DOI: 10.

590/1809-2950/13828222022015

ORIGINAL RESEARCH 148

Correlation between sleep and quality of life in
patients with heart failure
Correlação entre sono e qualidade de vida em pacientes com insuficiência cardíaca
Correlación entre sueño y calidad de vida en los pacientes con insuficiencia cardíaca
Ingrid Guerra Azevedo1, Elamara Marama de Araújo Vieira1, Nestor Rodrigues de Oliveira Neto2, Ivan
Daniel Bezerra Nogueira3, Flávio Emanoel Souza de Melo4, Patrícia Angélica de Miranda Silva Nogueira3

ABSTRACT | Heart failure (HF) is a serious and growing indivíduos incluídos no estudo, 23 pacientes o concluíram
public health problem on the world. Among its many (13 H), com idade média de 60,5 anos, classe funcional (CF)
features there are low quality of life (QOL) and excessive II e III, com fração de ejeção ≤ 45%. Aplicou-se o 36-item
daytime sleepiness (EDS) due to sleep disorders which Short-Form Health Survey (SF-36) para QV, Questionário
impairs its quality. It was identified the EDS and sleep de Pittsburgh para QS, e Escala de Sonolência de Epworth
quality in patients with HF and their SDE was c­ orrelated to para SDE. Ao final, 60,86% da amostra apresentaram QS
their QOL. Among the 52 subjects of the study, 23 patients ruim. Ao correlacionar-se QV com o grau de SDE, obtiveram-
completed the study (13 M), with average age of 60.5 years, se resultados significativos para dor (p=0,04 e r=-0,43),
functional class (FC) II and III, ejection fraction ≤ 45%. vitalidade - VT (p=0,05 e r=-0,40) e aspectos sociais -AS
Subjects were evaluated for their quality of sleep, EDS and (p=0,003 e r=-0,59). A amostra estudada apresenta QS ruim,
QOL. Questionnaires were applied in the form of interview com SDE estando presente e se correlacionando de forma
by using the SF-36 for QOL, Pittsburgh Sleep Quality Index negativa com QV em seus aspectos de dor, VT e AS.
Questionnaire for quality of sleep and Epworth Sleepiness Descritores | Insuficiência Cardíaca; Qualidade de Vida;
Scale for SDE. A total of 60.86% of the sample showed poor Distúrbios do Sono por Sonolência Excessiva.
sleep quality. Correlating QOL to EDS, significant results
were obtained in the pain (p=0.04 and r=-43), vitality RESUMEN | La insuficiencia cardíaca (IC) es un problema
(p=0.05 and r=-0.40) and social functioning (p=0.003 and mundialmente grave y creciente en la salud pública. La
r=-0.59). The sample has a poor sleep quality, with presence mala calidad de vida (QV) y la somnolencia excesiva
of SDE negatively correlated with QOL in aspects of vitality, (SDE), debida a los trastornos del sueño, son las
pain and social functioning. principales características que perjudican su calidad. Se
Keywords | Heart Failure; Quality of Life; Sleep Disorders identificó la SDE y la calidad del sueño (QS) en pacientes
by Excessive Somnolence con IC y se los correlacionó con estos pacientes. De
los 52 sujetos participantes, concluyeron el estudio 23
RESUMO | A insuficiência cardíaca (IC) é um problema grave pacientes (13 H), con un promedio de edad de 60,5 años,
e crescente de saúde pública no cenário mundial. Dentre suas la clase funcional (CF) II y III y fracción de eyección del
várias características, estão a baixa qualidade de vida (QV) e ≤ 45%. Se aplicó 36-item Short-Form Health Survey (SF-
sonolência diurna excessiva (SDE) em virtude dos distúrbios 36) a la QV, el cuestionario de Pittsburgh para la QS y
do sono, que prejudicam sua qualidade. Identificou-se a la Escala de Somnolencia de Epworth para la SDE. Los
SDE e a qualidade do sono (QS) em pacientes com IC e, resultados mostraron que en el 60,86% de la muestra
correlacionou-se a SDE à QV desses pacientes. Dos 52 no se obtuvo una buena QS y al correlacionarse la QV

