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Table of Contents
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 117-122

Quality of life after myocardial infarction in women from rural India

1 Department of Medicine, JNMC, Wardha, Maharashtra, India
2 Department of Medicine, JNMC, AVBRH, Wardha, Maharashtra, India

Date of Submission14-Apr-2019
Date of Decision28-May-2019
Date of Acceptance09-Jul-2019
Date of Web Publication19-Dec-2019

Correspondence Address:
Anjalee Anil Chiwhane
JNMC, DMIMS, Wardha (Sawangi), Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCFM.IJCFM_33_19

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Introduction: Health expenditures in survivors of myocardial infarction (MI) causes increased financial burden. Secondary prevention strategy can be planned with knowledge of health-related quality of life (HRQoL) in survivors of MI.
Aim: To study HRQOL using Mac New Heart questionnaire.
Objective: Female survivors of MI will undergo the questionnaire and the scores across physical, social and emotional domains will be noted.
Material and Methods: Observational study. Female survivors of MI attending follow up in cardiac outpatient department between January 2017 and January 2018 were subjected to MacNew Heart Disease HRQoL questionnaire.
Statistical Analysis Used: Pearson's correlation coefficient; software used was SPSS 22.0 version.
Results: Mean age 60 years; mean duration since MI – 7.88 months; 74% were married and 88% on vegetarian diet. Those women with mean age of 40 years, vegetarian and married had better mean scores. The emotional score improved over a period of time whereas the physical and social score remained the same.
Conclusion: Female survivors above 40 years showed poor scores across all three domains and therefore need early cardiac rehabilitation as also long-term follow up.

Keywords: Female survivors, health-related quality of life, myocardial infarction

How to cite this article:
Gupta Y, Chiwhane AA. Quality of life after myocardial infarction in women from rural India. Indian J Community Fam Med 2019;5:117-22

How to cite this URL:
Gupta Y, Chiwhane AA. Quality of life after myocardial infarction in women from rural India. Indian J Community Fam Med [serial online] 2019 [cited 2021 Sep 18];5:117-22. Available from: https://www.ijcfm.org/text.asp?2019/5/2/117/273520

  Introduction Top

Coronary artery disease is on the rise and in India, mortality varies from <10% in rural locations in less developed states to >35% in more developed urban locations.[1],[2] In 2015, there were an estimated 422.7 million cases of cardiovascular disease (CVD) (95% uncertainty interval: 415.53–427.87 million cases) and 17.92 million CVD deaths (95% uncertainty interval: 17.59–18.28 million CVD deaths).[2] In 2020, it is estimated that this disease will be responsible for a total of 11.1 million deaths globally.[3]

In India, more than 10.5 million deaths occur annually, and it was reported that CVD led to 20.3% of these deaths in men and 16.9% of all deaths in women.[1] The mortality varies from <10% in rural locations in less developed states to >35% in more developed urban locations.[2]

Heart disease affects women approximately 10 years later than men, possibly due to the protective effect of estrogen. A woman's risk of a heart disease increases steeply after menopause, when her low-density lipoprotein-cholesterol and triglyceride levels begin to increase and her good cholesterol level begins to fall. After menopause, women's cholesterol levels are, on average, higher than those of men of about the same age.[4]

Sex differences occur in the pathophysiology and clinical presentation of MI and affect treatment delays.[5] The prevalence and risk factors in Asian women with CAD is different from that of Western population as hyperlipidemia is major risk factor in Indian women.[6] The prevalence of CAD is more in the illiterate and the low-income group believed to be due to lack of access and affordability for acute care management and secondary prevention.[7] The Indian population of patients with MI show variance from conventional risk factors like association of chronic infection in addition to dyslipidemia, obesity, and hypertension.[8] MI survivors experienced lower health-related quality of life (HRQoL) on domains of general health, physical health, daily activity, and mental health compared to the general population.[9] After acute MI, there is limitation in physical activity and need for early cardiac rehabilitation.[10]

