Chin Med J 2008;121(7):592-596
Effect of dyspnea and clinical variables on the quality of life and
functional capacity in patients with chronic obstructive
pulmonary disease and congestive heart failure
Hale Karapolat, Sibel Eyigor, Alev Atasever, Mehdi Zoghi, Sanem Nalbantgil and Berrin Durmaz
Keywords: chronic obstructive pulmonary disease; congestive heart failure; dyspnea; disease severity;
quality of life; functional capacity
Background Chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are two chronic
diseases that affect negatively the functional condition and quality of life of patients. We assessed the effect of symptoms
and clinical variables on the functional capacity and quality of life in COPD and CHF patients.
Methods The study included 42 COPD and 39 CHF patients. In both patient groups, dyspnea was assessed using Borg
scale; functional capacity by shuttle-walk and cardiopulmonary exercise test and quality of life by short form-36 (SF36).
Results No statistically significant difference was found in neither of the two disease groups regarding the dyspnea score,
shuttle-walk test and the majority of subgroup scores of SF36 (P>0.05). A statistically significant difference was observed in
peak VO2 in favor of COPD group (P<0.05). No significant relationship was established between dyspnea score and forced
expiratory volume in one second (FEV1) in COPD patients, and left ventricular ejection fraction (LVEF) in CHF patients
(P>0.05). A significant negative correlation was observed between dyspnea score and functional capacity tests in both
disease groups (P<0.05). On the other hand, no relationship was found between LVEF and FEV1 and quality of life and
functional capacity (P>0.05).
Conclusions It was revealed that symptoms have an impact on functional capacity and quality of life in both disease
groups, however, objective indicators of disease severity do not show a similar relationship. Therefore, in addition to the
objective data related to the disease, we recommend that symptoms should also be taken into consideration to assess
cardiopulmonary rehabilitation program and during following-up.
Chin Med J 2008;121(7):592-596
widespread diseases that affect negatively the functional
condition and quality of life of patients.1 COPD causes
restrictions in daily life activities as a result of reduced
pulmonary function, dyspnea, or limitation in exercise
tolerance. In CHF, functional disability stemming from
dyspnea, fatigue, and reduced exercise capacity leads to
similar limitations.1 Dyspnea appears as the main
symptom in these diseases and it is stated that the
frequency of dyspnea is similar in both diseases.2 While
the objective indicator of airflow limitation is forced
expiratory volume in one second (FEV1) in COPD, the
objective indicator of physical functioning in CHF is the
left ventricular ejection fraction (LVEF).1 These two
measurements can be considered as indicators of the
disease severity. Although underlying causes of these
disorders are quite different and may have differential
effects on health and quality of life, the process through
which disease affects health for COPD and CHF patients
may be comparable.
One of the major objectives in the treatment of COPD
and CHF patients is the recovery of functional capacity.
Providing information regarding quality of life in such
chronic diseases does matter in the development of
treatment guidelines.3 Most clinicians prefer clinical
hronic obstructive pulmonary disease (COPD) and
congestive heart failure (CHF) are two chronic and
history to objective methods as far as assessment and
monitoring is concerned. However, it is thought that the
relationship among symptoms, disease indicators,
functional capacity, and quality of life is not so clear with
these two diseases and it is very probable to encounter
with contraversial results.4 Therefore, the following were
aimed to (1) assess in the two groups of disease, the effect
of symptoms and disease indicators on the functional
capacity and the quality of life, and (2) compare the two
diseases with respect to symptoms, functional capacity
and quality of life.
Subjects and study design
Consecutive patients with COPD and CHF were recruited
from a university rehabilitation centre for rehabilitation
Ege University Medical Faculty Physical Medicine and
Rehabilitation Department, Turkey (Karapolat H, Eyigor S and
Ege University Medical Faculty Pulmonary Medicine Department,
Turkey (Atasever A)
Ege University Medical Faculty Cardiology Department, Turkey
(Zoghi M and Nalbantgil S)
Correspondence to: Prof. Hale Karapolat, Ege University
Medical Faculty Physical Medicine
Department, 35100 Bornova, Izmir, Turkey (Tel: 902323902406. Fax:
902323881953-120. Email: email@example.com)
Chinese Medical Journal 2008; 121(7):592-596
program from September 2005 to May 2006. Forty-two
COPD and 39 CHF outpatients were included. The data
used in this study are a part of a different study that
studied the effects of a rehabilitation programme and
therefore assessed the COPD and CHF patients both
before and after rehabilitation programme participation.