A study developed at Onofre Lopes University Hospital, of Universidade Federal do Rio Grande do Norte (UFRN) – Natal (RN), Brazil.
1
Resident in the Multi-Professional Residency Program in Adult Intensive Therapy at the Federal University of Rio Grande do Norte –
Natal (RN), Brazil.
2
Cardiologist at Onofre Lopes University Hospital – Natal (RN), Brazil.
3
Physical therapist, professor at Universidade Federal do Rio Grande do Norte (UFRN) – Natal (RN), Brazil.
4
Physical therapist, master’s degree student in Physical Therapy at the Federal University of Rio Grande do Norte – Natal (RN), Brazil.

Mailing address: Patrícia Nogueira – Av. Senador Salgado Filho, 3000 – Lagoa Nova – CEP: 59072-970 – Caixa Postal 1524 – Natal (RN), Brazil. E-mail: idpa02@ufrnet.br. This
study was presented at the XVII International Symposium on Respiratory Physical Therapy and ICU Physical Therapy.
Presentation: Jul. 2014 – Accepted for publication: Mar. 2015 – This study was approved by the Ethics Committee, protocol no. 0147.0.061.000-11.

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 Azevedo et al. Sleep and quality of life in heart failure

con el grado SDE los resultados fueron significativos al dolor la SDE correlacionándola negativamente con la QV en los
(p=0,04 y r=-0,43), a la vitalidad - VT (p=0,05 y r=-0,40) y a aspectos dolor, VT y AS.
los aspectos sociales - AS (p=0,003 y r=-0,59). En la muestra Palabras clave | Insuficiencia Cardíaca; Calidad de Vida; Trastornos
estudiada se mostró una mala QS, además estaba presente del Sueño por Somnolencia Excesiva.

INTRODUCTION interest in measuring the factors which affect the QoL

in those patients, in an attempt to obtain data which
Heart failure (HF) is a serious health care problem result in better clinical interventions.
worldwide, with large impacts in morbidity and m ­ ortality We have hypothesized the presence of EDS and bad
and significant financial expenditure. It is characterized QoS in evaluated patients, and a possible correlation
for having a bad prognosis1. In Brazil, 6.4 million between EDS and QoL. This study aimed to identify
individuals are estimated to have HF2, with 450 thousand QoS and EDS in patients with HF, and to correlate
other new cases a year3. It is a complex syvndrome whose their EDS to their QoL.
patients’ functional abilities (FA) progressively decline,
with consequent exercise intolerance4.
The symptoms regarding exercise intolerance are METHODOLOGY
frequent in HF5 and they are related to changes in the
respiratory function6. Not only do those alterations result Subjects
in functional limitations and higher breathing effort
due to hyperpnea that exists during the performance Based on the study by Casida et al.17, which showed
of exercises7, but also in hindered quality of life (QoL)8. the linear correlation coefficient between EDS and QoL
Besides the decline in QoL, recent studies have is r=0.6, the established sample size was 20 subjects,
shown the high prevalence of sleep disorders in HF, considering an alpha level of 0.05 and a test power of 0.80.
which are taken as indicators for heart failure severity The calculation was conducted by Bio Estat 5.3 software.
in certain European patients. Apneas and repeated 52 patients with HF were recruited, who were
awakening fragment sleep, worsening the fatigue and being supervised by a multidisciplinary team in the
causing excessive daytime sleepiness (EDS)10. cardiology ward of a high-complexity hospital in Natal
EDS is defined as trouble keeping a desired (RN). However, only 23 finished the study (Figure 1).
wakefulness level, with a feeling of sleepiness at improper 29 patients could not make it to the end as they had
times11. EDS in adults is not yet perfectly understood. trouble commuting to the evaluation site, had difficulty
In the general population, EDS is found 8%10 and 20% understanding the questionnaires, or could not arrange
of studied subjects12, and it interferes in professional their family commitments in a way that enabled them to
and family activities and in social relationships13,14. come to the ward where the research would take place.
Subjects with impaired sleep were shown to be Patients were considered to be eligible if they had
incapable of quickly responding to external stimuli and been diagnosed with HF, were between 18 and 90 years
to have more trouble concentrating, due to limitations old, fell into NYHA classes II and III (New York Heart
in sleep quality or quantity, which damages their ability Association - NYHA), either had pacemakers or not,
to perform certain activities14. Thus, screening work on had the consent from the cardiologists supervising
sleep alterations must be a constant practice among them, were found to be stable in regards to procedures
professionals dealing with HF15. EDS prevalence in and medications, had no cognitive deficits or any other
adults with HF is still under investigation, and the comorbidities which could interfere n the evaluations.
factors EDS correlates with are still unknown16. Patients who could give up the study during the
Therefore, evaluating quality of sleep (QoS) and execution of tests and the ones who did not understand
EDS is observed to be required, in order to better guide the orders were excluded from the test.
therapeutic procedures and identify patients at risk. All patients signed consent forms before their
Due to the absence of a cure to HF, there is increasing evaluations. This research was conducted according to

