CHRONIC DISEASE AND HEART FAILURE

Validation of an instrument to measure the impact of coronary disease on patients daily life
Rafaela AB dos Santos, Roberta CM Rodrigues, Katia M Padilha, Simey de LL Rodrigues, Thais M Spana and Maria CBJ Gallani

Aim. To evaluate the psychometric Instrument to Measure the Impact of Coronary Disease on Patients Everyday Life (IDCV) when applied on patients with coronary disease being followed at an outpatient clinic. Methods. One hundred and fty-three patients with coronary disease were registered. Patients were analysed in terms of acceptability, ceiling and oor effect, reliability (using Cronbachs alpha coefcient) and convergent construct validity (by means of Spearman correlation) between the domains of IDCV and of Medical Outcomes Trust Short-form Health Survey (SF-36) and MacNew Heart Disease Health-related Quality of Life Questionnaire. Results. Evidence was found for high acceptability of IDCV. No evidence was found for ceiling and oor effects regarding the total score of IDCV; however, ceiling and oor effects were found from the adjustment to the disease domain. Evidence was found for reliability of the instrument as a whole and for its domains (Cronbachs a ranged between 070085). Similar domains on the IDCV, MacNew and SF-36 were correlated: Physical impact symptoms on the IDCV with the physical function domain on MacNew (r = 064) and with most domains on the SF-36 related to the physical dimension; Social impact and emotional impact on the IDCV with emotional function (r = 053) and social function (r = 055) on the MacNew and mental health on SF-36 (r = 055). However, smaller correlations of moderate/high magnitude were found between different constructs entre: Social and emotional impact on the IDCV with physical function on the MacNew (r = 056) and with the following domains: Functional capacity (r = 050), general health (r = 052) and vitality (r = 050) on SF-36. Conclusion. The IDCV is an instrument with evidence regarding reliability and convergent validity also for the population of patients with coronary disease. Further studies to validate its factor structure could offer contributions for understanding the psychometric performance of the IDCV among patients with coronary disease. Key words: coronary disease, nursing, quality of life, validation study
Accepted for publication: 9 August 2011

Introduction
Arterial coronary disease (ACD) is the leading cause of death in adults in developed countries. In the USA, it accounted for
Authors: Rafaela AB dos Santos, Nurse, Department of Nursing, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp; Roberta CM Rodrigues, Nurse and Associate Professor, Department of Nursing, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp; Katia M Padilha, Nurse and PhD Student, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp; Simey de LL Rodrigues, Nurse, Reference Emergency Unit, Hospital de Clinics, Unicamp; Thais M Spana, Nurse and PhD Student, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp; Maria CBJ Gallani, Nurse and

half a million deaths each year (American Heart Association 2008, Han et al. 2009), and in Brazil, one of its main clinical manifestations myocardial infarction (MI) caused 5799 hospitalisations in the national public health system the
Associate Professor, Department of Nursing, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp, Sao Paulo, Brazil Correspondence: Rafaela Aparecida Batista dos Santos, Nurse, Department of Nursing, Faculdade de Ciencias Medicas (FCM), Sate University of Campinas Unicamp, Rua Tessalia Vieira de Camargo, 126 - Cx. Postal: 6111. Cidade Universitaria Zeferino Vaz - Campinas - SP - Brazil. CEP: 13083-887. Telephone: +55 19 3521 8820; +55 19 3521 8845. E-mail: rafaphn@fcm.unicamp.br

