ijcs International Journal of Cardiovascular Sciences Int J Cardiovasc Sci 2359-4802 2359-5647 Sociedade Brasileira de Cardiologia ZLq3y6c93Db369stfKKVLMb S2359-56472021005009201 S2359-56472021000600068 ijcs.20190185 10.36660/ijcs.20190185 ORIGINAL ARTICLE Influence of Factors Affecting Quality of Life on in-Hospital Cardiovascular Events of Patients with Acute Myocardial Infarction with and without ST-segment Elevation 0000-0003-0331-0306 Jesus Monique Tavares de 1 0000-0001-8604-7237 Costa Ingrid Maria Novais Barros de Carvalho 1 2 0000-0002-2859-0853 Silva Danielle Góes da 3 0000-0002-1918-7122 Silva José Rodrigo Santos 4 0000-0002-4884-3379 Barreto-Filho José Augusto Soares 1 5 6 7 0000-0003-0622-6257 Almeida-Santos Marcos Antonio 7 8 0000-0002-4325-0590 Oliveira Joselina Luzia Meneses 1 5 6 7 0000-0002-5538-7121 Buarque Mirella Dornelas Batalha Moreira 9 10 0000-0003-0635-3109 Andrade Fabrício Anjos de 11 0000-0002-4158-9726 Sousa Antônio Carlos Sobral 1 5 6 7 Postgraduate Program in Health Sciences Federal University of Sergipe São Cristóvão SE Brazil Postgraduate Program in Health Sciences of the Federal University of Sergipe (UFS), São Cristóvão, SE - Brazil Federal Institute of Education, Science and Technology of Sergipe São Cristóvão SE Brazil Federal Institute of Education, Science and Technology of Sergipe, São Cristóvão, SE - Brazil Nutrition Departament UFS São Cristóvão SE Brazil Nutrition Departament of the UFS, São Cristóvão, SE - Brazil Statistics Departament UFS São Cristóvão SE Brazil Statistics Departament of the UFS, São Cristóvão, SE - Brazil Division of Cardiology University Hospital Aracaju SE Brazil Division of Cardiology of the University Hospital, Aracaju, SE - Brazil Medicine Departament UFS São Cristóvão SE Brazil Medicine Departament of the UFS, São Cristóvão, SE - Brazil São Lucas Clínic and Hospital Rede D'Or - São Luiz Aracaju SE Brazil São Lucas Clínic and Hospital / Rede D'Or - São Luiz, Aracaju, SE - Brazil Postgraduate Program in Health and Environment Tiradentes University Aracaju SE Brazil Postgraduate Program in Health and Environment of Tiradentes University, Aracaju, SE - Brazil Heart Hospital of Sergipe Aracaju SE Brazil Heart Hospital of Sergipe, Aracaju, SE - Brazil Charity Foundation Surgery Hospital Aracaju SE Brazil Charity Foundation Surgery Hospital, Aracaju, SE - Brazil Primavera Hospital Aracaju SE Brazil Primavera Hospital, Aracaju, SE - Brazil Mailing Address: Monique de Jesus Universidade Federal de Sergipe - R. Cláudio Batista, s/n. Postal Code: 49060-108, Palestina, Aracaju, SE – Brazil. E-mail: monique_tavaresj@hotmail.com

Author contributions

Conception and design of the research: Jesus MT, Costa IMNBC, Silva DG, Silva JRS, Buarque MDBM, Sousa ACS. Acquisition of data: Jesus MT, Costa IMNBC, Buarque MDBM, Andrade FA, Sousa ACS. Analysis and interpretation of the data: Jesus MT, Costa IMNBC, Silva DG, Silva JRS, Barreto Filho JAS, Almeida-Santos MA, Oliveira JLM, Sousa ACS. Statistical analysis: Silva JRS. Writing of the manuscript: Jesus MT, Silva DG, Almeida-Santos MA, Oliveira JLM, Sousa ACS. Critical revision of the manuscript for intellectual content: Jesus MT, Silva DG, Almeida-Santos MA, Oliveira JLM, Sousa ACS.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

 07 07 2021 2021 34 5 Supl 1 68 77 10 10 2019 28 05 2020 04 10 2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background

Acute myocardial infarction (AMI), with and without ST-segment elevation (STEMI and NSTEMI, respectively), is the principal cause of cardiovascular morbidity and mortality in Brazil and around the world. Modifiable risk factors (RF) and quality of life (QOL) may correlate with the type of AMI.

 Objective

To evaluate the influence of QOL and RF on the type of AMI and in-hospital cardiovascular events in STEMI and NSTEMI patients.

 Methods

This was an observational, cross-sectional study. Patients with AMI attending four referral hospitals (three private and one public) for cardiovascular disease treatment were assessed for QOL using the Brazilian version of the 36-item short form survey. A p < 0.05 was considered statistically significant.