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Excluded subjects n=29

Subjects selected to – Personal reasons;
Allocation

the study n=52 – Impossibility to commute to the evaluation site;

– Impossibility to understand questionaires;
– Family commitments preventing participation.

Subjects included in
the evaluation n=23
Evaluation

Subjects whose data

were analysed after
the evaluation n=23

Figure 1. Flowchart of the study

Resolution 196/96 of Brazil’s National Health Council et al.,18) was applied in order to assess QoS. It contained
(Conselho Nacional de Saúde - CNS), and it was approved ten open and semi-open questions, which make up
by the Research Ethics Committee of the institution, seven components: 1) subjective sleep quality; 2) sleep
under protocol no. 481/2011. latency; 3) sleep duration; 4) habitual sleep efficiency;
5) sleep disturbances; 6) use of sleeping medication; 7)
daytime sleepiness and dysfunctions. Each parameter
STUDY DYNAMICS has specific scores, and the total score is 21 points.
Scores over five indicated bad QoS18.
In this cross-sectional, exploratory and descriptive
study, selected patients, after being medically consented Excessive daytime sleepiness
to, were submitted to clinical evaluation, and were
asked about their life habits (general health perceptions, Epworth Sleepiness Scale (ESS) was used to evaluate
practice of physical exercises, and use of medications). EDS, in a version that had been translated and validated
The ejection fraction values in the echocardiograms they into the Portuguese language by Bertolazzi et al.19. It
brought on the evaluation day, which had been performed comprised key questions regarding eight everyday activities,
by their responsible cardiologists, were written down. which are used to analyze how sleep affects everyday life.
An anthropometric assessment was conducted in order Questions relate to everyday life habits. Even if patients
to characterize the sample. Subjects’ body weights and have not performed any of the items recently, they are
heights were measured in a WELMY® scale, model stimulated to try and find how they would affect them, and
R-100 (WELMY, Santa Bárbara d’Oeste, Brazil), and each situation is assigned the most proper scores, which
their body mass indices (BMI) were calculated. are the following: 0=no chance of dozing; 1=slight chance
Once they met the inclusion criteria, subjects were of dozing; 2=moderate chance of dozing; 3=high chance
analyzed for QoS, EDS, and QoL. Questionnaires were of dozing. The global score ranges from 0 to 24, and scores
applied as interviews by the same researcher, in order above 10 suggest EDS diagnoses19.
that illiterate patients be included.
Quality of life
Quality of sleep
36-item Short-Form Health Survey (SF-36) quality
Pittsburgh Sleep Quality Index (a version that had of life questionnaire was used to evaluate Quality of
been translated and validated to Portuguese by Bertolazi life - in a version that had been translated and validated

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 Azevedo et al. Sleep and quality of life in heart failure

into the Portuguese language by Ciconelli20. It comprises 62.5 (±20.6) for SRF; 50 (±39.2) for limitations due to
36 items which are subdivided in 8 dimensions: ERF, and 72 (±23.7) for MH.
physical role functioning (PRF); physical functioning
Table 1. General characteristics of the studied population
(PP); bodily pain; general health perceptions (GHP);
Age (years) 60,57±16,88
vitality (VT); social role functioning (SRF); emotional
Gender
role functioning (ERF); and mental health (MH). Each Feminine 10 (43.5%)52.1%
dimension generates a score which can range from 0 to Masculine 13 (56.5%)47.9%
100, zero corresponding to maximum disability and 100 Weight (kg) 1.61±0.09
to no disability20.
Height (m) -