Percutaneous transluminal coronary angioplasty (PTCA) is the treatment in myocardial infarction (MI), and in one study it was observed that undergoing revascularization improved the physical component of the HRQoL. Undergoing revascularization improved the physical summary component (PCS) in patients, but in the younger patients and those without personal antecedents or risk factors, the PCS was affected more, perhaps due to greater expectations for recovery in these patients.[11]

The need of long-term follow-up and cardiac rehabilitation improved HRQoL in patients with MI.[12]

A detailed search on “HRQOL in female survivors of MI in India,” from Google Scholar, Pub med, Springer and Research gate yielded negative results. This study was conducted keeping in mind trend changes in different population- and gender-specific presentation of MI and its effect on quality of life especially in the low middle-income group population. CVD-affected households with lower socioeconomic status were at heightened financial risk.[13]


To study HRQOL using Mac New Heart questionnaire.


Female survivors of MI will undergo the questionnaire and the scoring across physical, social and emotional domains.

  Material and Methods Top

  • Type of study: Observational
  • Study population: Female patients diagnosed with MI who underwent PTCA and attended follow-up in cardiac outpatient department between January 2017 and January 2018. Out of 55 study subjects, 2 refused consent and 3 were admitted for complications of MI
  • Study setting: Tertiary care rural hospital from central India
  • Sample size: 50
  • Selection criteria: Adult female patients diagnosed with MI having undergone angioplasty. Females with co-morbidities like chronic kidney disease, chronic obstructive pulmonary disorder, hepatic or cardiac failure, malignancy, HIV and other life-threatening illnesses or critically ill were excluded
  • Data collection procedures and instrument/tools: These patients were subjected to a detailed Mac New heart QOL questionnaire after prior consent. A validated Mac new heart quality of life indicators questionnaire has been used in this study. The original QLMI (Quality of Life after MI) items were generated through interviews with physicians, nurses, allied health professionals, patients with MI, and by reviewing the literature.[14] The Mac New Heart Disease HRQOL questionnaire (Mac-New) is a self-administered modification of the original QLMI instrument.[15],[16] The Mac New consists of 27 items which fall into three domains (a 13-item physical limitations domain scale, a 14-item emotional function domain scale, and a 13-item social function domain scale). There are 5 items that inquire about symptoms: angina/chest pain, shortness of breath, fatigue, dizziness, and aching legs. The Mac New has been successfully administered, to our knowledge, in at least 12 clinical and/or experimental studies to more than 5200 patients with heart diseases including “Lim LL-Y, Johnson NA, O'Connell RL, Heller RF: Quality of life and later adverse health outcomes in patients with suspected heart attack. Aust NZ J Pub Health 1998,” “Foster C, Oldridge NB, Dion W, Forsyth G, Grevenow P, Hansen MA, Laughlin J, Plitcha C, Rabas S, Sharkey RE, Schmidt DH: Time course of recovery during cardiac rehabilitation. J CardiopulmonRehabil 1995.” This questionnaire was not self-administered in this study but was translated by the interviewer as one on one interview. Researcher who conducted this interview made them understand the questions before documenting the scores. Questions pertaining to sexual life were not included
  • Ethical considerations: Local Institutional Ethics Committee gave approval.

  Results Top

[Table 1] shows baseline characteristics of the subjects.
Table 1: Baseline characteristics of the subjects

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[Graph 1] shows linear correlation of scores with each other which means that there is interdependence of scores with each other.

The mean age of the patients was 60 years. Hypertension was the most common comorbidity. Seventy-four percent of patients were married. More number of patients had only primary education. The average family income was between Rs. 5000 and Rs. 10,000.

Pearson's coefficient is applied to see for the linear relationship between the variables. There is a linear positive correlation between emotional, physical and social score, [Table 2].
Table 2: Correlation between Mac New Heart Quality of Life after Myocardial Infarction score Pearson's correlation coefficient

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The f-test was applied to more than 2 category variables and it was observed, a positive correlation of the score with age. It was observed that there was a positive correlation of women below 40 years of age and married with emotional score (P < 0.05), [Table 3].
Table 3: Association of demographic variables with emotional score

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There was a positive correlation of physical score in women below 40 years, vegetarian and married (P < 0.05) [Table 4].
Table 4: Association of demographic variables with physical score

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There was a positive correlation of social score in women below 40 years of age, vegetarian and married (P < 0.05). [Table 5].
Table 5: Association of demographic variables with social score

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Sample size n = 50.