 Results

We evaluated 480 volunteers; 51% were treated in one of the private hospitals. In total, 55.6% presented with STEMI, and 44.4% with NSTEMI. Patients from the public hospital were 8.56 times more likely to have STEMI compared to those from the private hospitals. There was a higher prevalence of smokers in STEMI (p < 0.028) patients. QOL was not associated with the type of AMI. A negative patient perception of the physical health and pain domains was observed. Although a significant difference between the physical and the mental health domains was not observed, individual domains were correlated with some in-hospital outcomes.

 Conclusion

There was a higher prevalence of smokers among individuals with STEMI. Domains of QOL showed a statistically significant relationship with the occurrence of in-hospital cardiovascular events, with no difference between the types of AMI.

 Cardiovascular Diseases/epidemiology Coronary Acute, Syndrome Myocardial Infarction Medication Adherence Risk Factors Introduction

The global scenario reveals an increase in the incidence of cardiovascular diseases.1 According to a report by the Pan American Health Organization (PAHO) published in 2017, 17.7 million people died from cardiovascular disease in 2015, representing 31% of all deaths globally. It directly affects health-related costs, and causes reduction in job productivity and quality of life (QOL).2,3

Acute coronary syndromes (ACS), including unstable angina (UA) and acute myocardial infarction (AMI) with and without ST-segment elevation (STEMI and NSTEMI, respectively) are among the main cardiovascular diseases.4 AMI is one of the leading causes of death and physical disabilities, and modifiable risk factors (RF) and QOL may correlate with the development of this disease.5-7

According to the PAHO report, most cardiovascular diseases can be prevented by addressing behavioral RF, such as tobacco use, unhealthy diet, obesity, lack of physical activity, and use of alcohol, by implementing strategies for the general population.2Additionally, control of RF and adherence to healthy habits can be associated with better QOL.8

QOL is related to the individual's perception of their own life, in connection with their goals and within the value system incorporated in decision-making.9 It depends on individual’s economic status, physical and mental health, social protection, political stability, and the environment.10

The measurement of QOL provides valuable information about the individual and helps clinicians to choose the best forms of treatment and rehabilitation. Despite the relationship between RF and the lifestyle of individuals with cardiovascular disease, recommendations to investigate parameters of QOL for estimation of cardiovascular events (CVEs), are not well established, and require further research. Therefore, the present study aimed to assess whether patient QOL affects the type of AMI and in-hospital outcomes.

 Methods Study design

This was a cross-sectional observational study, carried out from October 2013 to September 2015. This study is part of the research entitled "Adherence to drug treatment and lifestyle changes in patients with acute coronary syndrome" conducted in four renowned hospitals for cardiac treatments (three private and one public) in Aracaju, Sergipe, Brazil.11

 Subjects

Patients who presented with STEMI or NSTEMI were recruited by convenience sampling. We included patients of both genders, aged 18 years or older, diagnosed with AMI, and excluded patients with cardiogenic shock, unstable angina (UA), or Alzheimer's disease.

 Variables analyzed

The following variables, collected from medical records were analyzed: educational attainment, marital status, clinical presentation (type of infarction), comorbidities – dyslipidemia, systemic arterial hypertension (SAH), smoking, diabetes mellitus (DM), and family history of coronary artery disease (CAD) – and in-hospital events.

We performed anthropometric measurements – weight, height, waist circumference, and body mass index (BMI). We also analyzed physical activity records using the International Physical Activity Questionnaire (IPAQ, short version),12,13 and QOL using the Brazilian version of the Medical Outcomes Study Questionnaire 36-Item Short-Form Health Survey (SF-36).14,15

 Anthropometric measurements

Body weight, height, and BMI16of patients were determined. For body weight measurement, patients were dressed in light clothing, barefoot, standing on the platform of a digital scale (Filizola, 150 Kg) to the nearest 0.1 Kg. Height was measured to the nearest 0.1 m using a stadiometer (SECA).

 Physical activity

We used the IPAQ – short version to assess physical activity. Habitual physical activity levels were classified based on the consensus proposed by the Physical Fitness Laboratory of São Caetano do Sul, which is the coordinating center of IPAQ in Brazil. Patients were then classified into very active, active, irregularly active, and sedentary.12,13

 Quality of life

QOL was measured using the validated Portuguese language version14 of the SF-36 questionnaire.15

The SF-36 consists of 36 questions that address eight domains (or dimensions) of two major components: the physical component that involves functional capacity (10 items), pain (two items), general health status (five items), and physical performance (four items), and the mental component that covers mental health (five items), emotional (three items), social (two items), and vitality (four items). There is also one question aimed to compare current health perceived by the patient with that of a year ago.14,15

 Data analysis

We analyzed the data using the software R, version 3.5.1. Univariate descriptive analysis was performed by calculating the frequencies (absolute and relative) for the categorical variables, and mean and standard deviation for the continuous variables. Continuous variables that were not normally distributed were described as median and interquartile range.

Continuous variables with normal and without normal distribution were compared using the unpaired Student's t-test and the Mann-Whitney, respectively. Distribution normality was assessed using the Shapiro-Wilk test. For categorical variables, the chi-square test or the Fisher's exact test, with 95% confidence interval, was used as appropriate. The odds ratio (OR) was also calculated. Significance level was set at 0.05 (p<0.05).