BMI (Kg/m²) 25.19±3.63

STATISTICAL ANALYSIS
Functional class
(NYHA)
The data were analyzed with SPSS 17.0 software II 15 (65.2%)
(SPSS Inc., Chicago, IL, USA). The descriptive analysis III 8 (34.8%)
was presented as average and standard deviation (SD). HF Etiology
Pearson product-moment correlation coefficient was Idiopathic 14 (60.8%)
Ischemic 4 (17.4%)
used to check for the association between EDS and QoL, Valvular 3 (13%)
between age and QoS, and between age and QoL, once Hypertensive 2 (8.8%)
Kolmogorov-Smirnov test showed data were normally
LVEF (%) 29.18±7.38
distributed. Correlation was classified as perfect (r=1),
strong (1>r>0.75), moderate (0.75>r>0.5), weak (0.5>r>0), BMI - Body Mass Index; NYHA - New York Heart Association; LVEF - left ventricular ejection
fraction (echocardiogram). The values were shown as average and standard deviation (for
and inexistent (r=0). The significance level was 5%. gender, weight, height, BMI, and LVEF), with absolute and percentage values (for NYHA classes
and HF etiology)

RESULTS When QoL was correlated to EDS degrees

through SF-36, significant results were obtained in
The clinical and anthropometric characteristics of domains regarding bodily pain (p=0.04 and r=-0.43),
the sample can be found in Table 1. A large part of the VT (p=0.05 and r=-0.40) , and SRF (p=0.003 and
sample in this study was found to make use of diuretic r=-0.59)(Table 2).
drugs (100% - 23 subjects). 84.5% (20) of subjects made
Table 2. Correlation (r) obtained each domain of SF-36 quality of
use of beta blockers; 38.5% (9) made use of antiaggregant life questionnaire and excessive daytime sleepiness (Epworth), in
drugs; 30.8% (7) made use of lipid-lowering drugs, and 23 diagnosed with heart failure
15.4% (4) made use of antiarrhythmic agents. Around SF-36 r
69.6% (16) subjects used pacemakers. In regards to the PRF -0.37
practice of physical activity, 82.6% of patients (19) went BODILY -0.43*
walking for an average duration of 40, from 3 to 4 days PAIN
in the week. GHP 0.41
When evaluated for QoS, 60.9% (14) of the VT -0.40*
sample was found to have bad QoS, with Pittsburgh SRF -0.59
Sleep Quality Index scores >5, the average being 7 ERF -0.38
(±4.7). When evaluated for EDS, 39.1% (9) of the
MH -0.31
sample was found to have scores indicating EDS
(scores>10), and 52% (12) of the sample was found PRF – physical role functioning; PP – physical functioning; GHP –general health perceptions; VT
- vitality; SRF –social role functioning; ERF – emotional role functioning; MH –mental health.
to have ESS>8. The average ESS values in the studied *p≤0.05 for statistic significance

sample was 8 (±5.1).

In regards to QoL, SF-36 showed averages of 60 Correlation was tested between age and QoS, and
(±25.6) for PRF; 5 (±38.5) for CA; 62 (±29.8) for it has not yielded a significant result (p=0.417 and
bodily pain; 60 (±27.9) for GHP; 65 (±22.7) for VT; r=0.178). Besides that, the correlation between age and