COPD patients were included if they were; diagnosed as
COPD by a pulmonologist. Patients were eligible for
inclusion if they had a FEV1 that was between 30% and
80% of the predicted value (according to the GOLD
guideline),5 if their clinical condition was stable at the
time of inclusion, and if they had not had any infections
or COPD exacerbations in the previous 4 weeks.
Exclusion criteria were other disabling conditions or
severe diseases and/or coexistence of other causes of
impaired pulmonary function. CHF patients were
included if they were; diagnosed with CHF by a
cardiologist, registered with a LVEF less than 45%.
Furthermore, patients with CHF were excluded if they
suffered from angina pectoris or atrium fibrillation, if
they had heart transplant surgery, or if they had recently
(in the past year) had a myocardial infarction, other
disabling conditions or severe diseases. The study had a
cross-sectional design. Eligible patients received written
information about the study and an informed consent
Demographic data of all COPD and CHF patients were
taken from the patient files. All COPD and CHF patients
were assessed by the following methods. Before testing,
subjects were familiarized with both the test equipment
and the assessmet protocol.
Assessment of dyspnea
The subjects rated the sensation of difficulty in breathing
(dyspnea) using a modified Borg scale.6 This scale is a
linear scale of numbers ranking the magnitude of
difficulty in breathing, ranging from 0 (none) to 10
Pulmonary function test
FEV1% and FEV1/forced vital capacity (FVC)% of
COPD patients was assessed using Masterscreen CPX,
Viasys Health Care and in accordance with the criteria of
American Thoracic Society.7
Transthoracic echocardiography was performed on CHF
patients using Hewlett Packard Sonos 2000 device and
2.5 MHz transducer. Measurements were assessed
according to the recommendation of the American
Thoracic Society.8 LVEF was calculated by modified
Assessment of functional capacity
Functional capacity was assessed in both groups of
patients by cardiopulmonary exercise test and shuttle
Cardiopulmonary exercise test
Exercise testing was administered by the same person on
a treadmill (Model 770
electrocardiogram (ECG) monitoring using modified
Naughton protocol.9 Peak VO2 values obtained were
recorded (Masterscreen CPX with metabolic cart, Viasys
Heathcare, Jaeger, Würzburg, Germany).
Shuttle walk test
In this test, the patient was asked to walk with an
increasing pace between two marker cones placed 10
meters apart. Walking speed was adjusted according to
bleeps slightly incrementing every minute (0, 17 m/s) that
was heard from a tape. The test included 12 stages. The
test was terminated when a patient became so breathless
that he/she could not keep up with the desired pace. This
test was administered to the patients one day before the
maximal exercise testing. Results of the second exercise
test were used for the analysis.10,11
Quality of life
Quality of life of patients was assessed using SF 36.12
SF 36 is a 36-item questionnaire form which evaluates
physical functioning, role-physical, role-emotional, social
functioning, general health, mental health, bodily pain
and vitality subtitles.
The results were analyzed using the Statistical Package
for Social Sciences (SPSS) version 10.0 software system
for Windows. To evaluate
characteristics, descriptive statistical methods were used.
Age-correction was performed when comparing two
groups of patients. Results after this correction are
presented in the results section. Normality of the
variables was tested by Kolmograf Smiroff test. Variables
were analyzed by analysis of covariance. Linear
correlation between variables was assessed using
Pearson’s linear corelation coefficient. P values less than
0.05 were considered statistically significant.
Forty-two COPD (male/female 36/6) and 39 CHF
(male/female 24/15) patients were included in the study.