 Ethical aspects

The study was approved by the Research Ethics Committee of the Federal University of Sergipe – CEP/UFS on 06/07/2013 under nº 302.544. All procedures were performed following the 2013 update of the Declaration of Helsinki. Informed consent was obtained from all the participants included in the study.

 Results Characteristics of the subjects

A total of 480 patients were included. Out of these patients, 267 (56%) had STEMI, and 213 (44%) had NSTEMI. Among them, 235 (49%) were treated in the public hospital, and 245 (51%) in private ones. The study sample was predominantly elderly and male. Most of them had complete elementary school and were married or lived with a partner. Regarding RF, most patients were overweight and had a sedentary lifestyle, were non-smokers, had SAH, dyslipidemia, and family history of CAD (Table 1).

– General characteristics of patients (n=480) with acute myocardial infarction, Aracaju, Sergipe, Brazil, 2019
Variables Category Frequency (n°) (%)
ACS type STEMI 267 (56)
NSTEMI 213 (44)
Health service Public 236 (49)
Private 244 (51)
Sex Masculine 305 (64)
Feminine 175 (36)
Color White 164 (36)
Black 64 (14)
Brown 230 (50)
Educational attainment Elementary School 266 (55)
High School 142 (30)
Higher Education 72 (15)
Weight excess Yes 317 (67)
No 159 (33)
Tobacco use Yes 92 (19)
Ex-smoker 170 (35)
No 218 (45)
DM Yes 169 (35)
No 311 (65)
SAH Yes 103 (21)
No 377 (79)
Dyslipidemia Yes 263 (55)
No 217 (45)
History of CAD Yes 276 (58)
No 204 (43)
IPAQ Sedentary 254 (53)
Active 226 (47)
Age group from18 to 49 63 (13)
from 50 to 59 117 (24)
from 60 to 69 158 (33)
from 70 to 79 93 (19)
80 or over 49 (10)
Marital status Married/Stable union 315 (66)
Divorced/Widow(er)/ 101 (21)
Single 63 (13)

ACS: acute coronary syndrome; AMI: acute myocardial infarction; STEMI: acute myocardial infarction with ST-segment elevation; NSTEMI: acute myocardial infarction without ST-segment elevation; DM: diabetes mellitus; CAD: coronary artery disease; IPAQ: International Physical Activity Questionnaire.

Considering the type of hospital, 189 patients who were treated in the public hospital were diagnosed with STEMI, compared with 78 patients with STEMI who were treated in private hospitals. Therefore, in the public health system, 80% of the patients with AMI were diagnosed with STEMI, compared to 32% in the private hospitals (p < 0.001), indicating a relationship between the type of AMI and the type of hospital. People treated in the public hospital were 8.56 times more likely to have STEMI compared to those treated in the private hospitals (Table 2).

– Relationship between types of acute myocardial infarction with qualitative variables, Aracaju, Sergipe, Brazil, 2019
Variable / Category AMI OR (CI 95%) p-value*
STEMI (%) NSTEMI (%)
Health Service
Public 189 (80) 47 (20) 8.56 (5.64-12.99) <0.001
Private 78 (32) 166 (68) 1.00
Sex
Masculine 183 (60) 122 (40) 1.62 (1.12-2.36) 0.014
Feminine 84 (48) 91 (52) 1.00
Race (skin color)
White 79 (48) 85 (52) 0.68 (0.45-1.01) 0.071
Black 40 (63) 24 (38) 1.22 (0.69-2.15)
Brown 133 (58) 97 (42) 1.00
Education
Elementary school 174 (65) 92 (35) 2.97 (1.74-5.08) <0.001
High school 65 (46) 77 (54) 1.33 (0.74-2.36)
Higher education 28 (39) 44 (61) 1.00
Overweight/Obesity
Yes 171 (54) 146 (46) 0.85 (0.58-1.25) 0.476
No 92 (58) 67 (42) 1.00
Tobacco use
Yes 60 (65) 32 (35) 1.91 (1.15-3.16) 0.028
Ex-smoker 99 (58) 71 (42) 1.42 (0.95-2.13)
No 108 (50) 110 (50) 1.00
DM
Yes 90 (53) 79 (47) 0.86 (0.59-1.26) 0.500
No 177 (57) 134 (43) 1.00
Hypertension
Yes 56 (54) 47 (46) 0.94 (0.61-1.45) 0.859
No 211 (56) 166 (44) 1.00
Dyslipidemia
Yes 136 (52) 127 (48) 0.70 (0.49-1.01) 0.071
No 131 (60) 86 (40) 1.00
History of CAD
Yes 151 (55) 125 (45) 0.92 (0.64-1.32) 0.707
No 116 (57) 88 (43) 1.00
IPAQ
Sedentary 139 (55) 115 (45) 0.93 (0.65-1.33) 0.742
Active 128 (57) 98 (43) 1.00
Age group
from18 to 49 41 (65) 22 (35) 3.51 (1.60-7.68) 0.016
from 50 to 59 71 (61) 46 (40) 2.91 (1.45-5.82)
from 60 to 69 87 (55) 71 (45) 2.31 (1.18-4.49)
from 70 to 79 51 (55) 42 (45) 2.29 (1.12-4.68)
80 or over 17 (35) 32 (65) 1.00
Marital status
Married/Stable union 175 (56) 140 (44) 0.62 (0.35-1.10) 0.075
Divorced/Widow(er)/ 49 (49) 52 (51) 0.47 (0.25-0.91)
Single 42 (67) 21 (33) 1.00