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Unique Heath System (SUS, Abbreviation in Portuguese for Sistema Unico de Saude) in September of year 2009 (DAT ASUS 2009). In addition to the nancial impact caused by ACD, experiencing an ischaemic event brings important repercussions upon the individuals life. The impact on physical aspects has been associated with experiencing the symptoms, particularly chest pain, dyspnoea and fatigue. Feelings associated with the fear of going through that incident again, such as insecurity, anxiety and depression, reect how emotional aspects have been compromised, whereas difculties faced to return to the work and nancial burdens are examples of the social impact of coronary disease in the individuals life (Stewart et al. 2000, Roebuck et al. 2001, Nakajima 2006, Yuval et al. 2007). The consequences of experiencing an ischaemic event can lead to different perceptions about the disease and treatment and therefore to different ways of the individuals adjusting to the new life condition. Understanding the patients perspective about their disease is central to make interventions in how patients deal with becoming ill, with the proposed treatment, and with their capacity in assuming the course of their disease. It is believed that the perceptions about the disease and its repercussions mediate the construction of the individuals perception about the impact that the diseases and treatment have in his or her life. Hence, it is important to consider the individuals beliefs regarding their disease, as the evaluation that the individual makes of the impact of the disease in his/ her life depends on the beliefs created in this respect, based on their personal living, their experiences in the social environment and their personality (Padilha et al. 2004). Considering that the impact of the disease is the result of the balance between the individuals perception about the consequences of the disease in the different dimension in their lives and their assessment (good or bad), it is likely that individuals who perceive a very negative impact of the disease in their lives will have a worse perception towards their quality of life. Padilha et al. (2007) constructed and validated an instrument that evaluates the impact of heart valve disease among patients, referred to as Instrument to Measure the Impact of Coronary Disease on Patients Everyday Life (IDCV abbreviation in Portuguese for Instrumento para Mensuraca o do Impacto da Doenca no Cotidiano do Valvopata). The IDCV presented satisfactory psychometric properties to measure the impact of the disease on the lives of patients with heart valve disease. Although the instrument had been designed to be applied in patients with heart valve disease, the rening of its items resulted in the selection of questions that are pertinent to patients who have other heart diseases with similar symptoms.
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Considering the importance of providing the scientic community with an instrument that would allow for evaluating how patients with coronary disease adjusts to their disease, this study was developed with the objective to verify the validity and reliability of the IDCV when applied in patients with coronary disease who followed at an outpatient clinic of a university hospital. The ndings of the present study could point at more efcacious conducts to reduce the impact of coronary diseases in the life of subjects and contribute to improving their quality of life.

Sample and methods

Type of study
This is a methodological study that Polit and Hungler (1995) dene as being the investigation of the methods to obtain, organise and analyse data with the purpose of constructing and validating instruments and research techniques.

Subjects
The study registered 153 patients with coronary disease being followed at the Outpatient Cardiology Clinic of Hospital das Clnicas at State University of Campinas, Sao Paulo, Brazil.

Sample size
The sample size was estimated according to Persons correlation coefcient between the IDCV and the domains on the MacNew and the Medical Outcomes Study Short Form-36 (SF-36), obtained based on the analysis of preliminary results. Considering correlation coefcients between 030040 and values of a = 005 and b = 010, a sample size of 113 subjects was estimated. The sample size was increased to 153 subjects attributing to the possible estimated losses in statistical analysis (Hulley & Cummings 1988).

Instruments
Instrument to measure the impact of coronary disease on patients everyday life IDCV The IDCV instrument was designed to assess the impact of heart valve disease on a patients daily life. The concept that the impact is a product of perceived consequences of the disease by means of an assessment of each consequence guided the development of two groups of items, each part composed of 14 items. Part A was designed to measure the degree of the impact perceived by subjects in the various