The sample size (n) is calculated according to the formula: n = z2 × p × (1-p)/e2. Where: z = 1.96 for a confidence level (α) of 95%.

P = prevalence of CAD 4%–6% in rural populations.[17]

n = 1.962 × 0.04× (1–0.04)/0.062.

n = 40.97 ≈ 50 patients needed in the study.

Statistical analysis was done by using descriptive and inferential statistics using Pearson's correlation coefficient and software used in the analysis was SPSS 22.0 version developed by IBM Corporation, New York and P < 0.05 is considered as level of significance.

  Discussion Top

Coronary artery disease prevalence in rural population in India is between 4% and 6%. This population is low middle-income group with average monthly income between Rs. 5000 and 10,000. Survivors of MI can burden the household income which may affect prognosis of this disease. This study evaluated factors affecting the quality of life in female survivors of MI. Irrespective of duration since MI, these patients were studied for HRQoL. Many studies followed the patients for more than 1 year. Female survivors of MI from rural population have very poor mean scores as observed in this study. Females younger than 40 years, married and on a vegetarian diet had better scores in all three domains. There were studies on HRQoL in female survivors of MI. Interestingly in a study by “Vladan Peric et al.” it was observed that the predictors of improvement of QOL after 2 years of coronary artery bypass graft (CABG) were serious angina, absence of hereditary load, male sex, and absence of diabetes.[18] Many studies compare between PTCA and CAD and observed that CABG had better QOL.[19] Few studies have tested the validity of Mac New Heart in all regions of world and in different languages and found it to be a useful tool. In this study, women with low middle-income group had very low mean scores in all the three domains but there was no positive correlation of family income with the scores. There was a positive correlation of one domain with the other and similar factors affecting all three domains which is a new finding in this study. Other studies have observed that all three scores improved with time. In other study across the globe, hypertension, dyslipidemia and smoking affected the scores whereas in this study older women, widowed, unmarried or separated, on mixed or nonvegetarian diet had poor scores. Contrary to observations by other studies, the presence of co-morbidities, low income or education did not affect the scores.

The HRQOL helps to make policy on cardiac rehabilitation, psychological counseling and support as well as creating awareness in those with poor scores. Strategy planning in secondary prevention as well as conscious use of health-care resources can avoid escalation of healthcare expenditures and unnecessary use of valuable healthcare services in the background of limited resources in a rural population. There is need for increased awareness, healthcare providers, policymaking on sex-specific presentation in MI. Offer effective psychological treatment, tailored secondary prevention, evaluate psychosocial risk factors (widowed, financial restraints, lack of family support) as part of early cardiac rehabilitation especially in women above 40 years.


This is a single-center study. However, the findings are still relevant to a national setting. This study is an cross-sectional design with subjects studied at each time point hence cannot reflect the changing QOL with increasing duration since MI. Combining variables for analysis and consideration of multiple other comorbidities, was inappropriate considering this small sample size.

  Conclusion Top

Limited factors affected the HRQOL in female survivors which can help in planning cardiac rehabilitation and secondary prevention in a subset of patients without the need to generalize the same in view of economizing health-care costs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women-2011 update: A guideline from the American Heart Association. J Am Coll Cardiol 2011;57:1404-23.  Back to cited text no. 4
Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, et al. Acute myocardial infarction in women: A scientific statement from the American Heart Association. Circulation 2016;133:916-47.  Back to cited text no. 5
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Gupta R, Gupta KD. Coronary heart disease in low socioeconomic status subjects in India: “An evolving epidemic”. Indian Heart J 2009;61:358-67.  Back to cited text no. 7
Zodpey SP, Shrikhande SN, Negandhi HN, Ughade SN, Joshi PP. Risk factors for acute myocardial infarction in central India: A case-control study. Indian J Community Med 2015;40:19-26.  Back to cited text no. 8
[PUBMED]  [Full text]  
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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