*Chi-square or Fisher's exact test. OR: Odds Ratio, AMI: Acute Myocardial Infarction; STEMI: Acute Myocardial Infarction with ST-segment elevation; NSTEMI: Acute Myocardial Infarction without ST-segment elevation; DM: Diabetes Mellitus; CAD: Coronary artery disease; IPAQ: International Physical Activity Questionnaire.

In addition, 183 (60%) of men had STEMI, compared to 84 (48%) of women. Men had a 1.62 times greater chance of having STEMI compared to women (p = 0.014). Low educational attainment and age group (between 18 and 49 years) also showed a significant relationship with the severity of infarction (Table 2).

Smoking, DM, SAH, dyslipidemia, obesity/overweight (BMI), and physical inactivity showed a significant relationship with the development STEMI. In the univariate analysis, these variables did not show any statistically significant differences related to the type of infarction (Table 2).

 QOL, AMI type, and in-hospital outcome

Considering that the SF-36 score ranges from 0 to 100 (with 0 being the worst state and 100 the best state), the mean scores for all domains ranged from 41 to 69. Only the physical aspects of the domains and pain had a mean value below 50. Social and mental health domains had the highest averages (Table 3)16. Comparisons of mean SF-36 scores between STEMI and NSTEMI showed no statistically significant differences (Table 4).17

– Summary of quantitative variables of the SF-36 questionnaire of acute myocardial infarction patients (n=480)16
Domains Average Median Standard deviation
FUNCTIONAL CAPACITY 54 55 32
PHYSICAL 41 25 42
PAIN 48 41 30
HEALTH 58 60 22
VITALITY 60 60 24
SOCIAL 68 75 29
EMOTIONAL 60 100 44
MENTAL 69 72 22

– Comparison of quantitative variables of the SF-36 questionnaire between the types of acute myocardial infarction (n=480)17
Domain STEMI NSTEMI p-value*
Median P25 P75 Median P25 P75
FUNCTIONAL CAPATICY 55 30 80 55 25 85 0.894
PHYSICAL 25 00 100 25 00 75 0.091
PAIN 41 20 72 41 20 62 0.688
HEALTH 62 42 77 57 42 72 0.544
VITALITY 65 45 83 60 40 75 0.065
SOCIAL 75 50 100 63 50 100 0.073
EMOTIONAL 100 00 100 100 00 100 0.564
MENTAL 72 56 88 72 52 84 0.285

*Mann-Whitney test. SD: Standard deviation; FC: Functional capacity; STEMI: Acute myocardial infarction with ST-segment elevation; NSTEMI: Acute Myocardial Infarction without ST-segment elevation

Table 518 shows the mean F-36 scores of AMI patients with and without in-hospital events. Functional capacity showed a statistically significant relationship in the univariate analysis with cardiovascular death (p < 0.024). Likewise, a statistically significant relationship between pain and acute and chronic renal failure (p < 0.041), and between cardiovascular death and physical performance (p < 0.040) was also found.

– Distribution of SF-36 domain scores according to the occurrence of in-hospital events in acute myocardial infarction patients18
Variables Domains
FC Physical Pain Mental Vitality Social Emotional Health
Angioplasty Y 54±32 42±42 49±31 69±22 61±24 70±29 60±44 59±56
N 53±32 39±42 47±30 68±22 59±24 64±29 61±44 54±58
Myocardial revascularization Y 53±32 32±40 42±26 70±23 59±23 60±30 55±47 54±24
N 54±32 42±42 49±31 69±21 61±24 69±29 61±44 58±22
Overall deaths Y 31±30 31±47 48±38 54±23 48±24 44±33 83±19 46±11
N 54±32 41±42 48±30 69±22 60±24 68±29 60±44 58±22
Cardiovascular deaths Y 38±34 21±36 40±20 61±26 48±24 58±23 60±39 54±17
N 55±32* 42±43* 49±31 69±21 61±24 69±29 60±45 58±22
Re-AMI Y 45±34 30±40 44±34 66±19 45±22 52±27 58±44 57±19
N 54±32 41±42 48±30 69±22 61±24 69±29 60±44 58±22
Post-AMI Angina Y 40±34 31±42 44±32 60±28 51±25 63±30 44±51 57±22
N 55±32 41±42 48±30 69±21 61±24 68±29 61±44 58±22
CHF Y 45±30 23±40 36±32 63±24 46±28 60±29 26±39 61±19
N 54±32 41±42 49±30 69±22 61±24 68±29 61±44 58±22
CS Y 50±30 25±43 50±30 66±21 58±18 73±22 60±37 57±20
N 54±32 41±42 48±30 69±22 61±24 68±29 60±44 58±22
CRA Y 44±30 21±32 42±18 63±30 53±24 63±29 60±37 57±23
N 54±32 41±42 48±31 69±21 60±24 68±29 60±44 58±22
CVA Y 42±42 50±50 48±12 68±10 53±6 58±38 67±33 60±7
N 54±32 41±42 49±30 69±22 60±24 68±29 60±44 58±22
CRI or ARF Y 37±21 8±14 17±6 45±23 42±15 38±22 56±19 47±16
N 54±32 41±42 48±30* 69±22 60±24 68±29 60,17±44 58±22