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dimensions of their life, while Part B was designed to consider their assessment (good or bad) of each of the highlighted consequences. In Part A, the patient is required to answer each of the items using the ve-point Likert scale that ranges from 1 (disagree strongly) 5 (agree strongly). In Part B, a Likert-type scale is used for each of the items with responses that range from 1 (very bad) 5 (very good). The items are grouped in four domains: Physical impact of the disease symptoms (items 11, 12 and 13), Impact of disease on activities of daily living (5, 7, 9, 10 and 14), Social and emotional impact of the disease (items 2, 3, 4 and 6) and Adjustment to the disease (1 and 8). To determine the nal score of the IDCV, the items were all changed towards one same direction. All items from part B and items 1, 5 and 8 from Part A, corresponding to the perceptions related to the positive impact, were inverted. To obtain the score, each item corresponds to the product of the scores obtained in Parts A and B of the IDCV, resulting in scores ranging from 125 for each statement evaluated. The closer the score is to 1, the lower the impact perceived by the subject and the closer to 25, the higher the impact. The total score of the impact is obtained by adding all the products obtained, thus scores range from 14350. A high score means that the patient realises the negative consequences of the disease in his/her life, and these consequences are, in fact, interpreted as negative. A low score means that the patient does not realise the consequences of the disease and treatment in his/her life and, in case they do occur, they will not be assessed as bad consequences. Although this instrument was originally developed in the Brazilian culture to assess the beliefs of patients with heart valve disease, it was found that the group of statements comprising the instrument assesses the impact of the chronicity imposed by heart diseases (Padilha et al. 2007). MacNew heart disease health-related quality of life questionnaire The MacNew questionnaire a specic health-related quality of life (HRQL) questionnaire is a modication of the Quality of Life after Myocardial Infarction (QLMI) questionnaire that was originally developed in English for patients who had survived an acute MI and who were referred for subsequent cardiac rehabilitation (Oldridge et al. 1991). Modications were made to the QLMI in 1993 and 1996, resulting in the QLMI-2 and then MacNew, which, on the basis of factor analysis, consists of 27 items in three domains (physical limitation, emotional function and social function) (Lim et al. 1993, Valenti et al. 1996). The Brazilian MacNew has a twoweek timeframe and consists of 27 items that are scored on a seven-point Likert-type scale: from 1 (poor HRQL) 7 (high HRQL). Items are associated with the following

domains: physical limitations (13 items), emotional function domain scale (14 items) and social function (13 items). It should be stressed that some items are present in more than one domain, and this derives from the original factor analyses of the MacNew when the decision was made to include any item with a factor weight of 040 in that domain (Lim et al. 1993, Valenti et al. 1996). Missing responses do not contribute to the score and item 27, sexual intercourse, may be excluded without altering the domain score as each domain score is calculated as the average of the responses in that domain. For example, if only 10 of the 14 emotional items were answered, the emotional score would be the average of 10 responses. If more than 50% of the items for a domain were missing, the score for that domain would be considered missing. The instrument also gives a global HRQL score, calculated as the average of all scored items unless one of the domain scores is missing. The MacNew questionnaire was linguistically adapted to Brazilian population by Benetti et al. (2001).) Additional psychometric properties of the Brazilian version however were veried by Nakajima et al. (2009). The present study found reliability for the instrument as a whole (Cronbachs a = 091) as for the domains physical function (084), emotional function (090) and social function (0.84). Medical outcomes study short form-36 (SF-36) The SF-36 is a generic HRQL questionnaire that was originally developed in English for the Medical Outcomes Study and has been validated in Brazil (Ciconelli et al. 1999). It contains 36 items in eight scales (physical functioning, rolephysical, pain, general health perception, vitality, social functioning, role-emotional and mental health) and one health transition item comparing current health condition to health condition 1 year earlier. Each dimension is individually analysed, and scores on the eight components may range from 0100, with higher scores indicating better HRQL (Ware et al. 1994). The present study found reliability for most domains of SF-36 (Cronbachs a values ranged between 064092).