Average age of COPD patients and CHF patients was
(65.88 ± 8.45) years and (45.51 ± 14.42) years,
respectively. Average duration of disease was (141.07 ±
119.53) months in COPD patient group and (44.22 ±
39.23) months in CHF group (P<0.05). There was no
significant difference between the two disease groups in
terms of co-morbidity (P>0.05, Tables 1 and 2). Average
FEV1% was (52.22 ± 15.72)% in COPD patients while
average LVEF was (28.59 ± 10.63)% in CHF patients
(Tables 1 and 2). No statistically significant difference
was found between the two groups with respect to Borg
dyspnea score, shuttle walk test and the majority of SF 36
subgroup scores (P>0.05, Table 3). A statistically
significant difference was observed in the peak VO2 value
in favour of COPD group (P<0.05, Table 3). Only SF 36
CE) with continuous
Chin Med J 2008;121(7):592-596
Table 1. Demographic and clinical variables in patients
with COPD (mean ± SD)
Disease duration (month)
Borg dyspnea score
SD: standard deviation; COPD: chronic obstructive pulmonary disease; FEV1:
forced expiratory volume in one second; FVC: forced vital capacity.
Table 2. Demographic and clinical variables in patients
with CHF (mean ± SD)
Disease duration (month)
Borg dyspnea score
SD: standard deviation; CHF: congestive heart failure; LVEF: left ventricular
physical function subgroup score yielded higher values in
COPD patients when compared to the CHF group
(P<0.05, Table 3).
Table 3. Comparison of functional capacity and quality of life
between COPD and CHF (mean ± SD)
Parameter COPD (n=42)
Peak VO2 (ml·kg-1·s-1) 17.71 ± 4.42*
Shuttle walk test (meter) 293.81 ± 110.05
Physical function 54.49 ± 46.35*
Physical role 48.72 ± 29.05
Pain 57.16 ± 25.97
General health 39.15 ± 23.17
Vitality 46.71 ± 21.19
Social function 60.97 ± 29.60
Emotional role 50.00 ± 50.85
Mental health 60.60 ± 21.70
COPD: chronic obstructive pulmonary disease; CHF: congestive heart failure;
SD: standard deviation; SF36: short form 36; *P<0.05.
No significant relationship was found between FEV1 and
Borg dyspnea score in COPD patients and between LVEF
and Borg dyspnea score in CHF patients (P>0.05). A
significant negative correlation was observed between
Borg dyspnea score and functional capacity tests in both
disease groups (shuttle walk test (r=−0.50) and VO2
(r=−0.52) for COPD group; and shuttle walk test
(r=−0.43) and VO2 (r=−0.33) for CHF group) (P<0.05).
Borg dyspnea score showed a significant negative
correlation with the scores of SF 36 subgroup physical
functioning (r=−0.47) and physical role (r=−0.40) in
COPD group while it was the case with bodily pain
(r=−0.44) and social functioning subgroup score of SF 36
(r=−0.46) in CHF group (P<0.05).
On the other hand, no relationship was found between
objective disease indicators (LVEF and FEV1) and quality
of life and functional capacity (P>0.05).
In our study, dyspnea symptom was found associated in
65.88 ± 8.45
141.07 ± 119.53
1.28 ± 1.70
52.22 ± 15.72
56.39 ± 10.77
45.51 ± 14.42
44.22 ± 39.23
2.08 ± 2.50
28.59 ± 10.63
15.69 ± 5.26
339.21 ± 116.07
46.35 ± 25.38
29.05 ± 37.04
64.16 ± 27.84
45.19 ± 23.30
47.81 ± 23.56
58.18 ± 37.23
33.89 ± 33.57
59.62 ± 26.94
both diseases with some aspects of functional capacity
and quality of life while indicators of disease severity did
not show any association with any of the two. No
remarkable difference was observed between the two
groups of disease with respect to symptom severity,
functional capacity, and quality of life.