FC: Functional Capacity MR: Myocardial Revascularization; AMI: Acute Myocardial Infarction; CS: Cardiogenic Shock; CRA: Cardiorespiratory Arrest; CHF: Congestive Heart Failure; CVA: Cerebrovascular Accident; CRI: Chronic Renal Insufficiency; ARF: Acute Renal Failure; Y: yes; N: no. *: p value < 0,05.

Unexpectedly, we did not observe a statistically significant difference between the mean scores of physical and mental health regarding the CVEs that occurred during hospitalization. We observed an association between emotional domain and congestive heart failure (CHF) (p < 0.004). Vitality was significantly related to the onset of CHF (p < 0.045), cardiovascular death (p < 0.012), and reinfarction (p < 0.007). The social aspect also showed a statistically significant relationship with CVEs, including angioplasty (p < 0.049), myocardial revascularization (MR) (p < 0.033), cardiovascular death (p < 0.047), and reinfarction (p < 0.010).

 Discussion

The study sample was predominantly elderly and male, and a family history of CAD was found in 58% of the patients. These three factors (age, sex, and history of CAD) are classified as non-modifiable RF. Among the modifiable RF, the most prevalent were obesity, hypertension, dyslipidemia, and physical inactivity; most patients were non-smokers or ex-smokers.

In a multicenter study carried out in Brazil, most patients were also male, with an average age varying between 61 and 65 years.19 International studies have also reported higher incidences of AMI in male elderly populations.20, 21 This may be related to the high life expectancy and men's health gap, which causes an increased prevalence of these chronic-degenerative diseases.

Regarding the type of infarction, there was a higher prevalence of STEMI (56%) compared to NSTEMI (44%). Marino et al.,22 described the profile of patients with ACS and found a higher prevalence of STEMI patients (n = 214) compared with NSTEMI patients (n = 73).22 The literature shows that the incidence of STEMI and NSTEMI varies across the world, and that, in European countries, the incidence of NSTEMI has been increasing.23,24

Regarding the type of hospital (public vs. private), the number of patients attending public (49.2%) and private hospitals (50.8%) was similar. Regarding the type of AMI, the number of STEMI cases was higher in the public hospital than in private hospitals. This may be explained by the fact that the public hospital where the study was conducted is a referral center for cardiac surgery in the Brazilian Unified Health System (SUS). In the patient selection process for surgery, higher priority is given to patients with STEMI.

Regarding the relationship between the type of AMI and RF, there was a significant correlation between STEMI and smoking. The nicotine present in tobacco is the most addictive psychoactive drug, and responsible for raising heart rate and blood pressure, in addition to promoting thrombogenicity. Approximately 21% of deaths are associated with tobacco. Smoking also interferes with individuals’ QOL.25,26

With respect to perception of health-related QOL by all the respondents, the mean scores for the domains of physical component and pain were low when compared with the dimensions of vitality, and social, emotional, and mental health. Studies that evaluated QOL during hospitalization observed a negative perception of QOL in both physical and pain domains, as well as of sleep and emotional reactions. The latter two were related to the type of AMI and the process of hospitalization. 27,28 Angina, together with feelings triggered by hospitalization, can influence pain and physical aspects.

In the last decades, research investigating the QOL of cardiac patients has reported a decline in their physical capacity due to dyspnea and fatigue.29, 30 The present study corroborates these findings and reinforces that these individuals require proper management not only of pain but also of the decline in physical capacity.

Contrary to expectations, we found no significant difference in QOL between the two types of AMI. Another similar study23 also found no significant difference between the AMI types, corroborating our results. This study also observed a reduction in patient QOL for all domains, except for the general health domain, following in-hospital CVEs.23

Mollon and Bhattacharjee,31 in a case-control study, identified that individuals who suffered AMI had lower QOL in the domains of general, physical, and mental health compared to individuals without AMI. In the domains of sleep, emotional support, and life satisfaction, there were no differences between AMI survivors and the control group.31

When analyzing the relationship between QOL and in-hospital outcomes of our patients, we identified that functional capacity, physical, social, and vitality domains were associated with cardiovascular death. New episodes of AMI were related to the vitality and social domains, and CHF was associated with the emotional and vitality domains. Regarding pain, higher scores were reported by the patients with acute and chronic renal failure.