Data analysis
The psychometric properties of the IDCV were assessed according to the criteria recommended by the Scientic Advisory Committee of the Medical Outcomes Trust (2002). The data were types on a Microsoft Excel spreadsheet and then transferred to the Statistical Analysis System for Windows (SAS ), version 8.02 (SAS Institute Inc., Cary, NC, USA), for the following statistical analyses. Acceptability, Median and Ceiling and oor effects. Acceptability was assessed by the percentage of unanswered items
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and by the proportion of patients that answered all items. The percentage of patients who scored at the oor level equivalent to the 10% worst possible results on the scale and the percentage of patients who scored at the ceiling level corresponding to the 10% best scores were also calculated for each of the domains on the IDCV (Bennett et al. 2002). Reliability. Cronbachs alpha was used to assess reliability, based on item homogeneity. Internal consistency was evidenced based on Cronbachs a >070 (Nunnally 1978). Validity. Convergent validity was tested using the Spearman correlation coefcient to test the correlation between scores on the IDCV and on MacNew and SF-36, considering coefcients <030 as of low magnitude, between 030050 moderate and >050 high magnitude (Ajzen & Fishbein 1980). The level of signicance adopted for the statistical tests was 5%.

According to the mean and median values of the total score, it is concluded that patients were in an intermediate situation, between low and high impact. The assessment performed did not nd any ceiling and oor effects for the total score on the IDCV. However, 490% of the patients scored oor for the domain adjustment to the disease (Table 2).

Reliability
Evidence was found for the internal consistency of the instrument as a whole (Cronbachs a = 085) and for the domains on the IDCV (071078). The internal consistency of the domain Adjustment to the disease was not assessed because is consists of two items (1 and 8); therefore, only the correlation between them was tested. The contribution of each item for the IDCV and its respective domains and the Cronbachs alpha of deleted items are presented in Table 2. Apart from items 1 and 8, which did not present item-total correlation, all the other items contributed to the internal consistency of the IDCV. A subtle improvement was found for the Cronbachs alpha coefcient in the domains physical impact of the disease symptoms and impact of the disease in activities of daily living if items 13 and 5 were excluded, respectively, but removing those items does not improve the alpha of the instrument as a whole.

Ethical aspects
The registered patients signed the Free and Informed consent Form, and the study was approved by the local ethics committee (Opinion 370/2007).

Results
Descriptive analysis
The sociodemographic and clinical characteristics of the 153 registered subjects are presented in Table 1. Most subjects were men (699%), with an mean age of 622 (SD 101) years, and with 49 (SD 39) years of education, married (667%), unemployed (700%), with average individual income of 23 (SD 19) minimum salaries (MS)/month and average family income of 38 (SD 28) MS/month. Most patients (915%) had had MI (alone or associated with angina postMI), with an average 12 (SD 08) previous MI and 29 (SD 11) associated clinical conditions and/or risk factors. All patients reported symptoms the month before the interview, with an average 13 (SD 12) associated symptoms. An average 58 (SD 17) medications were used per day. The left ventricular ejection fraction was reduced in 463% among the 134 patients with this information. Every patient answered all the items on the IDCV pointing at its high acceptability. As the total sum of the average impact can range between 14350 for the instrument as a whole, with the minimum score being obtained by adding the products ([1 1] 14) to the maximum score = ([5 5] 14), it was considered that individuals with a score below 170 perceive a low impact of the disease and those with score above 170 perceive a high impact of the disease on their lives.
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Validity
The correlations between the domains of the IDCV and those of the MacNew and SF-36 are presented on Table 3. Except for the IDCV domain adjustment to the disease, the remaining correlations were signicant and ranged from r = 033 to r = 067. As expected, negative correlations were observed between the global IDCV score and all other MacNew domains and most SF-36 domains. The correlation coefcients found between the IDCV and the MacNew presented greater magnitude than those between the IDCV and the SF-36, which points at the adequacy of the IDCV as a specic instrument for patients with heart disease. Considering specic analyses between similar domains, strong correlations were found between the domain Physical Impact symptoms of the IDCV and the physical function dimensions of the MacNew (r = 064) and most SF-36 dimensions related to the physical dimension functional capacity (r = 061), general health (r = 051) and pain (r = 056), except for the domain Physical aspects (r = 033). The domain Impact of disease on activities of daily living of the IDCV presented strong correlations with the emotional