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SF-36 questionnaire domains regarding QoL was also The results found through SF-36 in this sample
tested, but no significant correlations were obtained for yielded higher scores in 6 domains (PRF, Bodily pain,
all studied domains: Bodily pain: r=0,012 and p=0,957; GHP, VT, SRF, and MH), as compared to the ones
LF: r=0.192 and p=0.380; PRF: r=0.178 and p=0.417; from Bröstrom25, who studied 223 patients with HF, of
GHP: r=0.165 and p=0.452; VT: r=0.330 and p=0.124; NYHA classes II-IV, whose average age was 76.5 years
SRF: r=0.379 and p=0.075; ERF: r=0.105 and p=0.634, (higher than the average age in this sample). The QoL
and MH: r=0.200 and p=0361. in the studied sample is found to be better than the one
from Bröstrom25 study, and it can be explained through
the difference in ages between both studies (76.5 years
DISCUSSION versus 60.5 years), once QoL decreases as age increases26.
However, in this study, the correlation between age and
Recent studies have shown that screening work on QoL domains was not found to be significant, which
sleep alterations must be a constant practice among shows sample homogeneity despite the age variation.
professionals dealing with HF9. In this sample, 60.9% EDS interferes in professional activities and social
(14) of patients were found to have bad QoS. In the relationships, reduces cognitive performance, and
study by Santos et al.21, who evaluated 400 subjects increases the risk of accidents13,14. When QoL was
with HF (NYHA Classes I-IV), 68.5% (263) of the correlated with EDS degrees through SF-36, significant
patients were also found to be “bad sleepers” (score ≥5 results were found in regards to bodily pain, VT, and
in the Pittsburgh Sleep Quality Index). In our sample, SRF domains, showing that the worse EDS is, the
subjects were only classified as “bad sleepers” when worse its aspects will be.
they had scores above 518, which can justify the small In the study by Casida et al.17, QoL was evaluated
classification difference as compared to the study by through a specific questionnaire, the Minnesota Living
Santos21. The average slept hours were the same in both with Heart Failure Questionnaire (MLHFQ). Variables
studies (6 hours). regarding “day dysfunction due to sleepiness” (present
Another study included 101 patients (average age= 74 in Pittsburgh Sleep Quality Index) were related to
years; NYHA class II=63.4% of patients), of whom 81.2% physical (r=0.71, p=0.02) and emotional domains
(82) were classified as “bad sleepers”22. This evaluated (r=0.74, p=0.02) of QoL through the MLHFQ, as well
sample comprised patients with average age above the one as the global QoL measure (r=0.66, p=0.04). There were
in this study (60.5 years), which might explain the observed also significant correlations between global daytime
difference, as general population studies show that sleep sleepiness and physical (r=0.66, p=0.05), emotional
disorders get more frequent as the age increases23. (r=0.84, p=0.01) and global domains (r=0.82, p<0.01)
In this study, 52% (12) of the sample was found to of MLHFQ. Their findings were similar to ours, once
have ESS>8. In the study by Ferrier et al.24, 47% (25) of we have found, when QoL was correlated to EDS
patients were found to have ESS>8, and their sample degrees through SF-36, p=0.04 and r=-0.43 for bodily
comprised 75% (40) of patients of NYHA classes I and pain domain, p=0.05 and r=-0.40 for VT, and p=0.003
II. The fact that our sample found a higher number of and r=-0.59 for SRF domain. Such domains are directly
patients with ESS over 8 may be linked to the inclusion related to PP and ERF. A subject whose EDS interferes
of NYHA class III patients, which possibly suggests in their emotional role functioning will have their social
that, the worse the NYHA class, the higher is EDS, role functioning influenced.
as seen in Riegel et al.16 when they correlated NYHA Patients with HF undergo pain which may result
classification and EDS16. from a series of problems they face. For example,
Riegel et al.16, who investigated EDS prevalence and they may experience physical pain due to multiple
its correlation with fatigue in patients with HF, observed comorbidities27 and musculoskeletal pain because of
that 23.6% (66) of their sample were found to have EDS, lack of physical conditioning in HF. Loss of function
and its main determining factors were QoS, NYHA and dependency, which takes place as the disease
classification, the non-ingestion of diuretic drugs, and progresses, may result in spiritual/existential pains.
the lack of physical activity; however, the last two factors Dyspnea, which is common in HF, may limit a patient’s
were not significant. In that sample the correlation ability to interact socially, which contributes to his
between EDS and fatigue was r=0.38 (p < 0.001). social isolation and pain28.

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