Furthermore, in the present study, the occurrence of sepsis was related to functional capacity, and angioplasty and myocardial revascularization (MR) were associated with the social domain. Contrary to our expectations mean scores for the physical and the mental health dimensions were not different when the in-hospital events were considered.

Therefore, the social domain was related to a higher risk of in-hospital events. In a similar study, which evaluated the quality of life after MR surgery, we observed that the domain social relationships had the second highest score.31 According to Souza et al.,32 social support can act as a protective factor, by relieving stress during crises and facilitating the recovery from the disease.32

A major scientific challenge is the improvement in the evaluation of mortality predictors as well as the establishment of appropriate treatment. However, it is common sense to combine the established RF and the factors known to interfere with patient’s QOL for the creation of educational programs. One of the relevant achievements of the present study was to identify the differences in the QOL scores according to in-hospital events. These findings can serve as a basis for new scientific projects. Moreover, they prove that psychosocial factors are involved in the development and recovery from the disease.

Some limitations should be considered when interpreting the results. The QOL questionnaire was administered retrospectively, and hence participants’ responses relied on their memories. Additionally, since this is a generic tool, it did not focus on characteristics of AMI, and did not include diet as a risk factor.

 Conclusion

In the present investigation, we observed that, compared with NSTEMI patients, a higher prevalence of smokers was observed among STEMI patients. The other RF evaluated were associated with both types of AMI equally.

We observed a negative perception in the domains of physical aspects and pain of QOL in STEMI and NSTEMI patients, with no difference in QOL between these two groups. Regarding the association of QOL with in-hospital CVEs, a significant association was found of physical and mental health with the occurrence of events.