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Table 1 Sociodemographic and clinical characteristics of patients with coronary disease (n = 153). Campinas 2009 Variable Gender Age Education in years (n = 152) Marital status Categories Male Female % 699 301 622 (101) 49 (39) Married Separated/Divorced Common-law Widowed Single Employed Unemployed Housewife 667 91 65 118 59 209 699 91 23 (19) 38 (28) Myocardial infarction Angina 915 85 12 13 Chest pain Dyspnoea Syncope Arrhythmia Hypertension (SAH) Dyslipidemia Diabetes mellitus (DM) Obesity (BMI >30 kg/m2) Smoking Clinical Angioplasty and/or surgical myocardial revascularisation LVEF reduced 058 408 379 314 235 876 765 327 242 686 362 638 08 12 150 140 20 30 09 117 630 40 3282 025 Mean (SD) Median Variation

Work

Individual income (in MS) (n = 152) Family income (in MS) Characterisation of coronary disease Number of myocardial infarctions (n = 148) Number of associated symptoms (n = 152) Signs and Symptoms (in the past month) (n = 152) Number of associated clinical conditions and/or risk factors

29

11

35

Treatment

Number of medications being used Electrocardiogram data (n = 134)

58 (17) 463

60

211

LVEF, left ventricular ejection fraction; MS, minimum salaries.

function domains (r = 056) of the MacNew and with the mental health domain of the SF-36 (r = 056), and moderate correlation with the vitality (r = 045) and social aspect (r = 048) domains of the SF-36. These data point at the convergent validity of the IDCV, as there was strong correlation between similar dimensions. It should, however, be stressed that strong correlations were also found between divergent domains of the IDCV and MacNew and SF-36. Nevertheless, it is observed that correlations between similar domains were stronger than correlations between divergent domains. The ndings regarding the correlation of the IDCV with the MacNew and SF-36 domains support the convergent validity of the IDCV.

Because items 1 and 8 of the domain Adjustment to the disease showed no item-total correlation, the authors chose to verify the correlation of each with the domains of the MacNew and SF-36, but no correlations were found among these items and the domains of the MacNew and/or SF-36.

Discussion
This study sought to investigate the psychometric performance of the IDCV constructed in the Brazilian culture to measure the impact of heart valve disease on the life of patients with coronary disease. The application of IDCV in patients with coronary disease is justied by the evidences that the group of items comprising that instrument is
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490 Mean (SD) 1519 (650) 344 (198) 109 (83) 50 071 05 058 05 084 350 1520 14350 49299 375 775 125 085 Median MinMax observed Cronbachs a Item-total correlation of domains Alpha for the domain if item was excluded Item-total correlation of the IDCV Alpha of the total IDCV if item was excluded % Floor* 46 39 124 (85) 100 125 06 050 06 083 112 (81) 074 50 125 04 05 084 574 (280) 46 (55) 20 072 02 570 5125 15125 125 074 02 085 33 13 129 (86) 120 125 05 063 05 084 114 (86) 50 125 04 067 05 084 133 (88) 160 125 05 062 07 082

Table 2 Mean, median, Cronbachs alpha, item-total correlation and Cronbachs Alpha of the items were excluded for the domains and total score of the Instrument to Measure the Impact of Coronary Disease on Patients Everyday Life (IDCV) (n = 153). Campinas 2009

RAB dos Santos et al. % Ceiling

Domains of the IDCV

IDCV Total

Physical impact symptoms Item 11: Because of my heart condition, I experience intense shortness of breath. Item 12: Because of my heart condition, I experience intense tiredness. Item 13: Because of my heart condition, I experience dizzy spells. Impact on activities of daily living Item 5: I live ne with my heart condition. Item 7: After I got this heart condition, I started fearing something might happen to me. Item 9: Because of my heart condition, I started having sleep problems. Item 10: Because of my heart condition, I nd it difcult to run everyday errands.