Study results related to the handled characteristics of
these two diseases show some dissimilarities with our
results. In a study by Caroci et al,2 it was reported that
dyspnea intensity was greater in COPD patients than that
in CHF patients. However, FEV1% values of the
mentioned study seem lower than those of our patients. In
another study by Arnold et al,1 it was found that
self-reported physical functions were worse in COPD
patients. However, a comparison cannot be made between
the two studies as the methods used are different. It is
seen that the two groups of patients have lower scores of
quality of life than healthy individuals.13,14 It is
emphasized, supporting our conclusion that the effect on
quality of life in COPD and CHF patients is in general,
parallel in the two groups.3
Although some studies indicate a weak relationship
between the symptom of dyspnea and indicators of
disease severity (FEV1, LVEF),15-17 there also exist
some other studies, like the present study, which maintain
that no relationship is evident between them.1,4,15 We
believe that finding of no association between objective
indicators of health and clinical symptoms is
consequential for rehabilitation physicians. As there is no
significant relationship between the objective indicators
of disease and quality of life and functional capacity, we
believe that rehabilitation approaches intended for
patients would be more beneficial if they were planned to
improve symptoms, functional capacity, and quality of
The relationship between dyspnea symptom and quality
of life is of importance. Most clinicians conduct patient
monitoring and treatments focusing on symptoms. The
correlation between dyspnea and quality of life in COPD
was also indicated in other studies supportive of our
hypothesis.4,18-20 Dyspnea symptom was found by Hajiro
et al20 associated with subgroups of SF 36 other than
emotional and mental health subtitles, while another
study indicated that it was rather associated with mental
health.18 In our study, on the other hand, dyspnea
symptom was found more associated with the physical
component (physical functioning and role-physical) of the
patient. With these results, it can be assumed that dyspnea
symptoms will probably cause restrictions in the daily life
activities of patients.
The relationship between dyspnea symptom and quality
of life (particularly physical functioning) is also discussed
in CHF.1,4,21 In this study, correlation was observed
between dyspnea symptom and social functioning and
bodily pain subtitles in CHF patients. This situation can
Chinese Medical Journal 2008; 121(7):592-596
be explained by the fact that CHF patients do not want to
socialize with people or they prefer to stay at home due to
their disease (dyspnea).
It is reported that FEV1, which is of importance in terms
of severity of the disease in COPD patients, has a loose
connection with quality of life.15,22 However, FEV1 was
found associated with quality of life in some other
studies.13,23-25 No association could be established
between FEV1 and scores of quality of life in our study.
In accordance with other studies, a relationship was found
in CHF patients between the objective parameter, LEVF,
and quality of life.1,13,26,27 In conclusion, as there exist
many factors that affect the quality of life, it must be
remembered that objective indicators of health may not
be associated with quality of life.
It was reported that FEV1 does not appear to be a
predictor of impaired exercise tolerance in COPD
patients.28 It is also stated that there was no relationship
between LVEF and functional capacity in CHF
patients.1,29-31 A relationship was not established in our
study either, between the functional capacity and FEV1 or
LVEF. Objective health parameters were not directly
related to general health perceptions. This indicates that is
not the physical disorder per se but rather the resultant
limitations in physical functioning that are important
determinant of general health perceptions of patients.
Although LVEF and FEV1 provide an accurate indication
of disease severity, it may be more relevant for clinican to
know the physical limitations patients experience and
their health compatence as these factors are directly
related to patients’ health perceptions and their well-being
and therefore may be directive for the treatment of the
The strong points of our study include assessment of
functional capacity by use of objective methods and being
handled together with quality of life in the same study.
Furthermore, we believe that this study will be a resource
for studies to follow owing to its feature that it reflects
the characteristics of patient groups in our country.
Different patient age means and durations of disease can
account for the limitations of this study. However, a
special selection could not be made since the patients
were chosen among those
rehabilitation units. Assessments were made after
correction of the statistical method according to age and
duration of disease. Similar situations were encountered
in other studies as well.1 Limited number of patients and
inexistence of a healthy control group can also be
considered as a weak aspect.
In conclusion, this study has shown that both functional
capacity and quality of life are affected by the disease
symptom, however, objective indicators of disease
severity do not show such a relationship. These data
support the practice of developing a treatment program
after focusing on the symptom as currently employed by
most clinicians. Therefore, in addition to the objective
data related to the disease, we recommend that symptoms
should also be taken into consideration to assess
cardiopulmonary rehabilitation program and during
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Edited by WANG Mou-yue and LIU Dong-yun