 References 1. Huguenin FM, Pinheiro RS, Almeida RM, Infantos, AF. Caracterização dos padrões de variação dos cuidados de saúde a partir dos gastos com internações por infarto agudo do miocárdio no Sistema Único de Saúde. Rev. Bras. Epidemiol. 2016;19(2):229-42. Huguenin FM Pinheiro RS Almeida RM Infantos AF Caracterização dos padrões de variação dos cuidados de saúde a partir dos gastos com internações por infarto agudo do miocárdio no Sistema Único de Saúde Rev. Bras. Epidemiol 2016 19 2 229 242 2. Organização Pan-Americana de Saúde (OPAS). Doenças Cardiovasculares, 2017. [Cited in 2019 Ju 2]. Available from: https://www.paho.org/bra/ Organização Pan-Americana de Saúde (OPAS) Doenças Cardiovasculares 2017 Cited in 2019 Ju 2 https://www.paho.org/bra/ 3. Stevens B, Pezzullo L, Verdian L, Tomlinson J, George A, Bacal F. Os Custos das Doenças Cardíacas no Brasil. Arq Bras Cardiol. 2018;111(1):29-36. Stevens B Pezzullo L Verdian L Tomlinson J George A Bacal F Os Custos das Doenças Cardíacas no Brasil Arq Bras Cardiol 2018 111 1 29 36 4. Silva RB, Castro CM, Iser BP, Castilho LG. Perfil dos pacientes com síndromes coronarianas agudas em um hospital da Região Sul do Brasil. Rev Soc Bras Clin Med. 2016;14(1):33-7. Silva RB Castro CM Iser BP Castilho LG Perfil dos pacientes com síndromes coronarianas agudas em um hospital da Região Sul do Brasil Rev Soc Bras Clin Med 2016 14 1 33 37 5. World Health Organization (WHO). World report on ageing and health. Geneva; 2015. World Health Organization (WHO) World report on ageing and health Geneva 2015 6. Goswami DS, Manohar TP. Cardiometabolic Risk Factors in Acute Coronary Syndrome with Special Reference to Non-HDL Cholesterol. J. Assoc. Physicians India. 2016;64(10):30-6. Goswami DS Manohar TP Cardiometabolic Risk Factors in Acute Coronary Syndrome with Special Reference to Non-HDL Cholesterol J. Assoc. Physicians India 2016 64 10 30 36 7. Mannsverk J, Wilsgaard T, Mathiesen EB, Lochen ML, Rasmussen K, Thelle DS, et al. Trends in modifiable risk factors are associated with declining incidence of hospitalized and nonhospitalized acute coronary heart disease in a population. Circulation. 2016;5(133):74-81. Mannsverk J Wilsgaard T Mathiesen EB Lochen ML Rasmussen K Thelle DS et al Trends in modifiable risk factors are associated with declining incidence of hospitalized and nonhospitalized acute coronary heart disease in a population Circulation 2016 5 133 74 81 8. Cunha EF, Silva AM, Saad KR, Melo TA, Martinez BP, Carvalho VO, et al. Avaliação do estilo de vida de pacientes com infarto agudo do miocárdio admitidos em uma unidade coronariana. Rev Soc Bras Clin Med. 2016;14(1):18-21. Cunha EF Silva AM Saad KR Melo TA Martinez BP Carvalho VO et al Avaliação do estilo de vida de pacientes com infarto agudo do miocárdio admitidos em uma unidade coronariana Rev Soc Bras Clin Med 2016 14 1 18 21 9. Higginson IJ, Carr AJ. Using quality of life measures in the clinical setting. BMJ. 2001; 322 (7297):1297-300. Higginson IJ Carr AJ Using quality of life measures in the clinical setting BMJ 2001 322 7297 1297 1300 10. Dzubur A, Mekic M, Pesto S, Nabil N. Echocardiographic parameters as life quality predictors in patients after myocardial infarction treated with different methods. med arch. 2016;70(6):419-24. Dzubur A Mekic M Pesto S Nabil N Echocardiographic parameters as life quality predictors in patients after myocardial infarction treated with different methods med arch 2016 70 6 419 424 11. Costa IM, Silva DG, Barreto-Filho JA, Oliveira JL, Silva JR, Buraque MD, et al. Diet quality of patients with acute coronary syndrome receiving public and private health care. Nutrition. 2019 Mar;59:131-7. Costa IM Silva DG Barreto-Filho JA Oliveira JL Silva JR Buraque MD et al Diet quality of patients with acute coronary syndrome receiving public and private health care Nutrition 2019 03 59 131 137 12. IPAQ Research Committee. Guidelines for the data processing and analysis of the International Physical Activity Questionnaire. No. 2005. [Cited in 2019 Ju 2]. Available from: http://www.ipaq.ki.se/scoring.pdf. IPAQ Research Committee Guidelines for the data processing and analysis of the International Physical Activity Questionnaire 2005 Cited in 2019 Ju 2 http://www.ipaq.ki.se/scoring.pdf 13. Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira L, et al. Questionário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil. Rev Bras de Ativ Fís Saúde. 2001;6(2):5-12. Matsudo S Araújo T Matsudo V Andrade D Andrade E Oliveira L et al Questionário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil Rev Bras de Ativ Fís Saúde 2001 6 2 5 12 14. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário genérico de avaliação da qualidade de vida SF-36 (Brasil SF-36). Rev Bras Reumatol. 1999;39(3):143-50. Ciconelli RM Ferraz MB Santos W Meinão I Quaresma MR Tradução para a língua portuguesa e validação do questionário genérico de avaliação da qualidade de vida SF-36 (Brasil SF-36) Rev Bras Reumatol 1999 39 3 143 150 15. Ware JE, Sherbourne CD. The Mos 36-item short-form health survey (SF36). I. Conceptual frame work and item selection. Med Care. 1992;30(6):473-83. Ware JE Sherbourne CD The Mos 36-item short-form health survey (SF36). I. Conceptual frame work and item selection Med Care 1992 30 6 473 483 16. World Health Organization.(WHO) Obesity: preventing and managing the global epidemic. Report of a WHO consultation on obesity. Geneva; 1998. World Health Organization.(WHO) Obesity: preventing and managing the global epidemic Report of a WHO consultation on obesity Geneva 1998 17. World Health Organization. Physical status: the use and interpretation of anthropometry. Geneva; 1995. World Health Organization Physical status: the use and interpretation of anthropometry Geneva 1995 18. Lipschitz DA. Screening for nutritional status in the elderly. Primary Care. 1994;21(1):55-67. Lipschitz DA Screening for nutritional status in the elderly Primary Care 1994 21 1 55 67 19. Wang R, Neuenschwander FC, Filho AL, Moreira CM, dos Santos ES, et al. Uso de Intervenções Baseadas em Evidências na Síndrome Coronária Aguda − Subanálise do Registro ACCEPT. Arq Bras Cardiol. 