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Table 2 (Continued) Alpha of the total IDCV if item was excluded

Domains of the IDCV 152 (88) 497 (262) 108 (80) 50 078 05 076 05 470 4100 10100 125 200 125 05 063 062 083

Mean (SD)

Median

MinMax observed Cronbachs a

Item-total correlation of domains

Alpha for the domain if item was excluded

Item-total correlation of the IDCV

% Floor*

% Ceiling

084

46

52

153 (88)

200

125

04

077

05

084

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Item 14: Having a heart condition worries me Social and emotional impact Item 2: My heart condition made me dependant on other people. Item 3: My heart condition harmed my capacity for working as I did before. Item 4: Now, I became more irritated and nervous because of my heart condition. Item 6: I started feeling really upset after I got this heart condition. Adjustment to the disease

Item 1: After I got this heart condition, I started to care more about my health Item 8: My sex life today is the same as before having this heart condition

Validation of an instrument to measure the impact

*Estimated only for the constructs comprising three or more items

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RAB dos Santos et al. Table 3 Spearman correlation coefcients between the domains of the Instrument to Measure the Impact of Coronary Disease on Patients Everyday Life (IDCV) and the domains of the Brazilian versions of the MacNew and SF-36 (n = 159). Campinas 2009 IDCV Physical impact symptoms Impact of disease on activities of daily living Social and emotional impact Adjustment to the disease

Total MacNew Total Physical function Emotional function Social function SF-36 Functional capacity Physical aspects Pain General health Vitality Social aspects Emotional aspects Mental health

067 066 062 058 062 043 058 059 055 050 047 059

063 064 059 053 061 033 056 051 041 043 039 044

060 057 056 051 051 033 050 053 049 048 044 056

059 056 053 055 050 045 053 052 050 043 041 055

004 001 003 006 002 000 010 004 009 010 000 006

All domain correlations presented p < 0001 except the IDCV domain Adjustment to the disease, which presented no signicant correlation. The values marked in bold represent the correlation coefcients of greater magnitude between domains of the IDCV and those of the MacNew and SF-36.

pertinent for measuring the impact on patients with heart conditions with similar symptoms. The ndings indicate the instrument is acceptable, as all patients answered every item on the instrument. The total score of the IDCV may be considered potentially sensitive to detecting patients clinical regressions and improvements, as no ceiling or oor was identied for the group of items. Ceiling and oor effects were, however, identied for the domains, which may be considered of minor signicance, except for the adjustment to the disease domain that showed an expressive ceiling effect. The ceiling effect in this domain suggests that the IDCV might not be sensitive to detecting the subjects clinical improvement which may imply on limiting its use to assess the effectiveness of interventions designed to reduce the impact of coronary disease in the subjects life. Nevertheless, this domain presented important limitations in different psychometric performance tests applied in the present study, thus reproducing ndings observed in the original population of patients with heart valve disease (Padilha et al. 2007). The IDCV as a whole and most of its domains presented internal consistency (Cronbachs a ranging between 070078). The item-total correlation analysis and the nding that removing items did not make signicant improvements on Cronbachs alpha strengthens the homogeneity of the items in each domain, except for the domain Adjustment to the disease.

A previous study (Padilha et al. 2007) estimated Cronbachs a values between 068077 for the IDCV domains, except for the domain Adjustment to the disease (Cronbachs a = 020). The study showed that the inconsistency of the domain could be related to the construction of its items (item 1 After I got this heart condition I started to care more about my health and item 8 My sex life today is the same as before having this heart condition), which may have dubious interpretations. Subjects may interpret item 1 as a good or bad consequence. As for item 8, it may be difcult to assess the consequence of the disease because of the fact that there is no information about the quality of the individuals sex life before the disease. The present study results reinforce the recommendation by Padilha et al. (2007) in terms of the need to review the construction of these items and/or the exclusion of item 8, which would result in an increase in Cronbachs alpha, although of small signicance. In the present study, evidence of the convergent validity of the IDCV was supported by the correlation analysis with the domains of MacNew and SF-36. It was observed that stronger correlations occurred between the IDCV and MacNew, suggesting the adequacy of the IDCV as a specic instrument for patients with heart disease. Smaller correlations were also found, although of moderate or strong magnitude, among divergent domains. The small correlation between physical impact of the disease symp-

