stairs unassisted and
without stopping? 3.00
relations with peak VOz similar to that seen with the
Do heavy work around the house like strip and SAQ (Table IV). Scoring of the DASI, however, is
make the bed, hang out washing, or wash the more difficult because of its use of a composite score
car? 3.25 into orating 12 different groups of physical activ-
Do moderate gardening like weed or rake the ities.‘g The VSAQ and SAQ, in contrast, use only the
leaves? 4.25
Push an electric or petrol mower on level
MET value of the most demanding activity that a
ground? 4.50 patient perceives he or she can complete without
Participate in moderate activities like walk at a symptoms. Myers et al” found the VSAQ to have a
normal pace (4 km/h) or play golf and carry high correlation with treadmill time, but this was not
the clubs? 4.75
Walk briskly around an oval? 5.00
validated against measured VO,. The lower corre-
Do outdoor work like split wood or dig in the lation of VSAQ with measured peak VOz (r = 0.66)
garden? 5.50 in this study likely reflects the inaccuracy of using
Carry an &kg weight (e.g., load of wet washing) treadmill time to estimate peak VOz.
up 8 steps? 6.00
The SEES of the 4 questionnaires were between
Carry at least 10 kg (e.g., a suitcase) up 8 steps? 7.00
Carry objects that weigh at least 35 kg (e.g., 1 l-
5.4 and 6.8 ml *kg-‘*mm’, or 1.5 to 1.9 METS
year-old child)? 7.50
Participate in vigorous activities like swimming
(crawl), joging (8 km/h), cycling (17 km/h),
singles tennis? 9.00

MET = metabolic equivalent.

sured peak VO, and estimated functional capacity

derived from the SAS, DASI, VSAQ, and SAQ
when used in our patient population. The SAS ques-
tionnaire had the lowest correlation with peak VOz
(r = 0.35, p <O.OOl). The DASI, VSAQ, and SAQ
had much better correlation coefficients and similar
standard errors of the estimates.

DISCUSSION
Our study data demonstrate that the SAQ pro-
vides a measure of functional capacity that correlates
moderately well with measured peak V02 in an am-
bulatory cardiac population. The mean measured SAQ Score (METS)
peak VOz of our study population (19.9 + 7.3
ml-kg-‘.min-‘) is comparable to reviously re- FIGURE 1. Scatter plot illustrating a significant (p t0.001) rela-
ported values in cardiac patients.14-’c?Since the de- tionship between Specific Activity Questionnaire (SAQ) score
(metabolic equivalents; METS) and measured Q02
velopment of the NYHA classification, several mod- (ml * kg-’ - min-‘). The line of identity ~dashec/ line] is drawn to
ifications to the structure and content of activity show that the SAQ score in the majority of patients overestimates
questionnaires have been made in an attempt to im- actual measured V02.

1222 THE AMERICAN JOURNAL OF CARDIOLOGYe VOL. 77 JUNE 1, 1996


TABLE IV Pearson Product-Moment Correlations
Physical Activity Questionnaires With Measured
SAS DASI
Correlation with peak
i/O, 0.35 0.62
Standard error of estimate 6.82 5.76
p Value 0.001 0.001
DASI = Duke Activity Status Index’; SAG? = Specific
SAS = Specific Activity Scale closs9; VSAQ = Veterans
tionna~re.‘”
(Table IV). These findings indicate the inability of
these questionnaires to measure functional capacity
accurately in an individual subject, therefore restrict-
ing their application to group or population use. The
ability of the SAQ and other questionnaires to detect
changes in functional capacity over time was not ex-
amined here, and further investigation should ad-
dress their use in follow-up assessments.
The overestimation of functional capacitgy is a
common problem of earlier questionnaires,6. JO es-
pecially in individuals with a peak VO, of <5 METS.
This was also found in our study population, as in-
dicated by Figure 1. When developing the DASI,
Hlatky et al6 addressed this problem by including 6
questions relating to activities at or below this func-
tional level. Ironically, because of the cumulative na-
ture of the DASI score, this may have contributed to
its continued overestimation of functional capacity.
The simplified scoring method of the SAQ and
VSAQ was adopted in an effort to reduce this over-
estimation. The SAQ and VSAQ, however, contin-
ued to overestimate actual measured \;rO, in our sam-
ple. Although the MET values associated with
low-level physical activities may overstate measured
\j02, the more likely explanation is that cardiac pa-
tients tend to overestimate their actual physical ca-
pabilities, and this remains another limitation of cur-
rent activity questionnaires.
Therefore, the SAQ and other activity question-
naires should not be used to replace the exercise test
when a precise measure of functional capacity is re-
quired, as their accuracy is limited by a relatively
large SEE and overestimation in some patient sub-
groups. However, the SAQ should be a useful tool
METHODS/MEASURING
View publication stats
in cardiac population studies when individual exer-
of Current
Peak %‘O,
cise testing is impractical or uneconomical.
Acknowledgment: We gratefully acknowledge the
VSAQ SAQ assistance of Andrew Maiorana, MSc, in exercise
testing, and the Department of Cardiovascular Med-
0.66 0.71 icine, Sir Charles Gairdner Hospital, and the De-
5.44 5.43 partment of Human Movement, The University of
0.001 0.001
Western Australia, for their support of this study.
AcHvity Questionnaire;
Specific Activity Qves-
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