2014;102(4):319-326. Wang R Neuenschwander FC Filho AL Moreira CM Santos ES et al Uso de Intervenções Baseadas em Evidências na Síndrome Coronária Aguda − Subanálise do Registro ACCEPT Arq Bras Cardiol 2014 102 4 319 326 20. Krzysztofik MJ, Sokolski M, Kosowski M, Zimoch W, Lis A, Klepuszewski et al. Acute heart failure in patients admitted to the emergency department with acute myocardial infarction. Kardiologia Polska. 2017;75(4):306–15. Krzysztofik MJ Sokolski M Kosowski M Zimoch W Lis A Klepuszewski et al Acute heart failure in patients admitted to the emergency department with acute myocardial infarction Kardiologia Polska 2017 75 4 306 315 21. Ağaç MT, Ağaç S, Korkmaz L, Erkan H, Turan T, Bektaş H et al. A simple angiographic index to predict adverse clinical outcome associated with acute myocardial infarction. Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol. 2014; 42(4):321-9. Ağaç MT Ağaç S Korkmaz L Erkan H Turan T Bektaş H et al A simple angiographic index to predict adverse clinical outcome associated with acute myocardial infarction Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2014 42 4 321 329 22. Marino BC, Marcolino MS, Júnior RS, França AL, Passos PF, Lemos TR, et al. Perfil epidemiológico e indicadores de qualidade em pacientes com síndrome coronariana aguda na região norte de minas gerais – Projeto Minas Telecardio 2. Arq Bras Cardiol. 2016;107(2):106-15. Marino BC Marcolino MS Júnior RS França AL Passos PF Lemos TR et al Perfil epidemiológico e indicadores de qualidade em pacientes com síndrome coronariana aguda na região norte de minas gerais – Projeto Minas Telecardio 2 Arq Bras Cardiol 2016 107 2 106 115 23. Mahesh PK, Gunathunga MW, Jayasinghe S, Arnold SM, Haniffa R, Silva AP. Pre-event quality of life and its influence on the post-event quality of life among patients with ST elevation and non-ST elevation myocardial infarctions of a premier province of Sri Lanka. Health and Quality of Life Outcomes. 2017;15(54):1-10. Mahesh PK Gunathunga MW Jayasinghe S Arnold SM Haniffa R Silva AP Pre-event quality of life and its influence on the post-event quality of life among patients with ST elevation and non-ST elevation myocardial infarctions of a premier province of Sri Lanka Health and Quality of Life Outcomes 2017 15 54 1 10 24. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J. 2012; 33(20):2569–619. Steg PG James SK Atar D Badano LP Blömstrom-Lundqvist C Borger MA et al Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC) Eur Heart J 2012 33 20 2569 2619 25. Pinto MT, Pichon-Riviere A, Bardach A. Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos. Cad. Saúde Pública. 2015;31(6):1283-97. Pinto MT Pichon-Riviere A Bardach A Estimativa da carga do tabagismo no Brasil: mortalidade, morbidade e custos Cad. Saúde Pública 2015 31 6 1283 1297 26. Simão AF, Précoma DB, Andrade JP, Correa FH, Saraiva JF, Oliveira GM, et al. Sociedade Brasileira de Cardiologia. I Diretriz Brasileira de Prevenção Cardiovascular. Arq Bras Cardiol. 2013;101(2):1-63. Simão AF Précoma DB Andrade JP Correa FH Saraiva JF Oliveira GM et al Sociedade Brasileira de Cardiologia. I Diretriz Brasileira de Prevenção Cardiovascular Arq Bras Cardiol 2013 101 2 1 63 27. Santos JR, Reis SC, Reis MC, Soares AB, Jucá AL. Qualidade de vida de pacientes hospitalizados com doenças cardiovasculares: possibilidades de intervenção da terapia ocupacional. Rev Interinst Bras Ter Ocup. 2017;1(5):620-33. Santos JR Reis SC Reis MC Soares AB Jucá AL Qualidade de vida de pacientes hospitalizados com doenças cardiovasculares: possibilidades de intervenção da terapia ocupacional Rev Interinst Bras Ter Ocup 2017 1 5 620 633 28. Dessotte CA, Dantas RA, Schmidt A, Rossi LA. Qualidade de vida relacionada à saúde de sujeitos internados, decorrentes da primeira síndrome coronariana aguda. Rev. Latino-am. Enfermagem. 2011; 19(5):2-8. Dessotte CA Dantas RA Schmidt A Rossi LA Qualidade de vida relacionada à saúde de sujeitos internados, decorrentes da primeira síndrome coronariana aguda Rev. Latino-am. Enfermagem 2011 19 5 2 8 29. The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL): Position paper from the World Health Organization. Soc. Sci. Med. Oxford. 1995; 41(10):1403-9. The WHOQOL Group The World Health Organization Quality of Life Assessment (WHOQOL): Position paper from the World Health Organization Soc. Sci. Med. Oxford 1995 41 10 1403 1409 30. Mollon L, Bhattacharjee S. Health related quality of life among myocardial infarction survivors in the United States: a propensity score matched Analysis. Health and Quality of Life Outcomes. 2017; 15(235):1-10. Mollon L Bhattacharjee S Health related quality of life among myocardial infarction survivors in the United States: a propensity score matched Analysis Health and Quality of Life Outcomes 2017 15 235 1 10 31. Araújo HV, Figueiredo TR, Costa CR, Silveira MM, Belo RM, Bezerra SM. Quality of life of patients who undergone myocardial revascularization surgery. Rev Bras Enferm. 2017;70(2):257-64. Araújo HV Figueiredo TR Costa CR Silveira MM Belo RM Bezerra SM Quality of life of patients who undergone myocardial revascularization surgery Rev Bras Enferm 2017 70 2 257 264 32. Souza AR, Albuquerque LF, Silva FA, Machado RC. Fatores associados a um impacto na qualidade de vida pós revascularização miocárdica. Rev Rene. 2018; 19(3459):1-10. Souza AR Albuquerque LF Silva FA Machado RC Fatores associados a um impacto na qualidade de vida pós revascularização miocárdica Rev Rene 2018 19 3459 1 10

Study Association

This article is part of the thesis of master submitted by Monique Tavares de Jesus, from Universidade Federal de Sergipe.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Universidade de Sergipe under the protocol number 302.544. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

Sources of Funding: There were no external funding sources for this study.