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toms and the SF-36 domain Physical Aspects may be explained by the fact that they measure different dimensions. While the IDCV domain impact of the disease symptoms assesses the perception of symptoms, the SF-36 domain Physical Aspects assesses the limitation at work caused by physical limitations. The correlations between divergent constructs observed between the IDCV and the MacNew may be explained by the fact that one same item can be used to assess more than one domain on the MacNew (physical, emotional and social). For instance, the IDCV domain Physical impact of the disease symptoms was strongly correlated with the emotional function and social function of the MacNew. The MacNew domain emotional function contains two items that take part in the assessment of the physical domain. Similarly, the social domain comprises six items that are also included in the evaluation of the physical domain, which are all related to the limitation imposed by the disease, thus favouring the correlations. The strong correlation found between the IDCV domain social and emotional impact and the domain MacNew physical function (r = 056) may be explained by the fact that the MacNew domain Physical limitation involves several items that assess limitation, which is also assessed by the IDCV domain Social and Emotional Impact. It should be stressed that there is a lack of correlation between the domain adjustment to the disease and all the

other domains on the MacNew and SF-36, pointing at the need for further studies to evaluate the factorial composition of the MacNew.

Conclusion
The present study provides evidence that the IDCV is an instrument of easy understanding, with acceptable psychometric properties. The ndings point at the reliability of the total IDCV score and of most of its domains, except for the domain Adjustment to the disease. The convergent validity by means of the correlation between the IDCV and its domains with the generic and specic measures of HRQoL was only partially supported because of the identication of strong negative correlations between divergent constructs and the lack of correlation between the domain IDCV Adjustment to the disease and HRQoL measures. Further longitudinal studies should be perfumed with a view to assessing the responsiveness of the IDCV, in addition to studies aimed at conrmatory factor analysis.

Contributions
Study design: RCMR, MCBJG, KMP, RABS, SLLR; data collection and analysis: RCMR, MCBJG, KMP, RABS, SLLR, TSP and manuscript preparation: RCMR, KMP, RABS, MCBJG.

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RAB dos Santos et al. comprehensive rehabilitation after acute myocardial infarction. The American Journal of Cardiology 67, 10841089. Padilha KM, Gallani MCBJ & Colombo RCR (2004) Development of an instrument to measure beliefs and attitudes from heart valve disease patients. Rev Latino-am Enfermagem 12, 4539. Padilha KM, Gallani MCBJ & Colombo RCR (2007) Validity of an instrument to measure the impact of valve heart disease on the patients daily life. Journal of Clinical Nursing 16, 12851291. Polit DF & Hungler BP (1995) Fundamentos de pesquisa em enfermagem, 3rd edn. Artes Medicas, Porto Alegre, pp. 200219. Roebuck A, Furze G & Thompson DR (2001) Health related quality of life after myocardial infarction: an interview study. Journal of Advanced Nursing 34, 787794. Scientific Advisory Committee of the Medical Outcomes Trust (2002) Assessing health status and quality-oflife instruments: attributes and review criteria. Quality of Life Research 11, 193205. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA & Ware JE (2000) Function status and well-being of patients with chronic conditions. The Journal of the American Medical Association 262, 907913. Valenti L, Lim L, Heller RF & Knapp J (1996) An improved questionnaire for assessing quality of life after acute myocardial infarction. Quality of Life Research 5, 151161. Ware JE, Gandek B & The IQOLA Project Group (1994) The SF-36 health survey: development and use in mental health research and the IQOLA Project. International Journal of Mental Health 23, 4973. Yuval R, Halon DA & Lewis BS (2007) Perceived disability and lifestyle modification following hospitalization for non-ST elevation versus ST elevation acute coronary syndromes: the patients point of view. European Journal of Cardiovascular Nursing 6, 287292.

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